HCR Essential
Key Notes BE = This medication is not covered in Pennsylvania under the Health Care Reform Comprehensive and Health Care Reform Progressive Formularies for Individual Plans and may not be covered for Group Plans. Contact Member Services for more information. EX = This medication is not covered in Pennsylvania or West Virginia under the Health Care Reform Comprehensive and Health Care Reform Progressive Formularies for Individual Plans and may not be covered for Group Plans. Contact Member Services for more information. PA = Coverage of this drug is subject to review by the plan and is based on Pharmacy policy. QL = Limits the amount of drug that a beneficiary may receive in a certain period. SP = To assist in the management of select specialty medications, some pharmacy benefit designs require the Status use of a preferred specialty $0 = Preventative Medication pharmacy. Please call the number on 1 = Tier 1 the back of your member ID card for 2 = Tier 2 assistance. 3 = Tier 3 ST = For a step therapy drug to be 4 = Tier 4 covered, the beneficiary will be first lowercase italics = Generic drugs NF = Non-Formulary required to try a therapeutically UPPERCASE = Brand name drugs Special Tier = Special Tier equivalent medication. Drug Status Notes Analgesic, Anti-Inflammatory Or Antipyretic Analgesic Opioid Agonists PA; ST; QL (120 UNITS per 25 ACTIQ NF days) PA; ST; QL (14 DAY SUPPLY ALFENTA NF per 30 days) Last Approved Date: 09/24/2021 Formulary Version: 92
1 Drug Status Notes PA; ST; QL (14 DAY SUPPLY alfentanil NF per 30 days) ARYMO ER Special Tier PA; ST; QL (90 MG per 1 day) ASTRAMORPH-PF INJECTION SOLUTION 1 PA; ST; QL (14 DAY SUPPLY 3 MG/ML per 30 days) PA; ST; QL (186 TABLETS per codeine sulfate 1 25 days) CONZIP NF PA; ST; QL (90 MG per 1 day) DEMEROL (PF) INJECTION SOLUTION 50 PA; ST; QL (14 DAY SUPPLY NF MG/ML per 30 days) PA; ST; QL (14 DAY SUPPLY DEMEROL (PF) INJECTION SYRINGE NF per 30 days) DEMEROL INJECTION SOLUTION 100 PA; ST; QL (14 DAY SUPPLY NF MG/ML per 30 days) PA; ST; QL (248 TABLETS per DEMEROL ORAL TABLET 100 MG NF 25 days) PA; ST; QL (14 DAY SUPPLY DILAUDID (PF) INJECTION SOLUTION NF per 30 days) DILAUDID (PF) INJECTION SYRINGE 0.5 NF PA; ST MG/0.5 ML, 1 MG/ML, 2 MG/ML DILAUDID INJECTION NF PA; ST PA; ST; QL (2480 ML per 25 DILAUDID ORAL LIQUID NF days) PA; ST; QL (186 TABLETS per DILAUDID ORAL TABLET NF 25 days) PA; ST; QL (248 TABLETS per DISKETS NF 25 days) PA; ST; QL (248 TABLETS per DOLOPHINE ORAL NF 25 days) PA; ST; QL (20 PATCHES per 25 DURAGESIC NF days) PA; ST; QL (14 DAY SUPPLY DURAMORPH (PF) NF per 30 days) PA; ST; QL (60 TABLETS per 25 EXALGO ER NF days) PA; ST; QL (120 UNITS per 25 fentanyl citrate buccal lozenge on a handle 3 days) PA; ST; QL (120 units per 25 fentanyl citrate buccal tablet, effervescent NF days)
Last Approved Date: 09/24/2021 Formulary Version: 92
2 Drug Status Notes fentanyl transdermal patch 72 hour 100 mcg/hr, PA; ST; QL (20 PATCHES per 25 2 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr days) fentanyl transdermal patch 72 hour 37.5 PA; ST; QL (20 PATCHES per 25 NF mcg/hour, 62.5 mcg/hour, 87.5 mcg/hour days) PA; ST; QL (120 UNITS per 25 FENTORA NF days) hydrocodone bitartrate oral capsule, oral only, er PA; ST; QL (100 CAPSULES per NF 12hr 25 days) hydrocodone bitartrate oral tablet,oral PA; ST; QL (30 tablets per 25 1 only,ext.rel.24 hr days) hydromorphone (pf) injection syringe NF PA; ST hydromorphone in 0.9 % nacl intravenous patient NF PA control.analgesia soln 6 mg/30 ml hydromorphone in d5w (pf) intravenous syringe NF PA; ST PA; ST; QL (2480 ML per 25 hydromorphone oral liquid NF days) PA; ST; QL (186 TABLETS per hydromorphone oral tablet 1 25 days) PA; ST; QL (60 TABLETS per 25 hydromorphone oral tablet extended release 24 hr 3 days) PA; ST; QL (14 DAY SUPPLY hydromorphone rectal 2 per 30 days) PA; ST; QL (30 TABLETS per 25 HYSINGLA ER Special Tier days) INFUMORPH P/F INJECTION SOLUTION 10 PA; ST; QL (14 DAY SUPPLY NF MG/ML per 30 days) PA; ST; QL (14 DAY SUPPLY IONSYS NF per 30 days) KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 PA; ST; QL (62 CAPSULES per NF MG, 100 MG, 20 MG, 200 MG, 30 MG, 40 MG, 25 days) 50 MG, 60 MG, 80 MG LAZANDA NASAL SPRAY,NON-AEROSOL PA; ST; QL (30 BOTTLES per 25 NF 100 MCG/SPRAY, 400 MCG/SPRAY days) LAZANDA NASAL SPRAY,NON-AEROSOL NF PA; ST 300 MCG/SPRAY PA; ST; QL (186 TABLETS per levorphanol tartrate oral tablet 2 mg NF 25 days) PA; ST; QL (186 tablets per 25 levorphanol tartrate oral tablet 3 mg NF days)
Last Approved Date: 09/24/2021 Formulary Version: 92
3 Drug Status Notes meperidine (pf) injection solution 100 mg/ml, 25 PA; ST; QL (14 DAY SUPPLY NF mg/ml, 50 mg/ml per 30 days) PA; ST; QL (2500 ML per 25 meperidine oral solution 1 days) PA; ST; QL (248 TABLETS per meperidine oral tablet 1 25 days) PA; ST; QL (14 DAY SUPPLY methadone injection solution NF per 30 days) methadone intravenous 3 PA; ST methadone oral concentrate 3 PA; ST; QL (248 ML per 25 days) PA; ST; QL (1240 ML per 25 methadone oral solution 10 mg/5 ml 1 days) PA; ST; QL (2480 ML per 25 methadone oral solution 5 mg/5 ml 1 days) methadone oral syringe 10 mg/ml 3 PA; ST PA; ST; QL (248 TABLETS per methadone oral tablet 1 25 days) PA; ST; QL (248 TABLETS per methadone oral tablet,soluble NF 25 days) METHADOSE ORAL CONCENTRATE 3 PA; ST; QL (248 ML per 25 days) PA; ST; QL (248 TABLETS per METHADOSE ORAL TABLET,SOLUBLE NF 25 days) PA; ST; QL (14 DAY SUPPLY morphine (pf) injection solution 1 mg/ml NF per 30 days) PA; ST; QL (14 DAY SUPPLY morphine concentrate oral solution 1 per 30 days) PA; ST; QL (14 DAY SUPPLY morphine injection solution 15 mg/ml NF per 30 days) PA; ST; QL (14 DAY SUPPLY morphine intravenous solution 10 mg/ml NF per 30 days) PA; ST; QL (14 DAY SUPPLY morphine intravenous syringe 4 mg/ml NF per 30 days) PA; ST; QL (62 CAPSULES per morphine oral capsule, er multiphase 24 hr NF 25 days) PA; ST; QL (62 CAPSULES per morphine oral capsule,extend.release pellets NF 25 days) PA; ST; QL (2800 ML per 25 morphine oral solution 10 mg/5 ml 1 days) PA; ST; QL (1400 ML per 25 morphine oral solution 20 mg/5 ml (4 mg/ml) 1 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
4 Drug Status Notes PA; ST; QL (186 TABLETS per morphine oral tablet 1 25 days) PA; ST; QL (100 TABLETS per morphine oral tablet extended release 2 25 days) PA; ST; QL (14 DAY SUPPLY morphine rectal NF per 30 days) PA; ST; QL (100 TABLETS per MS CONTIN NF 25 days) PA; ST; QL (186 TABS per 25 NUCYNTA NF days) PA; ST; QL (62 TABLETS per 25 NUCYNTA ER NF days) PA; ST; QL (100 TABLETS per OPANA ER NF 25 days) OPANA INJECTION NF PA; ST PA; ST; QL (180 TABLETS per OPANA ORAL NF 25 days) PA; ST; QL (100 TABLETS per ORAMORPH SR 3 25 days) PA; ST; QL (180 TABLET per 25 OXAYDO NF days) PA; ST; QL (180 CAPSULE per oxycodone oral capsule NF 25 days) oxycodone oral concentrate NF PA; ST; QL (180 ML per 25 days) PA; ST; QL (5600 ML per 25 oxycodone oral solution 3 days) PA; ST; QL (180 TABLET per 25 oxycodone oral tablet 1 days) oxycodone oral tablet,oral only,ext.rel.12 hr 10 PA; ST; QL (100 TABLETS per NF mg, 20 mg, 40 mg, 80 mg 25 days) PA; ST; QL (100 TABLETS per OXYCONTIN 3 25 days) PA; ST; QL (180 TABLETS per oxymorphone oral tablet NF 25 days) PA; ST; QL (100 TABLETS per oxymorphone oral tablet extended release 12 hr 2 25 days) QDOLO NF PA; ST PA; ST; QL (180 TABLET per 25 ROXICODONE NF days)
Last Approved Date: 09/24/2021 Formulary Version: 92
5 Drug Status Notes PA; ST; QL (14 DAY SUPPLY ROXYBOND Special Tier per 30 days) PA; ST; QL (240 SPRAY UNITS SUBSYS NF per 25 days) tramadol oral capsule,er biphase 24 hr 17-83 NF PA; ST; QL (90 MG per 1 day) tramadol oral capsule,er biphase 24 hr 25-75 NF PA; ST; QL (90 MG per 1 day) PA; ST; QL (14 day supply per 30 tramadol oral tablet 100 mg NF dayss) PA; ST; QL (14 DAY SUPPLY tramadol oral tablet 50 mg 1 per 30 days) tramadol oral tablet extended release 24 hr 3 PA; ST; QL (90 MG per 1 day) tramadol oral tablet, er multiphase 24 hr 3 PA; ST; QL (90 MG per 1 day) PA; ST; QL (14 DAY SUPPLY ULTRAM NF per 30 days) ULTRAM ER ORAL TABLET EXTENDED NF PA; ST; QL (90 MG per 1 day) RELEASE 24 HR 300 MG PA; ST; QL (60 CAPSULES per XTAMPZA ER Special Tier 23 days) PA; ST; QL (100 CAPSULES per ZOHYDRO ER NF 25 days) Analgesic Opioid Codeine Combinations acetaminophen-codeine oral solution 120-12 PA; ST; QL (14 DAY SUPPLY 1 mg/5 ml per 30 days) PA; ST; QL (120 GM APAP acetaminophen-codeine oral tablet 1 COMP per 25 days) PA; ST; QL (14 DAY SUPPLY ASCOMP WITH CODEINE 3 per 30 days) PA; ST; QL (14 DAY SUPPLY BUTALBITAL COMPOUND W/CODEINE 3 per 30 days) PA; ST; QL (14 DAY SUPPLY BUTALBITAL COMPOUND-CODEINE 3 per 30 days) butalbital-acetaminop-caf-cod oral capsule 50- PA; ST; QL (120 GM APAP NF 300-40-30 mg COMP per 25 days) butalbital-acetaminop-caf-cod oral capsule 50- PA; ST; QL (120 GM APAP 3 325-40-30 mg COMP per 25 days) PA; ST; QL (14 DAY SUPPLY CAPITAL WITH CODEINE NF per 30 days) PA; ST; QL (14 DAY SUPPLY codeine-butalbital-asa-caff 3 per 30 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
6 Drug Status Notes FIORICET WITH CODEINE NF PA; ST; QL (120 GM per 25 days) PA; ST; QL (14 DAY SUPPLY FIORINAL-CODEINE #3 NF per 30 days) PA; ST; QL (120 GM APAP TYLENOL-CODEINE #3 NF COMP per 25 days) PA; ST; QL (120 GM APAP TYLENOL-CODEINE #4 NF COMP per 25 days) Analgesic Opioid Dihydrocodeine Combinations PA; ST; QL (14 DAY SUPPLY acetaminophen-caff-dihydrocod oral capsule NF per 30 days) PA; ST; QL (14 DAY SUPPLY aspirin-caffeine-dihydrocodein NF per 30 days) PA; ST; QL (300 TABLETS per PANLOR(ACETAM-CAFF-DIHYDROCOD) 3 25 days) PA; ST; QL (14 DAY SUPPLY SYNALGOS-DC NF per 30 days) PA; ST; QL (14 DAY SUPPLY TREZIX NF per 30 days) Analgesic Opioid Dihydrocodeine, Non- Salicylate Analgesic,Xanthine PA; ST; QL (14 DAY SUPPLY acetaminophen-caff-dihydrocod oral capsule NF per 30 days) PA; ST; QL (300 TABLETS per PANLOR(ACETAM-CAFF-DIHYDROCOD) 3 25 days) PA; ST; QL (14 DAY SUPPLY TREZIX NF per 30 days) Analgesic Opioid Dihydrocodeine, Salicylate Analgesic, Xanthine Comb PA; ST; QL (14 DAY SUPPLY aspirin-caffeine-dihydrocodein NF per 30 days) PA; ST; QL (14 DAY SUPPLY SYNALGOS-DC NF per 30 days) Analgesic Opioid Hydrocodone And Non-Salicylate Combinations PA; ST; QL (14 DAY SUPPLY APADAZ NF per 30 days) PA; ST; QL (14 DAY SUPPLY benzhydrocodone-acetaminophen NF per 30 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
7 Drug Status Notes hydrocodone-acetaminophen oral solution 7.5- PA; ST; QL (14 DAY SUPPLY 3 325 mg/15 ml per 30 days) hydrocodone-acetaminophen oral tablet 10-300 PA; ST; QL (120 GM APAP NF mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg COMP per 25 days) hydrocodone-acetaminophen oral tablet 10-325 PA; ST; QL (120 GM APAP 1 mg, 5-325 mg, 7.5-325 mg COMP per 25 days) PA; ST; QL (120 GM APAP LORCET (HYDROCODONE) 1 COMP per 25 days) PA; ST; QL (120 GM APAP LORCET HD 1 COMP per 25 days) PA; ST; QL (120 GM APAP LORCET PLUS 1 COMP per 25 days) LORTAB 10-325 1 PA; ST; QL (120 GM per 25 days) LORTAB 5-325 1 PA; ST; QL (120 GM per 25 days) LORTAB 7.5-325 1 PA; ST; QL (120 GM per 25 days) PA; ST; QL (14 DAY SUPPLY LORTAB ELIXIR NF per 30 days) PA; ST; QL (120 GM APAP NORCO NF COMP per 25 days) PA; ST; QL (120 GM APAP VICODIN NF COMP per 25 days) PA; ST; QL (120 GM APAP VICODIN ES NF COMP per 25 days) PA; ST; QL (120 GM APAP VICODIN HP NF COMP per 25 days) XODOL 10/300 NF PA; ST; QL (120 GM per 25 days) XODOL 5/300 NF PA; ST; QL (120 GM per 25 days) XODOL 7.5/300 NF PA; ST; QL (120 GM per 25 days) PA; ST; QL (14 DAY SUPPLY ZAMICET NF per 30 days) Analgesic Opioid Hydrocodone And Nsaid Combinations PA; ST; QL (14 DAY SUPPLY hydrocodone-ibuprofen oral tablet 10-200 mg 2 per 30 days) PA; ST; QL (14 DAY SUPPLY hydrocodone-ibuprofen oral tablet 5-200 mg NF per 30 days) PA; ST; QL (14 DAY SUPPLY hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 per 30 days) PA; ST; QL (14 DAY SUPPLY IBUDONE NF per 30 days) Last Approved Date: 09/24/2021 Formulary Version: 92
8 Drug Status Notes PA; ST; QL (14 DAY SUPPLY REPREXAIN 2 per 30 days) PA; ST; QL (14 DAY SUPPLY XYLON 10 2 per 30 days) Analgesic Opioid Hydrocodone Combinations hydrocodone-acetaminophen oral solution 7.5- PA; ST; QL (14 DAY SUPPLY 3 325 mg/15 ml per 30 days) hydrocodone-acetaminophen oral tablet 10-300 PA; ST; QL (120 GM APAP NF mg, 2.5-325 mg, 5-300 mg, 7.5-300 mg COMP per 25 days) hydrocodone-acetaminophen oral tablet 10-325 PA; ST; QL (120 GM APAP 1 mg, 5-325 mg, 7.5-325 mg COMP per 25 days) PA; ST; QL (14 DAY SUPPLY hydrocodone-ibuprofen oral tablet 10-200 mg 2 per 30 days) PA; ST; QL (14 DAY SUPPLY hydrocodone-ibuprofen oral tablet 5-200 mg NF per 30 days) PA; ST; QL (14 DAY SUPPLY hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 per 30 days) PA; ST; QL (14 DAY SUPPLY IBUDONE NF per 30 days) PA; ST; QL (120 GM APAP LORCET (HYDROCODONE) 1 COMP per 25 days) PA; ST; QL (120 GM APAP LORCET HD 1 COMP per 25 days) PA; ST; QL (120 GM APAP LORCET PLUS 1 COMP per 25 days) LORTAB 10-325 1 PA; ST; QL (120 GM per 25 days) LORTAB 5-325 1 PA; ST; QL (120 GM per 25 days) LORTAB 7.5-325 1 PA; ST; QL (120 GM per 25 days) PA; ST; QL (14 DAY SUPPLY LORTAB ELIXIR NF per 30 days) PA; ST; QL (120 GM APAP NORCO NF COMP per 25 days) PA; ST; QL (14 DAY SUPPLY REPREXAIN 2 per 30 days) PA; ST; QL (120 GM APAP VICODIN NF COMP per 25 days) PA; ST; QL (120 GM APAP VICODIN ES NF COMP per 25 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
9 Drug Status Notes PA; ST; QL (120 GM APAP VICODIN HP NF COMP per 25 days) XODOL 10/300 NF PA; ST; QL (120 GM per 25 days) XODOL 5/300 NF PA; ST; QL (120 GM per 25 days) XODOL 7.5/300 NF PA; ST; QL (120 GM per 25 days) PA; ST; QL (14 DAY SUPPLY XYLON 10 2 per 30 days) PA; ST; QL (14 DAY SUPPLY ZAMICET NF per 30 days) Analgesic Opioid Oxycodone And Non- Salicylate Combinations ENDOCET ORAL TABLET 10-325 MG, 2.5- PA; ST; QL (120 GM APAP NF 325 MG, 7.5-325 MG COMP per 25 days) PA; ST; QL (120 GM APAP ENDOCET ORAL TABLET 5-325 MG 2 COMP per 25 days) PA; ST; QL (120 GRAMS per 25 NALOCET NF days) PA; QL (14 day supply per 30 oxycodone-acetaminophen oral solution 3 Dayss) oxycodone-acetaminophen oral tablet 10-325 mg, PA; ST; QL (120 GM APAP NF 7.5-325 mg COMP per 25 days) oxycodone-acetaminophen oral tablet 2.5-300 mg NF PA; QL (120 grams per 25 Dayss) PA; ST; QL (120 GM APAP oxycodone-acetaminophen oral tablet 5-325 mg 2 COMP per 25 days) PA; ST; QL (120 GM APAP PERCOCET NF COMP per 25 days) PA; ST; QL (120 GM APAP PRIMLEV NF COMP per 25 days) PROLATE ORAL SOLUTION NF PA PROLATE ORAL TABLET NF PA; QL (120 grams per 25 Dayss) Analgesic Opioid Oxycodone And Nsaid Combinations PA; ST; QL (14 DAY SUPPLY ibuprofen-oxycodone 2 per 30 days) Analgesic Opioid Oxycodone And Salicylate Combinations PA; ST; QL (14 DAY SUPPLY oxycodone-aspirin NF per 30 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
10 Drug Status Notes Analgesic Opioid Oxycodone Combinations ENDOCET ORAL TABLET 10-325 MG, 2.5- PA; ST; QL (120 GM APAP NF 325 MG, 7.5-325 MG COMP per 25 days) PA; ST; QL (120 GM APAP ENDOCET ORAL TABLET 5-325 MG 2 COMP per 25 days) PA; ST; QL (14 DAY SUPPLY ibuprofen-oxycodone 2 per 30 days) PA; ST; QL (120 GRAMS per 25 NALOCET NF days) PA; QL (14 day supply per 30 oxycodone-acetaminophen oral solution 3 Dayss) oxycodone-acetaminophen oral tablet 10-325 mg, PA; ST; QL (120 GM APAP NF 7.5-325 mg COMP per 25 days) oxycodone-acetaminophen oral tablet 2.5-300 mg NF PA; QL (120 grams per 25 Dayss) PA; ST; QL (120 GM APAP oxycodone-acetaminophen oral tablet 5-325 mg 2 COMP per 25 days) PA; ST; QL (14 DAY SUPPLY oxycodone-aspirin NF per 30 days) PA; ST; QL (120 GM APAP PERCOCET NF COMP per 25 days) PA; ST; QL (120 GM APAP PRIMLEV NF COMP per 25 days) PROLATE ORAL SOLUTION NF PA PROLATE ORAL TABLET NF PA; QL (120 grams per 25 Dayss) Analgesic Opioid Partial-Mixed Agonists BELBUCA NF PA; ST; QL (2 FILMS per 1 day) PA; ST; QL (14 DAY SUPPLY BUPRENEX NF per 30 days) PA; ST; QL (14 DAY SUPPLY buprenorphine hcl injection NF per 30 days) buprenorphine transdermal patch weekly 10 PA; ST; QL (4 PATCHES per 25 3 mcg/hour, 15 mcg/hour, 20 mcg/hour, 5 mcg/hour days) buprenorphine transdermal patch weekly 7.5 PA; ST; QL (4 patches per 25 3 mcg/hour days) PA; ST; QL (14 DAY SUPPLY butorphanol injection solution NF per 30 days) butorphanol injection syringe NF PA; ST; QL (90 MG per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
11 Drug Status Notes PA; ST; QL (3 ML per 1 butorphanol nasal 3 DISPENSE) PA; ST; QL (4 PATCHES per 25 BUTRANS NF days) PA; ST; QL (14 DAY SUPPLY nalbuphine NF per 30 days) PA; ST; QL (14 DAY SUPPLY pentazocine-naloxone 3 per 30 days) TALWIN NF PA; ST; QL (90 MG per 1 day) Analgesic Opioid Tramadol And Non- Salicylate Combinations PA; ST; QL (120 GM APAP tramadol-acetaminophen NF COMP per 25 days) PA; ST; QL (120 GM APAP ULTRACET NF COMP per 25 days) Analgesic Opioid Tramadol Combinations PA; ST; QL (120 GM APAP tramadol-acetaminophen NF COMP per 25 days) PA; ST; QL (120 GM APAP ULTRACET NF COMP per 25 days) Analgesic Or Antipyretic Non- Opioid/Sedative Combinations BUPAP NF butalbital-acetaminophen oral tablet 25-325 mg, NF 50-300 mg butalbital-acetaminophen oral tablet 50-325 mg 1 butalbital-acetaminophen-caff oral tablet 1 CAPACET 3 ESGIC NF FIORICET NF TENCON 1 VANATOL LQ NF VTOL LQ NF ZEBUTAL 3
Last Approved Date: 09/24/2021 Formulary Version: 92
12 Drug Status Notes Anti-Inflammatory - Interleukin-1 Receptor Antagonist PA; ST; BE; QL (4 VIALS per 21 ARCALYST 4 days) Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Non-Seiective PA; ST; SP; BE; QL (8 EA per 21 ENBREL SUBCUTANEOUS RECON SOLN 4 days) ENBREL SUBCUTANEOUS SYRINGE 25 PA; ST; SP; BE; QL (8 4 MG/0.5 ML (0.5) SYRINGES per 21 days) ENBREL SUBCUTANEOUS SYRINGE 50 PA; ST; SP; QL (4 ML per 21 4 MG/ML (1 ML) days) PA; ST; SP; BE; QL (4 ML per 21 ENBREL SURECLICK 4 days) Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Tnf-Alpha Sel PA; ST; SP; BE; QL (1 KIT per 21 CIMZIA 4 days) PA; ST; SP; BE; QL (1 starter kit CIMZIA POWDER FOR RECONST 4 per 365 days) PA; ST; SP; BE; QL (3 UNITS per CIMZIA STARTER KIT 4 274 days) PA; ST; SP; BE; QL (2 units per HUMIRA 4 21 days) PA; ST; SP; QL (1 unit per 274 HUMIRA PEDIATRIC CROHNS START 4 days) PA; ST; SP; BE; QL (2 HUMIRA PEN 4 SYRINGES per 21 days) PA; ST; SP; QL (1 UNIT per 274 HUMIRA PEN CROHNS-UC-HS START 4 days) PA; ST; SP; QL (1 UNIT per 274 HUMIRA PEN PSOR-UVEITS-ADOL HS 4 days) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) 4 days) HUMIRA(CF) PEDI CROHNS STARTER PA; ST; BE; QL (1 unit per 274 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 4 days) ML HUMIRA(CF) PEDI CROHNS STARTER PA; ST; BE; QL (2 syringes per 21 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 4 days) ML-40 MG/0.4 ML
Last Approved Date: 09/24/2021 Formulary Version: 92
13 Drug Status Notes PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN 4 days) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN CROHNS-UC-HS 4 days) PA; ST; BE; QL (1 unit per 274 HUMIRA(CF) PEN PEDIATRIC UC 4 Dayss) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN PSOR-UV-ADOL HS 4 days) PA; ST; SP; BE; QL (1 unit per 21 SIMPONI SUBCUTANEOUS PEN INJECTOR 4 days) PA; ST; SP; BE; QL (1 UNIT per SIMPONI SUBCUTANEOUS SYRINGE 4 21 days) Dmard - Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agents PA; ST; SP; BE; QL (1 KIT per 21 CIMZIA 4 days) PA; ST; SP; BE; QL (1 starter kit CIMZIA POWDER FOR RECONST 4 per 365 days) PA; ST; SP; BE; QL (3 UNITS per CIMZIA STARTER KIT 4 274 days) PA; ST; SP; BE; QL (8 EA per 21 ENBREL SUBCUTANEOUS RECON SOLN 4 days) ENBREL SUBCUTANEOUS SYRINGE 25 PA; ST; SP; BE; QL (8 4 MG/0.5 ML (0.5) SYRINGES per 21 days) ENBREL SUBCUTANEOUS SYRINGE 50 PA; ST; SP; QL (4 ML per 21 4 MG/ML (1 ML) days) PA; ST; SP; BE; QL (4 ML per 21 ENBREL SURECLICK 4 days) PA; ST; SP; BE; QL (2 units per HUMIRA 4 21 days) PA; ST; SP; QL (1 unit per 274 HUMIRA PEDIATRIC CROHNS START 4 days) PA; ST; SP; BE; QL (2 HUMIRA PEN 4 SYRINGES per 21 days) PA; ST; SP; QL (1 UNIT per 274 HUMIRA PEN CROHNS-UC-HS START 4 days) PA; ST; SP; QL (1 UNIT per 274 HUMIRA PEN PSOR-UVEITS-ADOL HS 4 days) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) 4 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
14 Drug Status Notes HUMIRA(CF) PEDI CROHNS STARTER PA; ST; BE; QL (1 unit per 274 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 4 days) ML PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN 4 days) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN CROHNS-UC-HS 4 days) PA; ST; BE; QL (1 unit per 274 HUMIRA(CF) PEN PEDIATRIC UC 4 Dayss) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN PSOR-UV-ADOL HS 4 days) PA; ST; SP; BE; QL (1 unit per 21 SIMPONI SUBCUTANEOUS PEN INJECTOR 4 days) PA; ST; SP; BE; QL (1 UNIT per SIMPONI SUBCUTANEOUS SYRINGE 4 21 days) Dmard - Antimalarials hydroxychloroquine oral tablet 200 mg 2 PLAQUENIL NF Dmard - Antimetabolites methotrexate sodium (pf) injection solution 2 methotrexate sodium injection 3 methotrexate sodium oral 1 OTREXUP (PF) NF PA; ST RASUVO (PF) NF PA; ST REDITREX (PF) NF PA; ST TREXALL NF XATMEP NF Dmard - Antinflammatory, Select. Costimulation Modulator,T-Cell Inhib. PA; ST; SP; BE; QL (4 ORENCIA CLICKJECT NF SYRINGES per 21 days) ORENCIA SUBCUTANEOUS SYRINGE 125 PA; ST; SP; BE; QL (4 4 MG/ML SYRINGES per 21 days) ORENCIA SUBCUTANEOUS SYRINGE 50 PA; ST; BE; QL (4 syringes per 21 4 MG/0.4 ML, 87.5 MG/0.7 ML days) Dmard - Gold Compounds RIDAURA 3
Last Approved Date: 09/24/2021 Formulary Version: 92
15 Drug Status Notes Dmard - Immunosuppressives AZASAN NF azathioprine 3 CELLCEPT NF cyclophosphamide oral capsule 3 cyclophosphamide oral tablet NF cyclosporine modified oral capsule 3 cyclosporine modified oral solution NF cyclosporine oral capsule 3 GENGRAF ORAL CAPSULE 3 GENGRAF ORAL SOLUTION NF IMURAN NF mycophenolate mofetil 3 NEORAL NF SANDIMMUNE ORAL NF Dmard - Interleukin-1 Receptor Antagonist (Il-1Ra) PA; ST; BE; QL (28 SYRINGES KINERET 4 per 21 days) Dmard - Interleukin-6 (Il-6) Receptor Inhibitors, Monoclonal Antibody PA; ST; QL (4 auto-injectors per ACTEMRA ACTPEN 4 21 days) PA; ST; SP; QL (4 SYRINGES ACTEMRA SUBCUTANEOUS 4 per 21 days) KEVZARA SUBCUTANEOUS PEN INJECTOR 4 ST; BE PA; ST; SP; BE; QL (2 KEVZARA SUBCUTANEOUS SYRINGE 4 SYRINGES per 21 days) Dmard - Janus Kinase (Jak) Inhibitors PA; ST; BE; QL (1 TABLET per 1 OLUMIANT NF day) PA; ST; BE; QL (1 TABLET per 1 RINVOQ 4 day) XELJANZ ORAL SOLUTION 4 PA; ST; BE PA; ST; SP; BE; QL (2 TABLETS XELJANZ ORAL TABLET 5 MG 4 per 1 day) XELJANZ XR ORAL TABLET EXTENDED PA; ST; SP; BE; QL (1 TABLET 4 RELEASE 24 HR 11 MG per 1 day) Last Approved Date: 09/24/2021 Formulary Version: 92
16 Drug Status Notes Dmard - Other AZULFIDINE NF AZULFIDINE EN-TABS NF PA; ST; QL (8 tablets/capsules per CUPRIMINE NF 1 day) PA; QL (8 tablets/capsules per 1 DEPEN TITRATABS NF day) D-PENAMINE NF PA; ST; QL (16 tablets per 1 day) MINOCIN NF PA; ST minocycline oral capsule 1 minocycline oral tablet NF PA; ST penicillamine oral capsule 4 PA; BE sulfasalazine 1 Dmard - Phosphodiesterase-4 (Pde4) Inhibitors PA; ST; SP; BE; QL (2 TABLETS OTEZLA 4 per 1 day) PA; ST; SP; BE; QL (1 pack per OTEZLA STARTER 4 23 days) Dmard - Pyrimidine Synthesis Inhibitors ARAVA NF leflunomide 2 Immunomodulator - Rho Kinase Inhibitor REZUROCK NF Immunomodulator B-Lymphocyte Stimulator (Blys)-Specific Inhibitor Mcab PA; ST; SP; BE; QL (4 ML per 21 BENLYSTA SUBCUTANEOUS 4 days) Nsaid Analgesic And Histamine H2 Receptor Antagonist Combinations DUEXIS NF PA; ST ibuprofen-famotidine NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
17 Drug Status Notes Nsaid Analgesic And Prostaglandin Analog Combinations ARTHROTEC 50 NF ARTHROTEC 75 NF diclofenac-misoprostol NF Nsaid Analgesic And Proton Pump Inhibitor Combinations naproxen-esomeprazole NF PA; ST VIMOVO NF PA; ST Nsaid Analgesic, Cyclooxygenase-2 (Cox-2) Selective Inhibitors CELEBREX NF celecoxib oral capsule 100 mg, 200 mg, 50 mg 2 celecoxib oral capsule 400 mg 2 PA; ST Nsaid Analgesics (Cox Non-Specific) - Anthranilic Acid Derivatives meclofenamate 3 PA; ST mefenamic acid 3 PA; ST Nsaid Analgesics (Cox Non-Specific) - Other ketorolac nasal NF PA; ST QL (20 TABLETS per 1 ketorolac oral 2 DISPENSE) nabumetone 2 RELAFEN DS NF PA; ST PA; ST; QL (5 BOTTLES per 1 SPRIX NF DISPENSE) sulindac 1 tolmetin 3 PA; ST Nsaid Analgesics (Cox Non-Specific) - Oxicam Derivatives FELDENE NF meloxicam oral tablet 1 meloxicam submicronized NF MOBIC ORAL TABLET NF piroxicam 3 PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
18 Drug Status Notes QMIIZ ODT NF QL (1 TABLET per 1 day) PA; ST; QL (1 CAPSULE per 1 VIVLODEX NF day) Nsaid Analgesics (Cox Non-Specific) - Phenylacetic Acid Derivatives QL (9 UNITS (1 BOX) per 1 CAMBIA NF DISPENSE) diclofenac potassium 2 diclofenac sodium oral tablet extended release 24 1 hr diclofenac sodium oral tablet,delayed release 2 (dr/ec) 25 mg diclofenac sodium oral tablet,delayed release 1 (dr/ec) 50 mg, 75 mg diclofenac submicronized NF PA; ST; QL (3 capsules per 1 Day) VOLTAREN ORAL NF VOLTAREN-XR NF PA; ST; QL (4 CAPSULES per 1 ZIPSOR NF day) PA; ST; QL (3 CAPSULES per 1 ZORVOLEX NF day) Nsaid Analgesics (Cox Non-Specific) - Propionic Acid Derivatives ANAPROX DS NF DAYPRO NF EC-NAPROSYN NF fenoprofen oral capsule 400 mg NF PA; ST fenoprofen oral tablet 2 PA; ST flurbiprofen 2 ibuprofen oral suspension NF ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 ketoprofen oral capsule 25 mg NF PA; ST ketoprofen oral capsule 50 mg, 75 mg 2 ketoprofen oral capsule,ext rel. pellets 24 hr 200 NF mg NALFON ORAL CAPSULE 400 MG NF PA; ST NALFON ORAL TABLET NF PA; ST NAPRELAN CR NF PA; ST Last Approved Date: 09/24/2021 Formulary Version: 92
19 Drug Status Notes NAPROSYN ORAL SUSPENSION NF PA; ST NAPROSYN ORAL TABLET 500 MG NF naproxen oral suspension 2 naproxen oral tablet 1 naproxen oral tablet,delayed release (dr/ec) 1 naproxen sodium oral tablet 275 mg, 550 mg 1 naproxen sodium oral tablet, er multiphase 24 hr NF PA; ST oxaprozin 3 Nsaid Analgesics (Cyclooxygenase Inhibitors-Non-Selective) QL (9 UNITS (1 BOX) per 1 CAMBIA NF DISPENSE) Nsaid Analgesics, (Cox Non-Specific) - Indole Acetic Acid Derivatives etodolac oral capsule 2 etodolac oral tablet 2 etodolac oral tablet extended release 24 hr NF INDOCIN NF indomethacin oral capsule 1 indomethacin oral capsule, extended release 2 indomethacin submicronized NF PA; ST TIVORBEX NF PA; ST Salicylate Analgesic And Sedative Combinations butalbital-aspirin-caffeine oral capsule 2 FIORINAL NF Salicylate Analgesic Combinations choline,magnesium salicylate 2 Salicylate Analgesics ADULT LOW DOSE ASPIRIN $0 ASPIR-81 $0 ASPIRIN CHILDRENS $0 ASPIRIN LOW DOSE $0 aspirin oral tablet $0 aspirin oral tablet,chewable $0
Last Approved Date: 09/24/2021 Formulary Version: 92
20 Drug Status Notes aspirin oral tablet,delayed release (dr/ec) 325 $0 mg, 81 mg ASPIR-LOW $0 ASPIR-TRIN $0 BAYER ASPIRIN $0 BAYER CHEWABLE ASPIRIN NF CHILDREN'S ASPIRIN $0 diflunisal 2 DISALCID NF DURLAZA NF QL (1 CAPSULE per 1 day) E.C. PRIN $0 ECOTRIN $0 ECOTRIN LOW STRENGTH $0 ENTERIC COATED ASPIRIN $0 LITE COAT ASPIRIN $0 LO-DOSE ASPIRIN $0 salsalate NF Anesthetics General Anesthetic - Parenteral, Benzodiazepines midazolam in 0.9 % sod chlorid intravenous NF prefilled pump reservoir General Anesthetic Adjuncts - Opioid PA; ST; QL (14 DAY SUPPLY sufentanil citrate NF per 30 days) sufentanil citrate (pf) NF PA; ST Local Anesthetic - Amides lidocaine topical ointment NF PA; QL (50 GM per 30 days) Anorectal Preparations Anal Fissure Pain/Treatment Agents - Nitrates RECTIV 3 Anorectal - Glucocorticoids ANUCORT-HC NF ANUSOL-HC RECTAL SUPPOSITORY NF
Last Approved Date: 09/24/2021 Formulary Version: 92
21 Drug Status Notes HEMMOREX-HC RECTAL SUPPOSITORY 25 3 MG HEMMOREX-HC RECTAL SUPPOSITORY 30 2 MG hydrocortisone acetate rectal suppository 25 mg 3 hydrocortisone acetate rectal suppository 30 mg 2 PROCTOCORT RECTAL NF PROCTO-PAK 3 PROCTOZONE-HC 1 Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb ANA-LEX KIT NF ANALPRAM-HC RECTAL NF hydrocortisone-pramoxine rectal 2 lidocaine hcl-hydrocortison ac rectal cream NF lidocaine hcl-hydrocortison ac rectal gel NF lidocaine-hydrocortisone-aloe rectal gel 2 PRAMCORT 2 PROCORT NF PROCTOFOAM HC 3 Antidotes And Other Reversal Agents Antidote - Acetaminophen Poisoning acetylcysteine 2 Antidote Others GALZIN NF Chelating Agents - Copper PA; ST; QL (8 tablets/capsules per CUPRIMINE NF 1 day) PA; QL (8 tablets/capsules per 1 DEPEN TITRATABS NF day) D-PENAMINE NF PA; ST; QL (16 tablets per 1 day) penicillamine oral capsule 4 PA; BE PA; ST; BE; QL (8 capsules per 1 SYPRINE NF day) Chelating Agents - Iron deferasirox oral granules in packet NF PA; ST; BE
Last Approved Date: 09/24/2021 Formulary Version: 92
22 Drug Status Notes deferasirox oral tablet 180 mg 4 PA; ST deferasirox oral tablet 360 mg, 90 mg 4 PA; ST; BE deferasirox oral tablet, dispersible 4 PA deferiprone NF PA; ST EXJADE NF PA; ST; SP; BE FERRIPROX ORAL SOLUTION 3 PA; ST; BE PA; ST; BE; QL (9 tablets per 1 FERRIPROX ORAL TABLET NF day) JADENU NF PA; ST; SP; BE JADENU SPRINKLE NF PA; ST; SP; BE Chelating Agents - Lead Poisoning CHEMET 2 Mu-Opioid Receptor Antagonists, Peripherally-Acting alvimopan NF ENTEREG NF MOVANTIK NF QL (1 TABLET per 1 day) PA; ST; QL (3 TABLETS per 1 RELISTOR ORAL NF day) RELISTOR SUBCUTANEOUS SOLUTION NF PA; ST; QL (1 Syringe per 1 day) RELISTOR SUBCUTANEOUS SYRINGE NF PA; ST; QL (1 Syringe per 1 day) SYMPROIC 3 QL (1 TABLET per 1 day) Opioid Reversal Agents - Opioid Antagonists EVZIO NF PA; ST KLOXXADO 2 naloxone injection auto-injector NF naloxone injection solution 1 naloxone injection syringe 1 naltrexone 1 NARCAN 2 Anti-Infective Agents Amebicides paromomycin NF Aminoglycoside Antibiotic ARIKAYCE NF PA; BE; QL (236 ml per 21 days) Last Approved Date: 09/24/2021 Formulary Version: 92
23 Drug Status Notes neomycin 1 Aminomethylcycline Antibiotics QL (30 TABLETS per 1 NUZYRA (7 DAY WITH LOAD DOSE) NF DISPENSE) QL (30 TABLETS per 1 NUZYRA (7 DAY) NF DISPENSE) QL (30 TABLETS per 1 NUZYRA ORAL NF DISPENSE) Aminopenicillin Antibiotic amoxicillin oral capsule 1 amoxicillin oral suspension for reconstitution 1 amoxicillin oral tablet 1 amoxicillin oral tablet,chewable 125 mg, 250 mg 1 ampicillin oral capsule 1 MOXATAG NF Aminopenicillin Antibiotic - Beta- Lactamase Inhibitor Combinations amoxicillin-pot clavulanate oral suspension for 2 reconstitution amoxicillin-pot clavulanate oral tablet 2 amoxicillin-pot clavulanate oral tablet extended NF release 12 hr amoxicillin-pot clavulanate oral tablet,chewable 2 AUGMENTIN NF AUGMENTIN ES-600 NF AUGMENTIN XR NF Anthelmintic Agents - Benzimidazole Derivatives albendazole 3 ALBENZA NF EMVERM 4 Anthelmintic Agents - Macrocyclic Lactones ivermectin oral 2 STROMECTOL NF Anthelmintic Agents Other BILTRICIDE NF Last Approved Date: 09/24/2021 Formulary Version: 92
24 Drug Status Notes praziquantel 3 Antibacterial Folate Antagonist - Other Combinations BACTRIM NF BACTRIM DS NF sulfamethoxazole-trimethoprim intravenous NF sulfamethoxazole-trimethoprim oral suspension NF sulfamethoxazole-trimethoprim oral tablet 1 SULFATRIM 1 Antibacterial Folate Antagonist Others trimethoprim 1 Antibacterial Nitrofuran Derivatives FURADANTIN NF MACROBID NF MACRODANTIN NF nitrofurantoin 3 nitrofurantoin macrocrystal oral capsule 100 mg, 1 50 mg nitrofurantoin macrocrystal oral capsule 25 mg NF nitrofurantoin monohyd/m-cryst 1 Antibacterial Other fosfomycin tromethamine 3 MONUROL NF Antifungal - Allylamines terbinafine hcl oral 1 QL (22500 MG per 180 days) Antifungal - Amphoteric Polyene Macrolides nystatin oral tablet 1 Antifungal - Fluorinated Pyrimidine- Type Agents ANCOBON NF PA; ST flucytosine 3 Antifungal - Glucan Synthesis Inhibitor, Triterpenoid PA; ST; QL (1 pack (4 tablets) per BREXAFEMME NF 1 dispensing event) Last Approved Date: 09/24/2021 Formulary Version: 92
25 Drug Status Notes Antifungal - Glucan Synthesis Inhibitors PA; ST; QL (1 pack (4 tablets) per BREXAFEMME NF 1 dispensing event) Antifungal - Imidazoles ketoconazole oral 3 ORAVIG 3 Antifungal - Triazoles CRESEMBA ORAL NF DIFLUCAN NF fluconazole 1 itraconazole oral capsule 2 QL (18000 MG per 180 days) itraconazole oral solution NF QL (18000 MG per 180 days) NOXAFIL ORAL NF PA; ST ONMEL NF QL (18000 MG per 180 days) posaconazole 3 PA; ST SPORANOX ORAL SOLUTION NF QL (18000 MG per 180 days) SPORANOX PULSEPAK NF QL (18000 MG per 180 days) PA; ST; BE; QL (120 CAPSULES TOLSURA NF per 25 days) VFEND NF voriconazole oral 3 Antifungal Other griseofulvin microsize 3 griseofulvin ultramicrosize 3 Anti-Infective Immunologic Adjuvants - Interferons ACTIMMUNE 4 PA; SP; BE Antileprotic - Immunomodulators PA; SP; BE; QL (1 CAPSULE per THALOMID ORAL CAPSULE 100 MG, 50 MG 4 1 day) THALOMID ORAL CAPSULE 150 MG, 200 PA; SP; BE; QL (2 CAPSULES 4 MG per 1 day) Antileprotic - Sulfone Agents dapsone oral 3
Last Approved Date: 09/24/2021 Formulary Version: 92
26 Drug Status Notes Antimalarial Combinations PA; QL (12 TABLETS per 180 atovaquone-proguanil 2 days) PA; QL (24 TABLETS per 180 COARTEM 3 days) PA; QL (12 TABLETS per 180 MALARONE NF days) PA; QL (12 TABLETS per 180 MALARONE PEDIATRIC NF days) Antimalarials ARAKODA NF PA chloroquine phosphate 1 DARAPRIM NF PA; ST hydroxychloroquine oral tablet 200 mg 2 KRINTAFEL NF PA mefloquine 1 PLAQUENIL NF primaquine 2 pyrimethamine 4 PA; ST PA; QL (42 CAPSULES per 180 QUALAQUIN NF days) PA; QL (42 CAPSULES per 180 quinine sulfate 2 days) Antiprotozoal Agents - Nitrofuran Derivatives LAMPIT NF PA Antiprotozoal Agents - Nitroimidazole Derivatives PA; QL (60 DAY SUPPLY per benznidazole NF 720 days) Antiprotozoal Agents - Other atovaquone 3 MEPRON NF Antiprotozoal Agents (Antiparasitic) - 5-Nitrothiazolyl Derivatives ALINIA ORAL SUSPENSION FOR 4 RECONSTITUTION
Last Approved Date: 09/24/2021 Formulary Version: 92
27 Drug Status Notes ALINIA ORAL TABLET NF nitazoxanide 4 Antiprotozoal-Antibacterial 1St Generation 2-Methyl-5-Nitroimidazole FLAGYL NF metronidazole oral capsule NF metronidazole oral tablet 1 Antiprotozoal-Antibacterial 2Nd Generation 2-Methyl-5-Nitroimidazole SOLOSEC NF QL (1 packet per 30 days) TINDAMAX NF tinidazole 3 Antiretroviral - Ccr5 Co-Receptor Antagonist SELZENTRY ORAL SOLUTION 3 QL (920 mL per 1 MONTH) SELZENTRY ORAL TABLET 150 MG, 25 MG, 3 QL (2 TABLETS per 1 day) 75 MG SELZENTRY ORAL TABLET 300 MG 3 QL (4 TABLETS per 1 day) Antiretroviral - Cd4 Attachment Inhibitors RUKOBIA NF Antiretroviral - Hiv-1 Fusion Inhibitors FUZEON SUBCUTANEOUS RECON SOLN NF SP; QL (2 vials per 1 day) Antiretroviral - Hiv-1 Integrase Strand Transfer Inhibitors ISENTRESS HD 3 QL (2 TABLETS per 1 day) QL (1 box (60 packets) per 25 ISENTRESS ORAL POWDER IN PACKET NF days) ISENTRESS ORAL TABLET 3 QL (4 TABLETS per 1 day) ISENTRESS ORAL TABLET,CHEWABLE 3 QL (6 TABLETS per 1 day) TIVICAY 3 QL (2 TABLETS per 1 day) TIVICAY PD 3 QL (6 tablets per 1 day) Antiretroviral - Integrase Inhibitor And Nnrti Combinations JULUCA 3 QL (1 TABLET per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
28 Drug Status Notes Antiretroviral - Integrase Inhibitor And Nrti Combinations DOVATO 3 QL (1 TABLET per 1 day) Antiretroviral - Non-Nucleoside Reverse Transcriptase Inhib (Nnrti) EDURANT 3 QL (2 TABLETS per 1 day) efavirenz oral capsule 3 QL (3 CAPSULES per 1 day) etravirine NF QL (2 tablets per 1 Day) INTELENCE ORAL TABLET 100 MG, 200 MG NF QL (2 TABLETS per 1 day) INTELENCE ORAL TABLET 25 MG NF QL (4 TABLETS per 1 day) nevirapine oral suspension NF QL (5 BOTTLES per 25 days) nevirapine oral tablet NF QL (2 TABLETS per 1 day) nevirapine oral tablet extended release 24 hr 100 NF QL (3 TABLETS per 1 day) mg nevirapine oral tablet extended release 24 hr 400 NF QL (1 TABLET per 1 day) mg PIFELTRO NF QL (2 TABLETS per 1 day) RESCRIPTOR ORAL TABLET NF QL (6 TABLETS per 1 day) RESCRIPTOR ORAL TABLET, DISPERSIBLE NF QL (12 TABLETS per 1 day) SUSTIVA ORAL CAPSULE NF QL (3 CAPSULES per 1 day) SUSTIVA ORAL TABLET NF QL (1 TABLET per 1 day) VIRAMUNE ORAL SUSPENSION NF QL (5 BOTTLES per 25 days) VIRAMUNE ORAL TABLET NF QL (2 TABLETS per 1 day) VIRAMUNE XR ORAL TABLET EXTENDED NF QL (3 TABLETS per 1 day) RELEASE 24 HR 100 MG VIRAMUNE XR ORAL TABLET EXTENDED NF QL (1 TABLET per 1 day) RELEASE 24 HR 400 MG Antiretroviral - Nucleoside And Nucleotide Analog Rtis Combinations CIMDUO 3 QL (1 TABLET per 1 day) DESCOVY 3 QL (1 TABLET per 1 day) emtricitabine-tenofovir (tdf) 3 QL (1 tablet per 1 Day) TEMIXYS 3 QL (1 TABLET per 1 day) PA; ST; QL (1 TABLET per 1 TRUVADA NF day)
Last Approved Date: 09/24/2021 Formulary Version: 92
29 Drug Status Notes Antiretroviral - Nucleoside Reverse Transcriptase Inhibitors (Nrti) abacavir oral solution 3 QL (4 BOTTLES per 25 days) abacavir oral tablet 3 QL (2 TABLETS per 1 day) didanosine 3 QL (1 CAPSULE per 1 day) emtricitabine NF QL (1 capsule per 1 Day) EMTRIVA ORAL CAPSULE NF QL (1 CAPSULE per 1 day) EMTRIVA ORAL SOLUTION NF QL (5 BOTTLES per 25 days) EPIVIR ORAL SOLUTION NF QL (4 BOTTLES per 25 days) EPIVIR ORAL TABLET 150 MG NF QL (2 TABLETS per 1 day) EPIVIR ORAL TABLET 300 MG NF QL (1 TABLET per 1 day) lamivudine oral solution 2 QL (4 BOTTLES per 25 days) lamivudine oral tablet 150 mg 2 QL (2 TABLETS per 1 day) lamivudine oral tablet 300 mg 2 QL (1 TABLET per 1 day) RETROVIR ORAL CAPSULE NF QL (6 CAPSULES per 1 day) RETROVIR ORAL SYRUP NF QL (8 BOTTLES per 25 days) stavudine oral capsule 2 QL (2 CAPSULES per 1 day) VIDEX 2 GRAM PEDIATRIC 3 QL (6 BOTTLES per 25 days) VIDEX EC NF QL (1 CAPSULE per 1 day) ZERIT ORAL CAPSULE 15 MG, 20 MG, 40 NF QL (2 CAPSULES per 1 day) MG ZERIT ORAL CAPSULE 30 MG NF ZERIT ORAL RECON SOLN NF ZIAGEN ORAL SOLUTION NF QL (4 BOTTLES per 25 days) ZIAGEN ORAL TABLET NF QL (2 TABLETS per 1 day) zidovudine oral capsule 2 QL (6 CAPSULES per 1 day) zidovudine oral syrup 3 QL (8 BOTTLES per 25 days) zidovudine oral tablet 2 QL (2 TABLETS per 1 day) Antiretroviral - Nucleotide Analog Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate 3 QL (1 TABLET per 1 day) VIREAD ORAL POWDER NF QL (4 BOTTLES per 25 days) VIREAD ORAL TABLET NF QL (1 TABLET per 1 day) Antiretroviral Combinations - Protease Inhibitors EVOTAZ 3 QL (1 TABLET per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
30 Drug Status Notes KALETRA ORAL SOLUTION NF QL (2 BOTTLES per 25 days) KALETRA ORAL TABLET 100-25 MG NF QL (2 TABLETS per 1 day) KALETRA ORAL TABLET 200-50 MG NF QL (4 TABLETS per 1 day) lopinavir-ritonavir oral solution 3 QL (2 BOTTLES per 25 days) lopinavir-ritonavir oral tablet 100-25 mg 3 QL (2 tablets per 1 Day) lopinavir-ritonavir oral tablet 200-50 mg 3 QL (4 tablets per 1 Day) PREZCOBIX 3 QL (1 TABLET per 1 day) Antiretroviral- Nucleoside And Nucleotide Analogs,Protease Inhibitors SYMTUZA 3 QL (1 TABLET per 1 day) Antiretroviral-Integrase Inhibitor,Nucleoside And Nucleotide Rtis Comb BIKTARVY 3 QL (1 TABLET per 1 day) GENVOYA 3 QL (1 TABLET per 1 day) STRIBILD 3 QL (1 TABLET per 1 day) Antiretroviral-Nucleoside Analogs And Integrase Inhibitor Combinations TRIUMEQ 3 QL (1 TABLET per 1 day) Antiretroviral-Nucleoside Reverse Transcriptase Inhibitors (Nrti) Comb abacavir-lamivudine 2 QL (1 TABLET per 1 day) abacavir-lamivudine-zidovudine 2 QL (2 TABLETS per 1 day) COMBIVIR NF QL (2 TABLETS per 1 day) EPZICOM NF QL (1 TABLET per 1 day) lamivudine-zidovudine 2 QL (2 TABLETS per 1 day) TRIZIVIR NF QL (2 TABLETS per 1 day) Antiretroviral-Nucleoside, Nucleotide Analogs And Non-Nucleoside Rti ATRIPLA NF QL (1 TABLET per 1 day) COMPLERA 3 QL (1 TABLET per 1 day) DELSTRIGO NF QL (1 TABLET per 1 day) efavirenz-emtricitabin-tenofov 3 QL (1 tablet per 1 Day) efavirenz-lamivu-tenofov disop 3 QL (1 tablet per 1 Day) ODEFSEY 3 QL (1 TABLET per 1 day) SYMFI NF QL (1 TABLET per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
31 Drug Status Notes SYMFI LO NF QL (1 TABLET per 1 day) Antitubercular - Aminobenzoic Acid Analogs PASER 3 Antitubercular - D-Alanine Analogs cycloserine 3 Antitubercular - Diarylquinoline Antibiotics SIRTURO 4 Antitubercular - Isonicotinic Acid Derivatives isoniazid oral solution 3 isoniazid oral tablet 1 Antitubercular - Niacinamide Derivatives pyrazinamide 2 Antitubercular - Nitroimidazole Derivatives pretomanid NF QL (1 TABLET per 1 day) Antitubercular - Rifamycin And Derivatives MYCOBUTIN NF PRIFTIN 2 rifabutin 3 RIFADIN ORAL NF rifampin oral 1 Antitubercular Agents Other ethambutol 1 MYAMBUTOL ORAL TABLET 400 MG NF TRECATOR 3 Antitubercular Combinations RIFAMATE NF RIFATER 3 Carbapenem Antibiotic Combinations imipenem-cilastatin intravenous recon soln 250 3 mg Last Approved Date: 09/24/2021 Formulary Version: 92
32 Drug Status Notes Carbapenem Antibiotics (Thienamycins) ertapenem 3 INVANZ INJECTION NF meropenem intravenous recon soln 500 mg 3 Cephalosporin Antibiotics - 1St Generation cefadroxil oral capsule 1 cefadroxil oral suspension for reconstitution 250 1 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 cephalexin oral capsule 250 mg, 500 mg 1 cephalexin oral capsule 750 mg NF cephalexin oral suspension for reconstitution 1 cephalexin oral tablet 1 KEFLEX ORAL CAPSULE NF Cephalosporin Antibiotics - 2Nd Generation cefaclor oral capsule 1 cefaclor oral suspension for reconstitution 250 NF mg/5 ml, 375 mg/5 ml cefaclor oral tablet extended release 12 hr 1 cefprozil 1 cefuroxime axetil oral tablet 1 Cephalosporin Antibiotics - 3Rd Generation cefdinir 1 cefditoren pivoxil 3 cefixime NF cefpodoxime 2 SPECTRACEF ORAL TABLET 400 MG NF SUPRAX ORAL CAPSULE NF SUPRAX ORAL SUSPENSION FOR 3 RECONSTITUTION 100 MG/5 ML SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 200 MG/5 ML, 500 MG/5 NF ML
Last Approved Date: 09/24/2021 Formulary Version: 92
33 Drug Status Notes SUPRAX ORAL TABLET,CHEWABLE NF Cmv Antiviral Agent - Nucleoside Analogs VALCYTE NF valganciclovir oral recon soln NF valganciclovir oral tablet 3 Cmv Antiviral Agent - Terminase Complex Inhibitors PREVYMIS NF QL (100 TABLETS per 365 days) Fluoroquinolone Antibiotics AVELOX NF QL (28 TABLETS per 1 BAXDELA ORAL NF DISPENSE) CIPRO ORAL NF SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET 250 MG, 500 MG NF CIPRO XR NF ciprofloxacin 2 ciprofloxacin (mixture) 2 ciprofloxacin hcl oral tablet 100 mg 2 ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 1 mg FACTIVE 3 LEVAQUIN ORAL TABLET 500 MG, 750 MG NF levofloxacin oral solution 3 levofloxacin oral tablet 1 moxifloxacin oral 2 ofloxacin oral tablet 400 mg 1 Glycopeptide Antibiotics FIRVANQ 3 QL (2100 ML per 180 days) VANCOCIN NF QL (141 capsules per 180 days) vancomycin intravenous recon soln 10 gram, 500 3 mg vancomycin oral capsule 3 QL (141 capsules per 180 days) vancomycin oral recon soln 1 QL (2100 ML per 180 Dayss)
Last Approved Date: 09/24/2021 Formulary Version: 92
34 Drug Status Notes Hepatitis B Treatment- Nucleoside Analogs (Antiviral) BARACLUDE ORAL SOLUTION 3 SP; BE BARACLUDE ORAL TABLET NF SP; BE entecavir 4 SP; BE EPIVIR HBV ORAL SOLUTION NF QL (4 BOTTLES per 25 days) EPIVIR HBV ORAL TABLET NF lamivudine oral tablet 100 mg 4 Hepatitis B Treatment- Nucleotide Analogs (Antiviral) adefovir 3 SP HEPSERA NF SP tenofovir disoproxil fumarate 3 QL (1 TABLET per 1 day) VIREAD ORAL POWDER NF QL (4 BOTTLES per 25 days) VIREAD ORAL TABLET NF QL (1 TABLET per 1 day) Hepatitis C - Interferons PEGASYS 4 PA; ST; SP; BE PEGASYS PROCLICK 4 PA; ST; SP; BE PEGINTRON SUBCUTANEOUS KIT 50 4 PA; SP; BE MCG/0.5 ML Hepatitis C - Ns3/4A Serine Protease Inhibitors OLYSIO 1 BE Hepatitis C - Ns5a Inhibitor And Ns3/4A Protease Inhibitor Combination PA; SP; BE; QL (84 TABLETS MAVYRET 4 per 1 DISPENSE) PA; ST; SP; QL (84 DAY ZEPATIER NF SUPPLY per 720 days) Hepatitis C - Ns5a, Ns3/4A Protease, Nucleo.Ns5b Polymerase Inhib Comb PA; ST; SP; BE; QL (84 DAY VOSEVI NF SUPPLY per 720 days) Hepatitis C - Ns5b Polymerase And Ns5a Inhibitor Combinations PA; BE; QL (84 day supply per EPCLUSA ORAL TABLET 200-50 MG 4 720 Dayss)
Last Approved Date: 09/24/2021 Formulary Version: 92
35 Drug Status Notes PA; ST; SP; BE; QL (84 DAY EPCLUSA ORAL TABLET 400-100 MG 4 SUPPLY per 720 days) PA; BE; QL (28 tablets per 21 HARVONI ORAL PELLETS IN PACKET 4 Dayss) PA; QL (28 TABLETS per 21 HARVONI ORAL TABLET 45-200 MG 4 days) PA; SP; BE; QL (28 TABLETS HARVONI ORAL TABLET 90-400 MG 4 per 21 days) PA; BE; QL (28 TABLETS per 1 ledipasvir-sofosbuvir 4 DISPENSE) PA; BE; QL (84 DAY SUPPLY sofosbuvir-velpatasvir 4 per 720 days) Hepatitis C - Nucleos(T)Ide Analog Ns5b Polymerase Inhibitors PA; ST; BE; QL (28 tablets per 21 SOVALDI ORAL PELLETS IN PACKET NF Dayss) PA; ST; BE; QL (28 TABLETS SOVALDI ORAL TABLET 200 MG NF per 21 days) PA; SP; BE; QL (28 TABLETS SOVALDI ORAL TABLET 400 MG NF per 21 days) Hepatitis C - Nucleoside Analogs MODERIBA 4 SP MODERIBA DOSE PACK 4 REBETOL ORAL SOLUTION 1 SP; BE RIBASPHERE 4 SP; BE RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG 4 SP (28), 400-400 MG (28)-MG (28), 600-400 MG (28)-MG (28), 600-600 MG (28)-MG (28) RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 200 MG (7)- 400 MG 4 SP; BE (7), 400 MG (7)- 400 MG (7), 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7) ribavirin oral capsule 4 SP ribavirin oral tablet 200 mg 4 SP Hepatitis C- Ns5a, Ns3/4A Protease And Non-Nucleo.Ns5b Poly Inh. Comb PA; ST; SP; BE; QL (112 VIEKIRA PAK 4 TABLETS per 21 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
36 Drug Status Notes PA; ST; SP; BE; QL (84 DAY VIEKIRA XR 4 SUPPLY per 720 days) Herpes Antiviral Agent - Purine Analogs acyclovir oral capsule 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 1 SITAVIG NF PA; ST valacyclovir 1 VALTREX NF ZOVIRAX ORAL NF Herpes Antiviral Agent - Thymidine Analogs famciclovir 2 Influenza Antiviral Agents - Neuraminidase Inhibitors QL (20 CAPSULES per 1 oseltamivir oral capsule 30 mg 3 DISPENSE) QL (10 CAPSULES per 1 oseltamivir oral capsule 45 mg, 75 mg 3 DISPENSE) oseltamivir oral suspension for reconstitution 3 QL (180 ML per 1 DISPENSE) RELENZA DISKHALER 3 QL (20 UNITS per 1 DISPENSE) QL (20 CAPSULES per 3 TAMIFLU ORAL CAPSULE 30 MG NF MONTHs) QL (10 CAPSULES per 3 TAMIFLU ORAL CAPSULE 45 MG NF MONTHs) QL (10 CAPSULES per 1 TAMIFLU ORAL CAPSULE 75 MG NF DISPENSE) TAMIFLU ORAL SUSPENSION FOR NF QL (180 ML per 1 DISPENSE) RECONSTITUTION Influenza Antiviral Agents - Pa Endonuclease Inhibitor QL (2 TABLETS per 1 XOFLUZA ORAL TABLET 20 MG, 40 MG 3 DISPENSE) QL (1 tablet per 1 dispensing XOFLUZA ORAL TABLET 80 MG 3 event) Influenza-A Antiviral Agents FLUMADINE ORAL TABLET NF
Last Approved Date: 09/24/2021 Formulary Version: 92
37 Drug Status Notes rimantadine 2 Lincosamide Antibiotics CLEOCIN HCL NF CLEOCIN PEDIATRIC NF clindamycin hcl 1 clindamycin palmitate hcl 3 Macrolide Antibiotics azithromycin oral packet 3 azithromycin oral suspension for reconstitution 1 azithromycin oral tablet 1 clarithromycin oral suspension for reconstitution 1 clarithromycin oral tablet 1 clarithromycin oral tablet extended release 24 hr 2 DIFICID ORAL SUSPENSION FOR PA; ST; BE; QL (150 ML per 180 4 RECONSTITUTION Dayss) PA; ST; BE; QL (20 tablets per DIFICID ORAL TABLET 4 180 days) E.E.S. 400 ORAL TABLET 1 E.E.S. GRANULES NF ERYPED 200 NF ERYPED 400 NF ERY-TAB ORAL TABLET,DELAYED 1 RELEASE (DR/EC) 250 MG, 333 MG ERY-TAB ORAL TABLET,DELAYED NF RELEASE (DR/EC) 500 MG ERYTHROCIN (AS STEARATE) ORAL 1 TABLET 250 MG erythromycin ethylsuccinate oral suspension for 3 reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 1 erythromycin oral capsule,delayed release(dr/ec) NF erythromycin oral tablet NF erythromycin oral tablet,delayed release (dr/ec) 1 250 mg, 333 mg erythromycin oral tablet,delayed release (dr/ec) NF 500 mg ZITHROMAX ORAL NF
Last Approved Date: 09/24/2021 Formulary Version: 92
38 Drug Status Notes Misc Anti-Infective HIPREX NF methenamine mandelate oral tablet 0.5 g 3 methenamine mandelate oral tablet 1 gram 2 NEBUPENT NF pentamidine inhalation 2 UROQID-ACID NO.2 NF Misc Anti-Infective Combinations HYOPHEN NF PHOSPHASAL NF UR N-C NF URELLE NF URETRON D-S NF URIBEL NF URIMAR-T NF URIN DS NF UROGESIC-BLUE NF URO-MP NF URYL NF USTELL NF UTA NF UTIRA-C NF Oxazolidinone Antibiotics linezolid oral suspension for reconstitution 4 PA; QL (900 ML per 180 days) PA; QL (28 TABLETS per 180 linezolid oral tablet 4 days) QL (6 TABLETS per 1 SIVEXTRO ORAL NF DISPENSE) ZYVOX ORAL SUSPENSION FOR NF PA; QL (900 ML per 180 days) RECONSTITUTION PA; QL (28 CAPSULES per 180 ZYVOX ORAL TABLET NF days) Penicillin Antibiotic - Natural penicillin v potassium 1
Last Approved Date: 09/24/2021 Formulary Version: 92
39 Drug Status Notes Penicillin Antibiotic - Penicillinase- Resistant dicloxacillin 1 Pleuromutilin Antibiotics XENLETA ORAL NF QL (2 TABLETS per 1 day) Protease Inhibitors (Non-Peptidic) Antiretroviral APTIVUS NF QL (4 CAPSULES per 1 day) APTIVUS (WITH VITAMIN E) NF QL (4 BOTTLES per 25 days) PREZCOBIX 3 QL (1 TABLET per 1 day) PREZISTA ORAL SUSPENSION 3 QL (2 BOTTLES per 25 days) PREZISTA ORAL TABLET 150 MG 3 QL (6 TABLETS per 1 day) PREZISTA ORAL TABLET 600 MG 3 QL (2 TABLETS per 1 day) PREZISTA ORAL TABLET 75 MG, 800 MG 3 QL (1 TABLET per 1 day) Protease Inhibitors (Peptidic) Antiretroviral atazanavir oral capsule 150 mg, 300 mg 3 QL (1 CAPSULE per 1 day) atazanavir oral capsule 200 mg 3 QL (2 CAPSULES per 1 day) CRIXIVAN ORAL CAPSULE 200 MG NF QL (3 TABLETS per 1 day) CRIXIVAN ORAL CAPSULE 400 MG NF QL (6 TABLETS per 1 day) EVOTAZ 3 QL (1 TABLET per 1 day) fosamprenavir 3 QL (4 TABLETS per 1 day) INVIRASE ORAL CAPSULE 3 INVIRASE ORAL TABLET 3 QL (4 TABLETS per 1 day) LEXIVA ORAL SUSPENSION 3 QL (8 BOTTLES per 25 days) LEXIVA ORAL TABLET NF QL (4 TABLETS per 1 day) NORVIR ORAL POWDER IN PACKET NF QL (60 packets per 25 days) NORVIR ORAL SOLUTION 3 QL (2 BOTTLES per 25 days) NORVIR ORAL TABLET NF QL (12 TABLETS per 1 day) REYATAZ ORAL CAPSULE 150 MG, 300 MG NF QL (1 CAPSULE per 1 day) REYATAZ ORAL CAPSULE 200 MG NF QL (2 CAPSULES per 1 day) REYATAZ ORAL POWDER IN PACKET NF QL (6 PACKETS per 1 MONTH) ritonavir 3 QL (12 TABLETS per 1 day) VIRACEPT ORAL TABLET 250 MG NF QL (9 TABLETS per 1 day) VIRACEPT ORAL TABLET 625 MG NF QL (4 TABLETS per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
40 Drug Status Notes Respiratory Syncytial Virus (Rsv) Antiviral Agents VIRAZOLE NF Rifamycins And Related Derivative Antibiotics AEMCOLO 3 QL (12 TABLETS per 90 days) MYCOBUTIN NF PRIFTIN 2 rifabutin 3 RIFADIN ORAL NF rifampin oral 1 QL (9 TABLETS per 1 XIFAXAN ORAL TABLET 200 MG 3 DISPENSE) XIFAXAN ORAL TABLET 550 MG 4 PA; ST Sulfonamide Antibiotic sulfadiazine 3 Tetracycline Antibiotics ACTICLATE NF PA; ST AVIDOXY 2 demeclocycline 3 DORYX MPC NF PA; ST DORYX ORAL TABLET,DELAYED NF PA; ST RELEASE (DR/EC) 200 MG, 50 MG, 80 MG doxycycline hyclate intravenous NF doxycycline hyclate oral capsule 1 doxycycline hyclate oral tablet 100 mg, 50 mg 3 doxycycline hyclate oral tablet 150 mg, 75 mg NF doxycycline hyclate oral tablet,delayed release NF (dr/ec) 100 mg, 150 mg, 75 mg doxycycline monohydrate oral capsule 150 mg, NF 75 mg doxycycline monohydrate oral capsule,ir - delay NF rel,biphase doxycycline monohydrate oral suspension for 3 reconstitution doxycycline monohydrate oral tablet 100 mg, 150 2 mg, 75 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
41 Drug Status Notes doxycycline monohydrate oral tablet 50 mg 1 MINOCIN NF PA; ST minocycline oral capsule 1 minocycline oral capsule,extended release 24hr NF PA; ST minocycline oral tablet NF PA; ST minocycline oral tablet extended release 24 hr NF PA; ST MINOLIRA ER NF PA; ST MONDOXYNE NL NF MONODOX NF PA; ST MORGIDOX ORAL CAPSULE 100 MG 1 QL (30 TABLETS per 1 NUZYRA (7 DAY WITH LOAD DOSE) NF DISPENSE) QL (30 TABLETS per 1 NUZYRA (7 DAY) NF DISPENSE) QL (30 TABLETS per 1 NUZYRA ORAL NF DISPENSE) ORACEA NF SEYSARA NF PA; ST SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 NF PA; ST; BE MG, 80 MG TARGADOX NF PA; ST tetracycline 2 VIBRAMYCIN ORAL CAPSULE 100 MG NF PA; ST VIBRAMYCIN ORAL SUSPENSION FOR NF PA; ST RECONSTITUTION VIBRAMYCIN ORAL SYRUP NF PA; ST Antineoplastics Antineoplasic-Epiderm.Growth Factor- Egfr (Erbb1),Her-2 (Erbb2)R.Inhib PA; ST; BE; QL (6 tablets per 1 lapatinib 4 Day) PA; ST; SP; BE; QL (6 TABLETS TYKERB NF per 1 day) Antineoplastic - Cyp17 (17 Alpha- Hydroxylase/C17,20-Lyase) Inhibitor PA; BE; QL (4 TABLETS per 1 abiraterone oral tablet 250 mg 4 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
42 Drug Status Notes PA; ST; BE; QL (2 tablets per 1 abiraterone oral tablet 500 mg NF day) PA; ST; BE; QL (4 TABLETS per YONSA NF 1 day) PA; ST; SP; BE; QL (4 TABLETS ZYTIGA ORAL TABLET 250 MG NF per 1 day) PA; ST; SP; BE; QL (2 TABLETS ZYTIGA ORAL TABLET 500 MG NF per 1 day) Antineoplastic - 1St Generation Egfr Tyrosine Kinase Inhibitor PA; BE; QL (1 TABLET per 1 erlotinib oral tablet 100 mg, 150 mg 4 day) PA; BE; QL (2 TABLETS per 1 erlotinib oral tablet 25 mg 4 day) PA; BE; QL (1 TABLET per 1 IRESSA NF day) PA; SP; BE; QL (1 TABLET per 1 TARCEVA ORAL TABLET 100 MG, 150 MG NF day) PA; SP; BE; QL (2 TABLETS per TARCEVA ORAL TABLET 25 MG NF 1 day) Antineoplastic - 2Nd Generation Egfr Tyrosine Kinase Inhibitor PA; BE; QL (1 TABLET per 1 GILOTRIF 4 day) PA; ST; BE; QL (6 TABLETS per NERLYNX 4 1 day) PA; BE; QL (1 TABLET per 1 VIZIMPRO NF day) Antineoplastic - 3Rd Generation Egfr Tyrosine Kinase Inhibitor PA; ST; BE; QL (1 TABLET per 1 TAGRISSO NF day) Antineoplastic - Alkylating Agent - Alkyl Sulfonates MYLERAN 3 Antineoplastic - Alkylating Agent - Ethylenimines And Methylmelamines HEXALEN 3
Last Approved Date: 09/24/2021 Formulary Version: 92
43 Drug Status Notes Antineoplastic - Alkylating Agent - Methylhydrazines MATULANE 3 SP Antineoplastic - Alkylating Agent - Nitrogen Mustards ALKERAN NF cyclophosphamide oral capsule 3 cyclophosphamide oral tablet NF LEUKERAN 3 QL (5 TABLETS per 1 day) melphalan 3 Antineoplastic - Alkylating Agent - Nitrosoureas GLEOSTINE 3 Antineoplastic - Alkylating Agent - Triazenes TEMODAR ORAL NF SP; BE temozolomide 4 SP; BE Antineoplastic - Anaplastic Lymphoma Kinase (Alk) Inhibitors PA; SP; BE; QL (8 CAPSULES ALECENSA 4 per 1 day) PA; ST; BE; QL (4 TABLETS per ALUNBRIG ORAL TABLET 30 MG 4 1 day) PA; ST; BE; QL (1 dose packet ALUNBRIG ORAL TABLETS,DOSE PACK 4 per 720 days) PA; ST; BE; QL (1 TABLET per 1 LORBRENA ORAL TABLET 100 MG NF day) PA; ST; BE; QL (3 TABLETS per LORBRENA ORAL TABLET 25 MG NF 1 day) PA; SP; BE; QL (2 CAPSULES XALKORI 4 per 1 day) PA; SP; BE; QL (3 ZYKADIA ORAL CAPSULE 4 TABLETS/CAPSULES per 1 day) PA; BE; QL (3 TABLETS per 1 ZYKADIA ORAL TABLET 4 day) Antineoplastic - Antiadrenals LYSODREN 4
Last Approved Date: 09/24/2021 Formulary Version: 92
44 Drug Status Notes Antineoplastic - Antiandrogens PA; BE; QL (4 TABLETS per 1 abiraterone oral tablet 250 mg 4 day) PA; ST; BE; QL (2 tablets per 1 abiraterone oral tablet 500 mg NF day) bicalutamide 1 CASODEX NF PA; ST ERLEADA 4 PA; QL (4 TABLETS per 1 day) flutamide 2 NILANDRON NF PA; ST nilutamide 4 PA; BE; QL (4 TABLETS per 1 NUBEQA 4 day) PA; SP; BE; QL (4 capsules per 1 XTANDI ORAL CAPSULE 4 day) PA; ST; BE; QL (3 tablets per 1 XTANDI ORAL TABLET 40 MG 4 Day) PA; ST; BE; QL (2 tablets per 1 XTANDI ORAL TABLET 80 MG 4 Day) PA; ST; BE; QL (4 TABLETS per YONSA NF 1 day) PA; ST; SP; BE; QL (4 TABLETS ZYTIGA ORAL TABLET 250 MG NF per 1 day) PA; ST; SP; BE; QL (2 TABLETS ZYTIGA ORAL TABLET 500 MG NF per 1 day) Antineoplastic - Antimetabolite - Folic Acid Analogs methotrexate sodium (pf) injection recon soln NF methotrexate sodium (pf) injection solution 2 methotrexate sodium injection 3 methotrexate sodium oral 1 TREXALL NF XATMEP NF Antineoplastic - Antimetabolite - Purine Analogs mercaptopurine 3 PURIXAN NF TABLOID NF
Last Approved Date: 09/24/2021 Formulary Version: 92
45 Drug Status Notes Antineoplastic - Antimetabolite - Pyrimidine Analogs capecitabine 4 SP; BE PA; ST; BE; QL (14 tablets per 28 ONUREG NF days) XELODA NF PA; ST; SP; BE Antineoplastic - Antimetabolite - Urea Derivatives HYDREA NF hydroxyurea 3 Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations LONSURF 4 PA; ST; SP; BE Antineoplastic - Aromatase Inhibitors anastrozole 3 ARIMIDEX NF PA AROMASIN NF PA exemestane 3 FEMARA NF letrozole 2 Antineoplastic - B-Cell Lymphoma-2 (Bcl-2) Inhibitors PA; BE; QL (2 TABLETS per 1 VENCLEXTA ORAL TABLET 10 MG, 50 MG 4 day) PA; BE; QL (6 TABLETS per 1 VENCLEXTA ORAL TABLET 100 MG 4 day) VENCLEXTA STARTING PACK 4 PA; BE Antineoplastic - Braf Kinase Inhibitors PA; BE; QL (6 CAPSULES per 1 BRAFTOVI NF day) PA; SP; BE; QL (4 CAPSULES TAFINLAR 4 per 1 day) PA; SP; BE; QL (8 TABLETS per ZELBORAF 4 1 day) Antineoplastic - Bruton's Tyrosine Kinase (Btk) Inhibitor BRUKINSA NF PA; ST; QL (4 capsules per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
46 Drug Status Notes PA; ST; SP; QL (2 CAPSULES CALQUENCE NF per 1 day) PA; ST; BE; QL (3 CAPSULES IMBRUVICA ORAL CAPSULE 140 MG 4 per 1 day) PA; ST; BE; QL (1 CAPSULE per IMBRUVICA ORAL CAPSULE 70 MG 4 1 day) PA; ST; BE; QL (1 TABLET per 1 IMBRUVICA ORAL TABLET 4 day) Antineoplastic - Cyclin-Dependent Kinase (Cdk) 4/6 Inhibitors PA; ST; SP; BE; QL (21 IBRANCE ORAL CAPSULE 4 CAPSULES per 21 days) PA; ST; BE; QL (21 tablets per 21 IBRANCE ORAL TABLET 4 Dayss) KISQALI ORAL TABLET 200 MG/DAY (200 BE; QL (21 TABLETS per 28 NF MG X 1) days) KISQALI ORAL TABLET 400 MG/DAY (200 BE; QL (42 TABLETS per 28 NF MG X 2) days) KISQALI ORAL TABLET 600 MG/DAY (200 BE; QL (63 TABLETS per 28 NF MG X 3) days) PA; ST; SP; BE; QL (2 TABLETS VERZENIO 4 per 1 day) Antineoplastic - Epidermal Growth Factor Receptor-2 (Her2) Inhibitor PA; ST; BE; QL (4 tablets per 1 TUKYSA 4 day) Antineoplastic - Epipodophyllotoxins etoposide oral 4 SP; BE Antineoplastic - Estrogens EMCYT 4 Antineoplastic - Exportin-1 (Xpo1) Inhibitors XPOVIO ORAL TABLET 100 MG/WEEK (20 PA; ST; BE; QL (20 tablets per 21 NF MG X 5), 100 MG/WEEK (50 MG X 2) days) XPOVIO ORAL TABLET 40 MG/WEEK (20 PA; ST; BE; QL (8 tablets per 21 NF MG X 2), 40 MG/WEEK (40 MG X 1) days) XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MG/WEEK), 60MG TWICE WEEK NF QL (4 blister cards per 21 Dayss) (120 MG/WEEK)
Last Approved Date: 09/24/2021 Formulary Version: 92
47 Drug Status Notes XPOVIO ORAL TABLET 60 MG/WEEK (20 PA; ST; BE; QL (12 tablets per 21 NF MG X 3), 60 MG/WEEK (60 MG X 1) days) XPOVIO ORAL TABLET 80 MG/WEEK (20 PA; ST; BE; QL (16 tablets per 21 NF MG X 4), 80 MG/WEEK (40 MG X 2) days) XPOVIO ORAL TABLET 80MG TWICE PA; ST; QL (32 TABLETS per 21 NF WEEK (160 MG/WEEK) days) Antineoplastic - Ezh2 Histone Methyltransferase (Hmt) Inhibitor TAZVERIK NF PA; BE; QL (8 tablets per 1 day) Antineoplastic - Fibroblast Growth Factor Receptor (Fgfr) Kinase Inhib PA; ST; BE; QL (3 TABLETS per BALVERSA ORAL TABLET 3 MG NF 1 day) PA; ST; BE; QL (2 TABLETS per BALVERSA ORAL TABLET 4 MG NF 1 day) PA; ST; BE; QL (1 TABLET per 1 BALVERSA ORAL TABLET 5 MG NF day) PA; ST; BE; QL (14 tablets per 16 PEMAZYRE NF days) TRUSELTIQ ORAL CAPSULE 100 MG/DAY (100 MG X 1), 50 MG/DAY (25 MG X 2), 75 NF BE MG/DAY (25 MG X 3) TRUSELTIQ ORAL CAPSULE 125 PA; ST; BE; QL (1 pack per 28 NF MG/DAY(100 MG X1-25MG X1) days) Antineoplastic - Fms-Like Tyrosine Kinase 3 (Flt3) Inhibitors PA; BE; QL (3 TABLETS per 1 XOSPATA 4 day) Antineoplastic - Hedgehog Pathway Inhibitor PA; BE; QL (1 TABLET per 1 DAURISMO ORAL TABLET 100 MG NF day) PA; BE; QL (2 TABLETS per 1 DAURISMO ORAL TABLET 25 MG NF day) PA; SP; QL (1 CAPSULES per 1 ERIVEDGE 4 day) PA; SP; BE; QL (1 CAPSULE per ODOMZO 4 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
48 Drug Status Notes Antineoplastic - Histone Deacetylase (Hdac) Inhibitors PA; ST; SP; BE; QL (6 FARYDAK 4 CAPSULES per 16 days) PA; ST; SP; BE; QL (4 ZOLINZA 4 CAPSULES per 1 day) Antineoplastic - Interferons INTRON A INJECTION RECON SOLN 4 PA; SP; BE INTRON A INJECTION SOLUTION 6 4 PA; SP MILLION UNIT/ML SYLATRON 4 PA; SP; BE Antineoplastic - Janus Kinase (Jak) Inhibitors PA; ST; QL (2 TABLETS per 1 JAKAFI 4 day) Antineoplastic - Janus Kinase(Jak),Fms-Like Tyrosine Kinase(Flt) Inhib PA; ST; BE; QL (4 CAPSULES INREBIC NF per 1 day) Antineoplastic - Kinase Inhibitor And Aromatase Inhibitor Combination KISQALI FEMARA CO-PACK ORAL TABLET PA; BE; QL (49 TABLETS per 1 NF 200 MG/DAY(200 MG X 1)-2.5 MG DISPENSE) KISQALI FEMARA CO-PACK ORAL TABLET PA; BE; QL (70 TABLETS per 1 NF 400 MG/DAY(200 MG X 2)-2.5 MG DISPENSE) KISQALI FEMARA CO-PACK ORAL TABLET PA; BE; QL (91 TABLETS per 1 NF 600 MG/DAY(200 MG X 3)-2.5 MG DISPENSE) Antineoplastic - Kirsten Rat Sarcoma (Kras) Protein Inhibitor PA; ST; BE; QL (8 tablets per 1 LUMAKRAS NF day) Antineoplastic - Lhrh (Gnrh) Agonist Analog Pituitary Suppressants ELIGARD 4 SP ELIGARD (3 MONTH) 4 SP ELIGARD (4 MONTH) 4 SP ELIGARD (6 MONTH) 4 SP
Last Approved Date: 09/24/2021 Formulary Version: 92
49 Drug Status Notes leuprolide subcutaneous kit 4 SP LUPRON DEPOT (3 MONTH) 4 SP INTRAMUSCULAR SYRINGE KIT 22.5 MG LUPRON DEPOT (4 MONTH) 4 SP LUPRON DEPOT (6 MONTH) 4 SP LUPRON DEPOT INTRAMUSCULAR 4 SYRINGE KIT 7.5 MG TRELSTAR INTRAMUSCULAR SYRINGE 4 ZOLADEX 4 SP; BE Antineoplastic - Lhrh (Gnrh) Antagonist Pituitary Suppressants FIRMAGON KIT W DILUENT SYRINGE 4 SP ORGOVYX NF PA; BE; QL (1 tablet per 1 day) Antineoplastic - Mast Cell Stabilizers cromolyn oral 4 GASTROCROM NF Antineoplastic - Mek1 And Mek2 Kinase Inhibitors PA; QL (63 TABLETS per 21 COTELLIC NF days) KOSELUGO NF BE PA; ST; SP; BE; QL (3 TABLETS MEKINIST ORAL TABLET 0.5 MG 4 per 1 day) PA; ST; SP; BE; QL (1 TABLETS MEKINIST ORAL TABLET 2 MG 4 per 1 day) MEKTOVI NF PA; QL (6 TABLETS per 1 day) Antineoplastic - Mtor Kinase Inhibitors AFINITOR DISPERZ 4 PA; SP; BE PA; ST; SP; BE; QL (1 TABLET AFINITOR ORAL TABLET 10 MG 4 per 1 day) AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 PA; ST; SP; BE; QL (1 TABLET NF MG per 1 day) PA; ST; BE; QL (1 TABLET per 1 everolimus (antineoplastic) 4 day) Antineoplastic - Multikinase Inhibitors PA; ST; SP; BE; QL (1 TABLET CABOMETYX 4 per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
50 Drug Status Notes COMETRIQ ORAL CAPSULE 100 4 PA; BE; QL (100 MG per 1 day) MG/DAY(80 MG X1-20 MG X1) COMETRIQ ORAL CAPSULE 140 4 PA; BE; QL (140 MG per 1 day) MG/DAY(80 MG X1-20 MG X3) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 4 PA; BE; QL (60 MG per 1 day) MG X 3/DAY) PA; ST; BE; QL (1 tablet per 1 ICLUSIG ORAL TABLET 10 MG, 30 MG 4 day) PA; ST; SP; BE; QL (2 TABLETS ICLUSIG ORAL TABLET 15 MG 4 per 1 day) PA; ST; SP; BE; QL (1 TABLET ICLUSIG ORAL TABLET 45 MG 4 per 1 day) PA; ST; SP; BE; QL (4 TABLETS NEXAVAR 4 per 1 day) PA; ST; SP; BE; QL (84 STIVARGA 4 TABLETS per 21 days) PA; ST; BE; QL (4 tablets per 1 UKONIQ NF day) Antineoplastic - Mutant Isocitrate Dehydrogenase 1 (Midh1) Inhibitors PA; BE; QL (2 TABLETS per 1 TIBSOVO 4 day) Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (Midh2) Inhibitors PA; SP; BE; QL (1 TABLET per 1 IDHIFA 4 day) Antineoplastic - Phosphatidylinositol 3- Kinase (Pi3k) Inhibitors PA; ST; BE; QL (2 CAPSULES COPIKTRA NF per 1 day) PA; ST; BE; QL (2 TABLETS per ZYDELIG 4 1 day) Antineoplastic - Pi3k-Alpha Inhibitors PIQRAY ORAL TABLET 200 MG/DAY (200 PA; ST; BE; QL (28 TABLETS NF MG X 1) per 21 days) PIQRAY ORAL TABLET 250 MG/DAY (200 PA; ST; BE; QL (56 TABLETS MG X1-50 MG X1), 300 MG/DAY (150 MG X NF per 21 days) 2)
Last Approved Date: 09/24/2021 Formulary Version: 92
51 Drug Status Notes Antineoplastic - Pi3k-Delta And Gamma Inhibitors PA; ST; BE; QL (2 CAPSULES COPIKTRA NF per 1 day) Antineoplastic - Pi3k-Delta Inhibitors PA; ST; BE; QL (2 TABLETS per ZYDELIG 4 1 day) Antineoplastic - Poly (Adp-Ribose) Polymerase (Parp) Inhibitors PA; ST; SP; BE; QL (16 LYNPARZA ORAL CAPSULE 4 CAPSULES per 1 day) PA; ST; SP; BE; QL (4 TABLETS LYNPARZA ORAL TABLET 4 per 1 day) PA; ST; BE; QL (4 TABLETS per RUBRACA 4 1 day) PA; BE; QL (3 CAPSULES per 1 TALZENNA ORAL CAPSULE 0.25 MG NF day) PA; BE; QL (1 CAPSULE per 1 TALZENNA ORAL CAPSULE 1 MG NF day) PA; ST; BE; QL (3 CAPSULES ZEJULA 4 per 1 day) Antineoplastic - Progestins DEPO-PROVERA INTRAMUSCULAR NF SUSPENSION 400 MG/ML megestrol oral tablet 1 Antineoplastic - Proteasome Enzyme Inhibitors PA; ST; SP; BE; QL (3 NINLARO NF CAPSULES per 23 days) Antineoplastic - Protein-Tyrosine Kinase Inhibitors AYVAKIT ORAL TABLET 100 MG, 200 MG, PA; ST; BE; QL (1 tablet per 1 NF 300 MG Day) AYVAKIT ORAL TABLET 25 MG, 50 MG NF PA; BE; QL (1 tablet per 1 Day) PA; ST; SP; BE; QL (3 TABLETS BOSULIF ORAL TABLET 100 MG 4 per 1 day) PA; ST; BE; QL (1 TABLET per 1 BOSULIF ORAL TABLET 400 MG 4 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
52 Drug Status Notes PA; ST; SP; BE; QL (1 TABLETS BOSULIF ORAL TABLET 500 MG 4 per 1 day) BRUKINSA NF PA; ST; QL (4 capsules per 1 day) PA; ST; SP; QL (2 CAPSULES CALQUENCE NF per 1 day) PA; BE; QL (2 TABLETS per 1 CAPRELSA ORAL TABLET 100 MG 4 day) PA; BE; QL (1 TABLET per 1 CAPRELSA ORAL TABLET 300 MG 4 day) PA; ST; BE; QL (21 capsules per FOTIVDA NF 28 days) PA; SP; BE; QL (6 TABLETS per GLEEVEC ORAL TABLET 100 MG NF 1 day) PA; SP; BE; QL (2 TABLETS per GLEEVEC ORAL TABLET 400 MG NF 1 day) imatinib mesylate 100 mg tab 4 PA; ST; QL (6 tablets per 1 Day) imatinib mesylate 400 mg tab 4 PA; ST; QL (2 tablets per 1 Day) PA; ST; BE; QL (3 CAPSULES IMBRUVICA ORAL CAPSULE 140 MG 4 per 1 day) PA; ST; BE; QL (1 CAPSULE per IMBRUVICA ORAL CAPSULE 70 MG 4 1 day) PA; ST; BE; QL (1 TABLET per 1 IMBRUVICA ORAL TABLET 4 day) PA; ST; SP; QL (6 TABLETS per INLYTA ORAL TABLET 1 MG 4 1 day) PA; ST; SP; QL (4 TABLETS per INLYTA ORAL TABLET 5 MG 4 1 day) LENVIMA ORAL CAPSULE 10 MG/DAY (10 PA; ST; BE; QL (10 MG per 1 4 MG X 1) day) LENVIMA ORAL CAPSULE 12 MG/DAY (4 PA; ST; QL (3 CAPSULES per 1 4 MG X 3) day) LENVIMA ORAL CAPSULE 14 MG/DAY(10 PA; ST; BE; QL (14 MG per 1 4 MG X 1-4 MG X 1) day) LENVIMA ORAL CAPSULE 18 MG/DAY (10 PA; ST; BE; QL (18 MG per 1 4 MG X 1-4 MG X2) day) LENVIMA ORAL CAPSULE 20 MG/DAY (10 PA; ST; BE; QL (20 MG per 1 4 MG X 2) day) LENVIMA ORAL CAPSULE 24 MG/DAY(10 PA; ST; BE; QL (24 MG per 1 4 MG X 2-4 MG X 1) day)
Last Approved Date: 09/24/2021 Formulary Version: 92
53 Drug Status Notes PA; ST; QL (1 CAPSULE per 1 LENVIMA ORAL CAPSULE 4 MG 4 day) LENVIMA ORAL CAPSULE 8 MG/DAY (4 4 PA; ST; BE; QL (8 MG per 1 day) MG X 2) PA; SP; BE; QL (2 CAPSULES OFEV 4 per 1 day) PA; ST; BE; QL (3 tablets per 1 QINLOCK NF day) PA; ST; BE; QL (5 CAPSULES ROZLYTREK ORAL CAPSULE 100 MG NF per 1 day) PA; ST; BE; QL (3 CAPSULES ROZLYTREK ORAL CAPSULE 200 MG NF per 1 day) PA; BE; QL (8 CAPSULES per 1 RYDAPT 4 day) SPRYCEL ORAL TABLET 100 MG, 140 MG, PA; ST; SP; BE; QL (1 TABLET 4 50 MG, 70 MG, 80 MG per 1 day) PA; ST; SP; BE; QL (2 TABLETS SPRYCEL ORAL TABLET 20 MG 4 per 1 day) PA; ST; SP; BE; QL (1 CAPSULE SUTENT 4 per 1 day) TABRECTA NF PA; BE; QL (4 tablets per 1 day) PA; ST; SP; BE; QL (4 TASIGNA ORAL CAPSULE 150 MG, 200 MG 4 CAPSULES per 1 day) PA; ST; BE; QL (4 CAPSULES TASIGNA ORAL CAPSULE 50 MG 4 per 1 day) PA; ST; BE; QL (2 tablets per 1 TEPMETKO NF day) PA; BE; QL (4 CAPSULES per 1 TURALIO NF day) PA; ST; SP; BE; QL (4 TABLETS VOTRIENT 4 per 1 day) Antineoplastic - Retinoids tretinoin (antineoplastic) 4 BE Antineoplastic - Selective Estrogen Receptor Modulators (Serms) FARESTON NF SOLTAMOX 3 tamoxifen 3 toremifene 4
Last Approved Date: 09/24/2021 Formulary Version: 92
54 Drug Status Notes Antineoplastic - Selective Inhibitiors Of Nuclear Export (Sine) XPOVIO ORAL TABLET 100 MG/WEEK (20 PA; ST; BE; QL (20 tablets per 21 NF MG X 5), 100 MG/WEEK (50 MG X 2) days) XPOVIO ORAL TABLET 40 MG/WEEK (20 PA; ST; BE; QL (8 tablets per 21 NF MG X 2), 40 MG/WEEK (40 MG X 1) days) XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MG/WEEK), 60MG TWICE WEEK NF QL (4 blister cards per 21 Dayss) (120 MG/WEEK) XPOVIO ORAL TABLET 60 MG/WEEK (20 PA; ST; BE; QL (12 tablets per 21 NF MG X 3), 60 MG/WEEK (60 MG X 1) days) XPOVIO ORAL TABLET 80 MG/WEEK (20 PA; ST; BE; QL (16 tablets per 21 NF MG X 4), 80 MG/WEEK (40 MG X 2) days) XPOVIO ORAL TABLET 80MG TWICE PA; ST; QL (32 TABLETS per 21 NF WEEK (160 MG/WEEK) days) Antineoplastic - Selective Ret Kinase Inhibitor GAVRETO NF PA; QL (4 capsules per 1 day) PA; ST; BE; QL (6 capsules per 1 RETEVMO ORAL CAPSULE 40 MG NF day) RETEVMO ORAL CAPSULE 80 MG NF BE Antineoplastic - Selective Retinoid X Receptor Agonists bexarotene 4 PA; ST; SP; BE TARGRETIN ORAL NF PA; ST; SP; BE Antineoplastic - Thalidomide Analogs PA; ST; SP; BE; QL (21 capsules POMALYST 4 per 21 days) PA; ST; SP; BE; QL (1 CAPSULE REVLIMID 4 per 1 day) PA; SP; BE; QL (1 CAPSULE per THALOMID ORAL CAPSULE 100 MG, 50 MG 4 1 day) THALOMID ORAL CAPSULE 150 MG, 200 PA; SP; BE; QL (2 CAPSULES 4 MG per 1 day) Antineoplastic - Topoisomerase I Inhibitors HYCAMTIN ORAL 4 SP
Last Approved Date: 09/24/2021 Formulary Version: 92
55 Drug Status Notes Antineoplastic - Tropomyosin Receptor Kinase (Trk) Inhibitor PA; BE; QL (2 CAPSULES per 1 VITRAKVI ORAL CAPSULE 100 MG 4 day) PA; BE; QL (6 CAPSULES per 1 VITRAKVI ORAL CAPSULE 25 MG 4 day) VITRAKVI ORAL SOLUTION 4 PA; BE; QL (10 ML per 1 day) Antineoplastic-Pyrimidine Analog And Cytidine Deaminase Inhibitor Comb INQOVI NF BE; QL (5 tablets per 28 days) Methotrexate Rescue Agents leucovorin calcium oral tablet 10 mg, 15 mg 2 leucovorin calcium oral tablet 25 mg 3 leucovorin calcium oral tablet 5 mg 1 Methotrexate Rescue Agents - Folic Acid Antagonist Type leucovorin calcium oral tablet 10 mg, 15 mg 2 leucovorin calcium oral tablet 25 mg 3 leucovorin calcium oral tablet 5 mg 1 Urinary Tract Protective Agents Used In Conjunction With Chemotherapy MESNEX ORAL 3 Biologicals Allergenic Extracts - Grass Pollen PA; ST; QL (1 TABLET per 1 GRASTEK 3 day) ORALAIR SUBLINGUAL TABLET 300 INDX PA; ST; QL (1 TABLET per 1 3 REACTIVITY day) Allergenic Extracts - Mite Extracts PA; ST; QL (1 TABLET per 1 ODACTRA NF day) Allergenic Extracts - Weed Pollen PA; ST; QL (1 TABLET per 1 RAGWITEK 3 day) Hepatitis A And Hepatitis B Vaccine Combinations TWINRIX $0 Last Approved Date: 09/24/2021 Formulary Version: 92
56 Drug Status Notes TWINRIX (PF) $0 QL (4 UNITS per 720 days) Hepatitis B Vaccine Combinations PEDIARIX $0 PEDIARIX (PF) $0 QL (4 UNITS per 720 days) VAXELIS (PF) $0 Hepatitis B Vaccines - Single Agents ENGERIX-B (HEPATITIS B)VACCINE $0 ENGERIX-B (PF) $0 QL (4 UNITS per 720 days) ENGERIX-B PEDIATRIC (PF) $0 QL (4 UNITS per 720 days) HEPLISAV-B (PF) $0 QL (4 UNITS per 720 days) RECOMBIVAX HB $0 RECOMBIVAX HB (PF) $0 QL (4 UNITS per 720 days) Live Vaccine And Live Virus Formulations QL (1 DOSE (0.5ML) per 185 FLUMIST QUAD 2019-2020 $0 days) FLUMIST QUAD 2020-2021 $0 QL (1 dose (0.5ml) per 185 Dayss) FLUMIST QUAD 2021-2022 $0 QL (1 dose (0.5ml) per 185 Dayss) ZOSTAVAX (PF) $0 Peanut Desensitization Agents PALFORZIA (LEVEL 1) NF PA; BE PALFORZIA (LEVEL 2) NF PA; BE PALFORZIA (LEVEL 3) NF PA; BE PALFORZIA (LEVEL 4) NF PA; BE PALFORZIA (LEVEL 5) NF PA; BE PALFORZIA (LEVEL 6) NF PA; BE PALFORZIA (LEVEL 7) NF PA; BE PALFORZIA (LEVEL 8) NF PA; BE PALFORZIA (LEVEL 9) NF PA; BE PALFORZIA (LEVEL 10) NF PA; BE PALFORZIA (LEVEL 11 UP-DOSE) NF PA; BE; QL (1 unit per 1 day) PALFORZIA INITIAL DOSE NF PA; BE PALFORZIA LEVEL 11 MAINTENANCE NF PA; BE; QL (1 unit per 1 day) Toxoid Vaccine Combinations PEDIARIX $0 PEDIARIX (PF) $0 QL (4 UNITS per 720 days) Last Approved Date: 09/24/2021 Formulary Version: 92
57 Drug Status Notes VAXELIS (PF) $0 Vaccine Bacterial - Gram Negative Cocci MENQUADFI (PF) $0 Vaccine Bacterial - Gram Positive Cocci PNEUMOVAX-23 $0 PREVNAR 13 (PF) $0 Vaccine Mixed Combinations (Bacterial And Viral) VAXELIS (PF) $0 Vaccine Viral - Covid-19 (Sars-Cov-2) JANSSEN COVID-19 VACCINE (EUA) $0 QL (2 prescriptions per 720 Dayss) QL (2 prescriptions per 720 Day MODERNA COVID-19 VACCINE (EUA) $0 Periods) QL (2 prescriptions per 720 Day PFIZER COVID-19 VACCINE (EUA) $0 Periods) Vaccine Viral - Human Papillomavirus (Hpv) Vaccines GARDASIL (PF) $0 GARDASIL 9 (PF) $0 Vaccine Viral - Influenza A And B QL (1 DOSE (0.5ML) per 185 AFLURIA 2018-2019 $0 days) QL (1 DOSE (0.5ML) per 185 AFLURIA 2018-2019 (PF) $0 days) QL (1 DOSE (0.5ML) per 185 AFLURIA QD 2019-20(3YR UP)(PF) $0 days) QL (1 DOSE (0.5ML) per 185 AFLURIA QD 2019-20(6-35MO)(PF) $0 days) AFLURIA QD 2020-21(3YR UP)(PF) $0 QL (1 dose (0.5ml) per 185 Dayss) AFLURIA QD 2020-21(6-35MO)(PF) $0 QL (1 dose (0.5ml) per 185 Dayss) AFLURIA QD 2021-22(3YR UP)(PF) $0 QL (1 dose (0.5ml) per 185 Dayss) AFLURIA QD 2021-22(6-35MO)(PF) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 AFLURIA QUAD 2018-2019 $0 days) QL (1 DOSE (0.5ML) per 185 AFLURIA QUAD 2018-2019 (PF) $0 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
58 Drug Status Notes AFLURIA QUAD 2019-20(6MO UP) $0 QL (1 dose (0.5ml) per 185 days) AFLURIA QUAD 2020-2021(6MO UP) $0 QL (1 dose (0.5ml) per 185 Dayss) AFLURIA QUAD 2021-2022(6MO UP) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUAD 2019-2020 (65 YR UP)(PF) $0 days) FLUAD 2020-2021 (65 YR UP)(PF) $0 QL (1 dose (0.5ml) per 185 Dayss) FLUAD QUAD 2020-21(65Y UP)(PF) $0 QL (1 dose (0.5ml) per 185 days) FLUAD QUAD 2021-22(65Y UP)(PF) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUARIX QUAD 2019-2020 (PF) $0 days) FLUARIX QUAD 2020-2021 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) FLUARIX QUAD 2021-2022 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) FLUBLOK QUAD 2020-2021 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) FLUBLOK QUAD 2021-2022 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUCELVAX QUAD 2019-2020 $0 days) QL (1 DOSE (0.5ML) per 185 FLUCELVAX QUAD 2019-2020 (PF) $0 days) FLUCELVAX QUAD 2020-2021 $0 QL (1 dose (0.5ml) per 185 Dayss) FLUCELVAX QUAD 2020-2021 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) FLUCELVAX QUAD 2021-2022 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLULAVAL QUAD 2018-2019 $0 days) QL (1 DOSE (0.5ML) per 185 FLULAVAL QUAD 2018-2019 (PF) $0 days) QL (1 DOSE (0.5ML) per 185 FLULAVAL QUAD 2019-2020 $0 days) QL (1 DOSE (0.5ML) per 185 FLULAVAL QUAD 2019-2020 (PF) $0 days) FLULAVAL QUAD 2020-2021 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) FLULAVAL QUAD 2021-2022 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUMIST QUAD 2019-2020 $0 days) FLUMIST QUAD 2020-2021 $0 QL (1 dose (0.5ml) per 185 Dayss) FLUMIST QUAD 2021-2022 $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUZONE HIGH-DOSE 2018-19 (PF) $0 days) QL (1 DOSE (0.5ML) per 185 FLUZONE HIGH-DOSE 2019-20 (PF) $0 days) Last Approved Date: 09/24/2021 Formulary Version: 92
59 Drug Status Notes FLUZONE HIGHDOSE QUAD 20-21 PF $0 FLUZONE HIGHDOSE QUAD 21-22 PF $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUZONE QUAD 2019-2020 $0 days) QL (1 DOSE (0.5ML) per 185 FLUZONE QUAD 2019-2020 (PF) $0 days) FLUZONE QUAD 2020-2021 $0 QL (1 dose (0.5ml) per 185 Dayss) FLUZONE QUAD 2020-2021 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) INTRAMUSCULAR SUSPENSION FLUZONE QUAD 2021-2022 (PF) $0 QL (1 dose (0.5ml) per 185 Dayss) QL (1 DOSE (0.5ML) per 185 FLUZONE QUAD PEDI 2019-20 (PF) $0 days) Vaccine Viral - Varicella SHINGRIX (PF) $0 ZOSTAVAX (PF) $0 Cardiovascular Therapy Agents Ace Inhibitor And Calcium Channel Blocker Combinations amlodipine-benazepril NF LOTREL NF PRESTALIA NF TARKA NF trandolapril-verapamil NF Ace Inhibitor And Diuretic Combinations ACCURETIC NF benazepril-hydrochlorothiazide NF captopril-hydrochlorothiazide NF enalapril-hydrochlorothiazide 1 fosinopril-hydrochlorothiazide NF lisinopril-hydrochlorothiazide 1 LOTENSIN HCT NF moexipril-hydrochlorothiazide 2 quinapril-hydrochlorothiazide NF VASERETIC NF ZESTORETIC NF
Last Approved Date: 09/24/2021 Formulary Version: 92
60 Drug Status Notes Ace Inhibitors ACCUPRIL NF ALTACE NF benazepril 1 captopril 2 enalapril maleate oral tablet 1 EPANED NF PA; ST; QL (40 ML per 1 day) fosinopril 1 lisinopril 1 LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 NF MG moexipril 2 perindopril erbumine 2 PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 NF MG QBRELIS NF PA; ST; QL (5 ML per 1 day) quinapril 1 ramipril 1 trandolapril 1 VASOTEC NF ZESTRIL NF Aldosterone Receptor Antagonists ALDACTONE NF CAROSPIR NF PA; ST eplerenone 2 INSPRA NF KERENDIA NF spironolactone 1 Alpha-Beta Blockers carvedilol 1 carvedilol phosphate NF COREG NF COREG CR NF labetalol oral 2
Last Approved Date: 09/24/2021 Formulary Version: 92
61 Drug Status Notes Angiotensin Ii Receptor Blocker (Arb)- Calcium Channel Blocker Comb. amlodipine-olmesartan NF QL (1 TABLET per 1 day) amlodipine-valsartan NF QL (1 TABLET per 1 day) AZOR NF QL (1 TABLET per 1 day) EXFORGE NF QL (1 TABLET per 1 day) telmisartan-amlodipine NF TWYNSTA NF Angiotensin Ii Receptor Blocker (Arb)- Calcium Channel Blocker-Diuretic amlodipine-valsartan-hcthiazid NF EXFORGE HCT NF olmesartan-amlodipin-hcthiazid NF TRIBENZOR NF Angiotensin Ii Receptor Blocker (Arb)- Diuretic Combinations ATACAND HCT NF AVALIDE NF QL (1 TABLET per 1 day) BENICAR HCT NF QL (1 TABLET per 1 day) candesartan-hydrochlorothiazid NF DIOVAN HCT NF QL (1 TABLET per 1 day) EDARBYCLOR NF HYZAAR NF irbesartan-hydrochlorothiazide 2 QL (1 TABLET per 1 day) losartan-hydrochlorothiazide 1 MICARDIS HCT NF olmesartan-hydrochlorothiazide NF QL (1 TABLET per 1 day) telmisartan-hydrochlorothiazid NF valsartan-hydrochlorothiazide 2 QL (1 TABLET per 1 day) Angiotensin Ii Receptor Blocker- Neprilysin Inhibitor Comb. (Arni) ENTRESTO 3 PA; QL (2 TABLETS per 1 day) Angiotensin Ii Receptor Blockers (Arbs) ATACAND NF AVAPRO NF QL (1 TABLET per 1 day) BENICAR ORAL TABLET 20 MG, 40 MG NF QL (1 TABLET per 1 day) Last Approved Date: 09/24/2021 Formulary Version: 92
62 Drug Status Notes BENICAR ORAL TABLET 5 MG NF QL (3 TABLETS per 1 day) candesartan 3 COZAAR ORAL TABLET 100 MG NF QL (1 TABLET per 1 day) COZAAR ORAL TABLET 25 MG NF QL (3 TABLETS per 1 day) COZAAR ORAL TABLET 50 MG NF QL (2 TABLETS per 1 day) DIOVAN ORAL TABLET 160 MG, 40 MG, 80 NF QL (2 TABLETS per 1 day) MG DIOVAN ORAL TABLET 320 MG NF QL (1 TABLET per 1 day) EDARBI 3 PA; ST eprosartan 3 irbesartan 2 QL (1 TABLET per 1 day) losartan oral tablet 100 mg 1 QL (1 TABLET per 1 day) losartan oral tablet 25 mg 1 QL (3 TABLETS per 1 day) losartan oral tablet 50 mg 1 QL (2 TABLETS per 1 day) MICARDIS NF olmesartan oral tablet 20 mg, 40 mg 3 QL (1 TABLET per 1 day) olmesartan oral tablet 5 mg 3 QL (3 TABLETS per 1 day) telmisartan 3 valsartan oral tablet 160 mg, 40 mg, 80 mg 3 QL (2 TABLETS per 1 day) valsartan oral tablet 320 mg 3 QL (1 TABLET per 1 day) Antianginal - Coronary Vasodilators (Nitrates) DILATRATE-SR 3 QL (36 PACKETS per 1 GONITRO NF DISPENSE) ISOCHRON NF ISORDIL NF ISORDIL TITRADOSE ORAL TABLET 5 MG NF isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 2 mg, 5 mg isosorbide dinitrate oral tablet 40 mg NF isosorbide dinitrate oral tablet extended release 3 isosorbide mononitrate oral tablet 1 isosorbide mononitrate oral tablet extended 2 release 24 hr 120 mg isosorbide mononitrate oral tablet extended 1 release 24 hr 30 mg, 60 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
63 Drug Status Notes MINITRAN NF NITRO-BID 3 NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, NF 0.6 MG/HR NITRO-DUR TRANSDERMAL PATCH 24 3 HOUR 0.3 MG/HR, 0.8 MG/HR nitroglycerin oral 1 nitroglycerin transdermal patch 24 hour 1 nitroglycerin translingual 3 NITROLINGUAL NF NITROMIST NF NITROSTAT NF Antianginal And Anti-Ischemic Agents VERQUVO NF PA; ST; QL (1 tablet per 1 day) Antianginal And Anti-Ischemic Agents, Non-Hemodynamic RANEXA NF PA; ST ranolazine 3 PA; ST Antiarrhythmic - Class Ia disopyramide phosphate oral capsule 2 NORPACE NF NORPACE CR NF quinidine gluconate oral 2 quinidine sulfate oral tablet 2 Antiarrhythmic - Class Ib mexiletine 2 phenytoin sodium NF Antiarrhythmic - Class Ic flecainide oral tablet 100 mg, 50 mg 1 flecainide oral tablet 150 mg 2 propafenone oral capsule,extended release 12 hr 3 propafenone oral tablet 1 RYTHMOL SR NF Antiarrhythmic - Class Ii BETAPACE NF
Last Approved Date: 09/24/2021 Formulary Version: 92
64 Drug Status Notes SORINE 1 sotalol oral 1 SOTYLIZE NF Antiarrhythmic - Class Iii amiodarone oral 2 MULTAQ 4 PACERONE ORAL TABLET 100 MG, 200 MG, 2 400 MG TIKOSYN NF Antiarrhythmic - Class Iv CALAN NF verapamil oral tablet 1 Antihyperlipidemic - Apolipoprotein B- 100 Synthesis Inhibitor KYNAMRO 4 PA; ST; SP; BE Antihyperlipidemic - Atp-Citrate Lyase (Acly) Inhibitor NEXLETOL NF PA; ST; QL (1 tablet per 1 day) Antihyperlipidemic - Bile Acid Sequestrants CHOLESTYRAMINE LIGHT ORAL POWDER 2 colesevelam 3 COLESTID ORAL PACKET NF COLESTID ORAL TABLET NF colestipol oral packet 3 colestipol oral tablet 2 PREVALITE ORAL POWDER 2 QUESTRAN ORAL POWDER IN PACKET NF WELCHOL NF Antihyperlipidemic - Fibric Acid Derivatives ANTARA ORAL CAPSULE 30 MG, 90 MG NF PA; ST fenofibrate micronized oral capsule 130 mg, 43 NF mg fenofibrate micronized oral capsule 134 mg, 200 1 mg, 67 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
65 Drug Status Notes fenofibrate nanocrystallized oral tablet 145 mg, 1 48 mg fenofibrate oral capsule NF PA; ST fenofibrate oral tablet 120 mg, 40 mg 3 PA; ST fenofibrate oral tablet 160 mg, 54 mg 1 fenofibric acid 1 fenofibric acid (choline) NF FENOGLIDE NF PA; ST FIBRICOR NF PA; ST gemfibrozil 1 LIPOFEN NF PA; ST LOPID NF TRICOR NF PA; ST TRIGLIDE ORAL TABLET 160 MG NF PA; ST TRILIPIX NF PA; ST Antihyperlipidemic - Hmg Coa Reductase Inhibitors (Statins) ALTOPREV ORAL TABLET EXTENDED NF QL (1.5 TABLETS per 1 day) RELEASE 24 HR 20 MG ALTOPREV ORAL TABLET EXTENDED NF QL (1 TABLET per 1 day) RELEASE 24 HR 40 MG, 60 MG atorvastatin oral tablet 10 mg, 20 mg, 40 mg 1 QL (1.5 TABLETS per 1 day) atorvastatin oral tablet 80 mg 1 QL (1 TABLET per 1 day) CRESTOR ORAL TABLET 10 MG, 20 MG, 5 NF QL (1.5 TABLETS per 1 day) MG CRESTOR ORAL TABLET 40 MG NF QL (1 TABLET per 1 day) EZALLOR SPRINKLE NF QL (1 CAPSULE per 1 day) FLOLIPID NF QL (150 ML per 25 days) PA; ST; QL (3 CAPSULES per 1 fluvastatin oral capsule 20 mg 3 day) PA; ST; QL (2 CAPSULES per 1 fluvastatin oral capsule 40 mg 3 day) PA; ST; QL (1 TABLET per 1 fluvastatin oral tablet extended release 24 hr NF day) LESCOL ORAL CAPSULE 20 MG NF QL (3 CAPSULES per 1 day) LESCOL ORAL CAPSULE 40 MG NF QL (2 CAPSULES per 1 day) LESCOL XL NF QL (1 TABLET per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
66 Drug Status Notes LIPITOR ORAL TABLET 10 MG, 20 MG, 40 NF QL (1.5 TABLETS per 1 day) MG LIPITOR ORAL TABLET 80 MG NF QL (1 TABLET per 1 day) PA; ST; QL (1.5 TABLETS per 1 LIVALO ORAL TABLET 1 MG, 2 MG 3 day) PA; ST; QL (1 TABLET per 1 LIVALO ORAL TABLET 4 MG 3 day) lovastatin oral tablet 10 mg, 20 mg 1 QL (1.5 TABLETS per 1 day) lovastatin oral tablet 40 mg 1 QL (2 TABLETS per 1 day) PRAVACHOL ORAL TABLET 20 MG, 40 MG NF QL (1.5 TABLETS per 1 day) PRAVACHOL ORAL TABLET 80 MG NF QL (1 TABLET per 1 day) pravastatin oral tablet 10 mg, 20 mg, 40 mg 1 QL (1.5 TABLETS per 1 day) pravastatin oral tablet 80 mg 1 QL (1 TABLET per 1 day) rosuvastatin oral tablet 10 mg, 20 mg, 5 mg 3 QL (1.5 TABLETS per 1 day) rosuvastatin oral tablet 40 mg 3 QL (1 TABLET per 1 day) simvastatin oral suspension NF QL (150 ML per 25 days) simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 QL (1.5 TABLETS per 1 day) simvastatin oral tablet 80 mg 1 QL (1 TABLET per 1 day) ZOCOR ORAL TABLET 10 MG, 20 MG, 40 NF QL (1.5 TABLETS per 1 day) MG ZOCOR ORAL TABLET 80 MG NF QL (1 TABLET per 1 day) ZYPITAMAG NF PA; ST Antihyperlipidemic - Nicotinic Acid Derivatives niacin oral tablet extended release 24 hr NF NIACOR NF NIASPAN EXTENDED-RELEASE NF Antihyperlipidemic - Omega-3 Fatty Acid Type icosapent ethyl NF QL (4 capsules per 1 Day) LOVAZA NF omega-3 acid ethyl esters 3 VASCEPA ORAL CAPSULE 0.5 GRAM NF QL (8 capsules per 1 day) VASCEPA ORAL CAPSULE 1 GRAM NF QL (4 capsules per 1 day) Antihyperlipidemic - Pcsk9 Inhibitors PA; ST; SP; BE; QL (2 ML per 23 PRALUENT PEN NF days)
Last Approved Date: 09/24/2021 Formulary Version: 92
67 Drug Status Notes PA; ST; SP; BE; QL (1 cartridge REPATHA PUSHTRONEX 3 per 1 MONTH) PA; ST; SP; BE; QL (2 ML per 23 REPATHA SURECLICK 3 days) PA; ST; SP; BE; QL (2 ML per 23 REPATHA SYRINGE 3 days) Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor ezetimibe 3 ZETIA NF Antihyperlipidemic- Atp-Citrate Lyase And Cholesterol Absorption Inhib NEXLIZET NF PA; QL (1 tablet per 1 Day) Antihyperlipidemic Hmg Coa Reduct Inhib And Calcium Channel Blocker amlodipine-atorvastatin NF QL (1 TABLET per 1 day) CADUET NF QL (1 TABLET per 1 day) Antihyperlipidemic-Hmg Coa Reduct Inhib And Cholesterol Absorp Inhibit ezetimibe-simvastatin 3 QL (1 TABLET per 1 day) ROSZET NF PA; ST; QL (1 tablet per 1 day) VYTORIN 10-10 NF QL (1 TABLET per 1 day) VYTORIN 10-20 NF QL (1 TABLET per 1 day) VYTORIN 10-40 NF QL (1 TABLET per 1 day) VYTORIN 10-80 NF QL (1 TABLET per 1 day) Antihyperlipidemic-Microsomal Triglyceride Transfer Protein (Mtp)Inhib JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 4 PA; ST; BE MG JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 4 PA; ST 60 MG Beta Blockers Cardiac Selective atenolol 1 betaxolol oral 2 bisoprolol fumarate 1 BYSTOLIC 3 PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
68 Drug Status Notes KAPSPARGO SPRINKLE NF PA; ST LOPRESSOR ORAL NF metoprolol succinate 1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 1 mg metoprolol tartrate oral tablet 37.5 mg, 75 mg 3 TENORMIN NF TOPROL XL NF Beta Blockers Cardiac Selective, Intrinsic Sympathomimetic Activity acebutolol 1 Beta Blockers Non-Cardiac Select., Intrinsic Sympathomimetic Activity pindolol 2 Beta Blockers Non-Cardiac Selective BETAPACE NF CORGARD NF HEMANGEOL NF PA INDERAL LA NF INNOPRAN XL NF nadolol 2 propranolol oral capsule,extended release 24 hr 3 propranolol oral solution 1 propranolol oral tablet 10 mg, 20 mg, 40 mg, 80 1 mg propranolol oral tablet 60 mg 3 SORINE 1 sotalol oral 1 SOTYLIZE NF timolol maleate oral 2 Bradykinin B2 Receptor Antagonists FIRAZYR NF PA; ST; SP icatibant 4 PA; BE Calcium Channel Blocker - Nsaid, Cox- 2 Selective Inhibitor Combination CONSENSI NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
69 Drug Status Notes Calcium Channel Blockers - Benzothiazepines CARDIZEM CD NF CARDIZEM LA NF CARDIZEM ORAL TABLET 120 MG, 30 MG, NF 60 MG CARTIA XT 1 diltiazem hcl oral capsule,ext.rel 24h degradable 1 120 mg, 240 mg diltiazem hcl oral capsule,extended release 12 hr 1 diltiazem hcl oral capsule,extended release 24 hr 1 120 mg, 240 mg, 300 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 24hr 1 120 mg, 240 mg, 300 mg, 360 mg diltiazem hcl oral tablet 1 diltiazem hcl oral tablet extended release 24 hr 1 240 mg, 300 mg, 360 mg, 420 mg TIADYLT ER ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 1 300 MG, 420 MG TIAZAC NF Calcium Channel Blockers - Dihydropyridines ADALAT CC NF AFEDITAB CR 1 amlodipine 1 CONJUPRI NF PA; ST; QL (1 tablet per 1 Day) felodipine 1 isradipine 2 PA; ST; QL (2 BOTTLES per 25 KATERZIA NF days) nicardipine oral 2 nifedipine oral capsule 1 nifedipine oral tablet extended release 1 nisoldipine 1 NORVASC NF PROCARDIA NF PROCARDIA XL NF Last Approved Date: 09/24/2021 Formulary Version: 92
70 Drug Status Notes SULAR ORAL TABLET EXTENDED NF RELEASE 24 HR 17 MG, 34 MG, 8.5 MG Calcium Channel Blockers - Dihydropyridines - Cerebrovascular Specific nimodipine 3 NYMALIZE ORAL SOLUTION 60 MG/10 ML, NF 60 MG/20 ML NYMALIZE ORAL SYRINGE NF Calcium Channel Blockers - Phenylakylamines CALAN NF CALAN SR NF verapamil oral 1 VERELAN NF VERELAN PM NF Cardiac Selective Beta Blocker-Thiazide Diuretic And Related Comb. atenolol-chlorthalidone 1 bisoprolol-hydrochlorothiazide 1 DUTOPROL NF LOPRESSOR HCT NF metoprolol ta-hydrochlorothiaz 3 TENORETIC 100 NF TENORETIC 50 NF ZIAC NF Cardiovascular Sympathomimetic - Anaphylaxis Therapy Single Agents AUVI-Q INJECTION AUTO-INJECTOR 0.1 PA; QL (2 UNITS per 1 NF MG/0.1 ML DISPENSE) AUVI-Q INJECTION AUTO-INJECTOR 0.15 PA; ST; QL (2 UNITS per 1 NF MG/0.15 ML, 0.3 MG/0.3 ML DISPENSE) epinephrine injection auto-injector 0.15 mg/0.15 NF QL (2 UNITS per 1 DISPENSE) ml epinephrine injection auto-injector 0.15 mg/0.3 2 QL (2 UNITS per 1 DISPENSE) ml, 0.3 mg/0.3 ml PA; ST; QL (2 UNITS per 1 EPIPEN 2-PAK NF DISPENSE) Last Approved Date: 09/24/2021 Formulary Version: 92
71 Drug Status Notes PA; ST; QL (2 UNITS per 1 EPIPEN JR 2-PAK NF DISPENSE) SYMJEPI INJECTION SYRINGE 0.3 MG/0.3 NF ML Cardiovascular Sympathomimetics PA; ST; BE; QL (3 capsules per 1 droxidopa oral capsule 100 mg 4 day) PA; ST; BE; QL (6 capsules per 1 droxidopa oral capsule 200 mg, 300 mg 4 day) midodrine 2 PA; BE; QL (3 CAPSULES per 1 NORTHERA ORAL CAPSULE 100 MG NF day) NORTHERA ORAL CAPSULE 200 MG, 300 PA; BE; QL (6 CAPSULES per 1 NF MG day) Central Alpha-2 Agonists-Thiazide Diuretic And Related Comb. methyldopa-hydrochlorothiazide NF Central Alpha-2 Receptor Agonists CATAPRES NF CATAPRES-TTS-1 NF CATAPRES-TTS-2 NF CATAPRES-TTS-3 NF clonidine 3 clonidine hcl oral tablet 1 guanfacine oral tablet 1 methyldopa 1 Digitalis Glycosides DIGITEK 1 DIGOX 1 digoxin oral 1 LANOXIN ORAL TABLET 125 MCG (0.125 NF MG), 250 MCG (0.25 MG) LANOXIN ORAL TABLET 187.5 MCG (0.1875 3 MG), 62.5 MCG (0.0625 MG) Direct Acting Vasodilators hydralazine oral 1 minoxidil oral 2
Last Approved Date: 09/24/2021 Formulary Version: 92
72 Drug Status Notes Diuretic - Aldosterone Receptor Antagonist, Non-Selective ALDACTONE NF CAROSPIR NF PA; ST spironolactone 1 Diuretic - Aldosterone Receptor Antagonist, Selective eplerenone 2 INSPRA NF Diuretic - Carbonic Anhydrase Inhibitors acetazolamide oral capsule, extended release NF acetazolamide oral tablet 2 methazolamide 3 Diuretic - Loop bumetanide oral 2 DEMADEX ORAL TABLET 10 MG, 20 MG NF EDECRIN NF furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 mg/ml) furosemide oral tablet 1 LASIX NF torsemide oral 1 Diuretic - Potassium Sparing amiloride 1 DYRENIUM NF Diuretic - Potassium Sparing-Thiazide And Related Combinations ALDACTAZIDE NF amiloride-hydrochlorothiazide 1 DYAZIDE NF MAXZIDE NF MAXZIDE-25MG NF spironolacton-hydrochlorothiaz 2 triamterene-hydrochlorothiazid oral capsule 1 37.5-25 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
73 Drug Status Notes triamterene-hydrochlorothiazid oral capsule 50- NF 25 mg triamterene-hydrochlorothiazid oral tablet 1 Diuretic - Selective Arginine Vasopressin V2 Receptor Antagonists SAMSCA NF PA; BE tolvaptan oral tablet 15 mg NF PA; BE tolvaptan oral tablet 30 mg 4 PA; BE Diuretic - Thiazides And Related chlorothiazide 1 chlorthalidone oral tablet 25 mg, 50 mg 1 DIURIL 2 hydrochlorothiazide 1 indapamide 1 methyclothiazide 2 metolazone 1 MICROZIDE NF Ganglionic Blocking, Non-Depolarizing VECAMYL NF Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Inhibitors PA; ST; QL (84 AMPULES per 21 CORLANOR ORAL SOLUTION NF days) CORLANOR ORAL TABLET 3 PA; ST Muscarinic Receptor Antagonists (Anticholinergic) atropine injection solution NF Non-Cardiac Selective Beta Blocker- Thiazide Diuretic And Related Comb. CORZIDE NF nadolol-bendroflumethiazide NF propranolol-hydrochlorothiazid NF Pah Agents - Selective Prostacyclin Receptor (Ip) Agonists UPTRAVI ORAL TABLET 1,000 MCG, 1,200 PA; BE; QL (2 TABLETS per 1 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 NF day) MCG, 800 MCG Last Approved Date: 09/24/2021 Formulary Version: 92
74 Drug Status Notes PA; BE; QL (8 TABLETS per 1 UPTRAVI ORAL TABLET 200 MCG NF day) PA; BE; QL (1 dose packet per UPTRAVI ORAL TABLETS,DOSE PACK NF 274 days) Peripheral Alpha-1 Receptor Blockers CARDURA NF PA; ST CARDURA XL NF PA; ST DIBENZYLINE NF PA; ST doxazosin 1 MINIPRESS NF phenoxybenzamine 1 PA; ST; BE prazosin 1 terazosin 1 Peripheral Vasodilators, Single Agents isoxsuprine NF Pheochromocytoma, Agents To Treat DEMSER NF metyrosine NF Plasma Kallikrein Inhibitor Agents, Recombinant Monoclonal Antibody PA; BE; QL (2 VIALS per 21 TAKHZYRO NF days) Plasma Kallikrein Inhibitor Agents, Small Molecule ORLADEYO NF PA; BE; QL (1 capsule per 1 day) Pulmonary Antihypertensive Agents - Prostacyclin-Type ORENITRAM ORAL TABLET EXTENDED PA; ST; BE; QL (3 TABLETS per 4 RELEASE 0.125 MG 1 day) ORENITRAM ORAL TABLET EXTENDED PA; BE; QL (6 TABLETS per 1 4 RELEASE 0.25 MG, 1 MG day) ORENITRAM ORAL TABLET EXTENDED PA; BE; QL (17 TABLETS per 1 4 RELEASE 2.5 MG day) ORENITRAM ORAL TABLET EXTENDED PA; BE; QL (9 TABLETS per 1 4 RELEASE 5 MG day) TYVASO 1.74 MG/2.9 ML SOLUTION 4 PA; QL (1 ampule per 1 Day) TYVASO INHALATION REFILL KIT 4 PA; QL (1 ampule per 1 Day)
Last Approved Date: 09/24/2021 Formulary Version: 92
75 Drug Status Notes TYVASO INHALATION STARTER KIT 4 PA; QL (1 ampule per 1 Day) TYVASO INSTITUTIONAL START KIT 4 PA; QL (1 ampule per 1 Day) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 4 PA; QL (1 KIT per 274 days) MG/2.9 ML PA; ST; BE; QL (9 AMPULES VENTAVIS 4 per 1 day) Pulmonary Antihypertensive Agents- Soluble Guanylate Cyclase Stimulator PA; BE; QL (3 TABLETS per 1 ADEMPAS 4 day) Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists PA; ST; BE; QL (1 TABLET per 1 ambrisentan 4 day) PA; ST; BE; QL (2 units per 1 bosentan 4 day) PA; SP; BE; QL (1 TABLETS per LETAIRIS NF 1 day) PA; SP; BE; QL (1 TABLET per 1 OPSUMIT 4 day) PA; SP; BE; QL (2 UNITS per 1 TRACLEER ORAL TABLET NF day) TRACLEER ORAL TABLET FOR PA; SP; BE; QL (4 TABLETS per NF SUSPENSION 1 day) Pulmonary Arterial Hypertension Agents-Selective Cgmp-Pde5 Inhibitors PA; ST; BE; QL (6 TABLETS per ADCIRCA NF 1 DISPENSE) ALYQ 4 BE; QL (2 TABLETS per 1 day) REVATIO INTRAVENOUS NF PA REVATIO ORAL SUSPENSION FOR NF PA; SP; BE; QL (6 ML per 1 day) RECONSTITUTION PA; SP; BE; QL (3 TABLETS per REVATIO ORAL TABLET NF 1 day) sildenafil (pulm.hypertension) oral suspension for NF PA; ST; BE; QL (6 ML per 1 day) reconstitution PA; ST; SP; QL (3 TABLETS per sildenafil (pulm.hypertension) oral tablet 4 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
76 Drug Status Notes Renin Inhibitor, Direct aliskiren 3 TEKTURNA NF Renin Inhibitor, Direct And Diuretic Combinations TEKTURNA HCT NF Vasodilator Combinations BIDIL NF Central Nervous System Agents Agents To Treat Episodic Cluster Headaches EMGALITY SYRINGE SUBCUTANEOUS PA; ST; QL (3 syringes (300mg) 4 SYRINGE 300 MG/3 ML (100 MG/ML X 3) per 30 days) Antianxiety Agent - Antihistamine Type hydroxyzine hcl oral solution NF hydroxyzine hcl oral tablet 1 hydroxyzine pamoate 1 VISTARIL NF Antianxiety Agent - Benzodiazepines ALPRAZOLAM INTENSOL 3 PA alprazolam oral tablet 1 PA alprazolam oral tablet extended release 24 hr 3 PA alprazolam oral tablet,disintegrating 3 PA ATIVAN ORAL NF chlordiazepoxide hcl 1 clonazepam oral tablet 1 clonazepam oral tablet,disintegrating NF clorazepate dipotassium 1 DIAZEPAM INTENSOL NF diazepam oral solution 5 mg/5 ml (1 mg/ml) NF diazepam oral tablet 1 KLONOPIN NF LORAZEPAM INTENSOL NF lorazepam oral tablet 1 oxazepam 3
Last Approved Date: 09/24/2021 Formulary Version: 92
77 Drug Status Notes TRANXENE T-TAB NF VALIUM NF XANAX NF PA XANAX XR NF PA Antianxiety Agent - Dicarbamate Type meprobamate 3 Antianxiety Agent - Non- Benzodiazepine buspirone 2 Anticonvulsant - Ampa-Type Glutamate Receptor Antagonists FYCOMPA ORAL SUSPENSION NF QL (680 ML per 23 days) FYCOMPA ORAL TABLET NF Anticonvulsant - Barbiturates And Derivatives MYSOLINE NF phenobarbital oral elixir 2 phenobarbital oral tablet 1 primidone 1 Anticonvulsant - Benzodiazepines clobazam 3 clonazepam oral tablet 1 clonazepam oral tablet,disintegrating NF DIASTAT NF QL (1 kit per 1 DISPENSE) DIASTAT ACUDIAL NF QL (1 kit per 1 DISPENSE) diazepam rectal 2 QL (1 kit per 1 DISPENSE) KLONOPIN NF NAYZILAM NF PA; QL (2 spray units per 25 days) ONFI NF PA; ST; BE; QL (1 FILM per 1 SYMPAZAN ORAL FILM 10 MG, 5 MG NF day) PA; ST; BE; QL (2 FILMS per 1 SYMPAZAN ORAL FILM 20 MG NF day) PA; ST; QL (4 blister packs per 1 VALTOCO NF dispensing event)
Last Approved Date: 09/24/2021 Formulary Version: 92
78 Drug Status Notes Anticonvulsant - Cannabinoid Type EPIDIOLEX NF PA; ST Anticonvulsant - Carbamates felbamate 3 FELBATOL NF Anticonvulsant - Carboxylic Acid Derivatives DEPAKENE NF DEPAKOTE NF DEPAKOTE ER NF DEPAKOTE SPRINKLES NF divalproex oral capsule, delayed rel sprinkle 3 divalproex oral tablet extended release 24 hr 3 divalproex oral tablet,delayed release (dr/ec) 1 valproic acid 1 valproic acid (as sodium salt) oral solution 250 1 mg/5 ml valproic acid (as sodium salt) oral solution 500 NF mg/10 ml (10 ml) Anticonvulsant - Functionalized Amino Acid VIMPAT ORAL SOLUTION 3 PA VIMPAT ORAL TABLET 3 PA Anticonvulsant - Gaba Analogs gabapentin oral capsule 2 gabapentin oral solution 250 mg/5 ml 2 gabapentin oral solution 300 mg/6 ml (6 ml) NF gabapentin oral tablet 600 mg, 800 mg 2 LYRICA NF PA; ST NEURONTIN NF pregabalin oral capsule 3 PA; ST pregabalin oral solution 3 PA; ST Anticonvulsant - Gaba Re-Uptake Inhibitor, Nipecotic Acid Derivatives GABITRIL NF tiagabine oral tablet 12 mg, 16 mg NF
Last Approved Date: 09/24/2021 Formulary Version: 92
79 Drug Status Notes tiagabine oral tablet 2 mg, 4 mg 3 Anticonvulsant - Gaba Transaminase (Gaba-T) Inhibitor SABRIL NF PA; ST; BE vigabatrin oral powder in packet NF PA; ST; SP; BE vigabatrin oral tablet NF PA; ST Anticonvulsant - Hydantoins DILANTIN NF DILANTIN EXTENDED NF DILANTIN INFATABS NF DILANTIN-125 NF PEGANONE 3 PHENYTEK NF phenytoin oral suspension 100 mg/4 ml NF phenytoin oral suspension 125 mg/5 ml 1 phenytoin oral tablet,chewable NF phenytoin sodium NF phenytoin sodium extended 3 Anticonvulsant - Iminostilbene Derivatives APTIOM NF carbamazepine oral capsule, er multiphase 12 hr 2 carbamazepine oral suspension 100 mg/5 ml 2 carbamazepine oral suspension 200 mg/10 ml NF carbamazepine oral tablet 1 carbamazepine oral tablet extended release 12 hr 3 100 mg carbamazepine oral tablet extended release 12 hr 2 200 mg, 400 mg carbamazepine oral tablet,chewable 1 CARBATROL NF EPITOL 1 oxcarbazepine oral suspension 2 oxcarbazepine oral tablet 1 OXTELLAR XR NF TEGRETOL ORAL SUSPENSION NF
Last Approved Date: 09/24/2021 Formulary Version: 92
80 Drug Status Notes TEGRETOL ORAL TABLET NF TEGRETOL XR NF TRILEPTAL NF Anticonvulsant - Monosaccharide Derivatives QUDEXY XR NF PA; ST TOPAMAX NF topiramate oral capsule, sprinkle 2 topiramate oral capsule,sprinkle,er 24hr NF PA; ST topiramate oral tablet 1 TROKENDI XR NF PA; ST Anticonvulsant - Phenyltriazine Derivatives LAMICTAL ODT NF LAMICTAL ODT STARTER (BLUE) NF LAMICTAL ODT STARTER (GREEN) NF LAMICTAL ODT STARTER (ORANGE) NF LAMICTAL ORAL TABLET NF LAMICTAL ORAL TABLET, CHEWABLE NF DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT NF LAMICTAL STARTER (GREEN) KIT NF LAMICTAL STARTER (ORANGE) KIT NF LAMICTAL XR NF LAMICTAL XR STARTER (BLUE) NF LAMICTAL XR STARTER (GREEN) NF LAMICTAL XR STARTER (ORANGE) NF lamotrigine oral tablet 1 lamotrigine oral tablet disintegrating, dose pk 3 lamotrigine oral tablet extended release 24hr NF lamotrigine oral tablet, chewable dispersible 3 lamotrigine oral tablet,disintegrating NF lamotrigine oral tablets,dose pack 25 mg (35) 3 Anticonvulsant - Pyrrolidine Derivatives BRIVIACT ORAL SOLUTION NF
Last Approved Date: 09/24/2021 Formulary Version: 92
81 Drug Status Notes BRIVIACT ORAL TABLET 3 ELEPSIA XR NF PA; ST KEPPRA ORAL NF KEPPRA XR NF levetiracetam oral solution 100 mg/ml 3 levetiracetam oral solution 500 mg/5 ml (5 ml) 1 levetiracetam oral tablet 1 levetiracetam oral tablet extended release 24 hr 2 ROWEEPRA ORAL TABLET 500 MG 1 SPRITAM NF Anticonvulsant - Succinimides CELONTIN ORAL CAPSULE 300 MG 2 ethosuximide 2 ZARONTIN NF Anticonvulsant - Sulfonamide Derivatives ZONEGRAN ORAL CAPSULE 100 MG, 25 MG NF zonisamide 1 Anticonvulsant - Triazole Derivatives BANZEL ORAL SUSPENSION NF BANZEL ORAL TABLET 200 MG NF BANZEL ORAL TABLET 400 MG 4 rufinamide 3 Anticonvulsant Others PA; ST; BE; QL (3 DIACOMIT ORAL CAPSULE 250 MG 4 capsules/packets per 1 day) PA; ST; BE; QL (6 DIACOMIT ORAL CAPSULE 500 MG 4 capsules/packets per 1 day) DIACOMIT ORAL POWDER IN PACKET 250 PA; ST; BE; QL (3 4 MG capsules/packets per 1 day) DIACOMIT ORAL POWDER IN PACKET 500 PA; ST; BE; QL (6 4 MG capsules/packets per 1 day) ST; QL (1 bottle (360ml) per 30 FINTEPLA NF days) XCOPRI NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
82 Drug Status Notes XCOPRI MAINTENANCE PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG NF PA; ST X1), 350 MG/DAY (200 MG X1-150MG X1) XCOPRI TITRATION PACK NF PA; ST Antidepressant - Alpha-2 Receptor Antagonists (Nassa) mirtazapine oral tablet 15 mg, 30 mg, 45 mg 1 mirtazapine oral tablet 7.5 mg 3 mirtazapine oral tablet,disintegrating 2 REMERON ORAL TABLET 15 MG, 30 MG NF REMERON SOLTAB NF Antidepressant - Mao Inhibitor Nonselective And Irreversible-Types A,B EMSAM 4 MARPLAN 3 NARDIL NF PARNATE NF phenelzine 3 tranylcypromine 3 Antidepressant - Selective Serotonin Reuptake Inhibitors (Ssris) CELEXA ORAL TABLET NF citalopram oral solution 2 citalopram oral tablet 1 escitalopram oxalate oral solution 3 escitalopram oxalate oral tablet 1 QL (1 TABLET per 1 day) fluoxetine oral capsule 1 QL (4 CAPSULES per 1 fluoxetine oral capsule,delayed release(dr/ec) NF MONTH) fluoxetine oral solution 3 fluoxetine oral tablet NF fluvoxamine oral capsule,extended release 24hr NF fluvoxamine oral tablet 100 mg, 50 mg 1 fluvoxamine oral tablet 25 mg 2 LEXAPRO ORAL TABLET NF QL (1 TABLET per 1 day) paroxetine hcl oral tablet 1 Last Approved Date: 09/24/2021 Formulary Version: 92
83 Drug Status Notes paroxetine hcl oral tablet extended release 24 hr 3 PA; ST PAXIL CR NF PA; ST PAXIL ORAL SUSPENSION NF PAXIL ORAL TABLET NF PA; ST PEXEVA NF PA; ST PROZAC ORAL CAPSULE NF SARAFEM ORAL TABLET 10 MG, 20 MG NF sertraline oral concentrate NF sertraline oral tablet 1 ZOLOFT NF Antidepressant - Serotonin-2 Antagonist-Reuptake Inhibitors (Saris) nefazodone 3 trazodone oral tablet 100 mg, 150 mg, 50 mg 1 trazodone oral tablet 300 mg NF Antidepressant - Serotonin- Norepinephrine Reuptake Inhibitors (Snris) CYMBALTA ORAL CAPSULE,DELAYED NF QL (2 CAPSULES per 1 day) RELEASE(DR/EC) 20 MG, 60 MG CYMBALTA ORAL CAPSULE,DELAYED NF QL (1 CAPSULE per 1 day) RELEASE(DR/EC) 30 MG desvenlafaxine oral tablet extended release 24hr NF PA; ST desvenlafaxine succinate 3 PA; ST DRIZALMA SPRINKLE NF PA; QL (1 CAPSULE per 1 day) duloxetine oral capsule,delayed release(dr/ec) 20 1 QL (2 CAPSULES per 1 day) mg, 60 mg duloxetine oral capsule,delayed release(dr/ec) 30 1 QL (1 CAPSULE per 1 day) mg duloxetine oral capsule,delayed release(dr/ec) 40 NF mg EFFEXOR XR ORAL CAPSULE,EXTENDED PA; ST; QL (1 CAPSULE per 1 NF RELEASE 24HR 150 MG day) EFFEXOR XR ORAL CAPSULE,EXTENDED PA; ST; QL (1 NF RELEASE 24HR 37.5 MG, 75 MG TABLET/CAPSULE per 1 day) FETZIMA NF PA; ST KHEDEZLA NF PA; ST PRISTIQ NF PA; ST Last Approved Date: 09/24/2021 Formulary Version: 92
84 Drug Status Notes SAVELLA 3 PA; ST venlafaxine oral capsule,extended release 24hr 3 QL (1 CAPSULE per 1 day) 150 mg venlafaxine oral capsule,extended release 24hr QL (1 TABLET/CAPSULE per 1 1 37.5 mg day) venlafaxine oral capsule,extended release 24hr 75 1 QL (3 CAPSULES per 1 day) mg venlafaxine oral tablet 1 venlafaxine oral tablet extended release 24hr 150 PA; ST; QL (1 TABLET per 1 NF mg day) venlafaxine oral tablet extended release 24hr 225 QL (1 TABLET/CAPSULE per 1 NF mg day) venlafaxine oral tablet extended release 24hr 37.5 PA; ST; QL (1 NF mg, 75 mg TABLET/CAPSULE per 1 day) Antidepressant - Ssri And 5Ht1a Partial Agonist VIIBRYD ORAL TABLET 3 PA; ST VIIBRYD ORAL TABLETS,DOSE PACK 10 3 PA; ST MG (7)- 20 MG (23) Antidepressant - Ssri And Serotonin (5- Ht) Receptor Modulator TRINTELLIX NF PA; ST Antidepressant - Tricyclic And Antipsychotic, Phenothiazine Comb perphenazine-amitriptyline 3 Antidepressant - Tricyclic- Benzodiazepine Combinations amitriptyline-chlordiazepoxide NF Antidepressant- Ssri And Atypical Antipsych,Dopamine,Serotonin Antagon PA; ST; QL (1 CAPSULE per 1 olanzapine-fluoxetine NF day) PA; ST; QL (1 CAPSULE per 1 SYMBYAX NF day) Antidepressant-Norepinephrine And Dopamine Reuptake Inhibitors (Ndris) APLENZIN NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
85 Drug Status Notes bupropion hcl oral tablet 1 bupropion hcl oral tablet extended release 24 hr 1 QL (3 TABLETS per 1 day) 150 mg bupropion hcl oral tablet extended release 24 hr 1 QL (1 TABLET per 1 day) 300 mg bupropion hcl oral tablet extended release 24 hr PA; ST; QL (1 TABLET per 1 NF 450 mg day) bupropion hcl oral tablet sustained-release 12 hr 1 QL (2 TABLETS per 1 day) PA; ST; QL (1 TABLET per 1 FORFIVO XL NF day) PA; ST; QL (2 TABLETS per 1 WELLBUTRIN SR NF day) WELLBUTRIN XL ORAL TABLET PA; ST; QL (3 TABLETS per 1 NF EXTENDED RELEASE 24 HR 150 MG day) WELLBUTRIN XL ORAL TABLET PA; ST; QL (1 TABLET per 1 NF EXTENDED RELEASE 24 HR 300 MG day) Antidepressant-Tricyclics And Related (Non-Select Reuptake Inhibitors) amitriptyline 1 amoxapine 2 ANAFRANIL NF clomipramine 3 desipramine 1 doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 1 mg, 75 mg doxepin oral capsule 150 mg 2 doxepin oral concentrate 1 imipramine hcl 1 imipramine pamoate 3 maprotiline 1 NORPRAMIN ORAL TABLET 10 MG, 25 MG NF nortriptyline oral capsule 1 nortriptyline oral solution NF PAMELOR NF protriptyline 1 SURMONTIL NF TOFRANIL NF trimipramine 3 Last Approved Date: 09/24/2021 Formulary Version: 92
86 Drug Status Notes Antiparkinson - Dopaminergic-Periph Comt-Dopa-Decarboxylase Inhib Comb carbidopa-levodopa-entacapone 3 STALEVO 100 NF STALEVO 125 NF STALEVO 150 NF STALEVO 200 NF STALEVO 50 NF STALEVO 75 NF Antiparkinson - Dopaminerg-Peripheral Dopa-Decarboxylase Inhibit Comb carbidopa-levodopa oral tablet 1 carbidopa-levodopa oral tablet extended release 2 carbidopa-levodopa oral tablet,disintegrating NF DUOPA NF RYTARY NF SINEMET NF SINEMET CR NF Antiparkinson Adjuvant - Adenosine Receptor Antagonist PA; ST; BE; QL (1 TABLET per 1 NOURIANZ NF day) Antiparkinson Adjuvant - Central/Peripheral Comt Inhibitors TASMAR ORAL TABLET 100 MG NF tolcapone 4 Antiparkinson Adjuvant - Peripheral Comt Inhibitors COMTAN NF entacapone 3 ONGENTYS ORAL CAPSULE 25 MG NF PA; ST; QL (1 capsule per 1 Day) ONGENTYS ORAL CAPSULE 50 MG NF PA; ST; QL (1 capsule per 1 day) Antiparkinson Adjuvant - Peripheral Dopa-Decarboxylase Inhibitors carbidopa 3 LODOSYN NF
Last Approved Date: 09/24/2021 Formulary Version: 92
87 Drug Status Notes Antiparkinson Therapy - Anticholinergic Agents benztropine oral 1 trihexyphenidyl 1 Antiparkinson Therapy - Dopamine Precursors INBRIJA NF PA; QL (5 BOXES per 25 days) Antiparkinson Therapy - Ergot Alkaloids And Derivatives bromocriptine 2 PARLODEL NF Antiparkinson Therapy - Monoamine Oxidase Inhibitor(Mao-B) AZILECT NF PA; ST rasagiline 3 PA; ST selegiline hcl 1 PA; ST; QL (1 TABLET per 1 XADAGO NF day) ZELAPAR NF Antiparkinson Therapy - Non-Ergot Dopamine Agonist Agents amantadine hcl 2 APOKYN 4 PA; ST; SP; BE PA; ST; SP; BE; QL (2 GOCOVRI NF CAPSULES per 1 day) KYNMOBI SUBLINGUAL FILM 10 MG, 15 PA; ST; BE; QL (5 films per 1 NF MG, 20 MG, 25 MG, 30 MG day) MIRAPEX NF MIRAPEX ER NF NEUPRO 3 QL (1 PATCH per 1 day) OSMOLEX ER ORAL TABLET, IR - ER, PA; ST; BE; QL (1 TABLET per 1 NF BIPHASIC 24HR 129 MG, 193 MG, 258 MG day) OSMOLEX ER ORAL TABLET, IR - ER, PA; ST; BE; QL (1 tablet per 1 BIPHASIC 24HR 322 MG/DAY(129 MG X1- NF Day) 193MG X1) pramipexole oral tablet 1
Last Approved Date: 09/24/2021 Formulary Version: 92
88 Drug Status Notes pramipexole oral tablet extended release 24 hr NF 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 4.5 mg REQUIP NF REQUIP XL NF ropinirole oral tablet 1 ropinirole oral tablet extended release 24 hr 3 Antipsychotic - Atyp Dopamine- Serotonin Antag Dibenzo-Oxepino Pyrroles asenapine maleate 3 PA; ST; QL (2 EA per 2 Days) PA; ST; QL (2 TABLETS per 1 SAPHRIS (BLACK CHERRY) 3 day) SAPHRIS SUBLINGUAL TABLET 10 MG NF PA; ST; QL (2 tablets per 1 Day) PA; ST; QL (2 TABLETS per 1 SAPHRIS SUBLINGUAL TABLET 2.5 MG NF day) SAPHRIS SUBLINGUAL TABLET 5 MG NF SECUADO NF PA; ST; QL (1 patch per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag- Benzisothiazolones GEODON ORAL NF QL (2 CAPSULES per 1 day) LATUDA ORAL TABLET 120 MG, 20 MG, 40 PA; ST; QL (1 TABLET per 1 3 MG, 60 MG day) PA; ST; QL (2 TABLETS per 1 LATUDA ORAL TABLET 80 MG 3 day) ziprasidone hcl 2 QL (2 CAPSULES per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag- Benzisoxazole Deriv PA; ST; QL (2 TABLETS per 1 FANAPT ORAL TABLET 3 day) FANAPT ORAL TABLETS,DOSE PACK 3 PA; QL (1 PACK per 720 days) INVEGA ORAL TABLET EXTENDED NF QL (1 TABLET per 1 day) RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED NF QL (2 TABLETS per 1 day) RELEASE 24HR 6 MG paliperidone oral tablet extended release 24hr 1.5 3 QL (1 TABLET per 1 day) mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr 6 3 QL (2 TABLETS per 1 day) mg
Last Approved Date: 09/24/2021 Formulary Version: 92
89 Drug Status Notes RISPERDAL ORAL SOLUTION NF QL (16 mL per 1 day) RISPERDAL ORAL TABLET 0.25 MG, 0.5 NF QL (2 TABLETS per 1 day) MG, 1 MG, 2 MG, 3 MG RISPERDAL ORAL TABLET 4 MG NF QL (4 TABLETS per 1 day) risperidone oral solution 1 QL (16 mL per 1 day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 1 QL (2 TABLETS per 1 day) mg, 3 mg risperidone oral tablet 4 mg 1 QL (4 TABLETS per 1 day) risperidone oral tablet,disintegrating 0.25 mg NF risperidone oral tablet,disintegrating 0.5 mg, 1 NF QL (2 TABLETS per 1 day) mg, 2 mg, 3 mg risperidone oral tablet,disintegrating 4 mg NF QL (4 TABLETS per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag-Butyrophenone Deriv CAPLYTA NF PA; ST; QL (1 capsule per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag-Dibenzodiazepine Der clozapine oral tablet 100 mg 3 QL (9 TABLETS per 1 day) clozapine oral tablet 200 mg 3 QL (4 TABLETS per 1 day) clozapine oral tablet 25 mg, 50 mg 2 QL (3 TABLETS per 1 day) clozapine oral tablet,disintegrating 100 mg, 12.5 3 QL (3 TABLETS per 1 day) mg, 25 mg clozapine oral tablet,disintegrating 150 mg NF QL (5 TABLETS per 1 day) clozapine oral tablet,disintegrating 200 mg NF QL (4 tablets per 1 day) CLOZARIL ORAL TABLET 100 MG NF QL (9 TABLETS per 1 day) CLOZARIL ORAL TABLET 25 MG, 50 MG NF QL (3 TABLETS per 1 day) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 NF QL (3 TABLETS per 1 day) MG, 25 MG FAZACLO ORAL NF QL (5 TABLETS per 1 day) TABLET,DISINTEGRATING 150 MG FAZACLO ORAL NF QL (4 TABLETS per 1 day) TABLET,DISINTEGRATING 200 MG VERSACLOZ NF QL (18 mL per 1 day) Antipsychotic - Butyrophenone Derivatives haloperidol lactate injection 2 haloperidol lactate oral NF Last Approved Date: 09/24/2021 Formulary Version: 92
90 Drug Status Notes haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 1 QL (3 TABLETS per 1 day) mg, 5 mg haloperidol oral tablet 20 mg 1 QL (5 TABLETS per 1 day) Antipsychotic - Dibenzoxazepine Derivatives ADASUVE NF loxapine succinate 2 Antipsychotic - Diphenylbutylpiperidine Derivatives ORAP NF pimozide 3 Antipsychotic - Phenothiazines, Aliphatic chlorpromazine oral tablet 3 Antipsychotic - Phenothiazines, Piperazine fluphenazine hcl oral concentrate NF fluphenazine hcl oral elixir 2 fluphenazine hcl oral tablet 3 perphenazine 2 trifluoperazine 2 Antipsychotic - Phenothiazines, Piperidine thioridazine 1 Antipsychotic - Thioxanthenes thiothixene 2 Antipsychotic -Atypical Dopamine- Serotonin Antag-Dibenzothiazepine Der quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 1 QL (3 TABLETS per 1 day) mg quetiapine oral tablet 300 mg, 400 mg 1 QL (2 TABLETS per 1 day) quetiapine oral tablet extended release 24 hr 150 3 QL (1 TABLET per 1 day) mg, 200 mg, 50 mg quetiapine oral tablet extended release 24 hr 300 3 QL (2 TABLETS per 1 day) mg, 400 mg SEROQUEL ORAL TABLET 100 MG, 200 MG, NF QL (3 TABLETS per 1 day) 25 MG, 50 MG
Last Approved Date: 09/24/2021 Formulary Version: 92
91 Drug Status Notes SEROQUEL ORAL TABLET 300 MG, 400 MG NF QL (2 TABLETS per 1 day) SEROQUEL XR ORAL TABLET EXTENDED NF QL (1 TABLET per 1 day) RELEASE 24 HR 150 MG, 200 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED NF QL (2 TABLETS per 1 day) RELEASE 24 HR 300 MG, 400 MG Antipsychotic -Atypical Dopamine- Serotonin Antag- Thienobenzodiazepines olanzapine oral tablet 1 QL (1 TABLET per 1 day) olanzapine oral tablet,disintegrating 2 QL (1 TABLET per 1 day) PA; ST; QL (1 CAPSULE per 1 olanzapine-fluoxetine NF day) PA; ST; QL (1 CAPSULE per 1 SYMBYAX NF day) ZYPREXA ORAL NF QL (1 TABLET per 1 day) ZYPREXA ZYDIS NF QL (1 TABLET per 1 day) Antipsychotic-Atyp Selective Serotonin 5-Ht2a Inverse Agonists (Ssia) PA; BE; QL (1 CAPSULES per 1 NUPLAZID ORAL CAPSULE NF day) PA; BE; QL (1 TABLET per 1 NUPLAZID ORAL TABLET 10 MG NF day) PA; BE; QL (2 TABLETS per 1 NUPLAZID ORAL TABLET 17 MG NF day) Antipsychotic-Atypical,D2 Receptor Partial Agonist-5Ht Serotonin Mixed PA; ST; QL (30 TABLETS per 25 ABILIFY MYCITE NF days) PA; ST; QL (30 tablets per 25 ABILIFY MYCITE MAINTENANCE KIT NF Dayss) PA; ST; QL (30 tablets per 25 ABILIFY MYCITE STARTER KIT NF Dayss) PA; ST; QL (1 TABLET per 1 ABILIFY ORAL TABLET NF day) aripiprazole oral solution 3 PA; ST; QL (30 mL per 1 day) PA; ST; QL (1 TABLET per 1 aripiprazole oral tablet 3 day) PA; ST; QL (2 TABLETS per 1 aripiprazole oral tablet,disintegrating 3 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
92 Drug Status Notes PA; ST; QL (1 TABLET per 1 REXULTI NF day) Antipsychotic-Atypical,D3/D2 Receptor Partial Agonist-Serotonin Mixed PA; ST; QL (1 CAPSULE per 1 VRAYLAR ORAL CAPSULE NF day) PA; ST; QL (1 CAPSULES per 1 VRAYLAR ORAL CAPSULE,DOSE PACK NF day) Attention Deficit-Hyperact. Disorder (Adhd)- Alpha-2 Receptor Agonist PA; ST; QL (4 TABLETS per 1 clonidine hcl oral tablet extended release 12 hr 3 day) guanfacine oral tablet extended release 24 hr 1 2 QL (7 TABLETS per 1 day) mg guanfacine oral tablet extended release 24 hr 2 2 QL (3 TABLETS per 1 day) mg guanfacine oral tablet extended release 24 hr 3 2 QL (2 TABLETS per 1 day) mg guanfacine oral tablet extended release 24 hr 4 2 QL (1 TABLET per 1 day) mg INTUNIV ER ORAL TABLET EXTENDED PA; ST; QL (7 TABLETS per 1 NF RELEASE 24 HR 1 MG day) INTUNIV ER ORAL TABLET EXTENDED PA; ST; QL (3 TABLETS per 1 NF RELEASE 24 HR 2 MG day) INTUNIV ER ORAL TABLET EXTENDED PA; ST; QL (2 TABLETS per 1 NF RELEASE 24 HR 3 MG day) INTUNIV ER ORAL TABLET EXTENDED PA; ST; QL (1 TABLET per 1 NF RELEASE 24 HR 4 MG day) PA; ST; QL (4 TABLETS per 1 KAPVAY NF day) Attention Deficit-Hyperactivity (Adhd) Therapy, Stimulant-Type ADDERALL ORAL TABLET 10 MG NF QL (6 TABLETS per 1 day) ADDERALL ORAL TABLET 12.5 MG NF QL (5 TABLETS per 1 day) ADDERALL ORAL TABLET 15 MG NF QL (4 TABLETS per 1 day) ADDERALL ORAL TABLET 20 MG NF QL (3 TABLETS per 1 day) ADDERALL ORAL TABLET 30 MG NF QL (2 TABLETS per 1 day) ADDERALL ORAL TABLET 5 MG NF QL (12 TABLETS per 1 day) ADDERALL ORAL TABLET 7.5 MG NF QL (8 TABLETS per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
93 Drug Status Notes ADDERALL XR NF QL (1 CAPSULES per 1 day) ADHANSIA XR ORAL CAPSULE, ER PA; ST; QL (3 CAPSULES per 1 NF BIPHASIC 20-80 25 MG day) ADHANSIA XR ORAL CAPSULE, ER PA; ST; QL (2 CAPSULES per 1 NF BIPHASIC 20-80 35 MG day) ADHANSIA XR ORAL CAPSULE, ER PA; ST; QL (1 CAPSULE per 1 BIPHASIC 20-80 45 MG, 55 MG, 70 MG, 85 NF day) MG amphetamine NF QL (450 ML per 1 DISPENSE) amphetamine sulfate NF PA; ST APTENSIO XR NF QL (1 CAPSULES per 1 day) AZSTARYS NF PA; ST; QL (1 capsule per 1 Day) CONCERTA ORAL TABLET EXTENDED NF QL (1 TABLET per 1 day) RELEASE 24HR 18 MG, 27 MG, 54 MG CONCERTA ORAL TABLET EXTENDED NF QL (2 TABLETS per 1 day) RELEASE 24HR 36 MG COTEMPLA XR-ODT NF SP; QL (2 TABLETS per 1 day) DAYTRANA NF QL (1 PATCH per 1 day) DESOXYN NF QL (5 TABLETS per 1 day) DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (6 CAPSULES per 1 day) EXTENDED RELEASE 10 MG DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (4 CAPSULES per 1 day) EXTENDED RELEASE 15 MG DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (12 CAPSULES per 1 day) EXTENDED RELEASE 5 MG dexmethylphenidate oral capsule,er biphasic 50- 2 QL (1 CAPSULES per 1 day) 50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg 1 QL (2 TABLETS per 1 day) dexmethylphenidate oral tablet 2.5 mg 1 QL (8 TABLETS per 1 day) dexmethylphenidate oral tablet 5 mg 1 QL (4 TABLETS per 1 day) dextroamphetamine oral capsule, extended 2 QL (6 CAPSULES per 1 day) release 10 mg dextroamphetamine oral capsule, extended 2 QL (4 CAPSULES per 1 day) release 15 mg dextroamphetamine oral capsule, extended 2 QL (12 CAPSULES per 1 day) release 5 mg dextroamphetamine oral tablet 10 mg 2 QL (6 TABLETS per 1 day) dextroamphetamine oral tablet 5 mg 2 QL (12 TABLETS per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
94 Drug Status Notes dextroamphetamine-amphetamine oral 3 QL (1 CAPSULES per 1 day) capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 10 1 QL (6 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 12.5 1 QL (5 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 15 1 QL (4 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 20 1 QL (3 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 30 1 QL (2 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 5 1 QL (12 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 7.5 1 QL (8 TABLETS per 1 day) mg DYANAVEL XR NF QL (240 ML per 25 days) EVEKEO NF PA; ST EVEKEO ODT ORAL PA; ST; QL (3 TABLETS per 1 NF TABLET,DISINTEGRATING 10 MG, 5 MG day) EVEKEO ODT ORAL PA; ST; QL (2 TABLETS per 1 NF TABLET,DISINTEGRATING 15 MG, 20 MG day) FOCALIN ORAL TABLET 10 MG NF QL (2 TABLETS per 1 day) FOCALIN ORAL TABLET 2.5 MG NF QL (8 TABLETS per 1 day) FOCALIN ORAL TABLET 5 MG NF QL (4 TABLETS per 1 day) FOCALIN XR NF QL (1 CAPSULES per 1 day) JORNAY PM NF QL (1 CAPSULE per 1 day) METADATE ER 2 QL (3 TABLETS per 1 day) methamphetamine 3 QL (5 TABLETS per 1 day) METHYLIN ORAL SOLUTION 10 MG/5 ML NF QL (1020 ML per 1 DISPENSE) METHYLIN ORAL SOLUTION 5 MG/5 ML NF QL (510 ML per 1 DISPENSE) methylphenidate hcl oral cap,er sprinkle,biphasic NF QL (1 capsule per 1 Day) 40-60 methylphenidate hcl oral capsule, er biphasic 30- 2 QL (1 CAPSULES per 1 day) 70 10 mg, 20 mg, 30 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic 50- 3 QL (1 CAPSULE per 1 day) 50 10 mg methylphenidate hcl oral capsule,er biphasic 50- 2 QL (1 CAPSULE per 1 day) 50 20 mg, 40 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
95 Drug Status Notes methylphenidate hcl oral capsule,er biphasic 50- 2 QL (2 CAPSULES per 1 day) 50 30 mg methylphenidate hcl oral capsule,er biphasic 50- NF QL (1 CAPSULE per 1 day) 50 60 mg methylphenidate hcl oral solution 10 mg/5 ml 3 QL (1020 ML per 1 DISPENSE) methylphenidate hcl oral solution 5 mg/5 ml 3 QL (510 ML per 1 DISPENSE) methylphenidate hcl oral tablet 10 mg 1 QL (6 TABLETS per 1 day) methylphenidate hcl oral tablet 20 mg 1 QL (3 TABLETS per 1 day) methylphenidate hcl oral tablet 5 mg 1 QL (12 TABLETS per 1 day) methylphenidate hcl oral tablet extended release 2 QL (6 TABLETS per 1 day) 10 mg methylphenidate hcl oral tablet extended release 2 QL (3 TABLETS per 1 day) 20 mg methylphenidate hcl oral tablet extended release 2 QL (1 TABLET per 1 day) 24hr 18 mg, 27 mg, 54 mg methylphenidate hcl oral tablet extended release 2 QL (2 TABLETS per 1 day) 24hr 36 mg methylphenidate hcl oral tablet,chewable 10 mg NF QL (6 TABLETS per 1 day) methylphenidate hcl oral tablet,chewable 2.5 mg NF QL (24 TABLETS per 1 day) methylphenidate hcl oral tablet,chewable 5 mg NF QL (12 TABLETS per 1 day) MYDAYIS NF QL (1 CAPSULE per 1 day) QUILLIVANT XR 3 QL (408 ML per 1 MONTH) RELEXXII NF QL (1 TABLET per 1 day) RITALIN NF QL (3 TABLETS per 1 day) RITALIN LA ORAL CAPSULE,ER BIPHASIC NF QL (1 CAPSULES per 1 day) 50-50 10 MG, 20 MG, 40 MG RITALIN LA ORAL CAPSULE,ER BIPHASIC NF QL (2 CAPSULES per 1 day) 50-50 30 MG VYVANSE ORAL CAPSULE 3 QL (1 CAPSULE per 1 day) ZENZEDI ORAL TABLET 10 MG 2 QL (6 TABLETS per 1 day) ZENZEDI ORAL TABLET 15 MG NF QL (4 TABLETS per 1 day) ZENZEDI ORAL TABLET 2.5 MG NF QL (24 TABLETS per 1 day) ZENZEDI ORAL TABLET 20 MG NF QL (3 TABLETS per 1 day) ZENZEDI ORAL TABLET 30 MG NF QL (2 TABLETS per 1 day) ZENZEDI ORAL TABLET 5 MG 2 QL (12 TABLETS per 1 day) ZENZEDI ORAL TABLET 7.5 MG NF QL (8 TABLETS per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
96 Drug Status Notes Attention Deficit-Hyperactivity Disorder (Adhd) Therapy, Nri-Type PA; ST; QL (10 CAPSULES per 1 atomoxetine oral capsule 10 mg 3 day) PA; ST; QL (1 CAPSULES per 1 atomoxetine oral capsule 100 mg, 80 mg 3 day) PA; ST; QL (6 CAPSULES per 1 atomoxetine oral capsule 18 mg 3 day) PA; ST; QL (4 CAPSULES per 1 atomoxetine oral capsule 25 mg 3 day) PA; ST; QL (3 CAPSULES per 1 atomoxetine oral capsule 40 mg 3 day) PA; ST; QL (2 CAPSULES per 1 atomoxetine oral capsule 60 mg 3 day) QELBREE NF PA; ST; QL (2 capsules per 1 day) PA; ST; QL (10 CAPSULES per 1 STRATTERA ORAL CAPSULE 10 MG NF day) STRATTERA ORAL CAPSULE 100 MG, 80 PA; ST; QL (1 CAPSULES per 1 NF MG day) PA; ST; QL (6 CAPSULES per 1 STRATTERA ORAL CAPSULE 18 MG NF day) PA; ST; QL (4 CAPSULES per 1 STRATTERA ORAL CAPSULE 25 MG NF day) PA; ST; QL (3 CAPSULES per 1 STRATTERA ORAL CAPSULE 40 MG NF day) PA; ST; QL (2 CAPSULES per 1 STRATTERA ORAL CAPSULE 60 MG NF day) Benzodiazepines ALPRAZOLAM INTENSOL 3 PA alprazolam oral tablet 1 PA alprazolam oral tablet extended release 24 hr 3 PA alprazolam oral tablet,disintegrating 3 PA amitriptyline-chlordiazepoxide NF ATIVAN ORAL NF chlordiazepoxide hcl 1 chlordiazepoxide-clidinium 2 clobazam 3 clonazepam oral tablet 1 clonazepam oral tablet,disintegrating NF Last Approved Date: 09/24/2021 Formulary Version: 92
97 Drug Status Notes clorazepate dipotassium 1 DIASTAT NF QL (1 kit per 1 DISPENSE) DIASTAT ACUDIAL NF QL (1 kit per 1 DISPENSE) DIAZEPAM INTENSOL NF diazepam oral solution 5 mg/5 ml (1 mg/ml) NF diazepam oral tablet 1 diazepam rectal 2 QL (1 kit per 1 DISPENSE) estazolam 2 flurazepam 2 HALCION ORAL TABLET 0.25 MG NF PA KLONOPIN NF LIBRAX (WITH CLIDINIUM) NF LORAZEPAM INTENSOL NF lorazepam oral tablet 1 midazolam in 0.9 % sod chlorid intravenous NF prefilled pump reservoir midazolam oral syrup 2 mg/ml NF PA NAYZILAM NF PA; QL (2 spray units per 25 days) ONFI NF oxazepam 3 RESTORIL NF PA; ST; BE; QL (1 FILM per 1 SYMPAZAN ORAL FILM 10 MG, 5 MG NF day) PA; ST; BE; QL (2 FILMS per 1 SYMPAZAN ORAL FILM 20 MG NF day) temazepam oral capsule 15 mg, 30 mg 1 temazepam oral capsule 22.5 mg, 7.5 mg NF TRANXENE T-TAB NF triazolam 2 PA VALIUM NF PA; ST; QL (4 blister packs per 1 VALTOCO NF dispensing event) XANAX NF PA XANAX XR NF PA Bipolar Therapy Agents - Anticonvulsant Type carbamazepine oral capsule, er multiphase 12 hr 2 Last Approved Date: 09/24/2021 Formulary Version: 92
98 Drug Status Notes carbamazepine oral suspension 100 mg/5 ml 2 carbamazepine oral suspension 200 mg/10 ml NF carbamazepine oral tablet 1 carbamazepine oral tablet extended release 12 hr 3 100 mg carbamazepine oral tablet extended release 12 hr 2 200 mg, 400 mg carbamazepine oral tablet,chewable 1 CARBATROL NF DEPAKENE NF DEPAKOTE NF DEPAKOTE ER NF DEPAKOTE SPRINKLES NF divalproex oral capsule, delayed rel sprinkle 3 divalproex oral tablet extended release 24 hr 3 divalproex oral tablet,delayed release (dr/ec) 1 EPITOL 1 EQUETRO NF LAMICTAL ODT NF LAMICTAL ODT STARTER (BLUE) NF LAMICTAL ODT STARTER (GREEN) NF LAMICTAL ODT STARTER (ORANGE) NF LAMICTAL STARTER (BLUE) KIT NF LAMICTAL STARTER (GREEN) KIT NF LAMICTAL STARTER (ORANGE) KIT NF lamotrigine oral tablet disintegrating, dose pk 3 lamotrigine oral tablet,disintegrating NF lamotrigine oral tablets,dose pack 25 mg (35) 3 TEGRETOL ORAL SUSPENSION NF TEGRETOL ORAL TABLET NF TEGRETOL XR NF valproic acid 1 valproic acid (as sodium salt) oral solution 250 1 mg/5 ml valproic acid (as sodium salt) oral solution 500 NF mg/10 ml (10 ml)
Last Approved Date: 09/24/2021 Formulary Version: 92
99 Drug Status Notes Bipolar Therapy Agents - Atypical Antipsychotics PA; ST; QL (30 TABLETS per 25 ABILIFY MYCITE NF days) PA; ST; QL (30 tablets per 25 ABILIFY MYCITE MAINTENANCE KIT NF Dayss) PA; ST; QL (30 tablets per 25 ABILIFY MYCITE STARTER KIT NF Dayss) PA; ST; QL (1 TABLET per 1 ABILIFY ORAL TABLET NF day) aripiprazole oral solution 3 PA; ST; QL (30 mL per 1 day) PA; ST; QL (1 TABLET per 1 aripiprazole oral tablet 3 day) PA; ST; QL (2 TABLETS per 1 aripiprazole oral tablet,disintegrating 3 day) asenapine maleate 3 PA; ST; QL (2 EA per 2 Days) GEODON ORAL NF QL (2 CAPSULES per 1 day) olanzapine oral tablet 1 QL (1 TABLET per 1 day) olanzapine oral tablet,disintegrating 2 QL (1 TABLET per 1 day) PA; ST; QL (1 CAPSULE per 1 olanzapine-fluoxetine NF day) quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 1 QL (3 TABLETS per 1 day) mg quetiapine oral tablet 300 mg, 400 mg 1 QL (2 TABLETS per 1 day) quetiapine oral tablet extended release 24 hr 150 3 QL (1 TABLET per 1 day) mg, 200 mg, 50 mg quetiapine oral tablet extended release 24 hr 300 3 QL (2 TABLETS per 1 day) mg, 400 mg RISPERDAL ORAL SOLUTION NF QL (16 mL per 1 day) RISPERDAL ORAL TABLET 0.25 MG, 0.5 NF QL (2 TABLETS per 1 day) MG, 1 MG, 2 MG, 3 MG RISPERDAL ORAL TABLET 4 MG NF QL (4 TABLETS per 1 day) risperidone oral solution 1 QL (16 mL per 1 day) risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 1 QL (2 TABLETS per 1 day) mg, 3 mg risperidone oral tablet 4 mg 1 QL (4 TABLETS per 1 day) risperidone oral tablet,disintegrating 0.25 mg NF risperidone oral tablet,disintegrating 0.5 mg, 1 NF QL (2 TABLETS per 1 day) mg, 2 mg, 3 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
100 Drug Status Notes risperidone oral tablet,disintegrating 4 mg NF QL (4 TABLETS per 1 day) PA; ST; QL (2 TABLETS per 1 SAPHRIS (BLACK CHERRY) 3 day) SAPHRIS SUBLINGUAL TABLET 10 MG NF PA; ST; QL (2 tablets per 1 Day) PA; ST; QL (2 TABLETS per 1 SAPHRIS SUBLINGUAL TABLET 2.5 MG NF day) SAPHRIS SUBLINGUAL TABLET 5 MG NF SEROQUEL ORAL TABLET 100 MG, 200 MG, NF QL (3 TABLETS per 1 day) 25 MG, 50 MG SEROQUEL ORAL TABLET 300 MG, 400 MG NF QL (2 TABLETS per 1 day) SEROQUEL XR ORAL TABLET EXTENDED NF QL (1 TABLET per 1 day) RELEASE 24 HR 150 MG, 200 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED NF QL (2 TABLETS per 1 day) RELEASE 24 HR 300 MG, 400 MG PA; ST; QL (1 CAPSULE per 1 SYMBYAX NF day) PA; ST; QL (1 CAPSULE per 1 VRAYLAR ORAL CAPSULE NF day) PA; ST; QL (1 CAPSULES per 1 VRAYLAR ORAL CAPSULE,DOSE PACK NF day) ziprasidone hcl 2 QL (2 CAPSULES per 1 day) ZYPREXA ORAL NF QL (1 TABLET per 1 day) ZYPREXA ZYDIS NF QL (1 TABLET per 1 day) Bipolar Therapy Agents - Lithium lithium carbonate 1 lithium citrate oral solution 8 meq/5 ml 1 LITHOBID NF Cannabis And Cannabinoid Receptor Agonists CESAMET 3 dronabinol 3 MARINOL NF SYNDROS NF Cns Stimulant - Amphetamine Combinations ADDERALL ORAL TABLET 10 MG NF QL (6 TABLETS per 1 day) ADDERALL ORAL TABLET 12.5 MG NF QL (5 TABLETS per 1 day) ADDERALL ORAL TABLET 15 MG NF QL (4 TABLETS per 1 day) Last Approved Date: 09/24/2021 Formulary Version: 92
101 Drug Status Notes ADDERALL ORAL TABLET 20 MG NF QL (3 TABLETS per 1 day) ADDERALL ORAL TABLET 30 MG NF QL (2 TABLETS per 1 day) ADDERALL ORAL TABLET 5 MG NF QL (12 TABLETS per 1 day) ADDERALL ORAL TABLET 7.5 MG NF QL (8 TABLETS per 1 day) ADDERALL XR NF QL (1 CAPSULES per 1 day) amphetamine NF QL (450 ML per 1 DISPENSE) dextroamphetamine-amphetamine oral 3 QL (1 CAPSULES per 1 day) capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 10 1 QL (6 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 12.5 1 QL (5 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 15 1 QL (4 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 20 1 QL (3 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 30 1 QL (2 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 5 1 QL (12 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 7.5 1 QL (8 TABLETS per 1 day) mg DYANAVEL XR NF QL (240 ML per 25 days) MYDAYIS NF QL (1 CAPSULE per 1 day) Cns Stimulant - Amphetamines amphetamine sulfate NF PA; ST DESOXYN NF QL (5 TABLETS per 1 day) DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (6 CAPSULES per 1 day) EXTENDED RELEASE 10 MG DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (4 CAPSULES per 1 day) EXTENDED RELEASE 15 MG DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (12 CAPSULES per 1 day) EXTENDED RELEASE 5 MG dextroamphetamine oral capsule, extended 2 QL (6 CAPSULES per 1 day) release 10 mg dextroamphetamine oral capsule, extended 2 QL (4 CAPSULES per 1 day) release 15 mg dextroamphetamine oral capsule, extended 2 QL (12 CAPSULES per 1 day) release 5 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
102 Drug Status Notes dextroamphetamine oral solution NF QL (2040 ML per 1 DISPENSE) dextroamphetamine oral tablet 10 mg 2 QL (6 TABLETS per 1 day) dextroamphetamine oral tablet 5 mg 2 QL (12 TABLETS per 1 day) EVEKEO NF PA; ST EVEKEO ODT ORAL PA; ST; QL (3 TABLETS per 1 NF TABLET,DISINTEGRATING 10 MG, 5 MG day) EVEKEO ODT ORAL PA; ST; QL (2 TABLETS per 1 NF TABLET,DISINTEGRATING 15 MG, 20 MG day) methamphetamine 3 QL (5 TABLETS per 1 day) PROCENTRA NF QL (2040 ML per 1 MONTH) ZENZEDI ORAL TABLET 10 MG 2 QL (6 TABLETS per 1 day) ZENZEDI ORAL TABLET 15 MG NF QL (4 TABLETS per 1 day) ZENZEDI ORAL TABLET 2.5 MG NF QL (24 TABLETS per 1 day) ZENZEDI ORAL TABLET 20 MG NF QL (3 TABLETS per 1 day) ZENZEDI ORAL TABLET 30 MG NF QL (2 TABLETS per 1 day) ZENZEDI ORAL TABLET 5 MG 2 QL (12 TABLETS per 1 day) ZENZEDI ORAL TABLET 7.5 MG NF QL (8 TABLETS per 1 day) Cns Stimulant - Analeptics, Methylxanthine-Type caffeine citrate oral NF Diabetic Peripheral Neuropathy Agents PA; ST; QL (1 TABLET per 1 LYRICA CR NF day) pregabalin oral tablet extended release 24 hr NF PA; ST; QL (1 tablet per 1 Day) Fibromyalgia Agents - Gaba Analogs LYRICA NF PA; ST pregabalin oral capsule 3 PA; ST pregabalin oral solution 3 PA; ST Fibromyalgia Agents - Serotonin- Norepinephrine Reuptake-Inhib (Snris) CYMBALTA ORAL CAPSULE,DELAYED NF QL (2 CAPSULES per 1 day) RELEASE(DR/EC) 20 MG, 60 MG CYMBALTA ORAL CAPSULE,DELAYED NF QL (1 CAPSULE per 1 day) RELEASE(DR/EC) 30 MG DRIZALMA SPRINKLE NF PA; QL (1 CAPSULE per 1 day) duloxetine oral capsule,delayed release(dr/ec) 20 1 QL (2 CAPSULES per 1 day) mg, 60 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
103 Drug Status Notes duloxetine oral capsule,delayed release(dr/ec) 30 1 QL (1 CAPSULE per 1 day) mg duloxetine oral capsule,delayed release(dr/ec) 40 NF mg SAVELLA 3 PA; ST Hsdd Agents-Mixed Serotonin Agonist/Antagonists ADDYI 3 PA; QL (1 TABLET per 1 day) Hsdd Agents-Non-Selective Melanocortin Receptor Agonist PA; BE; QL (4 auto-injectors per VYLEESI NF 25 days) Hypnotics - Melatonin M1/M2 Receptor Agonists PA; SP; BE; QL (1 CAPSULES HETLIOZ 4 per 1 day) PA; BE; QL (158 ML per 25 HETLIOZ LQ NF Dayss) ramelteon 3 PA; ST ROZEREM NF PA; ST Migraine Therapy - Analgesic- Vasoconstrictors isomethepten-caf-acetaminophen NF PRODRIN NF Migraine Therapy - Analgesic- Vasoconstrictor-Sedative Combinations isometh-dichloral-acetaminophn NF Migraine Therapy - Carboxylic Acid Derivatives DEPAKOTE ER NF divalproex oral tablet extended release 24 hr 3 Migraine Therapy - Cgrp Ligand Blocker, Monoclonal Antibody PA; ST; QL (5 ML (3 syringes) AJOVY AUTOINJECTOR 4 per 75 dayss) PA; ST; QL (5 ML (3 AJOVY SYRINGE 4 SYRINGES) per 75 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
104 Drug Status Notes EMGALITY PEN 4 PA; ST; QL (1 unit per 25 days) EMGALITY SYRINGE SUBCUTANEOUS 4 PA; ST; QL (1 unit per 25 days) SYRINGE 120 MG/ML Migraine Therapy - Cgrp Receptor Blockers (Gepants) NURTEC ODT NF QL (18 tablets per 25 days) UBRELVY NF QL (16 tablets per 30 days) Migraine Therapy - Cgrp Receptor Blockers, Monoclonal Antibody AIMOVIG AUTOINJECTOR 4 PA; ST; QL (1 ML per 25 days) AIMOVIG AUTOINJECTOR (2 PACK) 4 PA; ST; QL (2 ML per 25 days) Migraine Therapy - Ergot Alkaloids And Derivatives dihydroergotamine injection 3 PA; ST; QL (8 AMPULES per 25 dihydroergotamine nasal NF days) ERGOMAR 3 QL (20 tablets per 25 days) MIGRANAL NF QL (8 AMPULES per 25 days) Migraine Therapy - Ergot Combinations CAFERGOT NF MIGERGOT NF Migraine Therapy - Nsaid Analgesics(Cyclooxygenase Inhib-Non- Selectiv) QL (9 UNITS (1 BOX) per 1 CAMBIA NF DISPENSE) Migraine Therapy - Selective Serotonin Agonists 5-Ht(1) almotriptan malate 3 PA; ST; QL (100 MG per 25 days) AMERGE NF QL (20 MG per 25 days) eletriptan 3 PA; ST; QL (240 MG per 25 days) FROVA NF QL (30 MG per 25 days) frovatriptan 3 PA; ST; QL (30 MG per 25 days) IMITREX NF QL (900 MG per 25 days) IMITREX STATDOSE PEN SUBCUTANEOUS NF QL (900 MG per 25 days) PEN INJECTOR 4 MG/0.5 ML
Last Approved Date: 09/24/2021 Formulary Version: 92
105 Drug Status Notes IMITREX STATDOSE REFILL NF QL (900 MG per 25 days) SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML MAXALT ORAL TABLET 10 MG NF QL (120 MG per 25 days) MAXALT-MLT NF QL (120 MG per 25 days) naratriptan 1 QL (20 MG per 25 days) RELPAX NF PA; ST; QL (240 MG per 25 days) rizatriptan 1 QL (120 MG per 25 days) sumatriptan NF QL (900 MG per 25 days) sumatriptan succinate oral tablet 100 mg, 50 mg 1 QL (900 MG per 25 days) sumatriptan succinate oral tablet 25 mg 3 QL (900 MG per 25 days) sumatriptan succinate subcutaneous pen injector NF QL (900 MG per 25 days) 4 mg/0.5 ml sumatriptan succinate subcutaneous pen injector 3 QL (900 MG per 25 days) 6 mg/0.5 ml sumatriptan succinate subcutaneous solution NF QL (900 MG per 25 days) sumatriptan succinate subcutaneous syringe 6 3 mg/0.5 ml SUMAVEL DOSEPRO NF QL (900 MG per 25 days) TOSYMRA NF PA; ST; QL (900 mg per 25 days) zolmitriptan nasal NF QL (40 mg per 25 days) zolmitriptan oral 2 QL (40 MG per 25 days) ZOMIG NF QL (40 MG per 25 days) ZOMIG ZMT NF QL (40 MG per 25 days) Migraine Therapy - Selective Serotonin Agonists 5-Ht(1F) REYVOW ORAL TABLET 100 MG NF QL (8 tablets per 25 Dayss) REYVOW ORAL TABLET 50 MG NF QL (4 tablets per 25 Dayss) Migraine Therapy - Serotonin Agonist 5-Ht(1) And Nsaid Comb. TREXIMET NF QL (9 TABLETS per 25 days) Movement Disorder Drug Therapy PA; BE; QL (4 TABLETS per 1 AUSTEDO ORAL TABLET 12 MG, 6 MG NF day) PA; BE; QL (5 TABLETS per 1 AUSTEDO ORAL TABLET 9 MG NF day) PA; BE; QL (28 CAPSULES per INGREZZA INITIATION PACK NF 365 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
106 Drug Status Notes PA; BE; QL (1 CAPSULE per 1 INGREZZA ORAL CAPSULE 40 MG NF day) INGREZZA ORAL CAPSULE 60 MG NF PA; BE; QL (1 tablet per 1 day) PA; BE; QL (1 TABLET per 1 INGREZZA ORAL CAPSULE 80 MG NF day) PA; BE; QL (3 TABLETS per 1 tetrabenazine oral tablet 12.5 mg 4 day) PA; BE; QL (2 TABLETS per 1 tetrabenazine oral tablet 25 mg 4 day) PA; ST; SP; BE; QL (3 TABLETS XENAZINE ORAL TABLET 12.5 MG NF per 1 day) PA; ST; SP; BE; QL (2 TABLETS XENAZINE ORAL TABLET 25 MG NF per 1 day) Movement Disorder Therapy - Huntington's Disease PA; BE; QL (4 TABLETS per 1 AUSTEDO ORAL TABLET 12 MG, 6 MG NF day) PA; BE; QL (5 TABLETS per 1 AUSTEDO ORAL TABLET 9 MG NF day) PA; BE; QL (3 TABLETS per 1 tetrabenazine oral tablet 12.5 mg 4 day) PA; BE; QL (2 TABLETS per 1 tetrabenazine oral tablet 25 mg 4 day) PA; ST; SP; BE; QL (3 TABLETS XENAZINE ORAL TABLET 12.5 MG NF per 1 day) PA; ST; SP; BE; QL (2 TABLETS XENAZINE ORAL TABLET 25 MG NF per 1 day) Movement Disorder Therapy - Restless Legs Syndrome HORIZANT 3 PA; ST Movement Disorder Therapy - Tardive Dyskinesia PA; BE; QL (4 TABLETS per 1 AUSTEDO ORAL TABLET 12 MG, 6 MG NF day) PA; BE; QL (5 TABLETS per 1 AUSTEDO ORAL TABLET 9 MG NF day) PA; BE; QL (28 CAPSULES per INGREZZA INITIATION PACK NF 365 days) PA; BE; QL (1 CAPSULE per 1 INGREZZA ORAL CAPSULE 40 MG NF day) Last Approved Date: 09/24/2021 Formulary Version: 92
107 Drug Status Notes INGREZZA ORAL CAPSULE 60 MG NF PA; BE; QL (1 tablet per 1 day) PA; BE; QL (1 TABLET per 1 INGREZZA ORAL CAPSULE 80 MG NF day) Narcolepsy And Cataplexy Therapy Agents - Sedative-Type PA; ST; BE; QL (540 ML per 30 XYREM 4 days) PA; ST; BE; QL (540 ML per 30 XYWAV NF days) Narcolepsy Therapy Agents - Dopamine And Ne Reuptake Inhibitor (Dnri) PA; ST; QL (1 TABLET per 1 SUNOSI NF day) Narcolepsy Therapy Agents - H3- Receptor Antagonist/Inverse Agonist PA; ST; BE; QL (2 TABLETS per WAKIX NF 1 day) Narcolepsy Therapy Agents - Non- Sympathomimetic PA; ST; QL (1 TABLET per 1 armodafinil oral tablet 150 mg, 200 mg, 250 mg 3 day) PA; ST; QL (2 TABLETS per 1 armodafinil oral tablet 50 mg 3 day) modafinil 3 PA; QL (1 TABLET per 1 day) NUVIGIL ORAL TABLET 150 MG, 200 MG, PA; ST; QL (1 TABLET per 1 NF 250 MG day) PA; ST; QL (2 TABLETS per 1 NUVIGIL ORAL TABLET 50 MG NF day) PA; ST; QL (1 TABLET per 1 PROVIGIL NF day) Narcolepsy Therapy Agents - Stimulant- Type, Piperadine Derivative METHYLIN ORAL SOLUTION 10 MG/5 ML NF QL (1020 ML per 1 DISPENSE) METHYLIN ORAL SOLUTION 5 MG/5 ML NF QL (510 ML per 1 DISPENSE) methylphenidate hcl oral solution 10 mg/5 ml 3 QL (1020 ML per 1 DISPENSE) methylphenidate hcl oral solution 5 mg/5 ml 3 QL (510 ML per 1 DISPENSE) methylphenidate hcl oral tablet 10 mg 1 QL (6 TABLETS per 1 day) methylphenidate hcl oral tablet 20 mg 1 QL (3 TABLETS per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
108 Drug Status Notes methylphenidate hcl oral tablet 5 mg 1 QL (12 TABLETS per 1 day) methylphenidate hcl oral tablet,chewable 10 mg NF QL (6 TABLETS per 1 day) methylphenidate hcl oral tablet,chewable 2.5 mg NF QL (24 TABLETS per 1 day) methylphenidate hcl oral tablet,chewable 5 mg NF QL (12 TABLETS per 1 day) RITALIN NF QL (3 TABLETS per 1 day) Narcolepsy Therapy Agents- Stimulant- Type,Sympathomimetic,Amphetamines ADDERALL ORAL TABLET 10 MG NF QL (6 TABLETS per 1 day) ADDERALL ORAL TABLET 12.5 MG NF QL (5 TABLETS per 1 day) ADDERALL ORAL TABLET 15 MG NF QL (4 TABLETS per 1 day) ADDERALL ORAL TABLET 20 MG NF QL (3 TABLETS per 1 day) ADDERALL ORAL TABLET 30 MG NF QL (2 TABLETS per 1 day) ADDERALL ORAL TABLET 5 MG NF QL (12 TABLETS per 1 day) ADDERALL ORAL TABLET 7.5 MG NF QL (8 TABLETS per 1 day) amphetamine sulfate NF PA; ST DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (6 CAPSULES per 1 day) EXTENDED RELEASE 10 MG DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (4 CAPSULES per 1 day) EXTENDED RELEASE 15 MG DEXEDRINE SPANSULE ORAL CAPSULE, NF QL (12 CAPSULES per 1 day) EXTENDED RELEASE 5 MG dextroamphetamine oral capsule, extended 2 QL (6 CAPSULES per 1 day) release 10 mg dextroamphetamine oral capsule, extended 2 QL (4 CAPSULES per 1 day) release 15 mg dextroamphetamine oral capsule, extended 2 QL (12 CAPSULES per 1 day) release 5 mg dextroamphetamine oral tablet 10 mg 2 QL (6 TABLETS per 1 day) dextroamphetamine oral tablet 5 mg 2 QL (12 TABLETS per 1 day) dextroamphetamine-amphetamine oral tablet 10 1 QL (6 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 12.5 1 QL (5 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 15 1 QL (4 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 20 1 QL (3 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 30 1 QL (2 TABLETS per 1 day) mg Last Approved Date: 09/24/2021 Formulary Version: 92
109 Drug Status Notes dextroamphetamine-amphetamine oral tablet 5 1 QL (12 TABLETS per 1 day) mg dextroamphetamine-amphetamine oral tablet 7.5 1 QL (8 TABLETS per 1 day) mg EVEKEO NF PA; ST ZENZEDI ORAL TABLET 10 MG 2 QL (6 TABLETS per 1 day) ZENZEDI ORAL TABLET 15 MG NF QL (4 TABLETS per 1 day) ZENZEDI ORAL TABLET 2.5 MG NF QL (24 TABLETS per 1 day) ZENZEDI ORAL TABLET 20 MG NF QL (3 TABLETS per 1 day) ZENZEDI ORAL TABLET 30 MG NF QL (2 TABLETS per 1 day) ZENZEDI ORAL TABLET 5 MG 2 QL (12 TABLETS per 1 day) ZENZEDI ORAL TABLET 7.5 MG NF QL (8 TABLETS per 1 day) Neuropathic Pain Therapy PA; ST; QL (1 TABLET per 1 LYRICA CR NF day) pregabalin oral tablet extended release 24 hr NF PA; ST; QL (1 tablet per 1 Day) Postherpetic Neuralgia Agents GRALISE 30-DAY STARTER PACK NF PA; ST GRALISE ORAL TABLET EXTENDED NF PA; ST RELEASE 24 HR PA; ST; QL (1 TABLET per 1 LYRICA CR NF day) pregabalin oral tablet extended release 24 hr NF PA; ST; QL (1 tablet per 1 Day) Pseudobulbar Affect (Pba) Agents, Nmda Antagonists Type NUEDEXTA 3 PA Sedative-Hypnotic - Antihistamines diphenhydramine hcl oral capsule 50 mg NF Sedative-Hypnotic - Barbiturates BUTISOL NF phenobarbital oral elixir 2 phenobarbital oral tablet 1 SECONAL SODIUM NF Sedative-Hypnotic - Benzodiazepines estazolam 2 flurazepam 2
Last Approved Date: 09/24/2021 Formulary Version: 92
110 Drug Status Notes HALCION ORAL TABLET 0.25 MG NF PA midazolam oral syrup 2 mg/ml NF PA RESTORIL NF temazepam oral capsule 15 mg, 30 mg 1 temazepam oral capsule 22.5 mg, 7.5 mg NF triazolam 2 PA Sedative-Hypnotic - Gaba-Receptor Modulators AMBIEN NF PA; ST AMBIEN CR NF PA; ST EDLUAR NF PA; ST eszopiclone 2 INTERMEZZO NF PA; ST LUNESTA NF PA; ST SONATA NF zaleplon 1 zolpidem oral tablet 1 zolpidem oral tablet,ext release multiphase 2 zolpidem sublingual NF PA; ST Sedative-Hypnotic - Orexin Receptor Antagonist PA; ST; QL (1 TABLET per 1 BELSOMRA 3 day) DAYVIGO NF PA; ST; QL (1 tablet per 1 Day) Sedative-Hypnotic - Tricyclic Antidepressant Type doxepin oral tablet NF PA; ST SILENOR NF PA; ST Chemical Dependency, Agents To Treat Agents For Opioid Withdrawal, Central Alpha-2 Adrenergic Agonist-Type QL (14 DAY SUPPLY per 90 LUCEMYRA 3 days) Agents For Opioid Withdrawal, Opioid- Type BUNAVAIL BUCCAL FILM 2.1-0.3 MG 3 QL (6 FILMS per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
111 Drug Status Notes BUNAVAIL BUCCAL FILM 4.2-0.7 MG 3 QL (3 FILMS per 1 day) BUNAVAIL BUCCAL FILM 6.3-1 MG 3 QL (2 FILMS per 1 day) PA; QL (5 DAY SUPPLY per 60 buprenorphine hcl sublingual 1 days) buprenorphine-naloxone sublingual film 12-3 mg 1 QL (2 FILMS per 1 day) buprenorphine-naloxone sublingual film 2-0.5 mg 1 QL (5 FILMS per 1 day) buprenorphine-naloxone sublingual film 4-1 mg 1 QL (4 FILMS per 1 day) buprenorphine-naloxone sublingual film 8-2 mg 1 QL (3 FILMS per 1 day) buprenorphine-naloxone sublingual tablet 2-0.5 NF QL (5 TABLETS per 1 day) mg buprenorphine-naloxone sublingual tablet 8-2 mg NF QL (3 TABLETS per 1 day) SUBOXONE SUBLINGUAL FILM 12-3 MG NF QL (2 FILMS per 1 day) SUBOXONE SUBLINGUAL FILM 2-0.5 MG NF QL (5 FILMS per 1 day) SUBOXONE SUBLINGUAL FILM 4-1 MG NF QL (4 FILMS per 1 day) SUBOXONE SUBLINGUAL FILM 8-2 MG NF QL (3 FILMS per 1 day) SUBOXONE SUBLINGUAL TABLET NF ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 3 QL (3 TABLETS per 1 day) MG, 5.7-1.4 MG ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 3 QL (4 tablets per 1 day) MG ZUBSOLV SUBLINGUAL TABLET 11.4-2.9 3 QL (2 TABLETS per 1 day) MG, 8.6-2.1 MG ZUBSOLV SUBLINGUAL TABLET 2.9-0.71 3 QL (3 tablets per 1 day) MG Alcohol Abstinence Therapy - Glutamate And Gaba System Type acamprosate 3 Alcohol Deterrents ANTABUSE NF disulfiram 2 Smoking Deterrents - Ne And Dopamine Reuptake Inhibitor (Ndri)- Type bupropion hcl (smoking deter) $0 ZYBAN $0 Smoking Deterrents - Nicotine-Type NICODERM CQ $0
Last Approved Date: 09/24/2021 Formulary Version: 92
112 Drug Status Notes NICORELIEF $0 NICORETTE BUCCAL GUM $0 NICORETTE BUCCAL LOZENGE $0 nicotine $0 nicotine (polacrilex) buccal gum $0 nicotine (polacrilex) buccal lozenge $0 NICOTROL $0 NICOTROL NS $0 QUIT 2 $0 QUIT 4 $0 STOP SMOKING AID $0 Smoking Deterrents - Nicotinic Receptor Partial Agonist, Alpha4beta2 CHANTIX $0 CHANTIX CONTINUING MONTH BOX $0 CHANTIX STARTING MONTH BOX $0 varenicline NF Chemicals-Pharmaceutical Adjuvants Pharmaceutical Adjuvant - Flavoring Agents ethyl acetate NF Pharmaceutical Adjuvant - Inhalation Vehicles HYPER-SAL NF NEBUSAL INHALATION SOLUTION FOR NF NEBULIZATION 6 % PULMOSAL 2 sodium chloride inhalation 2 Cognitive Disorder Therapy Alzheimer's Disease Therapy - Cholinesterase Inhibitors ARICEPT NF donepezil oral tablet 10 mg, 5 mg 1 donepezil oral tablet 23 mg 3 donepezil oral tablet,disintegrating 2 EXELON PATCH NF Last Approved Date: 09/24/2021 Formulary Version: 92
113 Drug Status Notes galantamine oral capsule,ext rel. pellets 24 hr 2 galantamine oral solution NF galantamine oral tablet 2 RAZADYNE ER NF RAZADYNE ORAL TABLET NF rivastigmine NF rivastigmine tartrate 3 Alzheimer's Disease Therapy - Nmda Receptor Antagonists memantine oral solution 3 memantine oral tablet 2 memantine oral tablets,dose pack NF NAMENDA ORAL TABLET NF NAMENDA TITRATION PAK NF NAMENDA XR NF Alzheimer's Thx - Nmda Receptor Antag. And Cholinesterase Inhib. Comb NAMZARIC NF Cognitive Disorder Therapy - Cerebral Vasodilators ergoloid 3 Contraceptives Contraceptive - Vaginal Ph Modulator PHEXXI NF Contraceptive Implant - Progestin NEXPLANON $0 Contraceptive Injectable - Progestin DEPO-PROVERA INTRAMUSCULAR NF SUSPENSION 150 MG/ML DEPO-PROVERA INTRAMUSCULAR NF SYRINGE DEPO-SUBQ PROVERA 104 NF medroxyprogesterone intramuscular $0 Contraceptive Intrauterine - Copper Iud PARAGARD T 380A $0 Last Approved Date: 09/24/2021 Formulary Version: 92
114 Drug Status Notes Contraceptive Intrauterine - Progesterone Iud LILETTA $0 MIRENA NF SKYLA NF Contraceptive Oral - Biphasic AMETHIA $0 AMETHIA LO $0 ASHLYNA $0 AZURETTE (28) $0 BEKYREE (28) $0 CAMRESE $0 CAMRESE LO $0 DAYSEE $0 desog-e.estradiol/e.estradiol $0 KARIVA (28) $0 l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), $0 0.15 mg-30 mcg (84)/10 mcg (7) LO LOESTRIN FE NF LOSEASONIQUE NF MIRCETTE (28) NF PIMTREA (28) $0 SEASONIQUE NF VIORELE (28) $0 Contraceptive Oral - Monophasic ALTAVERA (28) $0 ALYACEN 1/35 (28) $0 AMETHYST (28) $0 APRI $0 AUBRA $0 AUROVELA 1/20 (21) $0 AUROVELA FE 1.5/30 (28) $0 AVIANE $0 BALCOLTRA NF BALZIVA (28) $0
Last Approved Date: 09/24/2021 Formulary Version: 92
115 Drug Status Notes BEYAZ NF BLISOVI 24 FE $0 BLISOVI FE 1/20 (28) $0 BREVICON (28) NF BRIELLYN $0 CHATEAL (28) $0 CRYSELLE (28) $0 CYCLAFEM 1/35 (28) $0 CYRED $0 DASETTA 1/35 (28) $0 DELYLA (28) $0 desogestrel-ethinyl estradiol $0 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02- NF 0.451 mg (24) (4) drospirenone-ethinyl estradiol $0 ELINEST $0 EMOQUETTE $0 ENSKYCE $0 ESTARYLLA $0 FALMINA (28) $0 GEMMILY NF GENERESS FE NF GIANVI (28) $0 HAILEY 24 FE $0 HAILEY FE 1.5/30 (28) $0 INTROVALE $0 JOLESSA $0 JULEBER $0 JUNEL 1.5/30 (21) $0 JUNEL 1/20 (21) $0 JUNEL FE 1.5/30 (28) $0 JUNEL FE 1/20 (28) $0 JUNEL FE 24 $0 KELNOR 1/35 (28) $0 KURVELO (28) $0 LARIN 1.5/30 (21) $0
Last Approved Date: 09/24/2021 Formulary Version: 92
116 Drug Status Notes LARIN 1/20 (21) $0 LARIN 24 FE $0 LARIN FE 1.5/30 (28) $0 LARIN FE 1/20 (28) $0 LAYOLIS FE $0 LESSINA $0 levonorgestrel-ethinyl estrad $0 LEVORA-28 $0 LOESTRIN 1.5/30 (21) NF LOESTRIN 1/20 (21) NF LOESTRIN FE 1.5/30 (28-DAY) NF LOESTRIN FE 1/20 (28-DAY) NF LORYNA (28) $0 LOW-OGESTREL (28) $0 LUTERA (28) $0 MARLISSA (28) $0 MIBELAS 24 FE NF MICROGESTIN 1.5/30 (21) $0 MICROGESTIN 1/20 (21) $0 MICROGESTIN 24 FE NF MICROGESTIN FE 1.5/30 (28) $0 MICROGESTIN FE 1/20 (28) $0 MINASTRIN 24 FE NF MONO-LINYAH $0 MONONESSA (28) $0 NECON 0.5/35 (28) $0 NEXTSTELLIS NF NIKKI (28) $0 noreth-ethinyl estradiol-iron $0 norethindrone ac-eth estradiol oral tablet 1-20 $0 mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet $0 norgestimate-ethinyl estradiol oral tablet 0.25-35 $0 mg-mcg NORTREL 0.5/35 (28) $0 NORTREL 1/35 (21) $0
Last Approved Date: 09/24/2021 Formulary Version: 92
117 Drug Status Notes OCELLA $0 OGESTREL (28) $0 ORSYTHIA $0 ORTHO-CYCLEN (28) NF ORTHO-NOVUM 1/35 (28) NF PHILITH $0 PIRMELLA ORAL TABLET 1-35 MG-MCG $0 PORTIA 28 $0 PREVIFEM $0 QUASENSE $0 RAJANI NF RECLIPSEN (28) $0 SAFYRAL NF SETLAKIN $0 SPRINTEC (28) $0 SRONYX $0 SYEDA $0 TARINA FE 1/20 (28) $0 TAYTULLA NF TYDEMY NF VIENVA $0 VYFEMLA (28) $0 WERA (28) $0 WYMZYA FE $0 YASMIN (28) NF YAZ (28) NF ZARAH $0 ZENCHENT (28) $0 ZOVIA 1/35E (28) $0 Contraceptive Oral - Progestin CAMILA $0 DEBLITANE $0 ERRIN $0 HEATHER $0 JENCYCLA $0 JOLIVETTE $0 Last Approved Date: 09/24/2021 Formulary Version: 92
118 Drug Status Notes LYZA $0 NORA-BE $0 norethindrone (contraceptive) $0 NORLYROC $0 ORTHO MICRONOR NF SHAROBEL $0 SLYND NF Contraceptive Oral - Quadraphasic NATAZIA NF QUARTETTE NF Contraceptive Oral - Triphasic ALYACEN 7/7/7 (28) $0 ARANELLE (28) $0 CAZIANT (28) $0 CYCLAFEM 7/7/7 (28) $0 CYCLESSA (28) NF DASETTA 7/7/7 (28) $0 ENPRESSE $0 ESTROSTEP FE-28 NF LEENA 28 $0 LEVONEST (28) $0 levonorg-eth estrad triphasic $0 MYZILRA $0 norgestimate-ethinyl estradiol oral tablet $0 0.18/0.215/0.25 mg-35 mcg (28) NORTREL 7/7/7 (28) $0 ORTHO TRI-CYCLEN (28) NF ORTHO TRI-CYCLEN LO (28) NF ORTHO-NOVUM 7/7/7 (28) NF PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 $0 MCG TILIA FE $0 TRI-ESTARYLLA $0 TRI-LEGEST FE $0 TRI-LINYAH $0 TRI-LO-ESTARYLLA $0
Last Approved Date: 09/24/2021 Formulary Version: 92
119 Drug Status Notes TRINESSA (28) $0 TRI-NORINYL (28) NF TRI-PREVIFEM (28) $0 TRI-SPRINTEC (28) $0 TRIVORA (28) $0 TRI-VYLIBRA $0 VELIVET TRIPHASIC REGIMEN (28) $0 Contraceptive Transdermal Combinations - Estrogen And Progestin Comb. TWIRLA NF XULANE $0 Contraceptives - Intravaginal, Systemic - Estrogen And Progestin Comb. ANNOVERA NF QL (1 ring per 275 days) ELURYNG $0 etonogestrel-ethinyl estradiol $0 NUVARING NF Emergency Contraceptives AFTERA NF ECONTRA EZ $0 ELLA $0 MY WAY $0 NEXT CHOICE ONE DOSE $0 OPCICON ONE-STEP $0 PLAN B ONE-STEP NF TAKE ACTION NF Emergency Contraceptives - Progesterone Agonist/Antagonist Type ELLA $0 Emergency Contraceptives - Progestin Type AFTERA NF ECONTRA EZ $0 MY WAY $0 NEXT CHOICE ONE DOSE $0 Last Approved Date: 09/24/2021 Formulary Version: 92
120 Drug Status Notes OPCICON ONE-STEP $0 PLAN B ONE-STEP NF TAKE ACTION NF Spermicides CONCEPTROL $0 GYNOL II $0 TODAY CONTRACEPTIVE SPONGE $0 VAGINAL CONTRACEPTIVE FILM $0 VAGINAL CONTRACEPTIVE FOAM $0 VCF CONTRACEPTIVE FILM $0 Dermatological Acne Therapy Systemic - Retinoids And Derivatives ABSORICA NF PA; ST ABSORICA LD NF PA; ST AMNESTEEM 3 CLARAVIS 3 isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 3 PA; ST mg isotretinoin oral capsule 25 mg, 35 mg NF PA; ST MYORISAN 3 ZENATANE 3 Acne Therapy Systemic - Tetracycline Antibiotic minocycline oral capsule,extended release 24hr NF PA; ST minocycline oral tablet extended release 24 hr NF PA; ST MINOLIRA ER NF PA; ST SEYSARA NF PA; ST SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 NF PA; ST; BE MG, 80 MG Acne Therapy Topical - Androgen Receptor Inhibitors PA; ST; QL (60 GM per 1 WINLEVI NF Dispense)
Last Approved Date: 09/24/2021 Formulary Version: 92
121 Drug Status Notes Acne Therapy Topical - Anti-Infective ACZONE NF AMZEEQ NF PA; ST azelaic acid 3 PA; ST AZELEX NF CLEOCIN T NF CLINDACIN P NF CLINDAGEL NF PA; ST clindamycin phosphate topical foam NF QL (100 GM per 1 DISPENSE) clindamycin phosphate topical gel 1 clindamycin phosphate topical lotion 1 clindamycin phosphate topical solution 1 clindamycin phosphate topical swab NF dapsone topical gel NF BE dapsone topical gel with pump NF ERY PADS 1 ERYGEL 3 BE erythromycin with ethanol topical gel 3 erythromycin with ethanol topical solution 1 erythromycin with ethanol topical swab 1 EVOCLIN NF QL (100 GM per 1 MONTH) FINACEA TOPICAL FOAM 3 PA; ST FINACEA TOPICAL GEL NF PA; ST KLARON NF sulfacetamide sodium (acne) 3 Acne Therapy Topical - Anti-Infective- Keratolytic Combinations ACANYA TOPICAL GEL WITH PUMP NF PA; ST AVAR LS TOPICAL CLEANSER NF AVAR LS TOPICAL PADS, MEDICATED NF AVAR TOPICAL CLEANSER 2 AVAR TOPICAL FOAM NF BE AVAR TOPICAL PADS, MEDICATED NF AVAR-E GREEN NF AVAR-E LS NF BENZACLIN NF Last Approved Date: 09/24/2021 Formulary Version: 92
122 Drug Status Notes BP 10-1 NF BE clindamycin-benzoyl peroxide topical gel 1.2 %(1 2 % base) -5 % clindamycin-benzoyl peroxide topical gel 1-5 % 3 clindamycin-benzoyl peroxide topical gel with NF pump 1.2-2.5 % DUAC NF BE erythromycin-benzoyl peroxide 2 NEUAC 2 BE ONEXTON TOPICAL GEL WITH PUMP NF PA; ST PLEXION NF PLEXION CLEANSING CLOTHS NF ROSANIL NF BE ROSULA NF BE ROSULA CLEANSING CLOTHS NF SSS 10-5 TOPICAL CREAM NF SSS 10-5 TOPICAL FOAM NF BE sulfacetamide sodium-sulfur topical cleanser 10-2 NF %, 9-4 %, 9-4.5 %, 9.8-4.8 % sulfacetamide sodium-sulfur topical cleanser 10-5 2 % (w/w) sulfacetamide sodium-sulfur topical cream 10-2 NF %, 9.8-4.8 % sulfacetamide sodium-sulfur topical lotion 10-5 % NF BE (w/v) sulfacetamide sodium-sulfur topical lotion 9.8-4.8 NF % sulfacetamide sodium-sulfur topical pads, NF medicated 10-4 % sulfacetamide sodium-sulfur topical suspension 8- NF 4 % SUMADAN TOPICAL CLEANSER NF SUMAXIN NF SUMAXIN TS NF Acne Therapy Topical - Anti-Infective- Retinoid Combinations VELTIN NF BE ZIANA NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
123 Drug Status Notes Acne Therapy Topical - Keratolytic BENZEFOAM ULTRA NF BENZEPRO (MICROSPHERES) NF BE BENZEPRO TOPICAL TOWELETTE NF benzoyl peroxide topical cleanser 7 % NF benzoyl peroxide topical foam 9.8 % NF BPO TOPICAL GEL 4 % NL BPO TOPICAL GEL 8 % NF BPO TOPICAL TOWELETTE NL ENZOCLEAR NF INOVA NF PACNEX NF Acne Therapy Topical - Keratolytic Combinations Other INOVA 4-1 NF INOVA 8-2 NF Acne Therapy Topical - Keratolytic Mixtures NUOX NF BE Acne Therapy Topical - Keratolytic- Glucocorticoid Combinations VANOXIDE-HC NF Acne Therapy Topical - Retinoid Combinations Other adapalene-benzoyl peroxide 3 EPIDUO FORTE NF EPIDUO TOPICAL GEL WITH PUMP NF BE Acne Therapy Topical - Retinoids And Derivatives adapalene topical cream NF adapalene topical gel 0.1 % NF adapalene topical gel 0.3 % 2 adapalene topical lotion NF adapalene topical solution NF adapalene topical swab NF AKLIEF NF PA; ST Last Approved Date: 09/24/2021 Formulary Version: 92
124 Drug Status Notes ALTRENO NF PA; ST; BE ARAZLO NF PA; ST ATRALIN NF PA; ST; BE AVITA TOPICAL CREAM 2 BE AVITA TOPICAL GEL NF BE DIFFERIN TOPICAL CREAM NF DIFFERIN TOPICAL GEL WITH PUMP NF DIFFERIN TOPICAL LOTION NF FABIOR NF PA; ST PLIXDA NF BE RETIN-A MICRO NF PA; ST; BE RETIN-A MICRO PUMP NF PA; ST; BE RETIN-A TOPICAL CREAM NF PA; ST; BE RETIN-A TOPICAL GEL NF PA; ST; BE RETIN-A TOPICAL LIQUID NF tazarotene topical foam NF PA; ST tretinoin 2 BE tretinoin microspheres topical gel NF BE TRETIN-X CREAM KIT NF PA; BE TRETIN-X TOPICAL CREAM 0.075 % NF PA; BE Antipsoriatic - Retinoid (Vitamin A Derivative) - Glucocorticoid PA; ST; QL (1 tube (100g) per 1 DUOBRII NF dispensing event) Antipsoriatic - Vitamin D Analog - Glucocorticoid Combinations calcipotriene-betamethasone topical ointment NF PA; ST calcipotriene-betamethasone topical suspension 3 PA; ST ENSTILAR NF PA; ST TACLONEX NF PA; ST WYNZORA NF PA; ST Antipsoriatic Agents - Interleukin 12 And Il-23 Inhibitors,Mc Antibody PA; ST; BE; QL (1 vial per 63 STELARA SUBCUTANEOUS SOLUTION 4 days) STELARA SUBCUTANEOUS SYRINGE 45 PA; ST; SP; BE; QL (1 vial per 63 4 MG/0.5 ML days) Last Approved Date: 09/24/2021 Formulary Version: 92
125 Drug Status Notes STELARA SUBCUTANEOUS SYRINGE 90 PA; ST; SP; BE; QL (1 SYRINGE 4 MG/ML per 63 days) Antipsoriatic Agents - Interleukin-23 (Il-23) Antagonist, Mc Antibody PA; ST; BE; QL (1 150mg/ml per SKYRIZI SUBCUTANEOUS PEN INJECTOR 4 84 days) SKYRIZI SUBCUTANEOUS SYRINGE 150 PA; ST; BE; QL (1 150mg/ml per 4 MG/ML 84 days) PA; ST; BE; QL (1 kit per 63 SKYRIZI SUBCUTANEOUS SYRINGE KIT 4 days) TREMFYA SUBCUTANEOUS AUTO- PA; ST; BE; QL (1 ML (1 unit) 4 INJECTOR per 42 days) PA; ST; SP; BE; QL (1 ML (1 TREMFYA SUBCUTANEOUS SYRINGE 4 UNIT) per 42 days) Antipsoriatic Agents-Interleukin-17 (Il- 17) Antagonist, Mc Antibody PA; ST; SP; BE; QL (2 ML per 21 COSENTYX (2 SYRINGES) 4 days) PA; ST; SP; BE; QL (2 ML per 21 COSENTYX PEN 4 days) PA; ST; SP; BE; QL (2 ML per 21 COSENTYX PEN (2 PENS) 4 days) COSENTYX SUBCUTANEOUS SYRINGE 150 PA; ST; SP; BE; QL (2 ML per 21 4 MG/ML days) COSENTYX SUBCUTANEOUS SYRINGE 75 PA; ST; BE; QL (1 syringe 4 MG/0.5 ML (75mg/0.5ml) per 28 days) PA; ST; BE; QL (2 SYRINGES SILIQ NF per 21 days) PA; ST; SP; BE; QL (1 ML per 21 TALTZ AUTOINJECTOR 4 days) PA; ST; SP; BE; QL (1 ML per 21 TALTZ AUTOINJECTOR (2 PACK) 4 days) PA; ST; SP; BE; QL (1 ML per 21 TALTZ AUTOINJECTOR (3 PACK) 4 days) PA; ST; SP; BE; QL (1 ML per 21 TALTZ SYRINGE 4 days) PA; ST; BE; QL (1 ML per 21 TALTZ SYRINGE (2 PACK) 4 Dayss) PA; ST; BE; QL (1 ML per 21 TALTZ SYRINGE (3 PACK) 4 Dayss)
Last Approved Date: 09/24/2021 Formulary Version: 92
126 Drug Status Notes Dermatitis Or Eczema Agents, Systemic-Interleukin-4 (Il-4Ra) Antag.Mab DUPIXENT PEN SUBCUTANEOUS PEN PA; ST; QL (2 syringes per 21 4 INJECTOR 300 MG/2 ML Dayss) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; QL (3 ML (2 4 SYRINGE 200 MG/1.14 ML syringes) per 21 days) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; QL (2 SYRINGES 4 SYRINGE 300 MG/2 ML per 21 days) Dermatitis Or Eczema Agents, Topical - Phosphodiesterase-4 Inhibitors EUCRISA NF PA; QL (60 GM per 1 DISPENSE) Dermatological - Antibacterial Aminoglycosides gentamicin topical 1 Dermatological - Antibacterial Other BACTROBAN TOPICAL CREAM NF CENTANY NF mupirocin 1 mupirocin calcium NF PA; ST Dermatological - Antibacterial Pleuromutilin Derivatives ALTABAX 3 Dermatological - Antibacterial Quinolones XEPI NF PA; ST; QL (30 GM per 30 days) Dermatological - Antibacterial- Glucocorticoid Combinations CORTISPORIN TOPICAL CREAM NF CORTISPORIN TOPICAL OINTMENT 3 NEO-SYNALAR 3 Dermatological - Anticholinergic Hyperhidrosis Treatment Agents QBREXZA NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
127 Drug Status Notes Dermatological - Antifungal Allylamines naftifine topical cream 1 % NF PA; ST naftifine topical cream 2 % 3 PA; ST naftifine topical gel 3 PA; ST NAFTIN TOPICAL CREAM 2 % NF PA; ST NAFTIN TOPICAL GEL NF PA; ST Dermatological - Antifungal Amphoteric Polyene Macrolides NYAMYC 1 nystatin topical 1 NYSTOP 1 Dermatological - Antifungal Benzylamines MENTAX 3 Dermatological - Antifungal Hydroxypyridinone CICLODAN TOPICAL CREAM 2 CICLODAN TOPICAL SOLUTION NF ciclopirox topical cream 2 ciclopirox topical gel 2 ciclopirox topical shampoo 2 ciclopirox topical solution 3 ciclopirox topical suspension 1 LOPROX TOPICAL SHAMPOO NF PA; ST PENLAC NF Dermatological - Antifungal Imidazole And Related Agents clotrimazole topical NF econazole 2 ECOZA NF PA; ST ERTACZO NF PA; ST EXELDERM NF PA; ST EXTINA NF PA; ST ketoconazole topical cream 1 ketoconazole topical foam 3 PA; ST Last Approved Date: 09/24/2021 Formulary Version: 92
128 Drug Status Notes ketoconazole topical shampoo 1 KETODAN 3 PA; ST KETODAN KIT 2 PA; ST LUZU 3 PA; ST miconazole nitrate-zinc ox-pet NF PA; ST NIZORAL TOPICAL SHAMPOO NF oxiconazole 3 PA; ST OXISTAT 3 PA; ST sulconazole NF PA; ST VUSION NF PA; ST XOLEGEL NF PA; ST Dermatological - Antifungal Oxaborole PA; ST; QL (10 ML per 1 KERYDIN NF DISPENSE) PA; ST; QL (10 ML per 1 tavaborole 3 Dispense) Dermatological - Antifungal Triazole PA; ST; QL (4 ML per 1 JUBLIA 3 DISPENSE) Dermatological - Antifungal- Glucocorticoid Combinations clotrimazole-betamethasone topical cream 1 clotrimazole-betamethasone topical lotion 2 LOTRISONE TOPICAL CREAM NF nystatin-triamcinolone 3 Dermatological - Antineoplastic Alkylating Agents VALCHLOR 4 PA; ST; BE Dermatological - Antineoplastic Antimetabolites CARAC NF PA; ST EFUDEX TOPICAL CREAM NF PA; ST EFUDEX TOPICAL SOLUTION NF FLUOROPLEX NF fluorouracil topical cream 3 fluorouracil topical solution 2
Last Approved Date: 09/24/2021 Formulary Version: 92
129 Drug Status Notes TOLAK NF Dermatological - Antineoplastic Or Premalig. Lesions - Antimicrotubule PA; ST; QL (5 packets per 60 KLISYRI NF days) Dermatological - Antineoplastic Or Premalig. Lesions -Diterpene Esters PICATO 4 PA; ST Dermatological - Antineoplastic Or Premalignant Lesions - Nsaid's diclofenac sodium topical gel 3 % NF PA; ST SOLARAZE NF PA; ST Dermatological - Antineoplastic Retinoids PANRETIN 4 BE Dermatological - Antineoplastic Selective Retinoid X Receptor Agonist TARGRETIN TOPICAL 4 SP Dermatological - Antiperspirants aluminum chloride 1 DRYSOL DAB-O-MATIC NF Dermatological - Antipsoriatic Agents Systemic, Photosensitizing methoxsalen 4 OXSORALEN ULTRA NF Dermatological - Antipsoriatic Agents Systemic, Vitamin A Derivatives acitretin 4 SORIATANE ORAL CAPSULE 10 MG, 17.5 NF MG, 25 MG Dermatological - Antipsoriatic Agents Topical PA; ST; QL (200 GM per 1 BRYHALI NF Dispense) calcipotriene scalp 3 calcipotriene topical cream 3
Last Approved Date: 09/24/2021 Formulary Version: 92
130 Drug Status Notes calcipotriene topical foam NF PA; ST calcipotriene topical ointment 3 CALCITRENE 3 calcitriol topical 3 PA; ST DOVONEX TOPICAL NF PA; ST PA; ST; QL (50 GM per 1 halobetasol propionate topical foam NF Dispense) PA; ST; QL (60 GM per 1 IMPOYZ NF Dispense) PA; ST; QL (50 GM per 1 LEXETTE NF Dispense) SORILUX NF PA; ST TAZORAC TOPICAL CREAM 0.05 % 3 PA; ST TAZORAC TOPICAL CREAM 0.1 % NF PA; ST TAZORAC TOPICAL GEL NF PA; ST VECTICAL NF PA; ST Dermatological - Antipsoriatics Systemic, Phosphodiesterase 4 Inhib. PA; ST; SP; BE; QL (2 TABLETS OTEZLA 4 per 1 day) PA; ST; SP; BE; QL (1 pack per OTEZLA STARTER 4 23 days) Dermatological - Antiseborrheic OVACE PLUS SHAMPOO NF OVACE PLUS TOPICAL CREAM NF OVACE PLUS TOPICAL FOAM NF OVACE PLUS TOPICAL LOTION NF SEB-PREV NF selenium sulfide topical lotion 1 selenium sulfide topical shampoo 2.25 % 2 selenium sulfide topical shampoo 2.3 % 3 SELRX NF sulfacetamide sodium topical cleanser NF sulfacetamide sodium topical shampoo NF TERSI FOAM NF Dermatological - Antiviral, Herpes acyclovir topical cream NF Last Approved Date: 09/24/2021 Formulary Version: 92
131 Drug Status Notes acyclovir topical ointment 3 DENAVIR 3 PA; ST ZOVIRAX TOPICAL NF Dermatological - Antiviral- Glucocorticoid Combinations XERESE NF PA; ST Dermatological - Burn Products Anti- Infective SILVADENE NF silver sulfadiazine 1 SSD 1 SULFAMYLON TOPICAL CREAM 3 SULFAMYLON TOPICAL PACKET NF Dermatological - Calcineurin Inhibitors ELIDEL NF PA; ST pimecrolimus 3 PA; ST PROTOPIC NF PA; ST tacrolimus topical 3 PA; ST Dermatological - Emollients ammonium lactate NF Dermatological - Enzymes QL (90 GM per 1 dispensing SANTYL 3 event) Dermatological - Glucocorticoid ALA-CORT TOPICAL CREAM 1 % NF ALA-CORT TOPICAL CREAM 2.5 % 1 ALA-SCALP NF PA; ST alclometasone 1 PA; ST; QL (60 GM per 1 amcinonide topical cream 3 Dispense) amcinonide topical lotion 3 PA; ST amcinonide topical ointment 3 PA; ST PA; ST; QL (60 GM per 1 APEXICON E 3 Dispense) betamethasone dipropionate 1 betamethasone valerate topical cream 1
Last Approved Date: 09/24/2021 Formulary Version: 92
132 Drug Status Notes PA; ST; QL (100 GM per 1 betamethasone valerate topical foam NF Dispense) betamethasone valerate topical lotion 1 betamethasone valerate topical ointment 1 betamethasone, augmented 1 PA; ST; QL (200 GM per 1 BRYHALI NF Dispense) PA; ST; QL (120 ML per 1 CAPEX NF Dispense) clobetasol scalp 2 clobetasol topical cream 2 clobetasol topical foam 3 QL (100 GM per 1 Dispense) clobetasol topical gel 2 clobetasol topical lotion 2 clobetasol topical ointment 2 clobetasol topical shampoo 2 clobetasol topical spray,non-aerosol NF clobetasol-emollient topical cream 3 clobetasol-emollient topical foam NF PA; ST PA; ST; QL (118 ML per 1 CLOBEX TOPICAL LOTION NF Dispense) PA; ST; QL (118 ML per 1 CLOBEX TOPICAL SHAMPOO NF Dispense) PA; ST; QL (125 ML per 1 CLOBEX TOPICAL SPRAY,NON-AEROSOL NF Dispense) PA; ST; QL (90 GM per 1 clocortolone pivalate NF Dispense) CLODAN 2 PA; ST; QL (90 GM per 1 CLODERM NF Dispense) PA; ST; QL (2 UNITS per 1 CORDRAN TAPE LARGE ROLL NF DISPENSE) PA; ST; QL (1 box/roll per 1 CORDRAN TAPE SMALL ROLL NF Dispense) PA; ST; QL (120 GM per 1 CORDRAN TOPICAL CREAM NF Dispense) PA; ST; QL (120 ML per 1 CORDRAN TOPICAL LOTION NF Dispense)
Last Approved Date: 09/24/2021 Formulary Version: 92
133 Drug Status Notes PA; ST; QL (60 GM per 1 CORDRAN TOPICAL OINTMENT NF Dispense) CORMAX SCALP 2 PA; ST; QL (60 GM per 1 CUTIVATE TOPICAL CREAM NF Dispense) PA; ST; QL (120 ML per 1 CUTIVATE TOPICAL LOTION NF Dispense) DERMA-SMOOTHE/FS BODY OIL 2 DERMA-SMOOTHE/FS SCALP OIL 2 DERMATOP TOPICAL OINTMENT NF PA; ST; QL (60 GM per 1 DESONATE NF Dispense) desonide topical cream 2 PA; ST; QL (60 GM per 1 desonide topical gel NF Dispense) desonide topical lotion NF desonide topical ointment 1 PA; ST; QL (60 GM per 1 DESOWEN TOPICAL CREAM NF Dispense) PA; ST; QL (118 ML per 1 DESOWEN TOPICAL LOTION NF Dispense) PA; ST; QL (100 GM per 1 desoximetasone topical cream 0.05 % 3 Dispense) desoximetasone topical cream 0.25 % 1 desoximetasone topical gel 2 PA; ST; QL (100 GM per 1 desoximetasone topical ointment 0.05 % 3 Dispense) desoximetasone topical ointment 0.25 % 2 desoximetasone topical spray,non-aerosol NF PA; ST; QL (60 GM per 1 diflorasone topical cream 4 Dispense) PA; ST; QL (60 GM per 1 diflorasone topical ointment NF Dispense) DIPROLENE (AUGMENTED) TOPICAL NF PA; ST LOTION DIPROLENE (AUGMENTED) TOPICAL PA; ST; QL (100 GM per 1 3 OINTMENT Dispense) DIPROLENE AF NF PA; ST ELOCON TOPICAL CREAM NF
Last Approved Date: 09/24/2021 Formulary Version: 92
134 Drug Status Notes ELOCON TOPICAL OINTMENT NF fluocinolone 2 fluocinonide topical cream 0.05 % 1 fluocinonide topical cream 0.1 % NF fluocinonide topical gel 1 fluocinonide topical ointment 1 fluocinonide topical solution 1 PA; ST; QL (120 GM per 1 flurandrenolide topical cream NF Dispense) PA; ST; QL (120 ML per 1 flurandrenolide topical lotion NF Dispense) PA; ST; QL (60 GM per 1 flurandrenolide topical ointment NF Dispense) fluticasone propionate topical cream 1 fluticasone propionate topical lotion NF fluticasone propionate topical ointment 3 PA; ST; QL (216 GM per 1 halcinonide 3 Dispense) halobetasol propionate topical cream 1 PA; ST; QL (50 GM per 1 halobetasol propionate topical foam NF Dispense) halobetasol propionate topical ointment 1 PA; ST; QL (216 GM per 1 HALOG TOPICAL CREAM NF Dispense) PA; ST; QL (60 GM per 1 HALOG TOPICAL OINTMENT 4 Dispense) PA; ST; QL (120 ML per 1 HALOG TOPICAL SOLUTION NF Dispense) hydrocortisone butyrate topical cream NF hydrocortisone butyrate topical ointment 1 hydrocortisone butyrate topical solution 1 hydrocortisone topical cream 0.5 %, 1 % NF hydrocortisone topical cream 2.5 % 1 hydrocortisone topical lotion NF hydrocortisone topical ointment 0.5 %, 1 % NF hydrocortisone topical ointment 2.5 % 1 hydrocortisone valerate 2 hydrocortisone-pramoxine topical cream 2.5-1 % 2 Last Approved Date: 09/24/2021 Formulary Version: 92
135 Drug Status Notes PA; ST; QL (68 ml (1 bottle) per 1 IMPEKLO NF dispensing event) PA; ST; QL (60 GM per 1 IMPOYZ NF Dispense) PA; ST; QL (200 GM per 1 KENALOG TOPICAL NF Dispense) PA; ST; QL (50 GM per 1 LEXETTE NF Dispense) PA; ST; QL (60 GM per 1 LOCOID LIPOCREAM NF Dispense) LOCOID TOPICAL CREAM NF PA; ST PA; ST; QL (118 ML per 1 LOCOID TOPICAL LOTION NF Dispense) LOCOID TOPICAL OINTMENT NF PA; ST LOCOID TOPICAL SOLUTION NF PA; ST PA; ST; QL (100 GM per 1 LUXIQ NF Dispense) mometasone topical 1 PA; ST; QL (120 GM per 1 NOLIX TOPICAL CREAM 3 Dispense) PA; ST; QL (120 ML per 1 NOLIX TOPICAL LOTION 3 Dispense) PA; ST; QL (100 GM per 1 OLUX NF Dispense) PA; ST; QL (100 GM per 1 OLUX-E NF Dispense) PANDEL NF prednicarbate topical cream NF prednicarbate topical ointment 1 PROCTOCORT TOPICAL NF PROCTO-PAK 3 PROCTOZONE-HC 1 PA; ST; QL (60 GM per 1 PSORCON NF Dispense) SCALACORT NF SCALACORT DK NF PA; ST; QL (120 ML per 1 SERNIVO NF Dispense)
Last Approved Date: 09/24/2021 Formulary Version: 92
136 Drug Status Notes PA; ST; QL (120 GM per 1 SYNALAR TOPICAL CREAM NF Dispense) PA; ST; QL (120 GM per 1 SYNALAR TOPICAL OINTMENT NF Dispense) PA; ST; QL (90 ML per 1 SYNALAR TOPICAL SOLUTION NF Dispense) PA; ST; QL (60 GM per 1 TEMOVATE TOPICAL CREAM NF Dispense) PA; ST; QL (30 GM per 1 TEMOVATE TOPICAL OINTMENT NF Dispense) PA; ST; QL (30 ML per 1 TEXACORT NF Dispense) PA; ST; QL (100 GM per 1 TOPICORT TOPICAL CREAM 0.05 % NF Dispense) PA; ST; QL (60 GM per 1 TOPICORT TOPICAL CREAM 0.25 % NF Dispense) PA; ST; QL (60 GM per 1 TOPICORT TOPICAL GEL NF Dispense) PA; ST; QL (100 GM per 1 TOPICORT TOPICAL OINTMENT 0.05 % NF Dispense) PA; ST; QL (60 GM per 1 TOPICORT TOPICAL OINTMENT 0.25 % NF Dispense) TOPICORT TOPICAL SPRAY,NON- PA; ST; QL (100 ML per 1 NF AEROSOL Dispense) triamcinolone acetonide topical aerosol NF triamcinolone acetonide topical cream 1 triamcinolone acetonide topical lotion 1 triamcinolone acetonide topical ointment 0.025 1 %, 0.1 %, 0.5 % PA; ST; QL (430 GM per 1 triamcinolone acetonide topical ointment 0.05 % NF Dispense) PA; ST; QL (430 GM per 1 TRIANEX NF Dispense) PA; ST; QL (85.2 GM per 1 TRIDERM TOPICAL CREAM 0.1 % 1 Dispense) TRIDERM TOPICAL CREAM 0.5 % 1 PA; ST PA; ST; QL (60 GM per 1 TRIDESILON NF Dispense) ULTRAVATE TOPICAL CREAM NF PA; ST ULTRAVATE TOPICAL OINTMENT NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
137 Drug Status Notes PA; ST; QL (120 GM per 1 VANOS NF Dispense) PA; ST; QL (100 GM per 1 VERDESO NF Dispense) Dermatological - Glucocorticoid- Emollient Combinations DERMASORB TA COMPLETE KIT NF SYNALAR CREAM KIT NF PA; ST SYNALAR OINTMENT KIT NF PA; ST ULTRAVATE X NF PA; ST Dermatological - Glucocorticoid-Local Anesthetic Combinations ANALPRAM-HC TOPICAL NF EPIFOAM 3 hydrocortisone-pramoxine topical cream 2.5-1 % 2 PRAMOSONE E NF PRAMOSONE TOPICAL CREAM 1-1 % NF PRAMOSONE TOPICAL LOTION NF PRAMOSONE TOPICAL OINTMENT NF Dermatological - Glucocorticoid-Skin Cleanser Combinations CLODAN KIT NF DERMASORB HC COMPLETE KIT NF SYNALAR TS NF PA; ST Dermatological - Immunomodulator - Catechins - Genital Wart/Hpv Tx VEREGEN 3 Dermatological - Immunomodulator - Imidazoquinolinamines ALDARA NF PA; ST imiquimod topical cream in metered-dose pump NF PA imiquimod topical cream in packet 3.75 % NF PA; ST imiquimod topical cream in packet 5 % 1 ZYCLARA TOPICAL CREAM IN METERED- NF PA; ST DOSE PUMP 2.5 % ZYCLARA TOPICAL CREAM IN PACKET NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
138 Drug Status Notes Dermatological - Keratolytic Combinations Other URAMAXIN GT TOPICAL KIT,CREAM AND NF GEL Dermatological - Keratolytic- Antimitotic Single Agents CONDYLOX TOPICAL GEL NF podofilox 2 Dermatological - Keratoplastic Tar Products coal tar NF Dermatological - Local Anesthetic Combinations lidocaine-prilocaine topical cream 2 QL (1 UNIT per 23 days) Dermatological - Nsaid Single Agents diclofenac epolamine NF QL (60 PATCHES per 180 days) diclofenac sodium topical drops NF QL (450 ML per 23 days) diclofenac sodium topical gel 1 % 3 QL (300 GRAMS per 23 days) FLECTOR NF QL (60 PATCHES per 180 days) LICART NF QL (30 patches per 180 Dayss) PENNSAID TOPICAL SOLUTION IN NF PA; ST; QL (112 GM per 23 days) METERED-DOSE PUMP VENNGEL ONE NF VOLTAREN TOPICAL NF QL (300 GM per 23 days) Dermatological - Photodynamic Therapy Agents Topical LEVULAN 3 Dermatological - Protectants STRATAMARK NF STRATATRIZ NF Dermatological - Rosacea Therapy, Systemic doxycycline monohydrate oral capsule,ir - delay NF rel,biphase ORACEA NF
Last Approved Date: 09/24/2021 Formulary Version: 92
139 Drug Status Notes Dermatological - Rosacea Therapy, Topical azelaic acid 3 PA; ST AZELEX NF FINACEA TOPICAL FOAM 3 PA; ST FINACEA TOPICAL GEL NF PA; ST ivermectin topical cream NF PA; ST METROCREAM NF PA; ST METROGEL TOPICAL GEL 0.75 % NF METROGEL TOPICAL GEL 1 % NF PA; ST METROGEL TOPICAL GEL WITH PUMP NF PA; ST METROLOTION NF PA; ST metronidazole topical cream 2 metronidazole topical gel 0.75 % 2 metronidazole topical gel 1 % NF metronidazole topical lotion NF MIRVASO 3 PA; ST NORITATE NF PA; ST RHOFADE NF PA; ST ROSADAN TOPICAL CREAM NF ROSADAN TOPICAL GEL 2 ROSADAN TOPICAL KIT, CLEANSER AND NF PA; ST GEL ROSADAN TOPICAL KIT,CLEANSER AND NF PA; ST CREAM SOOLANTRA NF PA; ST ZILXI NF ST; QL (1 can per 30 days) Dermatological - Topical Local Anesthetic Amides lidocaine hcl mucous membrane jelly 1 QL (60 ML per 30 days) lidocaine hcl mucous membrane jelly in NF QL (60 ML per 30 days) applicator lidocaine hcl topical cream 3 % 2 lidocaine topical adhesive patch,medicated 5 % NF PA; ST lidocaine topical ointment NF PA; QL (50 GM per 30 days) lidocaine-tetracaine NF LIDODERM NF PA; ST Last Approved Date: 09/24/2021 Formulary Version: 92
140 Drug Status Notes LIDOZION NF PLIAGLIS 3 PA ZTLIDO NF PA; ST; QL (3 units per 1 day) Dermatological - Topical Local Anesthetics And Combinations PRILO PATCH II NF Dermatological Antipruritics - Antihistamines doxepin topical 3 PA; ST; QL (45 GM per 90 days) PRUDOXIN NF PA; ST; QL (45 GM per 90 days) PA; ST; QL (45 GRAMS per 90 ZONALON NF days) Scabicide And Pediculicide Single Agents CROTAN NF ELIMITE NF EURAX 3 ivermectin topical lotion 3 lindane topical shampoo 3 malathion 2 NATROBA NF OVIDE NF permethrin 3 SKLICE NF spinosad 3 QL (6 bottles (1362 g) per 1 ULESFIA NF dispensing event) Wound Care - Growth Factor Agents REGRANEX 1 BE Diagnostic Agents Diagnostic Drugs - Metabolic Function MACRILEN NF QL (2 units per 720 days) METOPIRONE NF
Last Approved Date: 09/24/2021 Formulary Version: 92
141 Drug Status Notes Drugs To Treat Erectile Dysfunction Erectile Dysfunction (Ed) Drugs - Prostaglandins CAVERJECT IMPULSE NL BE; QL (18 injections per 75 days) CAVERJECT INTRACAVERNOSAL RECON NL BE; QL (18 injections per 75 days) SOLN EDEX NF BE; QL (18 injections per 75 days) BE; QL (18 suppositories per 75 MUSE NF days) Erectile Dysfunction (Ed) Drugs- Sel.Cgmp Phosphodiesterase Type5 Inhib PA; ST; BE; QL (18 TABLETS CIALIS ORAL TABLET 10 MG, 20 MG NF per 75 days) PA; ST; BE; QL (90 TABLETS CIALIS ORAL TABLET 2.5 MG, 5 MG NF per 75 days) BE; QL (18 TABLETS per 75 LEVITRA NF days) BE; QL (18 TABLETS per 75 sildenafil 3 days) BE; QL (18 TABLETS per 75 STAXYN NF days) BE; QL (6 TABLETS per 1 STENDRA NF prescription) BE; QL (18 TABLETS per 75 tadalafil oral tablet 10 mg, 20 mg 3 days) BE; QL (90 TABLETS per 75 tadalafil oral tablet 2.5 mg, 5 mg 3 days) PA; ST; BE; QL (18 TABLETS vardenafil oral tablet NF per 75 days) BE; QL (18 TABLETS per 75 VIAGRA NF days) Eating Disorder Therapy Anorexiant Combinations QSYMIA ORAL CAPSULE, ER MULTIPHASE PA; BE; QL (1 CAPSULE per 1 NF 24 HR 11.25-69 MG, 15-92 MG day) QSYMIA ORAL CAPSULE, ER MULTIPHASE PA; BE; QL (2 CAPSULES per 1 NF 24 HR 3.75-23 MG, 7.5-46 MG day)
Last Approved Date: 09/24/2021 Formulary Version: 92
142 Drug Status Notes Anorexiants ADIPEX-P NF BE benzphetamine oral tablet 25 mg NF BE benzphetamine oral tablet 50 mg 3 BE diethylpropion 3 BE LOMAIRA NF BE phendimetrazine tartrate 3 BE phentermine oral capsule 15 mg, 37.5 mg 3 BE phentermine oral capsule 30 mg NF BE phentermine oral tablet 3 BE REGIMEX NF BE Anti-Obesity - Fat Absorption Decreasing Agents PA; BE; QL (3 CAPSULES per 1 XENICAL NF day) Anti-Obesity - Glucagon-Like Peptide-1 (Glp-1) Receptor Agonists PA; ST; BE; QL (5 pens (15ml) SAXENDA NF per 30 days) WEGOVY NF PA Anti-Obesity - Melanocortin 4 (Mc4) Receptor Agonist PA; BE; QL (10 ML (10 vials) per IMCIVREE NF 25 days) Anti-Obesity-Opioid Antag/Norepinephrine And Dopamine Reuptake Inhibit CONTRAVE NF PA; BE; QL (4 tablets per 1 day) Appetite Stimulants - Cannabinoids dronabinol 3 MARINOL NF SYNDROS NF Appetite Stimulants - Progestin Hormone Type MEGACE ES NF megestrol oral suspension 400 mg/10 ml (40 1 mg/ml) Last Approved Date: 09/24/2021 Formulary Version: 92
143 Drug Status Notes megestrol oral suspension 625 mg/5 ml (125 NF mg/ml) Electrolyte Balance-Nutritional Products Amino Acid - Carnitine Derivatives levocarnitine oral tablet NF Amino Acids, Single Ingredient, Oral (Non-Injectable) PA; ST; SP; QL (6 packets per 1 ENDARI NF day) B-Complex Vitamin Combinations B COMPLEX 100 ORAL $0 BE b complex-vitamin c-folic acid oral tablet $0 BE B-100 COMPLEX NL BALANCED B-100 ORAL TABLET $0 BE B-COMPLEX NL b-complex with vitamin c oral tablet $0 BE DIALYVITE 800 ORAL TABLET $0 BE DIALYVITE 800 WITH ZINC 15 NF BE DIALYVITE 800 WITH ZINC 50 NF BE FULL SPECTRUM B-VITAMIN C $0 BE KOBEE $0 BE NATURAL B-100 COMPLEX $0 BE RENA-VITE $0 BE SUPER B COMPLEX-VITAMIN C $0 BE SUPER B MAXI COMPLEX $0 BE SUPER QUINTS $0 BE SUPERVITE NF BE vitamin b complex-folic acid oral tablet $0 BE B-Complex Vitamins B COMPLEX 1 $0 BE B COMPLEX-VITAMIN B12 NL BALANCE B-100 $0 BE BALANCE B-50 $0 BE BALANCED B-50 $0 BE BALANCED B-50 COMPLEX $0 BE
Last Approved Date: 09/24/2021 Formulary Version: 92
144 Drug Status Notes B-COMPLEX NL SUPER B-50 COMPLEX PLUS $0 BE vitamin b complex oral tablet $0 BE B-Complex Vitamins And Combinations RENA-VITE RX NL Diluents - Sodium Chloride sodium chloride 0.9 % injection NF Electrolyte Depleters - Ion Exchange Resin KIONEX (WITH SORBITOL) 1 LOKELMA ORAL POWDER IN PACKET 10 4 PA; QL (3 Packets per 1 day) GRAM LOKELMA ORAL POWDER IN PACKET 5 4 PA; QL (6 Packets per 1 day) GRAM sodium polystyrene sulfonate rectal enema 30 1 gram/120 ml VELTASSA 4 PA; QL (1 packet per 1 day) Irrigation Solutions lactated ringers irrigation NF PHYSIOLYTE NF PHYSIOSOL IRRIGATION NF ringer's irrigation 2 sodium chloride irrigation 1 water for irrigation, sterile 1 Minerals And Electrolytes - Calcium Replacement/Vitamin D Combinations CALCIUM 500 + D ORAL TABLET 500 NL MG(1,250MG) -400 UNIT CALCIUM 500 WITH D $0 BE CALCIUM 600 + D(3) ORAL CAPSULE 3 BE CALCIUM 600 + D(3) ORAL TABLET 600 NF BE MG(1,500MG) -200 UNIT calcium carbonate-vitamin d3 oral capsule 600 3 BE mg(1,500mg) -400 unit calcium citrate-vitamin d3 oral tablet 315 mg-5 3 BE mcg (200 unit)
Last Approved Date: 09/24/2021 Formulary Version: 92
145 Drug Status Notes OYSTER SHELL CALCIUM-VIT D3 ORAL $0 BE TABLET 250-125 MG-UNIT Minerals And Electrolytes - Iodine SSKI 2 STRONG IODINE ORAL 1 Minerals And Electrolytes - Iron ACCRUFER NF PA; ST; QL (2 capsules per 1 Day) AURYXIA 4 CHILDREN'S IRON $0 FE C PLUS 2 ferrous sulfate oral drops $0 ferrous sulfate oral syringe 15 mg iron (75 $0 mg)/ml NOVAFERRUM ORAL DROPS NF WEE CARE $0 Minerals And Electrolytes - Iron Combinations BIFERA RX NF CORVITA 150 2 CORVITE 150 NF FEROCON 2 FERROCITE PLUS 1 FERROGELS FORTE 1 FOCALGIN DSS 2 FOLIVANE-F 1 FOLIVANE-PLUS 1 FUSION PLUS 2 FUSION SPRINKLES NF HEMATINIC PLUS VIT/MINERALS 1 HEMATINIC/FOLIC ACID 1 HEMOCYTE-F NF MULTIGEN FOLIC NF MULTIGEN PLUS NF PROFERRIN-FORTE 2 TL-HEM 150 2 TRIGELS-F FORTE 1
Last Approved Date: 09/24/2021 Formulary Version: 92
146 Drug Status Notes VIRT-FEFA PLUS NF Minerals And Electrolytes - Potassium Combinations potassium bicarb and chloride 2 Minerals And Electrolytes - Potassium For Injection potassium chloride intravenous 1 Minerals And Electrolytes - Potassium, Oral EFFER-K 2 K-EFFERVESCENT 2 KLOR-CON NF KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 1 KLOR-CON M20 1 KLOR-CON SPRINKLE 1 KLOR-CON/EF 2 K-TAB ORAL TABLET EXTENDED 2 RELEASE 10 MEQ K-TAB ORAL TABLET EXTENDED NF RELEASE 20 MEQ K-TAB ORAL TABLET EXTENDED 1 RELEASE 8 MEQ potassium bicarb-citric acid 2 potassium chloride oral capsule, extended release 1 potassium chloride oral liquid 2 potassium chloride oral packet NF potassium chloride oral tablet extended release 1 10 meq, 8 meq potassium chloride oral tablet,er 1 particles/crystals 15 meq, 20 meq Multivitamin And Mineral Combinations CONCEPT OB NF BE CORVITE FREE NF BE
Last Approved Date: 09/24/2021 Formulary Version: 92
147 Drug Status Notes MACUZIN NF BE SUPERVITE (EC) NF BE VOL-PLUS 1 BE Multivitamins VIRT-PN DHA NF BE Nutritional Product - Lipid Others DOJOLVI NF PA; ST Nutritional Product - Medical Condition Specific Formulation PA; ST; SP; QL (6 packets per 1 ENDARI NF day) Pediatric Vitamins CHEWABLE MULTIVIT-A,B,D,E,K,ZN 2 BE PED MULTIVITAMINS-A,B,D,E,K,ZN 2 BE Pediatric Vitamins With Fluoride And Minerals Combinations MYKIDZ IRON FLUORIDE NF BE Pediatric Vitamins With Fluoride Combinations ESCAVITE $0 BE ESCAVITE D NF BE ESCAVITE LQ $0 BE FLORIVA $0 BE FLORIVA (FLUORIDE-VITAMIN D3) $0 BE FLORIVA PLUS NF BE MULTIVITAMIN WITH FLUORIDE $0 BE MULTI-VITAMIN WITH FLUORIDE ORAL $0 BE TABLET,CHEWABLE 0.25 MG, 0.5 MG MULTIVITAMINS WITH FLUORIDE $0 BE MULTIVIT-FLUOR (VIT E ACETATE) $0 BE MVC-FLUORIDE $0 BE QUFLORA NF BE QUFLORA PEDIATRIC DROPS NF BE TRI-VITAMIN WITH FLUORIDE $0 BE TRI-VITE WITH FLUORIDE ORAL DROPS $0 BE 0.5 MG FLUORIDE (1.1 MG)/ML
Last Approved Date: 09/24/2021 Formulary Version: 92
148 Drug Status Notes Prenatal Vitamins And Minerals CITRANATAL B-CALM (FE GLUC) NF BE CLASSIC PRENATAL $0 BE DAILY PRENATAL $0 BE KOSHER PRENATAL PLUS IRON NF BE KPN ORAL TABLET $0 BE NEONATAL-DHA NF ONE DAILY PRENATAL ORAL COMBO $0 BE PACK 28-800-440 MG-MCG-MG P D NATAL VITAMINS-FOLIC ACID $0 BE PERRY PRENATAL $0 BE pnv cmb#95-ferrous fumarate-fa $0 BE PRENATAL COMPLETE $0 BE PRENATAL FORMULA ORAL TABLET 28 $0 BE MG IRON- 800 MCG PRENATAL GUMMY $0 BE PRENATAL MULTIVITAMINS $0 BE PRENATAL ONE DAILY $0 BE PRENATAL ORAL TABLET 28 MG IRON- 800 $0 BE MCG PRENATAL PLUS (CALCIUM CARB) 1 BE PRENATAL TABLET $0 BE PRENATAL VITAMIN $0 BE PRENATAL VITAMIN WITH MINERALS $0 BE prenatal vit-iron fum-folic ac $0 BE prenatal vits96-iron fum-folic $0 BE PRENATAL WITH DHA-FOLIC ACID $0 BE TRICARE PRENATAL DHA ONE NF BE VITAFOL FE PLUS NF VITAFOL-ONE NF BE VOL-NATE 2 BE WESTGEL DHA NF Sodium Chloride Flushes BD PRE-FILLED NORMAL SALINE 2 MONOJECT PREFILL ADVANCED NS 2 NORMAL SALINE FLUSH 2
Last Approved Date: 09/24/2021 Formulary Version: 92
149 Drug Status Notes sodium chloride 0.9 % (flush) injection syringe 2 sodium chloride 0.9 % injection NF Sodium Chloride Solutions, Concentrated sodium chloride 3 % 2 sodium chloride 5 % 2 Sodium Chloride, Parenteral sodium chloride 0.45 % intravenous parenteral 2 solution sodium chloride 3 % 2 sodium chloride 5 % 2 Vitamins - B Preparation Combinations FOLTABS 800 $0 BE Vitamins - B-12, Cyanocobalamin And Derivatives cyanocobalamin (vitamin b-12) injection NF BE NASCOBAL NASAL GEL NF BE NASCOBAL NASAL SPRAY,NON-AEROSOL NF PA; ST Vitamins - B-3, Niacin And Derivatives niacin oral tablet extended release 1,000 mg, 500 NF BE mg, 750 mg Vitamins - D Derivatives calcitriol oral capsule 1 BE D-VITA 3 BE VITAMIN D2 1 BE VITAMIN D3 ORAL CAPSULE 25 MCG (1,000 NL UNIT) VITAMIN D3 ORAL TABLET 25 MCG (1,000 3 BE UNIT) Vitamins - Folic Acid And Derivatives FA-8 $0 folic acid oral tablet 400 mcg, 800 mcg $0 Vitamins - Folic Acid Combinations FOLTABS 800 $0 BE
Last Approved Date: 09/24/2021 Formulary Version: 92
150 Drug Status Notes Vitamins - K, Phytonadione And Derivatives MEPHYTON NF BE phytonadione (vitamin k1) injection NF BE phytonadione (vitamin k1) oral tablet 100 mcg 3 BE phytonadione (vitamin k1) oral tablet 5 mg 4 BE Endocrine Abortifacients Or Cervical Ripening Agents - Prostaglandin Analogs CERVIDIL NF PREPIDIL NF PROSTIN E2 NF Adrenal Steroid Inhibitors ISTURISA 4 PA; BE Agents To Treat Hypoglycemia (Hyperglycemics) QL (2 BOTTLES per 1 dispensing BAQSIMI 3 event) diazoxide NF GLUCAGEN HYPOKIT 3 QL (1 UNIT per 1 DISPENSE) GLUCAGON EMERGENCY KIT (HUMAN) NF QL (1 unit per 1 dispense) GVOKE HYPOPEN 1-PACK 3 QL (2 units per 1 dispense) GVOKE HYPOPEN 2-PACK 3 QL (2 units per 1 dispense) GVOKE PFS 1-PACK SYRINGE 3 QL (2 units per 1 dispense) GVOKE PFS 2-PACK SYRINGE 3 QL (2 units per 1 dispense) PROGLYCEM NF QL (2 prefilled ZEGALOGUE AUTOINJECTOR NF syringes/autoinjectors per 1 dispensing event) QL (2 prefilled ZEGALOGUE SYRINGE NF syringes/autoinjectors per 1 dispensing event) Amyloidosis Agents- Transthyretin (Ttr) Stabilizer PA; BE; QL (1 CAPSULE per 1 VYNDAMAX NF day)
Last Approved Date: 09/24/2021 Formulary Version: 92
151 Drug Status Notes PA; BE; QL (4 CAPSULES per 1 VYNDAQEL NF day) Amyloidosis Agents-Ttr Suppression, Antisense Oligonucleotide-Based PA; QL (6 ML (4 syringes) per 21 TEGSEDI NF days) Anabolic Steroid - Single Agents ANADROL-50 4 PA; ST OXANDRIN NF PA; ST oxandrolone 3 PA; ST Androgen - Single Agents ANDRODERM NF PA ANDROGEL TRANSDERMAL GEL IN NF PA METERED-DOSE PUMP ANDROGEL TRANSDERMAL GEL IN NF PA PACKET 1.62 % (40.5 MG/2.5 GRAM) ANDROID NF PA; ST AXIRON NF PA DEPO-TESTOSTERONE NF PA FORTESTA NF PA JATENZO ORAL CAPSULE 158 MG, 237 MG NF PA; QL (2 CAPSULES per 1 day) JATENZO ORAL CAPSULE 198 MG NF PA; QL (4 CAPSULES per 1 day) METHITEST NF PA methyltestosterone oral capsule 3 PA NATESTO NF PA STRIANT NF PA TESTIM NF PA testosterone cypionate intramuscular oil 100 1 PA mg/ml, 200 mg/ml testosterone cypionate intramuscular oil 50 NF PA mg/ml testosterone enanthate 1 PA testosterone transdermal gel NF PA testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 NF PA gram (1 %) testosterone transdermal gel in packet 1 % (25 3 PA mg/2.5gram), 1 % (50 mg/5 gram) Last Approved Date: 09/24/2021 Formulary Version: 92
152 Drug Status Notes testosterone transdermal gel in packet 1.62 % NF PA (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram) testosterone transdermal solution in metered NF PA pump w/app TESTRED NF PA; ST VOGELXO TRANSDERMAL GEL NF PA; ST VOGELXO TRANSDERMAL GEL IN NF PA METERED-DOSE PUMP XYOSTED NF PA Antidiuretic And Vasopressor Hormones DDAVP NASAL NF DDAVP ORAL NF desmopressin nasal spray,non-aerosol 10 3 mcg/spray (0.1 ml) desmopressin oral 3 NOCDURNA (MEN) NF QL (1 TABLET per 1 day) NOCDURNA (WOMEN) NF QL (1 TABLET per 1 day) NOCTIVA NF QL (1 bottle (3.8g) per 23 days) STIMATE NF Antihyperglycemic - Alpha-Glucosidase Inhibitors acarbose 1 GLYSET NF miglitol 3 PRECOSE NF Antihyperglycemic - Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors PA; ST; QL (1 TABLET per 1 alogliptin NF day) JANUVIA 3 QL (1 TABLET per 1 day) PA; ST; QL (1 TABLET per 1 NESINA NF day) PA; ST; QL (1 TABLET per 1 ONGLYZA NF day) TRADJENTA 3 QL (1 TABLET per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
153 Drug Status Notes Antihyperglycemic - Dopamine Receptor Agonists CYCLOSET 3 Antihyperglycemic - Glucocorticoid (Cortisol) Receptor Blocker (Gr-Ii) KORLYM 3 PA; ST Antihyperglycemic - Meglitinide Analog And Biguanide Combinations repaglinide-metformin 3 Antihyperglycemic - Meglitinide Analogs nateglinide 2 PRANDIN ORAL TABLET 1 MG, 2 MG NF repaglinide 3 STARLIX NF Antihyperglycemic - Sglt-2 Inhibitor And Biguanide Combinations INVOKAMET 3 QL (2 TABLETS per 1 day) INVOKAMET XR 3 QL (2 TABLETS per 1 day) PA; ST; QL (2 TABLETS per 1 SEGLUROMET NF day) SYNJARDY 3 QL (2 TABLETS per 1 day) SYNJARDY XR 3 XIGDUO XR ORAL TABLET, IR - ER, PA; ST; QL (1 TABLET per 1 BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5- NF day) 500 MG XIGDUO XR ORAL TABLET, IR - ER, PA; ST; QL (2 TABLETS per 1 NF BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG day) Antihyperglycemic - Sglt-2 Inhibitor And Dpp-4 Inhibitor Combinations GLYXAMBI 3 QL (1 TABLET per 1 day) PA; ST; QL (1 TABLET per 1 QTERN ORAL TABLET 10-5 MG NF day) PA; ST; QL (1 TABLET per 1 STEGLUJAN NF day)
Last Approved Date: 09/24/2021 Formulary Version: 92
154 Drug Status Notes Antihyperglycemic - Sodium Glucose Cotransporter-2 (Sglt2) Inhibitors PA; ST; QL (1 TABLET per 1 FARXIGA NF day) INVOKANA 3 QL (1 TABLET per 1 day) JARDIANCE 3 QL (1 TABLET per 1 day) PA; ST; QL (1 TABLET per 1 STEGLATRO NF day) Antihyperglycemic - Sulfonylurea And Biguanide Combinations glipizide-metformin NF GLUCOVANCE NF glyburide-metformin NF Antihyperglycemic - Sulfonylurea Derivatives AMARYL NF chlorpropamide 1 glimepiride 1 glipizide 1 GLUCOTROL NF GLUCOTROL XL NF glyburide 1 glyburide micronized 1 GLYNASE NF tolazamide 2 tolbutamide 1 Antihyperglycemic - Thiazolidinedione And Biguanide Combinations ACTOPLUS MET NF ACTOPLUS MET XR NF AVANDAMET NF pioglitazone-metformin NF Antihyperglycemic - Thiazolidinedione And Sulfonylurea Combinations DUETACT NF pioglitazone-glimepiride NF
Last Approved Date: 09/24/2021 Formulary Version: 92
155 Drug Status Notes Antihyperglycemic, Amylin Analog- Type SYMLINPEN 120 NF SYMLINPEN 60 NF Antihyperglycemic, Incretin Mimetic,Glp-1 Receptor Agonist Analog-Type ADLYXIN SUBCUTANEOUS PEN INJECTOR NF PA; ST 10 MCG/0.2 ML- 20 MCG/0.2 ML ADLYXIN SUBCUTANEOUS PEN INJECTOR PA; ST; QL (6 ML (2 PENS) per NF 20 MCG/0.2 ML 21 days) PA; ST; QL (4 units per 1 BYDUREON NF DISPENSE) PA; ST; QL (4 auto-injectors per BYDUREON BCISE NF 21 days) BYETTA SUBCUTANEOUS PEN INJECTOR PA; ST; QL (3 ML per 1 NF 10 MCG/DOSE(250 MCG/ML) 2.4 ML DISPENSE) BYETTA SUBCUTANEOUS PEN INJECTOR 5 PA; ST; QL (2 ML per 1 NF MCG/DOSE (250 MCG/ML) 1.2 ML DISPENSE) OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 3 QL (4 PENS per 21 days) MG/DOSE (2 MG/1.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR 3 QL (4 pens per 21 Dayss) 1 MG/DOSE (4 MG/3 ML) RYBELSUS 3 QL (1 TABLET per 1 day) PA; ST; QL (4 PENS per 1 TANZEUM NF MONTH) TRULICITY 3 QL (2 ML per 21 days) VICTOZA 2-PAK 3 QL (9 ML per 1 DISPENSE) VICTOZA 3-PAK 3 QL (9 ML per 1 DISPENSE) Antihyperglycemic-Dipeptidyl Peptidase-4 Inhibit And Thiazolidinedione PA; ST; QL (1 TABLET per 1 alogliptin-pioglitazone NF day) PA; ST; QL (1 TABLET per 1 OSENI NF day)
Last Approved Date: 09/24/2021 Formulary Version: 92
156 Drug Status Notes Antihyperglycemic-Dipeptidyl Peptidase-4(Dpp-4)Inhibitor And Biguanide PA; ST; QL (2 TABLETS per 1 alogliptin-metformin NF day) JANUMET 3 QL (2 TABLETS per 1 day) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 3 QL (1 TABLET per 1 day) MG JANUMET XR ORAL TABLET, ER 3 QL (2 TABLETS per 1 day) MULTIPHASE 24 HR 50-1,000 MG JENTADUETO 3 QL (2 TABLETS per 1 day) JENTADUETO XR ORAL TABLET, IR - ER, 3 QL (2 TABLETS per 1 day) BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, 3 QL (1 TABLET per 1 day) BIPHASIC 24HR 5-1,000 MG PA; ST; QL (2 TABLETS per 1 KAZANO NF day) KOMBIGLYZE XR ORAL TABLET, ER PA; ST; QL (2 TABLETS per 1 NF MULTIPHASE 24 HR 2.5-1,000 MG day) KOMBIGLYZE XR ORAL TABLET, ER PA; ST; QL (1 TABLET per 1 NF MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG day) Antihyperglycemic-Insulin, Long Acting And Glp-1 Receptor Agonist Comb PA; ST; QL (15 ML (5 PENS) per SOLIQUA 100/33 NF 25 days) XULTOPHY 100/3.6 3 Antihyperglycemic-Sglt-2 Inhibitor, Dpp-4 Inhibitor And Biguanide Comb TRIJARDY XR ORAL TABLET, IR - ER, 3 QL (1 tablet per 1 day) BIPHASIC 24HR 10-5-1,000 MG TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 25-5-1,000 3 MG TRIJARDY XR ORAL TABLET, IR - ER, 3 QL (2 tablets per 1 day) BIPHASIC 24HR 5-2.5-1,000 MG Antithyroid Agents, Thionamides - Imidazole Derivatives methimazole oral tablet 10 mg, 5 mg 1
Last Approved Date: 09/24/2021 Formulary Version: 92
157 Drug Status Notes TAPAZOLE NF Antithyroid Agents, Thionamides - Thiouracil Derivatives propylthiouracil 2 Bone Formation Agents - Sclerostin Inhibitor, Monoclonal Antibody PA; ST; BE; QL (2 SYRINGES EVENITY NF per 25 days) Bone Formation Stimulating Agents - Parathyroid Hormone Rel Peptides PA; ST; SP; BE; QL (1 PEN per TYMLOS 4 23 days) Bone Formation Stimulating Agents - Parathyroid Hormone-Type PA; ST; QL (3 ML per 1 FORTEO NF DISPENSE) PA; ST; QL (3 ML per 1 teriparatide NF Dispense) Bone Resorption Inhibitors - Bisphosphonate And Vitamin D Combinations FOSAMAX PLUS D ORAL TABLET 70 MG- PA; ST; QL (4 TABLETS per 1 3 2,800 UNIT MONTH) FOSAMAX PLUS D ORAL TABLET 70 MG- 3 PA; ST 5,600 UNIT Bone Resorption Inhibitors - Bisphosphonates ACTONEL ORAL TABLET 150 MG NF QL (1 TABLET per 1 DISPENSE) ACTONEL ORAL TABLET 30 MG, 5 MG NF QL (4 TABLETS per 1 ACTONEL ORAL TABLET 35 MG NF DISPENSE) alendronate oral solution NF QL (300 ML per 1 DISPENSE) alendronate oral tablet 10 mg, 40 mg, 5 mg 2 QL (4 TABLETS per 1 alendronate oral tablet 35 mg, 70 mg 1 DISPENSE) QL (4 TABLETS per 1 ATELVIA NF DISPENSE) BINOSTO NF
Last Approved Date: 09/24/2021 Formulary Version: 92
158 Drug Status Notes BONIVA ORAL NF QL (1 TABLET per 1 DISPENSE) etidronate disodium 3 FOSAMAX ORAL TABLET 70 MG NF QL (4 TABLETS per 1 MONTH) ibandronate oral 1 QL (1 TABLET per 1 MONTH) risedronate oral tablet 150 mg 2 QL (1 TABLET per 1 MONTH) risedronate oral tablet 30 mg, 5 mg 2 risedronate oral tablet 35 mg 2 QL (4 TABLETS per 1 MONTH) risedronate oral tablet,delayed release (dr/ec) 2 QL (4 TABLETS per 1 MONTH) Calcimimetic, Parathyroid Calcium Receptor Sensitivity Enhancer cinacalcet 4 BE SENSIPAR NF SP; BE Calcitonins calcitonin (salmon) injection NF calcitonin (salmon) nasal 2 QL (4 ML per 1 DISPENSE) Estrogen And Progestin With Antimineralocorticoid Activity,Combination ANGELIQ NF Estrogen And Selective Estrogen Receptor Modulator (Serm) Combinations DUAVEE 3 Estrogen-Androgen COVARYX 2 COVARYX H.S. 2 estrogens-methyltestosterone 2 Estrogen-Progestin ACTIVELLA NF AMABELZ 1 BIJUVA NF QL (4 PATCHES per 1 CLIMARA PRO NF DISPENSE) COMBIPATCH NF QL (8 PATCHES per 1 MONTH) estradiol-norethindrone acet 1 FEMHRT LOW DOSE NF
Last Approved Date: 09/24/2021 Formulary Version: 92
159 Drug Status Notes JEVANTIQUE LO 1 JINTELI 1 LOPREEZA 1 MIMVEY 1 MIMVEY LO 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 1 mg-mcg, 1-5 mg-mcg PREFEST NF PREMPHASE 3 PREMPRO 3 Estrogens QL (8 PATCHES per 1 ALORA NF DISPENSE) QL (4 PATCHES per 1 CLIMARA NF DISPENSE) DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 1 MG/GRAM (0.1 NF %) ELESTRIN NF ESTRACE ORAL NF estradiol oral 1 estradiol transdermal patch semiweekly 2 QL (8 PATCHES per 1 MONTH) estradiol transdermal patch weekly 2 QL (4 PATCHES per 1 MONTH) QL (1 (50G) GEL PUMP per 1 ESTROGEL 3 MONTH) estropipate oral tablet 0.75 mg 1 EVAMIST NF QL (9 ML per 1 DISPENSE) MENEST 3 MENOSTAR NF QL (4 PATCHES per 1 MONTH) MINIVELLE NF QL (8 PATCHES per 1 MONTH) PREMARIN ORAL 3 VIVELLE-DOT NF QL (8 PATCHES per 1 MONTH) Fertility Enhancer - Luteal Phase Supporting, Progesterone-Type CRINONE VAGINAL GEL 8 % NF PA; BE ENDOMETRIN 3 PA; BE
Last Approved Date: 09/24/2021 Formulary Version: 92
160 Drug Status Notes Fertility Enhancer - Ovulation Stimulant - Synthetic (Non-Fsh) clomiphene citrate 1 PA; BE Follicle-Stimulating And Luteinizing Hormones MENOPUR 4 PA; SP; BE Follicle-Stimulating Hormone (Fsh) FOLLISTIM AQ 4 PA; SP; BE GONAL-F NF PA; ST; SP; BE GONAL-F RFF NF PA; ST; SP; BE GONAL-F RFF PEN NF GONAL-F RFF REDI-JECT NF PA; ST; SP; BE Glucocorticoids PA; ST; BE; QL (3 capsules per 1 ALKINDI SPRINKLE NF day) CORTEF NF cortisone 1 DECADRON ORAL ELIXIR 2 DELTASONE 1 DEXABLISS NF DEXAMETHASONE INTENSOL 1 dexamethasone oral elixir 2 dexamethasone oral tablet 1 dexamethasone oral tablets,dose pack NF DEXONTO NF DEXPAK 10 DAY NF DEXPAK 13 DAY NF DEXPAK 6 DAY NF DXEVO NF EMFLAZA NF BE HEMADY NF PA; ST hydrocortisone oral 1 MEDROL NF MEDROL (PAK) NF methylprednisolone 1
Last Approved Date: 09/24/2021 Formulary Version: 92
161 Drug Status Notes MILLIPRED DP ORAL TABLETS,DOSE 1 PACK 5 MG (21 TABS) MILLIPRED DP ORAL TABLETS,DOSE 2 PACK 5 MG (48 TABS) MILLIPRED ORAL TABLET 1 ORAPRED ODT NF prednisolone oral solution 1 prednisolone sodium phosphate oral solution 15 1 mg/5 ml (3 mg/ml) prednisolone sodium phosphate oral solution 5 2 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral NF tablet,disintegrating PREDNISONE INTENSOL NF prednisone oral solution 2 prednisone oral tablet 1 prednisone oral tablets,dose pack 10 mg NF prednisone oral tablets,dose pack 5 mg 1 RAYOS NF PA; ST TAPERDEX ORAL TABLETS,DOSE PACK 1.5 NF MG (21 TABS) VERIPRED 20 NF ZCORT NF Gonadotropin Inhibitor Pituitary Suppressants danazol 2 Growth Hormone Receptor Antagonists SOMAVERT SUBCUTANEOUS RECON NF BE SOLN 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON 4 SOLN 25 MG, 30 MG Growth Hormone Releasing Hormones (Ghrh) EGRIFTA SV 4 PA; BE Growth Hormones GENOTROPIN 4 PA; ST; SP; BE GENOTROPIN MINIQUICK 4 PA; ST; SP; BE HUMATROPE 4 PA; ST; SP; BE Last Approved Date: 09/24/2021 Formulary Version: 92
162 Drug Status Notes NORDITROPIN FLEXPRO 4 PA; SP; BE NUTROPIN AQ NF NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 NF PA; ST MG/2 ML (10 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS NF PA; ST; SP; BE PEN INJECTOR 5 MG/2 ML (2.5 MG/ML) OMNITROPE NF PA; ST; SP; BE SAIZEN NF PA; ST; SP; BE SAIZEN CLICK.EASY NF PA; ST; BE SEROSTIM SUBCUTANEOUS RECON SOLN 4 PA; SP; BE 4 MG, 5 MG, 6 MG ZOMACTON NF PA; ST; SP; BE ZORBTIVE 4 PA; SP; BE Human Chorionic Gonadotropin (Hcg) chorionic gonadotropin, human injection recon NF PA; BE soln 12,000 unit, 6,000 unit chorionic gonadotropin, human injection recon NF BE soln 50,000 unit chorionic gonadotropin, human intramuscular NF PA; BE NOVAREL NF PA; BE OVIDREL 3 PA; BE PREGNYL 3 PA; BE Human Insulins - Fixed Combinations HUMULIN 70/30 INSULIN PEN 2 HUMULIN 70/30 U-100 INSULIN 2 HUMULIN 70/30 U-100 KWIKPEN 2 NOVOLIN 70/30 PENFILL 2 NOVOLIN 70/30 U-100 INSULIN 2 NOVOLIN 70-30 FLEXPEN U-100 2 Human Insulins - Intermediate Acting HUMULIN L 2 HUMULIN N NPH INSULIN KWIKPEN 2 HUMULIN N NPH U-100 INSULIN 2 HUMULIN N PEN 2 NOVOLIN N FLEXPEN 2 NOVOLIN N NPH U-100 INSULIN 2
Last Approved Date: 09/24/2021 Formulary Version: 92
163 Drug Status Notes NOVOLIN N PENFILL 2 Human Insulins - Rapid Acting AFREZZA 2 Human Insulins - Short Acting HUMULIN R REGULAR U-100 INSULN 2 HUMULIN R U-500 (CONC) INSULIN 3 NOVOLIN R FLEXPEN 2 NOVOLIN R PENFILL 2 NOVOLIN R REGULAR U-100 INSULN 2 Insulin Analogs - Fixed Combinations HUMALOG MIX 50-50 INSULN U-100 3 HUMALOG MIX 50-50 KWIKPEN 3 HUMALOG MIX 75-25 KWIKPEN 3 HUMALOG MIX 75-25(U-100)INSULN 3 insulin asp prt-insulin aspart 3 insulin lispro protamin-lispro 3 NOVOLOG MIX 70-30 U-100 INSULN 3 NOVOLOG MIX 70-30FLEXPEN U-100 3 Insulin Analogs - Long Acting BASAGLAR KWIKPEN U-100 INSULIN 2 LANTUS SOLOSTAR U-100 INSULIN NF LANTUS U-100 INSULIN NF LEVEMIR FLEXTOUCH U-100 INSULN NF LEVEMIR U-100 INSULIN NF SEMGLEE PEN U-100 INSULIN NF SEMGLEE U-100 INSULIN NF TOUJEO MAX U-300 SOLOSTAR NF TOUJEO SOLOSTAR U-300 INSULIN NF TRESIBA FLEXTOUCH U-100 NF TRESIBA FLEXTOUCH U-200 NF TRESIBA U-100 INSULIN NF Insulin Analogs - Rapid Acting ADMELOG SOLOSTAR U-100 INSULIN NF ADMELOG U-100 INSULIN LISPRO NF APIDRA SOLOSTAR U-100 INSULIN 4
Last Approved Date: 09/24/2021 Formulary Version: 92
164 Drug Status Notes APIDRA U-100 INSULIN 4 FIASP FLEXTOUCH U-100 INSULIN 3 FIASP PENFILL U-100 INSULIN 3 FIASP U-100 INSULIN 3 HUMALOG JUNIOR KWIKPEN U-100 3 HUMALOG KWIKPEN INSULIN 3 HUMALOG U-100 INSULIN 3 insulin aspart u-100 3 insulin lispro subcutaneous insulin pen 3 insulin lispro subcutaneous solution 3 LYUMJEV KWIKPEN U-100 INSULIN NF LYUMJEV KWIKPEN U-200 INSULIN NF LYUMJEV U-100 INSULIN NF NOVOLOG FLEXPEN U-100 INSULIN 3 NOVOLOG PENFILL U-100 INSULIN 3 NOVOLOG U-100 INSULIN ASPART 3 Insulin Response Enhancers - Biguanides FORTAMET NF PA; ST GLUCOPHAGE NF PA; ST GLUCOPHAGE XR NF PA; ST GLUMETZA NF PA; ST metformin oral solution NF PA; ST metformin oral tablet 1 metformin oral tablet extended release 24 hr 1 metformin oral tablet extended release 24hr NF PA; ST metformin oral tablet,er gast.retention 24 hr NF PA; ST RIOMET NF PA; ST PA; ST; QL (2 BOTTLES per 1 RIOMET ER NF DISPENSE) Insulin Response Enhancers - Thiazolidinediones (Ppar-Gamma Agonists) ACTOS NF AVANDIA ORAL TABLET 2 MG, 4 MG 3 PA; ST pioglitazone 1
Last Approved Date: 09/24/2021 Formulary Version: 92
165 Drug Status Notes Insulin-Like Growth Factor-1 (Igf-1) INCRELEX 4 PA; BE Leptin Hormone Analogs MYALEPT 4 PA; BE; QL (1 VIAL per 1 day) Lhrh (Gnrh) Agonist Analog Pit Suppres - Central Precocious Puberty LUPRON DEPOT-PED 4 SP LUPRON DEPOT-PED (3 MONTH) NF Lhrh (Gnrh) Agonist Analog Pituitary Supp. And Progestin Comb. LUPANETA PACK (1 MONTH) 4 SP LUPANETA PACK (3 MONTH) 4 SP Lhrh (Gnrh) Agonist Analog Pituitary Suppressants LUPRON DEPOT (3 MONTH) 4 SP INTRAMUSCULAR SYRINGE KIT 11.25 MG LUPRON DEPOT INTRAMUSCULAR 4 SP SYRINGE KIT 3.75 MG SYNAREL NF PA; BE Lhrh (Gnrh) Antagonist, Estrogen And Progestin Combinations MYFEMBREE NF PA; BE; QL (1 tablet per 1 day) ORIAHNN 4 PA; BE; QL (2 tablets per 1 day) Lhrh (Gnrh) Antagonists CETROTIDE 4 PA; SP ganirelix NF PA; SP PA; ST; BE; QL (1 TABLET per 1 ORILISSA ORAL TABLET 150 MG 4 day) PA; ST; BE; QL (2 TABLETS per ORILISSA ORAL TABLET 200 MG 4 1 day) Menopausal Symptoms Suppressant - Hormonal Agents INTRAROSA 3 QL (28 inserts per 21 days) Menopausal Symptoms Suppressant- Selective Estrogen Receptor Modulators OSPHENA 3
Last Approved Date: 09/24/2021 Formulary Version: 92
166 Drug Status Notes Menopausal Symptoms Suppressant- Ssri Antidepressant Type BRISDELLE NF PA; ST Mineralocorticoids fludrocortisone 1 Oxytocic - Ergot Alkaloids METHERGINE 3 QL (28 TABLETS per 180 days) methylergonovine oral 3 QL (28 TABLETS per 180 days) Parathyroid Hormones NATPARA 4 PA; ST; SP; BE Progestins AYGESTIN NF medroxyprogesterone oral 1 norethindrone acetate 1 progesterone 3 progesterone micronized 2 PROMETRIUM NF PROVERA NF Prolactin Inhibitor - Ergot Derivative Dopamine Receptor Agonists cabergoline 1 Rank Ligand (Rankl) Inhibitor, Mc Antibody PROLIA 4 PA; ST; SP; BE XGEVA NF SP Selective Estrogen Receptor Modulators (Serms) EVISTA NF raloxifene 3 Somatostatic Agents BYNFEZIA NF PA; ST; BE PA; ST; BE; QL (4 capsules per 1 MYCAPSSA NF day) octreotide acetate injection solution 4 SP; BE octreotide acetate injection syringe 100 mcg/ml (1 4 SP ml), 50 mcg/ml (1 ml) Last Approved Date: 09/24/2021 Formulary Version: 92
167 Drug Status Notes octreotide acetate injection syringe 500 mcg/ml (1 NF SP ml) SANDOSTATIN INJECTION SOLUTION 100 NF SP; BE MCG/ML, 50 MCG/ML, 500 MCG/ML SIGNIFOR 4 PA; BE SOMATULINE DEPOT NF BE Thyroid Hormone Combinations - Synthetic T3 And T4 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3 Thyroid Hormones - Animal Source (Porcine) ARMOUR THYROID 3 NATURE-THROID 1 NP THYROID ORAL TABLET 120 MG 3 NP THYROID ORAL TABLET 30 MG, 60 MG, 1 90 MG thyroid (pork) oral tablet 120 mg, 15 mg 3 WESTHROID 1 WP THYROID ORAL TABLET 113.75 MG, NF 16.25 MG, 48.75 MG, 97.5 MG WP THYROID ORAL TABLET 130 MG, 32.5 2 MG, 65 MG, 81.25 MG Thyroid Hormones - Synthetic T3 (Triiodothyronine) CYTOMEL NF liothyronine 1 Thyroid Hormones - Synthetic T4 (Thyroxine) EUTHYROX 1 levothyroxine oral capsule NF levothyroxine oral tablet 1
Last Approved Date: 09/24/2021 Formulary Version: 92
168 Drug Status Notes LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 1 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG SYNTHROID NF THYQUIDITY NF PA; ST TIROSINT NF TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 NF PA; ST MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML TIROSINT-SOL ORAL SOLUTION 37.5 NF MCG/ML, 44 MCG/ML, 62.5 MCG/ML UNITHROID 1 Gastrointestinal Therapy Agents Antidiarrheal - Antiperistaltic Agents loperamide oral capsule NF opium tincture 3 paregoric NF Antidiarrheal - Gastrointestinal Chloride Channel Inhibitors MYTESI NF Antidiarrheal - Tryptophan Hydroxylase Inhibitor PA; BE; QL (3 TABLETS per 1 XERMELO NF day) Antidiarrheal Antiperistaltic- Anticholinergic Combinations diphenoxylate-atropine oral liquid 2 diphenoxylate-atropine oral tablet 1 LOMOTIL NF MOTOFEN 3 Antidiarrheal Opioid Agents opium tincture 3 paregoric NF
Last Approved Date: 09/24/2021 Formulary Version: 92
169 Drug Status Notes Antiemetic - Anticholinergics TRANSDERM-SCOP NF Antiemetic - Antihistamines ANTIVERT ORAL TABLET 50 MG NF meclizine oral tablet 12.5 mg, 25 mg 1 Antiemetic - Antihistamine-Vitamin Combinations BONJESTA NF PA; ST; QL (2 tablets per 1 day) DICLEGIS NF PA; ST; QL (4 tablets per 1 day) doxylamine-pyridoxine (vit b6) 3 PA; ST; QL (4 tablets per 1 day) Antiemetic - Cannabinoid Type CESAMET 3 dronabinol 3 MARINOL NF SYNDROS NF Antiemetic - Dopamine (D2)/5-Ht3 Antagonists TIGAN ORAL CAPSULE 300 MG NF trimethobenzamide oral 2 Antiemetic - Phenothiazines COMPAZINE NF COMPRO 3 PHENADOZ 3 PHENERGAN RECTAL 3 prochlorperazine 3 prochlorperazine maleate 1 promethazine oral syrup 1 QL (136 ML per 1 day) promethazine oral tablet 1 promethazine rectal 3 PROMETHEGAN 3 Antiemetic - Selective Serotonin 5-Ht3 Antagonists ANZEMET ORAL NF granisetron hcl oral 3 ondansetron 2
Last Approved Date: 09/24/2021 Formulary Version: 92
170 Drug Status Notes ondansetron hcl oral solution NF ondansetron hcl oral tablet 1 QL (3 PATCHES per 1 SANCUSO NF DISPENSE) SUSTOL NF ZOFRAN ODT NF ZOFRAN ORAL NF ZUPLENZ NF Antiemetic - Substance P-Neurokinin 1 (Nk1) Receptor Antagonists QL (3 CAPSULES per 1 aprepitant oral capsule 80 mg 3 DISPENSE) QL (3 CAPSULES per 1 aprepitant oral capsule,dose pack 3 DISPENSE) QL (3 CAPSULES per 1 EMEND ORAL CAPSULE 125 MG, 80 MG NF DISPENSE) QL (1 CAPSULE per 1 EMEND ORAL CAPSULE 40 MG NF DISPENSE) QL (3 CAPSULES per 1 EMEND ORAL CAPSULE,DOSE PACK NF DISPENSE) QL (4 TABLETS per 1 VARUBI ORAL NF DISPENSE) Antiemetic - Substance P-Neurokinin 1 And 5-Ht3 Recept Antagonist Comb QL (1 CAPSULE per 1 AKYNZEO (NETUPITANT) 3 DISPENSE) Bile Acids CHOLBAM 4 PA; BE Chronic Idiopathic Const. Agents - Guanylate Cyclase-C (Gc-C) Agonists LINZESS ORAL CAPSULE 290 MCG 3 QL (1 CAPSULE per 1 day) PA; ST; QL (1 TABLET per 1 TRULANCE NF day) Colonic Acidifier (Ammonia Inhibitor) ENULOSE 1 GENERLAC 1 lactulose oral solution 10 gram/15 ml 1
Last Approved Date: 09/24/2021 Formulary Version: 92
171 Drug Status Notes Digestive Enzyme Mixtures CREON 4 PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 37,000-97,300- 149,900 NF UNIT PERTZYE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 16,000-57,500- 60,500 NF UNIT, 4,000-14,375- 15,125 UNIT, 8,000- 28,750- 30,250 UNIT VIOKACE NF ZENPEP NF Digestive Enzymes SUCRAID 4 PA; BE Gallstone Solubilizing (Litholysis) Agents ACTIGALL NF CHENODAL 4 PA; ST RELTONE NF URSO 250 NF URSO FORTE NF ursodiol oral capsule 300 mg 3 ursodiol oral tablet 2 Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists cimetidine NF cimetidine hcl oral 2 famotidine oral suspension NF famotidine oral tablet 20 mg, 40 mg 1 nizatidine oral capsule 3 nizatidine oral solution NF PEPCID NF PEPCID AC ORAL TABLET 20 MG NF ranitidine hcl oral capsule NF ranitidine hcl oral syrup 1 ranitidine hcl oral tablet 150 mg, 300 mg 1 ZANTAC ORAL TABLET NF
Last Approved Date: 09/24/2021 Formulary Version: 92
172 Drug Status Notes Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (Ppis) PA; ST; QL (1 TABLET per 1 ACIPHEX NF day) ACIPHEX SPRINKLE ORAL CAPSULE, PA; ST; QL (1 CAPSULE per 1 NF DELAYED REL SPRINKLE 10 MG day) ACIPHEX SPRINKLE ORAL CAPSULE, PA; ST; QL (1 CAPSULES per 1 NF DELAYED REL SPRINKLE 5 MG day) PA; ST; QL (1 CAPSULES per 1 DEXILANT 3 day) esomeprazole magnesium oral capsule,delayed PA; ST; QL (1 CAPSULE per 1 3 release(dr/ec) day) esomeprazole magnesium oral granules dr for NF PA; ST; QL (1 packet per 1 Day) susp in packet lansoprazole oral capsule,delayed release(dr/ec) 2 QL (1 capsule/tablet per 1 day) PA; ST; QL (1 CAPSULE per 1 lansoprazole oral tablet,disintegrat, delay rel NF day) NEXIUM ORAL CAPSULE,DELAYED PA; ST; QL (1 CAPSULE per 1 NF RELEASE(DR/EC) 40 MG day) PA; ST; QL (1 PACKET per 1 NEXIUM PACKET NF day) omeprazole magnesium oral capsule,delayed 1 QL (4 CAPSULES per 1 day) release(dr/ec) omeprazole oral capsule,delayed release(dr/ec) 1 QL (1 CAPSULE per 1 day) 10 mg omeprazole oral capsule,delayed release(dr/ec) 1 QL (4 CAPSULES per 1 day) 20 mg omeprazole oral capsule,delayed release(dr/ec) 1 QL (2 CAPSULES per 1 day) 40 mg pantoprazole intravenous NF PA; ST; QL (2 packets per 1 Day) pantoprazole oral tablet,delayed release (dr/ec) 1 QL (1 TABLET per 1 day) 20 mg pantoprazole oral tablet,delayed release (dr/ec) 1 QL (2 TABLETS per 1 day) 40 mg PREVACID ORAL CAPSULE,DELAYED PA; ST; QL (1 CAPSULES per 1 NF RELEASE(DR/EC) 30 MG day) PA; ST; QL (1 PREVACID SOLUTAB NF CAPSULE/TABLET per 1 day) PRILOSEC ORAL SUSP,DELAYED RELEASE PA; ST; QL (1 PACKET per 1 NF FOR RECON day)
Last Approved Date: 09/24/2021 Formulary Version: 92
173 Drug Status Notes PROTONIX ORAL GRANULES DR FOR SUSP PA; ST; QL (2 PACKETS per 1 NF IN PACKET day) PROTONIX ORAL TABLET,DELAYED PA; ST; QL (1 TABLET per 1 NF RELEASE (DR/EC) 20 MG day) PROTONIX ORAL TABLET,DELAYED PA; ST; QL (2 TABLETS per 1 NF RELEASE (DR/EC) 40 MG day) PA; ST; QL (1 CAPSULE per 1 rabeprazole oral capsule, delayed rel sprinkle NF day) PA; ST; QL (1 TABLET per 1 rabeprazole oral tablet,delayed release (dr/ec) 2 day) Gastric Acid Secretion Reducing-Proton Pump Inhibitor And Antacid Comb omeprazole-sodium bicarbonate oral capsule 40- NF PA; ST; QL (1 UNIT per 1 day) 1.1 mg-gram ZEGERID NF PA; ST; QL (1 UNIT per 1 day) Gastric Mucosa - Cytoprotective Prostaglandin Analogs CYTOTEC NF misoprostol 1 Gastrointestinal - Prokinetic Agents - 5- Ht4 Receptor Agonists PA; ST; QL (1 TABLET per 1 MOTEGRITY NF day) Gastrointestinal Prokinetic Agents - D2 Antagonist/5-Ht4 Agonists PA; ST; QL (1 bottle (9.8ml) per GIMOTI NF 21 days) metoclopramide hcl oral solution 1 metoclopramide hcl oral tablet 1 metoclopramide hcl oral tablet,disintegrating 10 3 mg metoclopramide hcl oral tablet,disintegrating 5 NF mg REGLAN ORAL NF Gi Antispasmodic - Belladonna Alkaloids ANASPAZ 2 atropine injection solution NF
Last Approved Date: 09/24/2021 Formulary Version: 92
174 Drug Status Notes ED-SPAZ 2 hyoscyamine sulfate oral 2 hyoscyamine sulfate sublingual 2 LEVBID NF LEVSIN ORAL NF LEVSIN/SL NF methscopolamine 3 NULEV NF OSCIMIN 2 OSCIMIN SL 2 OSCIMIN SR 2 SYMAX FASTABS 2 SYMAX-SL 2 SYMAX-SR 2 Gi Antispasmodic - Quaternary Ammonium Compounds GLYCATE NF PA; ST glycopyrrolate oral tablet 1 mg, 2 mg 2 propantheline NF ROBINUL FORTE NF ROBINUL ORAL NF Gi Antispasmodic - Synthetic Tertiary Amines dicyclomine oral capsule 1 dicyclomine oral solution 3 dicyclomine oral tablet 1 Gi Antispasmodic And Benzodiazepine Combinations chlordiazepoxide-clidinium 2 LIBRAX (WITH CLIDINIUM) NF Gi Antispasmodic And Opioid Combinations belladonna alkaloids-opium rectal suppository NF 16.2-30 mg
Last Approved Date: 09/24/2021 Formulary Version: 92
175 Drug Status Notes Gi Antispasmodic Combinations Other belladonna alkaloids-opium rectal suppository NF 16.2-30 mg BELLADONNA-PHENOBARBITAL NF chlordiazepoxide-clidinium 2 DONNATAL ORAL ELIXIR 16.2-0.1037 - NF 0.0194 MG/5 ML DONNATAL ORAL TABLET NF LIBRAX (WITH CLIDINIUM) NF phenobarb-hyoscy-atropine-scop oral elixir 16.2 NF mg-0.1037 mg/5 ml (5 ml) PHENOHYTRO ORAL ELIXIR 16.2-0.1037 - 3 0.0194 MG/5 ML PHENOHYTRO ORAL TABLET 3 Ibs Agent - Gastrointestinal Chloride Channel Activator Agents AMITIZA 3 QL (2 CAPSULES per 1 day) lubiprostone NF PA; ST; QL (2 capsules per 1 Day) Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists LINZESS ORAL CAPSULE 145 MCG, 290 3 QL (1 CAPSULE per 1 day) MCG PA; ST; QL (1 TABLET per 1 TRULANCE NF day) Ibs Agent - Mixed Opioid Receptor Agonist And Antagonist PA; ST; QL (2 TABLETS per 1 VIBERZI NF day) Ibs Agent - Selective 5-Ht3 Receptor Antagonists PA; ST; QL (2 TABLETS per 1 alosetron 3 day) PA; ST; QL (2 TABLETS per 1 LOTRONEX NF day) Ibs Agent - Selective Partial 5-Ht4 Receptor Agonists PA; ST; QL (2 TABLETS per 1 ZELNORM NF day)
Last Approved Date: 09/24/2021 Formulary Version: 92
176 Drug Status Notes Inflammatory Bowel Agent - Interleukin-12 And Il-23 Inhibitors, Mc Ab PA; ST; BE; QL (1 vial per 63 STELARA SUBCUTANEOUS SOLUTION 4 days) STELARA SUBCUTANEOUS SYRINGE 90 PA; ST; SP; BE; QL (1 SYRINGE 4 MG/ML per 63 days) Inflammatory Bowel Agent - Aminosalicylates And Related Agents APRISO NF ASACOL HD NF AZULFIDINE NF AZULFIDINE EN-TABS NF balsalazide 2 CANASA NF COLAZAL NF DELZICOL NF DIPENTUM 3 LIALDA NF mesalamine oral capsule (with del rel tablets) 3 mesalamine oral capsule,extended release 24hr 3 mesalamine oral tablet,delayed release (dr/ec) 3 1.2 gram mesalamine oral tablet,delayed release (dr/ec) NF 800 mg mesalamine rectal enema 2 mesalamine rectal suppository 3 PENTASA NF SFROWASA NF sulfasalazine 1 Inflammatory Bowel Agent - Glucocorticoids budesonide oral capsule,delayed,extend.release 3 budesonide oral tablet,delayed and ext.release NF COLOCORT NF CORTENEMA NF CORTIFOAM NF
Last Approved Date: 09/24/2021 Formulary Version: 92
177 Drug Status Notes ENTOCORT EC NF hydrocortisone rectal NF ORTIKOS NF UCERIS ORAL NF Inflammatory Bowel Agent - Janus Kinase (Jak) Inhibitors PA; ST; BE; QL (2 TABLETS per XELJANZ ORAL TABLET 10 MG 4 1 day) PA; ST; SP; BE; QL (2 TABLETS XELJANZ ORAL TABLET 5 MG 4 per 1 day) XELJANZ XR ORAL TABLET EXTENDED PA; ST; SP; BE; QL (1 TABLET 4 RELEASE 24 HR 11 MG per 1 day) XELJANZ XR ORAL TABLET EXTENDED PA; ST; BE; QL (1 tablet per 1 4 RELEASE 24 HR 22 MG day) Inflammatory Bowel Agent - Tumor Necrosis Factor Alpha Blockers PA; ST; SP; BE; QL (1 KIT per 21 CIMZIA 4 days) PA; ST; SP; BE; QL (1 starter kit CIMZIA POWDER FOR RECONST 4 per 365 days) PA; ST; SP; BE; QL (3 UNITS per CIMZIA STARTER KIT 4 274 days) PA; ST; SP; QL (1 unit per 274 HUMIRA PEDIATRIC CROHNS START 4 days) PA; ST; SP; BE; QL (2 HUMIRA PEN 4 SYRINGES per 21 days) PA; ST; SP; QL (1 UNIT per 274 HUMIRA PEN CROHNS-UC-HS START 4 days) PA; ST; SP; QL (1 UNIT per 274 HUMIRA PEN PSOR-UVEITS-ADOL HS 4 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 20 PA; ST; SP; BE; QL (2 units per 4 MG/0.4 ML, 40 MG/0.8 ML 21 days) HUMIRA(CF) PEDI CROHNS STARTER PA; ST; BE; QL (1 unit per 274 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 4 days) ML HUMIRA(CF) PEDI CROHNS STARTER PA; ST; BE; QL (2 syringes per 21 SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 4 days) ML-40 MG/0.4 ML PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN 4 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
178 Drug Status Notes PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN CROHNS-UC-HS 4 days) PA; ST; BE; QL (1 unit per 274 HUMIRA(CF) PEN PEDIATRIC UC 4 Dayss) PA; ST; BE; QL (2 syringes per 21 HUMIRA(CF) PEN PSOR-UV-ADOL HS 4 days) HUMIRA(CF) SUBCUTANEOUS SYRINGE PA; ST; BE; QL (2 syringes per 21 4 KIT 20 MG/0.2 ML, 40 MG/0.4 ML days) SIMPONI SUBCUTANEOUS PEN INJECTOR PA; ST; SP; BE; QL (1 unit per 21 4 100 MG/ML days) SIMPONI SUBCUTANEOUS SYRINGE 100 PA; ST; SP; BE; QL (1 UNIT per 4 MG/ML 21 days) Irritable Bowel Syndrome (Ibs) Agents PA; ST; QL (2 TABLETS per 1 alosetron 3 day) PA; ST; QL (2 TABLETS per 1 LOTRONEX NF day) lubiprostone NF PA; ST; QL (2 capsules per 1 Day) PA; ST; QL (2 TABLETS per 1 ZELNORM NF day) Laxative - Saline And Osmotic CITRATE OF MAGNESIA $0 CITROMA $0 CLEARLAX ORAL POWDER $0 CONSTULOSE 1 GAVILAX $0 GENTLELAX $0 GLYCOLAX ORAL POWDER $0 HEALTHYLAX $0 KRISTALOSE 2 lactulose oral packet NF lactulose oral solution 10 gram/15 ml 1 LAXATIVE PEG 3350 $0 magnesium citrate oral solution $0 MILK OF MAGNESIA $0 MILK OF MAGNESIA CONCENTRATED $0 MIRALAX ORAL POWDER IN PACKET $0 polyethylene glycol 3350 oral powder $0 Last Approved Date: 09/24/2021 Formulary Version: 92
179 Drug Status Notes polyethylene glycol 3350 oral powder in packet $0 17 gram, 4 gram, 4.25 gram POWDERLAX ORAL POWDER $0 PURELAX $0 SMOOTHLAX $0 Laxative - Saline/Osmotic Mixtures COLYTE WITH FLAVOR PACKS NF GAVILYTE-C $0 GAVILYTE-G $0 GAVILYTE-N $0 GOLYTELY ORAL POWDER IN PACKET $0 GOLYTELY ORAL RECON SOLN NF MOVIPREP NF NULYTELY WITH FLAVOR PACKS NF ORAL SALINE LAXATIVE ORAL LIQUID $0 OSMOPREP $0 peg 3350-electrolytes $0 PEG-3350 WITH FLAVOR PACKS $0 peg3350-sod sul-nacl-kcl-asb-c $0 peg-electrolyte soln $0 PHOSPHATE LAXATIVE $0 PLENVU $0 SUPREP BOWEL PREP KIT $0 SUTAB $0 TRILYTE WITH FLAVOR PACKETS $0 Laxative - Stimulant ALOPHEN (BISACODYL) $0 bisacodyl oral $0 BISA-LAX (BISACODYL) $0 CORRECTOL NF DUCODYL (BISACODYL) $0 DULCOLAX (BISACODYL) ORAL NF FLEET LAXATIVE (BISACODYL) $0 GENTLE LAXATIVE (BISACODYL) ORAL $0 LAXATIVE (BISACODYL) ORAL $0 LAXATIVE FEMININE $0 Last Approved Date: 09/24/2021 Formulary Version: 92
180 Drug Status Notes WOMAN'S LAXATIVE (BISACODYL) $0 WOMEN'S GENTLE LAXATIVE(BISAC) $0 WOMEN'S LAXATIVE (BISACODYL) $0 Laxative - Stimulant And Saline/Osmotic Combinations CLENPIQ $0 QL (320 ml per 30 days) PEG-PREP $0 PREPOPIK $0 Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives CARAFATE ORAL SUSPENSION NF QL (46 ML per 1 day) CARAFATE ORAL TABLET NF sucralfate oral suspension 3 QL (46 ML per 1 day) sucralfate oral tablet 1 Peptic Ulcer - Treatment Of H. Pylori: Antibiotic-Bismuth Combinations PA; ST; QL (224 tablets/capsules HELIDAC NF per 365 days) PA; ST; QL (120 capsules per 365 PYLERA NF days) Peptic Ulcer-Treatment H. Pylori- Proton Pump Inhibitor And Antibiotics OMECLAMOX-PAK NF PA; ST; QL (168 capsules per 365 TALICIA NF days) Short Bowel Syndrome (Sbs) - Glucagon-Like Peptide-2 (Glp-2) Analog GATTEX 30-VIAL 4 PA; SP; BE Short Bowel Syndrome (Sbs) Agents BYNFEZIA NF PA; ST; BE octreotide acetate injection solution 4 SP; BE octreotide acetate injection syringe 100 mcg/ml (1 4 SP ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 NF SP ml)
Last Approved Date: 09/24/2021 Formulary Version: 92
181 Drug Status Notes SAIZEN SUBCUTANEOUS RECON SOLN 8.8 NF PA; ST; SP; BE MG SANDOSTATIN INJECTION SOLUTION 100 NF SP; BE MCG/ML, 50 MCG/ML, 500 MCG/ML ZORBTIVE 4 PA; SP; BE Genitourinary Therapy Bph Agent- 5-Alpha Reductase Inhib And Alpha-1 Adrenoceptor Antag Comb dutasteride-tamsulosin NF JALYN NF PA; ST Cystinosis Therapy (Cystine Depleting Agents) CYSTAGON 3 PROCYSBI ORAL CAPSULE, DELAYED REL 4 PA; ST; BE SPRINKLE PROCYSBI ORAL GRANULES DEL NF PA; ST; BE RELEASE IN PACKET G.U. Irrigants acetic acid irrigation NF sorbitol irrigation NF G.U. Irrigants - Anti-Infective neomycin-polymyxin b gu NF Interstitial Cystitis Agents ELMIRON 3 Kidney Stone Agents THIOLA NF PA; ST; BE THIOLA EC ORAL TABLET,DELAYED PA; ST; BE; QL (20 TABLETS NF RELEASE (DR/EC) 100 MG per 1 day) THIOLA EC ORAL TABLET,DELAYED PA; ST; BE; QL (6 TABLETS per NF RELEASE (DR/EC) 300 MG 1 day) tiopronin NF PA; ST; BE Overactive Bladder Agents - Beta -3 Adrenergic Receptor Agonist GEMTESA NF PA; ST; QL (1 tablet per 1 day) MYRBETRIQ ORAL TABLET EXTENDED 3 RELEASE 24 HR
Last Approved Date: 09/24/2021 Formulary Version: 92
182 Drug Status Notes Phosphate Binders AURYXIA 4 calcium acetate(phosphat bind) 1 ELIPHOS 1 FOSRENOL NF lanthanum 4 PHOSLYRA NF RENAGEL NF RENVELA NF sevelamer carbonate oral powder in packet NF sevelamer hcl 4 VELPHORO 4 Phosphate Binders - Calcium-Based calcium acetate(phosphat bind) 1 ELIPHOS 1 PHOSLYRA NF Phosphate Binders - Iron-Based AURYXIA 4 VELPHORO 4 Polycystic Kidney Disease - Vasopressin V2 Receptor Antagonists JYNARQUE ORAL TABLET NF PA; BE JYNARQUE ORAL TABLETS, SEQUENTIAL PA; BE; QL (56 tablets per 28 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 4 days) MG (PM) JYNARQUE ORAL TABLETS, SEQUENTIAL PA; BE; QL (4 blister cards per 28 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 4 days) MG (PM), 90 MG (AM)/ 30 MG (PM) Prostatic Hypertrophy Agent - Alpha-1- Adrenoceptor Antagonists alfuzosin 2 FLOMAX NF PA; ST RAPAFLO NF PA; ST silodosin 3 PA; ST tamsulosin 1 UROXATRAL NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
183 Drug Status Notes Prostatic Hypertrophy Agent - Type Ii 5-Alpha Reductase Inhibitors finasteride oral tablet 5 mg 1 PROSCAR NF PA; ST Prostatic Hypertrophy Agent-Sel.Cgmp Phosphodiesterase Type5 Inhibitor PA; ST; BE; QL (90 TABLETS CIALIS ORAL TABLET 2.5 MG, 5 MG NF per 75 days) BE; QL (90 TABLETS per 75 tadalafil oral tablet 2.5 mg, 5 mg 3 days) Prostatic Hypertrophy Agent-Type I And Ii 5-Alpha Reductase Inhibitors AVODART NF PA; ST dutasteride 3 Urinary Acidifier - Bacterial Urease Inhibitor LITHOSTAT NF Urinary Acidifier - Phosphates K-PHOS NO 2 2 K-PHOS ORIGINAL 2 Urinary Alkalinizer - Citrates CYTRA-2 1 CYTRA-3 1 CYTRA-K 2 ORACIT 2 potassium citrate oral tablet extended release 10 2 meq (1,080 mg), 5 meq (540 mg) potassium citrate oral tablet extended release 15 3 meq potassium citrate-citric acid 2 SHOHL'S MODIFIED NF TRICITRATES 1 UROCIT-K 10 NF UROCIT-K 15 NF UROCIT-K 5 NF VIRTRATE-2 1 VIRTRATE-3 1 Last Approved Date: 09/24/2021 Formulary Version: 92
184 Drug Status Notes VIRTRATE-K 2 Urinary Analgesics phenazopyridine oral tablet 100 mg, 200 mg NF PYRIDIUM NF Urinary Antibacterial - Methenamine And Salts HIPREX NF methenamine mandelate oral tablet 0.5 g 3 methenamine mandelate oral tablet 1 gram 2 UROQID-ACID NO.2 NF Urinary Antibacterial - Nitrofuran Derivatives FURADANTIN NF MACROBID NF MACRODANTIN NF nitrofurantoin 3 nitrofurantoin macrocrystal oral capsule 100 mg, 1 50 mg nitrofurantoin macrocrystal oral capsule 25 mg NF nitrofurantoin monohyd/m-cryst 1 Urinary Antibacterial - Quinolones CIPRO XR NF ciprofloxacin (mixture) 2 Urinary Antibacterials Other fosfomycin tromethamine 3 MONUROL NF Urinary Anti-Infective Methenamine- Antispas-Analg Combinations HYOPHEN NF PHOSPHASAL NF UR N-C NF URELLE NF URETRON D-S NF URIBEL NF URIMAR-T NF URIN DS NF Last Approved Date: 09/24/2021 Formulary Version: 92
185 Drug Status Notes URO-MP NF USTELL NF UTIRA-C NF Urinary Anti-Infective Methenamine- Antispasmodic Combinations UROGESIC-BLUE NF URYL NF UTA NF Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder) ENABLEX NF solifenacin 3 VESICARE NF PA; ST; QL (300 ML per 25 VESICARE LS NF Dayss) Urinary Antispasmodic - Anticholinergics, Non-Selective ANASPAZ 2 ED-SPAZ 2 hyoscyamine sulfate oral 2 hyoscyamine sulfate sublingual 2 LEVBID NF LEVSIN ORAL NF LEVSIN/SL NF NULEV NF OSCIMIN 2 OSCIMIN SL 2 OSCIMIN SR 2 SYMAX FASTABS 2 SYMAX-SL 2 SYMAX-SR 2 Urinary Antispasmodic - Smooth Muscle Relaxants DETROL NF DETROL LA NF DITROPAN XL NF
Last Approved Date: 09/24/2021 Formulary Version: 92
186 Drug Status Notes flavoxate 2 GELNIQUE TRANSDERMAL GEL IN QL (30 GRAMS per 1 METERED-DOSE PUMP 100 MG/GRAM (10 NF DISPENSE) %) GELNIQUE TRANSDERMAL GEL IN QL (30 GRAMS per 1 NF PACKET DISPENSE) oxybutynin chloride oral syrup 1 oxybutynin chloride oral tablet 1 oxybutynin chloride oral tablet extended release 2 24hr OXYTROL NF QL (8 PATCHES per 1 MONTH) tolterodine 3 TOVIAZ 4 trospium oral capsule,extended release 24hr 3 trospium oral tablet 2 Urinary Retention Therapy - Parasympathomimetic Agents bethanechol chloride 2 URECHOLINE NF Gout And Hyperuricemia Therapy Gout Acute Therapy - Antimitotics PA; ST; QL (2 CAPSULES per 1 colchicine oral capsule 3 day) colchicine oral tablet 3 COLCRYS NF GLOPERBA NF PA; ST; QL (10 ML per 1 day) PA; ST; QL (2 CAPSULES per 1 MITIGARE NF day) Gout And Hyperuricemia - Antimitotic- Uricosuric Combinations probenecid-colchicine 3 Hyperuricemia Therapy - Uricosurics probenecid 1 Hyperuricemia Therapy - Xanthine Oxidase Inhibitors allopurinol 1 febuxostat 3 PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
187 Drug Status Notes ULORIC NF PA; ST ZYLOPRIM NF Hyperuricemia Tx - Urat1 Inhibitor And Xanthine Oxidase Inhibitor Comb PA; ST; QL (1 TABLET per 1 DUZALLO 3 day) Hematological Agents Agents To Treat Attp- Anti Von Willebrand Factor (Vwf) A1 Domain CABLIVI NF PA Agents To Treat Paroxysmal Nocturnal Hemoglobinuria (Pnh) EMPAVELI NF PA; QL (8 vials per 28 days) Anticoagulants - Coumarin COUMADIN ORAL 3 JANTOVEN 1 warfarin 1 Anti-Inhibitor Coagulation Complex FEIBA NF NF Blood Cell And Platelet Disorder Tx- Spleen Tyrosine Kinase Inhibitors PA; ST; BE; QL (2 TABLETS per TAVALISSE NF 1 day) C1 Esterase Inhibitor Agents BERINERT INTRAVENOUS KIT NF PA; ST; SP BERINERT INTRAVENOUS RECON SOLN NF PA; ST CINRYZE NF PA; ST; BE PA; ST; SP; BE; QL (20 vials per HAEGARDA NF 25 days) RUCONEST NF PA; ST; SP; BE Cxcr4 Chemokine Receptor Antagonists MOZOBIL 4 PA; SP; BE Direct Factor Xa Inhibitors BEVYXXA 4 QL (42 CAPSULES per 60 days) ELIQUIS DVT-PE TREAT 30D START 3 QL (1 dose packet per 365 days) ELIQUIS ORAL TABLET 2.5 MG 3 QL (2 TABLETS per 1 day) Last Approved Date: 09/24/2021 Formulary Version: 92
188 Drug Status Notes ELIQUIS ORAL TABLET 5 MG 3 QL (74 tablets per 25 days) SAVAYSA NF QL (1 TABLET per 1 day) QL (2 PACKS (102 TABLETS) XARELTO DVT-PE TREAT 30D START 3 per 274 days) XARELTO ORAL TABLET 10 MG, 20 MG 3 QL (1 TABLET per 1 day) XARELTO ORAL TABLET 15 MG, 2.5 MG 3 QL (2 TABLETS per 1 day) Erythropoietins ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 4 SP; BE MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML ARANESP (IN POLYSORBATE) INJECTION 4 SP; BE SYRINGE EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 4 SP; BE 3,000 UNIT/ML, 4,000 UNIT/ML MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 200 MCG/0.3 ML, 50 MCG/0.3 4 ML, 75 MCG/0.3 ML PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 4 SP; BE 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML RETACRIT NF BE Factor Ix Preparations ALPHANINE SD NF ALPROLIX NF BENEFIX NF IDELVION NF IXINITY NF PROFILNINE NF REBINYN NF RIXUBIS NF Factor Vii Preparations NOVOSEVEN RT NF SEVENFACT NF Factor Viii Preparations (Ahf) ADVATE NF
Last Approved Date: 09/24/2021 Formulary Version: 92
189 Drug Status Notes ADYNOVATE NF AFSTYLA NF ALPHANATE NF ELOCTATE NF ESPEROCT NF HELIXATE FS NF HEMOFIL M HIGH NF HEMOFIL M LOW NF HEMOFIL M MID NF HEMOFIL M SUPER HIGH NF HUMATE-P NF JIVI NF KOATE NF KOATE-DVI NF KOGENATE FS NF KOVALTRY NF NOVOEIGHT NF NUWIQ NF PA; ST; BE OBIZUR NF RECOMBINATE NF PA; ST; BE WILATE NF XYNTHA NF PA; ST; BE XYNTHA SOLOFUSE NF BE Factor Viii-Mimetic Agent, Monoclonal Antibody HEMLIBRA SUBCUTANEOUS SOLUTION PA; BE; QL (8 VIALS per 21 4 105 MG/0.7 ML, 150 MG/ML, 60 MG/0.4 ML days) HEMLIBRA SUBCUTANEOUS SOLUTION 30 PA; BE; QL (24 VIALS per 21 4 MG/ML days) Factor X Preparations COAGADEX NF Factor Xiii Preparations CORIFACT NF TRETTEN NF
Last Approved Date: 09/24/2021 Formulary Version: 92
190 Drug Status Notes Granulocyte Colony-Stimulating Factor (G-Csf) FULPHILA NF GRANIX SUBCUTANEOUS SYRINGE NF BE NEULASTA NF SP; BE NEUPOGEN INJECTION SOLUTION 300 NF SP; BE MCG/ML NEUPOGEN INJECTION SYRINGE NF SP; BE NIVESTYM NF NYVEPRIA NF BE UDENYCA NF BE ZARXIO 4 SP ZIEXTENZO NF BE Granulocyte-Macrophage Colony- Stimulating Factor (Gm-Csf) LEUKINE INJECTION RECON SOLN 4 SP; BE Hematorheologic Agents pentoxifylline 1 Hemostatic Systemic - Antifibrinolytic Agents AMICAR NF aminocaproic acid oral tablet NF FIBRYGA NF LYSTEDA NF RIASTAP NF tranexamic acid intravenous 4 tranexamic acid oral 3 Hemostatic Systemic- Von Willebrand Factor (Vwf) Preparations VONVENDI NF Heparin Flush Formulations heparin (porcine) in nacl (pf) intravenous 3 parenteral solution 1,000 unit/500 ml HEPARIN LOCK FLUSH 3 heparin lock flush (porcine) intravenous syringe 3
Last Approved Date: 09/24/2021 Formulary Version: 92
191 Drug Status Notes HEPARIN LOCKFLUSH(PORCINE)(PF) 3 INTRAVENOUS SYRINGE 100 UNIT/ML heparin, porcine (pf) intravenous syringe 1 3 unit/ml, 100 unit/ml Heparins heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 3 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous 3 parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 10,000 3 unit/ml, 20,000 unit/ml, 5,000 unit/ml HEPARIN LOCK FLUSH 3 heparin lock flush (porcine) intravenous syringe 3 HEPARIN LOCKFLUSH(PORCINE)(PF) 3 INTRAVENOUS SYRINGE 100 UNIT/ML heparin(porcine) in 0.45% nacl intravenous 3 parenteral solution 25,000 unit/250 ml heparin, porcine (pf) injection solution 1,000 3 unit/ml heparin, porcine (pf) injection syringe 5,000 3 unit/0.5 ml heparin, porcine (pf) intravenous syringe 1 3 unit/ml, 100 unit/ml heparin, porcine (pf) subcutaneous NF Indirect Factor Xa Inhibitors ARIXTRA SUBCUTANEOUS SYRINGE 10 NF BE MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML fondaparinux 4 BE Low Molecular Weight Heparins enoxaparin subcutaneous solution 3 enoxaparin subcutaneous syringe 3 BE FRAGMIN SUBCUTANEOUS SOLUTION 4 FRAGMIN SUBCUTANEOUS SYRINGE 4 BE LOVENOX NF BE Monoclonal Antibody - P-Selectin Inhibitors ADAKVEO NF Last Approved Date: 09/24/2021 Formulary Version: 92
192 Drug Status Notes Platelet Aggregation Inhib - Cyclopentyl-Triazolo-Pyrimidines (Cptps) BRILINTA 3 Platelet Aggregation Inhibitor Combinations AGGRENOX NF aspirin-dipyridamole 3 Platelet Aggregation Inhibitors - Phosphodiesterase Iii Inhibitors cilostazol 1 Platelet Aggregation Inhibitors - Quinazoline Agents AGRYLIN NF anagrelide 3 Platelet Aggregation Inhibitors - Salicylates ADULT LOW DOSE ASPIRIN $0 ASPIR-81 $0 ASPIRIN CHILDRENS $0 ASPIRIN LOW DOSE $0 aspirin oral tablet $0 aspirin oral tablet,chewable $0 aspirin oral tablet,delayed release (dr/ec) 325 $0 mg, 81 mg ASPIR-LOW $0 ASPIR-TRIN $0 BAYER ASPIRIN $0 BAYER CHEWABLE ASPIRIN NF CHILDREN'S ASPIRIN $0 DURLAZA NF QL (1 CAPSULE per 1 day) E.C. PRIN $0 ECOTRIN $0 ECOTRIN LOW STRENGTH $0 ENTERIC COATED ASPIRIN $0 LITE COAT ASPIRIN $0
Last Approved Date: 09/24/2021 Formulary Version: 92
193 Drug Status Notes LO-DOSE ASPIRIN $0 Platelet Aggregation Inhibitors - Thienopyridine Agents clopidogrel 1 EFFIENT NF PLAVIX NF prasugrel 3 Platelet Aggregation Inhibitors- Salicylates And Proton Pump Inhib Comb PA; ST; QL (1 TABLET per 1 aspirin-omeprazole NF day) PA; ST; QL (1 TABLET per 1 YOSPRALA NF day) Platelet Aggregation Inhib-Pdesterase And Adenosine Deaminase Inhibitr dipyridamole oral 3 Platelet Aggregation Inhib-Protease- Activ.Receptor-1(Par-1) Antagonist ZONTIVITY NF QL (1 TABLET per 1 day) Pnh - Complement (C3) Inhibitors EMPAVELI NF PA; QL (8 vials per 28 days) Sickle Cell Anemia Agents, Others DROXIA NF PA; ST; SP; QL (6 packets per 1 ENDARI NF day) SIKLOS ORAL TABLET 1,000 MG 4 PA SIKLOS ORAL TABLET 100 MG 4 PA; BE Sickle Hemoglobin (Hbs) Polymerization Inhibitor OXBRYTA NF PA; BE; QL (3 tablets per 1 day) Thrombin Inhibitor - Selective Direct And Reversible PRADAXA ORAL CAPSULE 150 MG, 75 MG NF QL (4 capsules per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
194 Drug Status Notes Thrombopoietin Receptor Agonists PA; ST; BE; QL (15 tablets per 28 DOPTELET (10 TAB PACK) NF Dayss) PA; ST; BE; QL (15 tablets per 28 DOPTELET (15 TAB PACK) NF Dayss) PA; ST; BE; QL (15 tablets per 28 DOPTELET (30 TAB PACK) NF Dayss) MULPLETA NF PA; QL (7 TABLETS per 28 days) NPLATE SUBCUTANEOUS RECON SOLN 4 PA; ST; BE 125 MCG NPLATE SUBCUTANEOUS RECON SOLN 4 PA; ST; SP; BE 250 MCG PROMACTA ORAL POWDER IN PACKET PA; ST; BE; QL (1 packet per 1 4 12.5 MG day) PROMACTA ORAL POWDER IN PACKET 25 PA; ST; BE; QL (1 packet per 1 4 MG Day) PA; ST; SP; BE; QL (1 TABLET PROMACTA ORAL TABLET 12.5 MG, 25 MG 4 per 1 day) PA; ST; SP; BE; QL (2 TABLETS PROMACTA ORAL TABLET 50 MG, 75 MG 4 per 1 day) Hepatobiliary System Treatment Agents Farnesoid X Receptor (Fxr) Agonist, Bile Acid Analog PA; ST; BE; QL (1 TABLET per 1 OCALIVA NF day) Ileal Bile Acid Transporter (Ibat) Inhibitor BYLVAY NF Immunosuppressive Agents Immunosuppressive - Calcineurin Inhibitors ASTAGRAF XL NF cyclosporine modified oral capsule 3 cyclosporine modified oral solution NF cyclosporine oral capsule 3 ENVARSUS XR NF GENGRAF ORAL CAPSULE 3 GENGRAF ORAL SOLUTION NF
Last Approved Date: 09/24/2021 Formulary Version: 92
195 Drug Status Notes PA; ST; BE; QL (6 capsules per 1 LUPKYNIS NF day) NEORAL NF PROGRAF ORAL NF SANDIMMUNE ORAL NF tacrolimus oral 3 Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors CELLCEPT NF mycophenolate mofetil 3 mycophenolate sodium 3 MYFORTIC NF Immunosuppressive - Interleukin-6 (Il- 6) Receptor Inhibitors ENSPRYNG NF PA; QL (1 syringe per 28 days) Immunosuppressive - Mammalian Target Of Rapamycin (Mtor) Inhibitors everolimus (immunosuppressive) 4 RAPAMUNE NF sirolimus 4 ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, NF 0.75 MG ZORTRESS ORAL TABLET 1 MG 4 Immunosuppressive - Purine Analogs AZASAN NF azathioprine 3 IMURAN NF Locomotor System Agents To Treat Periodic Paralysis - Carbonic Anhydrase Inhibitors PA; BE; QL (4 TABLETS per 1 KEVEYIS 4 day) Als Agents - Benzathiazoles EXSERVAN NF PA; QL (2 films per 1 Day) RILUTEK NF BE
Last Approved Date: 09/24/2021 Formulary Version: 92
196 Drug Status Notes riluzole 3 BE TIGLUTIK NF PA; BE; QL (600 ML per 25 days) Antimyasthenic Agent - Reversible Cholinesterase Inhibitors MESTINON ORAL NF MESTINON TIMESPAN NF pyridostigmine bromide oral tablet 30 mg NF pyridostigmine bromide oral tablet 60 mg 1 pyridostigmine bromide oral tablet extended NF release Antimyasthenic Agents Other guanidine 2 Skeletal Muscle Relaxant - Analgesic Salicylate Combinations carisoprodol-aspirin NF PA; ST PA; ST; QL (4 TABLETS per 1 NORGESIC FORTE NF day) PA; ST; QL (4 TABLETS per 1 ORPHENGESIC FORTE NF day) Skeletal Muscle Relaxant - Central Muscle Relaxants AMRIX NF PA; ST baclofen oral tablet 10 mg, 20 mg 1 baclofen oral tablet 5 mg NF carisoprodol oral tablet 250 mg NF PA; ST carisoprodol oral tablet 350 mg 1 PA chlorzoxazone oral tablet 250 mg, 375 mg, 750 NF PA; ST mg chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine oral capsule,extended release NF PA; ST 24hr cyclobenzaprine oral tablet 10 mg, 5 mg 1 cyclobenzaprine oral tablet 7.5 mg NF PA; ST FEXMID NF PA; ST LORZONE NF PA; ST METAXALL 3 PA; ST metaxalone 3 PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
197 Drug Status Notes methocarbamol oral 1 orphenadrine citrate oral 1 PA; ST; BE; QL (80 ML per 1 OZOBAX NF day) ROBAXIN ORAL NF ROBAXIN-750 NF SKELAXIN NF PA; ST SOMA NF PA; ST tizanidine oral capsule 3 tizanidine oral tablet 1 ZANAFLEX NF Skeletal Muscle Relaxant - Direct Muscle Relaxants DANTRIUM ORAL CAPSULE 25 MG, 50 MG NF dantrolene oral capsule 100 mg 3 dantrolene oral capsule 25 mg, 50 mg 2 Skeletal Muscle Relaxant - Opioid Analgesic Combinations carisoprodol-aspirin-codeine NF PA; ST; QL (90 MG per 1 day) Skeletal Muscle Relaxant, Salicylate, And Opioid Analgesic Comb. carisoprodol-aspirin-codeine NF PA; ST; QL (90 MG per 1 day) Spinal Muscular Atrophy - Motor Neuron 2 (Smn2) Splicing Modifier EVRYSDI NF PA; QL (80 ML per 20 days) Medical Supplies And Durable Medical Equipment (Dme) Medical Supplies And Dme - Blood Glucose Tests ACCU-CHEK AVIVA PLUS TEST STRP NF QL (7 test strips per 1 day) ACCU-CHEK COMPACT PLUS TEST NF QL (7 test strips per 1 day) ACCU-CHEK GUIDE TEST STRIPS NF QL (7 test strips per 1 day) ACCU-CHEK SMARTVIEW TEST STRIP NF QL (7 test strips per 1 day) ADVANCED GLUC METER TEST STRIP NF QL (7 test strips per 1 day) ADVOCATE TEST STRIPS NF QL (7 test strips per 1 day) ASSURE 4 STRIPS NF QL (7 test strips per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
198 Drug Status Notes ASSURE PLATINUM TEST STRIP NF QL (7 test strips per 1 day) ASSURE PRISM MULTI STRIP NF QL (7 test strips per 1 day) BREEZE 2 TEST STRIPS NF QL (7 test strips per 1 day) CLEVER CHOICE MICRO TEST STRIP NF QL (7 test strips per 1 day) CLEVER CHOICE PRO STRIP NF QL (7 test strips per 1 day) CLEVER CHOICE TEST STRIPS NF QL (7 test strips per 1 day) CLEVER CHOICE VOICE+ TEST NF QL (7 test strips per 1 day) CONTOUR NEXT TEST STRIPS NF QL (7 test strips per 1 day) CONTOUR TEST STRIPS NF QL (7 test strips per 1 day) EASY TOUCH BLU LINK TEST STRIP NF QL (7 strips per 1 day) EASY TRAK II TEST STRIP NF PA; ST; QL (7 strips per 1 Day) EVENCARE PROVIEW TEST STRIP NF PA; ST; QL (7 strips per 1 Day) FORA 6 CONNECT GLUCOSE STRIP NF QL (7 strips per 1 Day) FORA GTEL GLUCOSE TEST STRIP NF QL (7 strips per 1 day) FORA TN'G ADVAN PRO TEST STRIP NF QL (7 strips per 1 Day) FORTISCARE G1 TEST STRIP NF QL (7 strips per 1 Day) FREESTYLE INSULINX STRIP NF QL (7 test strips per 1 day) FREESTYLE INSULINX TEST STRIPS NF QL (7 test strips per 1 day) FREESTYLE LITE STRIPS NF QL (7 test strips per 1 day) FREESTYLE PRECISION NEO STRIPS NF QL (7 test strips per 1 day) FREESTYLE TEST NF QL (7 test strips per 1 day) GOJJI BLOOD GLUCOSE TEST STRIP NF PA; ST; QL (7 strips per 1 Day) HARMONY GLUCOSE TEST STRIP NF PA; ST; QL (7 strips per 1 Day) MICRODOT XTRA BLOOD GLUCOSE NF PA; ST; QL (7 strips per 1 Day) ONETOUCH VERIO TEST STRIPS NF QL (7 test strips per 1 day) PRECISION PCX PLUS TEST NF QL (7 test strips per 1 day) PRECISION PCX TEST NF QL (7 test strips per 1 day) PRECISION POINT OF CARE TEST NF QL (7 test strips per 1 day) PRECISION Q-I-D TEST NF QL (7 test strips per 1 day) PRECISION XTRA TEST NF QL (7 test strips per 1 day) PRODIGY NO CODING NF QL (7 test strips per 1 day) TRUE METRIX GLUCOSE TEST STRIP 3 QL (7 STRIPS per 1 day) VIVAGUARD INO TEST STRIP NF QL (7 strips per 1 day) Medical Supplies And Dme - Cervical Caps FEMCAP $0 Last Approved Date: 09/24/2021 Formulary Version: 92
199 Drug Status Notes Medical Supplies And Dme - Diaphragms CAYA CONTOURED NF WIDE-SEAL DIAPHRAGM 60 $0 WIDE-SEAL DIAPHRAGM 65 $0 WIDE-SEAL DIAPHRAGM 70 $0 WIDE-SEAL DIAPHRAGM 75 $0 WIDE-SEAL DIAPHRAGM 80 $0 WIDE-SEAL DIAPHRAGM 85 $0 WIDE-SEAL DIAPHRAGM 90 $0 WIDE-SEAL DIAPHRAGM 95 $0 Medical Supplies And Dme - Female Condoms FC2 FEMALE CONDOM $0 Medical Supplies And Dme - Glucose Monitoring Test Supplies DEXCOM G4 RECEIVER 3 QL (1 pack per 365 days) DEXCOM G4 TRANSMITTER 3 QL (1 UNIT per 75 days) DEXCOM G5 RECEIVER 3 QL (1 pack per 365 days) DEXCOM G5 TRANSMITTER 3 QL (1 UNIT per 75 days) QL (4 units (1 box) per 25 day DEXCOM G5-G4 SENSOR 3 rolling periods) DEXCOM G6 RECEIVER 3 QL (1 pack per 365 days) QL (4 units (1 box) per 25 day DEXCOM G6 SENSOR 3 rolling periods) DEXCOM G6 TRANSMITTER 3 QL (1 UNIT per 75 days) DEXCOM RECEIVER 3 QL (1 pack per 365 days) FREESTYLE LIBRE 10 DAY READER 3 QL (1 pack per 365 days) FREESTYLE LIBRE 10 DAY SENSOR 3 QL (3 KITS per 25 days) FREESTYLE LIBRE 14 DAY READER 3 QL (1 pack per 365 days) FREESTYLE LIBRE 14 DAY SENSOR 3 QL (2 KITS per 21 days) FREESTYLE LIBRE 2 READER 2 QL (1 pack per 365 days) FREESTYLE LIBRE 2 SENSOR 2 QL (2 kits per 21 days) Medical Supplies And Dme - Insulin Needles-Syringes And Admin Supplies OMNIPOD DASH PDM KIT 3 QL (10 pods per 30 Dayss)
Last Approved Date: 09/24/2021 Formulary Version: 92
200 Drug Status Notes Medical Supplies And Dme - Male Condoms AIMSCO LATEX CONDOM $0 CONDOMS-PREM LUBRICATED $0 FANTASY CONDOM $0 KIMONO CONDOMS(NON-LUBRICATED) $0 KIMONO MAXX CONDOMS $0 KIMONO MICROTHIN AQUA LUBE CON $0 KIMONO MICROTHIN CONDOMS $0 KIMONO MICROTHIN LARGE CONDOMS $0 KIMONO TEXTURED CONDOMS $0 TRUSTEX LUBRICATED CONDOMS $0 TRUSTEX-RIA LUB/SPERMICIDE $0 TRUSTEX-RIA LUBRICATED CONDOMS $0 TRUSTEX-RIA NON-LUB CONDOMS $0 Medical Supplies And Dme - Subcutaneous Insulin Delivery Devices CEQUR SIMPLICITY 3 QL (10 patches per 25 Dayss) V-GO 20 3 QL (30 devices per 30 Dayss) V-GO 30 3 QL (30 devices per 30 Dayss) V-GO 40 3 QL (30 devices per 30 Dayss) Medical Supply, Fdb Superset Medical Supply, Fdb Superset ACCU-CHEK AVIVA PLUS TEST STRP NF QL (7 test strips per 1 day) ACCU-CHEK COMPACT PLUS TEST NF QL (7 test strips per 1 day) ACCU-CHEK GUIDE TEST STRIPS NF QL (7 test strips per 1 day) ACCU-CHEK SMARTVIEW TEST STRIP NF QL (7 test strips per 1 day) ADVANCED GLUC METER TEST STRIP NF QL (7 test strips per 1 day) ADVOCATE TEST STRIPS NF QL (7 test strips per 1 day) AIMSCO LATEX CONDOM $0 ASSURE 4 STRIPS NF QL (7 test strips per 1 day) ASSURE PLATINUM TEST STRIP NF QL (7 test strips per 1 day) ASSURE PRISM MULTI STRIP NF QL (7 test strips per 1 day) BREEZE 2 TEST STRIPS NF QL (7 test strips per 1 day) CAYA CONTOURED NF CEQUR SIMPLICITY 3 QL (10 patches per 25 Dayss) Last Approved Date: 09/24/2021 Formulary Version: 92
201 Drug Status Notes CLEVER CHOICE MICRO TEST STRIP NF QL (7 test strips per 1 day) CLEVER CHOICE PRO STRIP NF QL (7 test strips per 1 day) CLEVER CHOICE TEST STRIPS NF QL (7 test strips per 1 day) CLEVER CHOICE VOICE+ TEST NF QL (7 test strips per 1 day) CONDOMS-PREM LUBRICATED $0 CONTOUR NEXT TEST STRIPS NF QL (7 test strips per 1 day) CONTOUR TEST STRIPS NF QL (7 test strips per 1 day) DEXCOM G4 RECEIVER 3 QL (1 pack per 365 days) DEXCOM G4 TRANSMITTER 3 QL (1 UNIT per 75 days) DEXCOM G5 RECEIVER 3 QL (1 pack per 365 days) DEXCOM G5 TRANSMITTER 3 QL (1 UNIT per 75 days) QL (4 units (1 box) per 25 day DEXCOM G5-G4 SENSOR 3 rolling periods) DEXCOM G6 RECEIVER 3 QL (1 pack per 365 days) QL (4 units (1 box) per 25 day DEXCOM G6 SENSOR 3 rolling periods) DEXCOM G6 TRANSMITTER 3 QL (1 UNIT per 75 days) DEXCOM RECEIVER 3 QL (1 pack per 365 days) EASY TOUCH BLU LINK TEST STRIP NF QL (7 strips per 1 day) EASY TRAK II TEST STRIP NF PA; ST; QL (7 strips per 1 Day) EVENCARE PROVIEW TEST STRIP NF PA; ST; QL (7 strips per 1 Day) FANTASY CONDOM $0 FC2 FEMALE CONDOM $0 FEMCAP $0 FORA 6 CONNECT GLUCOSE STRIP NF QL (7 strips per 1 Day) FORA GTEL GLUCOSE TEST STRIP NF QL (7 strips per 1 day) FORA TN'G ADVAN PRO TEST STRIP NF QL (7 strips per 1 Day) FORTISCARE G1 TEST STRIP NF QL (7 strips per 1 Day) FREESTYLE INSULINX STRIP NF QL (7 test strips per 1 day) FREESTYLE INSULINX TEST STRIPS NF QL (7 test strips per 1 day) FREESTYLE LIBRE 10 DAY READER 3 QL (1 pack per 365 days) FREESTYLE LIBRE 10 DAY SENSOR 3 QL (3 KITS per 25 days) FREESTYLE LIBRE 14 DAY READER 3 QL (1 pack per 365 days) FREESTYLE LIBRE 14 DAY SENSOR 3 QL (2 KITS per 21 days) FREESTYLE LIBRE 2 READER 2 QL (1 pack per 365 days) FREESTYLE LIBRE 2 SENSOR 2 QL (2 kits per 21 days)
Last Approved Date: 09/24/2021 Formulary Version: 92
202 Drug Status Notes FREESTYLE LITE STRIPS NF QL (7 test strips per 1 day) FREESTYLE PRECISION NEO STRIPS NF QL (7 test strips per 1 day) FREESTYLE TEST NF QL (7 test strips per 1 day) GOJJI BLOOD GLUCOSE TEST STRIP NF PA; ST; QL (7 strips per 1 Day) HARMONY GLUCOSE TEST STRIP NF PA; ST; QL (7 strips per 1 Day) KIMONO CONDOMS(NON-LUBRICATED) $0 KIMONO MAXX CONDOMS $0 KIMONO MICROTHIN AQUA LUBE CON $0 KIMONO MICROTHIN CONDOMS $0 KIMONO MICROTHIN LARGE CONDOMS $0 KIMONO TEXTURED CONDOMS $0 MICRODOT XTRA BLOOD GLUCOSE NF PA; ST; QL (7 strips per 1 Day) OMNIPOD DASH PDM KIT 3 QL (10 pods per 30 Dayss) ONETOUCH VERIO TEST STRIPS NF QL (7 test strips per 1 day) PRECISION PCX PLUS TEST NF QL (7 test strips per 1 day) PRECISION PCX TEST NF QL (7 test strips per 1 day) PRECISION POINT OF CARE TEST NF QL (7 test strips per 1 day) PRECISION Q-I-D TEST NF QL (7 test strips per 1 day) PRECISION XTRA TEST NF QL (7 test strips per 1 day) PRODIGY NO CODING NF QL (7 test strips per 1 day) TRUE METRIX GLUCOSE TEST STRIP 3 QL (7 STRIPS per 1 day) TRUSTEX LUBRICATED CONDOMS $0 TRUSTEX-RIA LUB/SPERMICIDE $0 TRUSTEX-RIA LUBRICATED CONDOMS $0 TRUSTEX-RIA NON-LUB CONDOMS $0 V-GO 20 3 QL (30 devices per 30 Dayss) V-GO 30 3 QL (30 devices per 30 Dayss) V-GO 40 3 QL (30 devices per 30 Dayss) VIVAGUARD INO TEST STRIP NF QL (7 strips per 1 day) WIDE-SEAL DIAPHRAGM 60 $0 WIDE-SEAL DIAPHRAGM 65 $0 WIDE-SEAL DIAPHRAGM 70 $0 WIDE-SEAL DIAPHRAGM 75 $0 WIDE-SEAL DIAPHRAGM 80 $0 WIDE-SEAL DIAPHRAGM 85 $0 WIDE-SEAL DIAPHRAGM 90 $0 Last Approved Date: 09/24/2021 Formulary Version: 92
203 Drug Status Notes WIDE-SEAL DIAPHRAGM 95 $0 Metabolic Disease Enzyme Replacement Agents Metabolic Disease Enzyme Replacement, Hypophosphatasia STRENSIQ SUBCUTANEOUS SOLUTION 40 4 PA MG/ML, 80 MG/0.8 ML Metabolic Dx Enzyme Replacement, Severe Combined Immune Deficiency ADAGEN NF Metabolic Modifiers Hyperparathyroid Treatment Agents - Vitamin D Analog-Type calcitriol oral capsule 1 BE doxercalciferol oral 3 paricalcitol hemodialysis port injection solution 2 NF mcg/ml paricalcitol intravenous solution 2 mcg/ml 3 paricalcitol oral 3 ZEMPLAR INTRAVENOUS SOLUTION 2 NF MCG/ML ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG NF Metabolic Modifier - Carnitine Replenisher Agents CARNITOR (SUGAR-FREE) NF CARNITOR ORAL TABLET NF levocarnitine (with sugar) NF levocarnitine oral tablet NF Metabolic Modifier - Gaucher's Disease, Type-1, Substrate Reduction Tx CERDELGA 4 PA; SP; QL (1 tablet per 1 day) PA; ST; QL (3 CAPSULES per 1 miglustat 4 day) PA; ST; BE; QL (3 CAPSULES ZAVESCA NF per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
204 Drug Status Notes Metabolic Modifier - Hereditary Orotic Aciduria Treatment Agents PA; BE; QL (4 PACKETS per 1 XURIDEN 4 day) Metabolic Modifier - Hereditary Tyrosinemia Treatment Agents nitisinone 4 PA; ST; BE NITYR 4 PA; SP; BE ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 NF ST; BE MG ORFADIN ORAL CAPSULE 20 MG NF PA; ST; BE ORFADIN ORAL SUSPENSION 4 PA; ST; BE Metabolic Modifier - Homocystinuria Treatment Agents CYSTADANE NF Metabolic Modifier - Urea Cycle Disorder Agents-Conjugating Agents BUPHENYL ORAL POWDER NF PA BUPHENYL ORAL TABLET NF PA; BE RAVICTI 1 PA; BE sodium phenylbutyrate oral powder 4 PA; SP sodium phenylbutyrate oral tablet 4 PA; SP; BE Metabolic Modifier-Carbamoyl Phosphate Synthetase 1 (Cps 1) Activator CARBAGLU 4 PA Pharmacoenhancer - Cytochrome P450 Inhibitors TYBOST 3 QL (1 TABLET per 1 day) Pharmacological Chaperone Tx - Alpha-Galactosidase A Enzyme Stabilizer PA; QL (14 CAPSULES per 21 GALAFOLD 4 days) Phenylketonuria(Pku) Tx Agents - Cofactor Of Phenylalanine Hydroxylase KUVAN ORAL POWDER IN PACKET 100 MG NF BE Last Approved Date: 09/24/2021 Formulary Version: 92
205 Drug Status Notes KUVAN ORAL POWDER IN PACKET 500 MG NF PA; SP; BE KUVAN ORAL TABLET,SOLUBLE NF PA; SP; BE PA; BE; QL (90 day supply per sapropterin 4 720 Dayss) Phenylketonuria(Pku) Tx Agents - Phenylalanine Ammonia Lyase PALYNZIQ NF PA; ST; BE Progeria Syndrome Treatment Agents - Farnyltransferase Inhibitor ZOKINVY NF PA; BE; QL (2 capsules per 1 day) Mouth-Throat-Dental - Preparations Dental Product - Fluoride Preparations CLINPRO 5000 2 DENTA 5000 PLUS 1 DENTAGEL 1 FLORIVA (FLUORIDE-VITAMIN D3) $0 BE FLUORABON $0 BE FLUOR-A-DAY NF BE FLUOR-A-DAY (WITH XYLITOL) $0 BE fluoride (sodium) dental cream 1 fluoride (sodium) dental paste 1 fluoride (sodium) dental solution 2 fluoride (sodium) oral drops $0 BE fluoride (sodium) oral tablet,chewable 0.25 $0 BE mg(0.55 mg sod. fluoride) FLUORIDEX SENSITIVITY RELIEF NF FLUORITAB $0 BE FLUORITAB ORAL TABLET,CHEWABLE 0.5 $0 BE MG (1.1 MG SODIUM FLUORID) LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. $0 BE FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID) PREVIDENT 5000 DRY MOUTH 2 PREVIDENT 5000 ENAMEL PROTECT 2 PREVIDENT 5000 ORTHO DEFENSE 2 PREVIDENT DENTAL SOLUTION NF BE
Last Approved Date: 09/24/2021 Formulary Version: 92
206 Drug Status Notes SF 5000 PLUS 1 SODIUM FLUORIDE 5000 DRY MOUTH 1 sodium fluoride-pot nitrate 1 Mouth And Throat - Antifungals clotrimazole mucous membrane 1 nystatin oral suspension 1 Mouth And Throat - Antiseptics chlorhexidine gluconate mucous membrane 1 PERIDEX NF PERIOGARD 1 Mouth And Throat - Artificial Saliva AQUORAL NF PA; ST CAPHOSOL NF PA; ST NEUTRASAL NF PA; ST SALIVAMAX NF PA; ST SALIVATERX NF XEROSTOMIA RELIEF NF PA; ST Mouth And Throat - Glucocorticoids ORALONE 2 triamcinolone acetonide dental 2 Mouth And Throat - Local Anesthetic Amides lidocaine hcl mucous membrane jelly 1 QL (60 ML per 30 days) lidocaine hcl mucous membrane solution 4 % (40 NF mg/ml) LIDOCAINE VISCOUS 1 Mouth And Throat - Mucositis- Stomatitis Agents EPISIL NF PA GELCLAIR NF PA; ST GELX NF PA; ST MUGARD NF PA; ST Mouth And Throat - Protectants GELX NF PA; ST MUGARD NF PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
207 Drug Status Notes Mouth And Throat - Saliva Stimulants PA; ST; QL (3 CAPSULES per 1 cevimeline 3 day) PA; ST; QL (3 CAPSULES per 1 EVOXAC NF day) pilocarpine hcl oral tablet 5 mg 3 pilocarpine hcl oral tablet 7.5 mg 2 SALAGEN (PILOCARPINE) NF Periodontal Product - Tetracycline- Type, Collagenase Inhibitors doxycycline hyclate oral tablet 20 mg 1 Therapy For Drooling- Primary Or Secondary Sialorrhea-Anticholinergic CUVPOSA NF PA Multiple Sclerosis Agents Multiple Sclerosis Agent - Cd20 Specific Monoclonal Antibody KESIMPTA PEN NF PA; BE; QL (1 pen per 28 days) Multiple Sclerosis Agent - Interferons AVONEX (WITH ALBUMIN) NF SP AVONEX INTRAMUSCULAR PEN NF INJECTOR AVONEX INTRAMUSCULAR PEN NF SP; BE INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE NF BE AVONEX INTRAMUSCULAR SYRINGE KIT NF SP; BE BETASERON SUBCUTANEOUS KIT 4 SP; BE EXTAVIA 4 SP; BE PLEGRIDY INTRAMUSCULAR NF PLEGRIDY SUBCUTANEOUS PEN NF SP; BE INJECTOR PLEGRIDY SUBCUTANEOUS SYRINGE 125 NF SP; BE MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 NF SP MCG/0.5 ML- 94 MCG/0.5 ML REBIF (WITH ALBUMIN) 4 SP; BE REBIF REBIDOSE 4 SP; BE
Last Approved Date: 09/24/2021 Formulary Version: 92
208 Drug Status Notes REBIF TITRATION PACK 4 SP; BE Multiple Sclerosis Agent - Others PA; BE; QL (4 capsules per 1 BAFIERTAM NF Day) COPAXONE SUBCUTANEOUS SYRINGE 20 NF SP; BE; QL (30 ML per 21 days) MG/ML COPAXONE SUBCUTANEOUS SYRINGE 40 NF SP; BE; QL (14 ML per 21 days) MG/ML dimethyl fumarate oral capsule,delayed PA; BE; QL (2 capsules per 1 4 release(dr/ec) 120 mg, 240 mg Day) glatiramer subcutaneous syringe 20 mg/ml 4 BE; QL (30 ML per 21 days) glatiramer subcutaneous syringe 40 mg/ml 4 BE; QL (14 ML per 21 days) GLATOPA SUBCUTANEOUS SYRINGE 20 4 SP; BE; QL (30 ML per 21 days) MG/ML TECFIDERA ORAL CAPSULE,DELAYED PA; SP; BE; QL (1 pack per 274 NF RELEASE(DR/EC) 120 MG (14)- 240 MG (46) days) TECFIDERA ORAL CAPSULE,DELAYED PA; SP; BE; QL (2 CAPSULES NF RELEASE(DR/EC) 120 MG, 240 MG per 1 day) VUMERITY NF PA; BE; QL (4 capsules per 1 day) Multiple Sclerosis Agent - Potassium Channel Blocker PA; SP; BE; QL (20 MG per 1 AMPYRA NF day) dalfampridine 4 PA; QL (20 mg per 1 day) PA; ST; QL (8 TABLETS per 1 FIRDAPSE NF day) PA; BE; QL (10 TABLETS per 1 RUZURGI 4 day) Multiple Sclerosis Agent - Purine Nucleoside Analogs PA; ST; BE; QL (20 TABLETS MAVENCLAD (10 TABLET PACK) NF per 1 year) PA; ST; BE; QL (20 TABLETS MAVENCLAD (4 TABLET PACK) NF per 1 year) PA; ST; BE; QL (20 TABLETS MAVENCLAD (5 TABLET PACK) NF per 1 year) PA; ST; BE; QL (20 TABLETS MAVENCLAD (6 TABLET PACK) NF per 1 year)
Last Approved Date: 09/24/2021 Formulary Version: 92
209 Drug Status Notes PA; ST; BE; QL (20 TABLETS MAVENCLAD (7 TABLET PACK) NF per 1 year) PA; ST; BE; QL (20 TABLETS MAVENCLAD (8 TABLET PACK) NF per 1 year) PA; ST; BE; QL (20 TABLETS MAVENCLAD (9 TABLET PACK) NF per 1 year) Multiple Sclerosis Agent - Pyrimidine Synthesis Inhibitors PA; SP; BE; QL (1 TABLET per 1 AUBAGIO 4 day) Multiple Sclerosis Agent - Sphingosine 1-Phosphate Receptor Modulator PA; SP; QL (1 CAPSULES per 1 GILENYA ORAL CAPSULE 0.5 MG 4 day) PA; BE; QL (4 TABLETS per 1 MAYZENT ORAL TABLET 0.25 MG 4 day) PA; BE; QL (1 TABLET per 1 MAYZENT ORAL TABLET 2 MG 4 day) PA; BE; QL (1 starter pack per MAYZENT STARTER PACK 4 720 days) PONVORY NF PA; BE PA; ST; BE; QL (2 starter packs PONVORY 14-DAY STARTER PACK NF per 1 Year) ZEPOSIA NF BE; QL (1 capsule per 1 day) PA; QL (1 pack (37 capsules) per ZEPOSIA STARTER KIT NF 365 days) PA; QL (1 pack (7 capsules) per ZEPOSIA STARTER PACK NF 365 days) Ophthalmic Agents Miotics - Cholinesterase Inhibitors PHOSPHOLINE IODIDE 3 Miotics - Direct Acting ISOPTO CARPINE NF pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 1 4 % Mydriatic And Cycloplegic Combinations CYCLOMYDRIL 2
Last Approved Date: 09/24/2021 Formulary Version: 92
210 Drug Status Notes cyclopen-tropic-phenyleph-watr NF cyclop-trop-propa-phen-ket-wat NF MYDRIATIC3 (TROP-CYCLOPENT-PE) 3 PAREMYD NF Ophthalmic - Adrenergic Receptor Agonist UPNEEQ (PF) NF Ophthalmic - Adrenergic-Carbonic Anhydrase Inhibitor Combinations brimonidine-dorzolamide (pf) NF SIMBRINZA 3 Ophthalmic - Antibacterial- Glucocorticoid Combinations BLEPHAMIDE NF BLEPHAMIDE S.O.P. NF gatifloxacin-dexamethasone NF MAXITROL NF neomycin-bacitracin-poly-hc NF neomycin-polymyxin b-dexameth 1 neomycin-polymyxin-hc ophthalmic (eye) NF NEO-POLYCIN HC NF PRED-G NF PRED-G S.O.P. NF prednisolone acet-gatifloxacin NF prednisolone sod ph-moxiflox NF sulfacetamide-prednisolone 1 TOBRADEX NF TOBRADEX ST NF tobramycin-dexamethasone 3 ZYLET NF Ophthalmic - Antibacterial- Glucocorticoid-Nsaid Combinations prednisol ace-gatiflox-bromfen NF prednisoln sp-gatiflox-bromfen NF prednisoln sp-moxiflox-bromfen NF prednisolone-moxiflox-bromfen NF Last Approved Date: 09/24/2021 Formulary Version: 92
211 Drug Status Notes Ophthalmic - Anticholinergics atropine ophthalmic (eye) drops 1 atropine ophthalmic (eye) drops, emulsion NF atropine ophthalmic (eye) ointment 1 CYCLOGYL NF cyclopentolate ophthalmic (eye) drops 1 %, 2 % 1 HOMATROPAIRE 2 homatropine hbr 2 ISOPTO ATROPINE NF MYDRIACYL NF tropicamide 1 Ophthalmic - Antihistamines azelastine ophthalmic (eye) 1 bepotastine besilate 3 BEPREVE 3 ELESTAT NF EMADINE 3 epinastine 2 LASTACAFT 3 olopatadine ophthalmic (eye) 3 PATADAY NF PATADAY ONCE DAILY RELIEF NF OPHTHALMIC (EYE) DROPS 0.2 % PATANOL NF PAZEO NF ZERVIATE NF PA; ST Ophthalmic - Anti-Inflammatory, Glucocorticoids ALREX NF dexamethasone sodium phosphate ophthalmic 1 (eye) DUREZOL 3 PA; ST; QL (1 bottle per 1 EYSUVIS NF dispensing event) FLAREX NF fluorometholone 1
Last Approved Date: 09/24/2021 Formulary Version: 92
212 Drug Status Notes FML FORTE NF FML LIQUIFILM NF FML S.O.P. NF INVELTYS NF LOTEMAX NF QL (2 BOTTLES per 1 LOTEMAX SM NF DISPENSE) loteprednol etabonate ophthalmic (eye) drops,gel NF loteprednol etabonate ophthalmic (eye) 3 drops,suspension MAXIDEX NF OMNIPRED NF PRED FORTE NF PRED MILD NF prednisolone acetate 2 prednisolone acetate (pf) NF prednisolone sodium phosphate ophthalmic (eye) 2 Ophthalmic - Anti-Inflammatory, Immunomodulators CEQUA NF PA; ST; QL (60 vials per 25 days) CYCLOSPORINE IN KLARITY NF RESTASIS 3 Ophthalmic - Anti-Inflammatory, Lfa-1 Antagonists XIIDRA NF PA; ST Ophthalmic - Anti-Inflammatory, Nsaids ACULAR NF ACULAR LS NF ACUVAIL (PF) NF bromfenac 3 QL (10 ML (2 BOTTLES) per 540 BROMSITE NF days) diclofenac sodium ophthalmic (eye) 1 flurbiprofen sodium 1 ILEVRO 3 ketorolac ophthalmic (eye) drops 0.4 % NF Last Approved Date: 09/24/2021 Formulary Version: 92
213 Drug Status Notes ketorolac ophthalmic (eye) drops 0.5 % 1 NEVANAC NF PROLENSA NF VOLTAREN OPHTHALMIC (EYE) NF Ophthalmic - Beta Blocker-Adrenergic- Carbonic Anhydrase Inhibitor Comb timolol-brimonidi-dorzolam(pf) NF Ophthalmic - Beta Blockers-Adrenergic Combinations COMBIGAN 3 Ophthalmic - Beta Blockers-Carbonic Anhydrase Inhibitor Combinations COSOPT (PF) NF dorzolamide-timolol 1 dorzolamide-timolol (pf) NF Ophthalmic - Beta Blockers- Prostaglandin Analog Combinations timolol-latanoprost(pf) NF Ophthalmic - Carbonic Anhydrase Inhibitors AZOPT NF brinzolamide 3 dorzolamide 1 dorzolamide (pf) NF TRUSOPT NF Ophthalmic - Cystine Depleting Agents PA; QL (20 ML (vials) per 28 CYSTADROPS 4 days) SP; QL (60 ML (4 bottles) per 28 CYSTARAN 4 days) Ophthalmic - Decongestants phenylephrine hcl ophthalmic (eye) 1 Ophthalmic - Diagnostic Agents FLUCAINE NF fluorescein-proparacaine NF
Last Approved Date: 09/24/2021 Formulary Version: 92
214 Drug Status Notes Ophthalmic - Human Nerve Growth Factor (Hngf) PA; ST; BE; QL (56 VIALS per OXERVATE NF 42 days) Ophthalmic - Intraocular Pressure Reducing Agents, Beta-Blockers BETAGAN OPHTHALMIC (EYE) DROPS 0.5 NF % betaxolol ophthalmic (eye) 2 BETIMOL NF BETOPTIC S NF carteolol 1 ISTALOL NF levobunolol ophthalmic (eye) drops 0.5 % 1 metipranolol 1 timolol maleate (pf) NF timolol maleate ophthalmic (eye) drops 1 timolol maleate ophthalmic (eye) drops, once 3 daily timolol maleate ophthalmic (eye) gel forming NF solution TIMOPTIC OCUDOSE (PF) OPHTHALMIC NF (EYE) DROPPERETTE 0.5 % TIMOPTIC OPHTHALMIC (EYE) DROPS 0.25 NF % TIMOPTIC-XE NF Ophthalmic - Local Anesthetic Esters ALTACAINE 1 proparacaine 1 TETCAINE 1 tetracaine hcl (pf) ophthalmic (eye) NF TETRAVISC FORTE OPHTHALMIC (EYE) NF DROPS,HYPERVISCOUS Ophthalmic - Local Anesthetic, Amides AKTEN (PF) NF Ophthalmic - Mast Cell Stabilizers ALOCRIL 3
Last Approved Date: 09/24/2021 Formulary Version: 92
215 Drug Status Notes ALOMIDE 3 cromolyn ophthalmic (eye) 1 Ophthalmic - Mydriatic-Nsaid Combinations MYDRIATIC4(TROP-PROP-PE-KTRLC) NF tropic-proparacai-pe-ketor-wat NF Ophthalmic - Rho Kinase Inhibitor And Prostaglandin Analog Combination PA; ST; QL (1 bottle (2.5ml) per 1 ROCKLATAN NF DISPENSE) Ophthalmic Antibacterial Mixtures AK-POLY-BAC 1 neomycin-bacitracin-polymyxin NF neomycin-polymyxin-gramicidin NF NEO-POLYCIN NF POLYCIN 1 polymyxin b sulf-trimethoprim 1 POLYTRIM NF Ophthalmic Antibiotic - Aminoglycosides GENTAK OPHTHALMIC (EYE) OINTMENT 1 gentamicin ophthalmic (eye) 1 tobramycin ophthalmic (eye) 1 TOBREX NF Ophthalmic Antibiotic - Dehydropeptidase Inhibitors bacitracin ophthalmic (eye) 2 Ophthalmic Antibiotic - Fluoroquinolones BESIVANCE 3 CILOXAN NF ciprofloxacin hcl ophthalmic (eye) 1 gatifloxacin 3 levofloxacin ophthalmic (eye) 2 MOXEZA NF moxifloxacin ophthalmic (eye) 3
Last Approved Date: 09/24/2021 Formulary Version: 92
216 Drug Status Notes OCUFLOX NF ofloxacin ophthalmic (eye) 1 VIGAMOX NF ZYMAXID NF Ophthalmic Antibiotic - Macrolides AZASITE 3 erythromycin ophthalmic (eye) 1 Ophthalmic Antibiotic - Sulfonamides BLEPH-10 NF sulfacetamide sodium ophthalmic (eye) drops 1 sulfacetamide sodium ophthalmic (eye) ointment 2 Ophthalmic Antifungals NATACYN 3 Ophthalmic Antifungals - Tetraene Polyene-Type NATACYN 3 Ophthalmic Antiseptics BETADINE OPHTHALMIC PREP 2 Ophthalmic Antivirals trifluridine 2 VIROPTIC NF ZIRGAN 3 Ophthalmic-Intraocular Press. Reducing, Sel. Alpha Adrenergic Agonists ALPHAGAN P NF apraclonidine 2 brimonidine ophthalmic (eye) drops 0.15 % NF brimonidine ophthalmic (eye) drops 0.2 % 1 IOPIDINE NF Ophthalmic-Intraocular Pressure Reducing Agents, Prostaglandin Analogs bimatoprost ophthalmic (eye) 3 QL (3 ML per 1 DISPENSE) latanoprost 1
Last Approved Date: 09/24/2021 Formulary Version: 92
217 Drug Status Notes latanoprost (pf) NF LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 3 QL (3 ML per 1 DISPENSE) % TRAVATAN Z NF PA; ST travoprost 3 PA; ST; QL (5 ml per 1 VYZULTA NF DISPENSE) XALATAN NF PA; ST PA; ST; QL (3 ML (1 bottle) per 1 XELPROS NF DISPENSE) ZIOPTAN (PF) 3 Ophthalmic-Intraocular Pressure Reducing Agents, Rho Kinase Inhibitors PA; ST; QL (5 ML per 1 RHOPRESSA NF DISPENSE) Organ Preservation Solutions Cardioplegic Solutions CARDIOPLEGIA INDUCTION 4:1 PERFUSION SOLUTION 36 MEQ/500 ML NF (POTASSIUM) Otic (Ear) Otic (Ear) - Anti-Infective- Glucocorticoid Combinations CIPRO HC 3 CIPRODEX NF ciprofloxacin-dexamethasone 3 QL (28 vials (2 cartons) per 135 ciprofloxacin-fluocinolone NF days) COLY-MYCIN S 2 neomycin-polymyxin-hc otic (ear) 2 OTOVEL 3 Otic (Ear) - Anti-Infectives Other acetic acid otic (ear) 1 Otic (Ear) - Fluoroquinolones CETRAXAL NF ciprofloxacin hcl otic (ear) NF ofloxacin otic (ear) 2
Last Approved Date: 09/24/2021 Formulary Version: 92
218 Drug Status Notes Otic (Ear) - Glucocorticoids DERMOTIC OIL NF fluocinolone acetonide oil 2 hydrocortisone-acetic acid 2 Otic (Ear) - Pinna Combinations CORTANE-B NF Respiratory Therapy Agents 1St Generation Antihistamine- Decongestant Combinations PROMETHAZINE VC NF 1St Generation Antihistamine- Decongestant-Anticholinergic Combinations RESPA-AR NF 2Nd Generation Antihistamine- Decongestant Combinations CLARINEX-D 12 HOUR NF SEMPREX-D NF Antihistamine - 1St Generation - Ethanolamines carbinoxamine maleate oral liquid 2 carbinoxamine maleate oral tablet 4 mg 2 PA; ST; QL (4 TABLETS per 1 carbinoxamine maleate oral tablet 6 mg NF day) clemastine oral syrup NF clemastine oral tablet 2.68 mg 1 diphenhydramine hcl injection solution 50 mg/ml 2 diphenhydramine hcl oral capsule 50 mg NF KARBINAL ER NF PA; ST; QL (4 TABLETS per 1 RYVENT NF day) Antihistamine - 1St Generation - Phenothiazines PHENADOZ 3 PHENERGAN RECTAL 3 promethazine oral syrup 1 QL (136 ML per 1 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
219 Drug Status Notes promethazine oral tablet 1 promethazine rectal 3 PROMETHEGAN 3 Antihistamine - 1St Generation - Piperidines cyproheptadine oral syrup NF cyproheptadine oral tablet 1 Antihistamines - 1St Generation carbinoxamine maleate oral liquid 2 carbinoxamine maleate oral tablet 4 mg 2 PA; ST; QL (4 TABLETS per 1 carbinoxamine maleate oral tablet 6 mg NF day) clemastine oral syrup NF clemastine oral tablet 2.68 mg 1 cyproheptadine oral syrup NF cyproheptadine oral tablet 1 diphenhydramine hcl injection solution 50 mg/ml 2 diphenhydramine hcl oral capsule 50 mg NF KARBINAL ER NF PHENADOZ 3 PHENERGAN RECTAL 3 promethazine oral syrup 1 QL (136 ML per 1 day) promethazine oral tablet 1 promethazine rectal 3 PROMETHEGAN 3 PA; ST; QL (4 TABLETS per 1 RYVENT NF day) Antihistamines - 2Nd Generation cetirizine oral solution 1 mg/ml NF CLARINEX ORAL SYRUP 3 CLARINEX ORAL TABLET NF desloratadine 3 levocetirizine oral solution NF levocetirizine oral tablet 3 XYZAL NF
Last Approved Date: 09/24/2021 Formulary Version: 92
220 Drug Status Notes Antihistamines - 2Nd Generation - Piperazines cetirizine oral solution 1 mg/ml NF levocetirizine oral solution NF levocetirizine oral tablet 3 XYZAL NF Antihistamines - 2Nd Generation - Piperidines CLARINEX ORAL SYRUP 3 CLARINEX ORAL TABLET NF desloratadine 3 Antitussives - Non-Opioid benzonatate oral capsule 100 mg, 200 mg 1 benzonatate oral capsule 150 mg NF TESSALON PERLES NF Asthma Therapy - 5-Lipoxygenase Inhibitors zileuton 4 PA; ST ZYFLO NF PA; ST Asthma Therapy - Alpha/Beta Adrenergic Agents epinephrine injection syringe 0.1 mg/ml NF QL (2 units per 1 DISPENSE) Asthma Therapy - Inhaled Corticosteroids (Glucocorticoids) QL (18 GRAMS per 1 AEROSPAN 2 DISPENSE) QL (1 INHALER per 1 ALVESCO NF DISPENSE) PA; ST; QL (2 inhalers per 720 ARMONAIR DIGIHALER NF Dayss) QL (1 INHALER per 1 ARMONAIR RESPICLICK NF DISPENSE) ARNUITY ELLIPTA 2 ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 2 QL (13 GM per 1 DISPENSE) 200 MCG/ACTUATION
Last Approved Date: 09/24/2021 Formulary Version: 92
221 Drug Status Notes ASMANEX HFA INHALATION HFA 2 QL (1 inhaler per 1 retail dispense) AEROSOL INHALER 50 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED QL (1 INHALER per 1 110 MCG/ ACTUATION (30), 220 MCG/ 2 DISPENSE) ACTUATION (120), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED NF 110 MCG/ ACTUATION (7) ASMANEX TWISTHALER INHALATION QL (1 INHALER per 1 AEROSOL POWDR BREATH ACTIVATED NF DISPENSE) 220 MCG/ ACTUATION (14) budesonide inhalation 2 PA FLOVENT DISKUS INHALATION BLISTER QL (60 BLISTERS per 1 2 WITH DEVICE 100 MCG/ACTUATION DISPENSE) FLOVENT DISKUS INHALATION BLISTER 2 QL (240 UNITS per 1 DISPENSE) WITH DEVICE 250 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER 2 QL (60 UNITS per 1 DISPENSE) WITH DEVICE 50 MCG/ACTUATION FLOVENT HFA INHALATION HFA QL (12 GRAMS per 1 2 AEROSOL INHALER 110 MCG/ACTUATION DISPENSE) FLOVENT HFA INHALATION HFA QL (24 GRAMS per 1 2 AEROSOL INHALER 220 MCG/ACTUATION DISPENSE) FLOVENT HFA INHALATION HFA QL (11 GRAMS per 1 2 AEROSOL INHALER 44 MCG/ACTUATION DISPENSE) PULMICORT NF PA PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 2 QL (2 INHALERS per 1 MONTH) 180 MCG/ACTUATION PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 2 QL (1 INHALER per 1 MONTH) MCG/ACTUATION QVAR INHALATION AEROSOL 40 2 MCG/ACTUATION QVAR INHALATION AEROSOL 80 2 QL (18 GM per 1 DISPENSE) MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 2 QL (1 INHALER per 30 days) MCG/ACTUATION
Last Approved Date: 09/24/2021 Formulary Version: 92
222 Drug Status Notes QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 2 QL (2 Inhalers per 30 days) MCG/ACTUATION Asthma Therapy - Interleukin-4 (Il-4) Receptor Alpha Antagonists, Mab DUPIXENT PEN SUBCUTANEOUS PEN PA; ST; QL (2 syringes per 21 4 INJECTOR 300 MG/2 ML Dayss) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; QL (3 ML (2 4 SYRINGE 200 MG/1.14 ML syringes) per 21 days) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; QL (2 SYRINGES 4 SYRINGE 300 MG/2 ML per 21 days) Asthma Therapy - Interleukin-5 (Il-5) Receptor Alpha Antagonists, Mab FASENRA PEN NF PA; ST; QL (1 UNIT per 42 days) Asthma Therapy - Leukotriene Receptor Antagonists ACCOLATE NF PA; ST montelukast oral granules in packet 3 montelukast oral tablet 1 montelukast oral tablet,chewable 1 SINGULAIR NF zafirlukast 1 PA; ST Asthma Therapy - Mast Cell Stabilizers cromolyn inhalation 2 Asthma Therapy - Monoclonal Antibodies To Immunoglobulin E (Ige) PA; ST; BE; QL (1 ML per 21 XOLAIR SUBCUTANEOUS SYRINGE NF Dayss) Asthma Therapy - Xanthines ELIXOPHYLLIN NF THEO-24 NF THEOCHRON ORAL TABLET EXTENDED 1 RELEASE 12 HR 100 MG, 200 MG theophylline oral solution 3 theophylline oral tablet extended release 12 hr 1
Last Approved Date: 09/24/2021 Formulary Version: 92
223 Drug Status Notes Asthma Therapy- Monoclonal Antibody - Interleukin-5 (Il-5) Antagonists NUCALA SUBCUTANEOUS AUTO- PA; ST; BE; QL (1 UNIT per 21 NF INJECTOR days) PA; ST; BE; QL (1 UNIT per 21 NUCALA SUBCUTANEOUS SYRINGE NF days) Asthma/Copd - Phosphodiesterase-4 (Pde4) Inhibitors DALIRESP 3 Asthma/Copd - Anticholinergic Agents, Inhaled Long Acting INCRUSE ELLIPTA NF LONHALA MAGNAIR 25 MCG REFILL NF QL (1 Refill kit per per 30 days) LONHALA MAGNAIR 25 MCG STARTER NF QL (1 Starter kit per per 720 days) QL (60 CAPSULES per 1 SEEBRI NEOHALER NF DISPENSE) SPIRIVA RESPIMAT 3 SPIRIVA WITH HANDIHALER 3 TUDORZA PRESSAIR 3 PA; ST; QL (90 ML (30 vials) per YUPELRI NF 1 DISPENSE) Asthma/Copd - Anticholinergic Agents, Inhaled Short Acting ATROVENT HFA 3 ipratropium bromide inhalation 2 Asthma/Copd - Beta 2-Adrenergic Agents, Inhaled, Ultra-Long Acting ARCAPTA NEOHALER NF STRIVERDI RESPIMAT NF Asthma/Copd Therapy - Beta 2- Adrenergic Agents, Inhaled, Long Acting arformoterol NF BROVANA NF formoterol fumarate 3 PERFOROMIST 3 SEREVENT DISKUS 3
Last Approved Date: 09/24/2021 Formulary Version: 92
224 Drug Status Notes Asthma/Copd Therapy - Beta 2- Adrenergic Agents, Inhaled, Short Acting QL (2 albuterol/levalbuterol albuterol sulfate inhalation hfa aerosol inhaler 2 inhalers per 25 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg 1 /3 ml (0.083 %), 2.5 mg/0.5 ml levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 0.63 mg/3 ml, 1.25 3 mg/0.5 ml QL (2 albuterol/levalbuterol levalbuterol tartrate NF inhalers per 25 days) PA; ST; QL (2 inhalers per 720 PROAIR DIGIHALER NF days) QL (2 albuterol/levalbuterol PROAIR HFA NF inhalers per 25 days) QL (2 albuterol/levalbuterol PROAIR RESPICLICK NF inhalers per 25 days) QL (2 albuterol/levalbuterol PROVENTIL HFA NF inhalers per 25 days) QL (2 albuterol/levalbuterol VENTOLIN HFA 2 inhalers per 25 days) XOPENEX CONCENTRATE NF QL (2 albuterol/levalbuterol XOPENEX HFA 2 inhalers per 25 days) XOPENEX INHALATION SOLUTION FOR NEBULIZATION 0.31 MG/3 ML, 0.63 MG/3 NF ML Asthma/Copd Therapy - Beta Adrenergic Agents albuterol sulfate oral syrup 1 albuterol sulfate oral tablet 2 albuterol sulfate oral tablet extended release 12 2 hr metaproterenol 1 terbutaline oral 2 terbutaline subcutaneous NF
Last Approved Date: 09/24/2021 Formulary Version: 92
225 Drug Status Notes Asthma/Copd Therapy - Beta Adrenergic-Anticholinergic Combinations ANORO ELLIPTA 3 QL (1 INHALER per 1 MONTH) COMBIVENT RESPIMAT NF PA; ST; QL (1 INHALER per 1 DUAKLIR PRESSAIR NF dispensing event) ipratropium-albuterol 2 STIOLTO RESPIMAT 3 QL (4 GRAMS per 1 DISPENSE) QL (60 CAPSULES per 1 UTIBRON NEOHALER NF DISPENSE) Asthma/Copd Therapy - Beta Adrenergic-Glucocorticoid Combinations QL (60 BLISTERS per 1 ADVAIR DISKUS NF DISPENSE) QL (12 GRAMS per 1 ADVAIR HFA NF DISPENSE) PA; ST; QL (2 inhalers per 720 AIRDUO DIGIHALER NF Dayss) QL (1 INHALER per 1 AIRDUO RESPICLICK NF DISPENSE) QL (60 BLISTERS per 1 BREO ELLIPTA 3 DISPENSE) QL (11 GRAMS per 1 budesonide-formoterol NF DISPENSE) DULERA INHALATION HFA AEROSOL QL (13 GRAMS per 1 INHALER 100-5 MCG/ACTUATION, 200-5 3 DISPENSE) MCG/ACTUATION DULERA INHALATION HFA AEROSOL 3 INHALER 50-5 MCG/ACTUATION fluticasone propion-salmeterol inhalation aerosol QL (1 INHALER per 1 2 powdr breath activated DISPENSE) fluticasone propion-salmeterol inhalation blister QL (60 BLISTERS per 1 2 with device DISPENSE) SYMBICORT NF QL (1 INHALER per 1 MONTH) QL (60 BLISTERS per 1 WIXELA INHUB 2 DISPENSE)
Last Approved Date: 09/24/2021 Formulary Version: 92
226 Drug Status Notes Asthma/Copd Tx - Beta-Adrenergic- Anticholinergic-Glucocorticoid Comb, QL (10.7 g (1 cannister) per 30 BREZTRI AEROSPHERE NF days) TRELEGY ELLIPTA INHALATION BLISTER 3 QL (1 INHALER per 30 days) WITH DEVICE 100-62.5-25 MCG TRELEGY ELLIPTA INHALATION BLISTER 3 QL (1 inhaler per 1 Dispense) WITH DEVICE 200-62.5-25 MCG Cystic Fibrosis - Inhaled Aminoglycosides PA; ST; SP; QL (28 DAY BETHKIS NF SUPPLY per 42 days) PA; ST; QL (28 DAY SUPPLY KITABIS PAK 4 per 42 days) PA; ST; SP; BE; QL (28 DAY TOBI NF SUPPLY per 42 days) PA; ST; SP; QL (28 DAY TOBI PODHALER INHALATION CAPSULE 4 SUPPLY per 42 days) SP; BE; QL (28 DAY SUPPLY tobramycin in 0.225 % nacl 4 per 42 days) PA; QL (28 day supply per 42 tobramycin inhalation 4 Dayss) Cystic Fibrosis - Inhaled Monobactams CAYSTON 4 PA; QL (84 ML per 42 days) Cystic Fibrosis - Inhaled Osmotic Agents PA; ST; QL (560 capsules per 1 BRONCHITOL NF dispense) Cystic Fibrosis-Transmembrane Conductance Regulator (Cftr) Potentiator KALYDECO ORAL GRANULES IN PACKET NF PA; QL (2 units per 1 day) 25 MG KALYDECO ORAL GRANULES IN PACKET NF PA; SP; QL (2 UNITS per 1 day) 50 MG, 75 MG PA; SP; QL (2 TABLETS per 1 KALYDECO ORAL TABLET 4 day)
Last Approved Date: 09/24/2021 Formulary Version: 92
227 Drug Status Notes Cystic Fib-Transmemb Conduct. Reg.(Cftr) Potentiator And Corrector Cmb ORKAMBI ORAL GRANULES IN PACKET 4 PA; BE; QL (2 packets per 1 day) PA; BE; QL (120 TABLETS per ORKAMBI ORAL TABLET 100-125 MG 4 23 days) PA; SP; BE; QL (4 TABLETS per ORKAMBI ORAL TABLET 200-125 MG 4 1 day) PA; BE; QL (2 TABLETS per 1 SYMDEKO 4 day) TRIKAFTA ORAL TABLETS, SEQUENTIAL PA; BE; QL (84 TABLETS per 21 4 100-50-75 MG(D) /150 MG (N) days) TRIKAFTA ORAL TABLETS, SEQUENTIAL PA; BE; QL (84 tablets per 21 4 50-25-37.5 MG (D)/75 MG (N) Dayss) Lung Surfactants CUROSURF INTRATRACHEAL NF SUSPENSION 120 MG/1.5 ML INFASURF NF SURFAXIN NF SURVANTA NF Mucolytics acetylcysteine 2 PA; SP; BE; QL (150 ML per 23 PULMOZYME 4 days) Nasal Antibiotics BACTROBAN NASAL NF Nasal Anticholinergics ipratropium bromide nasal 2 Nasal Antihistamine And Anti- Inflammatory Steroid Combinations azelastine-fluticasone NF PA; ST DYMISTA NF PA; ST Nasal Antihistamines ASTEPRO NASAL SPRAY,NON-AEROSOL NF azelastine nasal 2 olopatadine nasal 3 PATANASE NF
Last Approved Date: 09/24/2021 Formulary Version: 92
228 Drug Status Notes Nasal Corticosteroids BECONASE AQ NF PA; ST budesonide nasal NF FLONASE NF PA; ST flunisolide 2 fluticasone propionate nasal 1 mometasone nasal NF NASONEX NF PA; ST OMNARIS NF PA; ST QNASL NF PA; ST RHINOCORT AQUA NF PA; ST triamcinolone acetonide nasal NF VERAMYST NF PA; ST PA; ST; SP; QL (1 pack per 1 XHANCE NF DISPENSE) ZETONNA NF PA; ST Non-Opioid Antitussive-1St Gen.Antihistamine-Decongestant Combinations BROMFED DM NF brompheniramine-pseudoeph-dm NF Non-Opioid Antitussive-Antihistamine Combinations promethazine-dm NF Non-Opioid Antitussive-Decongestant- Expectorant Combinations TUSNEL PEDIATRIC ORAL LIQUID NF Opioid Antitussive-1St Generation Antihistamine Combinations hydrocodone-chlorpheniramine 2 PA; ST promethazine-codeine 1 PA; ST TUSSICAPS NF PA; ST TUSSIONEX PENNKINETIC ER NF PA; ST TUXARIN ER NF PA; ST TUZISTRA XR NF PA; ST VITUZ 3 PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
229 Drug Status Notes ZODRYL AC 25 NF PA; ST ZODRYL AC 30 NF PA; ST ZODRYL AC 35 NF PA; ST ZODRYL AC 40 NF PA; ST ZODRYL AC 50 NF PA; ST ZODRYL AC 60 NF PA; ST ZODRYL AC 80 NF PA; ST Z-TUSS AC NF PA; ST Opioid Antitussive-1St Generation Antihistamine-Decongestant Comb. CAPCOF 2 PA; ST HISTEX-AC NF PA; ST hydrocodone-cpm-pseudoephed NF PA; ST MAR-COF BP NF PA; ST MAXI-TUSS CD NF PA; ST M-END PE NF PA; ST POLY-TUSSIN AC 2 PA; ST PROMETHAZINE VC-CODEINE NF PA; ST PRO-RED AC (W/ DEXCHLORPHENIR) NF PA; ST RYDEX NF PA; ST ZODRYL DAC 25 NF PA; ST ZODRYL DAC 30 NF PA; ST ZODRYL DAC 35 NF PA; ST ZODRYL DAC 40 NF PA; ST ZODRYL DAC 50 NF PA; ST ZODRYL DAC 60 NF PA; ST ZODRYL DAC 80 NF PA; ST Opioid Antitussive-Anticholinergic Combinations HYCODAN NF PA hydrocodone-homatropine oral syrup 5-1.5 mg/5 2 PA; ST ml hydrocodone-homatropine oral tablet 2 PA; ST HYDROMET 2 PA; ST TUSSIGON 2 PA; ST
Last Approved Date: 09/24/2021 Formulary Version: 92
230 Drug Status Notes Opioid Antitussive-Decongestant- Expectorant Combinations CODITUSSIN DAC NF PA; ST GUAIFENESIN DAC NF PA; ST LORTUSS EX NF PA; ST TUSNEL C NF PA; ST ZODRYL DEC 25 NF PA; ST ZODRYL DEC 30 NF PA; ST ZODRYL DEC 35 NF PA; ST ZODRYL DEC 40 NF PA; ST ZODRYL DEC 50 NF PA; ST ZODRYL DEC 60 NF PA; ST ZODRYL DEC 80 NF PA; ST Opioid Antitussive-Expectorant Combinations CHERATUSSIN AC 1 PA; ST codeine-guaifenesin 1 PA; ST CODITUSSIN AC NF PA; ST hydrocodone-guaifenesin NF PA; ST MAR-COF CG NF PA; ST M-CLEAR WC 1 PA; ST NINJACOF-XG NF PA; ST OBREDON NF PA; ST Pulmonary Fibrosis Treatment Agents - Antifibrotic Therapy PA; BE; QL (9 ESBRIET ORAL CAPSULE 4 TABLETS/CAPSULES per 1 day) PA; BE; QL (3 TABLETS per 1 ESBRIET ORAL TABLET 801 MG NF day) Pulmonary Fibrosis Treatment Agents - Multikinase Inhibitors PA; SP; BE; QL (2 CAPSULES OFEV 4 per 1 day) Vaginal Products Vaginal Antibacterial - Lincosamides CLEOCIN VAGINAL NF
Last Approved Date: 09/24/2021 Formulary Version: 92
231 Drug Status Notes clindamycin phosphate vaginal 1 Vaginal Antibacterial - Sulfonamides AVC VAGINAL 3 Vaginal Antifungal - Imidazoles GYNAZOLE-1 3 MICONAZOLE-3 VAGINAL SUPPOSITORY 2 Vaginal Antifungal - Triazoles terconazole vaginal cream 1 terconazole vaginal suppository 2 Vaginal Antiprotozoal-Antibacterial - Nitroimidazole Derivatives METROGEL VAGINAL NF metronidazole vaginal 2 NUVESSA NF VANDAZOLE 2 Vaginal Antiseptic Mixtures FEM PH NF RELAGARD NF Vaginal Estrogens ESTRACE VAGINAL NF estradiol vaginal tablet 3 ESTRING NF QL (1 RING per 1 DISPENSE) FEMRING NF QL (1 RING per 1 DISPENSE) PREMARIN VAGINAL 3 VAGIFEM NF Vaginal Progestins CRINONE VAGINAL GEL 4 % NF
Last Approved Date: 09/24/2021 Formulary Version: 92
232 Index abacavir...... 30 ACULAR LS...... 213 AFLURIA QD 2021-22(3YR abacavir-lamivudine...... 31 ACUVAIL (PF)...... 213 UP)(PF)...... 58 abacavir-lamivudine-zidovudine 31 acyclovir...... 37, 131, 132 AFLURIA QD 2021-22(6- ABILIFY...... 92, 100 ACZONE...... 122 35MO)(PF)...... 58 ABILIFY MYCITE...... 92, 100 ADAGEN...... 204 AFLURIA QUAD 2018-2019.... 58 ABILIFY MYCITE ADAKVEO...... 192 AFLURIA QUAD 2018-2019 MAINTENANCE KIT...... 92, 100 ADALAT CC...... 70 (PF)...... 58 ABILIFY MYCITE STARTER adapalene...... 124 AFLURIA QUAD 2019- KIT...... 92, 100 adapalene-benzoyl peroxide..... 124 20(6MO UP)...... 59 abiraterone...... 42, 43, 45 ADASUVE...... 91 AFLURIA QUAD 2020- ABSORICA...... 121 ADCIRCA...... 76 2021(6MO UP)...... 59 ABSORICA LD...... 121 ADDERALL...... 93, 101, 102, 109 AFLURIA QUAD 2021- acamprosate...... 112 ADDERALL XR...... 94, 102 2022(6MO UP)...... 59 ACANYA...... 122 ADDYI...... 104 AFREZZA...... 164 acarbose...... 153 adefovir...... 35 AFSTYLA...... 190 ACCOLATE...... 223 ADEMPAS...... 76 AFTERA...... 120 ACCRUFER...... 146 ADHANSIA XR...... 94 AGGRENOX...... 193 ACCU-CHEK AVIVA PLUS ADIPEX-P...... 143 AGRYLIN...... 193 TEST STRP...... 198, 201 ADLYXIN...... 156 AIMOVIG AUTOINJECTOR..105 ACCU-CHEK COMPACT ADMELOG SOLOSTAR U- AIMOVIG AUTOINJECTOR PLUS TEST...... 198, 201 100 INSULIN...... 164 (2 PACK)...... 105 ACCU-CHEK GUIDE TEST ADMELOG U-100 INSULIN AIMSCO LATEX CONDOM..201 STRIPS...... 198, 201 LISPRO...... 164 AIRDUO DIGIHALER...... 226 ACCU-CHEK SMARTVIEW ADULT LOW DOSE ASPIRIN AIRDUO RESPICLICK...... 226 TEST STRIP...... 198, 201 ...... 20, 193 AJOVY AUTOINJECTOR...... 104 ACCUPRIL...... 61 ADVAIR DISKUS...... 226 AJOVY SYRINGE...... 104 ACCURETIC...... 60 ADVAIR HFA...... 226 AKLIEF...... 124 acebutolol...... 69 ADVANCED GLUC METER AK-POLY-BAC...... 216 acetaminophen-caff-dihydrocod... 7 TEST STRIP...... 198, 201 AKTEN (PF)...... 215 acetaminophen-codeine...... 6 ADVATE...... 189 AKYNZEO (NETUPITANT)...171 acetazolamide...... 73 ADVOCATE TEST STRIPS ALA-CORT...... 132 acetic acid...... 182, 218 ...... 198, 201 ALA-SCALP...... 132 acetylcysteine...... 22, 228 ADYNOVATE...... 190 albendazole...... 24 ACIPHEX...... 173 AEMCOLO...... 41 ALBENZA...... 24 ACIPHEX SPRINKLE...... 173 AEROSPAN...... 221 albuterol sulfate...... 225 acitretin...... 130 AFEDITAB CR...... 70 alclometasone...... 132 ACTEMRA...... 16 AFINITOR...... 50 ALDACTAZIDE...... 73 ACTEMRA ACTPEN...... 16 AFINITOR DISPERZ...... 50 ALDACTONE...... 61, 73 ACTICLATE...... 41 AFLURIA 2018-2019...... 58 ALDARA...... 138 ACTIGALL...... 172 AFLURIA 2018-2019 (PF)...... 58 ALECENSA...... 44 ACTIMMUNE...... 26 AFLURIA QD 2019-20(3YR alendronate...... 158 ACTIQ...... 1 UP)(PF)...... 58 ALFENTA...... 1 ACTIVELLA...... 159 AFLURIA QD 2019-20(6- alfentanil...... 2 ACTONEL...... 158 35MO)(PF)...... 58 alfuzosin...... 183 ACTOPLUS MET...... 155 AFLURIA QD 2020-21(3YR ALINIA...... 27, 28 ACTOPLUS MET XR...... 155 UP)(PF)...... 58 aliskiren...... 77 ACTOS...... 165 AFLURIA QD 2020-21(6- ALKERAN...... 44 ACULAR...... 213 35MO)(PF)...... 58 ALKINDI SPRINKLE...... 161 Last Approved Date: 09/24/2021 Formulary Version: 92
233 allopurinol...... 187 amitriptyline-chlordiazepoxide APRI...... 115 almotriptan malate...... 105 ...... 85, 97 APRISO...... 177 ALOCRIL...... 215 amlodipine...... 70 APTENSIO XR...... 94 alogliptin...... 153 amlodipine-atorvastatin...... 68 APTIOM...... 80 alogliptin-metformin...... 157 amlodipine-benazepril...... 60 APTIVUS...... 40 alogliptin-pioglitazone...... 156 amlodipine-olmesartan...... 62 APTIVUS (WITH VITAMIN ALOMIDE...... 216 amlodipine-valsartan...... 62 E)...... 40 ALOPHEN (BISACODYL)..... 180 amlodipine-valsartan-hcthiazid..62 AQUORAL...... 207 ALORA...... 160 ammonium lactate...... 132 ARAKODA...... 27 alosetron...... 176, 179 AMNESTEEM...... 121 ARANELLE (28)...... 119 ALPHAGAN P...... 217 amoxapine...... 86 ARANESP (IN ALPHANATE...... 190 amoxicillin...... 24 POLYSORBATE)...... 189 ALPHANINE SD...... 189 amoxicillin-pot clavulanate...... 24 ARAVA...... 17 alprazolam...... 77, 97 amphetamine...... 94, 102 ARAZLO...... 125 ALPRAZOLAM INTENSOL amphetamine sulfate... 94, 102, 109 ARCALYST...... 13 ...... 77, 97 ampicillin...... 24 ARCAPTA NEOHALER...... 224 ALPROLIX...... 189 AMPYRA...... 209 arformoterol...... 224 ALREX...... 212 AMRIX...... 197 ARICEPT...... 113 ALTABAX...... 127 AMZEEQ...... 122 ARIKAYCE...... 23 ALTACAINE...... 215 ANADROL-50...... 152 ARIMIDEX...... 46 ALTACE...... 61 ANAFRANIL...... 86 aripiprazole...... 92, 100 ALTAVERA (28)...... 115 anagrelide...... 193 ARIXTRA...... 192 ALTOPREV...... 66 ANA-LEX KIT...... 22 armodafinil...... 108 ALTRENO...... 125 ANALPRAM-HC...... 22, 138 ARMONAIR DIGIHALER...... 221 aluminum chloride...... 130 ANAPROX DS...... 19 ARMONAIR RESPICLICK.....221 ALUNBRIG...... 44 ANASPAZ...... 174, 186 ARMOUR THYROID...... 168 ALVESCO...... 221 anastrozole...... 46 ARNUITY ELLIPTA...... 221 alvimopan...... 23 ANCOBON...... 25 AROMASIN...... 46 ALYACEN 1/35 (28)...... 115 ANDRODERM...... 152 ARTHROTEC 50...... 18 ALYACEN 7/7/7 (28)...... 119 ANDROGEL...... 152 ARTHROTEC 75...... 18 ALYQ...... 76 ANDROID...... 152 ARYMO ER...... 2 AMABELZ...... 159 ANGELIQ...... 159 ASACOL HD...... 177 amantadine hcl...... 88 ANNOVERA...... 120 ASCOMP WITH CODEINE...... 6 AMARYL...... 155 ANORO ELLIPTA...... 226 asenapine maleate...... 89, 100 AMBIEN...... 111 ANTABUSE...... 112 ASHLYNA...... 115 AMBIEN CR...... 111 ANTARA...... 65 ASMANEX HFA...... 221, 222 ambrisentan...... 76 ANTIVERT...... 170 ASMANEX TWISTHALER.... 222 amcinonide...... 132 ANUCORT-HC...... 21 ASPIR-81...... 20, 193 AMERGE...... 105 ANUSOL-HC...... 21 aspirin...... 20, 21, 193 AMETHIA...... 115 ANZEMET...... 170 ASPIRIN CHILDRENS..... 20, 193 AMETHIA LO...... 115 APADAZ...... 7 ASPIRIN LOW DOSE...... 20, 193 AMETHYST (28)...... 115 APEXICON E...... 132 aspirin-caffeine-dihydrocodein.....7 AMICAR...... 191 APIDRA SOLOSTAR U-100 aspirin-dipyridamole...... 193 amiloride...... 73 INSULIN...... 164 aspirin-omeprazole...... 194 amiloride-hydrochlorothiazide... 73 APIDRA U-100 INSULIN...... 165 ASPIR-LOW...... 21, 193 aminocaproic acid...... 191 APLENZIN...... 85 ASPIR-TRIN...... 21, 193 amiodarone...... 65 APOKYN...... 88 ASSURE 4 STRIPS...... 198, 201 AMITIZA...... 176 apraclonidine...... 217 ASSURE PLATINUM TEST amitriptyline...... 86 aprepitant...... 171 STRIP...... 199, 201
Last Approved Date: 09/24/2021 Formulary Version: 92
234 ASSURE PRISM MULTI AZASAN...... 16, 196 BECONASE AQ...... 229 STRIP...... 199, 201 AZASITE...... 217 BEKYREE (28)...... 115 ASTAGRAF XL...... 195 azathioprine...... 16, 196 BELBUCA...... 11 ASTEPRO...... 228 azelaic acid...... 122, 140 belladonna alkaloids-opium ASTRAMORPH-PF...... 2 azelastine...... 212, 228 ...... 175, 176 ATACAND...... 62 azelastine-fluticasone...... 228 BELLADONNA- ATACAND HCT...... 62 AZELEX...... 122, 140 PHENOBARBITAL...... 176 atazanavir...... 40 AZILECT...... 88 BELSOMRA...... 111 ATELVIA...... 158 azithromycin...... 38 benazepril...... 61 atenolol...... 68 AZOPT...... 214 benazepril-hydrochlorothiazide..60 atenolol-chlorthalidone...... 71 AZOR...... 62 BENEFIX...... 189 ATIVAN...... 77, 97 AZSTARYS...... 94 BENICAR...... 62, 63 atomoxetine...... 97 AZULFIDINE...... 17, 177 BENICAR HCT...... 62 atorvastatin...... 66 AZULFIDINE EN-TABS...17, 177 BENLYSTA...... 17 atovaquone...... 27 AZURETTE (28)...... 115 BENZACLIN...... 122 atovaquone-proguanil...... 27 B COMPLEX 1...... 144 BENZEFOAM ULTRA...... 124 ATRALIN...... 125 B COMPLEX 100...... 144 BENZEPRO...... 124 ATRIPLA...... 31 B COMPLEX-VITAMIN B12. 144 BENZEPRO atropine...... 74, 174, 212 b complex-vitamin c-folic acid..144 (MICROSPHERES)...... 124 ATROVENT HFA...... 224 B-100 COMPLEX...... 144 benzhydrocodone- AUBAGIO...... 210 bacitracin...... 216 acetaminophen...... 7 AUBRA...... 115 baclofen...... 197 benznidazole...... 27 AUGMENTIN...... 24 BACTRIM...... 25 benzonatate...... 221 AUGMENTIN ES-600...... 24 BACTRIM DS...... 25 benzoyl peroxide...... 124 AUGMENTIN XR...... 24 BACTROBAN...... 127 benzphetamine...... 143 AUROVELA 1/20 (21)...... 115 BACTROBAN NASAL...... 228 benztropine...... 88 AUROVELA FE 1.5/30 (28)....115 BAFIERTAM...... 209 bepotastine besilate...... 212 AURYXIA...... 146, 183 BALANCE B-100...... 144 BEPREVE...... 212 AUSTEDO...... 106, 107 BALANCE B-50...... 144 BERINERT...... 188 AUVI-Q...... 71 BALANCED B-100...... 144 BESIVANCE...... 216 AVALIDE...... 62 BALANCED B-50...... 144 BETADINE OPHTHALMIC AVANDAMET...... 155 BALANCED B-50 COMPLEX144 PREP...... 217 AVANDIA...... 165 BALCOLTRA...... 115 BETAGAN...... 215 AVAPRO...... 62 balsalazide...... 177 betamethasone dipropionate.....132 AVAR...... 122 BALVERSA...... 48 betamethasone valerate.... 132, 133 AVAR LS...... 122 BALZIVA (28)...... 115 betamethasone, augmented...... 133 AVAR-E GREEN...... 122 BANZEL...... 82 BETAPACE...... 64, 69 AVAR-E LS...... 122 BAQSIMI...... 151 BETASERON...... 208 AVC VAGINAL...... 232 BARACLUDE...... 35 betaxolol...... 68, 215 AVELOX...... 34 BASAGLAR KWIKPEN U-100 bethanechol chloride...... 187 AVIANE...... 115 INSULIN...... 164 BETHKIS...... 227 AVIDOXY...... 41 BAXDELA...... 34 BETIMOL...... 215 AVITA...... 125 BAYER ASPIRIN...... 21, 193 BETOPTIC S...... 215 AVODART...... 184 BAYER CHEWABLE BEVYXXA...... 188 AVONEX...... 208 ASPIRIN...... 21, 193 bexarotene...... 55 AVONEX (WITH ALBUMIN) 208 B-COMPLEX...... 144, 145 BEYAZ...... 116 AXIRON...... 152 b-complex with vitamin c...... 144 bicalutamide...... 45 AYGESTIN...... 167 BD PRE-FILLED NORMAL BIDIL...... 77 AYVAKIT...... 52 SALINE...... 149 BIFERA RX...... 146
Last Approved Date: 09/24/2021 Formulary Version: 92
235 BIJUVA...... 159 BUPRENEX...... 11 candesartan...... 63 BIKTARVY...... 31 buprenorphine...... 11 candesartan-hydrochlorothiazid.62 BILTRICIDE...... 24 buprenorphine hcl...... 11, 112 CAPACET...... 12 bimatoprost...... 217 buprenorphine-naloxone...... 112 CAPCOF...... 230 BINOSTO...... 158 bupropion hcl...... 86 capecitabine...... 46 bisacodyl...... 180 bupropion hcl (smoking deter)..112 CAPEX...... 133 BISA-LAX (BISACODYL)..... 180 buspirone...... 78 CAPHOSOL...... 207 bisoprolol fumarate...... 68 BUTALBITAL COMPOUND CAPITAL WITH CODEINE...... 6 bisoprolol-hydrochlorothiazide.. 71 W/CODEINE...... 6 CAPLYTA...... 90 BLEPH-10...... 217 BUTALBITAL COMPOUND- CAPRELSA...... 53 BLEPHAMIDE...... 211 CODEINE...... 6 captopril...... 61 BLEPHAMIDE S.O.P...... 211 butalbital-acetaminop-caf-cod...... 6 captopril-hydrochlorothiazide....60 BLISOVI 24 FE...... 116 butalbital-acetaminophen...... 12 CARAC...... 129 BLISOVI FE 1/20 (28)...... 116 butalbital-acetaminophen-caff....12 CARAFATE...... 181 BONIVA...... 159 butalbital-aspirin-caffeine...... 20 CARBAGLU...... 205 BONJESTA...... 170 BUTISOL...... 110 carbamazepine...... 80, 98, 99 bosentan...... 76 butorphanol...... 11, 12 CARBATROL...... 80, 99 BOSULIF...... 52, 53 BUTRANS...... 12 carbidopa...... 87 BP 10-1...... 123 BYDUREON...... 156 carbidopa-levodopa...... 87 BPO...... 124 BYDUREON BCISE...... 156 carbidopa-levodopa-entacapone 87 BRAFTOVI...... 46 BYETTA...... 156 carbinoxamine maleate.....219, 220 BREEZE 2 TEST STRIPS199, 201 BYLVAY...... 195 CARDIOPLEGIA BREO ELLIPTA...... 226 BYNFEZIA...... 167, 181 INDUCTION 4:1...... 218 BREVICON (28)...... 116 BYSTOLIC...... 68 CARDIZEM...... 70 BREXAFEMME...... 25, 26 cabergoline...... 167 CARDIZEM CD...... 70 BREZTRI AEROSPHERE...... 227 CABLIVI...... 188 CARDIZEM LA...... 70 BRIELLYN...... 116 CABOMETYX...... 50 CARDURA...... 75 BRILINTA...... 193 CADUET...... 68 CARDURA XL...... 75 brimonidine...... 217 CAFERGOT...... 105 carisoprodol...... 197 brimonidine-dorzolamide (pf)...211 caffeine citrate...... 103 carisoprodol-aspirin...... 197 brinzolamide...... 214 CALAN...... 65, 71 carisoprodol-aspirin-codeine... 198 BRISDELLE...... 167 CALAN SR...... 71 CARNITOR...... 204 BRIVIACT...... 81, 82 calcipotriene...... 130, 131 CARNITOR (SUGAR-FREE)..204 BROMFED DM...... 229 calcipotriene-betamethasone....125 CAROSPIR...... 61, 73 bromfenac...... 213 calcitonin (salmon)...... 159 carteolol...... 215 bromocriptine...... 88 CALCITRENE...... 131 CARTIA XT...... 70 brompheniramine-pseudoeph- calcitriol...... 131, 150, 204 carvedilol...... 61 dm...... 229 CALCIUM 500 + D...... 145 carvedilol phosphate...... 61 BROMSITE...... 213 CALCIUM 500 WITH D...... 145 CASODEX...... 45 BRONCHITOL...... 227 CALCIUM 600 + D(3)...... 145 CATAPRES...... 72 BROVANA...... 224 calcium acetate(phosphat bind) 183 CATAPRES-TTS-1...... 72 BRUKINSA...... 46, 53 calcium carbonate-vitamin d3.. 145 CATAPRES-TTS-2...... 72 BRYHALI...... 130, 133 calcium citrate-vitamin d3...... 145 CATAPRES-TTS-3...... 72 budesonide...... 177, 222, 229 CALQUENCE...... 47, 53 CAVERJECT...... 142 budesonide-formoterol...... 226 CAMBIA...... 19, 20, 105 CAVERJECT IMPULSE...... 142 bumetanide...... 73 CAMILA...... 118 CAYA CONTOURED..... 200, 201 BUNAVAIL...... 111, 112 CAMRESE...... 115 CAYSTON...... 227 BUPAP...... 12 CAMRESE LO...... 115 CAZIANT (28)...... 119 BUPHENYL...... 205 CANASA...... 177 cefaclor...... 33
Last Approved Date: 09/24/2021 Formulary Version: 92
236 cefadroxil...... 33 chorionic gonadotropin, human163 CLIMARA...... 160 cefdinir...... 33 CIALIS...... 142, 184 CLIMARA PRO...... 159 cefditoren pivoxil...... 33 CICLODAN...... 128 CLINDACIN P...... 122 cefixime...... 33 ciclopirox...... 128 CLINDAGEL...... 122 cefpodoxime...... 33 cilostazol...... 193 clindamycin hcl...... 38 cefprozil...... 33 CILOXAN...... 216 clindamycin palmitate hcl...... 38 cefuroxime axetil...... 33 CIMDUO...... 29 clindamycin phosphate..... 122, 232 CELEBREX...... 18 cimetidine...... 172 clindamycin-benzoyl peroxide.. 123 celecoxib...... 18 cimetidine hcl...... 172 CLINPRO 5000...... 206 CELEXA...... 83 CIMZIA...... 13, 14, 178 clobazam...... 78, 97 CELLCEPT...... 16, 196 CIMZIA POWDER FOR clobetasol...... 133 CELONTIN...... 82 RECONST...... 13, 14, 178 clobetasol-emollient...... 133 CENTANY...... 127 CIMZIA STARTER KIT CLOBEX...... 133 cephalexin...... 33 ...... 13, 14, 178 clocortolone pivalate...... 133 CEQUA...... 213 cinacalcet...... 159 CLODAN...... 133 CEQUR SIMPLICITY...... 201 CINRYZE...... 188 CLODAN KIT...... 138 CERDELGA...... 204 CIPRO...... 34 CLODERM...... 133 CERVIDIL...... 151 CIPRO HC...... 218 clomiphene citrate...... 161 CESAMET...... 101, 170 CIPRO XR...... 34, 185 clomipramine...... 86 cetirizine...... 220, 221 CIPRODEX...... 218 clonazepam...... 77, 78, 97 CETRAXAL...... 218 ciprofloxacin...... 34 clonidine...... 72 CETROTIDE...... 166 ciprofloxacin (mixture)...... 34, 185 clonidine hcl...... 72, 93 cevimeline...... 208 ciprofloxacin hcl...... 34, 216, 218 clopidogrel...... 194 CHANTIX...... 113 ciprofloxacin-dexamethasone... 218 clorazepate dipotassium...... 77, 98 CHANTIX CONTINUING ciprofloxacin-fluocinolone...... 218 clotrimazole...... 128, 207 MONTH BOX...... 113 citalopram...... 83 clotrimazole-betamethasone..... 129 CHANTIX STARTING CITRANATAL B-CALM (FE clozapine...... 90 MONTH BOX...... 113 GLUC)...... 149 CLOZARIL...... 90 CHATEAL (28)...... 116 CITRATE OF MAGNESIA..... 179 COAGADEX...... 190 CHEMET...... 23 CITROMA...... 179 coal tar...... 139 CHENODAL...... 172 CLARAVIS...... 121 COARTEM...... 27 CHERATUSSIN AC...... 231 CLARINEX...... 220, 221 codeine sulfate...... 2 CHEWABLE MULTIVIT- CLARINEX-D 12 HOUR...... 219 codeine-butalbital-asa-caff...... 6 A,B,D,E,K,ZN...... 148 clarithromycin...... 38 codeine-guaifenesin...... 231 CHILDREN'S ASPIRIN.....21, 193 CLASSIC PRENATAL...... 149 CODITUSSIN AC...... 231 CHILDREN'S IRON...... 146 CLEARLAX...... 179 CODITUSSIN DAC...... 231 chlordiazepoxide hcl...... 77, 97 clemastine...... 219, 220 COLAZAL...... 177 chlordiazepoxide-clidinium CLENPIQ...... 181 colchicine...... 187 ...... 97, 175, 176 CLEOCIN...... 231 COLCRYS...... 187 chlorhexidine gluconate...... 207 CLEOCIN HCL...... 38 colesevelam...... 65 chloroquine phosphate...... 27 CLEOCIN PEDIATRIC...... 38 COLESTID...... 65 chlorothiazide...... 74 CLEOCIN T...... 122 colestipol...... 65 chlorpromazine...... 91 CLEVER CHOICE MICRO COLOCORT...... 177 chlorpropamide...... 155 TEST STRIP...... 199, 202 COLY-MYCIN S...... 218 chlorthalidone...... 74 CLEVER CHOICE PRO.. 199, 202 COLYTE WITH FLAVOR chlorzoxazone...... 197 CLEVER CHOICE TEST PACKS...... 180 CHOLBAM...... 171 STRIPS...... 199, 202 COMBIGAN...... 214 CHOLESTYRAMINE LIGHT...65 CLEVER CHOICE VOICE+ COMBIPATCH...... 159 choline,magnesium salicylate..... 20 TEST...... 199, 202 COMBIVENT RESPIMAT...... 226
Last Approved Date: 09/24/2021 Formulary Version: 92
237 COMBIVIR...... 31 COSOPT (PF)...... 214 CYTRA-K...... 184 COMETRIQ...... 51 COTELLIC...... 50 DAILY PRENATAL...... 149 COMPAZINE...... 170 COTEMPLA XR-ODT...... 94 dalfampridine...... 209 COMPLERA...... 31 COUMADIN...... 188 DALIRESP...... 224 COMPRO...... 170 COVARYX...... 159 danazol...... 162 COMTAN...... 87 COVARYX H.S...... 159 DANTRIUM...... 198 CONCEPT OB...... 147 COZAAR...... 63 dantrolene...... 198 CONCEPTROL...... 121 CREON...... 172 dapsone...... 26, 122 CONCERTA...... 94 CRESEMBA...... 26 DARAPRIM...... 27 CONDOMS-PREM CRESTOR...... 66 DASETTA 1/35 (28)...... 116 LUBRICATED...... 201, 202 CRINONE...... 160, 232 DASETTA 7/7/7 (28)...... 119 CONDYLOX...... 139 CRIXIVAN...... 40 DAURISMO...... 48 CONJUPRI...... 70 cromolyn...... 50, 216, 223 DAYPRO...... 19 CONSENSI...... 69 CROTAN...... 141 DAYSEE...... 115 CONSTULOSE...... 179 CRYSELLE (28)...... 116 DAYTRANA...... 94 CONTOUR NEXT TEST CUPRIMINE...... 17, 22 DAYVIGO...... 111 STRIPS...... 199, 202 CUROSURF...... 228 DDAVP...... 153 CONTOUR TEST STRIPS CUTIVATE...... 134 DEBLITANE...... 118 ...... 199, 202 CUVPOSA...... 208 DECADRON...... 161 CONTRAVE...... 143 cyanocobalamin (vitamin b-12) 150 deferasirox...... 22, 23 CONZIP...... 2 CYCLAFEM 1/35 (28)...... 116 deferiprone...... 23 COPAXONE...... 209 CYCLAFEM 7/7/7 (28)...... 119 DELSTRIGO...... 31 COPIKTRA...... 51, 52 CYCLESSA (28)...... 119 DELTASONE...... 161 CORDRAN...... 133, 134 cyclobenzaprine...... 197 DELYLA (28)...... 116 CORDRAN TAPE LARGE CYCLOGYL...... 212 DELZICOL...... 177 ROLL...... 133 CYCLOMYDRIL...... 210 DEMADEX...... 73 CORDRAN TAPE SMALL cyclopentolate...... 212 demeclocycline...... 41 ROLL...... 133 cyclopen-tropic-phenyleph-watr DEMEROL...... 2 COREG...... 61 ...... 211 DEMEROL (PF)...... 2 COREG CR...... 61 cyclophosphamide...... 16, 44 DEMSER...... 75 CORGARD...... 69 cyclop-trop-propa-phen-ket-wat DENAVIR...... 132 CORIFACT...... 190 ...... 211 DENTA 5000 PLUS...... 206 CORLANOR...... 74 cycloserine...... 32 DENTAGEL...... 206 CORMAX...... 134 CYCLOSET...... 154 DEPAKENE...... 79, 99 CORRECTOL...... 180 cyclosporine...... 16, 195 DEPAKOTE...... 79, 99 CORTANE-B...... 219 CYCLOSPORINE IN DEPAKOTE ER...... 79, 99, 104 CORTEF...... 161 KLARITY...... 213 DEPAKOTE SPRINKLES...79, 99 CORTENEMA...... 177 cyclosporine modified...... 16, 195 DEPEN TITRATABS...... 17, 22 CORTIFOAM...... 177 CYMBALTA...... 84, 103 DEPO-PROVERA...... 52, 114 cortisone...... 161 cyproheptadine...... 220 DEPO-SUBQ PROVERA 104. 114 CORTISPORIN...... 127 CYRED...... 116 DEPO-TESTOSTERONE...... 152 CORVITA 150...... 146 CYSTADANE...... 205 DERMA-SMOOTHE/FS CORVITE 150...... 146 CYSTADROPS...... 214 BODY OIL...... 134 CORVITE FREE...... 147 CYSTAGON...... 182 DERMA-SMOOTHE/FS CORZIDE...... 74 CYSTARAN...... 214 SCALP OIL...... 134 COSENTYX...... 126 CYTOMEL...... 168 DERMASORB HC COSENTYX (2 SYRINGES)...126 CYTOTEC...... 174 COMPLETE KIT...... 138 COSENTYX PEN...... 126 CYTRA-2...... 184 DERMASORB TA COSENTYX PEN (2 PENS).... 126 CYTRA-3...... 184 COMPLETE KIT...... 138
Last Approved Date: 09/24/2021 Formulary Version: 92
238 DERMATOP...... 134 dextroamphetamine DIPROLENE (AUGMENTED)134 DERMOTIC OIL...... 219 ...... 94, 102, 103, 109 DIPROLENE AF...... 134 DESCOVY...... 29 dextroamphetamine- dipyridamole...... 194 desipramine...... 86 amphetamine...... 95, 102, 109, 110 DISALCID...... 21 desloratadine...... 220, 221 DIACOMIT...... 82 DISKETS...... 2 desmopressin...... 153 DIALYVITE 800...... 144 disopyramide phosphate...... 64 desog-e.estradiol/e.estradiol.....115 DIALYVITE 800 WITH ZINC disulfiram...... 112 desogestrel-ethinyl estradiol.....116 15...... 144 DITROPAN XL...... 186 DESONATE...... 134 DIALYVITE 800 WITH ZINC DIURIL...... 74 desonide...... 134 50...... 144 divalproex...... 79, 99, 104 DESOWEN...... 134 DIASTAT...... 78, 98 DIVIGEL...... 160 desoximetasone...... 134 DIASTAT ACUDIAL...... 78, 98 DOJOLVI...... 148 DESOXYN...... 94, 102 diazepam...... 77, 78, 98 DOLOPHINE...... 2 desvenlafaxine...... 84 DIAZEPAM INTENSOL..... 77, 98 donepezil...... 113 desvenlafaxine succinate...... 84 diazoxide...... 151 DONNATAL...... 176 DETROL...... 186 DIBENZYLINE...... 75 DOPTELET (10 TAB PACK)..195 DETROL LA...... 186 DICLEGIS...... 170 DOPTELET (15 TAB PACK)..195 DEXABLISS...... 161 diclofenac epolamine...... 139 DOPTELET (30 TAB PACK)..195 dexamethasone...... 161 diclofenac potassium...... 19 DORYX...... 41 DEXAMETHASONE diclofenac sodium19, 130, 139, 213 DORYX MPC...... 41 INTENSOL...... 161 diclofenac submicronized...... 19 dorzolamide...... 214 dexamethasone sodium diclofenac-misoprostol...... 18 dorzolamide (pf)...... 214 phosphate...... 212 dicloxacillin...... 40 dorzolamide-timolol...... 214 DEXCOM G4 RECEIVER dicyclomine...... 175 dorzolamide-timolol (pf)...... 214 ...... 200, 202 didanosine...... 30 DOVATO...... 29 DEXCOM G4 TRANSMITTER diethylpropion...... 143 DOVONEX...... 131 ...... 200, 202 DIFFERIN...... 125 doxazosin...... 75 DEXCOM G5 RECEIVER DIFICID...... 38 doxepin...... 86, 111, 141 ...... 200, 202 diflorasone...... 134 doxercalciferol...... 204 DEXCOM G5 TRANSMITTER DIFLUCAN...... 26 doxycycline hyclate...... 41, 208 ...... 200, 202 diflunisal...... 21 doxycycline monohydrate DEXCOM G5-G4 SENSOR DIGITEK...... 72 ...... 41, 42, 139 ...... 200, 202 DIGOX...... 72 doxylamine-pyridoxine (vit b6).170 DEXCOM G6 RECEIVER digoxin...... 72 D-PENAMINE...... 17, 22 ...... 200, 202 dihydroergotamine...... 105 DRIZALMA SPRINKLE... 84, 103 DEXCOM G6 SENSOR...200, 202 DILANTIN...... 80 dronabinol...... 101, 143, 170 DEXCOM G6 TRANSMITTER DILANTIN EXTENDED...... 80 drospirenone-e.estradiol-lm.fa. 116 ...... 200, 202 DILANTIN INFATABS...... 80 drospirenone-ethinyl estradiol..116 DEXCOM RECEIVER.... 200, 202 DILANTIN-125...... 80 DROXIA...... 194 DEXEDRINE SPANSULE DILATRATE-SR...... 63 droxidopa...... 72 ...... 94, 102, 109 DILAUDID...... 2 DRYSOL DAB-O-MATIC...... 130 DEXILANT...... 173 DILAUDID (PF)...... 2 DUAC...... 123 dexmethylphenidate...... 94 diltiazem hcl...... 70 DUAKLIR PRESSAIR...... 226 DEXONTO...... 161 dimethyl fumarate...... 209 DUAVEE...... 159 DEXPAK 10 DAY...... 161 DIOVAN...... 63 DUCODYL (BISACODYL).... 180 DEXPAK 13 DAY...... 161 DIOVAN HCT...... 62 DUETACT...... 155 DEXPAK 6 DAY...... 161 DIPENTUM...... 177 DUEXIS...... 17 diphenhydramine hcl.110, 219, 220 DULCOLAX (BISACODYL)..180 diphenoxylate-atropine...... 169 DULERA...... 226
Last Approved Date: 09/24/2021 Formulary Version: 92
239 duloxetine...... 84, 103, 104 ELESTAT...... 212 ENSTILAR...... 125 DUOBRII...... 125 ELESTRIN...... 160 entacapone...... 87 DUOPA...... 87 eletriptan...... 105 entecavir...... 35 DUPIXENT PEN...... 127, 223 ELIDEL...... 132 ENTEREG...... 23 DUPIXENT SYRINGE.... 127, 223 ELIGARD...... 49 ENTERIC COATED ASPIRIN DURAGESIC...... 2 ELIGARD (3 MONTH)...... 49 ...... 21, 193 DURAMORPH (PF)...... 2 ELIGARD (4 MONTH)...... 49 ENTOCORT EC...... 178 DUREZOL...... 212 ELIGARD (6 MONTH)...... 49 ENTRESTO...... 62 DURLAZA...... 21, 193 ELIMITE...... 141 ENULOSE...... 171 dutasteride...... 184 ELINEST...... 116 ENVARSUS XR...... 195 dutasteride-tamsulosin...... 182 ELIPHOS...... 183 ENZOCLEAR...... 124 DUTOPROL...... 71 ELIQUIS...... 188, 189 EPANED...... 61 DUZALLO...... 188 ELIQUIS DVT-PE TREAT EPCLUSA...... 35, 36 D-VITA...... 150 30D START...... 188 EPIDIOLEX...... 79 DXEVO...... 161 ELIXOPHYLLIN...... 223 EPIDUO...... 124 DYANAVEL XR...... 95, 102 ELLA...... 120 EPIDUO FORTE...... 124 DYAZIDE...... 73 ELMIRON...... 182 EPIFOAM...... 138 DYMISTA...... 228 ELOCON...... 134, 135 epinastine...... 212 DYRENIUM...... 73 ELOCTATE...... 190 epinephrine...... 71, 221 E.C. PRIN...... 21, 193 ELURYNG...... 120 EPIPEN 2-PAK...... 71 E.E.S. 400...... 38 EMADINE...... 212 EPIPEN JR 2-PAK...... 72 E.E.S. GRANULES...... 38 EMCYT...... 47 EPISIL...... 207 EASY TOUCH BLU LINK EMEND...... 171 EPITOL...... 80, 99 TEST STRIP...... 199, 202 EMFLAZA...... 161 EPIVIR...... 30 EASY TRAK II TEST STRIP EMGALITY PEN...... 105 EPIVIR HBV...... 35 ...... 199, 202 EMGALITY SYRINGE..... 77, 105 eplerenone...... 61, 73 EC-NAPROSYN...... 19 EMOQUETTE...... 116 EPOGEN...... 189 econazole...... 128 EMPAVELI...... 188, 194 eprosartan...... 63 ECONTRA EZ...... 120 EMSAM...... 83 EPZICOM...... 31 ECOTRIN...... 21, 193 emtricitabine...... 30 EQUETRO...... 99 ECOTRIN LOW STRENGTH emtricitabine-tenofovir (tdf)...... 29 ergoloid...... 114 ...... 21, 193 EMTRIVA...... 30 ERGOMAR...... 105 ECOZA...... 128 EMVERM...... 24 ERIVEDGE...... 48 EDARBI...... 63 ENABLEX...... 186 ERLEADA...... 45 EDARBYCLOR...... 62 enalapril maleate...... 61 erlotinib...... 43 EDECRIN...... 73 enalapril-hydrochlorothiazide....60 ERRIN...... 118 EDEX...... 142 ENBREL...... 13, 14 ERTACZO...... 128 EDLUAR...... 111 ENBREL SURECLICK...... 13, 14 ertapenem...... 33 ED-SPAZ...... 175, 186 ENDARI...... 144, 148, 194 ERY PADS...... 122 EDURANT...... 29 ENDOCET...... 10, 11 ERYGEL...... 122 efavirenz...... 29 ENDOMETRIN...... 160 ERYPED 200...... 38 efavirenz-emtricitabin-tenofov....31 ENGERIX-B (HEPATITIS ERYPED 400...... 38 efavirenz-lamivu-tenofov disop...31 B)VACCINE...... 57 ERY-TAB...... 38 EFFER-K...... 147 ENGERIX-B (PF)...... 57 ERYTHROCIN (AS EFFEXOR XR...... 84 ENGERIX-B PEDIATRIC (PF).57 STEARATE)...... 38 EFFIENT...... 194 enoxaparin...... 192 erythromycin...... 38, 217 EFUDEX...... 129 ENPRESSE...... 119 erythromycin ethylsuccinate...... 38 EGRIFTA SV...... 162 ENSKYCE...... 116 erythromycin with ethanol...... 122 ELEPSIA XR...... 82 ENSPRYNG...... 196 erythromycin-benzoyl peroxide.123
Last Approved Date: 09/24/2021 Formulary Version: 92
240 ESBRIET...... 231 EXFORGE...... 62 FERROGELS FORTE...... 146 ESCAVITE...... 148 EXFORGE HCT...... 62 ferrous sulfate...... 146 ESCAVITE D...... 148 EXJADE...... 23 FETZIMA...... 84 ESCAVITE LQ...... 148 EXSERVAN...... 196 FEXMID...... 197 escitalopram oxalate...... 83 EXTAVIA...... 208 FIASP FLEXTOUCH U-100 ESGIC...... 12 EXTINA...... 128 INSULIN...... 165 esomeprazole magnesium...... 173 EYSUVIS...... 212 FIASP PENFILL U-100 ESPEROCT...... 190 EZALLOR SPRINKLE...... 66 INSULIN...... 165 ESTARYLLA...... 116 ezetimibe...... 68 FIASP U-100 INSULIN...... 165 estazolam...... 98, 110 ezetimibe-simvastatin...... 68 FIBRICOR...... 66 ESTRACE...... 160, 232 FA-8...... 150 FIBRYGA...... 191 estradiol...... 160, 232 FABIOR...... 125 FINACEA...... 122, 140 estradiol-norethindrone acet.... 159 FACTIVE...... 34 finasteride...... 184 ESTRING...... 232 FALMINA (28)...... 116 FINTEPLA...... 82 ESTROGEL...... 160 famciclovir...... 37 FIORICET...... 12 estrogens-methyltestosterone....159 famotidine...... 172 FIORICET WITH CODEINE...... 7 estropipate...... 160 FANAPT...... 89 FIORINAL...... 20 ESTROSTEP FE-28...... 119 FANTASY CONDOM..... 201, 202 FIORINAL-CODEINE #3...... 7 eszopiclone...... 111 FARESTON...... 54 FIRAZYR...... 69 ethambutol...... 32 FARXIGA...... 155 FIRDAPSE...... 209 ethosuximide...... 82 FARYDAK...... 49 FIRMAGON KIT W DILUENT ethyl acetate...... 113 FASENRA PEN...... 223 SYRINGE...... 50 etidronate disodium...... 159 FAZACLO...... 90 FIRVANQ...... 34 etodolac...... 20 FC2 FEMALE CONDOM 200, 202 FLAGYL...... 28 etonogestrel-ethinyl estradiol... 120 FE C PLUS...... 146 FLAREX...... 212 etoposide...... 47 febuxostat...... 187 flavoxate...... 187 etravirine...... 29 FEIBA NF...... 188 flecainide...... 64 EUCRISA...... 127 felbamate...... 79 FLECTOR...... 139 EURAX...... 141 FELBATOL...... 79 FLEET LAXATIVE EUTHYROX...... 168 FELDENE...... 18 (BISACODYL)...... 180 EVAMIST...... 160 felodipine...... 70 FLOLIPID...... 66 EVEKEO...... 95, 103, 110 FEM PH...... 232 FLOMAX...... 183 EVEKEO ODT...... 95, 103 FEMARA...... 46 FLONASE...... 229 EVENCARE PROVIEW TEST FEMCAP...... 199, 202 FLORIVA...... 148 STRIP...... 199, 202 FEMHRT LOW DOSE...... 159 FLORIVA (FLUORIDE- EVENITY...... 158 FEMRING...... 232 VITAMIN D3)...... 148, 206 everolimus (antineoplastic)...... 50 fenofibrate...... 66 FLORIVA PLUS...... 148 everolimus fenofibrate micronized...... 65 FLOVENT DISKUS...... 222 (immunosuppressive)...... 196 fenofibrate nanocrystallized...... 66 FLOVENT HFA...... 222 EVISTA...... 167 fenofibric acid...... 66 FLUAD 2019-2020 (65 YR EVOCLIN...... 122 fenofibric acid (choline)...... 66 UP)(PF)...... 59 EVOTAZ...... 30, 40 FENOGLIDE...... 66 FLUAD 2020-2021 (65 YR EVOXAC...... 208 fenoprofen...... 19 UP)(PF)...... 59 EVRYSDI...... 198 fentanyl...... 3 FLUAD QUAD 2020-21(65Y EVZIO...... 23 fentanyl citrate...... 2 UP)(PF)...... 59 EXALGO ER...... 2 FENTORA...... 3 FLUAD QUAD 2021-22(65Y EXELDERM...... 128 FEROCON...... 146 UP)(PF)...... 59 EXELON PATCH...... 113 FERRIPROX...... 23 FLUARIX QUAD 2019-2020 exemestane...... 46 FERROCITE PLUS...... 146 (PF)...... 59
Last Approved Date: 09/24/2021 Formulary Version: 92
241 FLUARIX QUAD 2020-2021 FLUORIDEX SENSITIVITY FORA GTEL GLUCOSE TEST (PF)...... 59 RELIEF...... 206 STRIP...... 199, 202 FLUARIX QUAD 2021-2022 FLUORITAB...... 206 FORA TN'G ADVAN PRO (PF)...... 59 fluorometholone...... 212 TEST STRIP...... 199, 202 FLUBLOK QUAD 2020-2021 FLUOROPLEX...... 129 FORFIVO XL...... 86 (PF)...... 59 fluorouracil...... 129 formoterol fumarate...... 224 FLUBLOK QUAD 2021-2022 fluoxetine...... 83 FORTAMET...... 165 (PF)...... 59 fluphenazine hcl...... 91 FORTEO...... 158 FLUCAINE...... 214 flurandrenolide...... 135 FORTESTA...... 152 FLUCELVAX QUAD 2019- flurazepam...... 98, 110 FORTISCARE G1 TEST 2020...... 59 flurbiprofen...... 19 STRIP...... 199, 202 FLUCELVAX QUAD 2019- flurbiprofen sodium...... 213 FOSAMAX...... 159 2020 (PF)...... 59 flutamide...... 45 FOSAMAX PLUS D...... 158 FLUCELVAX QUAD 2020- fluticasone propionate...... 135, 229 fosamprenavir...... 40 2021...... 59 fluticasone propion-salmeterol.226 fosfomycin tromethamine....25, 185 FLUCELVAX QUAD 2020- fluvastatin...... 66 fosinopril...... 61 2021 (PF)...... 59 fluvoxamine...... 83 fosinopril-hydrochlorothiazide... 60 FLUCELVAX QUAD 2021- FLUZONE HIGH-DOSE 2018- FOSRENOL...... 183 2022 (PF)...... 59 19 (PF)...... 59 FOTIVDA...... 53 fluconazole...... 26 FLUZONE HIGH-DOSE 2019- FRAGMIN...... 192 flucytosine...... 25 20 (PF)...... 59 FREESTYLE INSULINX 199, 202 fludrocortisone...... 167 FLUZONE HIGHDOSE QUAD FREESTYLE INSULINX FLULAVAL QUAD 2018-2019 59 20-21 PF...... 60 TEST STRIPS...... 199, 202 FLULAVAL QUAD 2018-2019 FLUZONE HIGHDOSE QUAD FREESTYLE LIBRE 10 DAY (PF)...... 59 21-22 PF...... 60 READER...... 200, 202 FLULAVAL QUAD 2019-2020 59 FLUZONE QUAD 2019-2020... 60 FREESTYLE LIBRE 10 DAY FLULAVAL QUAD 2019-2020 FLUZONE QUAD 2019-2020 SENSOR...... 200, 202 (PF)...... 59 (PF)...... 60 FREESTYLE LIBRE 14 DAY FLULAVAL QUAD 2020-2021 FLUZONE QUAD 2020-2021... 60 READER...... 200, 202 (PF)...... 59 FLUZONE QUAD 2020-2021 FREESTYLE LIBRE 14 DAY FLULAVAL QUAD 2021-2022 (PF)...... 60 SENSOR...... 200, 202 (PF)...... 59 FLUZONE QUAD 2021-2022 FREESTYLE LIBRE 2 FLUMADINE...... 37 (PF)...... 60 READER...... 200, 202 FLUMIST QUAD 2019-2020 FLUZONE QUAD PEDI 2019- FREESTYLE LIBRE 2 ...... 57, 59 20 (PF)...... 60 SENSOR...... 200, 202 FLUMIST QUAD 2020-2021 FML FORTE...... 213 FREESTYLE LITE STRIPS ...... 57, 59 FML LIQUIFILM...... 213 ...... 199, 203 FLUMIST QUAD 2021-2022 FML S.O.P...... 213 FREESTYLE PRECISION ...... 57, 59 FOCALGIN DSS...... 146 NEO STRIPS...... 199, 203 flunisolide...... 229 FOCALIN...... 95 FREESTYLE TEST...... 199, 203 fluocinolone...... 135 FOCALIN XR...... 95 FROVA...... 105 fluocinolone acetonide oil...... 219 folic acid...... 150 frovatriptan...... 105 fluocinonide...... 135 FOLIVANE-F...... 146 FULL SPECTRUM B- FLUORABON...... 206 FOLIVANE-PLUS...... 146 VITAMIN C...... 144 FLUOR-A-DAY...... 206 FOLLISTIM AQ...... 161 FULPHILA...... 191 FLUOR-A-DAY (WITH FOLTABS 800...... 150 FURADANTIN...... 25, 185 XYLITOL)...... 206 fondaparinux...... 192 furosemide...... 73 fluorescein-proparacaine...... 214 FORA 6 CONNECT FUSION PLUS...... 146 fluoride (sodium)...... 206 GLUCOSE STRIP...... 199, 202 FUSION SPRINKLES...... 146
Last Approved Date: 09/24/2021 Formulary Version: 92
242 FUZEON...... 28 GLUCAGEN HYPOKIT...... 151 halcinonide...... 135 FYCOMPA...... 78 GLUCAGON EMERGENCY HALCION...... 98, 111 gabapentin...... 79 KIT (HUMAN)...... 151 halobetasol propionate..... 131, 135 GABITRIL...... 79 GLUCOPHAGE...... 165 HALOG...... 135 GALAFOLD...... 205 GLUCOPHAGE XR...... 165 haloperidol...... 91 galantamine...... 114 GLUCOTROL...... 155 haloperidol lactate...... 90 GALZIN...... 22 GLUCOTROL XL...... 155 HARMONY GLUCOSE TEST ganirelix...... 166 GLUCOVANCE...... 155 STRIP...... 199, 203 GARDASIL (PF)...... 58 GLUMETZA...... 165 HARVONI...... 36 GARDASIL 9 (PF)...... 58 glyburide...... 155 HEALTHYLAX...... 179 GASTROCROM...... 50 glyburide micronized...... 155 HEATHER...... 118 gatifloxacin...... 216 glyburide-metformin...... 155 HELIDAC...... 181 gatifloxacin-dexamethasone..... 211 GLYCATE...... 175 HELIXATE FS...... 190 GATTEX 30-VIAL...... 181 GLYCOLAX...... 179 HEMADY...... 161 GAVILAX...... 179 glycopyrrolate...... 175 HEMANGEOL...... 69 GAVILYTE-C...... 180 GLYNASE...... 155 HEMATINIC PLUS GAVILYTE-G...... 180 GLYSET...... 153 VIT/MINERALS...... 146 GAVILYTE-N...... 180 GLYXAMBI...... 154 HEMATINIC/FOLIC ACID.....146 GAVRETO...... 55 GOCOVRI...... 88 HEMLIBRA...... 190 GELCLAIR...... 207 GOJJI BLOOD GLUCOSE HEMMOREX-HC...... 22 GELNIQUE...... 187 TEST STRIP...... 199, 203 HEMOCYTE-F...... 146 GELX...... 207 GOLYTELY...... 180 HEMOFIL M HIGH...... 190 gemfibrozil...... 66 GONAL-F...... 161 HEMOFIL M LOW...... 190 GEMMILY...... 116 GONAL-F RFF...... 161 HEMOFIL M MID...... 190 GEMTESA...... 182 GONAL-F RFF PEN...... 161 HEMOFIL M SUPER HIGH....190 GENERESS FE...... 116 GONAL-F RFF REDI-JECT....161 heparin (porcine)...... 192 GENERLAC...... 171 GONITRO...... 63 heparin (porcine) in 5 % dex.... 192 GENGRAF...... 16, 195 GRALISE...... 110 heparin (porcine) in nacl (pf) GENOTROPIN...... 162 GRALISE 30-DAY STARTER ...... 191, 192 GENOTROPIN MINIQUICK.. 162 PACK...... 110 HEPARIN LOCK FLUSH191, 192 GENTAK...... 216 granisetron hcl...... 170 heparin lock flush (porcine) gentamicin...... 127, 216 GRANIX...... 191 ...... 191, 192 GENTLE LAXATIVE GRASTEK...... 56 HEPARIN (BISACODYL)...... 180 griseofulvin microsize...... 26 LOCKFLUSH(PORCINE)(PF) 192 GENTLELAX...... 179 griseofulvin ultramicrosize...... 26 heparin(porcine) in 0.45% nacl 192 GENVOYA...... 31 GUAIFENESIN DAC...... 231 heparin, porcine (pf)...... 192 GEODON...... 89, 100 guanfacine...... 72, 93 HEPLISAV-B (PF)...... 57 GIANVI (28)...... 116 guanidine...... 197 HEPSERA...... 35 GILENYA...... 210 GVOKE HYPOPEN 1-PACK..151 HETLIOZ...... 104 GILOTRIF...... 43 GVOKE HYPOPEN 2-PACK..151 HETLIOZ LQ...... 104 GIMOTI...... 174 GVOKE PFS 1-PACK HEXALEN...... 43 glatiramer...... 209 SYRINGE...... 151 HIPREX...... 39, 185 GLATOPA...... 209 GVOKE PFS 2-PACK HISTEX-AC...... 230 GLEEVEC...... 53 SYRINGE...... 151 HOMATROPAIRE...... 212 GLEOSTINE...... 44 GYNAZOLE-1...... 232 homatropine hbr...... 212 glimepiride...... 155 GYNOL II...... 121 HORIZANT...... 107 glipizide...... 155 HAEGARDA...... 188 HUMALOG JUNIOR glipizide-metformin...... 155 HAILEY 24 FE...... 116 KWIKPEN U-100...... 165 GLOPERBA...... 187 HAILEY FE 1.5/30 (28)...... 116
Last Approved Date: 09/24/2021 Formulary Version: 92
243 HUMALOG KWIKPEN hydralazine...... 72 imiquimod...... 138 INSULIN...... 165 HYDREA...... 46 IMITREX...... 105 HUMALOG MIX 50-50 hydrochlorothiazide...... 74 IMITREX STATDOSE PEN....105 INSULN U-100...... 164 hydrocodone bitartrate...... 3 IMITREX STATDOSE HUMALOG MIX 50-50 hydrocodone-acetaminophen....8, 9 REFILL...... 106 KWIKPEN...... 164 hydrocodone-chlorpheniramine229 IMPEKLO...... 136 HUMALOG MIX 75-25 hydrocodone-cpm-pseudoephed230 IMPOYZ...... 131, 136 KWIKPEN...... 164 hydrocodone-guaifenesin...... 231 IMURAN...... 16, 196 HUMALOG MIX 75-25(U- hydrocodone-homatropine...... 230 INBRIJA...... 88 100)INSULN...... 164 hydrocodone-ibuprofen...... 8, 9 INCRELEX...... 166 HUMALOG U-100 INSULIN..165 hydrocortisone...... 135, 161, 178 INCRUSE ELLIPTA...... 224 HUMATE-P...... 190 hydrocortisone acetate...... 22 indapamide...... 74 HUMATROPE...... 162 hydrocortisone butyrate...... 135 INDERAL LA...... 69 HUMIRA...... 13, 14, 178 hydrocortisone valerate...... 135 INDOCIN...... 20 HUMIRA PEDIATRIC hydrocortisone-acetic acid...... 219 indomethacin...... 20 CROHNS START...... 13, 14, 178 hydrocortisone-pramoxine indomethacin submicronized...... 20 HUMIRA PEN...... 13, 14, 178 ...... 22, 135, 138 INFASURF...... 228 HUMIRA PEN CROHNS-UC- HYDROMET...... 230 INFUMORPH P/F...... 3 HS START...... 13, 14, 178 hydromorphone...... 3 INGREZZA...... 107, 108 HUMIRA PEN PSOR- hydromorphone (pf)...... 3 INGREZZA INITIATION UVEITS-ADOL HS...... 13, 14, 178 hydromorphone in 0.9 % nacl...... 3 PACK...... 106, 107 HUMIRA(CF)...... 13, 14, 179 hydromorphone in d5w (pf)...... 3 INLYTA...... 53 HUMIRA(CF) PEDI CROHNS hydroxychloroquine...... 15, 27 INNOPRAN XL...... 69 STARTER...... 13, 15, 178 hydroxyurea...... 46 INOVA...... 124 HUMIRA(CF) PEN...... 14, 15, 178 hydroxyzine hcl...... 77 INOVA 4-1...... 124 HUMIRA(CF) PEN CROHNS- hydroxyzine pamoate...... 77 INOVA 8-2...... 124 UC-HS...... 14, 15, 179 HYOPHEN...... 39, 185 INQOVI...... 56 HUMIRA(CF) PEN hyoscyamine sulfate...... 175, 186 INREBIC...... 49 PEDIATRIC UC...... 14, 15, 179 HYPER-SAL...... 113 INSPRA...... 61, 73 HUMIRA(CF) PEN PSOR-UV- HYSINGLA ER...... 3 insulin asp prt-insulin aspart....164 ADOL HS...... 14, 15, 179 HYZAAR...... 62 insulin aspart u-100...... 165 HUMULIN 70/30 INSULIN ibandronate...... 159 insulin lispro...... 165 PEN...... 163 IBRANCE...... 47 insulin lispro protamin-lispro...164 HUMULIN 70/30 U-100 IBUDONE...... 8, 9 INTELENCE...... 29 INSULIN...... 163 ibuprofen...... 19 INTERMEZZO...... 111 HUMULIN 70/30 U-100 ibuprofen-famotidine...... 17 INTRAROSA...... 166 KWIKPEN...... 163 ibuprofen-oxycodone...... 10, 11 INTRON A...... 49 HUMULIN L...... 163 icatibant...... 69 INTROVALE...... 116 HUMULIN N NPH INSULIN ICLUSIG...... 51 INTUNIV ER...... 93 KWIKPEN...... 163 icosapent ethyl...... 67 INVANZ...... 33 HUMULIN N NPH U-100 IDELVION...... 189 INVEGA...... 89 INSULIN...... 163 IDHIFA...... 51 INVELTYS...... 213 HUMULIN N PEN...... 163 ILEVRO...... 213 INVIRASE...... 40 HUMULIN R REGULAR U- imatinib...... 53 INVOKAMET...... 154 100 INSULN...... 164 IMBRUVICA...... 47, 53 INVOKAMET XR...... 154 HUMULIN R U-500 (CONC) IMCIVREE...... 143 INVOKANA...... 155 INSULIN...... 164 imipenem-cilastatin...... 32 IONSYS...... 3 HYCAMTIN...... 55 imipramine hcl...... 86 IOPIDINE...... 217 HYCODAN...... 230 imipramine pamoate...... 86 ipratropium bromide...... 224, 228
Last Approved Date: 09/24/2021 Formulary Version: 92
244 ipratropium-albuterol...... 226 JULUCA...... 28 KISQALI FEMARA CO-PACK 49 irbesartan...... 63 JUNEL 1.5/30 (21)...... 116 KITABIS PAK...... 227 irbesartan-hydrochlorothiazide..62 JUNEL 1/20 (21)...... 116 KLARON...... 122 IRESSA...... 43 JUNEL FE 1.5/30 (28)...... 116 KLISYRI...... 130 ISENTRESS...... 28 JUNEL FE 1/20 (28)...... 116 KLONOPIN...... 77, 78, 98 ISENTRESS HD...... 28 JUNEL FE 24...... 116 KLOR-CON...... 147 ISOCHRON...... 63 JUXTAPID...... 68 KLOR-CON 10...... 147 isometh-dichloral- JYNARQUE...... 183 KLOR-CON 8...... 147 acetaminophn...... 104 KADIAN...... 3 KLOR-CON M10...... 147 isomethepten-caf- KALETRA...... 31 KLOR-CON M15...... 147 acetaminophen...... 104 KALYDECO...... 227 KLOR-CON M20...... 147 isoniazid...... 32 KAPSPARGO SPRINKLE...... 69 KLOR-CON SPRINKLE...... 147 ISOPTO ATROPINE...... 212 KAPVAY...... 93 KLOR-CON/EF...... 147 ISOPTO CARPINE...... 210 KARBINAL ER...... 219, 220 KLOXXADO...... 23 ISORDIL...... 63 KARIVA (28)...... 115 KOATE...... 190 ISORDIL TITRADOSE...... 63 KATERZIA...... 70 KOATE-DVI...... 190 isosorbide dinitrate...... 63 KAZANO...... 157 KOBEE...... 144 isosorbide mononitrate...... 63 K-EFFERVESCENT...... 147 KOGENATE FS...... 190 isotretinoin...... 121 KEFLEX...... 33 KOMBIGLYZE XR...... 157 isoxsuprine...... 75 KELNOR 1/35 (28)...... 116 KORLYM...... 154 isradipine...... 70 KENALOG...... 136 KOSELUGO...... 50 ISTALOL...... 215 KEPPRA...... 82 KOSHER PRENATAL PLUS ISTURISA...... 151 KEPPRA XR...... 82 IRON...... 149 itraconazole...... 26 KERENDIA...... 61 KOVALTRY...... 190 ivermectin...... 24, 140, 141 KERYDIN...... 129 K-PHOS NO 2...... 184 IXINITY...... 189 KESIMPTA PEN...... 208 K-PHOS ORIGINAL...... 184 JADENU...... 23 ketoconazole...... 26, 128, 129 KPN...... 149 JADENU SPRINKLE...... 23 KETODAN...... 129 KRINTAFEL...... 27 JAKAFI...... 49 KETODAN KIT...... 129 KRISTALOSE...... 179 JALYN...... 182 ketoprofen...... 19 K-TAB...... 147 JANSSEN COVID-19 ketorolac...... 18, 213, 214 KURVELO (28)...... 116 VACCINE (EUA)...... 58 KEVEYIS...... 196 KUVAN...... 205, 206 JANTOVEN...... 188 KEVZARA...... 16 KYNAMRO...... 65 JANUMET...... 157 KHEDEZLA...... 84 KYNMOBI...... 88 JANUMET XR...... 157 KIMONO CONDOMS(NON- l norgest/e.estradiol-e.estrad.... 115 JANUVIA...... 153 LUBRICATED)...... 201, 203 labetalol...... 61 JARDIANCE...... 155 KIMONO MAXX CONDOMS lactated ringers...... 145 JATENZO...... 152 ...... 201, 203 lactulose...... 171, 179 JENCYCLA...... 118 KIMONO MICROTHIN LAMICTAL...... 81 JENTADUETO...... 157 AQUA LUBE CON...... 201, 203 LAMICTAL ODT...... 81, 99 JENTADUETO XR...... 157 KIMONO MICROTHIN LAMICTAL ODT STARTER JEVANTIQUE LO...... 160 CONDOMS...... 201, 203 (BLUE)...... 81, 99 JINTELI...... 160 KIMONO MICROTHIN LAMICTAL ODT STARTER JIVI...... 190 LARGE CONDOMS...... 201, 203 (GREEN)...... 81, 99 JOLESSA...... 116 KIMONO TEXTURED LAMICTAL ODT STARTER JOLIVETTE...... 118 CONDOMS...... 201, 203 (ORANGE)...... 81, 99 JORNAY PM...... 95 KINERET...... 16 LAMICTAL STARTER JUBLIA...... 129 KIONEX (WITH SORBITOL) 145 (BLUE) KIT...... 81, 99 JULEBER...... 116 KISQALI...... 47
Last Approved Date: 09/24/2021 Formulary Version: 92
245 LAMICTAL STARTER leuprolide...... 50 lisinopril-hydrochlorothiazide....60 (GREEN) KIT...... 81, 99 levalbuterol hcl...... 225 LITE COAT ASPIRIN...... 21, 193 LAMICTAL STARTER levalbuterol tartrate...... 225 lithium carbonate...... 101 (ORANGE) KIT...... 81, 99 LEVAQUIN...... 34 lithium citrate...... 101 LAMICTAL XR...... 81 LEVBID...... 175, 186 LITHOBID...... 101 LAMICTAL XR STARTER LEVEMIR FLEXTOUCH U- LITHOSTAT...... 184 (BLUE)...... 81 100 INSULN...... 164 LIVALO...... 67 LAMICTAL XR STARTER LEVEMIR U-100 INSULIN.... 164 LO LOESTRIN FE...... 115 (GREEN)...... 81 levetiracetam...... 82 LOCOID...... 136 LAMICTAL XR STARTER LEVITRA...... 142 LOCOID LIPOCREAM...... 136 (ORANGE)...... 81 levobunolol...... 215 LO-DOSE ASPIRIN...... 21, 194 lamivudine...... 30, 35 levocarnitine...... 144, 204 LODOSYN...... 87 lamivudine-zidovudine...... 31 levocarnitine (with sugar)...... 204 LOESTRIN 1.5/30 (21)...... 117 lamotrigine...... 81, 99 levocetirizine...... 220, 221 LOESTRIN 1/20 (21)...... 117 LAMPIT...... 27 levofloxacin...... 34, 216 LOESTRIN FE 1.5/30 (28- LANOXIN...... 72 LEVONEST (28)...... 119 DAY)...... 117 lansoprazole...... 173 levonorgestrel-ethinyl estrad.... 117 LOESTRIN FE 1/20 (28-DAY)117 lanthanum...... 183 levonorg-eth estrad triphasic....119 LOKELMA...... 145 LANTUS SOLOSTAR U-100 LEVORA-28...... 117 LOMAIRA...... 143 INSULIN...... 164 levorphanol tartrate...... 3 LOMOTIL...... 169 LANTUS U-100 INSULIN...... 164 levothyroxine...... 168 LONHALA MAGNAIR lapatinib...... 42 LEVOXYL...... 169 REFILL...... 224 LARIN 1.5/30 (21)...... 116 LEVSIN...... 175, 186 LONHALA MAGNAIR LARIN 1/20 (21)...... 117 LEVSIN/SL...... 175, 186 STARTER...... 224 LARIN 24 FE...... 117 LEVULAN...... 139 LONSURF...... 46 LARIN FE 1.5/30 (28)...... 117 LEXAPRO...... 83 loperamide...... 169 LARIN FE 1/20 (28)...... 117 LEXETTE...... 131, 136 LOPID...... 66 LASIX...... 73 LEXIVA...... 40 lopinavir-ritonavir...... 31 LASTACAFT...... 212 LIALDA...... 177 LOPREEZA...... 160 latanoprost...... 217 LIBRAX (WITH CLIDINIUM) LOPRESSOR...... 69 latanoprost (pf)...... 218 ...... 98, 175, 176 LOPRESSOR HCT...... 71 LATUDA...... 89 LICART...... 139 LOPROX...... 128 LAXATIVE (BISACODYL)....180 lidocaine...... 21, 140 lorazepam...... 77, 98 LAXATIVE FEMININE...... 180 lidocaine hcl...... 140, 207 LORAZEPAM INTENSOL. 77, 98 LAXATIVE PEG 3350...... 179 lidocaine hcl-hydrocortison ac... 22 LORBRENA...... 44 LAYOLIS FE...... 117 LIDOCAINE VISCOUS...... 207 LORCET (HYDROCODONE) 8, 9 LAZANDA...... 3 lidocaine-hydrocortisone-aloe....22 LORCET HD...... 8, 9 ledipasvir-sofosbuvir...... 36 lidocaine-prilocaine...... 139 LORCET PLUS...... 8, 9 LEENA 28...... 119 lidocaine-tetracaine...... 140 LORTAB 10-325...... 8, 9 leflunomide...... 17 LIDODERM...... 140 LORTAB 5-325...... 8, 9 LENVIMA...... 53, 54 LIDOZION...... 141 LORTAB 7.5-325...... 8, 9 LESCOL...... 66 LILETTA...... 115 LORTAB ELIXIR...... 8, 9 LESCOL XL...... 66 lindane...... 141 LORTUSS EX...... 231 LESSINA...... 117 linezolid...... 39 LORYNA (28)...... 117 LETAIRIS...... 76 LINZESS...... 171, 176 LORZONE...... 197 letrozole...... 46 liothyronine...... 168 losartan...... 63 leucovorin calcium...... 56 LIPITOR...... 67 losartan-hydrochlorothiazide..... 62 LEUKERAN...... 44 LIPOFEN...... 66 LOSEASONIQUE...... 115 LEUKINE...... 191 lisinopril...... 61 LOTEMAX...... 213
Last Approved Date: 09/24/2021 Formulary Version: 92
246 LOTEMAX SM...... 213 magnesium citrate...... 179 melphalan...... 44 LOTENSIN...... 61 MALARONE...... 27 memantine...... 114 LOTENSIN HCT...... 60 MALARONE PEDIATRIC...... 27 M-END PE...... 230 loteprednol etabonate...... 213 malathion...... 141 MENEST...... 160 LOTREL...... 60 maprotiline...... 86 MENOPUR...... 161 LOTRISONE...... 129 MAR-COF BP...... 230 MENOSTAR...... 160 LOTRONEX...... 176, 179 MAR-COF CG...... 231 MENQUADFI (PF)...... 58 lovastatin...... 67 MARINOL...... 101, 143, 170 MENTAX...... 128 LOVAZA...... 67 MARLISSA (28)...... 117 meperidine...... 4 LOVENOX...... 192 MARPLAN...... 83 meperidine (pf)...... 4 LOW-OGESTREL (28)...... 117 MATULANE...... 44 MEPHYTON...... 151 loxapine succinate...... 91 MAVENCLAD (10 TABLET meprobamate...... 78 lubiprostone...... 176, 179 PACK)...... 209 MEPRON...... 27 LUCEMYRA...... 111 MAVENCLAD (4 TABLET mercaptopurine...... 45 LUDENT FLUORIDE...... 206 PACK)...... 209 meropenem...... 33 LUMAKRAS...... 49 MAVENCLAD (5 TABLET mesalamine...... 177 LUMIGAN...... 218 PACK)...... 209 MESNEX...... 56 LUNESTA...... 111 MAVENCLAD (6 TABLET MESTINON...... 197 LUPANETA PACK (1 PACK)...... 209 MESTINON TIMESPAN...... 197 MONTH)...... 166 MAVENCLAD (7 TABLET METADATE ER...... 95 LUPANETA PACK (3 PACK)...... 210 metaproterenol...... 225 MONTH)...... 166 MAVENCLAD (8 TABLET METAXALL...... 197 LUPKYNIS...... 196 PACK)...... 210 metaxalone...... 197 LUPRON DEPOT...... 50, 166 MAVENCLAD (9 TABLET metformin...... 165 LUPRON DEPOT (3 MONTH) PACK)...... 210 methadone...... 4 ...... 50, 166 MAVYRET...... 35 METHADOSE...... 4 LUPRON DEPOT (4 MONTH). 50 MAXALT...... 106 methamphetamine...... 95, 103 LUPRON DEPOT (6 MONTH). 50 MAXALT-MLT...... 106 methazolamide...... 73 LUPRON DEPOT-PED...... 166 MAXIDEX...... 213 methenamine mandelate..... 39, 185 LUPRON DEPOT-PED (3 MAXITROL...... 211 METHERGINE...... 167 MONTH)...... 166 MAXI-TUSS CD...... 230 methimazole...... 157 LUTERA (28)...... 117 MAXZIDE...... 73 METHITEST...... 152 LUXIQ...... 136 MAXZIDE-25MG...... 73 methocarbamol...... 198 LUZU...... 129 MAYZENT...... 210 methotrexate sodium...... 15, 45 LYNPARZA...... 52 MAYZENT STARTER PACK 210 methotrexate sodium (pf)...... 15, 45 LYRICA...... 79, 103 M-CLEAR WC...... 231 methoxsalen...... 130 LYRICA CR...... 103, 110 meclizine...... 170 methscopolamine...... 175 LYSODREN...... 44 meclofenamate...... 18 methyclothiazide...... 74 LYSTEDA...... 191 MEDROL...... 161 methyldopa...... 72 LYUMJEV KWIKPEN U-100 MEDROL (PAK)...... 161 methyldopa- INSULIN...... 165 medroxyprogesterone...... 114, 167 hydrochlorothiazide...... 72 LYUMJEV KWIKPEN U-200 mefenamic acid...... 18 methylergonovine...... 167 INSULIN...... 165 mefloquine...... 27 METHYLIN...... 95, 108 LYUMJEV U-100 INSULIN....165 MEGACE ES...... 143 methylphenidate hcl LYZA...... 119 megestrol...... 52, 143, 144 ...... 95, 96, 108, 109 MACRILEN...... 141 MEKINIST...... 50 methylprednisolone...... 161 MACROBID...... 25, 185 MEKTOVI...... 50 methyltestosterone...... 152 MACRODANTIN...... 25, 185 meloxicam...... 18 metipranolol...... 215 MACUZIN...... 148 meloxicam submicronized...... 18 metoclopramide hcl...... 174
Last Approved Date: 09/24/2021 Formulary Version: 92
247 metolazone...... 74 MIRALAX...... 179 MULTIVITAMINS WITH METOPIRONE...... 141 MIRAPEX...... 88 FLUORIDE...... 148 metoprolol succinate...... 69 MIRAPEX ER...... 88 MULTIVIT-FLUOR (VIT E metoprolol ta-hydrochlorothiaz..71 MIRCERA...... 189 ACETATE)...... 148 metoprolol tartrate...... 69 MIRCETTE (28)...... 115 mupirocin...... 127 METROCREAM...... 140 MIRENA...... 115 mupirocin calcium...... 127 METROGEL...... 140 mirtazapine...... 83 MUSE...... 142 METROGEL VAGINAL...... 232 MIRVASO...... 140 MVC-FLUORIDE...... 148 METROLOTION...... 140 misoprostol...... 174 MY WAY...... 120 metronidazole...... 28, 140, 232 MITIGARE...... 187 MYALEPT...... 166 metyrosine...... 75 MOBIC...... 18 MYAMBUTOL...... 32 mexiletine...... 64 modafinil...... 108 MYCAPSSA...... 167 MIBELAS 24 FE...... 117 MODERIBA...... 36 MYCOBUTIN...... 32, 41 MICARDIS...... 63 MODERIBA DOSE PACK...... 36 mycophenolate mofetil...... 16, 196 MICARDIS HCT...... 62 MODERNA COVID-19 mycophenolate sodium...... 196 miconazole nitrate-zinc ox-pet..129 VACCINE (EUA)...... 58 MYDAYIS...... 96, 102 MICONAZOLE-3...... 232 moexipril...... 61 MYDRIACYL...... 212 MICRODOT XTRA BLOOD moexipril-hydrochlorothiazide... 60 MYDRIATIC3 (TROP- GLUCOSE...... 199, 203 mometasone...... 136, 229 CYCLOPENT-PE)...... 211 MICROGESTIN 1.5/30 (21).... 117 MONDOXYNE NL...... 42 MYDRIATIC4(TROP-PROP- MICROGESTIN 1/20 (21)...... 117 MONODOX...... 42 PE-KTRLC)...... 216 MICROGESTIN 24 FE...... 117 MONOJECT PREFILL MYFEMBREE...... 166 MICROGESTIN FE 1.5/30 (28) ADVANCED NS...... 149 MYFORTIC...... 196 ...... 117 MONO-LINYAH...... 117 MYKIDZ IRON FLUORIDE...148 MICROGESTIN FE 1/20 (28)..117 MONONESSA (28)...... 117 MYLERAN...... 43 MICROZIDE...... 74 montelukast...... 223 MYORISAN...... 121 midazolam...... 98, 111 MONUROL...... 25, 185 MYRBETRIQ...... 182 midazolam in 0.9 % sod chlorid MORGIDOX...... 42 MYSOLINE...... 78 ...... 21, 98 morphine...... 4, 5 MYTESI...... 169 midodrine...... 72 morphine (pf)...... 4 MYZILRA...... 119 MIGERGOT...... 105 morphine concentrate...... 4 nabumetone...... 18 miglitol...... 153 MOTEGRITY...... 174 nadolol...... 69 miglustat...... 204 MOTOFEN...... 169 nadolol-bendroflumethiazide...... 74 MIGRANAL...... 105 MOVANTIK...... 23 naftifine...... 128 MILK OF MAGNESIA...... 179 MOVIPREP...... 180 NAFTIN...... 128 MILK OF MAGNESIA MOXATAG...... 24 nalbuphine...... 12 CONCENTRATED...... 179 MOXEZA...... 216 NALFON...... 19 MILLIPRED...... 162 moxifloxacin...... 34, 216 NALOCET...... 10, 11 MILLIPRED DP...... 162 MOZOBIL...... 188 naloxone...... 23 MIMVEY...... 160 MS CONTIN...... 5 naltrexone...... 23 MIMVEY LO...... 160 MUGARD...... 207 NAMENDA...... 114 MINASTRIN 24 FE...... 117 MULPLETA...... 195 NAMENDA TITRATION PAK MINIPRESS...... 75 MULTAQ...... 65 ...... 114 MINITRAN...... 64 MULTIGEN FOLIC...... 146 NAMENDA XR...... 114 MINIVELLE...... 160 MULTIGEN PLUS...... 146 NAMZARIC...... 114 MINOCIN...... 17, 42 MULTIVITAMIN WITH NAPRELAN CR...... 19 minocycline...... 17, 42, 121 FLUORIDE...... 148 NAPROSYN...... 20 MINOLIRA ER...... 42, 121 MULTI-VITAMIN WITH naproxen...... 20 minoxidil...... 72 FLUORIDE...... 148 naproxen sodium...... 20
Last Approved Date: 09/24/2021 Formulary Version: 92
248 naproxen-esomeprazole...... 18 NEXT CHOICE ONE DOSE... 120 norethindrone ac-eth estradiol naratriptan...... 106 NEXTSTELLIS...... 117 ...... 117, 160 NARCAN...... 23 niacin...... 67, 150 norethindrone-e.estradiol-iron. 117 NARDIL...... 83 NIACOR...... 67 NORGESIC FORTE...... 197 NASCOBAL...... 150 NIASPAN EXTENDED- norgestimate-ethinyl estradiol NASONEX...... 229 RELEASE...... 67 ...... 117, 119 NATACYN...... 217 nicardipine...... 70 NORITATE...... 140 NATAZIA...... 119 NICODERM CQ...... 112 NORLYROC...... 119 nateglinide...... 154 NICORELIEF...... 113 NORMAL SALINE FLUSH.... 149 NATESTO...... 152 NICORETTE...... 113 NORPACE...... 64 NATPARA...... 167 nicotine...... 113 NORPACE CR...... 64 NATROBA...... 141 nicotine (polacrilex)...... 113 NORPRAMIN...... 86 NATURAL B-100 COMPLEX 144 NICOTROL...... 113 NORTHERA...... 72 NATURE-THROID...... 168 NICOTROL NS...... 113 NORTREL 0.5/35 (28)...... 117 NAYZILAM...... 78, 98 nifedipine...... 70 NORTREL 1/35 (21)...... 117 NEBUPENT...... 39 NIKKI (28)...... 117 NORTREL 7/7/7 (28)...... 119 NEBUSAL...... 113 NILANDRON...... 45 nortriptyline...... 86 NECON 0.5/35 (28)...... 117 nilutamide...... 45 NORVASC...... 70 nefazodone...... 84 nimodipine...... 71 NORVIR...... 40 neomycin...... 24 NINJACOF-XG...... 231 NOURIANZ...... 87 neomycin-bacitracin-poly-hc....211 NINLARO...... 52 NOVAFERRUM...... 146 neomycin-bacitracin-polymyxin216 nisoldipine...... 70 NOVAREL...... 163 neomycin-polymyxin b gu...... 182 nitazoxanide...... 28 NOVOEIGHT...... 190 neomycin-polymyxin b- nitisinone...... 205 NOVOLIN 70/30 PENFILL..... 163 dexameth...... 211 NITRO-BID...... 64 NOVOLIN 70/30 U-100 neomycin-polymyxin-gramicidin NITRO-DUR...... 64 INSULIN...... 163 ...... 216 nitrofurantoin...... 25, 185 NOVOLIN 70-30 FLEXPEN neomycin-polymyxin-hc.... 211, 218 nitrofurantoin macrocrystal25, 185 U-100...... 163 NEONATAL-DHA...... 149 nitrofurantoin monohyd/m-cryst NOVOLIN N FLEXPEN...... 163 NEO-POLYCIN...... 216 ...... 25, 185 NOVOLIN N NPH U-100 NEO-POLYCIN HC...... 211 nitroglycerin...... 64 INSULIN...... 163 NEORAL...... 16, 196 NITROLINGUAL...... 64 NOVOLIN N PENFILL...... 164 NEO-SYNALAR...... 127 NITROMIST...... 64 NOVOLIN R FLEXPEN...... 164 NERLYNX...... 43 NITROSTAT...... 64 NOVOLIN R PENFILL...... 164 NESINA...... 153 NITYR...... 205 NOVOLIN R REGULAR U- NEUAC...... 123 NIVESTYM...... 191 100 INSULN...... 164 NEULASTA...... 191 nizatidine...... 172 NOVOLOG FLEXPEN U-100 NEUPOGEN...... 191 NIZORAL...... 129 INSULIN...... 165 NEUPRO...... 88 NOCDURNA (MEN)...... 153 NOVOLOG MIX 70-30 U-100 NEURONTIN...... 79 NOCDURNA (WOMEN)...... 153 INSULN...... 164 NEUTRASAL...... 207 NOCTIVA...... 153 NOVOLOG MIX 70- NEVANAC...... 214 NOLIX...... 136 30FLEXPEN U-100...... 164 nevirapine...... 29 NORA-BE...... 119 NOVOLOG PENFILL U-100 NEXAVAR...... 51 NORCO...... 8, 9 INSULIN...... 165 NEXIUM...... 173 NORDITROPIN FLEXPRO.... 163 NOVOLOG U-100 INSULIN NEXIUM PACKET...... 173 noreth-ethinyl estradiol-iron.... 117 ASPART...... 165 NEXLETOL...... 65 norethindrone (contraceptive).. 119 NOVOSEVEN RT...... 189 NEXLIZET...... 68 norethindrone acetate...... 167 NOXAFIL...... 26 NEXPLANON...... 114 NP THYROID...... 168
Last Approved Date: 09/24/2021 Formulary Version: 92
249 NPLATE...... 195 OLYSIO...... 35 ORTHO MICRONOR...... 119 NUBEQA...... 45 OMECLAMOX-PAK...... 181 ORTHO TRI-CYCLEN (28).... 119 NUCALA...... 224 omega-3 acid ethyl esters...... 67 ORTHO TRI-CYCLEN LO NUCYNTA...... 5 omeprazole...... 173 (28)...... 119 NUCYNTA ER...... 5 omeprazole magnesium...... 173 ORTHO-CYCLEN (28)...... 118 NUEDEXTA...... 110 omeprazole-sodium bicarbonate ORTHO-NOVUM 1/35 (28).... 118 NULEV...... 175, 186 ...... 174 ORTHO-NOVUM 7/7/7 (28)... 119 NULYTELY WITH FLAVOR OMNARIS...... 229 ORTIKOS...... 178 PACKS...... 180 OMNIPOD DASH PDM KIT OSCIMIN...... 175, 186 NUOX...... 124 ...... 200, 203 OSCIMIN SL...... 175, 186 NUPLAZID...... 92 OMNIPRED...... 213 OSCIMIN SR...... 175, 186 NURTEC ODT...... 105 OMNITROPE...... 163 oseltamivir...... 37 NUTROPIN AQ...... 163 ondansetron...... 170 OSENI...... 156 NUTROPIN AQ NUSPIN...... 163 ondansetron hcl...... 171 OSMOLEX ER...... 88 NUVARING...... 120 ONE DAILY PRENATAL...... 149 OSMOPREP...... 180 NUVESSA...... 232 ONETOUCH VERIO TEST OSPHENA...... 166 NUVIGIL...... 108 STRIPS...... 199, 203 OTEZLA...... 17, 131 NUWIQ...... 190 ONEXTON...... 123 OTEZLA STARTER...... 17, 131 NUZYRA...... 24, 42 ONFI...... 78, 98 OTOVEL...... 218 NUZYRA (7 DAY WITH ONGENTYS...... 87 OTREXUP (PF)...... 15 LOAD DOSE)...... 24, 42 ONGLYZA...... 153 OVACE PLUS...... 131 NUZYRA (7 DAY)...... 24, 42 ONMEL...... 26 OVACE PLUS SHAMPOO..... 131 NYAMYC...... 128 ONUREG...... 46 OVIDE...... 141 NYMALIZE...... 71 OPANA...... 5 OVIDREL...... 163 nystatin...... 25, 128, 207 OPANA ER...... 5 OXANDRIN...... 152 nystatin-triamcinolone...... 129 OPCICON ONE-STEP.....120, 121 oxandrolone...... 152 NYSTOP...... 128 opium tincture...... 169 oxaprozin...... 20 NYVEPRIA...... 191 OPSUMIT...... 76 OXAYDO...... 5 OBIZUR...... 190 ORACEA...... 42, 139 oxazepam...... 77, 98 OBREDON...... 231 ORACIT...... 184 OXBRYTA...... 194 OCALIVA...... 195 ORAL SALINE LAXATIVE... 180 oxcarbazepine...... 80 OCELLA...... 118 ORALAIR...... 56 OXERVATE...... 215 octreotide acetate...... 167, 168, 181 ORALONE...... 207 oxiconazole...... 129 OCUFLOX...... 217 ORAMORPH SR...... 5 OXISTAT...... 129 ODACTRA...... 56 ORAP...... 91 OXSORALEN ULTRA...... 130 ODEFSEY...... 31 ORAPRED ODT...... 162 OXTELLAR XR...... 80 ODOMZO...... 48 ORAVIG...... 26 oxybutynin chloride...... 187 OFEV...... 54, 231 ORENCIA...... 15 oxycodone...... 5 ofloxacin...... 34, 217, 218 ORENCIA CLICKJECT...... 15 oxycodone-acetaminophen....10, 11 OGESTREL (28)...... 118 ORENITRAM...... 75 oxycodone-aspirin...... 10, 11 olanzapine...... 92, 100 ORFADIN...... 205 OXYCONTIN...... 5 olanzapine-fluoxetine....85, 92, 100 ORGOVYX...... 50 oxymorphone...... 5 olmesartan...... 63 ORIAHNN...... 166 OXYTROL...... 187 olmesartan-amlodipin-hcthiazid.62 ORILISSA...... 166 OYSTER SHELL CALCIUM- olmesartan-hydrochlorothiazide.62 ORKAMBI...... 228 VIT D3...... 146 olopatadine...... 212, 228 ORLADEYO...... 75 OZEMPIC...... 156 OLUMIANT...... 16 orphenadrine citrate...... 198 OZOBAX...... 198 OLUX...... 136 ORPHENGESIC FORTE...... 197 P D NATAL VITAMINS- OLUX-E...... 136 ORSYTHIA...... 118 FOLIC ACID...... 149
Last Approved Date: 09/24/2021 Formulary Version: 92
250 PACERONE...... 65 PEG-3350 WITH FLAVOR PHEXXI...... 114 PACNEX...... 124 PACKS...... 180 PHILITH...... 118 PALFORZIA (LEVEL 1)...... 57 peg3350-sod sul-nacl-kcl-asb-c 180 PHOSLYRA...... 183 PALFORZIA (LEVEL 2)...... 57 PEGANONE...... 80 PHOSPHASAL...... 39, 185 PALFORZIA (LEVEL 3)...... 57 PEGASYS...... 35 PHOSPHATE LAXATIVE...... 180 PALFORZIA (LEVEL 4)...... 57 PEGASYS PROCLICK...... 35 PHOSPHOLINE IODIDE...... 210 PALFORZIA (LEVEL 5)...... 57 peg-electrolyte soln...... 180 PHYSIOLYTE...... 145 PALFORZIA (LEVEL 6)...... 57 PEGINTRON...... 35 PHYSIOSOL IRRIGATION.... 145 PALFORZIA (LEVEL 7)...... 57 PEG-PREP...... 181 phytonadione (vitamin k1)...... 151 PALFORZIA (LEVEL 8)...... 57 PEMAZYRE...... 48 PICATO...... 130 PALFORZIA (LEVEL 9)...... 57 penicillamine...... 17, 22 PIFELTRO...... 29 PALFORZIA (LEVEL 10)...... 57 penicillin v potassium...... 39 pilocarpine hcl...... 208, 210 PALFORZIA (LEVEL 11 UP- PENLAC...... 128 pimecrolimus...... 132 DOSE)...... 57 PENNSAID...... 139 pimozide...... 91 PALFORZIA INITIAL DOSE... 57 pentamidine...... 39 PIMTREA (28)...... 115 PALFORZIA LEVEL 11 PENTASA...... 177 pindolol...... 69 MAINTENANCE...... 57 pentazocine-naloxone...... 12 pioglitazone...... 165 paliperidone...... 89 pentoxifylline...... 191 pioglitazone-glimepiride...... 155 PALYNZIQ...... 206 PEPCID...... 172 pioglitazone-metformin...... 155 PAMELOR...... 86 PEPCID AC...... 172 PIQRAY...... 51 PANCREAZE...... 172 PERCOCET...... 10, 11 PIRMELLA...... 118, 119 PANDEL...... 136 PERFOROMIST...... 224 piroxicam...... 18 PANLOR(ACETAM-CAFF- PERIDEX...... 207 PLAN B ONE-STEP...... 120, 121 DIHYDROCOD)...... 7 perindopril erbumine...... 61 PLAQUENIL...... 15, 27 PANRETIN...... 130 PERIOGARD...... 207 PLAVIX...... 194 pantoprazole...... 173 permethrin...... 141 PLEGRIDY...... 208 PARAGARD T 380A...... 114 perphenazine...... 91 PLENVU...... 180 paregoric...... 169 perphenazine-amitriptyline...... 85 PLEXION...... 123 PAREMYD...... 211 PERRY PRENATAL...... 149 PLEXION CLEANSING paricalcitol...... 204 PERTZYE...... 172 CLOTHS...... 123 PARLODEL...... 88 PEXEVA...... 84 PLIAGLIS...... 141 PARNATE...... 83 PFIZER COVID-19 VACCINE PLIXDA...... 125 paromomycin...... 23 (EUA)...... 58 PNEUMOVAX-23...... 58 paroxetine hcl...... 83, 84 PHENADOZ...... 170, 219, 220 pnv cmb#95-ferrous fumarate-fa PASER...... 32 phenazopyridine...... 185 ...... 149 PATADAY...... 212 phendimetrazine tartrate...... 143 podofilox...... 139 PATADAY ONCE DAILY phenelzine...... 83 POLYCIN...... 216 RELIEF...... 212 PHENERGAN...... 170, 219, 220 polyethylene glycol 3350.. 179, 180 PATANASE...... 228 phenobarb-hyoscy-atropine- polymyxin b sulf-trimethoprim..216 PATANOL...... 212 scop...... 176 POLYTRIM...... 216 PAXIL...... 84 phenobarbital...... 78, 110 POLY-TUSSIN AC...... 230 PAXIL CR...... 84 PHENOHYTRO...... 176 POMALYST...... 55 PAZEO...... 212 phenoxybenzamine...... 75 PONVORY...... 210 PED MULTIVITAMINS- phentermine...... 143 PONVORY 14-DAY A,B,D,E,K,ZN...... 148 phenylephrine hcl...... 214 STARTER PACK...... 210 PEDIARIX...... 57 PHENYTEK...... 80 PORTIA 28...... 118 PEDIARIX (PF)...... 57 phenytoin...... 80 posaconazole...... 26 peg 3350-electrolytes...... 180 phenytoin sodium...... 64, 80 potassium bicarb and chloride. 147 phenytoin sodium extended...... 80 potassium bicarb-citric acid..... 147
Last Approved Date: 09/24/2021 Formulary Version: 92
251 potassium chloride...... 147 PRENATAL...... 149 PROCARDIA...... 70 potassium citrate...... 184 PRENATAL COMPLETE...... 149 PROCARDIA XL...... 70 potassium citrate-citric acid..... 184 PRENATAL FORMULA...... 149 PROCENTRA...... 103 POWDERLAX...... 180 PRENATAL GUMMY...... 149 prochlorperazine...... 170 PRADAXA...... 194 PRENATAL prochlorperazine maleate...... 170 PRALUENT PEN...... 67 MULTIVITAMINS...... 149 PROCORT...... 22 PRAMCORT...... 22 PRENATAL ONE DAILY...... 149 PROCRIT...... 189 pramipexole...... 88, 89 PRENATAL PLUS PROCTOCORT...... 22, 136 PRAMOSONE...... 138 (CALCIUM CARB)...... 149 PROCTOFOAM HC...... 22 PRAMOSONE E...... 138 PRENATAL TABLET...... 149 PROCTO-PAK...... 22, 136 PRANDIN...... 154 PRENATAL VITAMIN...... 149 PROCTOZONE-HC...... 22, 136 prasugrel...... 194 PRENATAL VITAMIN WITH PROCYSBI...... 182 PRAVACHOL...... 67 MINERALS...... 149 PRODIGY NO CODING. 199, 203 pravastatin...... 67 prenatal vit-iron fum-folic ac....149 PRODRIN...... 104 praziquantel...... 25 prenatal vits96-iron fum-folic...149 PROFERRIN-FORTE...... 146 prazosin...... 75 PRENATAL WITH DHA- PROFILNINE...... 189 PRECISION PCX PLUS TEST FOLIC ACID...... 149 progesterone...... 167 ...... 199, 203 PREPIDIL...... 151 progesterone micronized...... 167 PRECISION PCX TEST.. 199, 203 PREPOPIK...... 181 PROGLYCEM...... 151 PRECISION POINT OF CARE PRESTALIA...... 60 PROGRAF...... 196 TEST...... 199, 203 pretomanid...... 32 PROLATE...... 10, 11 PRECISION Q-I-D TEST 199, 203 PREVACID...... 173 PROLENSA...... 214 PRECISION XTRA TEST199, 203 PREVACID SOLUTAB...... 173 PROLIA...... 167 PRECOSE...... 153 PREVALITE...... 65 PROMACTA...... 195 PRED FORTE...... 213 PREVIDENT...... 206 promethazine...... 170, 219, 220 PRED MILD...... 213 PREVIDENT 5000 DRY PROMETHAZINE VC...... 219 PRED-G...... 211 MOUTH...... 206 PROMETHAZINE VC- PRED-G S.O.P...... 211 PREVIDENT 5000 ENAMEL CODEINE...... 230 prednicarbate...... 136 PROTECT...... 206 promethazine-codeine...... 229 prednisol ace-gatiflox-bromfen.211 PREVIDENT 5000 ORTHO promethazine-dm...... 229 prednisoln sp-gatiflox-bromfen 211 DEFENSE...... 206 PROMETHEGAN...... 170, 220 prednisoln sp-moxiflox-bromfen PREVIFEM...... 118 PROMETRIUM...... 167 ...... 211 PREVNAR 13 (PF)...... 58 propafenone...... 64 prednisolone...... 162 PREVYMIS...... 34 propantheline...... 175 prednisolone acetate...... 213 PREZCOBIX...... 31, 40 proparacaine...... 215 prednisolone acetate (pf)...... 213 PREZISTA...... 40 propranolol...... 69 prednisolone acet-gatifloxacin. 211 PRIFTIN...... 32, 41 propranolol-hydrochlorothiazid. 74 prednisolone sod ph-moxiflox...211 PRILO PATCH II...... 141 propylthiouracil...... 158 prednisolone sodium phosphate PRILOSEC...... 173 PRO-RED AC (W/ ...... 162, 213 primaquine...... 27 DEXCHLORPHENIR)...... 230 prednisolone-moxiflox-bromfen 211 primidone...... 78 PROSCAR...... 184 prednisone...... 162 PRIMLEV...... 10, 11 PROSTIN E2...... 151 PREDNISONE INTENSOL.....162 PRINIVIL...... 61 PROTONIX...... 174 PREFEST...... 160 PRISTIQ...... 84 PROTOPIC...... 132 pregabalin...... 79, 103, 110 PROAIR DIGIHALER...... 225 protriptyline...... 86 PREGNYL...... 163 PROAIR HFA...... 225 PROVENTIL HFA...... 225 PREMARIN...... 160, 232 PROAIR RESPICLICK...... 225 PROVERA...... 167 PREMPHASE...... 160 probenecid...... 187 PROVIGIL...... 108 PREMPRO...... 160 probenecid-colchicine...... 187 PROZAC...... 84
Last Approved Date: 09/24/2021 Formulary Version: 92
252 PRUDOXIN...... 141 ranolazine...... 64 RETEVMO...... 55 PSORCON...... 136 RAPAFLO...... 183 RETIN-A...... 125 PULMICORT...... 222 RAPAMUNE...... 196 RETIN-A MICRO...... 125 PULMICORT FLEXHALER...222 rasagiline...... 88 RETIN-A MICRO PUMP...... 125 PULMOSAL...... 113 RASUVO (PF)...... 15 RETROVIR...... 30 PULMOZYME...... 228 RAVICTI...... 205 REVATIO...... 76 PURELAX...... 180 RAYOS...... 162 REVLIMID...... 55 PURIXAN...... 45 RAZADYNE...... 114 REXULTI...... 93 PYLERA...... 181 RAZADYNE ER...... 114 REYATAZ...... 40 pyrazinamide...... 32 REBETOL...... 36 REYVOW...... 106 PYRIDIUM...... 185 REBIF (WITH ALBUMIN)..... 208 REZUROCK...... 17 pyridostigmine bromide...... 197 REBIF REBIDOSE...... 208 RHINOCORT AQUA...... 229 pyrimethamine...... 27 REBIF TITRATION PACK..... 209 RHOFADE...... 140 QBRELIS...... 61 REBINYN...... 189 RHOPRESSA...... 218 QBREXZA...... 127 RECLIPSEN (28)...... 118 RIASTAP...... 191 QDOLO...... 5 RECOMBINATE...... 190 RIBASPHERE...... 36 QELBREE...... 97 RECOMBIVAX HB...... 57 RIBASPHERE RIBAPAK...... 36 QINLOCK...... 54 RECOMBIVAX HB (PF)...... 57 ribavirin...... 36 QMIIZ ODT...... 19 RECTIV...... 21 RIDAURA...... 15 QNASL...... 229 REDITREX (PF)...... 15 rifabutin...... 32, 41 QSYMIA...... 142 REGIMEX...... 143 RIFADIN...... 32, 41 QTERN...... 154 REGLAN...... 174 RIFAMATE...... 32 QUALAQUIN...... 27 REGRANEX...... 141 rifampin...... 32, 41 QUARTETTE...... 119 RELAFEN DS...... 18 RIFATER...... 32 QUASENSE...... 118 RELAGARD...... 232 RILUTEK...... 196 QUDEXY XR...... 81 RELENZA DISKHALER...... 37 riluzole...... 197 QUESTRAN...... 65 RELEXXII...... 96 rimantadine...... 38 quetiapine...... 91, 100 RELISTOR...... 23 ringer's...... 145 QUFLORA...... 148 RELPAX...... 106 RINVOQ...... 16 QUFLORA PEDIATRIC RELTONE...... 172 RIOMET...... 165 DROPS...... 148 REMERON...... 83 RIOMET ER...... 165 QUILLIVANT XR...... 96 REMERON SOLTAB...... 83 risedronate...... 159 quinapril...... 61 RENAGEL...... 183 RISPERDAL...... 90, 100 quinapril-hydrochlorothiazide....60 RENA-VITE...... 144 risperidone...... 90, 100, 101 quinidine gluconate...... 64 RENA-VITE RX...... 145 RITALIN...... 96, 109 quinidine sulfate...... 64 RENVELA...... 183 RITALIN LA...... 96 quinine sulfate...... 27 repaglinide...... 154 ritonavir...... 40 QUIT 2...... 113 repaglinide-metformin...... 154 rivastigmine...... 114 QUIT 4...... 113 REPATHA PUSHTRONEX...... 68 rivastigmine tartrate...... 114 QVAR...... 222 REPATHA SURECLICK...... 68 RIXUBIS...... 189 QVAR REDIHALER...... 222, 223 REPATHA SYRINGE...... 68 rizatriptan...... 106 rabeprazole...... 174 REPREXAIN...... 9 ROBAXIN...... 198 RAGWITEK...... 56 REQUIP...... 89 ROBAXIN-750...... 198 RAJANI...... 118 REQUIP XL...... 89 ROBINUL...... 175 raloxifene...... 167 RESCRIPTOR...... 29 ROBINUL FORTE...... 175 ramelteon...... 104 RESPA-AR...... 219 ROCKLATAN...... 216 ramipril...... 61 RESTASIS...... 213 ropinirole...... 89 RANEXA...... 64 RESTORIL...... 98, 111 ROSADAN...... 140 ranitidine hcl...... 172 RETACRIT...... 189 ROSANIL...... 123
Last Approved Date: 09/24/2021 Formulary Version: 92
253 ROSULA...... 123 SEGLUROMET...... 154 SLYND...... 119 ROSULA CLEANSING selegiline hcl...... 88 SMOOTHLAX...... 180 CLOTHS...... 123 selenium sulfide...... 131 sodium chloride...... 113, 145 rosuvastatin...... 67 SELRX...... 131 sodium chloride 0.45 %...... 150 ROSZET...... 68 SELZENTRY...... 28 sodium chloride 0.9 %...... 145, 150 ROWEEPRA...... 82 SEMGLEE PEN U-100 sodium chloride 0.9 % (flush)...150 ROXICODONE...... 5 INSULIN...... 164 sodium chloride 3 %...... 150 ROXYBOND...... 6 SEMGLEE U-100 INSULIN....164 sodium chloride 5 %...... 150 ROZEREM...... 104 SEMPREX-D...... 219 SODIUM FLUORIDE 5000 ROZLYTREK...... 54 SENSIPAR...... 159 DRY MOUTH...... 207 RUBRACA...... 52 SEREVENT DISKUS...... 224 sodium fluoride-pot nitrate...... 207 RUCONEST...... 188 SERNIVO...... 136 sodium phenylbutyrate...... 205 rufinamide...... 82 SEROQUEL...... 91, 92, 101 sodium polystyrene sulfonate....145 RUKOBIA...... 28 SEROQUEL XR...... 92, 101 sofosbuvir-velpatasvir...... 36 RUZURGI...... 209 SEROSTIM...... 163 SOLARAZE...... 130 RYBELSUS...... 156 sertraline...... 84 solifenacin...... 186 RYDAPT...... 54 SETLAKIN...... 118 SOLIQUA 100/33...... 157 RYDEX...... 230 sevelamer carbonate...... 183 SOLODYN...... 42, 121 RYTARY...... 87 sevelamer hcl...... 183 SOLOSEC...... 28 RYTHMOL SR...... 64 SEVENFACT...... 189 SOLTAMOX...... 54 RYVENT...... 219, 220 SEYSARA...... 42, 121 SOMA...... 198 SABRIL...... 80 SF 5000 PLUS...... 207 SOMATULINE DEPOT...... 168 SAFYRAL...... 118 SFROWASA...... 177 SOMAVERT...... 162 SAIZEN...... 163, 182 SHAROBEL...... 119 SONATA...... 111 SAIZEN CLICK.EASY...... 163 SHINGRIX (PF)...... 60 SOOLANTRA...... 140 SALAGEN (PILOCARPINE).. 208 SHOHL'S MODIFIED...... 184 sorbitol...... 182 SALIVAMAX...... 207 SIGNIFOR...... 168 SORIATANE...... 130 SALIVATERX...... 207 SIKLOS...... 194 SORILUX...... 131 salsalate...... 21 sildenafil...... 142 SORINE...... 65, 69 SAMSCA...... 74 sildenafil (pulm.hypertension).... 76 sotalol...... 65, 69 SANCUSO...... 171 SILENOR...... 111 SOTYLIZE...... 65, 69 SANDIMMUNE...... 16, 196 SILIQ...... 126 SOVALDI...... 36 SANDOSTATIN...... 168, 182 silodosin...... 183 SPECTRACEF...... 33 SANTYL...... 132 SILVADENE...... 132 spinosad...... 141 SAPHRIS...... 89, 101 silver sulfadiazine...... 132 SPIRIVA RESPIMAT...... 224 SAPHRIS (BLACK CHERRY) SIMBRINZA...... 211 SPIRIVA WITH ...... 89, 101 SIMPONI...... 14, 15, 179 HANDIHALER...... 224 sapropterin...... 206 simvastatin...... 67 spironolactone...... 61, 73 SARAFEM...... 84 SINEMET...... 87 spironolacton-hydrochlorothiaz. 73 SAVAYSA...... 189 SINEMET CR...... 87 SPORANOX...... 26 SAVELLA...... 85, 104 SINGULAIR...... 223 SPORANOX PULSEPAK...... 26 SAXENDA...... 143 sirolimus...... 196 SPRINTEC (28)...... 118 SCALACORT...... 136 SIRTURO...... 32 SPRITAM...... 82 SCALACORT DK...... 136 SITAVIG...... 37 SPRIX...... 18 SEASONIQUE...... 115 SIVEXTRO...... 39 SPRYCEL...... 54 SEB-PREV...... 131 SKELAXIN...... 198 SRONYX...... 118 SECONAL SODIUM...... 110 SKLICE...... 141 SSD...... 132 SECUADO...... 89 SKYLA...... 115 SSKI...... 146 SEEBRI NEOHALER...... 224 SKYRIZI...... 126 SSS 10-5...... 123
Last Approved Date: 09/24/2021 Formulary Version: 92
254 STALEVO 100...... 87 SUMAXIN TS...... 123 tacrolimus...... 132, 196 STALEVO 125...... 87 SUNOSI...... 108 tadalafil...... 142, 184 STALEVO 150...... 87 SUPER B COMPLEX- TAFINLAR...... 46 STALEVO 200...... 87 VITAMIN C...... 144 TAGRISSO...... 43 STALEVO 50...... 87 SUPER B MAXI COMPLEX.. 144 TAKE ACTION...... 120, 121 STALEVO 75...... 87 SUPER B-50 COMPLEX TAKHZYRO...... 75 STARLIX...... 154 PLUS...... 145 TALICIA...... 181 stavudine...... 30 SUPER QUINTS...... 144 TALTZ AUTOINJECTOR...... 126 STAXYN...... 142 SUPERVITE...... 144 TALTZ AUTOINJECTOR (2 STEGLATRO...... 155 SUPERVITE (EC)...... 148 PACK)...... 126 STEGLUJAN...... 154 SUPRAX...... 33, 34 TALTZ AUTOINJECTOR (3 STELARA...... 125, 126, 177 SUPREP BOWEL PREP KIT.. 180 PACK)...... 126 STENDRA...... 142 SURFAXIN...... 228 TALTZ SYRINGE...... 126 STIMATE...... 153 SURMONTIL...... 86 TALTZ SYRINGE (2 PACK).. 126 STIOLTO RESPIMAT...... 226 SURVANTA...... 228 TALTZ SYRINGE (3 PACK).. 126 STIVARGA...... 51 SUSTIVA...... 29 TALWIN...... 12 STOP SMOKING AID...... 113 SUSTOL...... 171 TALZENNA...... 52 STRATAMARK...... 139 SUTAB...... 180 TAMIFLU...... 37 STRATATRIZ...... 139 SUTENT...... 54 tamoxifen...... 54 STRATTERA...... 97 SYEDA...... 118 tamsulosin...... 183 STRENSIQ...... 204 SYLATRON...... 49 TANZEUM...... 156 STRIANT...... 152 SYMAX FASTABS...... 175, 186 TAPAZOLE...... 158 STRIBILD...... 31 SYMAX-SL...... 175, 186 TAPERDEX...... 162 STRIVERDI RESPIMAT...... 224 SYMAX-SR...... 175, 186 TARCEVA...... 43 STROMECTOL...... 24 SYMBICORT...... 226 TARGADOX...... 42 STRONG IODINE...... 146 SYMBYAX...... 85, 92, 101 TARGRETIN...... 55, 130 SUBOXONE...... 112 SYMDEKO...... 228 TARINA FE 1/20 (28)...... 118 SUBSYS...... 6 SYMFI...... 31 TARKA...... 60 SUCRAID...... 172 SYMFI LO...... 32 TASIGNA...... 54 sucralfate...... 181 SYMJEPI...... 72 TASMAR...... 87 sufentanil citrate...... 21 SYMLINPEN 120...... 156 tavaborole...... 129 sufentanil citrate (pf)...... 21 SYMLINPEN 60...... 156 TAVALISSE...... 188 SULAR...... 71 SYMPAZAN...... 78, 98 TAYTULLA...... 118 sulconazole...... 129 SYMPROIC...... 23 tazarotene...... 125 sulfacetamide sodium...... 131, 217 SYMTUZA...... 31 TAZORAC...... 131 sulfacetamide sodium (acne).... 122 SYNALAR...... 137 TAZVERIK...... 48 sulfacetamide sodium-sulfur.....123 SYNALAR CREAM KIT...... 138 TECFIDERA...... 209 sulfacetamide-prednisolone...... 211 SYNALAR OINTMENT KIT..138 TEGRETOL...... 80, 81, 99 sulfadiazine...... 41 SYNALAR TS...... 138 TEGRETOL XR...... 81, 99 sulfamethoxazole-trimethoprim.. 25 SYNALGOS-DC...... 7 TEGSEDI...... 152 SULFAMYLON...... 132 SYNAREL...... 166 TEKTURNA...... 77 sulfasalazine...... 17, 177 SYNDROS...... 101, 143, 170 TEKTURNA HCT...... 77 SULFATRIM...... 25 SYNJARDY...... 154 telmisartan...... 63 sulindac...... 18 SYNJARDY XR...... 154 telmisartan-amlodipine...... 62 SUMADAN...... 123 SYNTHROID...... 169 telmisartan-hydrochlorothiazid.. 62 sumatriptan...... 106 SYPRINE...... 22 temazepam...... 98, 111 sumatriptan succinate...... 106 TABLOID...... 45 TEMIXYS...... 29 SUMAVEL DOSEPRO...... 106 TABRECTA...... 54 TEMODAR...... 44 SUMAXIN...... 123 TACLONEX...... 125 TEMOVATE...... 137
Last Approved Date: 09/24/2021 Formulary Version: 92
255 temozolomide...... 44 timolol maleate (pf)...... 215 tramadol...... 6 TENCON...... 12 timolol-brimonidi-dorzolam(pf) 214 tramadol-acetaminophen...... 12 tenofovir disoproxil fumarate30, 35 timolol-latanoprost(pf)...... 214 trandolapril...... 61 TENORETIC 100...... 71 TIMOPTIC...... 215 trandolapril-verapamil...... 60 TENORETIC 50...... 71 TIMOPTIC OCUDOSE (PF)... 215 tranexamic acid...... 191 TENORMIN...... 69 TIMOPTIC-XE...... 215 TRANSDERM-SCOP...... 170 TEPMETKO...... 54 TINDAMAX...... 28 TRANXENE T-TAB...... 78, 98 terazosin...... 75 tinidazole...... 28 tranylcypromine...... 83 terbinafine hcl...... 25 tiopronin...... 182 TRAVATAN Z...... 218 terbutaline...... 225 TIROSINT...... 169 travoprost...... 218 terconazole...... 232 TIROSINT-SOL...... 169 trazodone...... 84 teriparatide...... 158 TIVICAY...... 28 TRECATOR...... 32 TERSI FOAM...... 131 TIVICAY PD...... 28 TRELEGY ELLIPTA...... 227 TESSALON PERLES...... 221 TIVORBEX...... 20 TRELSTAR...... 50 TESTIM...... 152 tizanidine...... 198 TREMFYA...... 126 testosterone...... 152, 153 TL-HEM 150...... 146 TRESIBA FLEXTOUCH U- testosterone cypionate...... 152 TOBI...... 227 100...... 164 testosterone enanthate...... 152 TOBI PODHALER...... 227 TRESIBA FLEXTOUCH U- TESTRED...... 153 TOBRADEX...... 211 200...... 164 TETCAINE...... 215 TOBRADEX ST...... 211 TRESIBA U-100 INSULIN...... 164 tetrabenazine...... 107 tobramycin...... 216, 227 tretinoin...... 125 tetracaine hcl (pf)...... 215 tobramycin in 0.225 % nacl...... 227 tretinoin (antineoplastic)...... 54 tetracycline...... 42 tobramycin-dexamethasone...... 211 tretinoin microspheres...... 125 TETRAVISC FORTE...... 215 TOBREX...... 216 TRETIN-X...... 125 TEXACORT...... 137 TODAY CONTRACEPTIVE TRETIN-X CREAM KIT...... 125 THALOMID...... 26, 55 SPONGE...... 121 TRETTEN...... 190 THEO-24...... 223 TOFRANIL...... 86 TREXALL...... 15, 45 THEOCHRON...... 223 TOLAK...... 130 TREXIMET...... 106 theophylline...... 223 tolazamide...... 155 TREZIX...... 7 THIOLA...... 182 tolbutamide...... 155 triamcinolone acetonide THIOLA EC...... 182 tolcapone...... 87 ...... 137, 207, 229 thioridazine...... 91 tolmetin...... 18 triamterene-hydrochlorothiazid thiothixene...... 91 TOLSURA...... 26 ...... 73, 74 THYQUIDITY...... 169 tolterodine...... 187 TRIANEX...... 137 thyroid (pork)...... 168 tolvaptan...... 74 triazolam...... 98, 111 THYROLAR-1...... 168 TOPAMAX...... 81 TRIBENZOR...... 62 THYROLAR-1/2...... 168 TOPICORT...... 137 TRICARE PRENATAL DHA THYROLAR-1/4...... 168 topiramate...... 81 ONE...... 149 THYROLAR-2...... 168 TOPROL XL...... 69 TRICITRATES...... 184 THYROLAR-3...... 168 toremifene...... 54 TRICOR...... 66 TIADYLT ER...... 70 torsemide...... 73 TRIDERM...... 137 tiagabine...... 79, 80 TOSYMRA...... 106 TRIDESILON...... 137 TIAZAC...... 70 TOUJEO MAX U-300 TRI-ESTARYLLA...... 119 TIBSOVO...... 51 SOLOSTAR...... 164 trifluoperazine...... 91 TIGAN...... 170 TOUJEO SOLOSTAR U-300 trifluridine...... 217 TIGLUTIK...... 197 INSULIN...... 164 TRIGELS-F FORTE...... 146 TIKOSYN...... 65 TOVIAZ...... 187 TRIGLIDE...... 66 TILIA FE...... 119 TRACLEER...... 76 trihexyphenidyl...... 88 timolol maleate...... 69, 215 TRADJENTA...... 153 TRIJARDY XR...... 157
Last Approved Date: 09/24/2021 Formulary Version: 92
256 TRIKAFTA...... 228 TUSSIGON...... 230 URSO 250...... 172 TRI-LEGEST FE...... 119 TUSSIONEX PENNKINETIC URSO FORTE...... 172 TRILEPTAL...... 81 ER...... 229 ursodiol...... 172 TRI-LINYAH...... 119 TUXARIN ER...... 229 URYL...... 39, 186 TRILIPIX...... 66 TUZISTRA XR...... 229 USTELL...... 39, 186 TRI-LO-ESTARYLLA...... 119 TWINRIX...... 56 UTA...... 39, 186 TRILYTE WITH FLAVOR TWINRIX (PF)...... 57 UTIBRON NEOHALER...... 226 PACKETS...... 180 TWIRLA...... 120 UTIRA-C...... 39, 186 trimethobenzamide...... 170 TWYNSTA...... 62 VAGIFEM...... 232 trimethoprim...... 25 TYBOST...... 205 VAGINAL CONTRACEPTIVE trimipramine...... 86 TYDEMY...... 118 FILM...... 121 TRINESSA (28)...... 120 TYKERB...... 42 VAGINAL CONTRACEPTIVE TRI-NORINYL (28)...... 120 TYLENOL-CODEINE #3...... 7 FOAM...... 121 TRINTELLIX...... 85 TYLENOL-CODEINE #4...... 7 valacyclovir...... 37 TRI-PREVIFEM (28)...... 120 TYMLOS...... 158 VALCHLOR...... 129 TRI-SPRINTEC (28)...... 120 TYVASO...... 75 VALCYTE...... 34 TRIUMEQ...... 31 TYVASO INSTITUTIONAL valganciclovir...... 34 TRI-VITAMIN WITH START KIT...... 76 VALIUM...... 78, 98 FLUORIDE...... 148 TYVASO REFILL KIT...... 75 valproic acid...... 79, 99 TRI-VITE WITH FLUORIDE. 148 TYVASO STARTER KIT...... 76 valproic acid (as sodium salt) TRIVORA (28)...... 120 UBRELVY...... 105 ...... 79, 99 TRI-VYLIBRA...... 120 UCERIS...... 178 valsartan...... 63 TRIZIVIR...... 31 UDENYCA...... 191 valsartan-hydrochlorothiazide... 62 TROKENDI XR...... 81 UKONIQ...... 51 VALTOCO...... 78, 98 tropicamide...... 212 ULESFIA...... 141 VALTREX...... 37 tropic-proparacai-pe-ketor-wat 216 ULORIC...... 188 VANATOL LQ...... 12 trospium...... 187 ULTRACET...... 12 VANCOCIN...... 34 TRUE METRIX GLUCOSE ULTRAM...... 6 vancomycin...... 34 TEST STRIP...... 199, 203 ULTRAM ER...... 6 VANDAZOLE...... 232 TRULANCE...... 171, 176 ULTRAVATE...... 137 VANOS...... 138 TRULICITY...... 156 ULTRAVATE X...... 138 VANOXIDE-HC...... 124 TRUSELTIQ...... 48 UNITHROID...... 169 vardenafil...... 142 TRUSOPT...... 214 UPNEEQ (PF)...... 211 varenicline...... 113 TRUSTEX LUBRICATED UPTRAVI...... 74, 75 VARUBI...... 171 CONDOMS...... 201, 203 UR N-C...... 39, 185 VASCEPA...... 67 TRUSTEX-RIA URAMAXIN GT...... 139 VASERETIC...... 60 LUB/SPERMICIDE...... 201, 203 URECHOLINE...... 187 VASOTEC...... 61 TRUSTEX-RIA URELLE...... 39, 185 VAXELIS (PF)...... 57, 58 LUBRICATED CONDOMS URETRON D-S...... 39, 185 VCF CONTRACEPTIVE ...... 201, 203 URIBEL...... 39, 185 FILM...... 121 TRUSTEX-RIA NON-LUB URIMAR-T...... 39, 185 VECAMYL...... 74 CONDOMS...... 201, 203 URIN DS...... 39, 185 VECTICAL...... 131 TRUVADA...... 29 UROCIT-K 10...... 184 VELIVET TRIPHASIC TUDORZA PRESSAIR...... 224 UROCIT-K 15...... 184 REGIMEN (28)...... 120 TUKYSA...... 47 UROCIT-K 5...... 184 VELPHORO...... 183 TURALIO...... 54 UROGESIC-BLUE...... 39, 186 VELTASSA...... 145 TUSNEL C...... 231 URO-MP...... 39, 186 VELTIN...... 123 TUSNEL PEDIATRIC...... 229 UROQID-ACID NO.2...... 39, 185 VENCLEXTA...... 46 TUSSICAPS...... 229 UROXATRAL...... 183
Last Approved Date: 09/24/2021 Formulary Version: 92
257 VENCLEXTA STARTING VIRT-PN DHA...... 148 WERA (28)...... 118 PACK...... 46 VIRTRATE-2...... 184 WESTGEL DHA...... 149 venlafaxine...... 85 VIRTRATE-3...... 184 WESTHROID...... 168 VENNGEL ONE...... 139 VIRTRATE-K...... 185 WIDE-SEAL DIAPHRAGM 60 VENTAVIS...... 76 VISTARIL...... 77 ...... 200, 203 VENTOLIN HFA...... 225 VITAFOL FE PLUS...... 149 WIDE-SEAL DIAPHRAGM 65 VERAMYST...... 229 VITAFOL-ONE...... 149 ...... 200, 203 verapamil...... 65, 71 vitamin b complex...... 145 WIDE-SEAL DIAPHRAGM 70 VERDESO...... 138 vitamin b complex-folic acid.....144 ...... 200, 203 VEREGEN...... 138 VITAMIN D2...... 150 WIDE-SEAL DIAPHRAGM 75 VERELAN...... 71 VITAMIN D3...... 150 ...... 200, 203 VERELAN PM...... 71 VITRAKVI...... 56 WIDE-SEAL DIAPHRAGM 80 VERIPRED 20...... 162 VITUZ...... 229 ...... 200, 203 VERQUVO...... 64 VIVAGUARD INO TEST WIDE-SEAL DIAPHRAGM 85 VERSACLOZ...... 90 STRIP...... 199, 203 ...... 200, 203 VERZENIO...... 47 VIVELLE-DOT...... 160 WIDE-SEAL DIAPHRAGM 90 VESICARE...... 186 VIVLODEX...... 19 ...... 200, 203 VESICARE LS...... 186 VIZIMPRO...... 43 WIDE-SEAL DIAPHRAGM 95 VFEND...... 26 VOGELXO...... 153 ...... 200, 204 V-GO 20...... 201, 203 VOL-NATE...... 149 WILATE...... 190 V-GO 30...... 201, 203 VOL-PLUS...... 148 WINLEVI...... 121 V-GO 40...... 201, 203 VOLTAREN...... 19, 139, 214 WIXELA INHUB...... 226 VIAGRA...... 142 VOLTAREN-XR...... 19 WOMAN'S LAXATIVE VIBERZI...... 176 VONVENDI...... 191 (BISACODYL)...... 181 VIBRAMYCIN...... 42 voriconazole...... 26 WOMEN'S GENTLE VICODIN...... 8, 9 VOSEVI...... 35 LAXATIVE(BISAC)...... 181 VICODIN ES...... 8, 9 VOTRIENT...... 54 WOMEN'S LAXATIVE VICODIN HP...... 8, 10 VRAYLAR...... 93, 101 (BISACODYL)...... 181 VICTOZA 2-PAK...... 156 VTOL LQ...... 12 WP THYROID...... 168 VICTOZA 3-PAK...... 156 VUMERITY...... 209 WYMZYA FE...... 118 VIDEX 2 GRAM PEDIATRIC.. 30 VUSION...... 129 WYNZORA...... 125 VIDEX EC...... 30 VYFEMLA (28)...... 118 XADAGO...... 88 VIEKIRA PAK...... 36 VYLEESI...... 104 XALATAN...... 218 VIEKIRA XR...... 37 VYNDAMAX...... 151 XALKORI...... 44 VIENVA...... 118 VYNDAQEL...... 152 XANAX...... 78, 98 vigabatrin...... 80 VYTORIN 10-10...... 68 XANAX XR...... 78, 98 VIGAMOX...... 217 VYTORIN 10-20...... 68 XARELTO...... 189 VIIBRYD...... 85 VYTORIN 10-40...... 68 XARELTO DVT-PE TREAT VIMOVO...... 18 VYTORIN 10-80...... 68 30D START...... 189 VIMPAT...... 79 VYVANSE...... 96 XATMEP...... 15, 45 VIOKACE...... 172 VYZULTA...... 218 XCOPRI...... 82 VIORELE (28)...... 115 WAKIX...... 108 XCOPRI MAINTENANCE VIRACEPT...... 40 warfarin...... 188 PACK...... 83 VIRAMUNE...... 29 water for irrigation, sterile...... 145 XCOPRI TITRATION PACK....83 VIRAMUNE XR...... 29 WEE CARE...... 146 XELJANZ...... 16, 178 VIRAZOLE...... 41 WEGOVY...... 143 XELJANZ XR...... 16, 178 VIREAD...... 30, 35 WELCHOL...... 65 XELODA...... 46 VIROPTIC...... 217 WELLBUTRIN SR...... 86 XELPROS...... 218 VIRT-FEFA PLUS...... 147 WELLBUTRIN XL...... 86 XENAZINE...... 107
Last Approved Date: 09/24/2021 Formulary Version: 92
258 XENICAL...... 143 ZEBUTAL...... 12 ZODRYL DAC 60...... 230 XENLETA...... 40 ZEGALOGUE ZODRYL DAC 80...... 230 XEPI...... 127 AUTOINJECTOR...... 151 ZODRYL DEC 25...... 231 XERESE...... 132 ZEGALOGUE SYRINGE...... 151 ZODRYL DEC 30...... 231 XERMELO...... 169 ZEGERID...... 174 ZODRYL DEC 35...... 231 XEROSTOMIA RELIEF...... 207 ZEJULA...... 52 ZODRYL DEC 40...... 231 XGEVA...... 167 ZELAPAR...... 88 ZODRYL DEC 50...... 231 XHANCE...... 229 ZELBORAF...... 46 ZODRYL DEC 60...... 231 XIFAXAN...... 41 ZELNORM...... 176, 179 ZODRYL DEC 80...... 231 XIGDUO XR...... 154 ZEMPLAR...... 204 ZOFRAN...... 171 XIIDRA...... 213 ZENATANE...... 121 ZOFRAN ODT...... 171 XODOL 10/300...... 8, 10 ZENCHENT (28)...... 118 ZOHYDRO ER...... 6 XODOL 5/300...... 8, 10 ZENPEP...... 172 ZOKINVY...... 206 XODOL 7.5/300...... 8, 10 ZENZEDI...... 96, 103, 110 ZOLADEX...... 50 XOFLUZA...... 37 ZEPATIER...... 35 ZOLINZA...... 49 XOLAIR...... 223 ZEPOSIA...... 210 zolmitriptan...... 106 XOLEGEL...... 129 ZEPOSIA STARTER KIT...... 210 ZOLOFT...... 84 XOPENEX...... 225 ZEPOSIA STARTER PACK... 210 zolpidem...... 111 XOPENEX CONCENTRATE. 225 ZERIT...... 30 ZOMACTON...... 163 XOPENEX HFA...... 225 ZERVIATE...... 212 ZOMIG...... 106 XOSPATA...... 48 ZESTORETIC...... 60 ZOMIG ZMT...... 106 XPOVIO...... 47, 48, 55 ZESTRIL...... 61 ZONALON...... 141 XTAMPZA ER...... 6 ZETIA...... 68 ZONEGRAN...... 82 XTANDI...... 45 ZETONNA...... 229 zonisamide...... 82 XULANE...... 120 ZIAC...... 71 ZONTIVITY...... 194 XULTOPHY 100/3.6...... 157 ZIAGEN...... 30 ZORBTIVE...... 163, 182 XURIDEN...... 205 ZIANA...... 123 ZORTRESS...... 196 XYLON 10...... 9, 10 zidovudine...... 30 ZORVOLEX...... 19 XYNTHA...... 190 ZIEXTENZO...... 191 ZOSTAVAX (PF)...... 57, 60 XYNTHA SOLOFUSE...... 190 zileuton...... 221 ZOVIA 1/35E (28)...... 118 XYOSTED...... 153 ZILXI...... 140 ZOVIRAX...... 37, 132 XYREM...... 108 ZIOPTAN (PF)...... 218 ZTLIDO...... 141 XYWAV...... 108 ziprasidone hcl...... 89, 101 Z-TUSS AC...... 230 XYZAL...... 220, 221 ZIPSOR...... 19 ZUBSOLV...... 112 YASMIN (28)...... 118 ZIRGAN...... 217 ZUPLENZ...... 171 YAZ (28)...... 118 ZITHROMAX...... 38 ZYBAN...... 112 YONSA...... 43, 45 ZOCOR...... 67 ZYCLARA...... 138 YOSPRALA...... 194 ZODRYL AC 25...... 230 ZYDELIG...... 51, 52 YUPELRI...... 224 ZODRYL AC 30...... 230 ZYFLO...... 221 zafirlukast...... 223 ZODRYL AC 35...... 230 ZYKADIA...... 44 zaleplon...... 111 ZODRYL AC 40...... 230 ZYLET...... 211 ZAMICET...... 8, 10 ZODRYL AC 50...... 230 ZYLOPRIM...... 188 ZANAFLEX...... 198 ZODRYL AC 60...... 230 ZYMAXID...... 217 ZANTAC...... 172 ZODRYL AC 80...... 230 ZYPITAMAG...... 67 ZARAH...... 118 ZODRYL DAC 25...... 230 ZYPREXA...... 92, 101 ZARONTIN...... 82 ZODRYL DAC 30...... 230 ZYPREXA ZYDIS...... 92, 101 ZARXIO...... 191 ZODRYL DAC 35...... 230 ZYTIGA...... 43, 45 ZAVESCA...... 204 ZODRYL DAC 40...... 230 ZYVOX...... 39 ZCORT...... 162 ZODRYL DAC 50...... 230
Last Approved Date: 09/24/2021 Formulary Version: 92
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