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Video Library A Amiodarone Aspirin Abacavir and Lamivudine* Amitiza* Atenolol Abilify Amitriptyline ATGAM* Abraxane infusion* Amlodipine Atorvastatin Acetaminophen Amlodipine and Benazepril Atripla* Acetaminophen and Codeine Oral Solution Ammonium lactate cream Atrovent HFA inhaler Acetaminophen and Codeine Tablet Amoxicillin Aubagio* Acetylcysteine Amoxicillin and Clavulanate Auryxia Actemra* Amoxicillin and Clavulanate Chewable Tablet Auvi-Q Acyclovir tablets and capsules Amoxicillin and Clavulanate Suspension Avastin* Adacel Tdap vaccine Amoxicillin Chewable Tablet Avonex* Adapalene Amoxicillin Suspension Azathioprine* Adapalene and benzoyl peroxide Amphetamine Salts (Mixed Salts of a Single Azelaic Acid 15% Adderall Entity Amphetamine) Azithromycin Adderall XR Amphetamine Salts XR (Mixed salts of a Azithromycin Suspension Single Entity Amphetamine) Adlyxin pen B Ampicillin sulbactam Advair HFA Baclofen Ampyra tablet* Advate* Banzel* Anastrozole tablet* Afinitor Disperz tablet* BAQSIMI* Androgel Afinitor tablet* Baraclude tablet* Anoro Ellipta Inhaler Aimovig injection* Basaglar KwikPen Apidra Solostar pen Ajovy injection* Belsomra tablet Apidra vial Akynzeo Capsule and Injection* Benazepril Apriso Albuterol solution for nebulizer BeneFIX* Aptiom tablet Alendronate Benicar Aranesp singleject, vial* Alimta* Benlysta IV infusion* Aripiprazole Allopurinol Benzonatate Arixtra* Alprazolam Benzoyl Peroxide Arnuity Ellipta Alprolix* Benztropine Asacol HD Alvesco inhaler Betapace and Betapace AF Asmanex Twisthaler All titles include both English and Spanish Sept 2020 Page | 1 Video Library Betaseron* Bystolic Celecoxib Bevespi Aerosphere inhaler C Cellcept capsule, tablet* Bevyxxa capsule Cabergoline* Cephalexin Capsule Bicalutamide Cabometyx tablet* Cephalexin Suspension Biktarvy tablet* Calcipotriene cream, ointment, solution Cetirizine Bisacodyl suppository Calcitriol Cetrotide* Bisacodyl tablet Calcium acetate tablets and capsules Cheratussin AC Bisoprolol Calcium carbonate Chlorthalidone Boostrix Calcium carbonate chewable Cholestyramine and Cholestyramine Light Bosulif* Calcium and Vitamin D powder Botox* Caltrate Cialis Braftovi* Candesartan Ciclopirox gel Breo Ellipta Inhaler Capecitabine* Ciclopirox nail lacqer Brilinta Captopril Ciclopirox shampoo Brintellix tablet Carbamazepine Cimduo tablet* Briviact injection, solution, tablet Carbamazepine extended-release tablet Cimzia Prefilled Syringe* Brovana* Carisoprodol Cinacalcet tablet Budesonide extended-release tablet* Carvedilol Ciprofloxacin Budesonide Suspension for Jet Nebulizer Cayston* Citalopram Bumetanide injection Cefadroxil capsule, suspension, tablet Claravis* Bumetanide tablet Cefazolin Clarithromycin Buprenorphine and Naloxone film Cefdinir Clarithromycin XL Buprenorphine patch Cefdinir Suspension Clindamycin Buprenorphine Sublingual Tablet Cefepime Clobetasol propionate cream, foam, gel, Bupropion SR Cefoxitin lotion, ointment, solution, spray Bupropion XL Ceftazidime Clomiphene* Buspirone Ceftriaxone Clonazepam Butalbital acetaminophen and caffeine Cefuroxime axetil Clonidine Bydureon Cefuroxime sodium Clopidogrel Byetta Celebrex Clotrimazole and Betamethasone Codeine tablet All titles include both English and Spanish Sept 2020 Page | 2 Video Library Colchicine tablet Diclofenac 1% Emgality injection* Colestipol tablet and dry granules Diclofenac Gel 3% Enalapril Combivent Respimat Dicloxacillin Enbrel* Combivir* Dicyclomine Endari powder* Compazine Dificid* Endocet Complera tablet* Digoxin Engerix-B vaccine Copaxone* Diltiazem extended-release Enoxaparin* Copegus Diltiazem tablet Entecavir liquid, tablet* Copiktra* Diovan Entresto Cosentyx* Diphenhydramine Entyvio* Coumadin Diphenoxylate and atropine Epclusa Creon capsule Disopyramide Epidiolex liquid* Crestor Divalproex delayed-release EpiPen 2-Pak® Cyclobenzaprine Docusate EpiPen Jr 2-Pak® Cyclophosphamide capsule tablet* Donepezil Epogen vial* Cyclosporine capsule* Dorzolamide eye drops Epzicom* Cyclosporine oral solution* Dovato* Erivedge* Cymbalta Doxazosin Erleada D Doxepin Erlotinib* Daklinza* Doxycycline hyclate capsule, tablet Erythromycin base tablet Dalfampridine* Doxycycline hyclate delayed-release tablet Escitalopram Dapsone gel Dronabinol Esmolol Darifenacin extended-release tablet Dulera inhaler Esomeprazole magnesium Descovy tablet* Duloxetine Estradiol Desonide cream, lotion, ointment Dupixent injection* Eszopiclone Desvenlafaxine extended-release tablet E Ethacrynic acid Dexamethasone Sodium Phosphate Injection Econazole cream Eucrisa ointment* Dexilant Effient tablet Euflexxa* Diazepam Eliquis Evotaz tablet* Diclofenac Eloctate* Exelon Patch All titles include both English and Spanish Sept 2020 Page | 3 Video Library Exemestane* Furosemide Hepsera* Extavia* Furosemide Injection Herceptin* Eylea* G HumaLOG 100 units per 1 mL Ezetimibe tablet Gabapentin HumaLog KwikPen U-100 F Galantamine (Razadyne) Humatrope* Famotidine Ganirelix* Humira injection* Farxiga Gardisil 9 Humulin 70-30 Kwikpen Faslodex* Gemfibrozil tablet Humulin 70-30 vial Febuxostat Genotropin injection* Humulin-N Kwikpen Fentanyl injection Gentamicin injection Humulin-N vial Fentanyl patch Genvoya tablet* Humulin-R U-100 Ferrous sulfate Gilenya* Hydralazine Fiasp Flextouch pen, vial Gilotrif* Hydrochlorothiazide Finasteride Glatiramer* Hydrocodone and Acetaminophen Flecainide Glatopa* Hydrocortisone cream Flovent HFA Inhaler Gleevec tablet* Hydromorphone ER Flu vaccine (intramuscular) Glimepiride Hydromorphone Injection Fluconazole Glipizide Hydromorphone solution, tablet Fluocinonide cream, gel, ointment, solution Glipizide XL Hydroxychloroquine tablet Fluorouracil Cream Glucagon kit for injection Hydroxyurea* Fluoxetine Glyburide Hydroxyzine hydrochloride Fluticasone and Salmeterol Diskus Glyxambi tablet Hydroxyzine pamoate Fluticasone Nasal Spray Gonal-F* Hyoscyamine liquid, tablet Folic acid Granix* Hysingla ER tablet Fondaparinux prefilled syringe* Guaifenesin and Codeine Oral Solution I Forteo* H Ibandronate injection Fosamprenavir* Harvoni* Ibandronate tablet Fosinopril Hectorol Ibrance capsule* Fosrenol chewable tablet, powder Hemlibra vial* Ibuprofen Fragmin prefilled syringe, vial* Heparin Imatinib tablet* All titles include both English and Spanish Sept 2020 Page | 4 Video Library Imbruvica capsule, tablet Ketoconazole cream, foam Levofloxacin Imipenem and cilastatin Ketoconazole shampoo Levothyroxine Immune Globulin IV (IVIG)* Ketorolac Levoxyl Incruse Ellipta Kevzara injection* Lialda* Indomethacin Keytruda* Lidocaine and Prilocaine cream Inlyta* Kineret* Lidocaine patch Intelence* Kisqali Femara Co-pack tablet* Lidoderm Skin Patch Intuniv Kisqali tablet* Linezolid Invanz Klor-Con M tablets Linzess Invega Kogenate FS* Lisinopril Invokamet tablet Kymriah* Lisinopril and Hydrochlorothiazide Invokana L Lispro Insulin U-100 Ipratropium and Albuterol Solution for Labetalol Lispro KwikPen Nebulizer Lamotrigine Livalo Irbesartan Lansoprazole capsule Lonsurf tablet* Isentress* Lantus SoloSTAR Loperamide Isosorbide mononitrate Lantus Vials Loratadine Itraconazole Latanoprost Eye Drops Lorazepam J Latuda Losartan Jadenu sprinkle granules, tablet* Leflunomide tablet Losartan and Hydrochlorothiazide Jakafi tablet* Letairis tablet* Lovastatin Jantoven Letrozole tablet* Lovaza Janumet Leukeran* Lucentis* Januvia Leuprolide acetate* Lumigan Jardiance Levemir FlexTouch pen Lupron Depot* Juluca tablet* Levemir Vials Lynparza capsule, tablet* K Levetiracetam Lyrica Kaletra* Levocarnitine injection M Kalydeko* Levocarnitine oral solution Magnesium citrate liquid Kapvay Levocarnitine tablet Magnesium oxide tablet All titles include both English and Spanish Sept 2020 Page | 5 Video Library Magnesium sulfate injection Metoprolol XL (metoprolol succinate) Naloxone injection Makena injection* Metronidazole Namenda Mavenclad* Mexiletine Naproxen Mavyret tablet* Minocycline* Narcan nasal spray Mayzent* Minocycline ER* Nasonex Nasal Spray Meclizine Mirtazapine Nerlynx* Mekinist* MMR II vaccine Nesina Melatonin Mobic tablet Neulasta* Meloxicam Monoclate-P* Neulasta Onpro Autoinjector* Melphalan* Montelukast Neupogen* Memantine extended-release capsule Morphine Extended-Release Tablet Nexavar* Memantine liquid, tablet Morphine Injection Nexium capsule Menopur* Morphine injection preservative-free Niaspan Meperidine injection Morphine tablet Nicotine patch Meropenem Movantik Nifedipine Mesalamine DR Moviprep Nifedipine extended-release Metformin extended-release tablet Moxifloxacin injection, tablet Ninlaro* Metformin tablet Mugard mouth rinse* Nitrofurantoin Methadone Multaq Nitroglycerin sublingual Methocarbamol Multi-vitamins Norditropin* Methotrexate* Mupirocin Ointment Norgestimate with Ethinyl Estradiol Methyldopa Mycophenolate mofetil capsule, tablet* Nortriptyline capsule and solution Methylphenidate Mycophenolic acid tablet* Norvir tablets Methylphenidate extended-release Mydayis capsule Novarel* Methylphenidate extended-release (long- Myfortic tablet* Novolin 70-30 vial acting) Mylanta Novolin-N vial Methylprednisolone Myrbetriq tablet extended-release NovoLog FlexTouch pen Methylprednisolone Sodium Succinate N NovoLog Vials Injection Nabumetone Nucala injection* Metoclopramide Nadolol Nucynta Metoprolol tartrate All titles include both English and Spanish Sept 2020 Page | 6 Video Library Nucynta ER OxyContin Pregabalin Nulojix* Ozempic pen Pregnyl* Nuvaring P Premarin Nystatin cream Pancreaze* Prepopik O Pantoprazole tablet Prevnar 13 vaccine Ocrevus infusion* Paroxetine Prezcobix tablet* Odefsey tablet* Pegasys* Prezista*
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  • Drugs That Are Not Covered

    Drugs That Are Not Covered

    Drugs that are Not Covered* Current 10/1/21 In addition to this list, newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has had an opportunity to review the medication, to determine whether the medication will be covered and if so, which tier will apply based on safety, efficacy and the availability of other products within that class of medications. The current list of newly marketed drugs can be found on our New to Market Drug list. Abilify tablets albuterol HFA inhalers (authorized Apexicon E cream Abilify MyCite tablets generics for ProAir, Proventil, Ventolin Apidra vials Absorica capsules HFA inhalers) Apidra SoloStar injection Absorica LD capsules Aldactone tablets Aplenzin tablets Abstral sublingual tablets Aldara cream Apriso capsules Acanya gel and pump gel Alkindi sprinkle capsules Arava tablets Accupril tablets Allegra Children’s Allergy ODT Arazlo lotion acetaminophen 320.5 mg/caffeine 30 Allegra ODT, suspension and tablets Arestin microspheres mg/dihydrocodeine 16 mg Alltizal tablets Aricept tablets capsulesAciphex tablets alogliptin (authorized generic for Aricept ODT Aciphex Sprinkle capsules Nesina) Arimidex tablets Acticlate tablets alogliptin/metformin tablets (authorized Arixtra injection Active-Prep kits generic for Kazano) ArmonAir Digihaler inhaler Activella tablets alogliptin/pioglitazone (authorized ArmonAir Respiclick inhaler Actonel tablets generic for Oseni) Aromasin tablets Actoplus Met tablets Alphagan P 0.1% eye drops Arthrotec 50 and 75 tablets Actos