11699 HMK Progressive State Exchange
HCR Progressive
Key Notes $3-Copay = Beginning January 1, 2015, this medication may be eligible for a $3 copay depending on the Group's Plan. Contact Member Services for more information. 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 use of a preferred specialty Status pharmacy. Please call the number on $0 = Preventative Medication the back of your member ID card for 1 = Tier 1 assistance. 2 = Tier 2 SPT = This drug may incur a higher 3 = Tier 3 copay/coinsurance. Contact Member 4 = Tier 4 Services for more information. lowercase italics = Generic drugs NF = Non-Formulary ST = For a step therapy drug to be UPPERCASE = Brand name drugs Special Tier = Special Tier covered, the beneficiary will be first required to try a therapeutically equivalent medication.
Last Approved Date: 09/23/2021 Formulary Version: 91
1 Drug Status Notes Alternative Therapy Alternative Therapy - Unclassified NUMOISYN MUCOUS MEMBRANE LIQUID 3 Analgesic, Anti-Inflammatory Or Antipyretic Analgesic - Neuronal (N)-Type Calcium Channel Blockers (Nccbs) PRIALT 3 PA Analgesic Opioid Agonists PA; ST; QL (120 UNITS per 25 ACTIQ 3 days) ALFENTA 3 PA alfentanil 3 PA ARYMO ER Special Tier PA PA; QL (186 TABLETS per 25 codeine sulfate 1 days) CONZIP 3 PA DEMEROL (PF) INJECTION SOLUTION 50 3 PA MG/ML DEMEROL (PF) INJECTION SYRINGE 3 PA DEMEROL INJECTION SOLUTION 100 3 PA MG/ML PA; QL (248 TABLETS per 25 DEMEROL ORAL TABLET 100 MG 3 days) DILAUDID (PF) INJECTION SOLUTION 3 PA DILAUDID (PF) INJECTION SYRINGE 0.5 3 PA MG/0.5 ML, 1 MG/ML, 2 MG/ML, 4 MG/ML DILAUDID INJECTION 3 PA DILAUDID ORAL LIQUID 3 PA; QL (2480 ML per 25 days) PA; QL (186 TABLETS per 25 DILAUDID ORAL TABLET 3 days) DILAUDID-HP (PF) 3 PA PA; QL (248 TABLETS per 25 DISKETS 1 days) PA; QL (248 TABLETS per 25 DOLOPHINE ORAL 3 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
2 Drug Status Notes PA; QL (20 PATCHES per 25 DURAGESIC 3 days) DURAMORPH (PF) 3 PA PA; QL (60 TABLETS per 25 EXALGO ER 3 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 3 Dayss) fentanyl transdermal patch 72 hour 100 mcg/hr, PA; ST; QL (20 patches per 25 3 12 mcg/hr, 25 mcg/hr, 50 mcg/hr days) fentanyl transdermal patch 72 hour 37.5 PA; QL (20 PATCHES per 25 mcg/hour, 62.5 mcg/hour, 75 mcg/hr, 87.5 3 days) mcg/hour PA; ST; QL (120 UNITS per 25 FENTORA 3 days) hydrocodone bitartrate oral capsule, oral only, er PA; QL (100 capsules per 25 3 12hr dayss) hydrocodone bitartrate oral tablet,oral PA; ST; QL (30 tablets per 25 3 only,ext.rel.24 hr Dayss) hydromorphone (pf) injection syringe 3 PA hydromorphone (pf)-0.9 % nacl intravenous 3 PA syringe 1 mg/ml hydromorphone in 0.9 % nacl intravenous patient 3 PA control.analgesia soln 6 mg/30 ml hydromorphone in d5w (pf) intravenous syringe 3 PA hydromorphone injection syringe 0.5 mg/0.5 ml, 1 3 mg/ml, 2 mg/ml hydromorphone oral liquid 1 PA; QL (2480 ML per 25 days) PA; QL (186 TABLETS per 25 hydromorphone oral tablet 1 days) hydromorphone oral tablet extended release 24 hr 3 QL (60 TABLETS per 25 days) hydromorphone rectal 1 PA; QL (30 TABLETS per 25 HYSINGLA ER Special Tier days) INFUMORPH P/F 3 PA IONSYS 3 PA
Last Approved Date: 09/23/2021 Formulary Version: 91
3 Drug Status Notes KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 PA; QL (62 CAPSULES per 25 3 MG, 100 MG, 20 MG, 200 MG, 30 MG, 50 MG, days) 60 MG, 80 MG KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 40 3 PA MG LAZANDA NASAL SPRAY,NON-AEROSOL PA; ST; QL (30 BOTTLES per 25 3 100 MCG/SPRAY, 400 MCG/SPRAY days) LAZANDA NASAL SPRAY,NON-AEROSOL 3 PA 300 MCG/SPRAY PA; ST; QL (14 day supply per 30 levorphanol tartrate oral tablet 2 mg 3 days) PA; ST; QL (186 tablets per 25 levorphanol tartrate oral tablet 3 mg 3 days) meperidine (pf) injection solution 100 mg/ml, 25 3 PA mg/ml, 50 mg/ml meperidine oral solution 1 PA; QL (2500 ML per 25 days) PA; QL (248 TABLETS per 25 meperidine oral tablet 1 days) methadone injection solution 3 PA METHADONE INTENSOL 1 QL (248 ML per 25 days) methadone intravenous 1 PA methadone oral concentrate 1 PA; QL (248 ML per 25 days) methadone oral solution 10 mg/5 ml 1 PA; QL (1240 ML per 25 days) methadone oral solution 5 mg/5 ml 1 PA; QL (2480 ML per 25 days) methadone oral syringe 10 mg/ml 1 PA PA; QL (248 TABLETS per 25 methadone oral tablet 1 days) methadone oral tablet,soluble 1 PA; QL (248 EA per 25 days) METHADOSE ORAL CONCENTRATE 1 PA; QL (248 ML per 25 days) PA; QL (248 TABLETS per 25 METHADOSE ORAL TABLET,SOLUBLE 1 days) morphine (pf) injection solution 0.5 mg/ml, 1 3 PA mg/ml morphine concentrate oral solution 1 QL (930 ML per 25 days) morphine concentrate oral syringe 3 morphine injection solution 10 mg/ml, 2 mg/ml, 4 3 PA mg/ml Last Approved Date: 09/23/2021 Formulary Version: 91
4 Drug Status Notes morphine injection solution 15 mg/ml, 8 mg/ml 1 PA morphine injection syringe 10 mg/ml, 2 mg/ml, 4 3 mg/ml, 5 mg/ml, 8 mg/ml morphine intramuscular 3 morphine intravenous solution 10 mg/ml 1 PA morphine intravenous syringe 4 mg/ml 3 PA morphine oral solution 10 mg/5 ml 1 PA; QL (2800 ML per 25 days) morphine oral solution 20 mg/5 ml (4 mg/ml) 1 PA; QL (1400 ML per 25 days) PA; QL (186 TABLETS per 25 morphine oral tablet 1 days) morphine oral tablet extended release 1 QL (100 TABLETS per 25 days) morphine rectal suppository 10 mg, 20 mg 1 PA morphine rectal suppository 30 mg, 5 mg 1 PA; QL (100 TABLETS per 25 MS CONTIN 3 days) NUCYNTA 3 PA; QL (186 TABS per 25 days) PA; QL (62 TABLETS per 25 NUCYNTA ER 3 days) OPANA ER ORAL TABLET EXTENDED 3 PA RELEASE 12 HR OPANA ER ORAL TABLET,ORAL 3 PA ONLY,EXT.REL.12 HR OPANA INJECTION 3 PA PA; QL (180 TABLETS per 25 OPANA ORAL 3 days) PA; ST; QL (180 TABLET per 25 OXAYDO 3 days) PA; QL (180 CAPSULE per 25 oxycodone oral capsule 1 days) oxycodone oral concentrate 1 PA; QL (180 ML per 25 days) oxycodone oral solution 1 PA; QL (5600 ML per 25 days) oxycodone oral syringe 3 PA; QL (180 TABLET per 25 oxycodone oral tablet 1 days) OXYCONTIN ORAL TABLET EXTENDED 3 PA; QL (100 EA per 25 days) RELEASE 12 HR OXYCONTIN ORAL TABLET,ORAL 3 PA ONLY,EXT.REL.12 HR
Last Approved Date: 09/23/2021 Formulary Version: 91
5 Drug Status Notes PA; QL (180 TABLETS per 25 oxymorphone oral tablet 1 days) PA; QL (100 TABLETS per 25 oxymorphone oral tablet extended release 12 hr 1 days) QDOLO 3 PA; ST PA; QL (180 TABLET per 25 ROXICODONE ORAL TABLET 15 MG, 30 MG 3 days) ROXICODONE ORAL TABLET 5 MG 3 PA ROXYBOND Special Tier QL (14 day supply per 30 dayss) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 1,200 MCG (600 MCG/SPRAY X 2), 3 PA; ST; QL (240 EA per 25 days) 1,600 MCG (800 MCG/SPRAY X 2) SUBSYS SUBLINGUAL SPRAY,NON- AEROSOL 100 MCG/SPRAY, 200 PA; ST; QL (240 SPRAY UNITS 3 MCG/SPRAY, 400 MCG/SPRAY, 600 per 25 days) MCG/SPRAY, 800 MCG/SPRAY tramadol oral capsule,er biphase 24 hr 17-83 3 PA tramadol oral capsule,er biphase 24 hr 25-75 3 PA PA; ST; QL (14 day supply per 30 tramadol oral tablet 100 mg 3 dayss) tramadol oral tablet 50 mg 1 PA tramadol oral tablet extended release 24 hr 1 PA tramadol oral tablet, er multiphase 24 hr 1 PA ULTRAM 3 PA ULTRAM ER ORAL TABLET EXTENDED 3 PA RELEASE 24 HR 300 MG XTAMPZA ER Special Tier PA; QL (60 EA per 30 days) ZOHYDRO ER 3 PA; QL (100 CAPS per 25 days) Analgesic Opioid Codeine Combinations acetaminophen-codeine oral solution 1 acetaminophen-codeine oral tablet 300-15 mg, QL (120 GM APAP COMP per 25 1 300-60 mg days) PA; QL (120 GM APAP COMP acetaminophen-codeine oral tablet 300-30 mg 1 per 25 days) ASCOMP WITH CODEINE 1 PA BUTALBITAL COMPOUND W/CODEINE 1 PA BUTALBITAL COMPOUND-CODEINE 1 PA
Last Approved Date: 09/23/2021 Formulary Version: 91
6 Drug Status Notes butalbital-acetaminop-caf-cod oral capsule 50- 1 PA 300-40-30 mg butalbital-acetaminop-caf-cod oral capsule 50- PA; QL (120 GM APAP COMP 1 325-40-30 mg per 25 days) CAPITAL WITH CODEINE 3 PA codeine-butalbital-asa-caff 1 PA FIORICET WITH CODEINE 3 PA FIORINAL-CODEINE #3 3 PA PA; QL (120 GM APAP COMP TYLENOL-CODEINE #3 3 per 25 days) PA; QL (120 GM APAP COMP TYLENOL-CODEINE #4 3 per 25 days) Analgesic Opioid Dihydrocodeine Combinations acetaminophen-caff-dihydrocod oral capsule 1 PA acetaminophen-caff-dihydrocod oral tablet NL PA aspirin-caffeine-dihydrocodein 1 PA DVORAH 1 PANLOR(ACETAM-CAFF-DIHYDROCOD) 1 PA SYNALGOS-DC 3 PA TREZIX 3 PA Analgesic Opioid Dihydrocodeine, Non- Salicylate Analgesic,Xanthine acetaminophen-caff-dihydrocod oral capsule 1 PA acetaminophen-caff-dihydrocod oral tablet NL PA DVORAH 1 PANLOR(ACETAM-CAFF-DIHYDROCOD) 1 PA TREZIX 3 PA Analgesic Opioid Dihydrocodeine, Salicylate Analgesic, Xanthine Comb aspirin-caffeine-dihydrocodein 1 PA SYNALGOS-DC 3 PA Analgesic Opioid Hydrocodone And Non-Salicylate Combinations hydrocodone-acetaminophen oral solution 3
Last Approved Date: 09/23/2021 Formulary Version: 91
7 Drug Status Notes hydrocodone-acetaminophen oral tablet 10-300 1 PA mg, 2.5-325 mg hydrocodone-acetaminophen oral tablet 10-325 PA; QL (120 GM APAP COMP 1 mg, 5-300 mg, 5-325 mg per 25 days) hydrocodone-acetaminophen oral tablet 7.5-300 1 mg hydrocodone-acetaminophen oral tablet 7.5-325 QL (120 GM APAP COMP per 25 1 mg days) LORCET (HYDROCODONE) 1 PA LORCET HD 1 PA LORCET PLUS 1 PA LORTAB 10-325 1 PA LORTAB 5-325 1 PA LORTAB 7.5-325 1 PA LORTAB ELIXIR 3 PA PA; QL (120 GM APAP COMP NORCO 3 per 25 days) VICODIN 1 PA VICODIN ES 1 PA VICODIN HP 1 PA PA; QL (120 GM APAP COMP XODOL 10/300 3 per 25 days) PA; QL (120 GM APAP COMP XODOL 5/300 3 per 25 days) PA; QL (120 GM APAP COMP XODOL 7.5/300 3 per 25 days) ZAMICET 1 PA Analgesic Opioid Hydrocodone And Nsaid Combinations hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 1 PA 200 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 IBUDONE 3 PA REPREXAIN 1 PA XYLON 10 1 PA
Last Approved Date: 09/23/2021 Formulary Version: 91
8 Drug Status Notes Analgesic Opioid Hydrocodone Combinations hydrocodone-acetaminophen oral solution 3 hydrocodone-acetaminophen oral tablet 10-300 1 PA mg, 2.5-325 mg hydrocodone-acetaminophen oral tablet 10-325 PA; QL (120 GM APAP COMP 1 mg, 5-300 mg, 5-325 mg per 25 days) hydrocodone-acetaminophen oral tablet 7.5-300 1 mg hydrocodone-acetaminophen oral tablet 7.5-325 QL (120 GM APAP COMP per 25 1 mg days) hydrocodone-ibuprofen oral tablet 10-200 mg, 5- 1 PA 200 mg hydrocodone-ibuprofen oral tablet 7.5-200 mg 1 IBUDONE 3 PA LORCET (HYDROCODONE) 1 PA LORCET HD 1 PA LORCET PLUS 1 PA LORTAB 10-325 1 PA LORTAB 5-325 1 PA LORTAB 7.5-325 1 PA LORTAB ELIXIR 3 PA PA; QL (120 GM APAP COMP NORCO 3 per 25 days) REPREXAIN 1 PA VICODIN 1 PA VICODIN ES 1 PA VICODIN HP 1 PA PA; QL (120 GM APAP COMP XODOL 10/300 3 per 25 days) PA; QL (120 GM APAP COMP XODOL 5/300 3 per 25 days) PA; QL (120 GM APAP COMP XODOL 7.5/300 3 per 25 days) XYLON 10 1 PA ZAMICET 1 PA
Last Approved Date: 09/23/2021 Formulary Version: 91
9 Drug Status Notes Analgesic Opioid Oxycodone And Non- Salicylate Combinations ENDOCET ORAL TABLET 10-325 MG, 5-325 PA; QL (120 GM APAP COMP 1 MG, 7.5-325 MG per 25 days) ENDOCET ORAL TABLET 2.5-325 MG 1 PA NALOCET 3 QL (120 grams per 25 dayss) oxycodone-acetaminophen oral solution 1 oxycodone-acetaminophen oral tablet 10-325 mg, PA; QL (120 GM APAP COMP 1 5-325 mg, 7.5-325 mg per 25 days) oxycodone-acetaminophen oral tablet 2.5-300 mg 3 PA; QL (120 grams per 25 Dayss) PA; QL (120 GM APAP COMP PERCOCET 3 per 25 days) PRIMLEV 3 PA PROLATE ORAL SOLUTION 3 PA PROLATE ORAL TABLET 3 PA; QL (120 grams per 25 Dayss) Analgesic Opioid Oxycodone And Nsaid Combinations ibuprofen-oxycodone 1 PA Analgesic Opioid Oxycodone And Salicylate Combinations oxycodone-aspirin 1 PA Analgesic Opioid Oxycodone Combinations ENDOCET ORAL TABLET 10-325 MG, 5-325 PA; QL (120 GM APAP COMP 1 MG, 7.5-325 MG per 25 days) ENDOCET ORAL TABLET 2.5-325 MG 1 PA ibuprofen-oxycodone 1 PA NALOCET 3 QL (120 grams per 25 dayss) oxycodone-acetaminophen oral solution 1 oxycodone-acetaminophen oral tablet 10-325 mg, PA; QL (120 GM APAP COMP 1 5-325 mg, 7.5-325 mg per 25 days) oxycodone-acetaminophen oral tablet 2.5-300 mg 3 PA; QL (120 grams per 25 Dayss) oxycodone-aspirin 1 PA PA; QL (120 GM APAP COMP PERCOCET 3 per 25 days) PRIMLEV 3 PA
Last Approved Date: 09/23/2021 Formulary Version: 91
10 Drug Status Notes PROLATE ORAL SOLUTION 3 PA PROLATE ORAL TABLET 3 PA; QL (120 grams per 25 Dayss) Analgesic Opioid Partial-Mixed Agonists BELBUCA 3 PA; ST; QL (2 films per 1 day) BUPRENEX 3 PA buprenorphine hcl injection 3 PA 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) butorphanol injection 3 PA PA; QL (1 INHALER per 1 butorphanol nasal 1 MONTH) PA; ST; QL (4 PATCHES per 25 BUTRANS 3 days) nalbuphine 3 PA pentazocine-naloxone 3 PA TALWIN 3 PA Analgesic Opioid Tramadol And Non- Salicylate Combinations PA; QL (120 GM APAP COMP tramadol-acetaminophen 1 per 25 days) PA; QL (120 GM APAP COMP ULTRACET 3 per 25 days) Analgesic Opioid Tramadol Combinations PA; QL (120 GM APAP COMP tramadol-acetaminophen 1 per 25 days) PA; QL (120 GM APAP COMP ULTRACET 3 per 25 days) Analgesic Or Antipyretic Non- Opioid/Sedative Combinations butalbital-acetaminophen oral capsule 3 butalbital-acetaminophen oral tablet 25-325 mg, 3 50-300 mg butalbital-acetaminophen oral tablet 50-325 mg 1
Last Approved Date: 09/23/2021 Formulary Version: 91
11 Drug Status Notes butalbital-acetaminophen-caff oral capsule 50- 1 300-40 mg butalbital-acetaminophen-caff oral tablet 1 CAPACET 1 ESGIC 3 FIORICET 3 MARGESIC 1 MARTEN-TAB 1 PHRENILIN FORTE(WITH CAFFEINE) 1 TENCON 1 VTOL LQ 3 ZEBUTAL 1 Anti-Inflammatory - Interleukin-1 Beta Blockers ILARIS (PF) 3 Anti-Inflammatory - Interleukin-1 Receptor Antagonist ARCALYST 4 PA; BE; SPT Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Non-Seiective ENBREL MINI 3 PA; ST; SP; BE; SPT; QL (8 ENBREL SUBCUTANEOUS RECON SOLN 3 prefilled syrs per 21 days) ENBREL SUBCUTANEOUS SYRINGE 25 PA; ST; SP; BE; SPT; QL (8 3 MG/0.5 ML (0.5) SYRINGES per 21 days) ENBREL SUBCUTANEOUS SYRINGE 50 PA; ST; SP; SPT; QL (4 ML per 3 MG/ML (1 ML) 21 days) PA; ST; SP; BE; SPT; QL (4 ML ENBREL SURECLICK 3 per 21 days) Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agnts,Tnf-Alpha Sel CIMZIA 4 ST; BE CIMZIA POWDER FOR RECONST 4 ST; BE PA; ST; SP; BE; SPT; QL (2 CIMZIA STARTER KIT 4 prefilled syrs per 28 days) PA; ST; SP; BE; SPT; QL (2 units HUMIRA 3 per 21 days) Last Approved Date: 09/23/2021 Formulary Version: 91
12 Drug Status Notes PA; ST; SP; SPT; QL (1 unit per HUMIRA PEDIATRIC CROHNS START 3 274 days) PA; ST; SP; BE; SPT; QL (2 HUMIRA PEN 3 SYRINGES per 21 days) PA; ST; SP; SPT; QL (2 HUMIRA PEN CROHNS-UC-HS START 3 SYRINGES per 21 days) PA; ST; SP; SPT; QL (2 HUMIRA PEN PSOR-UVEITS-ADOL HS 3 SYRINGES per 21 days) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) 3 per 21 days) PA; ST; BE; SPT; QL (1 unit per HUMIRA(CF) PEDI CROHNS STARTER 3 274 dayss) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN 3 per 21 days) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN CROHNS-UC-HS 3 per 21 days) PA; ST; BE; SPT; QL (1 unit per HUMIRA(CF) PEN PEDIATRIC UC 3 274 Dayss) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN PSOR-UV-ADOL HS 3 per 21 days) PA; ST; SP; BE; SPT; QL (1 SIMPONI SUBCUTANEOUS PEN INJECTOR 4 prefilled syrs per 28 days) PA; ST; SP; BE; SPT; QL (1 SIMPONI SUBCUTANEOUS SYRINGE 4 UNIT per 21 days) Dmard - Anti-Inflammatory Tumor Necrosis Factor Inhibiting Agents PA; ST; SP; BE; SPT; QL (1 KIT CIMZIA 4 per 21 days) PA; ST; SP; BE; SPT; QL (1 CIMZIA POWDER FOR RECONST 4 Starter Kit per 365 days) PA; ST; SP; BE; SPT; QL (2 CIMZIA STARTER KIT 4 prefilled syrs per 28 days) ENBREL MINI 3 PA; ST; SP; BE; SPT; QL (8 ENBREL SUBCUTANEOUS RECON SOLN 3 prefilled syrs per 21 days) ENBREL SUBCUTANEOUS SYRINGE 25 PA; ST; SP; BE; SPT; QL (8 3 MG/0.5 ML (0.5) SYRINGES per 21 days) ENBREL SUBCUTANEOUS SYRINGE 50 PA; ST; SP; SPT; QL (4 ML per 3 MG/ML (1 ML) 21 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
13 Drug Status Notes PA; ST; SP; BE; SPT; QL (4 ML ENBREL SURECLICK 3 per 21 days) PA; ST; SP; BE; SPT; QL (2 units HUMIRA 3 per 21 days) PA; ST; SP; SPT; QL (1 unit per HUMIRA PEDIATRIC CROHNS START 3 274 days) PA; ST; SP; BE; SPT; QL (2 HUMIRA PEN 3 SYRINGES per 21 days) PA; ST; SP; SPT; QL (2 HUMIRA PEN CROHNS-UC-HS START 3 SYRINGES per 21 days) PA; ST; SP; SPT; QL (2 HUMIRA PEN PSOR-UVEITS-ADOL HS 3 SYRINGES per 21 days) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) 3 per 21 days) HUMIRA(CF) PEDI CROHNS STARTER PA; ST; BE; SPT; QL (1 unit per SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 3 274 dayss) ML PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN 3 per 21 days) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN CROHNS-UC-HS 3 per 21 days) PA; ST; BE; SPT; QL (1 unit per HUMIRA(CF) PEN PEDIATRIC UC 3 274 Dayss) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN PSOR-UV-ADOL HS 3 per 21 days) PA; ST; SP; BE; SPT; QL (1 SIMPONI SUBCUTANEOUS PEN INJECTOR 4 prefilled syrs per 28 days) PA; ST; SP; BE; SPT; QL (1 SIMPONI SUBCUTANEOUS SYRINGE 4 UNIT per 21 days) Dmard - Antimalarials hydroxychloroquine 1 PLAQUENIL 3 Dmard - Antimetabolites methotrexate sodium 1 methotrexate sodium (pf) injection solution 1 OTREXUP (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.4 ML, 12.5 MG/0.4 ML, 15 3 PA; ST MG/0.4 ML, 17.5 MG/0.4 ML, 20 MG/0.4 ML, 22.5 MG/0.4 ML, 25 MG/0.4 ML
Last Approved Date: 09/23/2021 Formulary Version: 91
14 Drug Status Notes OTREXUP (PF) SUBCUTANEOUS AUTO- 3 INJECTOR 7.5 MG/0.4 ML RASUVO (PF) SUBCUTANEOUS AUTO- INJECTOR 10 MG/0.2 ML, 12.5 MG/0.25 ML, 15 MG/0.3 ML, 17.5 MG/0.35 ML, 20 MG/0.4 3 PA; ST ML, 22.5 MG/0.45 ML, 25 MG/0.5 ML, 30 MG/0.6 ML, 7.5 MG/0.15 ML RASUVO (PF) SUBCUTANEOUS AUTO- 3 INJECTOR 27.5 MG/0.55 ML REDITREX (PF) 3 PA; ST RHEUMATREX 3 TREXALL 3 XATMEP 3 ST Dmard - Antinflammatory, Select. Costimulation Modulator,T-Cell Inhib. PA; ST; SP; BE; QL (4 Syringes ORENCIA CLICKJECT 3 per 21 days) ORENCIA SUBCUTANEOUS SYRINGE 125 PA; ST; SP; BE; SPT; QL (4 4 MG/ML SYRINGES per 21 days) ORENCIA SUBCUTANEOUS SYRINGE 50 PA; ST; SP; BE; SPT; QL (4 4 MG/0.4 ML, 87.5 MG/0.7 ML Syringes per 21 Days) Dmard - Gold Compounds RIDAURA 3 Dmard - Immunosuppressives AZASAN 3 azathioprine 1 CELLCEPT ORAL CAPSULE 3 CELLCEPT ORAL SUSPENSION FOR 2 RECONSTITUTION CELLCEPT ORAL TABLET 3 cyclophosphamide oral capsule 1 cyclophosphamide oral tablet 3 cyclosporine modified 1 cyclosporine oral 1 GENGRAF 1 IMURAN 3 mycophenolate mofetil 1
Last Approved Date: 09/23/2021 Formulary Version: 91
15 Drug Status Notes NEORAL 3 SANDIMMUNE ORAL 3 Dmard - Interleukin-1 Receptor Antagonist (Il-1Ra) PA; ST; BE; SPT; QL (28 KINERET 4 SYRINGES per 21 days) Dmard - Interleukin-6 (Il-6) Receptor Inhibitors, Monoclonal Antibody PA; ST; BE; SPT; QL (4 prefilled ACTEMRA ACTPEN 3 autoinjectors per 28 Dayss) ACTEMRA INTRAVENOUS 3 BE PA; ST; SP; BE; SPT; QL (4 ACTEMRA SUBCUTANEOUS 3 SYRINGES per 21 days) KEVZARA SUBCUTANEOUS PEN INJECTOR 4 ST; BE PA; ST; SP; BE; SPT; QL (2 KEVZARA SUBCUTANEOUS SYRINGE 4 syringes per 28 days) Dmard - Janus Kinase (Jak) Inhibitors PA; ST; BE; SPT; QL (1 tablet per OLUMIANT ORAL TABLET 1 MG 4 1 day) PA; ST; BE; SPT; QL (1 tablet per OLUMIANT ORAL TABLET 2 MG 4 1 Day) PA; ST; BE; SPT; QL (1 tablet per RINVOQ 3 1 day) XELJANZ ORAL SOLUTION 3 PA; ST; BE; SPT PA; ST; SP; BE; SPT; QL (68 XELJANZ ORAL TABLET 5 MG 3 TABLETS per 1 MONTH) XELJANZ XR ORAL TABLET EXTENDED PA; ST; SP; BE; SPT; QL (1 tablet 3 RELEASE 24 HR 11 MG per 1 day) Dmard - Other AZULFIDINE 3 AZULFIDINE EN-TABS 3 PA; ST; $3-Copay; SPT; QL (8 CUPRIMINE 4 tablets/capsules per 1 day) PA; ST; $3-Copay; SPT; QL (8 DEPEN TITRATABS 4 tablets/capsules per 1 day) D-PENAMINE 3 PA; QL (16 tablets per 1 day) MINOCIN ORAL CAPSULE 100 MG, 50 MG 3
Last Approved Date: 09/23/2021 Formulary Version: 91
16 Drug Status Notes MINOCIN ORAL CAPSULE 75 MG 3 PA; ST minocycline oral capsule 1 minocycline oral tablet 1 PA; ST penicillamine oral capsule 3 PA; ST; BE; SPT sulfasalazine 1 SULFAZINE 1 Dmard - Phosphodiesterase-4 (Pde4) Inhibitors PA; ST; SP; BE; SPT; QL (68 OTEZLA 3 TABLETS per 1 MONTH) PA; ST; SP; BE; SPT; QL (1 OTEZLA STARTER 3 Starter Kit per 1 FILL) Dmard - Pyrimidine Synthesis Inhibitors ARAVA 3 leflunomide 1 Immunomodulator - Rho Kinase Inhibitor REZUROCK 3 Immunomodulator B-Lymphocyte Stimulator (Blys)-Specific Inhibitor Mcab BENLYSTA SUBCUTANEOUS AUTO- PA; ST; SP; BE; QL (4 3 INJECTOR autoinjectors per 28 days) PA; ST; SP; BE; QL (4 syringes BENLYSTA SUBCUTANEOUS SYRINGE 3 per 28 days) Nsaid Analgesic And Histamine H2 Receptor Antagonist Combinations DUEXIS 3 PA; ST ibuprofen-famotidine 3 PA; ST Nsaid Analgesic And Prostaglandin Analog Combinations ARTHROTEC 50 3 ARTHROTEC 75 3 diclofenac-misoprostol 1
Last Approved Date: 09/23/2021 Formulary Version: 91
17 Drug Status Notes Nsaid Analgesic And Proton Pump Inhibitor Combinations naproxen-esomeprazole 3 PA; ST VIMOVO 3 PA; ST Nsaid Analgesic, Cyclooxygenase-2 (Cox-2) Selective Inhibitors CELEBREX 3 celecoxib 3 Nsaid Analgesics (Cox Non-Specific) - Anthranilic Acid Derivatives meclofenamate 1 PONSTEL 3 Nsaid Analgesics (Cox Non-Specific) - Other ketorolac injection syringe 3 ketorolac intramuscular solution 3 ketorolac intramuscular syringe 3 ketorolac nasal 3 PA; ST QL (20 TABLETS per 3 ketorolac oral 1 MONTHs) nabumetone 1 RELAFEN DS 3 PA; ST PA; ST; QL (5 bottles per 1 SPRIX 3 dispense) sulindac 1 tolmetin 1 Nsaid Analgesics (Cox Non-Specific) - Oxicam Derivatives FELDENE 3 meloxicam oral tablet 1 $3-Copay meloxicam submicronized 3 PA; ST; QL (1 EA per 1 Day) MOBIC 3 piroxicam 1 QMIIZ ODT 3 QL (1 tablet per 1 day) PA; ST; QL (1 CAPSULE per 1 VIVLODEX 3 day) Last Approved Date: 09/23/2021 Formulary Version: 91
18 Drug Status Notes Nsaid Analgesics (Cox Non-Specific) - Phenylacetic Acid Derivatives PA; ST; QL (1 box (9 packets) per CAMBIA 3 30 dayss) diclofenac potassium 1 diclofenac sodium oral tablet extended release 24 1 hr diclofenac sodium oral tablet,delayed release 1 (dr/ec) 25 mg, 50 mg diclofenac sodium oral tablet,delayed release 1 $3-Copay (dr/ec) 75 mg diclofenac submicronized 3 PA; ST; QL (3 capsules per 1 Day) VOLTAREN-XR 3 ZIPSOR 3 PA; ST; QL (4 Capsules per 1 day) ZORVOLEX 3 PA; ST; QL (3 Capsules per 1 day) Nsaid Analgesics (Cox Non-Specific) - Propionic Acid Derivatives ANAPROX DS 3 DAYPRO 3 EC-NAPROSYN 3 EC-NAPROXEN 1 fenoprofen oral tablet 1 flurbiprofen 1 IBU 1 ibuprofen oral suspension 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 $3-Copay ketoprofen oral capsule 25 mg 3 PA; ST ketoprofen oral capsule 50 mg, 75 mg 1 ketoprofen oral capsule,ext rel. pellets 24 hr 200 1 mg NALFON ORAL CAPSULE 400 MG 3 PA; ST NAPRELAN CR 3 PA; ST NAPROSYN ORAL SUSPENSION 3 PA; ST NAPROSYN ORAL TABLET 500 MG 3 naproxen oral suspension 1 naproxen oral tablet 1 $3-Copay
Last Approved Date: 09/23/2021 Formulary Version: 91
19 Drug Status Notes 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 3 PA; ST 750 mg oxaprozin 1 PROFENO 1 Nsaid Analgesics (Cyclooxygenase Inhibitors-Non-Selective) PA; ST; QL (1 box (9 packets) per CAMBIA 3 30 dayss) Nsaid Analgesics, (Cox Non-Specific) - Indole Acetic Acid Derivatives etodolac 1 INDOCIN 3 indomethacin oral capsule 1 $3-Copay indomethacin oral capsule, extended release 1 indomethacin submicronized 3 PA; ST TIVORBEX 3 PA; ST Salicylate Analgesic And Sedative Combinations butalbital-aspirin-caffeine 1 FIORINAL 3 Salicylate Analgesic Combinations choline,magnesium salicylate 1 Salicylate Analgesics ADULT ASPIRIN REGIMEN 1 ADULT LOW DOSE ASPIRIN $0 ASPIR-81 1 ASPIRIN CHILDRENS 1 ASPIRIN LOW DOSE 1 ASPIRIN LOW-STRENGTH $0 aspirin oral tablet 325 mg 1 aspirin oral tablet 81 mg $0 aspirin oral tablet,chewable 1
Last Approved Date: 09/23/2021 Formulary Version: 91
20 Drug Status Notes aspirin oral tablet,delayed release (dr/ec) 325 1 mg, 81 mg ASPIR-LOW 1 ASPIR-TRIN 1 BAYER ASPIRIN 1 BAYER CHEWABLE ASPIRIN 3 CHILD ASPIRIN 1 CHILDREN'S ASPIRIN 1 diflunisal 1 DISALCID 3 DURLAZA 3 QL (1 CAPSULE per 1 day) E.C. PRIN 1 ECOTRIN $0 ECOTRIN LOW STRENGTH 1 ENTERIC COATED ASPIRIN $0 HALFPRIN $0 LITE COAT ASPIRIN 1 LO-DOSE ASPIRIN $0 MINIPRIN $0 salsalate 1 ST JOSEPH ASPIRIN 1 ST. JOSEPH ASPIRIN 1 Anesthetics General Anesthetic - Inhalant Volatile desflurane 1 FORANE 1 isoflurane 1 sevoflurane 1 SOJOURN 1 TERRELL 1 General Anesthetic - Parenteral, Benzodiazepines midazolam (pf) injection syringe 3 midazolam in 0.9 % sod chlorid intravenous 3 prefilled pump reservoir
Last Approved Date: 09/23/2021 Formulary Version: 91
21 Drug Status Notes midazolam intravenous syringe 150 mg/30 ml (5 3 mg/ml) General Anesthetic Adjuncts - Opioid remifentanil 3 PA sufentanil citrate 3 PA sufentanil citrate (pf) 3 PA ULTIVA 3 PA Local Anesthetic - Amides BUFFERED LIDOCAINE INJECTION 3 SYRINGE 0.9 % (10 ML) lidocaine topical ointment 3 PA; QL (50 GM per 30 days) LTA PRE-ATTACHED 1 Anorectal Preparations Anorectal - Glucocorticoids ANUCORT-HC 3 ANUSOL-HC RECTAL 3 HEMMOREX-HC 1 hydrocortisone acetate rectal 1 hydrocortisone topical cream with perineal 1 applicator 2.5 % PROCTOCORT RECTAL 3 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOSOL HC 1 PROCTOZONE-HC 1 Anorectal - Hemorrhoidal Rectal Glucocorticoid-Local Anesthetic Comb ANALPRAM E 3 ANALPRAM-HC 3 ANALPRAM-HC SINGLES 3 hydrocortisone-pramoxine rectal 1 lidocaine hcl-hydrocortison ac rectal cream 1 lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 3 3-1 % (7 gram) lidocaine-hydrocortisone-aloe rectal gel 1
Last Approved Date: 09/23/2021 Formulary Version: 91
22 Drug Status Notes lidocaine-hydrocortisone-aloe rectal kit 3 PRAMCORT 1 PROCTOFOAM HC 3 ZYPRAM 3 Antidotes And Other Reversal Agents Antidote - Acetaminophen Poisoning CETYLEV 3 Antidote - Cholinesterase Reactivating Agent pralidoxime 3 Antidote - Cholinesterase Reactivating Agent And Muscarinic Antagonist DUODOTE 3 Antidote Others GALZIN 2 Chelating Agents - Copper $3-Copay; QL (8 tablets/capsules CUPRIMINE 4 per 1 day) $3-Copay; QL (8 tablets/capsules DEPEN TITRATABS 4 per 1 day) D-PENAMINE 3 PA; QL (16 tablets per 1 day) penicillamine oral capsule 3 PA; ST; BE; SPT PA; ST; BE; SPT; QL (8 capsules SYPRINE 4 per 1 day) Chelating Agents - Iron deferasirox oral granules in packet 4 PA; ST; BE; SPT deferasirox oral tablet 180 mg 4 PA; ST; SPT deferasirox oral tablet 360 mg, 90 mg 4 PA; ST; BE; SPT deferasirox oral tablet, dispersible 3 PA; SPT deferiprone 4 PA; ST; $3-Copay; SPT EXJADE 4 PA; ST; SP; BE; SPT FERRIPROX ORAL SOLUTION 3 PA; ST; BE PA; ST; BE; SPT; QL (9 tablets FERRIPROX ORAL TABLET 4 per 1 day) JADENU 4 PA; ST; SP; BE; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
23 Drug Status Notes JADENU SPRINKLE 4 PA; ST; SP; BE; SPT Chelating Agents - Lead Poisoning CHEMET 3 Emetics ipecac 3 Mu-Opioid Receptor Antagonists, Peripherally-Acting alvimopan 3 ENTEREG 3 MOVANTIK 2 QL (1 Tablet per 1 day) RELISTOR ORAL 3 PA; ST; QL (3 tablets per 1 day) RELISTOR SUBCUTANEOUS SOLUTION 3 RELISTOR SUBCUTANEOUS SYRINGE 3 PA; ST; QL (1 Syringe per 1 day) SYMPROIC 2 ST; QL (1 tablet per 1 Day) Opioid Reversal Agents - Opioid Antagonists EVZIO 3 PA; ST KLOXXADO 2 naloxone injection auto-injector 3 naloxone injection solution 1 naloxone injection syringe 1 naltrexone 1 NARCAN 2 Anti-Infective Agents Amebicides paromomycin 3 Aminoglycoside Antibiotic PA; BE; SPT; QL (1 box (28 vials) ARIKAYCE 4 per 28 Dayss) neomycin 1 streptomycin 3 Aminomethylcycline Antibiotics NUZYRA (7 DAY WITH LOAD DOSE) 4 NUZYRA (7 DAY) 4
Last Approved Date: 09/23/2021 Formulary Version: 91
24 Drug Status Notes NUZYRA ORAL 4 Aminopenicillin Antibiotic amoxicillin oral capsule 1 $3-Copay amoxicillin oral suspension for reconstitution 1 $3-Copay amoxicillin oral tablet 1 $3-Copay amoxicillin oral tablet, er multiphase 24 hr 3 amoxicillin oral tablet,chewable 125 mg, 250 mg 1 amoxicillin oral tablet,chewable 400 mg 1 $3-Copay ampicillin oral capsule 250 mg 1 $3-Copay ampicillin oral capsule 500 mg 1 ampicillin oral suspension for reconstitution 1 MOXATAG 3 Aminopenicillin Antibiotic - Beta- Lactamase Inhibitor Combinations amoxicillin-pot clavulanate oral suspension for 1 reconstitution amoxicillin-pot clavulanate oral tablet 250-125 1 mg amoxicillin-pot clavulanate oral tablet 500-125 1 $3-Copay mg, 875-125 mg amoxicillin-pot clavulanate oral tablet extended 3 release 12 hr amoxicillin-pot clavulanate oral tablet,chewable 1 AUGMENTIN ES-600 3 AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML, 250- 3 62.5 MG/5 ML AUGMENTIN ORAL TABLET 500-125 MG, 3 875-125 MG AUGMENTIN XR 3 Anthelmintic Agents - Benzimidazole Derivatives albendazole 1 albendazole (bulk) 3 ALBENZA 3 EMVERM 2
Last Approved Date: 09/23/2021 Formulary Version: 91
25 Drug Status Notes Anthelmintic Agents - Macrocyclic Lactones ivermectin oral 3 STROMECTOL 3 Anthelmintic Agents Other BILTRICIDE 3 praziquantel 1 Antibacterial Folate Antagonist - Other Combinations BACTRIM 3 BACTRIM DS 3 sulfamethoxazole-trimethoprim oral suspension 1 sulfamethoxazole-trimethoprim oral tablet 1 $3-Copay SULFATRIM 1 Antibacterial Folate Antagonist Others PRIMSOL 3 trimethoprim 1 TRIMPEX 3 Antibacterial Nitrofuran Derivatives FURADANTIN 3 MACROBID 3 MACRODANTIN 3 nitrofurantoin 1 nitrofurantoin macrocrystal oral capsule 100 mg, 1 50 mg nitrofurantoin macrocrystal oral capsule 25 mg 3 nitrofurantoin monohyd/m-cryst 1 Antibacterial Other fosfomycin tromethamine 3 MONUROL 3 Antifungal - Allylamines LAMISIL ORAL GRANULES IN PACKET 3 LAMISIL ORAL TABLET 3 QL (22500 MG per 180 days) $3-Copay; QL (22500 MG per 180 terbinafine hcl oral 1 days) Last Approved Date: 09/23/2021 Formulary Version: 91
26 Drug Status Notes Antifungal - Amphoteric Polyene Macrolides nystatin (bulk) powder 1 billion unit, 10 billion unit, 150 million unit, 2 billion unit, 5 billion unit, 3 50 million unit, 500 million unit nystatin oral 1 Antifungal - Fluorinated Pyrimidine- Type Agents ANCOBON 3 PA; ST flucytosine 1 Antifungal - Glucan Synthesis Inhibitor, Triterpenoid PA; ST; QL (1 pack (4 tablets) per BREXAFEMME 3 1 dispensing event) Antifungal - Glucan Synthesis Inhibitors PA; ST; QL (1 pack (4 tablets) per BREXAFEMME 3 1 dispensing event) Antifungal - Imidazoles ketoconazole oral 1 ORAVIG 3 Antifungal - Triazoles DIFLUCAN 3 fluconazole oral suspension for reconstitution 1 fluconazole oral tablet 100 mg, 200 mg, 50 mg 1 fluconazole oral tablet 150 mg 1 $3-Copay QL (18000 mg per 180 day itraconazole oral capsule 1 periods) itraconazole oral solution 3 NOXAFIL ORAL 3 PA; ST posaconazole 3 PA; ST SPORANOX ORAL CAPSULE 3 QL (18000 EA per 180 days) SPORANOX ORAL SOLUTION 3 QL (18000 MG per 180 days) PA; BE; SPT; QL (120 capsules TOLSURA 4 per 30 Dayss) VFEND 3
Last Approved Date: 09/23/2021 Formulary Version: 91
27 Drug Status Notes voriconazole oral 3 Antifungal Other griseofulvin microsize 1 griseofulvin ultramicrosize 1 GRIS-PEG (ULTRAMICROSIZE) 3 Anti-Infective Immunologic Adjuvants - Interferons ACTIMMUNE 3 PA; SP; BE; SPT Antileprotic - Immunomodulators PA; SP; BE; SPT; QL (1 capsule THALOMID ORAL CAPSULE 100 MG, 50 MG 4 per 1 day) THALOMID ORAL CAPSULE 150 MG, 200 PA; SP; BE; SPT; QL (2 capsules 4 MG per 1 day) Antileprotic - Sulfone Agents dapsone oral 3 Antimalarial Combinations PA; QL (12 TABLETS per 180 atovaquone-proguanil 1 days) PA; QL (24 TABLETS per 180 COARTEM 3 days) PA; QL (12 TABLETS per 180 MALARONE 3 days) PA; QL (12 TABLETS per 180 MALARONE PEDIATRIC 3 days) Antimalarials ARAKODA 3 PA chloroquine phosphate 1 DARAPRIM 3 PA; ST hydroxychloroquine 1 KRINTAFEL 3 PA mefloquine 1 PLAQUENIL 3 primaquine 1 pyrimethamine 3 PA; ST PA; QL (42 CAPSULES per 180 QUALAQUIN 3 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
28 Drug Status Notes PA; QL (42 CAPSULES per 180 quinine sulfate 1 days) Antiprotozoal Agents - Nitrofuran Derivatives LAMPIT 3 PA Antiprotozoal Agents - Nitroimidazole Derivatives benznidazole 3 PA; QL (60 tablets per 720 Days) Antiprotozoal Agents - Other atovaquone 3 IMPAVIDO 3 MEPRON 3 Antiprotozoal Agents (Antiparasitic) - 5-Nitrothiazolyl Derivatives ALINIA 3 nitazoxanide 3 Antiprotozoal-Antibacterial 1St Generation 2-Methyl-5-Nitroimidazole FLAGYL 3 metronidazole oral capsule 1 metronidazole oral tablet 1 $3-Copay Antiprotozoal-Antibacterial 2Nd Generation 2-Methyl-5-Nitroimidazole SOLOSEC 3 QL (1 packet per 30 Days) TINDAMAX 3 tinidazole 3 Antiretroviral - Ccr5 Co-Receptor Antagonist SELZENTRY ORAL SOLUTION 2 QL (920 mL per 1 Month) SELZENTRY ORAL TABLET 150 MG, 25 MG, 2 QL (2 tablets per 1 day) 75 MG SELZENTRY ORAL TABLET 300 MG 2 QL (4 tablets per 1 day) Antiretroviral - Cd4 Attachment Inhibitors RUKOBIA 3
Last Approved Date: 09/23/2021 Formulary Version: 91
29 Drug Status Notes Antiretroviral - Hiv-1 Fusion Inhibitors FUZEON SUBCUTANEOUS KIT 3 SP; QL (2 vials per 1 day) FUZEON SUBCUTANEOUS RECON SOLN 3 QL (2 vials per 1 day) Antiretroviral - Hiv-1 Integrase Strand Transfer Inhibitors ISENTRESS HD 2 QL (2 tablets per 1 day) QL (1 box (60 packets) per 30 ISENTRESS ORAL POWDER IN PACKET 3 days) ISENTRESS ORAL TABLET 2 QL (4 tablets per 1 day) ISENTRESS ORAL TABLET,CHEWABLE 2 QL (6 tablets per 1 day) TIVICAY ORAL TABLET 10 MG, 25 MG 2 TIVICAY ORAL TABLET 50 MG 2 QL (2 TABLETS per 1 day) TIVICAY PD 2 QL (6 tablets per 1 day) VITEKTA 3 QL (1 TABLET per 1 day) Antiretroviral - Integrase Inhibitor And Nnrti Combinations JULUCA 2 QL (1 TABLET per 1 DAY) Antiretroviral - Integrase Inhibitor And Nrti Combinations DOVATO 2 QL (1 tablet per 1 day) Antiretroviral - Non-Nucleoside Reverse Transcriptase Inhib (Nnrti) EDURANT 3 QL (2 TABLETS per 1 day) efavirenz oral capsule 1 QL (3 Capsules per 1 day) efavirenz oral tablet 1 etravirine 3 QL (2 tablets per 1 Day) INTELENCE ORAL TABLET 100 MG, 200 MG 3 QL (2 tablets per 1 day) INTELENCE ORAL TABLET 25 MG 3 QL (4 tablets per 1 day) nevirapine oral suspension 3 QL (5 bottles per 30 days) nevirapine oral tablet 3 QL (2 tablets per 1 day) nevirapine oral tablet extended release 24 hr 100 3 QL (3 tablets per 1 day) mg nevirapine oral tablet extended release 24 hr 400 3 QL (1 tablet per 1 day) mg PIFELTRO 3 QL (2 tablets per 1 Day) RESCRIPTOR ORAL TABLET 3 QL (6 tablets per 1 day) Last Approved Date: 09/23/2021 Formulary Version: 91
30 Drug Status Notes RESCRIPTOR ORAL TABLET, DISPERSIBLE 3 QL (12 tablets per 1 day) SUSTIVA ORAL CAPSULE 3 QL (3 CAPSULES per 1 day) SUSTIVA ORAL TABLET 3 QL (1 TABLET per 1 day) VIRAMUNE ORAL SUSPENSION 3 QL (5 bottles per 30 days) VIRAMUNE ORAL TABLET 3 QL (2 tablets per 1 day) VIRAMUNE XR ORAL TABLET EXTENDED 3 QL (3 tablets per 1 day) RELEASE 24 HR 100 MG VIRAMUNE XR ORAL TABLET EXTENDED 3 QL (1 tablet per 1 day) RELEASE 24 HR 400 MG Antiretroviral - Nucleoside And Nucleotide Analog Rtis Combinations CIMDUO 2 QL (1 tablet per 1 day) DESCOVY 2 QL (1 TABLET per 1 day) emtricitabine-tenofovir (tdf) 1 QL (1 tablet per 1 Day) TEMIXYS 2 QL (1 tablet per 1 day) TRUVADA 3 PA; ST; QL (1 tablet per 1 day) Antiretroviral - Nucleoside Reverse Transcriptase Inhibitors (Nrti) abacavir oral solution 1 QL (4 bottles per 30 dayss) abacavir oral tablet 1 QL (2 tablets per 1 day) didanosine 1 QL (1 capsule per 1 day) emtricitabine 3 QL (1 capsule per 1 Day) EMTRIVA ORAL CAPSULE 3 QL (1 capsule per 1 day) EMTRIVA ORAL SOLUTION 3 QL (5 bottles per 30 days) EPIVIR ORAL SOLUTION 3 QL (4 bottles per 30 days) EPIVIR ORAL TABLET 150 MG 3 QL (2 tablets per 1 day) EPIVIR ORAL TABLET 300 MG 3 QL (1 tablet per 1 day) lamivudine oral solution 1 QL (4 bottles per 30 days) lamivudine oral tablet 150 mg 1 QL (2 tablets per 1 day) lamivudine oral tablet 300 mg 1 QL (1 tablet per 1 day) RETROVIR ORAL CAPSULE 3 QL (6 capsules per 1 day) RETROVIR ORAL SYRUP 3 QL (8 bottles per 30 days) stavudine oral capsule 1 QL (2 capsules per 1 day) VIDEX 2 GRAM PEDIATRIC 2 QL (6 bottles per 30 days) VIDEX 4 GRAM PEDIATRIC 2
Last Approved Date: 09/23/2021 Formulary Version: 91
31 Drug Status Notes VIDEX EC 3 QL (1 capsule per 1 day) ZERIT 3 ZIAGEN ORAL SOLUTION 3 QL (4 bottles per 30 days) ZIAGEN ORAL TABLET 3 QL (2 tablets per 1 day) zidovudine oral capsule 1 QL (6 capsules per 1 day) zidovudine oral syrup 1 QL (8 bottles per 30 days) zidovudine oral tablet 1 QL (2 tablets per 1 day) Antiretroviral - Nucleotide Analog Reverse Transcriptase Inhibitors tenofovir disoproxil fumarate 1 QL (1 Tablet per 1 day) VIREAD ORAL POWDER 3 QL (4 bottles per 30 days) VIREAD ORAL TABLET 3 QL (1 TABLET per 1 day) Antiretroviral Combinations - Protease Inhibitors EVOTAZ 2 QL (1 TABLET per 1 day) KALETRA ORAL SOLUTION 3 QL (2 bottles per 30 days) KALETRA ORAL TABLET 100-25 MG 3 QL (2 tablets per 1 day) KALETRA ORAL TABLET 200-50 MG 3 QL (4 tablets per 1 day) lopinavir-ritonavir oral solution 1 QL (2 bottles per 30 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 2 QL (1 TABLET per 1 day) Antiretroviral- Nucleoside And Nucleotide Analogs,Protease Inhibitors SYMTUZA 2 QL (1 Tablet per 1 Day) Antiretroviral-Integrase Inhibitor,Nucleoside And Nucleotide Rtis Comb BIKTARVY 2 QL (1 Tablet per 1 Day) GENVOYA 2 QL (1 TABLET per 1 day) STRIBILD 2 QL (1 TABLET per 1 day) Antiretroviral-Nucleoside Analogs And Integrase Inhibitor Combinations TRIUMEQ 2 QL (1 TABLET per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
32 Drug Status Notes Antiretroviral-Nucleoside Reverse Transcriptase Inhibitors (Nrti) Comb abacavir-lamivudine 1 QL (1 TABLET per 1 day) abacavir-lamivudine-zidovudine 1 QL (2 tablets per 1 day) COMBIVIR 3 EPZICOM 3 QL (1 TABLET per 1 day) lamivudine-zidovudine 1 QL (2 tablets per 1 day) TRIZIVIR 3 QL (2 tablets per 1 day) Antiretroviral-Nucleoside, Nucleotide Analogs And Non-Nucleoside Rti ATRIPLA 3 QL (1 TABLET per 1 day) COMPLERA 2 QL (1 TABLET per 1 day) DELSTRIGO 3 QL (1 tablet per 1 Day) efavirenz-emtricitabin-tenofov 1 QL (1 tablet per 1 Day) efavirenz-lamivu-tenofov disop 1 QL (1 tablet per 1 Day) ODEFSEY 2 QL (1 TABLET per 1 day) SYMFI 3 QL (1 tablet per 1 day) SYMFI LO 3 QL (1 tablet per 1 day) Antitubercular - Aminobenzoic Acid Analogs PASER 2 Antitubercular - D-Alanine Analogs cycloserine 3 Antitubercular - Diarylquinoline Antibiotics SIRTURO 4 SPT Antitubercular - Isonicotinic Acid Derivatives isoniazid oral solution 1 isoniazid oral tablet 1 $3-Copay Antitubercular - Niacinamide Derivatives pyrazinamide 1
Last Approved Date: 09/23/2021 Formulary Version: 91
33 Drug Status Notes Antitubercular - Nitroimidazole Derivatives PA; ST; QL (1 tablet per 1 day (or pretomanid 3 270 tablets per year)) Antitubercular - Rifamycin And Derivatives MYCOBUTIN 3 PRIFTIN 3 rifabutin 1 RIFADIN ORAL 3 rifampin oral 1 Antitubercular Agents Other ethambutol 1 MYAMBUTOL ORAL TABLET 400 MG 3 TRECATOR 3 Antitubercular Combinations RIFAMATE 3 RIFATER 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 $3-Copay cephalexin oral capsule 750 mg 1 cephalexin oral suspension for reconstitution 1 cephalexin oral tablet 1 DAXBIA 3 KEFLEX ORAL CAPSULE 3 Cephalosporin Antibiotics - 2Nd Generation cefaclor oral capsule 1 cefaclor oral suspension for reconstitution 125 1 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml
Last Approved Date: 09/23/2021 Formulary Version: 91
34 Drug Status Notes cefaclor oral tablet extended release 12 hr 1 cefprozil 1 CEFTIN ORAL SUSPENSION FOR 3 RECONSTITUTION CEFTIN ORAL TABLET 500 MG 3 cefuroxime axetil oral tablet 1 $3-Copay Cephalosporin Antibiotics - 3Rd Generation CEDAX 3 cefdinir 1 cefditoren pivoxil 3 cefixime oral capsule 3 cefixime oral suspension for reconstitution 1 cefpodoxime 3 ceftibuten 3 ceftriaxone injection recon soln 1 gram, 10 gram, 1 2 gram, 250 mg, 500 mg SPECTRACEF ORAL TABLET 400 MG 3 SUPRAX ORAL CAPSULE 3 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 3 ML SUPRAX ORAL SUSPENSION FOR 2 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 3 Cmv Antiviral Agent - Inorganic Pyrophosphate Analogs foscarnet 3 FOSCAVIR 3 Cmv Antiviral Agent - Nucleoside Analogs CYTOVENE 3 ganciclovir sodium intravenous recon soln 3 VALCYTE 3 valganciclovir 3
Last Approved Date: 09/23/2021 Formulary Version: 91
35 Drug Status Notes Cmv Antiviral Agent - Nucleotide Analogs cidofovir 3 VISTIDE 3 Cmv Antiviral Agent - Terminase Complex Inhibitors QL (100 TABLETS per 365 PREVYMIS INTRAVENOUS 3 DAYSs) SPT; QL (100 TABLETS per 365 PREVYMIS ORAL 4 DAYSs) Fluoroquinolone Antibiotics AVELOX 3 AVELOX ABC PACK 3 BAXDELA ORAL 3 QL (28 tablets per 1 Month) CIPRO ORAL 3 SUSPENSION,MICROCAPSULE RECON CIPRO ORAL TABLET 250 MG, 500 MG 3 CIPRO XR 3 ciprofloxacin 1 ciprofloxacin (mixture) 1 ciprofloxacin hcl oral tablet 100 mg 1 ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 1 $3-Copay mg FACTIVE 3 LEVAQUIN ORAL TABLET 3 levofloxacin 25 mg/ml solution 1 levofloxacin 250 mg/10 ml soln once-a-day, inner 3 levofloxacin 500 mg/20 ml soln once-a-day, inner 3 levofloxacin oral solution 250 mg/10 ml 1 levofloxacin oral tablet 1 $3-Copay moxifloxacin oral 3 ofloxacin oral tablet 300 mg, 400 mg 1 Glycopeptide Antibiotics FIRVANQ 2 QL (2100 ML per 180 days) PA; QL (141 capsules per 180 VANCOCIN 3 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
36 Drug Status Notes PA; QL (141 capsules per 180 vancomycin oral capsule 3 days) vancomycin oral recon soln 1 QL (2100 ML per 180 days) Hepatitis B Treatment- Nucleoside Analogs (Antiviral) BARACLUDE 4 SP; BE; SPT entecavir 3 ST; BE; SPT EPIVIR HBV ORAL SOLUTION 2 EPIVIR HBV ORAL TABLET 3 lamivudine oral tablet 100 mg 1 TYZEKA 4 SPT Hepatitis B Treatment- Nucleotide Analogs (Antiviral) adefovir 3 HEPSERA 4 SP; $3-Copay; SPT tenofovir disoproxil fumarate 1 QL (1 Tablet per 1 day) VEMLIDY 3 QL (1 tablet per 1 Day) VIREAD ORAL POWDER 3 QL (4 bottles per 30 days) VIREAD ORAL TABLET 3 QL (1 TABLET per 1 day) Hepatitis C - Interferons PEGASYS 3 PA; SP; BE; SPT PEGASYS PROCLICK 3 PA; SP; BE; SPT PEGINTRON REDIPEN 3 PA; SP; SPT PEGINTRON SUBCUTANEOUS KIT 120 3 PA; SP; SPT MCG/0.5 ML, 150 MCG/0.5 ML PEGINTRON SUBCUTANEOUS KIT 50 3 PA; SP; BE; SPT MCG/0.5 ML Hepatitis C - Ns3/4A Serine Protease Inhibitors PA; SP; BE; SPT; QL (28 OLYSIO 1 CAPSULES per 21 days) Hepatitis C - Ns5a Inhibitor And Ns3/4A Protease Inhibitor Combination PA; SP; BE; SPT; QL (84 tablets MAVYRET 3 per 28 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
37 Drug Status Notes PA; SP; SPT; QL (56 TABLETS TECHNIVIE 3 per 21 days) PA; SP; SPT; QL (28 Tablets per ZEPATIER 4 28 days) Hepatitis C - Ns5a Replication Complex Inhibitors PA; SP; SPT; QL (28 TABLETS DAKLINZA 4 per 21 days) Hepatitis C - Ns5a, Ns3/4A Protease, Nucleo.Ns5b Polymerase Inhib Comb PA; ST; SP; BE; SPT; QL (28 VOSEVI 4 tablets per 28 days) Hepatitis C - Ns5b Polymerase And Ns5a Inhibitor Combinations PA; BE; SPT; QL (84 day supply EPCLUSA ORAL TABLET 200-50 MG 3 per 720 Dayss) PA; SP; BE; SPT; QL (1 tablet per EPCLUSA ORAL TABLET 400-100 MG 3 1 day) PA; BE; SPT; QL (28 tablets per HARVONI ORAL PELLETS IN PACKET 3 21 days) PA; ST; SPT; QL (84 day supply HARVONI ORAL TABLET 45-200 MG 3 per 720 Dayss) PA; SP; BE; SPT; QL (28 HARVONI ORAL TABLET 90-400 MG 3 TABLETS per 21 days) PA; BE; SPT; QL (28 tablets per ledipasvir-sofosbuvir 3 21 Dayss) PA; BE; SPT; QL (28 tablets per sofosbuvir-velpatasvir 3 21 days) Hepatitis C - Nucleos(T)Ide Analog Ns5b Polymerase Inhibitors PA; ST; BE; SPT; QL (28 tablets SOVALDI ORAL PELLETS IN PACKET 4 per 21 Dayss) PA; ST; BE; SPT; QL (84 day SOVALDI ORAL TABLET 200 MG 4 supply per 720 Dayss) PA; SP; BE; SPT; QL (28 SOVALDI ORAL TABLET 400 MG 4 TABLETS per 21 days) Hepatitis C - Nucleoside Analogs COPEGUS 4 SP; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
38 Drug Status Notes MODERIBA 3 SP; SPT MODERIBA DOSE PACK 3 SP; BE REBETOL ORAL SOLUTION 1 SP; BE; SPT RIBASPHERE 3 SP; BE; SPT RIBASPHERE RIBAPAK ORAL TABLETS,DOSE PACK 200 MG (28)- 400 MG 3 SP; SPT (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 3 SP; BE; SPT (7), 400 MG (7)- 400 MG (7), 600 MG (7)- 400 MG (7), 600 MG (7)- 600 MG (7) ribavirin oral capsule 3 SP; SPT ribavirin oral tablet 200 mg 3 SP; SPT Hepatitis C- Ns5a, Ns3/4A Protease And Non-Nucleo.Ns5b Poly Inh. Comb PA; SP; BE; SPT; QL (112 VIEKIRA PAK 3 TABLETS per 21 days) PA; SP; BE; SPT; QL (28 tablets VIEKIRA XR 3 per 28 days) Herpes Antiviral Agent - Purine Analogs acyclovir oral capsule 1 $3-Copay acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 1 $3-Copay SITAVIG 3 PA; ST valacyclovir 1 VALTREX 3 ZOVIRAX ORAL 3 Herpes Antiviral Agent - Thymidine Analogs famciclovir 1 FAMVIR 3 Influenza Antiviral Agents - Neuraminidase Inhibitors oseltamivir oral capsule 30 mg 1 QL (20 capsules per 3 months) oseltamivir oral capsule 45 mg, 75 mg 1 QL (10 capsules per 3 months)
Last Approved Date: 09/23/2021 Formulary Version: 91
39 Drug Status Notes oseltamivir oral suspension for reconstitution 1 RELENZA DISKHALER 3 QL (5 ROTADISKS per 1 day) TAMIFLU ORAL CAPSULE 30 MG 3 QL (20 capsules per 3 months) TAMIFLU ORAL CAPSULE 45 MG 3 QL (10 capsules per 3 months) QL (10 CAPSULES per 3 TAMIFLU ORAL CAPSULE 75 MG 3 MONTHs) TAMIFLU ORAL SUSPENSION FOR 3 QL (3 bottles per 3 months) RECONSTITUTION Influenza Antiviral Agents - Pa Endonuclease Inhibitor XOFLUZA ORAL TABLET 20 MG, 40 MG 2 QL (2 tablets per 1 prescription) QL (1 tablet per 1 dispensing XOFLUZA ORAL TABLET 80 MG 2 event) Influenza-A Antiviral Agents FLUMADINE ORAL TABLET 3 rimantadine 1 Ketolide Antibiotics KETEK 3 Lincosamide Antibiotics CLEOCIN HCL 3 CLEOCIN PEDIATRIC 3 clindamycin hcl 1 clindamycin palmitate hcl 3 Macrolide Antibiotics azithromycin oral packet 1 azithromycin oral suspension for reconstitution 1 azithromycin oral tablet 250 mg, 500 mg 1 $3-Copay azithromycin oral tablet 600 mg 1 BIAXIN ORAL SUSPENSION FOR 3 RECONSTITUTION 250 MG/5 ML BIAXIN ORAL TABLET 3 clarithromycin 1 DIFICID ORAL SUSPENSION FOR PA; ST; BE; $3-Copay; SPT; QL 4 RECONSTITUTION (150 ML per 180 Dayss) PA; ST; BE; $3-Copay; SPT; QL DIFICID ORAL TABLET 4 (20 tablets per 180 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
40 Drug Status Notes E.E.S. 200 3 E.E.S. 400 ORAL TABLET 1 E.E.S. GRANULES 3 ERYPED 3 ERYPED 200 3 ERYPED 400 3 ERY-TAB ORAL TABLET,DELAYED 1 RELEASE (DR/EC) 250 MG, 333 MG ERY-TAB ORAL TABLET,DELAYED 3 RELEASE (DR/EC) 500 MG ERYTHROCIN (AS STEARATE) ORAL 1 TABLET 250 MG erythromycin ethylsuccinate oral suspension for 1 reconstitution erythromycin ethylsuccinate oral tablet 1 erythromycin oral 1 erythromycin stearate oral tablet 250 mg 1 PCE 3 ZITHROMAX ORAL 3 ZITHROMAX TRI-PAK 3 ZITHROMAX Z-PAK 3 ZMAX 3 Misc Anti-Infective HIPREX 3 methenamine hippurate 1 methenamine mandelate 1 NEBUPENT 3 pentamidine inhalation 1 UROQID-ACID NO.2 3 Misc Anti-Infective Combinations AZUPHEN MB 1 HYOLEV MB 1 HYOPHEN 1 INDIOMIN MB 3 methen-sod phos-meth blue-hyos 1 PHOSPHASAL 1 Last Approved Date: 09/23/2021 Formulary Version: 91
41 Drug Status Notes UR N-C 1 URAMIT MB 1 URELLE 3 URETRON D-S 1 URIBEL 3 URIMAR-T 1 URIN DS 1 URO-458 1 UROAV-B 1 UROGESIC-BLUE 1 UROLET MB 1 URO-MP 1 UROPHEN MB 1 URYL 1 USTELL 1 UTA 3 UTIRA-C 1 VILAMIT MB 1 VILEVEV MB 1 Oxazolidinone Antibiotics linezolid oral suspension for reconstitution 3 PA; QL (28 CAPSULES per 180 linezolid oral tablet 3 days) SIVEXTRO ORAL 3 QL (6 TABLETS per 3 MONTHs) ZYVOX ORAL SUSPENSION FOR 3 PA; QL (900 ML per 180 days) RECONSTITUTION PA; QL (28 CAPSULES per 180 ZYVOX ORAL TABLET 3 days) Penicillin Antibiotic - Natural BICILLIN L-A 3 penicillin g procaine 3 penicillin v potassium 1 $3-Copay Penicillin Antibiotic - Penicillinase- Resistant dicloxacillin 1
Last Approved Date: 09/23/2021 Formulary Version: 91
42 Drug Status Notes Penicillin Natural Antibiotic Combinations - Extended Release BICILLIN C-R 3 Pleuromutilin Antibiotics XENLETA ORAL 4 SPT; QL (10 tablets per 180 days) Polymyxins And Derivatives - Single Agents BACIIM 3 bacitracin intramuscular 3 Protease Inhibitors (Non-Peptidic) Antiretroviral APTIVUS 3 QL (4 capsules per 1 day) APTIVUS (WITH VITAMIN E) 3 QL (4 bottles per 30 days) PREZCOBIX 2 QL (1 TABLET per 1 day) PREZISTA ORAL SUSPENSION 2 QL (2 bottles per 30 days) PREZISTA ORAL TABLET 150 MG 2 QL (6 tablets per 1 day) PREZISTA ORAL TABLET 600 MG 2 QL (2 TABLETS per 1 day) PREZISTA ORAL TABLET 75 MG, 800 MG 2 QL (1 TABLET per 1 day) Protease Inhibitors (Peptidic) Antiretroviral atazanavir oral capsule 150 mg, 300 mg 1 QL (1 Capsule per 1 day) atazanavir oral capsule 200 mg 1 QL (2 Capsules per 1 day) CRIXIVAN ORAL CAPSULE 200 MG 3 QL (3 tablets per 1 day) CRIXIVAN ORAL CAPSULE 400 MG 3 QL (6 tablets per 1 day) EVOTAZ 2 QL (1 TABLET per 1 day) fosamprenavir 1 QL (4 tablets per 1 day) INVIRASE ORAL CAPSULE 2 INVIRASE ORAL TABLET 2 QL (4 tablets per 1 day) LEXIVA ORAL SUSPENSION 3 QL (8 bottles per 30 days) LEXIVA ORAL TABLET 3 QL (4 tablets per 1 day) NORVIR ORAL POWDER IN PACKET 3 QL (60 packets per 30 days) NORVIR ORAL SOLUTION 2 QL (2 bottles per 30 days) NORVIR ORAL TABLET 3 QL (12 tablets per 1 day) REYATAZ ORAL CAPSULE 150 MG, 300 MG 3 QL (1 CAPSULE per 1 day) REYATAZ ORAL CAPSULE 200 MG 3 QL (2 CAPSULES per 1 day) Last Approved Date: 09/23/2021 Formulary Version: 91
43 Drug Status Notes REYATAZ ORAL POWDER IN PACKET 3 QL (6 PACKETS per 1 MONTH) ritonavir 1 QL (12 tablets per 1 day) VIRACEPT ORAL TABLET 250 MG 3 QL (9 tablets per 1 day) VIRACEPT ORAL TABLET 625 MG 3 QL (4 tablets per 1 day) Respiratory Syncytial Virus (Rsv) Antiviral Agents ribavirin inhalation 1 VIRAZOLE 3 Rifamycins And Related Derivative Antibiotics AEMCOLO 2 QL (12 tablets per 90 days) MYCOBUTIN 3 PRIFTIN 3 rifabutin 1 RIFADIN ORAL 3 rifampin oral 1 XIFAXAN ORAL TABLET 200 MG 3 QL (9 TABLETS per 3 MONTHs) XIFAXAN ORAL TABLET 550 MG 3 PA Sulfonamide Antibiotic sulfadiazine 3 Tetracycline Antibiotics ACTICLATE 3 PA; ST AVIDOXY 1 COREMINO 3 demeclocycline 3 DORYX ORAL TABLET,DELAYED 3 PA; ST RELEASE (DR/EC) 200 MG, 80 MG doxycycline hyclate oral capsule 1 doxycycline hyclate oral tablet 100 mg, 50 mg 1 doxycycline hyclate oral tablet 150 mg, 75 mg 3 doxycycline monohydrate oral capsule 100 mg 3 $3-Copay doxycycline monohydrate oral capsule 150 mg, 3 50 mg, 75 mg doxycycline monohydrate oral capsule,ir - delay 3 rel,biphase
Last Approved Date: 09/23/2021 Formulary Version: 91
44 Drug Status Notes doxycycline monohydrate oral suspension for 3 reconstitution doxycycline monohydrate oral tablet 3 MINOCIN 3 PA; ST minocycline oral capsule 1 minocycline oral capsule,extended release 24hr 3 PA; ST minocycline oral tablet 1 PA; ST minocycline oral tablet extended release 24 hr 3 105 mg, 115 mg, 55 mg, 65 mg, 80 mg minocycline oral tablet extended release 24 hr 3 PA 135 mg, 45 mg, 90 mg MINOLIRA ER 3 PA; ST MONDOXYNE NL 1 MONODOX 3 PA; ST MORGIDOX 1 NUZYRA (7 DAY WITH LOAD DOSE) 4 NUZYRA (7 DAY) 4 NUZYRA ORAL 4 OKEBO 1 ORACEA 3 SEYSARA 3 SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 3 PA; ST MG, 80 MG SOLOXIDE 1 TARGADOX 3 PA; ST tetracycline 1 VIBRAMYCIN ORAL CAPSULE 100 MG 3 PA; ST VIBRAMYCIN ORAL SUSPENSION FOR 3 PA; ST RECONSTITUTION VIBRAMYCIN ORAL SYRUP 2 PA; ST XIMINO 3 Antineoplastics Antineoplasic-Epiderm.Growth Factor- Egfr (Erbb1),Her-2 (Erbb2)R.Inhib PA; ST; BE; SPT; QL (6 tablets lapatinib 3 per 1 Day) Last Approved Date: 09/23/2021 Formulary Version: 91
45 Drug Status Notes PA; ST; SP; BE; SPT; QL (6 TYKERB 4 Tablets per 1 day) Antineoplastic - Cyp17 (17 Alpha- Hydroxylase/C17,20-Lyase) Inhibitor PA; BE; SPT; QL (4 tablets per 1 abiraterone oral tablet 250 mg 3 day) PA; ST; BE; SPT; QL (2 tablets abiraterone oral tablet 500 mg 4 per 1 day) PA; ST; BE; SPT; QL (4 Tablets YONSA 4 per 1 Day) ZYTIGA ORAL TABLET 250 MG 4 BE PA; ST; SP; BE; SPT; QL (2 ZYTIGA ORAL TABLET 500 MG 4 tablets per 1 day) Antineoplastic - 1St Generation Egfr Tyrosine Kinase Inhibitor PA; ST; BE; SPT; QL (1 tablet per erlotinib oral tablet 100 mg, 150 mg 3 1 day) PA; ST; BE; SPT; QL (2 tablets erlotinib oral tablet 25 mg 3 per 1 day) PA; BE; SPT; QL (34 TABLETS IRESSA 4 per 1 MONTH) PA; SP; BE; SPT; QL (1 Tablet TARCEVA ORAL TABLET 100 MG, 150 MG 4 per 1 day) PA; SP; BE; SPT; QL (2 tablets TARCEVA ORAL TABLET 25 MG 4 per 1 day) Antineoplastic - 2Nd Generation Egfr Tyrosine Kinase Inhibitor PA; BE; SPT; QL (1 Tablet per 1 GILOTRIF 4 day) PA; ST; BE; SPT; QL (6 tablets NERLYNX 4 per 1 day) PA; BE; SPT; QL (1 tablet per 1 VIZIMPRO 4 Day) Antineoplastic - 3Rd Generation Egfr Tyrosine Kinase Inhibitor PA; ST; BE; SPT; QL (1 TABLET TAGRISSO 4 per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
46 Drug Status Notes Antineoplastic - Alkylating Agent - Alkyl Sulfonates MYLERAN 2 Antineoplastic - Alkylating Agent - Ethylenimines And Methylmelamines HEXALEN 3 Antineoplastic - Alkylating Agent - Methylhydrazines MATULANE 3 SP; SPT Antineoplastic - Alkylating Agent - Nitrogen Mustards ALKERAN 3 cyclophosphamide oral capsule 1 cyclophosphamide oral tablet 3 LEUKERAN 2 QL (5 tablets per 1 day) melphalan 1 Antineoplastic - Alkylating Agent - Nitrosoureas GLEOSTINE 3 Antineoplastic - Alkylating Agent - Triazenes TEMODAR ORAL 4 SP; BE; SPT temozolomide 3 SP; BE; SPT Antineoplastic - Anaplastic Lymphoma Kinase (Alk) Inhibitors PA; ST; BE; SPT; QL (8 Capsules ALECENSA 3 per 1 day) ALUNBRIG ORAL TABLET 180 MG, 90 MG 4 PA; ST; BE; SPT; QL (4 tablets ALUNBRIG ORAL TABLET 30 MG 4 per 1 day) PA; ST; BE; SPT; QL (1 dose ALUNBRIG ORAL TABLETS,DOSE PACK 4 packet per 720 days) PA; ST; BE; SPT; QL (1 tablet per LORBRENA ORAL TABLET 100 MG 4 1 Day) PA; ST; BE; SPT; QL (3 tablets LORBRENA ORAL TABLET 25 MG 4 per 1 Day)
Last Approved Date: 09/23/2021 Formulary Version: 91
47 Drug Status Notes PA; SP; BE; SPT; QL (2 Capsules XALKORI 3 per 1 day) PA; BE; SPT; QL (170 ZYKADIA ORAL CAPSULE 4 CAPSULES per 1 MONTH) PA; ST; BE; SPT; QL (3 tablets ZYKADIA ORAL TABLET 4 per 1 day) Antineoplastic - Antiadrenals LYSODREN 3 Antineoplastic - Antiandrogens PA; BE; SPT; QL (4 tablets per 1 abiraterone oral tablet 250 mg 3 day) PA; ST; BE; SPT; QL (2 tablets abiraterone oral tablet 500 mg 4 per 1 day) bicalutamide 1 CASODEX 3 PA; ST PA; ST; $3-Copay; SPT; QL (4 ERLEADA 3 Tablets per 1 day) flutamide 1 NILANDRON 3 PA; ST nilutamide 1 PA; BE; SPT; QL (4 tablets per 1 NUBEQA 4 day) PA; SP; BE; SPT; QL (4 capsules XTANDI ORAL CAPSULE 3 per 1 day) PA; ST; BE; SPT; QL (3 tablets XTANDI ORAL TABLET 40 MG 3 per 1 day) PA; ST; BE; SPT; QL (2 tablets XTANDI ORAL TABLET 80 MG 3 per 1 day) PA; ST; BE; SPT; QL (4 Tablets YONSA 4 per 1 Day) PA; ST; SP; BE; SPT; QL (4 ZYTIGA ORAL TABLET 250 MG 4 Tablets per 1 day) PA; ST; SP; BE; SPT; QL (2 ZYTIGA ORAL TABLET 500 MG 4 tablets per 1 day) Antineoplastic - Antimetabolite - Folic Acid Analogs methotrexate sodium 1 methotrexate sodium (pf) injection solution 1
Last Approved Date: 09/23/2021 Formulary Version: 91
48 Drug Status Notes TREXALL 3 XATMEP 3 ST Antineoplastic - Antimetabolite - Purine Analogs mercaptopurine 1 PURIXAN 3 TABLOID 3 Antineoplastic - Antimetabolite - Pyrimidine Analogs capecitabine 3 SP; BE; SPT PA; ST; BE; SPT; QL (14 tablets ONUREG 4 per 28 days) XELODA 4 PA; ST; SP; BE; SPT Antineoplastic - Antimetabolite - Urea Derivatives HYDREA 3 hydroxyurea 1 Antineoplastic - Antimetabolites - Pyrimidine Analog Combinations LONSURF 4 PA; ST; SP; BE; SPT Antineoplastic - Aromatase Inhibitors anastrozole 1 ARIMIDEX 3 PA; ST AROMASIN 3 PA; ST exemestane 1 FEMARA 3 PA; ST letrozole 1 Antineoplastic - B-Cell Lymphoma-2 (Bcl-2) Inhibitors PA; ST; SP; BE; SPT; QL (2 VENCLEXTA ORAL TABLET 10 MG, 50 MG 3 tablets per 1 day) PA; ST; SP; BE; SPT; QL (6 VENCLEXTA ORAL TABLET 100 MG 3 tablets per 1 day) VENCLEXTA STARTING PACK 3 PA; ST; SP; BE; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
49 Drug Status Notes Antineoplastic - Braf Kinase Inhibitors PA; ST; BE; SPT; QL (6 capsules BRAFTOVI 4 per 1 Day) PA; SP; BE; SPT; QL (4 Capsules TAFINLAR 3 per 1 day) PA; SP; BE; SPT; QL (8 Tablets ZELBORAF 3 per 1 day) Antineoplastic - Bruton's Tyrosine Kinase (Btk) Inhibitor PA; ST; SPT; QL (4 capsules per 1 BRUKINSA 4 day) PA; ST; SP; $3-Copay; SPT; QL CALQUENCE 4 (2 capsules per 1 Day) PA; ST; BE; SPT; QL (1 capsule IMBRUVICA ORAL CAPSULE 70 MG 4 per 1 day) PA; ST; BE; SPT; QL (1 tablet per IMBRUVICA ORAL TABLET 4 1 day) Antineoplastic - Cyclin-Dependent Kinase (Cdk) 4/6 Inhibitors PA; ST; BE; SPT; QL (21 IBRANCE ORAL CAPSULE 3 CAPSULES per 1 MONTH) PA; ST; BE; SPT; QL (21 tablets IBRANCE ORAL TABLET 3 per 21 Dayss) KISQALI ORAL TABLET 200 MG/DAY (200 BE; SPT; QL (21 tablets per 28 4 MG X 1) days) KISQALI ORAL TABLET 400 MG/DAY (200 BE; SPT; QL (42 tablets per 28 4 MG X 2) days) KISQALI ORAL TABLET 600 MG/DAY (200 BE; SPT; QL (63 tablets per 28 4 MG X 3) days) PA; ST; SP; BE; SPT; QL (2 VERZENIO 3 tablets per 1 Day) Antineoplastic - Epidermal Growth Factor Receptor-2 (Her2) Inhibitor PA; ST; BE; SPT; QL (4 tablets TUKYSA 3 per 1 day) Antineoplastic - Epipodophyllotoxins etoposide intravenous 3 SP etoposide oral 3 SP; BE; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
50 Drug Status Notes TOPOSAR 3 SP Antineoplastic - Estrogens EMCYT 3 Antineoplastic - Exportin-1 (Xpo1) Inhibitors XPOVIO ORAL TABLET 100 MG/WEEK (20 PA; ST; BE; SPT; QL (20 tablets 4 MG X 5), 100 MG/WEEK (50 MG X 2) per 21 days) XPOVIO ORAL TABLET 40 MG/WEEK (20 PA; ST; BE; SPT; QL (8 tablets 4 MG X 2), 40 MG/WEEK (40 MG X 1) per 21 days) XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MG/WEEK), 60MG TWICE WEEK 4 QL (4 blister cards per 21 Dayss) (120 MG/WEEK) XPOVIO ORAL TABLET 60 MG/WEEK (20 PA; ST; BE; SPT; QL (12 tablets 4 MG X 3), 60 MG/WEEK (60 MG X 1) per 21 days) XPOVIO ORAL TABLET 80 MG/WEEK (20 PA; ST; BE; SPT; QL (16 tablets 4 MG X 4), 80 MG/WEEK (40 MG X 2) per 21 days) XPOVIO ORAL TABLET 80MG TWICE PA; ST; SPT; QL (32 tablets (1 4 WEEK (160 MG/WEEK) carton) per 28 dayss) Antineoplastic - Ezh2 Histone Methyltransferase (Hmt) Inhibitor PA; BE; SPT; QL (8 tablets per 1 TAZVERIK 4 day) Antineoplastic - Fibroblast Growth Factor Receptor (Fgfr) Kinase Inhib PA; ST; BE; SPT; QL (3 tablets BALVERSA ORAL TABLET 3 MG 4 per 1 day) PA; ST; BE; SPT; QL (2 tablets BALVERSA ORAL TABLET 4 MG 4 per 1 day) PA; ST; BE; SPT; QL (1 tablet per BALVERSA ORAL TABLET 5 MG 4 1 day) PA; ST; BE; SPT; QL (14 tablets PEMAZYRE 4 per 16 days) TRUSELTIQ ORAL CAPSULE 100 MG/DAY (100 MG X 1), 50 MG/DAY (25 MG X 2), 75 3 BE MG/DAY (25 MG X 3) TRUSELTIQ ORAL CAPSULE 125 PA; ST; BE; SPT; QL (1 pack per 4 MG/DAY(100 MG X1-25MG X1) 28 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
51 Drug Status Notes Antineoplastic - Fms-Like Tyrosine Kinase 3 (Flt3) Inhibitors PA; BE; SPT; QL (3 tablets per 1 XOSPATA 4 Day) Antineoplastic - Hedgehog Pathway Inhibitor PA; BE; SPT; QL (1 tablet per 1 DAURISMO ORAL TABLET 100 MG 4 Day) PA; EX; BE; SPT; QL (2 tablets DAURISMO ORAL TABLET 25 MG 4 per 1 Day) PA; SP; SPT; QL (34 CAPSULES ERIVEDGE 3 per 1 MONTH) PA; SP; BE; SPT; QL (1 capsule ODOMZO 4 per 1 day) Antineoplastic - Histone Deacetylase (Hdac) Inhibitors PA; BE; SPT; QL (6 Capsules per FARYDAK 4 16 days) PA; ST; SP; BE; SPT; QL (4 ZOLINZA 3 capsules per 1 day) Antineoplastic - Interferons INTRON A INJECTION RECON SOLN 3 PA; SP; BE; SPT INTRON A INJECTION SOLUTION 3 PA; SP; SPT SYLATRON 4 PA; SP; BE; SPT SYLATRON 4-PACK 4 PA; SP; SPT Antineoplastic - Interleukins PROLEUKIN 3 SPT Antineoplastic - Janus Kinase (Jak) Inhibitors PA; SP; SPT; QL (2 tablets per 1 JAKAFI 3 day) Antineoplastic - Janus Kinase(Jak),Fms-Like Tyrosine Kinase(Flt) Inhib PA; ST; BE; SPT; QL (4 capsules INREBIC 4 per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
52 Drug Status Notes Antineoplastic - Kinase Inhibitor And Aromatase Inhibitor Combination PA; BE; SPT; QL (1 pack per 28 KISQALI FEMARA CO-PACK 4 days) Antineoplastic - Kirsten Rat Sarcoma (Kras) Protein Inhibitor PA; ST; BE; SPT; QL (8 tablets LUMAKRAS 4 per 1 day) Antineoplastic - Lhrh (Gnrh) Agonist Analog Pituitary Suppressants ELIGARD 4 SP; SPT ELIGARD (3 MONTH) 4 SP; SPT ELIGARD (4 MONTH) 4 SP; SPT ELIGARD (6 MONTH) 4 SP; SPT leuprolide subcutaneous kit 3 SP; SPT LUPRON DEPOT (3 MONTH) 3 SP; SPT INTRAMUSCULAR SYRINGE KIT 22.5 MG LUPRON DEPOT (4 MONTH) 3 SP; SPT LUPRON DEPOT (6 MONTH) 2 SP; SPT LUPRON DEPOT INTRAMUSCULAR 3 SP; SPT SYRINGE KIT 7.5 MG TRELSTAR DEPOT 4 SPT TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 4 SPT MG TRELSTAR INTRAMUSCULAR SYRINGE 4 SPT TRELSTAR LA 4 SPT ZOLADEX 4 SP; BE; SPT Antineoplastic - Lhrh (Gnrh) Antagonist Pituitary Suppressants FIRMAGON 4 SP; SPT FIRMAGON KIT W DILUENT SYRINGE 4 PA; BE; SPT; QL (1 tablet per 1 ORGOVYX 4 day) Antineoplastic - Mast Cell Stabilizers cromolyn oral 1 GASTROCROM 3 Last Approved Date: 09/23/2021 Formulary Version: 91
53 Drug Status Notes Antineoplastic - Mek1 And Mek2 Kinase Inhibitors PA; ST; $3-Copay; SPT; QL (63 COTELLIC 4 Tablets per 21 days) KOSELUGO ORAL CAPSULE 10 MG 3 BE PA; BE; SPT; QL (4 capsules per KOSELUGO ORAL CAPSULE 25 MG 4 1 day) PA; SP; BE; SPT; QL (3 Tablets MEKINIST ORAL TABLET 0.5 MG 3 per 1 day) PA; SP; BE; SPT; QL (1 Tablets MEKINIST ORAL TABLET 2 MG 3 per 1 day) PA; ST; SPT; QL (6 tablets per 1 MEKTOVI 4 Day) Antineoplastic - Mtor Kinase Inhibitors AFINITOR DISPERZ 4 PA; SP; BE; SPT PA; ST; SP; BE; SPT; QL (1 AFINITOR ORAL TABLET 10 MG, 5 MG 4 Capsule per 1 day) PA; SP; BE; SPT; QL (1 capsule AFINITOR ORAL TABLET 2.5 MG, 7.5 MG 4 per 1 day) PA; ST; BE; SPT; QL (1 tablet per everolimus (antineoplastic) 4 1 day) Antineoplastic - Multikinase Inhibitors PA; BE; SPT; QL (1 Tablet per 1 CABOMETYX 3 day) PA; BE; SPT; QL (1 Capsule per 1 COMETRIQ 3 day) PA; ST; BE; SPT; QL (1 tablet per ICLUSIG ORAL TABLET 10 MG, 30 MG 3 1 day) PA; ST; SP; BE; SPT; QL (2 ICLUSIG ORAL TABLET 15 MG 3 tablets per 1 day) PA; ST; SP; BE; SPT; QL (1 tablet ICLUSIG ORAL TABLET 45 MG 3 per 1 day) PA; ST; SP; BE; SPT; QL (4 NEXAVAR 3 Tablets per 1 day) PA; ST; BE; SPT; QL (84 Tablets STIVARGA 3 per 21 days) PA; ST; BE; SPT; QL (4 tablets UKONIQ 4 per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
54 Drug Status Notes Antineoplastic - Mutant Isocitrate Dehydrogenase 1 (Midh1) Inhibitors PA; BE; SPT; QL (2 tablets per 1 TIBSOVO 4 Day) Antineoplastic - Mutant Isocitrate Dehydrogenase 2 (Midh2) Inhibitors PA; ST; SP; BE; SPT; QL (1 tablet IDHIFA 4 per 1 day) Antineoplastic - Phosphatidylinositol 3- Kinase (Pi3k) Inhibitors PA; ST; BE; SPT; QL (2 capsules COPIKTRA 4 per 1 Day) PA; ST; BE; SPT; QL (2 tablets ZYDELIG 4 per 1 day) Antineoplastic - Pi3k-Alpha Inhibitors PIQRAY ORAL TABLET 200 MG/DAY (200 PA; BE; QL (28 tablets per 28 4 MG X 1) days) PIQRAY ORAL TABLET 250 MG/DAY (200 PA; BE; QL (56 tablets per 28 MG X1-50 MG X1), 300 MG/DAY (150 MG X 4 days) 2) Antineoplastic - Pi3k-Delta And Gamma Inhibitors PA; ST; BE; SPT; QL (2 capsules COPIKTRA 4 per 1 Day) Antineoplastic - Pi3k-Delta Inhibitors PA; ST; BE; SPT; QL (2 tablets ZYDELIG 4 per 1 day) Antineoplastic - Poly (Adp-Ribose) Polymerase (Parp) Inhibitors LYNPARZA ORAL CAPSULE 4 PA; ST; SP; BE; SPT PA; ST; SP; BE; SPT; QL (4 LYNPARZA ORAL TABLET 4 tablets per 1 Day) PA; BE; SPT; QL (4 Tablets per 1 RUBRACA ORAL TABLET 200 MG, 300 MG 4 day) PA; ST; BE; SPT; QL (4 tablets RUBRACA ORAL TABLET 250 MG 4 per 1 Day) PA; BE; SPT; QL (3 capsules per TALZENNA ORAL CAPSULE 0.25 MG 4 1 Day)
Last Approved Date: 09/23/2021 Formulary Version: 91
55 Drug Status Notes PA; BE; SPT; QL (1 capsule per 1 TALZENNA ORAL CAPSULE 1 MG 4 Day) ZEJULA 4 PA; BE; QL (3 capsules per 1 day) Antineoplastic - Progestins DEPO-PROVERA INTRAMUSCULAR 3 SUSPENSION 400 MG/ML megestrol oral tablet 1 Antineoplastic - Proteasome Enzyme Inhibitors PA; ST; SP; BE; SPT; QL (1 NINLARO 4 capsule per 1 day) Antineoplastic - Protein-Tyrosine Kinase Inhibitors AYVAKIT ORAL TABLET 100 MG, 200 MG, PA; ST; BE; SPT; QL (1 tablet per 4 300 MG 1 Day) PA; BE; SPT; QL (1 tablet per 1 AYVAKIT ORAL TABLET 25 MG, 50 MG 4 Day) PA; ST; BE; SPT; QL (3 tablets BOSULIF ORAL TABLET 100 MG 4 per 1 day) BOSULIF ORAL TABLET 400 MG 4 PA; BE; SPT PA; ST; BE; SPT; QL (1 tablets BOSULIF ORAL TABLET 500 MG 4 per 1 day) PA; ST; SPT; QL (4 capsules per 1 BRUKINSA 4 day) PA; ST; SP; $3-Copay; SPT; QL CALQUENCE 4 (2 capsules per 1 Day) PA; BE; SPT; QL (2 Tablets per 1 CAPRELSA ORAL TABLET 100 MG 4 day) PA; BE; SPT; QL (1 Tablet per 1 CAPRELSA ORAL TABLET 300 MG 4 day) FOTIVDA 3 BE PA; ST; SP; BE; SPT; QL (6 GLEEVEC ORAL TABLET 100 MG 4 tablets per 1 day) PA; ST; SP; BE; SPT; QL (2 GLEEVEC ORAL TABLET 400 MG 4 tablets per 1 day) imatinib mesylate 100 mg tab 3 PA; ST; QL (6 tablets per 1 Day) imatinib mesylate 400 mg tab 3 PA; ST; QL (2 tablets per 1 Day) imatinib oral tablet 100 mg, 400 mg 3
Last Approved Date: 09/23/2021 Formulary Version: 91
56 Drug Status Notes PA; ST; BE; SPT; QL (3 capsules IMBRUVICA ORAL CAPSULE 140 MG 4 per 1 day) PA; ST; BE; SPT; QL (1 capsule IMBRUVICA ORAL CAPSULE 70 MG 4 per 1 day) PA; ST; BE; SPT; QL (1 tablet per IMBRUVICA ORAL TABLET 4 1 day) PA; ST; SP; SPT; QL (6 tablets INLYTA ORAL TABLET 1 MG 3 per 1 day) PA; ST; SP; SPT; QL (4 Tablets INLYTA ORAL TABLET 5 MG 3 per 1 day) LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), PA; BE; SPT; QL (1 capsule per 1 4 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG day) X 2-4 MG X 1) LENVIMA ORAL CAPSULE 12 MG/DAY (4 4 MG X 3), 4 MG LENVIMA ORAL CAPSULE 18 MG/DAY (10 PA; SP; BE; SPT; QL (1 capsule 4 MG X 1-4 MG X2), 8 MG/DAY (4 MG X 2) per 1 day) PA; SP; BE; SPT; QL (68 OFEV 4 TABLETS per 1 MONTH) PA; ST; BE; SPT; QL (3 tablets QINLOCK 1 per 1 day) PA; ST; BE; SPT; QL (5 capsules ROZLYTREK ORAL CAPSULE 100 MG 1 per 1 day) PA; ST; BE; SPT; QL (3 capsules ROZLYTREK ORAL CAPSULE 200 MG 1 per 1 day) PA; ST; BE; SPT; QL (8 capsules RYDAPT 4 per 1 day) SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 PA; ST; SP; BE; SPT; QL (1 3 MG Capsule per 1 day) PA; SP; BE; SPT; QL (1 Capsule SPRYCEL ORAL TABLET 140 MG, 80 MG 3 per 1 day) PA; ST; SP; BE; SPT; QL (2 SPRYCEL ORAL TABLET 20 MG 3 Tablets per 1 day) SUTENT ORAL CAPSULE 12.5 MG, 25 MG, PA; ST; SP; BE; SPT; QL (1 3 50 MG Capsule per 1 day) PA; SP; BE; SPT; QL (1 capsule SUTENT ORAL CAPSULE 37.5 MG 3 per 1 day) PA; BE; SPT; QL (4 tablets per 1 TABRECTA 4 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
57 Drug Status Notes PA; SP; BE; SPT; QL (4 capsules TASIGNA ORAL CAPSULE 150 MG 3 per 1 day) PA; ST; SP; BE; SPT; QL (4 TASIGNA ORAL CAPSULE 200 MG 3 capsules per 1 day) PA; ST; BE; SPT; QL (4 capsules TASIGNA ORAL CAPSULE 50 MG 3 per 1 day) PA; ST; BE; SPT; QL (2 tablets TEPMETKO 4 per 1 day) PA; BE; SPT; QL (4 capsules per TURALIO 4 1 day) PA; ST; SP; BE; SPT; QL (4 VOTRIENT 3 Tablets per 1 day) Antineoplastic - Retinoids tretinoin (antineoplastic) 3 BE; SPT Antineoplastic - Selective Estrogen Receptor Modulators (Serms) FARESTON 3 SOLTAMOX 3 tamoxifen 1 toremifene 1 Antineoplastic - Selective Inhibitiors Of Nuclear Export (Sine) XPOVIO ORAL TABLET 100 MG/WEEK (20 PA; ST; BE; SPT; QL (20 tablets 4 MG X 5), 100 MG/WEEK (50 MG X 2) per 21 days) XPOVIO ORAL TABLET 40 MG/WEEK (20 PA; ST; BE; SPT; QL (8 tablets 4 MG X 2), 40 MG/WEEK (40 MG X 1) per 21 days) XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MG/WEEK), 60MG TWICE WEEK 4 QL (4 blister cards per 21 Dayss) (120 MG/WEEK) XPOVIO ORAL TABLET 60 MG/WEEK (20 PA; ST; BE; SPT; QL (12 tablets 4 MG X 3), 60 MG/WEEK (60 MG X 1) per 21 days) XPOVIO ORAL TABLET 80 MG/WEEK (20 PA; ST; BE; SPT; QL (16 tablets 4 MG X 4), 80 MG/WEEK (40 MG X 2) per 21 days) XPOVIO ORAL TABLET 80MG TWICE PA; ST; SPT; QL (32 tablets (1 4 WEEK (160 MG/WEEK) carton) per 28 dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
58 Drug Status Notes Antineoplastic - Selective Ret Kinase Inhibitor PA; $3-Copay; SPT; QL (4 GAVRETO 4 capsules per 1 day) PA; ST; BE; SPT; QL (6 capsules RETEVMO ORAL CAPSULE 40 MG 4 per 1 day) RETEVMO ORAL CAPSULE 80 MG 3 BE Antineoplastic - Selective Retinoid X Receptor Agonists bexarotene 3 PA; ST; SP; BE; SPT TARGRETIN ORAL 4 PA; ST; SP; BE; SPT Antineoplastic - Thalidomide Analogs PA; ST; SP; BE; SPT; QL (21 POMALYST 4 capsules per 21 days) PA; ST; SP; BE; SPT; QL (1 REVLIMID 3 capsule per 1 day) THALOMID 4 BE Antineoplastic - Topoisomerase I Inhibitors HYCAMTIN ORAL 4 SP; SPT Antineoplastic - Tropomyosin Receptor Kinase (Trk) Inhibitor VITRAKVI 3 BE Antineoplastic - Vinca Alkaloids And Analogs NAVELBINE 3 Antineoplastic-Pyrimidine Analog And Cytidine Deaminase Inhibitor Comb PA; BE; SPT; QL (5 tablets per 28 INQOVI 4 days) Epidermal Growth Factor Recept Blocker (Her-2 Type), Rec-Mc Antibody OGIVRI 3 Fluorouracil And Related Rescue Agents VISTOGARD 3
Last Approved Date: 09/23/2021 Formulary Version: 91
59 Drug Status Notes Methotrexate Rescue Agents leucovorin calcium oral 1 Methotrexate Rescue Agents - Folic Acid Antagonist Type leucovorin calcium oral 1 Urinary Tract Protective Agents Used In Conjunction With Chemotherapy MESNEX ORAL 3 Antiseptics And Disinfectants Antiseptic - Biguanides chlorhexidine gluconate (bulk) 3 Antiseptic - Iodine/Iodophores IODOFLEX 3 IODOSORB 3 LUGOLS TOPICAL 1 Antiseptic - Others FORMADON TOPICAL SOLUTION 1 glutaraldehyde 3 Antiseptic - Quaternary Ammonium benzalkonium chloride (bulk) 3 Disinfectants - Aldehydes FORMADON TOPICAL SOLUTION 1 Biologicals Allergenic Extracts - Grass Pollen PA; ST; QL (34 TABLETS per 1 GRASTEK 3 MONTH) ORALAIR SUBLINGUAL TABLET 300 INDX PA; ST; QL (34 TABLETS per 1 3 REACTIVITY MONTH) Allergenic Extracts - Mite Extracts ODACTRA 3 PA; ST; QL (1 tablet per 1 Day) Allergenic Extracts - Weed Pollen PA; QL (34 TABLETS per 1 RAGWITEK 3 MONTH)
Last Approved Date: 09/23/2021 Formulary Version: 91
60 Drug Status Notes Hepatitis A And Hepatitis B Vaccine Combinations TWINRIX $0 TWINRIX (PF) 3 Hepatitis A Vaccine - Single Agents HAVRIX (PF) 3 VAQTA (PF) 3 Hepatitis B Vaccine Combinations PEDIARIX $0 PEDIARIX (PF) 3 VAXELIS (PF) $0 Hepatitis B Vaccines - Single Agents ENGERIX-B (HEPATITIS B)VACCINE $0 ENGERIX-B (PF) 3 ENGERIX-B PEDIATRIC (PF) 3 HEPLISAV-B (PF) 3 RECOMBIVAX HB $0 RECOMBIVAX HB (PF) 3 Immune Globulin - Gamma Globulin (Igg), Human ASCENIV 3 Live Vaccine And Live Virus Formulations FLUMIST QUAD 2016-2017 3 FLUMIST QUAD 2017-2018 3 FLUMIST QUAD 2018-2019 3 FLUMIST QUAD 2019-2020 2 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) M-M-R II (PF) 3 PROQUAD (PF) 3 ROTARIX 3 ROTATEQ VACCINE 3 VARIVAX (PF) 3 ZOSTAVAX (PF) 3 Last Approved Date: 09/23/2021 Formulary Version: 91
61 Drug Status Notes Peanut Desensitization Agents PALFORZIA (LEVEL 1) 4 PA; BE; SPT PALFORZIA (LEVEL 2) 4 PA; BE; SPT PALFORZIA (LEVEL 3) 4 PA; BE; SPT PALFORZIA (LEVEL 4) 4 PA; BE; SPT PALFORZIA (LEVEL 5) 4 PA; BE; SPT PALFORZIA (LEVEL 6) 4 PA; BE; SPT PALFORZIA (LEVEL 7) 4 PA; BE; SPT PALFORZIA (LEVEL 8) 4 PA; BE; SPT PALFORZIA (LEVEL 9) 4 PA; BE; SPT PALFORZIA (LEVEL 10) 4 PA; BE; SPT PA; BE; SPT; QL (1 unit per 1 PALFORZIA (LEVEL 11 UP-DOSE) 4 day) PALFORZIA INITIAL DOSE 4 PA; BE; SPT PA; BE; SPT; QL (1 unit per 1 PALFORZIA LEVEL 11 MAINTENANCE 4 day) Toxoid Vaccine Combinations ADACEL(TDAP ADOLESN/ADULT)(PF) 3 BOOSTRIX TDAP 3 DAPTACEL (DTAP PEDIATRIC) (PF) 3 INFANRIX (DTAP) (PF) 3 KINRIX (PF) 3 PEDIARIX $0 PEDIARIX (PF) 3 PENTACEL (PF) INTRAMUSCULAR KIT 15 3 LF UNIT-20 MCG-5 LF/0.5 ML QUADRACEL (PF) 3 TDVAX 3 TENIVAC (PF) 3 tetanus,diphtheria tox ped(pf) 3 VAXELIS (PF) $0 Vaccine Bacterial - Gram Negative Bacilli (Non-Enteric) ACTHIB (PF) 3 HIBERIX (PF) 3
Last Approved Date: 09/23/2021 Formulary Version: 91
62 Drug Status Notes PEDVAX HIB (PF) 3 PENTACEL ACTHIB COMPONENT (PF) 3 Vaccine Bacterial - Gram Negative Cocci MENACTRA (PF) INTRAMUSCULAR 3 SOLUTION MENOMUNE - A/C/Y/W-135 3 MENOMUNE - A/C/Y/W-135 (PF) 3 MENQUADFI (PF) $0 MENVEO A-C-Y-W-135-DIP (PF) 3 Vaccine Bacterial - Gram Negative Cocci And Bacilli MENHIBRIX (PF) 3 Vaccine Bacterial - Gram Positive Cocci PNEUMOVAX-23 3 PREVNAR 13 (PF) 3 Vaccine Bacterial - Meningococcal Group B Vaccines BEXSERO 3 TRUMENBA 3 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 CERVARIX VACCINE (PF) 3 GARDASIL (PF) 3 GARDASIL 9 (PF) 3
Last Approved Date: 09/23/2021 Formulary Version: 91
63 Drug Status Notes Vaccine Viral - Influenza A And B AFLURIA 2016-2017 3 AFLURIA 2016-2017 (PF) 3 AFLURIA 2017-2018 3 AFLURIA 2017-2018 (PF) 3 AFLURIA 2018-2019 3 AFLURIA 2018-2019 (PF) 3 AFLURIA QD 2019-20(3YR UP)(PF) 2 AFLURIA QD 2019-20(6-35MO)(PF) 2 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) AFLURIA QUAD 2016-2017 (PF) 3 AFLURIA QUAD 2017-2018 3 AFLURIA QUAD 2017-2018 (PF) 3 AFLURIA QUAD 2018-2019 3 AFLURIA QUAD 2018-2019 (PF) 3 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) EZ FLU 2016-17 (AFLURIA) (PF) 3 EZ FLU 2016-17 (FLUVIRIN) (PF) 3 EZ FLU 2018-19(FLUCELVAX)(PF) 3 EZ FLU16-17(FLUZON QD PED)(PF) 3 FLUAD 2016-2017 (65 YR UP)(PF) 3 FLUAD 2017-2018 (65 YR UP)(PF) 3 FLUAD 2018-2019 (65 YR UP)(PF) 3 FLUAD 2019-2020 (65 YR UP)(PF) 2 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) FLUARIX QUAD 2016-2017 (PF) 3 FLUARIX QUAD 2017-2018 (PF) 3 FLUARIX QUAD 2018-2019 (PF) 3 Last Approved Date: 09/23/2021 Formulary Version: 91
64 Drug Status Notes FLUARIX QUAD 2019-2020 (PF) 2 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 2016-2017 (PF) 3 FLUBLOK 2017-2018 (PF) 3 FLUBLOK QUAD 2017-2018 (PF) 3 FLUBLOK QUAD 2018-2019 (PF) 3 FLUBLOK QUAD 2019-2020 (PF) 2 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) FLUCELVAX QUAD 2016-2017 (PF) 3 FLUCELVAX QUAD 2017-2018 3 FLUCELVAX QUAD 2017-2018 (PF) 3 FLUCELVAX QUAD 2018-2019 3 FLUCELVAX QUAD 2018-2019 (PF) 3 FLUCELVAX QUAD 2019-2020 2 FLUCELVAX QUAD 2019-2020 (PF) 2 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) FLULAVAL QUAD 2016-2017 3 FLULAVAL QUAD 2016-2017 (PF) 3 FLULAVAL QUAD 2017-2018 3 FLULAVAL QUAD 2017-2018 (PF) 3 FLULAVAL QUAD 2018-2019 3 FLULAVAL QUAD 2018-2019 (PF) 3 FLULAVAL QUAD 2019-2020 2 FLULAVAL QUAD 2019-2020 (PF) 2 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) FLUMIST QUAD 2016-2017 3 FLUMIST QUAD 2017-2018 3 FLUMIST QUAD 2018-2019 3 FLUMIST QUAD 2019-2020 2 FLUMIST QUAD 2020-2021 $0 QL (1 dose (0.5ml) per 185 Dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
65 Drug Status Notes FLUMIST QUAD 2021-2022 $0 QL (1 dose (0.5ml) per 185 Dayss) FLUVIRIN 2016-2017 3 FLUVIRIN 2016-2017 (PF) 3 FLUVIRIN 2017-2018 3 FLUVIRIN 2017-2018 (PF) 3 FLUZONE HIGH-DOSE 2016-17 (PF) 3 FLUZONE HIGH-DOSE 2017-18 (PF) 3 FLUZONE HIGH-DOSE 2018-19 (PF) 3 FLUZONE HIGH-DOSE 2019-20 (PF) 2 FLUZONE HIGHDOSE QUAD 20-21 PF $0 FLUZONE HIGHDOSE QUAD 21-22 PF $0 QL (1 dose (0.5ml) per 185 Dayss) FLUZONE INTRADERM QUAD 2016-17 3 FLUZONE INTRADERM QUAD 2017-18 3 FLUZONE QUAD 2016-2017 (PF) 3 FLUZONE QUAD 2017-2018 (PF) 3 FLUZONE QUAD 2018-2019 3 FLUZONE QUAD 2018-2019 (PF) 3 INTRAMUSCULAR SYRINGE FLUZONE QUAD 2019-2020 $0 FLUZONE QUAD 2019-2020 (PF) 2 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) FLUZONE QUAD PEDI 2016-17 (PF) 3 FLUZONE QUAD PEDI 2017-18 (PF) 3 FLUZONE QUAD PEDI 2018-19 (PF) 3 FLUZONE QUAD PEDI 2019-20 (PF) 2 Vaccine Viral - Measles M-M-R II (PF) 3 PROQUAD (PF) 3 Vaccine Viral - Mumps And Related M-M-R II (PF) 3 PROQUAD (PF) 3
Last Approved Date: 09/23/2021 Formulary Version: 91
66 Drug Status Notes Vaccine Viral - Poliomyelitis IPOL 3 Vaccine Viral - Rotavirus ROTARIX 3 ROTATEQ VACCINE 3 Vaccine Viral - Rubella M-M-R II (PF) 3 PROQUAD (PF) 3 Vaccine Viral - Varicella PROQUAD (PF) 3 SHINGRIX (PF) 3 VARIVAX (PF) 3 ZOSTAVAX (PF) 3 Vaccine Viral Combinations M-M-R II (PF) 3 PROQUAD (PF) 3 Cardiovascular Therapy Agents Ace Inhibitor And Calcium Channel Blocker Combinations amlodipine-benazepril 1 LOTREL 3 PRESTALIA 3 TARKA 3 trandolapril-verapamil 1 Ace Inhibitor And Diuretic Combinations ACCURETIC 3 benazepril-hydrochlorothiazide 1 captopril-hydrochlorothiazide 1 enalapril-hydrochlorothiazide 1 fosinopril-hydrochlorothiazide 1 lisinopril-hydrochlorothiazide 1 $3-Copay LOTENSIN HCT 3 moexipril-hydrochlorothiazide 1
Last Approved Date: 09/23/2021 Formulary Version: 91
67 Drug Status Notes quinapril-hydrochlorothiazide 1 VASERETIC 3 ZESTORETIC 3 Ace Inhibitors ACCUPRIL 3 ACEON ORAL TABLET 4 MG, 8 MG 3 ALTACE 3 benazepril 1 $3-Copay captopril 1 enalapril maleate oral tablet 1 EPANED ORAL RECON SOLN 3 EPANED ORAL SOLUTION 3 PA; ST; QL (40 ML per 1 Day) fosinopril 1 lisinopril 1 $3-Copay LOTENSIN ORAL TABLET 10 MG, 20 MG, 40 3 MG MAVIK ORAL TABLET 1 MG, 2 MG 3 moexipril 1 perindopril erbumine 1 PRINIVIL ORAL TABLET 10 MG, 20 MG, 5 3 MG QBRELIS 3 PA; ST quinapril 1 ramipril 1 trandolapril 1 VASOTEC 3 ZESTRIL 3 Aldosterone Receptor Antagonists ALDACTONE 3 CAROSPIR 3 PA; ST eplerenone 3 INSPRA 3 KERENDIA 3 spironolactone oral tablet 100 mg, 50 mg 1 $3-Copay spironolactone oral tablet 25 mg 1
Last Approved Date: 09/23/2021 Formulary Version: 91
68 Drug Status Notes Alpha-Beta Blockers carvedilol 1 $3-Copay carvedilol phosphate 3 PA; ST COREG 3 PA; ST COREG CR 3 PA; ST labetalol oral 1 Angiotensin Ii Receptor Blocker (Arb)- Beta-Adrenergic Blocker Comb. BYVALSON 3 Angiotensin Ii Receptor Blocker (Arb)- Calcium Channel Blocker Comb. amlodipine-olmesartan 3 amlodipine-valsartan 3 QL (34 TABLETS per 1 MONTH) AZOR 3 QL (34 TABLETS per 1 MONTH) EXFORGE 3 QL (34 TABLETS per 1 MONTH) telmisartan-amlodipine 1 TWYNSTA 3 Angiotensin Ii Receptor Blocker (Arb)- Calcium Channel Blocker-Diuretic amlodipine-valsartan-hcthiazid 3 EXFORGE HCT 3 olmesartan-amlodipin-hcthiazid 3 TRIBENZOR 3 Angiotensin Ii Receptor Blocker (Arb)- Diuretic Combinations ATACAND HCT 3 AVALIDE 3 QL (34 TABLETS per 1 MONTH) BENICAR HCT 3 QL (34 TABLETS per 1 MONTH) candesartan-hydrochlorothiazid 1 DIOVAN HCT 3 QL (34 TABLETS per 1 MONTH) EDARBYCLOR 3 HYZAAR 3 irbesartan-hydrochlorothiazide 1 QL (34 TABLETS per 1 MONTH) losartan-hydrochlorothiazide 1 $3-Copay MICARDIS HCT 3 Last Approved Date: 09/23/2021 Formulary Version: 91
69 Drug Status Notes olmesartan-hydrochlorothiazide 3 QL (1 tablet per 1 day) telmisartan-hydrochlorothiazid 1 valsartan-hydrochlorothiazide 1 QL (34 TABLETS per 1 MONTH) Angiotensin Ii Receptor Blocker- Neprilysin Inhibitor Comb. (Arni) PA; QL (60 TABLETS per 1 ENTRESTO 3 MONTH) Angiotensin Ii Receptor Blockers (Arbs) ATACAND 3 AVAPRO 3 QL (34 TABLETS per 1 MONTH) BENICAR ORAL TABLET 20 MG, 40 MG 3 QL (34 TABLETS per 1 MONTH) QL (102 TABLETS per 1 BENICAR ORAL TABLET 5 MG 3 MONTH) candesartan 1 COZAAR ORAL TABLET 100 MG 3 QL (34 TABLETS per 1 MONTH) QL (102 TABLETS per 1 COZAAR ORAL TABLET 25 MG 3 MONTH) COZAAR ORAL TABLET 50 MG 3 QL (68 TABLETS per 1 MONTH) DIOVAN ORAL TABLET 160 MG, 40 MG, 80 3 QL (68 TABLETS per 1 MONTH) MG DIOVAN ORAL TABLET 320 MG 3 QL (34 TABLETS per 1 MONTH) EDARBI 3 eprosartan 1 irbesartan 1 QL (34 TABLETS per 1 MONTH) $3-Copay; QL (34 TABLETS per losartan oral tablet 100 mg 1 1 MONTH) $3-Copay; QL (102 TABLETS per losartan oral tablet 25 mg 1 1 MONTH) $3-Copay; QL (68 TABLETS per losartan oral tablet 50 mg 1 1 MONTH) MICARDIS 3 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 1 valsartan oral tablet 160 mg, 40 mg, 80 mg 1 QL (68 TABLETS per 1 MONTH) valsartan oral tablet 320 mg 1 QL (34 TABLETS per 1 MONTH)
Last Approved Date: 09/23/2021 Formulary Version: 91
70 Drug Status Notes Antianginal - Coronary Vasodilators (Nitrates) DILATRATE-SR 3 GONITRO 3 ISOCHRON 3 ISORDIL 3 ISORDIL TITRADOSE ORAL TABLET 5 MG 3 isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 1 mg, 5 mg isosorbide dinitrate oral tablet 40 mg 3 isosorbide dinitrate oral tablet extended release 1 isosorbide dinitrate sublingual tablet 5 mg 1 isosorbide mononitrate 1 $3-Copay MINITRAN 3 NITRO-BID 1 NITRO-DUR 3 nitroglycerin oral 1 nitroglycerin sublingual 1 nitroglycerin transdermal patch 24 hour 1 nitroglycerin translingual 1 NITROLINGUAL 3 NITROMIST 3 NITROSTAT 3 NITRO-TIME 1 Antianginal And Anti-Ischemic Agents VERQUVO 3 PA; ST; QL (1 tablet per 1 day) Antianginal And Anti-Ischemic Agents, Non-Hemodynamic RANEXA 3 PA; ST ranolazine 3 PA; ST Antiarrhythmic - Class Ia disopyramide phosphate 1 NORPACE 3 NORPACE CR 3 quinidine gluconate oral 1
Last Approved Date: 09/23/2021 Formulary Version: 91
71 Drug Status Notes quinidine sulfate 1 Antiarrhythmic - Class Ib mexiletine 1 Antiarrhythmic - Class Ic flecainide 1 propafenone oral capsule,extended release 12 hr 3 propafenone oral tablet 1 RYTHMOL ORAL TABLET 225 MG 3 RYTHMOL SR 3 Antiarrhythmic - Class Ii BETAPACE 3 BETAPACE AF 3 SORINE 1 SOTALOL AF 1 sotalol oral 1 SOTYLIZE 3 Antiarrhythmic - Class Iii amiodarone oral 1 CORDARONE 3 dofetilide 3 MULTAQ 3 PACERONE ORAL TABLET 100 MG, 200 MG, 1 400 MG TIKOSYN 3 Antiarrhythmic - Class Iv CALAN 3 verapamil oral tablet 120 mg, 80 mg 1 $3-Copay verapamil oral tablet 40 mg 1 Antihyperlipidemic - Apolipoprotein B- 100 Synthesis Inhibitor KYNAMRO 4 PA; SP; BE; SPT Antihyperlipidemic - Atp-Citrate Lyase (Acly) Inhibitor NEXLETOL 3 PA; ST; QL (1 tablet per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
72 Drug Status Notes Antihyperlipidemic - Bile Acid Sequestrants cholestyramine (with sugar) 1 CHOLESTYRAMINE LIGHT 1 colesevelam 3 COLESTID 3 colestipol 1 PREVALITE 1 QUESTRAN LIGHT 3 QUESTRAN ORAL POWDER IN PACKET 3 WELCHOL 3 Antihyperlipidemic - Fibric Acid Derivatives ANTARA ORAL CAPSULE 30 MG, 90 MG 3 PA; ST fenofibrate micronized 1 fenofibrate nanocrystallized oral tablet 145 mg, 1 48 mg fenofibrate oral capsule 3 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) 1 FENOGLIDE 3 PA; ST FIBRICOR 3 PA; ST gemfibrozil 1 $3-Copay LIPOFEN 3 PA; ST LOFIBRA 3 LOPID 3 TRICOR 3 PA; ST TRIGLIDE ORAL TABLET 160 MG 3 PA; ST TRILIPIX 3 PA; ST Antihyperlipidemic - Hmg Coa Reductase Inhibitors (Statins) ALTOPREV ORAL TABLET EXTENDED 3 PA; ST; QL (1.5 tablets per 1 day) RELEASE 24 HR 20 MG
Last Approved Date: 09/23/2021 Formulary Version: 91
73 Drug Status Notes ALTOPREV ORAL TABLET EXTENDED 3 PA; ST; QL (1 tablet per 1 day) RELEASE 24 HR 40 MG, 60 MG $3-Copay; QL (1.5 tablets per 1 atorvastatin oral tablet 10 mg, 20 mg, 40 mg 1 day) atorvastatin oral tablet 80 mg 1 $3-Copay; QL (1 tablet per 1 day) CRESTOR ORAL TABLET 10 MG, 20 MG, 5 3 PA; ST; QL (1.5 tablets per 1 day) MG CRESTOR ORAL TABLET 40 MG 3 QL (1 tablet per 1 day) EZALLOR SPRINKLE 3 PA; ST; QL (1 capsule per 1 Day) FLOLIPID 3 PA; QL (150 ml per 30 Days) fluvastatin oral capsule 20 mg 1 QL (3 capsules per 1 day) fluvastatin oral capsule 40 mg 1 QL (2 capsules per 1 day) fluvastatin oral tablet extended release 24 hr 3 QL (1 tablet per 1 day) LESCOL ORAL CAPSULE 20 MG 3 PA; ST; QL (3 capsules per 1 day) LESCOL ORAL CAPSULE 40 MG 3 PA; ST; QL (2 capsules per 1 day) LESCOL XL 3 PA; ST; QL (1 tablet per 1 day) LIPITOR ORAL TABLET 10 MG, 20 MG, 40 3 PA; ST; QL (1.5 tablets per 1 day) MG LIPITOR ORAL TABLET 80 MG 3 PA; ST; QL (1 tablet per 1 day) LIVALO ORAL TABLET 1 MG, 2 MG 3 PA; ST; QL (1.5 tablets per 1 day) LIVALO ORAL TABLET 4 MG 3 PA; ST; QL (1 tablet per 1 day) $3-Copay; QL (1.5 tablets per 1 lovastatin oral tablet 10 mg, 20 mg 1 day) lovastatin oral tablet 40 mg 1 $3-Copay; QL (1 tablet per 1 day) PRAVACHOL ORAL TABLET 20 MG, 40 MG 3 PA; ST; QL (1.5 tablets per 1 day) PRAVACHOL ORAL TABLET 80 MG 3 PA; ST; QL (1 tablet per 1 day) $3-Copay; QL (1.5 tablets per 1 pravastatin oral tablet 10 mg, 20 mg, 40 mg 1 day) pravastatin oral tablet 80 mg 1 $3-Copay; QL (1 tablet per 1 day) rosuvastatin oral tablet 10 mg, 20 mg, 5 mg 1 QL (1.5 tablets per 1 day) rosuvastatin oral tablet 40 mg 1 QL (1 tablet per 1 day) PA; ST; QL (150 ML per 25 simvastatin oral suspension 3 dayss) $3-Copay; QL (1.5 tablets per 1 simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg 1 day) simvastatin oral tablet 80 mg 1 $3-Copay; QL (1 tablet per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
74 Drug Status Notes ZOCOR ORAL TABLET 10 MG, 20 MG, 40 3 PA; ST; QL (1.5 tablets per 1 day) MG, 5 MG ZOCOR ORAL TABLET 80 MG 3 PA; ST; QL (1 tablet per 1 day) ZYPITAMAG 3 PA; ST Antihyperlipidemic - Nicotinic Acid Derivatives niacin oral tablet 500 mg 3 niacin oral tablet extended release 24 hr 1 NIACOR 3 NIASPAN EXTENDED-RELEASE 3 Antihyperlipidemic - Omega-3 Fatty Acid Type icosapent ethyl 1 QL (4 capsules per 1 Day) LOVAZA 3 omega-3 acid ethyl esters 1 TRIKLO 1 VASCEPA ORAL CAPSULE 0.5 GRAM 2 QL (8 capsules per 1 day) VASCEPA ORAL CAPSULE 1 GRAM 2 QL (4 capsules per 1 day) Antihyperlipidemic - Pcsk9 Inhibitors PA; ST; SP; BE; QL (2 PENS per PRALUENT PEN 3 1 MONTH) PA; ST; SP; BE; QL (2 Auto- REPATHA PUSHTRONEX 2 Injectors per 1 Month) PA; ST; SP; BE; QL (2 AUTO- REPATHA SURECLICK 2 INJECTORS per 1 MONTH) PA; ST; SP; BE; QL (2 REPATHA SYRINGE 2 SYRINGES per 1 MONTH) Antihyperlipidemic - Selective Cholesterol Absorption Inhibitor ezetimibe 3 ZETIA 3 Antihyperlipidemic- Atp-Citrate Lyase And Cholesterol Absorption Inhib NEXLIZET 3 PA; QL (1 tablet per 1 Day)
Last Approved Date: 09/23/2021 Formulary Version: 91
75 Drug Status Notes Antihyperlipidemic Hmg Coa Reduct Inhib And Calcium Channel Blocker amlodipine-atorvastatin 1 QL (1 tablet per 1 day) CADUET 3 QL (1 tablet per 1 day) Antihyperlipidemic-Hmg Coa Reduct Inhib And Cholesterol Absorp Inhibit ezetimibe-simvastatin 1 QL (1 tablet per 1 day) ROSZET 3 PA; ST; QL (1 tablet per 1 day) VYTORIN 10-10 3 PA; ST; QL (1 tablet per 1 day) VYTORIN 10-20 3 PA; ST; QL (1 tablet per 1 day) VYTORIN 10-40 3 PA; ST; QL (1 tablet per 1 day) VYTORIN 10-80 3 PA; ST; 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; SPT MG JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 4 60 MG Beta Blockers Cardiac Selective atenolol 1 $3-Copay betaxolol oral 1 bisoprolol fumarate 1 BYSTOLIC 3 KAPSPARGO SPRINKLE 3 PA; ST LOPRESSOR ORAL 3 PA; ST metoprolol succinate 1 metoprolol tartrate oral tablet 100 mg, 25 mg, 50 1 $3-Copay mg metoprolol tartrate oral tablet 37.5 mg, 75 mg 1 TENORMIN 3 PA; ST TOPROL XL 3 ZEBETA 3 PA; ST Beta Blockers Cardiac Selective, Intrinsic Sympathomimetic Activity acebutolol 1 Last Approved Date: 09/23/2021 Formulary Version: 91
76 Drug Status Notes SECTRAL 3 PA; ST Beta Blockers Non-Cardiac Select., Intrinsic Sympathomimetic Activity pindolol 1 Beta Blockers Non-Cardiac Selective BETAPACE 3 BETAPACE AF 3 CORGARD 3 PA; ST HEMANGEOL 3 INDERAL LA 3 PA; ST INDERAL XL 3 PA; ST INNOPRAN XL 3 PA; ST nadolol 1 propranolol oral 1 SORINE 1 SOTALOL AF 1 sotalol oral 1 SOTYLIZE 3 timolol maleate oral 1 Bradykinin B2 Receptor Antagonists FIRAZYR 4 PA; ST; $3-Copay; SPT icatibant 3 PA; ST; BE; SPT Calcium Channel Blocker - Nsaid, Cox- 2 Selective Inhibitor Combination CONSENSI 3 PA; ST Calcium Channel Blockers - Benzothiazepines CARDIZEM CD 3 CARDIZEM LA 3 CARDIZEM ORAL TABLET 120 MG, 30 MG, 3 60 MG CARTIA XT 1 DILT-CD 1 diltiazem hcl oral capsule,ext.rel 24h degradable 1 diltiazem hcl oral capsule,extended release 12 hr 1
Last Approved Date: 09/23/2021 Formulary Version: 91
77 Drug Status Notes diltiazem hcl oral capsule,extended release 24 hr 1 diltiazem hcl oral capsule,extended release 24hr 1 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended release 24hr 3 360 mg diltiazem hcl oral tablet 1 diltiazem hcl oral tablet extended release 24 hr 1 DILT-XR 1 MATZIM LA 1 TAZTIA XT 1 TIADYLT ER ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 180 MG, 240 MG, 1 300 MG, 420 MG TIAZAC 3 Calcium Channel Blockers - Dihydropyridines ADALAT CC 3 AFEDITAB CR 1 amlodipine 1 $3-Copay CONJUPRI 3 PA; ST; QL (1 tablet per 1 Day) felodipine 1 isradipine 1 PA; ST; QL (2 bottles (300ml) per KATERZIA 3 30 days) nicardipine oral 1 NIFEDICAL XL 1 nifedipine oral capsule 3 nifedipine oral tablet extended release 1 nifedipine oral tablet extended release 24hr 1 nisoldipine 3 NORVASC 3 PROCARDIA 3 PROCARDIA XL 3 SULAR ORAL TABLET EXTENDED 3 RELEASE 24 HR 17 MG, 34 MG, 8.5 MG
Last Approved Date: 09/23/2021 Formulary Version: 91
78 Drug Status Notes Calcium Channel Blockers - Dihydropyridines - Cerebrovascular Specific nimodipine 3 NYMALIZE 3 Calcium Channel Blockers - Phenylakylamines CALAN SR 3 verapamil oral capsule, 24 hr er pellet ct 3 verapamil oral capsule,ext rel. pellets 24 hr 120 1 mg, 180 mg, 240 mg verapamil oral capsule,ext rel. pellets 24 hr 360 3 mg verapamil oral tablet 1 verapamil oral tablet extended release 1 VERELAN 3 VERELAN PM 3 Cardiac Selective Beta Blocker-Thiazide Diuretic And Related Comb. atenolol-chlorthalidone 1 bisoprolol-hydrochlorothiazide 1 DUTOPROL 3 PA; ST LOPRESSOR HCT 3 PA; ST metoprolol su-hydrochlorothiaz oral tablet 1 extended release 24 hr 100-12.5 mg, 50-12.5 mg metoprolol ta-hydrochlorothiaz 1 TENORETIC 100 3 PA; ST TENORETIC 50 3 PA; ST ZIAC 3 PA; ST Cardiovascular Sympathomimetic - Anaphylaxis Therapy Single Agents AUVI-Q INJECTION AUTO-INJECTOR 0.1 4 SPT MG/0.1 ML AUVI-Q INJECTION AUTO-INJECTOR 0.15 PA; ST; QL (2 devices per 1 4 MG/0.15 ML copay) AUVI-Q INJECTION AUTO-INJECTOR 0.3 PA; ST; SPT; QL (2 devices per 1 4 MG/0.3 ML copay) Last Approved Date: 09/23/2021 Formulary Version: 91
79 Drug Status Notes epinephrine injection auto-injector 0.15 mg/0.15 2 QL (2 Devices per 1 Copay) ml epinephrine injection auto-injector 0.15 mg/0.3 1 QL (2 units per 1 dispense) ml epinephrine injection auto-injector 0.3 mg/0.3 ml 1 QL (2 Devices per 1 Copay) epinephrine injection solution 1 mg/ml 1 EPINEPHRINESNAP-V 3 PA; ST; QL (2 devices per 1 EPIPEN 3 copay) PA; ST; QL (2 Devices per 1 EPIPEN 2-PAK 3 copay) PA; ST; QL (2 devices per 1 EPIPEN JR 3 copay) PA; ST; QL (2 Devices per 1 EPIPEN JR 2-PAK 3 copay) SYMJEPI 3 Cardiovascular Sympathomimetics BIORPHEN 3 PA; ST; BE; SPT; QL (3 capsules droxidopa oral capsule 100 mg 4 per 1 day) PA; ST; BE; SPT; QL (6 capsules droxidopa oral capsule 200 mg, 300 mg 4 per 1 day) epinephrine injection solution 1 mg/ml 1 midodrine 1 PA; ST; BE; SPT; QL (3 capsules NORTHERA ORAL CAPSULE 100 MG 4 per 1 day) NORTHERA ORAL CAPSULE 200 MG, 300 PA; ST; BE; SPT; QL (6 capsules 4 MG per 1 day) Central Alpha-2 Agonists-Thiazide Diuretic And Related Comb. methyldopa-hydrochlorothiazide 1 Central Alpha-2 Receptor Agonists CATAPRES 3 CATAPRES-TTS-1 3 CATAPRES-TTS-2 3 CATAPRES-TTS-3 3 clonidine 1
Last Approved Date: 09/23/2021 Formulary Version: 91
80 Drug Status Notes clonidine hcl oral tablet 1 $3-Copay guanfacine oral tablet 1 methyldopa 1 TENEX 3 Digitalis Glycosides DIGITEK 1 DIGOX 1 digoxin injection syringe 3 digoxin oral 1 LANOXIN ORAL 2 Direct Acting Vasodilators hydralazine oral tablet 10 mg, 25 mg, 50 mg 1 $3-Copay hydralazine oral tablet 100 mg 1 minoxidil oral 1 Diuretic - Aldosterone Receptor Antagonist, Non-Selective ALDACTONE 3 CAROSPIR 3 PA; ST spironolactone oral tablet 100 mg, 50 mg 1 $3-Copay spironolactone oral tablet 25 mg 1 Diuretic - Aldosterone Receptor Antagonist, Selective eplerenone 3 INSPRA 3 Diuretic - Carbonic Anhydrase Inhibitors acetazolamide 1 DIAMOX SEQUELS 3 methazolamide 1 NEPTAZANE 3 Diuretic - Loop bumetanide oral 1 DEMADEX ORAL TABLET 10 MG, 20 MG, 5 3 MG EDECRIN 3 Last Approved Date: 09/23/2021 Formulary Version: 91
81 Drug Status Notes ethacrynic acid 1 furosemide injection syringe 3 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 mg/ml) furosemide oral solution 40 mg/4 ml 3 furosemide oral tablet 1 $3-Copay LASIX 3 torsemide oral 1 Diuretic - Potassium Sparing amiloride 1 DYRENIUM 3 triamterene 3 Diuretic - Potassium Sparing-Thiazide And Related Combinations ALDACTAZIDE 3 amiloride-hydrochlorothiazide 1 DYAZIDE 3 MAXZIDE 3 MAXZIDE-25MG 3 spironolacton-hydrochlorothiaz 1 triamterene-hydrochlorothiazid oral capsule 1 $3-Copay 37.5-25 mg triamterene-hydrochlorothiazid oral capsule 50- 1 25 mg triamterene-hydrochlorothiazid oral tablet 1 $3-Copay Diuretic - Selective Arginine Vasopressin V2 Receptor Antagonists SAMSCA 4 PA; BE; SPT tolvaptan oral tablet 15 mg 4 PA; BE; SPT tolvaptan oral tablet 30 mg 3 PA; BE; SPT Diuretic - Thiazides And Related chlorothiazide 1 chlorthalidone oral tablet 25 mg, 50 mg 1 DIURIL 3 hydrochlorothiazide 1 $3-Copay
Last Approved Date: 09/23/2021 Formulary Version: 91
82 Drug Status Notes indapamide 1 methyclothiazide 1 metolazone 1 MICROZIDE 3 Ganglionic Blocking, Non-Depolarizing VECAMYL 3 Hyperpolarization-Activated Cyclic Nucleotide-Gated Channel Inhibitors PA; ST; QL (3 cartons (84 CORLANOR ORAL SOLUTION 3 ampules) per 28 Dayss) CORLANOR ORAL TABLET 3 PA; ST Muscarinic Receptor Antagonists (Anticholinergic) ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML, 2 3 MG/0.7 ML atropine injection solution 3 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 3 Non-Cardiac Selective Beta Blocker- Thiazide Diuretic And Related Comb. CORZIDE 3 PA; ST nadolol-bendroflumethiazide 1 propranolol-hydrochlorothiazid 1 Pah Agents - Selective Prostacyclin Receptor (Ip) Agonists PA; BE; SPT; QL (2 tablets per 1 UPTRAVI ORAL TABLET 4 day) PA; BE; SPT; QL (1 does-pack per UPTRAVI ORAL TABLETS,DOSE PACK 4 274 days) Patent Ductus Arteriosus (Pda) Treatment Agents, Prostaglandin-Type alprostadil 3 Peripheral Alpha-1 Receptor Blockers CARDURA 3 PA; ST CARDURA XL 3 PA; ST DIBENZYLINE 3 PA; ST; $3-Copay
Last Approved Date: 09/23/2021 Formulary Version: 91
83 Drug Status Notes doxazosin 1 MINIPRESS 3 phenoxybenzamine 1 PA; BE prazosin 1 terazosin 1 Peripheral Vasodilators, Single Agents isoxsuprine 1 Pheochromocytoma, Agents To Treat DEMSER 3 metyrosine 3 Plasma Kallikrein Inhibitor Agents, Recombinant Monoclonal Antibody PA; BE; SPT; QL (2 single-dose TAKHZYRO 4 vials per 28 Dayss) Plasma Kallikrein Inhibitor Agents, Small Molecule PA; BE; SPT; QL (1 capsule per 1 ORLADEYO 4 day) Pulmonary Antihypertensive Agents - Prostacyclin-Type ORENITRAM ORAL TABLET EXTENDED PA; ST; BE; SPT; QL (3 tablets 4 RELEASE 0.125 MG per 1 day) ORENITRAM ORAL TABLET EXTENDED PA; BE; SPT; QL (6 tablets per 1 4 RELEASE 0.25 MG, 1 MG day) ORENITRAM ORAL TABLET EXTENDED PA; BE; SPT; QL (17 tablets per 1 4 RELEASE 2.5 MG day) ORENITRAM ORAL TABLET EXTENDED 4 PA; BE; SPT RELEASE 5 MG 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) TYVASO INHALATION SOLUTION FOR NEBULIZATION 1.74 MG/2.9 ML (0.6 4 MG/ML) TYVASO INHALATION STARTER KIT 4 PA; QL (1 ampule per 1 day) TYVASO INSTITUTIONAL START KIT 4 PA; QL (1 ampule per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
84 Drug Status Notes TYVASO INSTITUTIONAL START KIT INHALATION SOLUTION FOR 4 NEBULIZATION 1.74 MG/2.9 ML TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 4 MG/2.9 ML (0.6 MG/ML) TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION 1.74 4 MG/2.9 ML PA; BE; SPT; QL (9 ampules per 1 VENTAVIS 4 Day) Pulmonary Antihypertensive Agents- Soluble Guanylate Cyclase Stimulator PA; BE; SPT; QL (3 tablets per 1 ADEMPAS 4 day) Pulmonary Arterial Hypertension - Endothelin Receptor Antagonists ambrisentan 3 BE bosentan 3 BE PA; SP; BE; SPT; QL (1 tablets LETAIRIS 4 per 1 day) PA; SP; BE; SPT; QL (1 tablet per OPSUMIT 1 1 day) TRACLEER ORAL TABLET 4 PA; SP; BE; SPT TRACLEER ORAL TABLET FOR PA; SP; BE; SPT; QL (4 tablets 4 SUSPENSION per 1 Day) Pulmonary Arterial Hypertension Agents-Selective Cgmp-Pde5 Inhibitors PA; ST; BE; SPT; QL (6 tablets ADCIRCA 4 per 1 dispense) ALYQ 3 BE; QL (6 tablets per 1 dispense) REVATIO INTRAVENOUS 3 PA; QL (6 mL per 1 Day) REVATIO ORAL SUSPENSION FOR PA; BE; SPT; QL (6 ML per 1 4 RECONSTITUTION day) PA; SP; BE; SPT; QL (3 tablets REVATIO ORAL TABLET 4 per 1 day) sildenafil (pulm.hypertension) oral suspension for 4 BE reconstitution
Last Approved Date: 09/23/2021 Formulary Version: 91
85 Drug Status Notes PA; SP; SPT; QL (3 tablets per 1 sildenafil (pulm.hypertension) oral tablet 3 day) tadalafil (pulm. hypertension) 3 Renin Inhibitor, Direct aliskiren 3 TEKTURNA 3 Renin Inhibitor, Direct And Diuretic Combinations TEKTURNA HCT 3 Vasodilator Combinations BIDIL 3 Central Nervous System Agents Agents To Treat Episodic Cluster Headaches EMGALITY SYRINGE SUBCUTANEOUS PA; ST; QL (3 syringes (300mg) 2 SYRINGE 300 MG/3 ML (100 MG/ML X 3) per 30 days) Antianxiety Agent - Antihistamine Type hydroxyzine 10 mg/5 ml soln 1 hydroxyzine 10 mg/5 ml syrup 1 hydroxyzine 50 mg/25 ml syrup 3 hydroxyzine hcl intramuscular 3 hydroxyzine hcl oral solution 10 mg/5 ml 3 hydroxyzine hcl oral tablet 1 $3-Copay hydroxyzine pamoate oral capsule 100 mg 1 hydroxyzine pamoate oral capsule 25 mg, 50 mg 1 $3-Copay VISTARIL 3 Antianxiety Agent - Benzodiazepines alprazolam 1 PA ALPRAZOLAM INTENSOL 1 PA ATIVAN ORAL 3 chlordiazepoxide hcl 1 clonazepam 1 clorazepate dipotassium 1 diazepam injection syringe 3 DIAZEPAM INTENSOL 1 Last Approved Date: 09/23/2021 Formulary Version: 91
86 Drug Status Notes diazepam oral solution 1 diazepam oral tablet 1 KLONOPIN 3 LORAZEPAM INTENSOL 1 lorazepam oral concentrate 1 lorazepam oral tablet 1 oxazepam 1 TRANXENE T-TAB 3 VALIUM 3 XANAX 3 PA XANAX XR 3 PA Antianxiety Agent - Dicarbamate Type meprobamate 3 Antianxiety Agent - Non- Benzodiazepine buspirone oral tablet 10 mg, 15 mg, 5 mg 1 $3-Copay buspirone oral tablet 30 mg, 7.5 mg 1 Anticonvulsant - Ampa-Type Glutamate Receptor Antagonists FYCOMPA ORAL SUSPENSION 3 QL (680 ML per 25 days) FYCOMPA ORAL TABLET 3 Anticonvulsant - Barbiturates And Derivatives MYSOLINE 3 phenobarbital 1 primidone 1 Anticonvulsant - Benzodiazepines clobazam 1 clonazepam 1 QL (2 APPLICATORS per 3 DIASTAT 3 MONTHs) QL (2 APPLICATORS per 3 DIASTAT ACUDIAL 3 MONTHs) QL (2 APPLICATORS per 3 diazepam rectal kit 12.5-15-17.5-20 mg 1 MONTHs)
Last Approved Date: 09/23/2021 Formulary Version: 91
87 Drug Status Notes diazepam rectal kit 2.5 mg, 5-7.5-10 mg 1 KLONOPIN 3 NAYZILAM 3 PA; QL (2 spray units per 25 days) ONFI 3 PA; ST; BE; SPT; QL (2 films per SYMPAZAN 4 1 day) PA; ST; QL (4 blister packs per 1 VALTOCO 3 dispensing event) Anticonvulsant - Cannabinoid Type EPIDIOLEX 4 PA; $3-Copay Anticonvulsant - Carbamates felbamate 3 FELBATOL 3 Anticonvulsant - Carboxylic Acid Derivatives DEPAKENE 3 DEPAKOTE 3 DEPAKOTE ER 3 DEPAKOTE SPRINKLES 3 divalproex 1 valproic acid 1 valproic acid (as sodium salt) oral solution 250 1 mg/5 ml, 500 mg/10 ml (10 ml) valproic acid (bulk) 3 Anticonvulsant - Functionalized Amino Acid VIMPAT ORAL SOLUTION 3 PA VIMPAT ORAL TABLET 3 PA Anticonvulsant - Gaba Analogs gabapentin oral capsule 1 gabapentin oral solution 250 mg/5 ml, 300 mg/6 1 ml (6 ml) gabapentin oral tablet 600 mg, 800 mg 1 LYRICA 3 PA; ST NEURONTIN 3 pregabalin oral capsule 3 PA; ST Last Approved Date: 09/23/2021 Formulary Version: 91
88 Drug Status Notes pregabalin oral solution 3 PA; ST Anticonvulsant - Gaba Re-Uptake Inhibitor, Nipecotic Acid Derivatives GABITRIL 3 tiagabine 3 Anticonvulsant - Gaba Transaminase (Gaba-T) Inhibitor SABRIL 4 PA; ST; BE; SPT vigabatrin oral powder in packet 4 PA; ST; SP; BE; SPT vigabatrin oral tablet 4 VIGADRONE 3 Anticonvulsant - Hydantoins DILANTIN 2 DILANTIN EXTENDED 2 DILANTIN INFATABS 3 DILANTIN KAPSEAL 2 DILANTIN-125 3 PEGANONE 3 PHENYTEK 3 phenytoin oral suspension 1 phenytoin oral tablet,chewable 1 phenytoin sodium extended 1 Anticonvulsant - Iminostilbene Derivatives APTIOM 3 carbamazepine 1 CARBATROL 3 EPITOL 1 oxcarbazepine 1 OXTELLAR XR 3 TEGRETOL ORAL SUSPENSION 3 TEGRETOL ORAL TABLET 3 TEGRETOL XR 3 TRILEPTAL 3
Last Approved Date: 09/23/2021 Formulary Version: 91
89 Drug Status Notes Anticonvulsant - Monosaccharide Derivatives QUDEXY XR 3 PA; ST TOPAMAX 3 topiramate oral capsule, sprinkle 1 topiramate oral capsule,sprinkle,er 24hr 3 PA; ST topiramate oral tablet 1 TROKENDI XR 3 PA; ST Anticonvulsant - Phenyltriazine Derivatives LAMICTAL ODT 3 LAMICTAL ODT STARTER (BLUE) 3 LAMICTAL ODT STARTER (GREEN) 3 LAMICTAL ODT STARTER (ORANGE) 3 LAMICTAL ORAL TABLET 3 LAMICTAL ORAL TABLET, CHEWABLE 3 DISPERSIBLE 25 MG, 5 MG LAMICTAL STARTER (BLUE) KIT 3 LAMICTAL STARTER (GREEN) KIT 3 LAMICTAL STARTER (ORANGE) KIT 3 LAMICTAL XR 3 LAMICTAL XR STARTER (BLUE) 3 LAMICTAL XR STARTER (GREEN) 3 LAMICTAL XR STARTER (ORANGE) 3 lamotrigine oral tablet 1 lamotrigine oral tablet disintegrating, dose pk 3 lamotrigine oral tablet extended release 24hr 3 lamotrigine oral tablet, chewable dispersible 1 lamotrigine oral tablet,disintegrating 3 lamotrigine oral tablets,dose pack 1 SUBVENITE 1 SUBVENITE STARTER (BLUE) KIT 1 SUBVENITE STARTER (GREEN) KIT 1 SUBVENITE STARTER (ORANGE) KIT 1
Last Approved Date: 09/23/2021 Formulary Version: 91
90 Drug Status Notes Anticonvulsant - Potassium Channel Opener POTIGA 3 Anticonvulsant - Pyrrolidine Derivatives BRIVIACT ORAL 3 ELEPSIA XR 4 PA; ST; SPT KEPPRA ORAL 3 KEPPRA XR 3 levetiracetam oral solution 1 levetiracetam oral tablet 1 levetiracetam oral tablet extended release 24 hr 3 ROWEEPRA 1 SPRITAM 3 Anticonvulsant - Succinimides CELONTIN ORAL CAPSULE 300 MG 3 ethosuximide 1 ZARONTIN 3 Anticonvulsant - Sulfonamide Derivatives ZONEGRAN ORAL CAPSULE 100 MG, 25 MG 3 zonisamide 1 Anticonvulsant - Triazole Derivatives BANZEL 3 rufinamide 3 Anticonvulsant Others PA; ST; BE; SPT; QL (3 DIACOMIT ORAL CAPSULE 250 MG 4 capsules/packets per 1 day) PA; ST; BE; SPT; QL (6 DIACOMIT ORAL CAPSULE 500 MG 4 capsules/packets per 1 day) DIACOMIT ORAL POWDER IN PACKET 250 PA; ST; BE; SPT; QL (3 4 MG capsules/packets per 1 day) DIACOMIT ORAL POWDER IN PACKET 500 PA; ST; BE; SPT; QL (6 4 MG capsules/packets per 1 day) PA; ST; $3-Copay; SPT; QL (1 FINTEPLA 4 bottle (360ml) per 30 days) Last Approved Date: 09/23/2021 Formulary Version: 91
91 Drug Status Notes XCOPRI 3 PA; ST XCOPRI MAINTENANCE PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG 3 PA; ST X1), 350 MG/DAY (200 MG X1-150MG X1) XCOPRI TITRATION PACK 3 PA; ST Antidepressant - Alpha-2 Receptor Antagonists (Nassa) mirtazapine 1 REMERON 3 REMERON SOLTAB 3 Antidepressant - Mao Inhibitor Nonselective And Irreversible-Types A,B EMSAM 3 MARPLAN 3 NARDIL 3 PARNATE 3 phenelzine 1 tranylcypromine 1 Antidepressant - Selective Serotonin Reuptake Inhibitors (Ssris) CELEXA ORAL TABLET 3 citalopram oral solution 1 citalopram oral tablet 1 $3-Copay escitalopram oxalate oral solution 1 QL (680 ML per 34 days) escitalopram oxalate oral tablet 10 mg, 5 mg 1 QL (34 TABLETS per 1 MONTH) escitalopram oxalate oral tablet 20 mg 1 QL (1.5 tablets per 1 day) fluoxetine oral capsule 1 $3-Copay fluoxetine oral capsule,delayed release(dr/ec) 1 fluoxetine oral solution 1 fluoxetine oral tablet 10 mg, 20 mg 1 fluoxetine oral tablet 60 mg 3 PA fluvoxamine oral capsule,extended release 24hr 3 fluvoxamine oral tablet 1 LEXAPRO ORAL SOLUTION 3 QL (680 ML per 34 days) LEXAPRO ORAL TABLET 10 MG, 5 MG 3 QL (34 TABLETS per 1 MONTH) Last Approved Date: 09/23/2021 Formulary Version: 91
92 Drug Status Notes LEXAPRO ORAL TABLET 20 MG 3 QL (1.5 tablets per 1 day) paroxetine hcl oral tablet 1 $3-Copay paroxetine hcl oral tablet extended release 24 hr 1 PA; ST PAXIL CR 3 PA; ST PAXIL ORAL SUSPENSION 3 PAXIL ORAL TABLET 3 PA; ST PEXEVA 3 PA; ST PROZAC ORAL CAPSULE 3 QL (4 CAPSULES per 1 PROZAC WEEKLY 3 MONTH) SARAFEM ORAL TABLET 10 MG, 20 MG 3 sertraline oral concentrate 1 sertraline oral tablet 1 $3-Copay ZOLOFT 3 Antidepressant - Serotonin-2 Antagonist-Reuptake Inhibitors (Saris) nefazodone 3 trazodone oral tablet 100 mg, 150 mg, 50 mg 1 $3-Copay trazodone oral tablet 300 mg 1 Antidepressant - Serotonin- Norepinephrine Reuptake Inhibitors (Snris) CYMBALTA ORAL CAPSULE,DELAYED 3 QL (68 EA per 34 days) RELEASE(DR/EC) 20 MG, 60 MG CYMBALTA ORAL CAPSULE,DELAYED 3 QL (34 EA per 34 days) RELEASE(DR/EC) 30 MG desvenlafaxine fumarate 3 desvenlafaxine oral tablet extended release 24 hr 3 desvenlafaxine oral tablet extended release 24hr 3 50 mg desvenlafaxine succinate 3 PA; ST DRIZALMA SPRINKLE 3 PA; ST; QL (1 capsule per 1 Day) duloxetine oral capsule,delayed release(dr/ec) 20 1 QL (68 EA per 34 days) mg duloxetine oral capsule,delayed release(dr/ec) 30 1 QL (34 EA per 34 days) mg
Last Approved Date: 09/23/2021 Formulary Version: 91
93 Drug Status Notes duloxetine oral capsule,delayed release(dr/ec) 60 1 QL (64 capsules per 32 days) mg EFFEXOR XR ORAL CAPSULE,EXTENDED PA; ST; QL (1 CAPSULE per 1 3 RELEASE 24HR 150 MG day) EFFEXOR XR ORAL CAPSULE,EXTENDED PA; ST; QL (34 TABLETS per 1 3 RELEASE 24HR 37.5 MG, 75 MG MONTH) FETZIMA 3 PA; ST KHEDEZLA 3 PA; ST PRISTIQ 3 PA; ST SAVELLA 3 PA; ST venlafaxine oral capsule,extended release 24hr 1 QL (1 CAPSULE per 1 day) 150 mg venlafaxine oral capsule,extended release 24hr 1 QL (34 TABLETS per 1 MONTH) 37.5 mg, 75 mg venlafaxine oral tablet 1 venlafaxine oral tablet extended release 24hr 150 PA; ST; QL (1 TABLET per 1 1 mg day) venlafaxine oral tablet extended release 24hr 225 1 QL (34 TABLETS per 1 MONTH) mg venlafaxine oral tablet extended release 24hr 37.5 PA; ST; QL (34 TABLETS per 1 1 mg, 75 mg MONTH) 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 3 PA; ST Antidepressant - Tricyclic And Antipsychotic, Phenothiazine Comb perphenazine-amitriptyline 1 Antidepressant - Tricyclic- Benzodiazepine Combinations amitriptyline-chlordiazepoxide 1
Last Approved Date: 09/23/2021 Formulary Version: 91
94 Drug Status Notes Antidepressant- Ssri And Atypical Antipsych,Dopamine,Serotonin Antagon olanzapine-fluoxetine 1 PA; ST SYMBYAX 3 PA; ST; QL (1 capsule per 1 day) Antidepressant-Norepinephrine And Dopamine Reuptake Inhibitors (Ndris) APLENZIN 3 PA; ST bupropion hcl er 200 mg tablet 3 bupropion hcl oral tablet 1 bupropion hcl oral tablet extended release 24 hr QL (102 TABLETS per 1 3 150 mg MONTH) bupropion hcl oral tablet extended release 24 hr 3 QL (34 TABLETS per 1 MONTH) 300 mg bupropion hcl oral tablet extended release 24 hr 3 PA; ST; QL (1 tablet per 1 day) 450 mg bupropion hcl oral tablet sustained-release 12 hr 1 QL (68 TABLETS per 1 MONTH) 100 mg, 200 mg bupropion hcl oral tablet sustained-release 12 hr 1 QL (68 EA per 34 days) 150 mg bupropion hcl sr 200 mg tablet 1 FORFIVO XL 3 PA; ST PA; ST; QL (68 TABLETS per 1 WELLBUTRIN SR 3 MONTH) WELLBUTRIN XL ORAL TABLET PA; ST; QL (102 TABLETS per 1 3 EXTENDED RELEASE 24 HR 150 MG MONTH) WELLBUTRIN XL ORAL TABLET PA; ST; QL (34 TABLETS per 1 3 EXTENDED RELEASE 24 HR 300 MG MONTH) Antidepressant-Tricyclics And Related (Non-Select Reuptake Inhibitors) amitriptyline oral tablet 10 mg, 25 mg 1 $3-Copay amitriptyline oral tablet 100 mg, 150 mg, 50 mg, 1 75 mg amoxapine 1 ANAFRANIL 3 clomipramine 3 desipramine 1
Last Approved Date: 09/23/2021 Formulary Version: 91
95 Drug Status Notes doxepin oral capsule 1 doxepin oral concentrate 1 imipramine hcl 1 $3-Copay imipramine pamoate 3 maprotiline 1 NORPRAMIN ORAL TABLET 10 MG, 25 MG 3 nortriptyline oral capsule 10 mg, 25 mg, 50 mg 1 $3-Copay nortriptyline oral capsule 75 mg 1 nortriptyline oral solution 1 PAMELOR 3 protriptyline 1 SURMONTIL 3 TOFRANIL 3 Antiparkinson - Dopaminergic-Periph Comt-Dopa-Decarboxylase Inhib Comb carbidopa-levodopa-entacapone 3 STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 Antiparkinson - Dopaminerg-Peripheral Dopa-Decarboxylase Inhibit Comb carbidopa-levodopa oral tablet 1 carbidopa-levodopa oral tablet extended release 3 carbidopa-levodopa oral tablet,disintegrating 1 DUOPA 3 RYTARY 3 SINEMET 3 SINEMET CR 3 Antiparkinson Adjuvant - Adenosine Receptor Antagonist PA; ST; BE; SPT; QL (1 tablet per NOURIANZ 4 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
96 Drug Status Notes Antiparkinson Adjuvant - Central/Peripheral Comt Inhibitors TASMAR ORAL TABLET 100 MG 3 Antiparkinson Adjuvant - Peripheral Comt Inhibitors COMTAN 3 ONGENTYS ORAL CAPSULE 25 MG 3 PA; ST; QL (1 capsule per 1 Day) ONGENTYS ORAL CAPSULE 50 MG 3 PA; ST; QL (1 capsule per 1 day) Antiparkinson Adjuvant - Peripheral Dopa-Decarboxylase Inhibitors carbidopa 1 LODOSYN 3 Antiparkinson Therapy - Anticholinergic Agents benztropine oral 1 $3-Copay trihexyphenidyl oral elixir 1 trihexyphenidyl oral tablet 2 mg 1 $3-Copay trihexyphenidyl oral tablet 5 mg 1 Antiparkinson Therapy - Dopamine Precursors PA; ST; SPT; QL (5 cartons (300 INBRIJA 4 capsules) per 1 Month) Antiparkinson Therapy - Ergot Alkaloids And Derivatives bromocriptine 1 PARLODEL 3 Antiparkinson Therapy - Monoamine Oxidase Inhibitor(Mao-B) AZILECT 3 PA; ST rasagiline 3 PA; ST selegiline hcl 1 XADAGO 3 PA; QL (1 tablet per 1 Day) ZELAPAR 3
Last Approved Date: 09/23/2021 Formulary Version: 91
97 Drug Status Notes Antiparkinson Therapy - Non-Ergot Dopamine Agonist Agents amantadine hcl 1 APOKYN 3 PA; ST; SP; BE; SPT PA; ST; SP; BE; SPT; QL (2 GOCOVRI 4 capsules per 1 Day) KYNMOBI SUBLINGUAL FILM 10 MG, 15 PA; ST; BE; SPT; QL (5 films per 4 MG, 20 MG, 25 MG, 30 MG 1 day) MIRAPEX 3 MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 3 3 MG, 4.5 MG NEUPRO 3 QL (30 PATCHES per 1 MONTH) OSMOLEX ER ORAL TABLET, IR - ER, PA; ST; BE; SPT; QL (1 tablet per 4 BIPHASIC 24HR 129 MG, 193 MG, 258 MG 1 day) OSMOLEX ER ORAL TABLET, IR - ER, PA; ST; BE; SPT; QL (1 tablet per BIPHASIC 24HR 322 MG/DAY(129 MG X1- 4 1 Day) 193MG X1) pramipexole oral tablet 1 REQUIP 3 REQUIP XL 3 ropinirole oral tablet 1 Antipsychotic - Atyp Dopamine- Serotonin Antag Dibenzo-Oxepino Pyrroles asenapine maleate 3 QL (2 EA per 2 Days) SAPHRIS SUBLINGUAL TABLET 10 MG, 5 3 MG SAPHRIS SUBLINGUAL TABLET 2.5 MG 3 QL (2 tablets per 1 day) SECUADO 3 PA; ST; QL (1 patch per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag- Benzisothiazolones GEODON INTRAMUSCULAR 3 GEODON ORAL 3 QL (2 capsules per 1 day) LATUDA ORAL TABLET 120 MG, 20 MG, 40 3 PA; ST; QL (1 tablet per 1 day) MG, 60 MG LATUDA ORAL TABLET 80 MG 3 PA; ST; QL (2 tablets per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
98 Drug Status Notes ziprasidone hcl 1 QL (2 capsules per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag- Benzisoxazole Deriv FANAPT ORAL TABLET 1 MG, 2 MG, 4 MG, 3 QL (2 tablets per 1 day) 6 MG, 8 MG FANAPT ORAL TABLET 10 MG, 12 MG 3 FANAPT ORAL TABLETS,DOSE PACK 3 INVEGA ORAL TABLET EXTENDED 3 QL (1 tablet per 1 day) RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED 3 QL (2 tablets per 1 day) RELEASE 24HR 6 MG paliperidone 3 RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING 0.5 MG, 1 MG, 2 3 QL (1 tablet per 1 day) MG, 3 MG RISPERDAL M-TAB ORAL 3 QL (4 tablets per 1 day) TABLET,DISINTEGRATING 4 MG RISPERDAL ORAL SOLUTION 3 QL (16 mL per 1 day) RISPERDAL ORAL TABLET 0.25 MG, 0.5 3 QL (2 tablets per 1 day) MG, 1 MG, 2 MG, 3 MG RISPERDAL ORAL TABLET 4 MG 3 QL (4 tablets per 1 day) risperidone oral solution 1 QL (16 mL per 1 day) risperidone oral syringe 3 risperidone oral tablet 1 risperidone oral tablet,disintegrating 0.25 mg 1 risperidone oral tablet,disintegrating 0.5 mg, 1 1 QL (1 tablet per 1 day) mg, 2 mg, 3 mg risperidone oral tablet,disintegrating 4 mg 1 QL (4 tablets per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag-Butyrophenone Deriv CAPLYTA 3 PA; ST; QL (1 capsule per 1 day) Antipsychotic - Atypical Dopamine- Serotonin Antag-Dibenzodiazepine Der clozapine oral tablet 100 mg 1 QL (9 tablets per 1 day) clozapine oral tablet 200 mg, 50 mg 1 clozapine oral tablet 25 mg 1 QL (3 tablets per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
99 Drug Status Notes clozapine oral tablet,disintegrating 100 mg, 12.5 1 QL (3 tablets per 1 day) mg, 25 mg clozapine oral tablet,disintegrating 150 mg, 200 3 QL (5 tablets per 1 day) mg CLOZARIL ORAL TABLET 100 MG 3 QL (9 tablets per 1 day) CLOZARIL ORAL TABLET 200 MG 3 QL (4 tablets per 1 day) CLOZARIL ORAL TABLET 25 MG, 50 MG 3 QL (3 tablets per 1 day) FAZACLO ORAL TABLET,DISINTEGRATING 100 MG, 12.5 3 QL (3 tablets per 1 day) MG, 25 MG FAZACLO ORAL 3 QL (5 tablets per 1 day) TABLET,DISINTEGRATING 150 MG FAZACLO ORAL 3 QL (4 tablets per 1 day) TABLET,DISINTEGRATING 200 MG VERSACLOZ 3 QL (18 mL per 1 day) Antipsychotic - Butyrophenone Derivatives haloperidol decanoate 1 haloperidol lactate oral 1 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 3 loxapine succinate 1 Antipsychotic - Dihydroindolones molindone 3 Antipsychotic - Diphenylbutylpiperidine Derivatives ORAP 3 pimozide 3 Antipsychotic - Phenothiazines, Aliphatic chlorpromazine oral tablet 1
Last Approved Date: 09/23/2021 Formulary Version: 91
100 Drug Status Notes Antipsychotic - Phenothiazines, Piperazine fluphenazine decanoate 1 fluphenazine hcl oral 1 perphenazine 1 prochlorperazine maleate 1 trifluoperazine 1 Antipsychotic - Phenothiazines, Piperidine thioridazine 3 Antipsychotic - Thioxanthenes thiothixene 1 Antipsychotic -Atypical Dopamine- Serotonin Antag-Dibenzothiazepine Der quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 1 QL (1 tablet 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, 3 QL (3 tablets per 1 day) 25 MG, 50 MG SEROQUEL ORAL TABLET 300 MG, 400 MG 3 QL (2 tablets per 1 day) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 200 MG, 300 MG, 50 3 QL (1 tablet per 1 day) MG SEROQUEL XR ORAL TABLET EXTENDED 3 QL (2 tablets per 1 day) RELEASE 24 HR 400 MG Antipsychotic -Atypical Dopamine- Serotonin Antag- Thienobenzodiazepines olanzapine intramuscular 3 olanzapine oral 1 QL (1 tablet per 1 day) olanzapine-fluoxetine 1 PA; ST SYMBYAX 3 PA; ST; QL (1 capsule per 1 day) ZYPREXA INTRAMUSCULAR 3 Last Approved Date: 09/23/2021 Formulary Version: 91
101 Drug Status Notes ZYPREXA ORAL 3 QL (1 tablet per 1 day) ZYPREXA RELPREVV 3 ZYPREXA ZYDIS 3 QL (1 tablet per 1 day) Antipsychotic-Atyp Selective Serotonin 5-Ht2a Inverse Agonists (Ssia) PA; BE; SPT; QL (1 Capsule per 1 NUPLAZID ORAL CAPSULE 4 Day) PA; BE; SPT; QL (1 Tablet per 1 NUPLAZID ORAL TABLET 10 MG 4 Day) NUPLAZID ORAL TABLET 17 MG 4 PA; BE; SPT; QL (2 EA per 1 day) Antipsychotic-Atypical,D2 Receptor Partial Agonist-5Ht Serotonin Mixed ABILIFY MYCITE 4 PA; ST; SPT; QL (30 tablets per ABILIFY MYCITE MAINTENANCE KIT 4 25 Dayss) PA; ST; SPT; QL (30 tablets per ABILIFY MYCITE STARTER KIT 4 25 Dayss) ABILIFY ORAL TABLET 3 PA; ST; QL (1 tablet per 1 day) aripiprazole oral solution 3 PA; ST; QL (30 mL per 1 day) aripiprazole oral tablet 3 PA; ST; QL (1 tablet per 1 day) aripiprazole oral tablet,disintegrating 3 PA; ST REXULTI 3 PA; ST; QL (1 tablet per 1 day) Antipsychotic-Atypical,D3/D2 Receptor Partial Agonist-Serotonin Mixed VRAYLAR ORAL CAPSULE 3 PA; ST; QL (1 capsule per 1 day) VRAYLAR ORAL CAPSULE,DOSE PACK 3 PA; ST Attention Deficit-Hyperact. Disorder (Adhd)- Alpha-2 Receptor Agonist clonidine hcl oral tablet extended release 12 hr 3 PA; ST guanfacine oral tablet extended release 24 hr 1 3 PA; ST; QL (7 tablets per 1 day) mg guanfacine oral tablet extended release 24 hr 2 3 PA; ST; QL (3 tablets per 1 day) mg guanfacine oral tablet extended release 24 hr 3 3 PA; ST; QL (2 tablets per 1 day) mg guanfacine oral tablet extended release 24 hr 4 3 PA; ST; QL (1 tablet per 1 day) mg
Last Approved Date: 09/23/2021 Formulary Version: 91
102 Drug Status Notes INTUNIV ER ORAL TABLET EXTENDED 3 PA; ST; QL (7 tablets per 1 day) RELEASE 24 HR 1 MG INTUNIV ER ORAL TABLET EXTENDED 3 PA; ST; QL (3 tablets per 1 day) RELEASE 24 HR 2 MG INTUNIV ER ORAL TABLET EXTENDED 3 PA; ST; QL (2 tablets per 1 day) RELEASE 24 HR 3 MG INTUNIV ER ORAL TABLET EXTENDED 3 PA; ST; QL (1 tablet per 1 day) RELEASE 24 HR 4 MG PA; ST; QL (136 TABLETS per 1 KAPVAY 3 MONTH) Attention Deficit-Hyperactivity (Adhd) Therapy, Stimulant-Type ADHANSIA XR ORAL CAPSULE, ER 3 PA; ST; QL (3 tablets per 1 day) BIPHASIC 20-80 25 MG ADHANSIA XR ORAL CAPSULE, ER 3 PA; ST; QL (2 tablets per 1 day) BIPHASIC 20-80 35 MG ADHANSIA XR ORAL CAPSULE, ER BIPHASIC 20-80 45 MG, 55 MG, 70 MG, 85 3 PA; ST; QL (1 tablet per 1 day) MG ADZENYS ER 3 ADZENYS XR-ODT 3 amphetamine 3 QL (450 ML per 1 dispense) AZSTARYS 3 PA; ST; QL (1 capsule per 1 Day) CONCERTA ORAL TABLET EXTENDED 3 QL (34 TABLETS per 1 MONTH) RELEASE 24HR 18 MG, 27 MG, 54 MG CONCERTA ORAL TABLET EXTENDED 3 QL (68 TABLETS per 1 MONTH) RELEASE 24HR 36 MG COTEMPLA XR-ODT 3 ST; SP; QL (2 tablets per 1 day) DAYTRANA 3 QL (34 PATCHES per 1 MONTH) DEXEDRINE 1 dexmethylphenidate oral capsule,er biphasic 50- 3 QL (1 Capsule per 1 day) 50 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 5 mg dexmethylphenidate oral tablet 10 mg 1 QL (68 TABLETS per 1 MONTH) QL (272 TABLETS per 1 dexmethylphenidate oral tablet 2.5 mg 1 MONTH) QL (136 TABLETS per 1 dexmethylphenidate oral tablet 5 mg 1 MONTH) dextroamphetamine oral capsule, extended 1 release Last Approved Date: 09/23/2021 Formulary Version: 91
103 Drug Status Notes dextroamphetamine oral tablet 10 mg, 5 mg 1 dextroamphetamine-amphetamine oral 1 capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 10 QL (204 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 12.5 QL (170 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 15 QL (136 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 20 QL (102 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 30 1 QL (68 TABLETS per 1 MONTH) mg dextroamphetamine-amphetamine oral tablet 5 QL (408 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 7.5 QL (272 TABLETS per 1 1 mg MONTH) DYANAVEL XR 3 QL (240 ml per 34 days) EVEKEO 3 PA; ST EVEKEO ODT ORAL 3 PA; ST; QL (3 tablets per 1 day) TABLET,DISINTEGRATING 10 MG, 5 MG EVEKEO ODT ORAL 3 PA; ST; QL (2 tablets per 1 day) TABLET,DISINTEGRATING 15 MG, 20 MG FOCALIN ORAL TABLET 10 MG 3 QL (68 TABLETS per 1 MONTH) QL (272 TABLETS per 1 FOCALIN ORAL TABLET 2.5 MG 3 MONTH) QL (136 TABLETS per 1 FOCALIN ORAL TABLET 5 MG 3 MONTH) FOCALIN XR ORAL CAPSULE,ER BIPHASIC QL (34 CAPSULES per 1 3 50-50 10 MG, 15 MG, 20 MG, 30 MG, 5 MG MONTH) JORNAY PM 3 QL (1 capsule per 1 day) QL (34 CAPSULES per 1 METADATE CD 3 MONTH) QL (102 TABLETS per 1 METADATE ER 3 MONTH) METHYLIN ORAL SOLUTION 10 MG/5 ML 3 QL (900 ML per 1 MONTH) METHYLIN ORAL SOLUTION 5 MG/5 ML 3 QL (450 ML per 1 MONTH) methylphenidate hcl oral cap,er sprinkle,biphasic 3 QL (1 capsule per 1 Day) 40-60
Last Approved Date: 09/23/2021 Formulary Version: 91
104 Drug Status Notes methylphenidate hcl oral capsule, er biphasic 30- QL (34 CAPSULES per 1 1 70 10 mg, 20 mg, 30 mg, 50 mg, 60 mg MONTH) methylphenidate hcl oral capsule, er biphasic 30- 1 QL (34 EA per 34 days) 70 40 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- 3 QL (34 EA per 34 days) 50 20 mg methylphenidate hcl oral capsule,er biphasic 50- 3 QL (68 EA per 34 days) 50 30 mg methylphenidate hcl oral capsule,er biphasic 50- QL (34 CAPSULES per 1 3 50 40 mg MONTH) methylphenidate hcl oral capsule,er biphasic 50- 3 QL (34 EA per 34 Days) 50 60 mg methylphenidate hcl oral solution 10 mg/5 ml 1 QL (900 ML per 1 MONTH) methylphenidate hcl oral solution 5 mg/5 ml 1 QL (450 ML per 1 MONTH) QL (102 TABLETS per 1 methylphenidate hcl oral tablet 1 MONTH) methylphenidate hcl oral tablet extended release 1 QL (1 capsule per 1 day) 10 mg methylphenidate hcl oral tablet extended release QL (102 TABLETS per 1 1 20 mg MONTH) methylphenidate hcl oral tablet extended release 3 QL (34 TABLETS per 1 MONTH) 24hr 18 mg, 27 mg, 54 mg methylphenidate hcl oral tablet extended release 3 QL (68 TABLETS per 1 MONTH) 24hr 36 mg methylphenidate hcl oral tablet,chewable 1 MYDAYIS 3 QL (1 capsule per 1 day) QUILLICHEW ER ORAL TABLET,CHEW,IR- 3 QL (1 Tablet per 1 day) ER.BIPHASIC24HR 20 MG, 40 MG QUILLICHEW ER ORAL TABLET,CHEW,IR- QL (68 Chewable Tabs per 34 3 ER.BIPHASIC24HR 30 MG days) QUILLIVANT XR 3 QL (408 ML per 1 MONTH) RELEXXII 3 QL (1 tablet per 1 day) QL (102 TABLETS per 1 RITALIN 3 MONTH) QL (34 CAPSULES per 1 RITALIN LA 3 MONTH) VYVANSE ORAL CAPSULE 10 MG 3 QL (1 EA per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
105 Drug Status Notes VYVANSE ORAL CAPSULE 20 MG, 30 MG, QL (34 CAPSULES per 1 3 40 MG, 50 MG, 60 MG, 70 MG MONTH) VYVANSE ORAL TABLET,CHEWABLE 3 ZENZEDI ORAL TABLET 10 MG, 5 MG 1 Attention Deficit-Hyperactivity Disorder (Adhd) Therapy, Nri-Type PA; ST; QL (340 Capsules per 1 atomoxetine oral capsule 10 mg 3 Month) PA; ST; QL (34 Capsules per 1 atomoxetine oral capsule 100 mg, 80 mg 3 Month) PA; ST; QL (204 Capsules per 1 atomoxetine oral capsule 18 mg 3 Month) PA; ST; QL (136 Capsules per 1 atomoxetine oral capsule 25 mg 3 Month) PA; ST; QL (102 Capsules per 1 atomoxetine oral capsule 40 mg 3 Month) PA; ST; QL (68 Capsules per 1 atomoxetine oral capsule 60 mg 3 Month) QELBREE 3 PA; ST; QL (2 capsules per 1 day) PA; ST; QL (340 CAPSULES per STRATTERA ORAL CAPSULE 10 MG 3 1 MONTH) STRATTERA ORAL CAPSULE 100 MG, 80 PA; ST; QL (34 CAPSULES per 1 3 MG MONTH) PA; ST; QL (204 CAPSULES per STRATTERA ORAL CAPSULE 18 MG 3 1 MONTH) PA; ST; QL (136 TABLETS per 1 STRATTERA ORAL CAPSULE 25 MG 3 MONTH) PA; ST; QL (102 CAPSULES per STRATTERA ORAL CAPSULE 40 MG 3 1 MONTH) PA; ST; QL (68 CAPSULES per 1 STRATTERA ORAL CAPSULE 60 MG 3 MONTH) Benzodiazepines alprazolam 1 PA ALPRAZOLAM INTENSOL 1 PA amitriptyline-chlordiazepoxide 1 ATIVAN ORAL 3 chlordiazepoxide hcl 1 chlordiazepoxide-clidinium 3
Last Approved Date: 09/23/2021 Formulary Version: 91
106 Drug Status Notes clobazam 1 clonazepam 1 clorazepate dipotassium 1 QL (2 APPLICATORS per 3 DIASTAT 3 MONTHs) QL (2 APPLICATORS per 3 DIASTAT ACUDIAL 3 MONTHs) diazepam injection syringe 3 DIAZEPAM INTENSOL 1 diazepam oral solution 1 diazepam oral tablet 1 QL (2 APPLICATORS per 3 diazepam rectal kit 12.5-15-17.5-20 mg 1 MONTHs) diazepam rectal kit 2.5 mg, 5-7.5-10 mg 1 DORAL 3 estazolam 1 flurazepam 1 HALCION ORAL TABLET 0.25 MG 3 PA KLONOPIN 3 LIBRAX (WITH CLIDINIUM) 3 lorazepam injection syringe 2 mg/ml 3 LORAZEPAM INTENSOL 1 lorazepam oral concentrate 1 lorazepam oral tablet 1 midazolam (pf) injection syringe 3 midazolam hcl 2 mg/ml syrup 4 oral dispensers 1 midazolam hcl 5 mg/2.5 ml syrp inner 3 midazolam in 0.9 % sod chlorid intravenous 3 prefilled pump reservoir midazolam intravenous syringe 150 mg/30 ml (5 3 mg/ml) midazolam oral syrup 10 mg/5 ml (2 mg/ml) 3 midazolam oral syrup 2 mg/ml 1 NAYZILAM 3 PA; QL (2 spray units per 25 days) ONFI 3 oxazepam 1
Last Approved Date: 09/23/2021 Formulary Version: 91
107 Drug Status Notes quazepam 1 RESTORIL 3 PA; ST; BE; SPT; QL (2 films per SYMPAZAN 4 1 day) temazepam 1 TRANXENE T-TAB 3 triazolam 3 PA VALIUM 3 PA; ST; QL (4 blister packs per 1 VALTOCO 3 dispensing event) XANAX 3 PA XANAX XR 3 PA Bipolar Therapy Agents - Anticonvulsant Type carbamazepine oral capsule, er multiphase 12 hr 1 carbamazepine oral suspension 100 mg/5 ml, 200 1 mg/10 ml carbamazepine oral tablet 1 carbamazepine oral tablet extended release 12 hr 1 carbamazepine oral tablet,chewable 1 DEPAKENE 3 DEPAKOTE 3 DEPAKOTE ER 3 DEPAKOTE SPRINKLES 3 divalproex 1 EPITOL 1 EQUETRO 3 lamotrigine oral tablet disintegrating, dose pk 3 lamotrigine oral tablet,disintegrating 3 lamotrigine oral tablets,dose pack 1 SUBVENITE STARTER (BLUE) KIT 1 SUBVENITE STARTER (GREEN) KIT 1 SUBVENITE STARTER (ORANGE) KIT 1 TEGRETOL ORAL SUSPENSION 3 TEGRETOL XR ORAL TABLET EXTENDED 3 RELEASE 12 HR 100 MG
Last Approved Date: 09/23/2021 Formulary Version: 91
108 Drug Status Notes valproic acid 1 valproic acid (as sodium salt) oral solution 250 1 mg/5 ml, 500 mg/10 ml (10 ml) Bipolar Therapy Agents - Atypical Antipsychotics ABILIFY MYCITE 4 PA; ST; SPT; QL (30 tablets per ABILIFY MYCITE MAINTENANCE KIT 4 25 Dayss) PA; ST; SPT; QL (30 tablets per ABILIFY MYCITE STARTER KIT 4 25 Dayss) ABILIFY ORAL TABLET 3 PA; ST; QL (1 tablet per 1 day) aripiprazole oral solution 3 PA; ST; QL (30 mL per 1 day) aripiprazole oral tablet 3 PA; ST; QL (1 tablet per 1 day) aripiprazole oral tablet,disintegrating 3 PA; ST asenapine maleate 3 QL (2 EA per 2 Days) GEODON 3 olanzapine intramuscular 3 olanzapine oral 1 olanzapine-fluoxetine 1 PA; ST quetiapine oral tablet 1 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 3 RISPERDAL M-TAB 3 risperidone oral solution 1 risperidone oral syringe 3 risperidone oral tablet 1 risperidone oral tablet,disintegrating 1 SAPHRIS 3 QL (2 tablets per 1 day) SEROQUEL 3 SEROQUEL XR ORAL TABLET EXTENDED 3 RELEASE 24 HR SYMBYAX 3 PA; ST; QL (1 capsule per 1 day) VRAYLAR ORAL CAPSULE 3 PA; ST; QL (1 capsule per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
109 Drug Status Notes VRAYLAR ORAL CAPSULE,DOSE PACK 3 PA; ST ziprasidone hcl 1 ZYPREXA 3 ZYPREXA ZYDIS 3 Bipolar Therapy Agents - Lithium lithium carbonate oral capsule 1 $3-Copay lithium carbonate oral tablet 1 lithium carbonate oral tablet extended release 1 lithium citrate oral solution 8 meq/5 ml 1 LITHOBID 3 Cannabis And Cannabinoid Receptor Agonists CESAMET 3 dronabinol 3 MARINOL 3 SYNDROS 3 Cns Stimulant - Amphetamine Combinations QL (204 TABLETS per 1 ADDERALL ORAL TABLET 10 MG 3 MONTH) QL (170 TABLETS per 1 ADDERALL ORAL TABLET 12.5 MG 3 MONTH) QL (136 TABLETS per 1 ADDERALL ORAL TABLET 15 MG 3 MONTH) QL (102 TABLETS per 1 ADDERALL ORAL TABLET 20 MG 3 MONTH) ADDERALL ORAL TABLET 30 MG 3 QL (68 TABLETS per 1 MONTH) QL (408 TABLETS per 1 ADDERALL ORAL TABLET 5 MG 3 MONTH) QL (272 TABLETS per 1 ADDERALL ORAL TABLET 7.5 MG 3 MONTH) ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR 10 3 QL (34 TABLETS per 1 MONTH) MG, 15 MG, 5 MG ADDERALL XR ORAL QL (34 CAPSULES per 1 CAPSULE,EXTENDED RELEASE 24HR 20 3 MONTH) MG, 25 MG, 30 MG
Last Approved Date: 09/23/2021 Formulary Version: 91
110 Drug Status Notes ADZENYS ER 3 ADZENYS XR-ODT 3 amphetamine 3 QL (450 ML per 1 dispense) dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 1 QL (34 TABLETS per 1 MONTH) mg dextroamphetamine-amphetamine oral QL (34 CAPSULES per 1 capsule,extended release 24hr 20 mg, 25 mg, 30 1 MONTH) mg dextroamphetamine-amphetamine oral tablet 10 QL (204 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 12.5 QL (170 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 15 QL (136 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 20 QL (102 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 30 1 QL (68 TABLETS per 1 MONTH) mg dextroamphetamine-amphetamine oral tablet 5 QL (408 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 7.5 QL (272 TABLETS per 1 1 mg MONTH) DYANAVEL XR 3 QL (240 ml per 34 days) MYDAYIS 3 QL (1 capsule per 1 day) Cns Stimulant - Amphetamines QL (170 TABLETS per 1 DESOXYN 3 MONTH) DEXEDRINE 1 DEXEDRINE SPANSULE ORAL CAPSULE, QL (204 TABLETS per 1 3 EXTENDED RELEASE 10 MG MONTH) DEXEDRINE SPANSULE ORAL CAPSULE, QL (136 TABLETS per 1 3 EXTENDED RELEASE 15 MG MONTH) DEXEDRINE SPANSULE ORAL CAPSULE, QL (408 TABLETS per 1 3 EXTENDED RELEASE 5 MG MONTH) dextroamphetamine oral capsule, extended QL (204 TABLETS per 1 1 release 10 mg MONTH) dextroamphetamine oral capsule, extended QL (136 TABLETS per 1 1 release 15 mg MONTH)
Last Approved Date: 09/23/2021 Formulary Version: 91
111 Drug Status Notes dextroamphetamine oral capsule, extended QL (408 TABLETS per 1 1 release 5 mg MONTH) dextroamphetamine oral solution 1 QL (204 TABLETS per 1 dextroamphetamine oral tablet 10 mg 1 MONTH) QL (408 TABLETS per 1 dextroamphetamine oral tablet 5 mg 1 MONTH) EVEKEO 3 PA; ST EVEKEO ODT ORAL 3 PA; ST; QL (3 tablets per 1 day) TABLET,DISINTEGRATING 10 MG, 5 MG EVEKEO ODT ORAL 3 PA; ST; QL (2 tablets per 1 day) TABLET,DISINTEGRATING 15 MG, 20 MG QL (170 TABLETS per 1 methamphetamine 3 MONTH) PROCENTRA 1 QL (2040 ML per 1 MONTH) QL (204 TABLETS per 1 ZENZEDI ORAL TABLET 10 MG 1 MONTH) QL (816 TABLETS per 1 ZENZEDI ORAL TABLET 2.5 MG 3 MONTH) QL (408 TABLETS per 1 ZENZEDI ORAL TABLET 5 MG 1 MONTH) QL (272 TABLETS per 1 ZENZEDI ORAL TABLET 7.5 MG 3 MONTH) Cns Stimulant - Analeptics, Methylxanthine-Type caffeine citrate oral 3 Diabetic Peripheral Neuropathy Agents LYRICA CR 3 PA; ST pregabalin oral tablet extended release 24 hr 3 PA; ST; QL (1 tablet per 1 Day) Fibromyalgia Agents - Gaba Analogs LYRICA ORAL SOLUTION 3 pregabalin oral capsule 3 PA; ST pregabalin oral solution 3 PA; ST Fibromyalgia Agents - Serotonin- Norepinephrine Reuptake-Inhib (Snris) DRIZALMA SPRINKLE 3 PA; ST; QL (1 capsule per 1 Day)
Last Approved Date: 09/23/2021 Formulary Version: 91
112 Drug Status Notes duloxetine oral capsule,delayed release(dr/ec) 20 1 mg, 30 mg, 60 mg Hsdd Agents-Mixed Serotonin Agonist/Antagonists ADDYI 3 PA; QL (1 TABLET per 1 day) Hsdd Agents-Non-Selective Melanocortin Receptor Agonist PA; BE; SPT; QL (4 autoinjectors VYLEESI 4 per 30 dayss) Hypnotics - Melatonin M1/M2 Receptor Agonists PA; BE; $3-Copay; SPT; QL (34 HETLIOZ 4 CAPSULES per 1 MONTH) PA; BE; SPT; QL (158 ML per 25 HETLIOZ LQ 4 Dayss) ramelteon 3 PA; ST ROZEREM 3 PA Migraine Therapy - Analgesic- Vasoconstrictor-Sedative Combinations isometh-dichloral-acetaminophn 1 NODOLOR 1 Migraine Therapy - Carboxylic Acid Derivatives DEPAKOTE ER 3 divalproex oral tablet extended release 24 hr 1 Migraine Therapy - Cgrp Ligand Blocker, Monoclonal Antibody PA; ST; QL (5 ML (3 AJOVY AUTOINJECTOR 2 autoinectors) per 75 days) PA; ST; QL (5 ML (3 syringes) AJOVY SYRINGE 2 per 75 days) EMGALITY PEN 2 PA; ST; QL (1 unit per 25 days) EMGALITY SYRINGE SUBCUTANEOUS 2 PA; ST; QL (1 unit per 25 days) SYRINGE 120 MG/ML
Last Approved Date: 09/23/2021 Formulary Version: 91
113 Drug Status Notes Migraine Therapy - Cgrp Receptor Blockers (Gepants) PA; ST; QL (18 tablets per 25 NURTEC ODT 3 days) PA; ST; QL (16 tablets per 30 UBRELVY 3 days) Migraine Therapy - Cgrp Receptor Blockers, Monoclonal Antibody AIMOVIG AUTOINJECTOR (2 PACK) 2 PA; ST; QL (2 ML per 25 days) AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 2 PA; ST; QL (1 ML per 25 days) MG/ML AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 70 2 PA; ST; QL (1 ML per 1 Month) MG/ML Migraine Therapy - Ergot Alkaloids And Derivatives D.H.E.45 3 QL (24 ML per 25 days) PA; ST; QL (8 ampules per 25 dihydroergotamine injection 3 days) dihydroergotamine nasal 3 PA; ST PA; ST; QL (20 tablets per 25 ERGOMAR 3 days) PA; ST; QL (8 AMPULES per 25 MIGRANAL 3 days) Migraine Therapy - Ergot Combinations CAFERGOT 3 ergotamine-caffeine 1 MIGERGOT 3 Migraine Therapy - Nsaid Analgesics(Cyclooxygenase Inhib-Non- Selectiv) PA; ST; QL (1 box (9 packets) per CAMBIA 3 30 dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
114 Drug Status Notes Migraine Therapy - Selective Serotonin Agonists 5-Ht(1) AMERGE 3 PA; ST; QL (20 MG per 25 days) AXERT 3 PA; ST; QL (100 MG per 25 days) eletriptan 3 QL (240 MG per 25 days) FROVA 3 PA; ST; QL (30 MG per 25 days) PA; ST; QL (900 MG(oral equiv) IMITREX NASAL 3 per 25 days) IMITREX ORAL 3 PA; ST; QL (900 MG per 25 days) IMITREX STATDOSE PEN SUBCUTANEOUS 3 PA; ST; QL (900 MG per 25 days) PEN INJECTOR 4 MG/0.5 ML IMITREX STATDOSE PEN SUBCUTANEOUS 3 PA; ST; QL (900 ML per 30 days) PEN INJECTOR 6 MG/0.5 ML IMITREX STATDOSE REFILL 3 PA; ST; QL (900 ML per 30 days) SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML IMITREX STATDOSE REFILL 3 PA; ST; QL (900 MG per 25 days) SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML IMITREX SUBCUTANEOUS 3 PA; ST; QL (900 MG per 25 days) MAXALT 3 PA; ST; QL (120 MG per 25 days) MAXALT-MLT 3 PA; ST; QL (120 MG per 25 days) naratriptan 1 QL (20 MG per 25 days) ONZETRA XSAIL 3 PA; ST; QL (176 EA per 30 days) RELPAX 3 PA; ST; QL (240 MG per 25 days) rizatriptan 1 QL (120 MG per 25 days) QL (900 MG(oral equiv) per 25 sumatriptan 3 days) $3-Copay; QL (900 MG per 25 sumatriptan succinate oral 1 days) sumatriptan succinate subcutaneous cartridge 3 QL (4 ML per 30 days) sumatriptan succinate subcutaneous pen injector 3 QL (900 MG per 25 days) sumatriptan succinate subcutaneous solution 3 QL (900 MG per 25 days) sumatriptan succinate subcutaneous syringe 6 3 mg/0.5 ml SUMAVEL DOSEPRO SUBCUTANEOUS 3 NEEDLE-FREE INJECTOR 4 MG/0.5 ML SUMAVEL DOSEPRO SUBCUTANEOUS 3 PA; ST; QL (900 MG per 25 days) NEEDLE-FREE INJECTOR 6 MG/0.5 ML
Last Approved Date: 09/23/2021 Formulary Version: 91
115 Drug Status Notes PA; ST; QL (900 mg per 25 TOSYMRA 3 Dayss) ZEMBRACE SYMTOUCH 3 PA; ST; QL (48 ML per 30 days) zolmitriptan nasal 3 PA; ST; QL (40 mg per 25 days) zolmitriptan oral tablet 1 QL (40 MG per 25 days) zolmitriptan oral tablet,disintegrating 1 ZOMIG NASAL 3 PA; ST; QL (40 mg per 25 days) ZOMIG ORAL 3 PA; ST; QL (40 MG per 25 days) ZOMIG ZMT 3 PA; ST; QL (40 MG per 25 days) Migraine Therapy - Selective Serotonin Agonists 5-Ht(1F) REYVOW ORAL TABLET 100 MG 3 PA; QL (8 tablets per 25 Dayss) REYVOW ORAL TABLET 50 MG 3 PA; QL (4 tablets per 25 Dayss) Migraine Therapy - Serotonin Agonist 5-Ht(1) And Nsaid Comb. PA; ST; QL (9 tablets per 1 TREXIMET ORAL TABLET 10-60 MG 3 month) PA; ST; QL (9 TABLETS per 25 TREXIMET ORAL TABLET 85-500 MG 3 days) Movement Disorder Drug Therapy PA; BE; SPT; QL (4 tablets per 1 AUSTEDO ORAL TABLET 12 MG, 6 MG 4 day) PA; BE; SPT; QL (5 tablets per 1 AUSTEDO ORAL TABLET 9 MG 4 day) PA; BE; SPT; QL (2 tablets per 1 INGREZZA INITIATION PACK 4 day) PA; BE; SPT; QL (1 capsule per 1 INGREZZA ORAL CAPSULE 40 MG 4 day) PA; BE; SPT; QL (1 tablet per 1 INGREZZA ORAL CAPSULE 60 MG 4 day) PA; BE; SPT; QL (1 tablet per 1 INGREZZA ORAL CAPSULE 80 MG 4 Day) PA; BE; SPT; QL (3 tablets per 1 tetrabenazine oral tablet 12.5 mg 3 day) PA; BE; SPT; QL (2 tablets per 1 tetrabenazine oral tablet 25 mg 3 day) PA; BE; SPT; QL (3 tablets per 1 XENAZINE ORAL TABLET 12.5 MG 4 day) Last Approved Date: 09/23/2021 Formulary Version: 91
116 Drug Status Notes PA; BE; SPT; QL (2 tablets per 1 XENAZINE ORAL TABLET 25 MG 4 day) Movement Disorder Therapy - Huntington's Disease PA; BE; SPT; QL (4 tablets per 1 AUSTEDO ORAL TABLET 12 MG, 6 MG 4 day) PA; BE; SPT; QL (5 tablets per 1 AUSTEDO ORAL TABLET 9 MG 4 day) PA; BE; SPT; QL (3 tablets per 1 tetrabenazine oral tablet 12.5 mg 3 day) PA; BE; SPT; QL (2 tablets per 1 tetrabenazine oral tablet 25 mg 3 day) PA; BE; SPT; QL (3 tablets per 1 XENAZINE ORAL TABLET 12.5 MG 4 day) PA; BE; SPT; QL (2 tablets per 1 XENAZINE ORAL TABLET 25 MG 4 day) Movement Disorder Therapy - Restless Legs Syndrome HORIZANT 3 PA; ST Movement Disorder Therapy - Tardive Dyskinesia PA; BE; SPT; QL (4 tablets per 1 AUSTEDO ORAL TABLET 12 MG, 6 MG 4 day) PA; BE; SPT; QL (5 tablets per 1 AUSTEDO ORAL TABLET 9 MG 4 day) PA; BE; SPT; QL (2 tablets per 1 INGREZZA INITIATION PACK 4 day) PA; BE; SPT; QL (1 capsule per 1 INGREZZA ORAL CAPSULE 40 MG 4 day) PA; BE; SPT; QL (1 tablet per 1 INGREZZA ORAL CAPSULE 60 MG 4 day) PA; BE; SPT; QL (1 tablet per 1 INGREZZA ORAL CAPSULE 80 MG 4 Day) Narcolepsy And Cataplexy Therapy Agents - Sedative-Type PA; ST; BE; SPT; QL (540 ML XYREM 4 per 30 days) PA; ST; BE; SPT; QL (540 ML XYWAV 4 per 30 days) Last Approved Date: 09/23/2021 Formulary Version: 91
117 Drug Status Notes Narcolepsy Therapy Agents - Dopamine And Ne Reuptake Inhibitor (Dnri) SUNOSI 3 PA; ST; QL (1 tablet per 1 day) Narcolepsy Therapy Agents - H3- Receptor Antagonist/Inverse Agonist PA; ST; BE; SPT; QL (2 tablets WAKIX 4 per 1 day) Narcolepsy Therapy Agents - Non- Sympathomimetic PA; ST; QL (1 TABLET per 1 armodafinil 1 day) PA; QL (34 TABLETS per 1 modafinil 1 MONTH) NUVIGIL ORAL TABLET 150 MG, 200 MG, PA; ST; QL (34 TABLETS per 1 3 250 MG MONTH) PA; ST; QL (68 TABLETS per 1 NUVIGIL ORAL TABLET 50 MG 3 MONTH) PA; ST; QL (34 TABLETS per 1 PROVIGIL 3 MONTH) Narcolepsy Therapy Agents - Stimulant- Type, Piperadine Derivative METHYLIN ORAL SOLUTION 3 methylphenidate hcl oral solution 1 methylphenidate hcl oral tablet 1 methylphenidate hcl oral tablet,chewable 1 Narcolepsy Therapy Agents- Stimulant- Type,Sympathomimetic,Amphetamines DEXEDRINE 1 dextroamphetamine oral capsule, extended 1 release dextroamphetamine oral tablet 10 mg, 5 mg 1 dextroamphetamine-amphetamine oral tablet 10 QL (204 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 12.5 QL (170 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 15 QL (136 TABLETS per 1 1 mg MONTH)
Last Approved Date: 09/23/2021 Formulary Version: 91
118 Drug Status Notes dextroamphetamine-amphetamine oral tablet 20 QL (102 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 30 1 QL (68 TABLETS per 1 MONTH) mg dextroamphetamine-amphetamine oral tablet 5 QL (408 TABLETS per 1 1 mg MONTH) dextroamphetamine-amphetamine oral tablet 7.5 QL (272 TABLETS per 1 1 mg MONTH) EVEKEO 3 PA; ST ZENZEDI ORAL TABLET 10 MG, 5 MG 1 Neuropathic Pain Therapy LYRICA CR 3 PA; ST pregabalin oral tablet extended release 24 hr 3 PA; ST; QL (1 tablet per 1 Day) Postherpetic Neuralgia Agents GRALISE 30-DAY STARTER PACK 3 PA GRALISE ORAL TABLET EXTENDED 3 PA RELEASE 24 HR LYRICA CR 3 PA; ST pregabalin oral tablet extended release 24 hr 3 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 25 mg 3 diphenhydramine hcl oral capsule 50 mg 1 Sedative-Hypnotic - Barbiturates BUTISOL 3 phenobarbital 1 SECONAL SODIUM 1 Sedative-Hypnotic - Benzodiazepines DORAL 3 estazolam 1 flurazepam 1 HALCION ORAL TABLET 0.25 MG 3 PA lorazepam injection syringe 2 mg/ml 3 midazolam oral syrup 10 mg/5 ml (2 mg/ml) 3 Last Approved Date: 09/23/2021 Formulary Version: 91
119 Drug Status Notes midazolam oral syrup 2 mg/ml 1 quazepam 1 RESTORIL 3 temazepam 1 triazolam 3 PA Sedative-Hypnotic - Gaba-Receptor Modulators AMBIEN 3 PA; ST AMBIEN CR 3 PA; ST EDLUAR 3 PA; ST eszopiclone 1 INTERMEZZO 3 PA; ST LUNESTA 3 PA; ST SONATA 3 zaleplon 1 zolpidem oral 1 zolpidem sublingual 3 PA; ST ZOLPIMIST 3 PA; ST; QL (1 ML per 30 days) Sedative-Hypnotic - Orexin Receptor Antagonist PA; QL (34 TABLETS per 1 BELSOMRA 3 MONTH) DAYVIGO 3 PA; ST; QL (1 tablet per 1 Day) Sedative-Hypnotic - Tricyclic Antidepressant Type doxepin oral tablet 3 PA; ST SILENOR 3 PA; ST Chemical Dependency, Agents To Treat Agents For Opioid Withdrawal, Central Alpha-2 Adrenergic Agonist-Type LUCEMYRA 3 QL (14 day supply per 90 days) Agents For Opioid Withdrawal, Opioid- Type BUNAVAIL 3 QL (378 MG per 25 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
120 Drug Status Notes QL (5 DAYS SUPPLY per 1 buprenorphine hcl sublingual 1 FILL) 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 1 QL (720 MG per 25 days) SUBOXONE 3 QL (720 MG per 25 days) ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 3 QL (513 MG per 25 Days) 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 (513 MG per 25 days) MG, 5.7-1.4 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 1 Alcohol Deterrents ANTABUSE 3 disulfiram 1 Smoking Deterrents - Ne And Dopamine Reuptake Inhibitor (Ndri)- Type BUPROBAN $0 bupropion hcl (smoking deter) $0 ZYBAN 3 Smoking Deterrents - Nicotine-Type NICODERM CQ 2 NICORELIEF BUCCAL GUM 1 NICORELIEF BUCCAL LOZENGE $0 NICORETTE 2 nicotine 1 nicotine (polacrilex) 1 NICOTROL 2
Last Approved Date: 09/23/2021 Formulary Version: 91
121 Drug Status Notes NICOTROL NS 2 NTS STEP 1 1 QUIT 2 3 QUIT 4 3 STOP SMOKING AID BUCCAL GUM $0 STOP SMOKING AID BUCCAL LOZENGE 1 Smoking Deterrents - Nicotinic Receptor Partial Agonist, Alpha4beta2 CHANTIX 2 CHANTIX CONTINUING MONTH BOX 2 CHANTIX CONTINUING MONTH PAK $0 CHANTIX STARTING MONTH BOX 2 CHANTIX STARTING MONTH PAK $0 varenicline $0 Chemicals-Pharmaceutical Adjuvants Bulk Chemicals ALBA-DERM 3 albendazole (bulk) 3 benzalkonium chloride (bulk) 3 chlorhexidine gluconate (bulk) 3 coal tar (bulk) 3 ferric subsulfate (bulk) solution 3 glipizide (bulk) 3 glyburide (bulk) 3 glycolic acid (bulk) solution 3 lanolin (bulk) wax 3 nystatin (bulk) powder 1 billion unit, 10 billion unit, 150 million unit, 2 billion unit, 5 billion unit, 3 50 million unit, 500 million unit PEG 3350-GRX $0 permethrin (bulk) 3 polyethylene glycol 400 (bulk) 3 polysorbate 20 (bulk) 3 pyrithione zinc (bulk) 3 simethicone (bulk) 3
Last Approved Date: 09/23/2021 Formulary Version: 91
122 Drug Status Notes sodium hydroxide (bulk) solution 3 sodium lactate (bulk) 3 Chemicals - Acids glycolic acid (bulk) solution 3 Chemicals - Bases sodium hydroxide (bulk) solution 3 Pharmaceutical Adjuvant - Cream/Ointment Vehicles PEG 3350-GRX $0 polyethylene glycol 400 (bulk) 3 Pharmaceutical Adjuvant - Flavoring Agents ethyl acetate 3 Pharmaceutical Adjuvant - Inhalation Vehicles HYPER-SAL 3 NEBUSAL INHALATION SOLUTION FOR 1 NEBULIZATION 3 % NEBUSAL INHALATION SOLUTION FOR 3 NEBULIZATION 6 % PULMOSAL 1 sodium chloride inhalation 1 Pharmaceutical Adjuvant - Oral Vehicles ORA-PLUS 3 sorbitol solution 3 Pharmaceutical Adjuvant - Preservatives benzalkonium chloride (bulk) 3 Pharmaceutical Adjuvant - Surfactants polysorbate 20 (bulk) 3 polysorbate 40 3 polysorbate 60 3 polysorbate 80 3
Last Approved Date: 09/23/2021 Formulary Version: 91
123 Drug Status Notes Cognitive Disorder Therapy Alzheimer's Disease Therapy - Cholinesterase Inhibitors ARICEPT 3 ARICEPT ODT ORAL 3 TABLET,DISINTEGRATING 5 MG donepezil 1 EXELON ORAL CAPSULE 3 EXELON PATCH 3 galantamine 1 RAZADYNE ER 3 RAZADYNE ORAL TABLET 3 rivastigmine 3 rivastigmine tartrate 1 Alzheimer's Disease Therapy - Nmda Receptor Antagonists memantine hcl 10 mg/5 ml soln inner 1 memantine hcl 2 mg/ml solution 3 memantine oral solution 2 mg/ml 1 memantine oral tablet 3 memantine oral tablets,dose pack 3 NAMENDA 3 NAMENDA TITRATION PAK 3 NAMENDA XR 3 Alzheimer's Thx - Nmda Receptor Antag. And Cholinesterase Inhib. Comb NAMZARIC 3 Cognitive Disorder Therapy - Cerebral Vasodilators ergoloid 3 Contraceptives Contraceptive - Vaginal Ph Modulator PHEXXI 3 Contraceptive Implant - Progestin NEXPLANON $0 Last Approved Date: 09/23/2021 Formulary Version: 91
124 Drug Status Notes Contraceptive Injectable - Progestin DEPO-PROVERA INTRAMUSCULAR 3 SUSPENSION 150 MG/ML DEPO-PROVERA INTRAMUSCULAR 3 SYRINGE DEPO-SUBQ PROVERA 104 3 medroxyprogesterone intramuscular suspension $0 medroxyprogesterone intramuscular syringe 1 Contraceptive Intrauterine - Copper Iud PARAGARD T 380A 3 Contraceptive Intrauterine - Progesterone Iud KYLEENA 3 LILETTA $0 MIRENA $0 SKYLA $0 Contraceptive Oral - Biphasic AMETHIA 1 AMETHIA LO 1 ASHLYNA 1 AZURETTE (28) 1 BEKYREE (28) 1 CAMRESE 1 CAMRESE LO 1 DAYSEE 1 desog-e.estradiol/e.estradiol 1 KARIVA (28) 1 KIMIDESS (28) 1 l norgest/e.estradiol-e.estrad oral tablets,dose 1 pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose QL (1 TAB DISPENSER per 3 1 pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) MONTHs) LO LOESTRIN FE $0 LOSEASONIQUE $0 MIRCETTE (28) $0 Last Approved Date: 09/23/2021 Formulary Version: 91
125 Drug Status Notes NECON 10/11 (28) 1 PIMTREA (28) 1 SEASONIQUE $0 SIMLIYA (28) 1 SIMPESSE 1 VIORELE (28) 1 Contraceptive Oral - Monophasic AFIRMELLE 1 ALTAVERA (28) 1 ALYACEN 1/35 (28) 1 AMETHYST (28) 1 APRI 1 AUBRA 1 AUBRA EQ 1 AUROVELA 1.5/30 (21) 1 AUROVELA 1/20 (21) 1 AUROVELA 24 FE 1 AUROVELA FE 1.5/30 (28) 1 AUROVELA FE 1-20 (28) 1 AVIANE 1 AYUNA 1 BALCOLTRA $0 BALZIVA (28) 1 BEYAZ $0 BLISOVI 24 FE 1 BLISOVI FE 1.5/30 (28) 1 BLISOVI FE 1/20 (28) 1 BREVICON (28) $0 BRIELLYN 1 CHATEAL (28) 1 CHATEAL EQ (28) 1 CRYSELLE (28) 1 CYCLAFEM 1/35 (28) 1 CYRED 1 CYRED EQ 1 Last Approved Date: 09/23/2021 Formulary Version: 91
126 Drug Status Notes DASETTA 1/35 (28) 1 DELYLA (28) 1 DESOGEN $0 desogestrel-ethinyl estradiol 1 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02- $0 0.451 mg (24) (4) drospirenone-ethinyl estradiol $0 ELINEST 1 EMOQUETTE 1 ENSKYCE 1 ESTARYLLA 1 ethynodiol diac-eth estradiol 1 FALMINA (28) 1 FEMCON FE $0 FEMYNOR 1 GEMMILY $0 GENERESS FE $0 GIANVI (28) 1 GILDAGIA 1 GILDESS 1.5/30 (21) 1 GILDESS 1/20 (21) 1 GILDESS 24 FE 1 GILDESS FE 1.5/30 (28) 1 GILDESS FE 1/20 (28) 1 HAILEY 1 HAILEY 24 FE $0 HAILEY FE 1.5/30 (28) $0 INTROVALE 1 ISIBLOOM 1 JASMIEL (28) 1 JOLESSA 1 JULEBER 1 JUNEL 1.5/30 (21) 1 JUNEL 1/20 (21) 1 JUNEL FE 1.5/30 (28) 1
Last Approved Date: 09/23/2021 Formulary Version: 91
127 Drug Status Notes JUNEL FE 1/20 (28) 1 JUNEL FE 24 1 KAITLIB FE 1 KALLIGA 1 KELNOR 1/35 (28) 1 KELNOR 1-50 (28) 1 KURVELO (28) 1 LARIN 1.5/30 (21) 1 LARIN 1/20 (21) 1 LARIN 24 FE 1 LARIN FE 1.5/30 (28) 1 LARIN FE 1/20 (28) 1 LARISSIA 1 LAYOLIS FE 1 LESSINA 1 levonorgestrel-ethinyl estrad oral tablet 0.1-20 1 mg-mcg, 90-20 mcg (28) levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 $0 mg levonorgestrel-ethinyl estrad oral tablets,dose 1 pack,3 month LEVORA 0.15/30 (28) $0 LEVORA-28 1 LILLOW (28) 1 LO MINASTRIN FE $0 LOESTRIN 1.5/30 (21) $0 LOESTRIN 1/20 (21) $0 LOESTRIN 24 FE $0 LOESTRIN FE 1.5/30 (28-DAY) $0 LOESTRIN FE 1/20 (28-DAY) $0 LOMEDIA 24 FE 1 LORYNA (28) 1 LOW-OGESTREL (28) 1 LO-ZUMANDIMINE (28) 1 LUTERA (28) 1 MARLISSA (28) 1 Last Approved Date: 09/23/2021 Formulary Version: 91
128 Drug Status Notes MIBELAS 24 FE $0 MICROGESTIN 1.5/30 (21) 1 MICROGESTIN 1/20 (21) 1 MICROGESTIN 24 FE $0 MICROGESTIN FE 1.5/30 (28) 1 MICROGESTIN FE 1/20 (28) 1 MILI 1 MINASTRIN 24 FE $0 MODICON (28) $0 MONO-LINYAH 1 MONONESSA (28) 1 NECON 0.5/35 (28) 1 NECON 1/35 (28) 1 NECON 1/50 (28) 1 NEXTSTELLIS $0 NIKKI (28) 1 NORDETTE (28) $0 noreth-ethinyl estradiol-iron 1 norethindrone ac-eth estradiol oral tablet 1-20 1 mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral capsule $0 norethindrone-e.estradiol-iron oral tablet 1 mg- 20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg 1 (4) norethindrone-e.estradiol-iron oral tablet 1.5 mg- $0 30 mcg (21)/75 mg (7) norgestimate-ethinyl estradiol oral tablet 0.25-35 1 mg-mcg norgestrel-ethinyl estradiol 1 NORINYL 1/35 (28) $0 NORINYL 1+50 (28) $0 NORTREL 0.5/35 (28) 1 NORTREL 1/35 (21) 1 NORTREL 1/35 (28) 1 OCELLA 1 OGESTREL (28) 1
Last Approved Date: 09/23/2021 Formulary Version: 91
129 Drug Status Notes ORSYTHIA 1 ORTHO-CEPT (28) $0 ORTHO-CYCLEN (28) $0 ORTHO-NOVUM 1/35 (28) $0 OVCON-35 (28) $0 PHILITH 1 PIRMELLA ORAL TABLET 1-35 MG-MCG 1 PORTIA 28 1 PREVIFEM 1 QUASENSE 1 RAJANI $0 RECLIPSEN (28) 1 SAFYRAL $0 SETLAKIN 1 SPRINTEC (28) 1 SRONYX 1 SYEDA 1 TARINA 24 FE 1 TARINA FE 1/20 (28) 1 TARINA FE 1-20 EQ (28) 1 TAYTULLA $0 TYDEMY $0 VESTURA (28) 1 VIENVA 1 VYFEMLA (28) 1 VYLIBRA 1 WERA (28) 1 WYMZYA FE 1 YASMIN (28) $0 YAZ (28) $0 ZARAH 1 ZENCHENT (28) 1 ZENCHENT FE 1 ZEOSA $0 ZOVIA 1/35E (28) 1
Last Approved Date: 09/23/2021 Formulary Version: 91
130 Drug Status Notes ZOVIA 1/50E (28) 1 ZUMANDIMINE (28) 1 Contraceptive Oral - Progestin CAMILA 1 DEBLITANE 1 ERRIN 1 HEATHER 1 INCASSIA 1 JENCYCLA 1 JOLIVETTE 1 LYZA 1 NORA-BE 1 norethindrone (contraceptive) 1 NORLYDA 1 NORLYROC 1 NOR-Q-D $0 ORTHO MICRONOR $0 SHAROBEL 1 SLYND $0 TULANA 1 Contraceptive Oral - Quadraphasic FAYOSIM 1 l norgest/e.estradiol-e.estrad oral tablets,dose 1 pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg NATAZIA $0 QUARTETTE $0 RIVELSA 1 Contraceptive Oral - Triphasic ALYACEN 7/7/7 (28) 1 ARANELLE (28) 1 CAZIANT (28) 1 CYCLAFEM 7/7/7 (28) 1 CYCLESSA (28) $0 DASETTA 7/7/7 (28) 1 ENPRESSE 1 Last Approved Date: 09/23/2021 Formulary Version: 91
131 Drug Status Notes ESTROSTEP FE-28 $0 LEENA 28 1 LEVONEST (28) 1 levonorg-eth estrad triphasic 1 MYZILRA 1 NECON 7/7/7 (28) 1 norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25 mg-25 mcg, 0.18/0.215/0.25 mg- 1 35 mcg (28) NORTREL 7/7/7 (28) 1 ORTHO TRI-CYCLEN (28) $0 ORTHO TRI-CYCLEN LO (28) $0 ORTHO-NOVUM 7/7/7 (28) $0 PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 1 MCG TILIA FE 1 TRI FEMYNOR 1 TRI-ESTARYLLA 1 TRI-LEGEST FE 1 TRI-LINYAH 1 TRI-LO-ESTARYLLA 1 TRI-LO-MARZIA 1 TRI-LO-MILI 1 TRI-LO-SPRINTEC 1 TRI-MILI 1 TRINESSA (28) 1 TRINESSA LO 1 TRI-NORINYL (28) $0 TRI-PREVIFEM (28) 1 TRI-SPRINTEC (28) 1 TRIVORA (28) 1 TRI-VYLIBRA 1 TRI-VYLIBRA LO 1 VELIVET TRIPHASIC REGIMEN (28) 1
Last Approved Date: 09/23/2021 Formulary Version: 91
132 Drug Status Notes Contraceptive Transdermal Combinations - Estrogen And Progestin Comb. ORTHO EVRA $0 TWIRLA $0 XULANE 3 Contraceptives - Intravaginal, Systemic - Estrogen And Progestin Comb. ANNOVERA 3 SPT; QL (1 ring per 275 Dayss) ELURYNG $0 etonogestrel-ethinyl estradiol $0 NUVARING 3 Emergency Contraceptives AFTERA 3 ECONTRA EZ 3 QL (1 TABLET per 3 MONTHs) ECONTRA ONE-STEP 3 ELLA 2 FALLBACK SOLO 3 QL (1 TABLET per 3 MONTHs) levonorgestrel oral tablet 0.75 mg $0 levonorgestrel oral tablet 1.5 mg 3 MY CHOICE 3 MY WAY 3 QL (1 TABLET per 3 MONTHs) NEW DAY 3 NEXT CHOICE $0 NEXT CHOICE ONE DOSE 3 OPCICON ONE-STEP 3 QL (1 TABLET per 3 MONTHs) OPTION-2 3 PLAN B ONE-STEP 3 REACT 3 TAKE ACTION 3 QL (1 TABLET per 3 MONTHs) Emergency Contraceptives - Progesterone Agonist/Antagonist Type ELLA 2
Last Approved Date: 09/23/2021 Formulary Version: 91
133 Drug Status Notes Emergency Contraceptives - Progestin Type AFTERA 3 ECONTRA EZ 3 QL (1 TABLET per 3 MONTHs) ECONTRA ONE-STEP 3 FALLBACK SOLO 3 QL (1 TABLET per 3 MONTHs) levonorgestrel 3 MY CHOICE 3 MY WAY 3 QL (1 TABLET per 3 MONTHs) NEW DAY 3 NEXT CHOICE ONE DOSE 3 OPCICON ONE-STEP 3 QL (1 TABLET per 3 MONTHs) OPTION-2 3 PLAN B ONE-STEP 3 REACT 3 TAKE ACTION 3 QL (1 TABLET per 3 MONTHs) Spermicides CONCEPTROL 3 GYNOL II 3 TODAY CONTRACEPTIVE SPONGE 3 VAGINAL CONTRACEPTIVE FILM 3 VAGINAL CONTRACEPTIVE FOAM 3 VCF CONTRACEPTIVE FILM $0 VCF CONTRACEPTIVE GEL 3 Dermatological Acne Therapy Systemic - Retinoids And Derivatives ABSORICA 3 PA; ST ABSORICA LD 3 PA; ST AMNESTEEM 1 CLARAVIS 1 isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 1 PA; ST mg isotretinoin oral capsule 25 mg, 35 mg 3 PA; ST MYORISAN 1
Last Approved Date: 09/23/2021 Formulary Version: 91
134 Drug Status Notes ZENATANE 1 Acne Therapy Systemic - Tetracycline Antibiotic COREMINO 3 minocycline oral capsule,extended release 24hr 3 PA; ST minocycline oral tablet extended release 24 hr 105 mg, 115 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 3 mg minocycline oral tablet extended release 24 hr 3 PA 135 mg MINOLIRA ER 3 PA; ST SEYSARA 3 SOLODYN ORAL TABLET EXTENDED 3 PA; ST RELEASE 24 HR 105 MG, 55 MG, 80 MG SOLODYN ORAL TABLET EXTENDED 3 RELEASE 24 HR 115 MG, 65 MG XIMINO 3 Acne Therapy Topical - Androgen Receptor Inhibitors PA; ST; QL (60 GM per 1 WINLEVI 3 Dispense) Acne Therapy Topical - Anti-Infective ACZONE 3 AMZEEQ 3 PA; ST AZELEX 3 CLEOCIN T 3 CLINDACIN ETZ TOPICAL SWAB 1 CLINDACIN P 1 CLINDAGEL 3 PA; ST clindamycin phosphate topical foam 1 clindamycin phosphate topical gel 1 clindamycin phosphate topical lotion 1 clindamycin phosphate topical solution 1 clindamycin phosphate topical swab 1 dapsone topical 3 ERY PADS 1
Last Approved Date: 09/23/2021 Formulary Version: 91
135 Drug Status Notes ERYGEL 1 erythromycin with ethanol 1 EVOCLIN 3 QL (100 GM per 1 MONTH) FINACEA 3 PA KLARON 3 sulfacetamide sodium (acne) 1 Acne Therapy Topical - Anti-Infective- Keratolytic Combinations ACANYA TOPICAL GEL 3 PA; ST ACANYA TOPICAL GEL WITH PUMP 3 PA AVAR LS TOPICAL CLEANSER 3 AVAR TOPICAL CLEANSER 3 AVAR-E 3 AVAR-E LS 3 BENZACLIN 3 BENZACLIN PUMP 3 BENZAMYCIN 3 BENZAMYCINPAK 3 BP 10-1 1 CLEANSING WASH TOPICAL CLEANSER 1 clindamycin-benzoyl peroxide topical gel 1 clindamycin-benzoyl peroxide topical gel with 3 pump erythromycin-benzoyl peroxide 1 NEUAC 1 ONEXTON TOPICAL GEL 3 PA; ST ONEXTON TOPICAL GEL WITH PUMP 3 PA ROSULA 3 ROSULA CLEANSING CLOTHS 1 SSS 10-5 1 sulfacetamide sodium-sulfur 1 sulfacetamide sodium-sulfur topical pads, 1 medicated 10-4 % sulfacetamide sod-sulfur-urea 1 SULFACLEANSE 8-4 1
Last Approved Date: 09/23/2021 Formulary Version: 91
136 Drug Status Notes SUMAXIN 3 ZENCIA 1 Acne Therapy Topical - Anti-Infective- Retinoid Combinations clindamycin-tretinoin 1 ZIANA 3 PA; ST Acne Therapy Topical - Keratolytic BENZEFOAM 3 BENZEFOAM ULTRA 3 BENZEPRO TOPICAL TOWELETTE 3 benzoyl peroxide topical cleanser 10 %, 7 % 3 benzoyl peroxide topical cleanser 4 %, 6 % 1 benzoyl peroxide topical foam 5.3 % 1 benzoyl peroxide topical foam 9.8 % 3 benzoyl peroxide topical gel 10 %, 5 % 3 BPO 3 ENZOCLEAR 3 INOVA 3 PACNEX 3 PACNEX HP 3 PACNEX LP 3 potassium hydroxide 3 Acne Therapy Topical - Keratolytic Combinations Other INOVA 4-1 3 INOVA 8-2 3 Acne Therapy Topical - Keratolytic- Glucocorticoid Combinations VANOXIDE-HC 3 Acne Therapy Topical - Retinoid Combinations Other EPIDUO FORTE 3 EPIDUO TOPICAL GEL 3
Last Approved Date: 09/23/2021 Formulary Version: 91
137 Drug Status Notes Acne Therapy Topical - Retinoids And Derivatives adapalene topical cream 3 adapalene topical gel 0.1 % 3 adapalene topical gel 0.3 % 1 adapalene topical gel with pump 1 adapalene topical lotion 3 adapalene topical swab 3 AKLIEF 3 PA; ST ALTRENO 3 PA; ST ARAZLO 3 PA; ST ATRALIN 3 PA; ST AVITA TOPICAL CREAM 1 AVITA TOPICAL GEL 3 DIFFERIN 3 PA FABIOR 3 PA; ST PLIXDA 3 RETIN-A 3 PA; ST RETIN-A MICRO 3 PA; ST RETIN-A MICRO PUMP TOPICAL GEL WITH 3 PA; ST PUMP 0.04 %, 0.08 %, 0.1 % RETIN-A MICRO PUMP TOPICAL GEL WITH 3 PA PUMP 0.06 % tazarotene topical foam 3 PA; ST tretinoin topical cream 1 tretinoin topical gel 0.01 %, 0.025 % 1 TRETIN-X CREAM KIT 3 Antipsoriatic - Retinoid (Vitamin A Derivative) - Glucocorticoid PA; ST; SPT; QL (1 tube (100g) DUOBRII 4 per 1 dispensing event) Antipsoriatic - Vitamin D Analog - Glucocorticoid Combinations calcipotriene-betamethasone 3 PA; ST ENSTILAR 3 PA; ST TACLONEX 3 PA; ST Last Approved Date: 09/23/2021 Formulary Version: 91
138 Drug Status Notes WYNZORA 4 PA; ST; SPT Antipsoriatic Agents - Interleukin 12 And Il-23 Inhibitors,Mc Antibody PA; ST; BE; SPT; QL (1 vial per STELARA SUBCUTANEOUS SOLUTION 3 63 days) STELARA SUBCUTANEOUS SYRINGE 45 PA; ST; SP; BE; SPT; QL (1 vial 3 MG/0.5 ML per 63 days) STELARA SUBCUTANEOUS SYRINGE 90 PA; ST; SP; BE; SPT; QL (1 3 MG/ML SYRINGE per 63 days) Antipsoriatic Agents - Interleukin-23 (Il-23) Antagonist, Mc Antibody PA; ST; BE; SPT; QL (1 SKYRIZI SUBCUTANEOUS PEN INJECTOR 3 150mg/ml per 84 days) SKYRIZI SUBCUTANEOUS SYRINGE 150 PA; ST; BE; SPT; QL (1 3 MG/ML 150mg/ml per 84 days) PA; ST; BE; SPT; QL (2 prefilled SKYRIZI SUBCUTANEOUS SYRINGE KIT 3 syringes per 84 days) TREMFYA SUBCUTANEOUS AUTO- 3 ST; BE INJECTOR PA; ST; SP; BE; SPT; QL (1 TREMFYA SUBCUTANEOUS SYRINGE 3 syringe per 56 days) Antipsoriatic Agents-Interleukin-17 (Il- 17) Antagonist, Mc Antibody PA; ST; SP; BE; SPT; QL (2 ML COSENTYX (2 SYRINGES) 3 per 21 days) PA; ST; SP; BE; SPT; QL (2 ML COSENTYX PEN 3 per 21 days) PA; ST; SP; BE; SPT; QL (2 ML COSENTYX PEN (2 PENS) 3 per 21 days) COSENTYX SUBCUTANEOUS SYRINGE 150 PA; ST; SP; BE; SPT; QL (2 ML 3 MG/ML per 21 days) COSENTYX SUBCUTANEOUS SYRINGE 75 PA; ST; BE; SPT; QL (1 syringe 3 MG/0.5 ML (75mg/0.5ml) per 28 days) PA; ST; BE; SPT; QL (2 prefilled SILIQ 4 SYR per 28 Days) PA; ST; SP; BE; SPT; QL (1 ML TALTZ AUTOINJECTOR 4 per 21 days) PA; ST; SP; BE; SPT; QL (1 ML TALTZ AUTOINJECTOR (2 PACK) 4 per 21 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
139 Drug Status Notes PA; ST; SP; BE; SPT; QL (1 ML TALTZ AUTOINJECTOR (3 PACK) 4 per 21 days) PA; ST; SP; BE; SPT; QL (1 ML TALTZ SYRINGE 4 per 21 days) PA; ST; SP; BE; SPT; QL (1 ML TALTZ SYRINGE (2 PACK) 4 per 21 days) PA; ST; SP; BE; SPT; QL (1 ML TALTZ SYRINGE (3 PACK) 4 per 21 days) Dermatitis Or Eczema Agents, Systemic-Interleukin-4 (Il-4Ra) Antag.Mab DUPIXENT PEN SUBCUTANEOUS PEN PA; ST; SPT; QL (3 ML per 21 3 INJECTOR 200 MG/1.14 ML Dayss) DUPIXENT PEN SUBCUTANEOUS PEN PA; ST; SPT; QL (2 syringes per 3 INJECTOR 300 MG/2 ML 21 Dayss) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; SPT; QL (2 syringes 3 SYRINGE 200 MG/1.14 ML per 21 Dayss) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; SPT; QL (2 syringes 3 SYRINGE 300 MG/2 ML per 21 days) Dermatitis Or Eczema Agents, Topical - Phosphodiesterase-4 Inhibitors EUCRISA 3 PA; QL (60 gm per 34 days) Dermatological - Antibacterial Aminoglycosides gentamicin topical 1 Dermatological - Antibacterial And Antifungal Agents ALOQUIN 3 Dermatological - Antibacterial Other BACTROBAN TOPICAL CREAM 3 mupirocin 1 mupirocin calcium 1 PA; ST silver nitrate 1 Dermatological - Antibacterial Pleuromutilin Derivatives ALTABAX 3
Last Approved Date: 09/23/2021 Formulary Version: 91
140 Drug Status Notes Dermatological - Antibacterial Quinolones XEPI 3 PA; ST; QL (30 GM per 30 Dayss) Dermatological - Antibacterial,Antifungal Agent With Glucocorticoid ALA-QUIN 3 ALCORTIN A 3 PA; ST Dermatological - Antibacterial- Glucocorticoid Combinations CORTISPORIN TOPICAL 3 Dermatological - Anticholinergic Hyperhidrosis Treatment Agents QBREXZA 3 PA Dermatological - Antifungal Allylamines naftifine 3 PA; ST NAFTIN TOPICAL CREAM 2 % 3 PA; ST NAFTIN TOPICAL GEL 3 PA; ST Dermatological - Antifungal Amphoteric Polyene Macrolides NYAMYC 1 NYATA 1 nystatin topical cream 1 $3-Copay nystatin topical ointment 1 $3-Copay nystatin topical powder 1 NYSTOP 1 Dermatological - Antifungal Benzylamines MENTAX 3 Dermatological - Antifungal Hydroxypyridinone CICLODAN 1 ciclopirox 1 ciclopirox-ure-camph-menth-euc 1
Last Approved Date: 09/23/2021 Formulary Version: 91
141 Drug Status Notes ciclopirox-vite-nail lacq remo 1 LOPROX TOPICAL SHAMPOO 3 PA; ST PENLAC 3 Dermatological - Antifungal Imidazole And Related Agents clotrimazole topical 3 econazole 1 ECOZA 3 PA; ST ERTACZO 3 PA; ST EXELDERM 3 PA; ST EXTINA 3 PA; ST ketoconazole topical cream 1 ketoconazole topical foam 3 PA; ST ketoconazole topical shampoo 1 KETODAN 3 PA; ST KETODAN KIT 2 PA; ST luliconazole 3 LUZU 3 PA; ST NIZORAL TOPICAL SHAMPOO 3 oxiconazole 3 PA; ST OXISTAT 3 PA; ST sulconazole 3 PA; ST VUSION 3 PA; ST XOLEGEL 3 PA; ST Dermatological - Antifungal Oxaborole PA; ST; QL (1 BOTTLE per 1 KERYDIN 3 MONTH) PA; ST; QL (10 ML per 1 tavaborole 3 Dispense) Dermatological - Antifungal Triazole PA; ST; QL (1 BOTTLE per 1 JUBLIA 3 MONTH) Dermatological - Antifungal- Glucocorticoid Combinations clotrimazole-betamethasone 1
Last Approved Date: 09/23/2021 Formulary Version: 91
142 Drug Status Notes DERMAZENE TOPICAL CREAM 1 LOTRISONE TOPICAL CREAM 3 nystatin-triamcinolone 1 Dermatological - Antineoplastic Alkylating Agents VALCHLOR 4 PA; ST; BE; SPT Dermatological - Antineoplastic Antimetabolites CARAC 3 PA; ST EFUDEX TOPICAL CREAM 3 PA; ST FLUOROPLEX 2 fluorouracil topical cream 0.5 % 3 fluorouracil topical cream 5 % 1 fluorouracil topical solution 1 TOLAK 3 Dermatological - Antineoplastic Or Premalig. Lesions - Antimicrotubule PA; ST; QL (5 packets per 60 KLISYRI 3 days) Dermatological - Antineoplastic Or Premalig. Lesions -Diterpene Esters PICATO 3 PA; ST Dermatological - Antineoplastic Or Premalignant Lesions - Nsaid's diclofenac sodium topical gel 3 % 3 PA; ST SOLARAZE 3 PA; ST Dermatological - Antineoplastic Retinoids PANRETIN 1 BE; SPT Dermatological - Antineoplastic Selective Retinoid X Receptor Agonist TARGRETIN TOPICAL 2 SP; SPT Dermatological - Antiperspirants aluminum chloride 1 DRYSOL 3
Last Approved Date: 09/23/2021 Formulary Version: 91
143 Drug Status Notes DRYSOL DAB-O-MATIC 3 XERAC AC 3 Dermatological - Antipsoriatic Agents Systemic, Photosensitizing methoxsalen 1 OXSORALEN ULTRA 3 Dermatological - Antipsoriatic Agents Systemic, Vitamin A Derivatives SORIATANE ORAL CAPSULE 10 MG, 17.5 3 MG, 25 MG Dermatological - Antipsoriatic Agents Topical PA; ST; QL (200 GM per 1 BRYHALI 3 Dispense) calcipotriene scalp 1 calcipotriene topical cream 3 calcipotriene topical foam 3 PA; ST calcitriol topical 3 PA; ST DOVONEX TOPICAL 3 PA; ST DRITHOCREME HP 1 PA; ST; QL (50 GM per 1 halobetasol propionate topical foam 3 Dispense) PA; ST; QL (60 GM per 1 IMPOYZ 3 Dispense) PA; ST; QL (50 GM per 1 LEXETTE 3 Dispense) SORILUX 3 PA; ST tazarotene topical cream 1 TAZORAC 3 PA; ST PA; ST; QL (60 ML per 1 ULTRAVATE TOPICAL LOTION 3 Dispense) VECTICAL 3 PA; ST ZITHRANOL-RR 3 Dermatological - Antipsoriatics Systemic, Phosphodiesterase 4 Inhib. OTEZLA 3 ST; BE
Last Approved Date: 09/23/2021 Formulary Version: 91
144 Drug Status Notes OTEZLA STARTER 3 ST; BE Dermatological - Antiseborrheic OVACE 3 OVACE PLUS TOPICAL 3 CLEANSER,EXTENDED RELEASE SEB-PREV 1 selenium sulfide topical lotion 1 selenium sulfide topical shampoo 2.25 %, 2.3 % 1 sulfacetamide sodium topical 1 TERSI FOAM 3 Dermatological - Antiviral, Herpes acyclovir topical cream 3 acyclovir topical ointment 1 DENAVIR 3 PA; ST ZOVIRAX TOPICAL 3 Dermatological - Antiviral- Glucocorticoid Combinations XERESE 3 PA; ST Dermatological - Burn Products Anti- Infective mafenide acetate 1 SILVADENE 3 silver sulfadiazine 1 SSD 1 SULFAMYLON 3 THERMAZENE 1 Dermatological - Calcineurin Inhibitors ELIDEL 3 PA; ST pimecrolimus 3 PA PROTOPIC 3 PA; ST tacrolimus topical 3 PA; ST Dermatological - Depigmenting Agents BLANCHE 1 hydroquinone microspheres 1 hydroquinone topical cream 1 Last Approved Date: 09/23/2021 Formulary Version: 91
145 Drug Status Notes MELQUIN 3 1 Dermatological - Depigmenting Combinations ALPHAQUIN HP 1 MELPAQUE HP 1 Dermatological - Emollient Combinations Other HPR PLUS HYDROGEL 1 MB HYDROGEL 1 Dermatological - Emollient Mixtures AVO CREAM 1 BIAFINE EMULSION 3 CELACYN 1 ELETONE 3 EMULSION SB 1 HPR 1 HPR PLUS 1 HYLATOPIC 3 LUXAMEND 1 NIVATOPIC PLUS 1 PRUCLAIR 1 PRUTECT 3 SONAFINE 1 SP SCAR MANAGEMENT 1 Dermatological - Emollients ammonium lactate 3 lactic acid 3 LACTIC ACID E 3 Dermatological - Enzymes QL (90 GM per 1 dispensing SANTYL 2 event) Dermatological - Eyelid Cleansers ACUICYN 1 HYPOCYN 1
Last Approved Date: 09/23/2021 Formulary Version: 91
146 Drug Status Notes Dermatological - Glucocorticoid ALA-CORT TOPICAL CREAM 1 ALA-SCALP 3 PA; ST alclometasone 1 PA; ST; QL (60 GM per 1 amcinonide topical cream 1 Dispense) PA; ST; QL (60 ML per 1 amcinonide topical lotion 1 Dispense) amcinonide topical ointment 1 PA; ST PA; ST; QL (60 GM per 1 APEXICON E 1 Dispense) BESER 1 betamethasone dipropionate 1 betamethasone valerate topical cream 1 PA; ST; QL (100 GM per 1 betamethasone valerate topical foam 3 Dispense) betamethasone valerate topical lotion 1 betamethasone valerate topical ointment 1 betamethasone, augmented 1 PA; ST; QL (200 GM per 1 BRYHALI 3 Dispense) PA; ST; QL (120 ML per 1 CAPEX 3 Dispense) clobetasol scalp 1 clobetasol topical cream 1 clobetasol topical foam 3 QL (100 GM per 1 Dispense) clobetasol topical gel 1 clobetasol topical lotion 1 clobetasol topical ointment 1 clobetasol topical spray,non-aerosol 3 clobetasol-emollient topical cream 3 clobetasol-emollient topical foam 3 PA; ST PA; ST; QL (118 ML per 1 CLOBEX TOPICAL LOTION 3 Dispense) PA; ST; QL (118 ML per 1 CLOBEX TOPICAL SHAMPOO 3 Dispense)
Last Approved Date: 09/23/2021 Formulary Version: 91
147 Drug Status Notes PA; ST; QL (125 ML per 1 CLOBEX TOPICAL SPRAY,NON-AEROSOL 3 Dispense) PA; ST; QL (90 GM per 1 clocortolone pivalate 3 Dispense) CLODAN 1 PA; ST PA; ST; QL (90 GM per 1 CLODERM 3 Dispense) CORDRAN SP TOPICAL CREAM 0.05 % 3 CORDRAN TAPE LARGE ROLL 3 PA; ST PA; ST; QL (1 box/roll per 1 CORDRAN TAPE SMALL ROLL 3 Dispense) PA; ST; QL (120 GM per 1 CORDRAN TOPICAL CREAM 3 Dispense) PA; ST; QL (120 ML per 1 CORDRAN TOPICAL LOTION 3 Dispense) PA; ST; QL (60 GM per 1 CORDRAN TOPICAL OINTMENT 3 Dispense) CORMAX SCALP 1 PA; ST; QL (60 GM per 1 CUTIVATE TOPICAL CREAM 3 Dispense) PA; ST; QL (120 ML per 1 CUTIVATE TOPICAL LOTION 3 Dispense) DERMA-SMOOTHE/FS BODY OIL 3 DERMA-SMOOTHE/FS SCALP OIL 3 DERMATOP 3 PA; ST; QL (60 GM per 1 DESONATE 3 Dispense) desonide topical cream 1 PA; ST; QL (60 GM per 1 desonide topical gel 3 Dispense) desonide topical lotion 1 desonide topical ointment 1 PA; ST; QL (60 GM per 1 DESOWEN TOPICAL CREAM 3 Dispense) PA; ST; QL (118 ML per 1 DESOWEN TOPICAL LOTION 3 Dispense) PA; ST; QL (100 GM per 1 desoximetasone topical cream 0.05 % 3 Dispense)
Last Approved Date: 09/23/2021 Formulary Version: 91
148 Drug Status Notes desoximetasone topical cream 0.25 % 1 desoximetasone topical gel 1 PA; ST; QL (100 GM per 1 desoximetasone topical ointment 0.05 % 3 Dispense) desoximetasone topical ointment 0.25 % 1 desoximetasone topical spray,non-aerosol 3 PA; ST; QL (60 GM per 1 diflorasone 3 Dispense) DIPROLENE (AUGMENTED) TOPICAL 3 PA; ST LOTION DIPROLENE (AUGMENTED) TOPICAL PA; ST; QL (100 GM per 1 3 OINTMENT Dispense) DIPROLENE AF 3 PA; ST ELOCON 3 fluocinolone 1 fluocinolone and shower cap 1 fluocinonide 1 FLUOCINONIDE-E 1 fluocinonide-emollient 1 PA; ST; QL (120 GM per 1 flurandrenolide topical cream 3 Dispense) PA; ST; QL (120 ML per 1 flurandrenolide topical lotion 3 Dispense) PA; ST; QL (60 GM per 1 flurandrenolide topical ointment 3 Dispense) fluticasone propionate topical cream 1 fluticasone propionate topical ointment 1 halcinonide 3 PA; QL (216 GM per 1 Dispense) halobetasol propionate topical cream 1 PA; ST; QL (50 GM per 1 halobetasol propionate topical foam 3 Dispense) halobetasol propionate topical ointment 1 PA; ST; QL (216 GM per 1 HALOG TOPICAL CREAM 3 Dispense) PA; ST; QL (60 GM per 1 HALOG TOPICAL OINTMENT 3 Dispense) PA; ST; QL (120 ML per 1 HALOG TOPICAL SOLUTION 3 Dispense) Last Approved Date: 09/23/2021 Formulary Version: 91
149 Drug Status Notes hydrocortisone butyrate topical cream 1 hydrocortisone butyrate topical ointment 1 hydrocortisone butyrate topical solution 1 hydrocortisone butyr-emollient 1 hydrocortisone topical cream 0.5 % 3 hydrocortisone topical cream 1 % 1 hydrocortisone topical cream 2.5 % 1 $3-Copay hydrocortisone topical cream with perineal 1 applicator 2.5 % hydrocortisone topical lotion 1 % 3 hydrocortisone topical lotion 2.5 % 1 hydrocortisone topical ointment 1 % 1 hydrocortisone topical ointment 2.5 % 1 $3-Copay hydrocortisone valerate 1 hydrocortisone-pramoxine topical cream 2.5-1 % 1 PA; ST; QL (68 ml (1 bottle) per 1 IMPEKLO 3 dispensing event) PA; ST; QL (60 GM per 1 IMPOYZ 3 Dispense) PA; ST; QL (200 GM per 1 KENALOG TOPICAL 3 Dispense) PA; ST; QL (50 GM per 1 LEXETTE 3 Dispense) PA; ST; QL (60 GM per 1 LOCOID LIPOCREAM 3 Dispense) LOCOID TOPICAL CREAM 3 PA; ST PA; ST; QL (118 ML per 1 LOCOID TOPICAL LOTION 3 Dispense) LOCOID TOPICAL OINTMENT 3 PA; ST LOCOID TOPICAL SOLUTION 3 PA; ST PA; ST; QL (100 GM per 1 LUXIQ 3 Dispense) mometasone topical 1 PA; ST; QL (120 GM per 1 NOLIX TOPICAL CREAM 1 Dispense) PA; ST; QL (120 ML per 1 NOLIX TOPICAL LOTION 1 Dispense)
Last Approved Date: 09/23/2021 Formulary Version: 91
150 Drug Status Notes PA; ST; QL (100 GM per 1 OLUX 3 Dispense) PA; ST; QL (100 GM per 1 OLUX-E 3 Dispense) PANDEL 3 prednicarbate 1 PROCTOCORT TOPICAL 3 PROCTO-MED HC 1 PROCTO-PAK 1 PROCTOSOL HC TOPICAL 1 PROCTOZONE-HC 1 PA; ST; QL (60 GM per 1 PSORCON 3 Dispense) SCALACORT 1 SCALACORT DK 3 PA; ST; QL (120 ML per 1 SERNIVO 3 Dispense) PA; ST; QL (120 GM per 1 SYNALAR TOPICAL CREAM 3 Dispense) PA; ST; QL (120 GM per 1 SYNALAR TOPICAL OINTMENT 3 Dispense) PA; ST; QL (90 ML per 1 SYNALAR TOPICAL SOLUTION 3 Dispense) PA; ST; QL (60 GM per 1 TEMOVATE TOPICAL CREAM 3 Dispense) PA; ST; QL (30 GM per 1 TEMOVATE TOPICAL OINTMENT 3 Dispense) PA; ST; QL (30 ML per 1 TEXACORT 3 Dispense) PA; ST; QL (100 GM per 1 TOPICORT TOPICAL CREAM 0.05 % 3 Dispense) PA; ST; QL (60 GM per 1 TOPICORT TOPICAL CREAM 0.25 % 3 Dispense) PA; ST; QL (60 GM per 1 TOPICORT TOPICAL GEL 3 Dispense) PA; ST; QL (100 GM per 1 TOPICORT TOPICAL OINTMENT 0.05 % 3 Dispense) PA; ST; QL (60 GM per 1 TOPICORT TOPICAL OINTMENT 0.25 % 3 Dispense) Last Approved Date: 09/23/2021 Formulary Version: 91
151 Drug Status Notes TOPICORT TOPICAL SPRAY,NON- PA; ST; QL (100 ML per 1 3 AEROSOL Dispense) TOVET EMOLLIENT 1 triamcinolone acetonide topical aerosol 1 triamcinolone acetonide topical cream 1 $3-Copay triamcinolone acetonide topical lotion 1 triamcinolone acetonide topical ointment 0.025 1 $3-Copay %, 0.1 %, 0.5 % PA; ST; QL (430 GM per 1 triamcinolone acetonide topical ointment 0.05 % 3 Dispense) TRIANEX 1 QL (430 GM per 1 Dispense) PA; ST; $3-Copay; QL (85.2 GM TRIDERM TOPICAL CREAM 0.1 % 1 per 1 Dispense) TRIDERM TOPICAL CREAM 0.5 % 1 PA; ST PA; ST; QL (60 GM per 1 TRIDESILON 3 Dispense) ULTRAVATE TOPICAL CREAM 3 PA; ST PA; ST; QL (60 ML per 1 ULTRAVATE TOPICAL LOTION 3 Dispense) ULTRAVATE TOPICAL OINTMENT 3 PA; ST PA; ST; QL (120 GM per 1 VANOS 3 Dispense) VERDESO 3 QL (100 GM per 1 Dispense) Dermatological - Glucocorticoid- Emollient Combinations HALONATE 3 PEDIADERM HC 3 SYNALAR OINTMENT KIT 3 PA; ST ULTRAVATE X 3 PA; ST Dermatological - Glucocorticoid-Local Anesthetic Combinations EPIFOAM 3 hydrocortisone-pramoxine topical cream 2.5-1 % 1 lidocaine hcl-hydrocortison ac topical 1 PRAMOSONE 3 PRAMOSONE E 3
Last Approved Date: 09/23/2021 Formulary Version: 91
152 Drug Status Notes Dermatological - Glucocorticoid-Skin Cleanser Combinations CLODAN KIT 3 PA; ST SYNALAR TS 3 PA; ST XILAPAK 3 PA; ST Dermatological - Immunomodulator - Imidazoquinolinamines ALDARA 3 PA; ST imiquimod topical cream in metered-dose pump 3 PA imiquimod topical cream in packet 3.75 % 3 PA; ST imiquimod topical cream in packet 5 % 1 PA ZYCLARA TOPICAL CREAM IN METERED- 3 PA; ST DOSE PUMP 2.5 % ZYCLARA TOPICAL CREAM IN PACKET 3 PA; ST Dermatological - Immunomodulator - Interferons ALFERON N 4 PA; SPT Dermatological - Keratolytic Combinations Other GORDOFILM 3 Dermatological - Keratolytic- Antimitotic Combinations silver nitrate applicators 3 Dermatological - Keratolytic- Antimitotic Single Agents BENSAL HP NL BP-50% UREA 3 CEM-UREA 1 CONDYLOX 3 HYDRO 35 3 HYDRO 40 3 KERAFOAM 3 LATRIX NL podofilox 1 REA LO 39 1
Last Approved Date: 09/23/2021 Formulary Version: 91
153 Drug Status Notes REA LO 40 1 REMEVEN 3 SALACYN 1 SALEX TOPICAL COMBO PACK 3 SALEX TOPICAL CREAM,EXTENDED NL RELEASE salicylic acid topical cream 1 salicylic acid topical film forming liquid w/appl 1 27.5 % salicylic acid topical film forming liquid w/appl NL 28.5 % salicylic acid topical film-forming soln er w/ appl 1 salicylic acid topical foam 1 salicylic acid topical gel 1 salicylic acid topical liquid 1 salicylic acid topical lotion 1 salicylic acid topical shampoo 1 salicylic acid-ceramides no.1 1 SALIMEZ 1 SALIMEZ FORTE 3 SALVAX 1 TRI-CHLOR 3 trichloroacetic acid topical recon soln 85 % 3 ULTRASAL-ER NL URE-K 1 VIRASAL NL XALIX NL Dermatological - Keratoplastic Tar Products coal tar 3 coal tar (bulk) 3 Dermatological - Local Anesthetic Combinations DERMACINRX PRIZOPAK 1 lidocaine-prilocaine topical cream 1 QL (20 GM per 30 days) LIDOPRIL 1 Last Approved Date: 09/23/2021 Formulary Version: 91
154 Drug Status Notes RELADOR PAK 1 RELADOR PAK PLUS 1 Dermatological - Local Anesthetic Gas Single Agents ethyl chloride 1 Dermatological - Nsaid Single Agents diclofenac epolamine 3 QL (60 patches per 180 dayss) diclofenac sodium topical drops 1 QL (450 ML per 1 Month) diclofenac sodium topical gel 1 % 1 QL (300 GM per 1 Month) FLECTOR 3 QL (60 Patches per 180 days) FROTEK TOPICAL CREAM, METERED- 3 DOSE APPLICATOR KLOFENSAID II 1 LICART 3 QL (30 patches per 180 Dayss) PENNSAID TOPICAL SOLUTION IN PA; ST; QL (112 grams per 1 3 METERED-DOSE PUMP Month) VENNGEL ONE 3 VOLTAREN TOPICAL 3 QL (300 grams per 1 Month) Dermatological - Photodynamic Therapy Agents Topical LEVULAN 3 Dermatological - Protectant Combinations PR CREAM 1 RECEDO 1 Dermatological - Protectants BIONECT TOPICAL CREAM 3 BIONECT TOPICAL GEL 3 Dermatological - Retinoids (Vitamin A Derivatives) - Topical Cosmetic REFISSA 1 tazarotene topical cream 1 tretinoin (emollient) 1
Last Approved Date: 09/23/2021 Formulary Version: 91
155 Drug Status Notes Dermatological - Rosacea Therapy, Systemic doxycycline monohydrate oral capsule,ir - delay 3 rel,biphase ORACEA 3 Dermatological - Rosacea Therapy, Topical CLEANSING WASH TOPICAL CLEANSER 1 FINACEA TOPICAL FOAM 3 PA ivermectin topical cream 3 PA; ST METROCREAM 3 PA; ST METROGEL TOPICAL GEL 1 % 3 PA; ST METROGEL TOPICAL GEL WITH PUMP 3 PA; ST METROLOTION 3 PA; ST metronidazole topical 1 MIRVASO TOPICAL GEL 3 PA NORITATE 3 PA; ST RHOFADE 3 PA; ST ROSADAN TOPICAL CREAM 1 ROSADAN TOPICAL GEL 1 ROSADAN TOPICAL KIT, CLEANSER AND 3 PA; ST GEL ROSADAN TOPICAL KIT,CLEANSER AND 3 PA; ST CREAM SOOLANTRA 3 PA; ST sulfacetamide sod-sulfur-urea 1 ZILXI 3 ST; QL (1 can per 30 days) Dermatological - Topical Local Anesthetic Amides CIDALEAZE 1 GLYDO 3 lidocaine hcl mucous membrane jelly 1 QL (60 ML per 30 days) lidocaine hcl mucous membrane jelly in 3 QL (60 ML per 30 Days) applicator lidocaine hcl topical cream 3 % 1 lidocaine hcl topical lotion 3
Last Approved Date: 09/23/2021 Formulary Version: 91
156 Drug Status Notes lidocaine hcl topical ointment 1 lidocaine topical adhesive patch,medicated 5 % 3 PA; ST lidocaine topical ointment 3 lidocaine-tetracaine 3 PA; ST LIDODERM 3 PA LIDO-K 1 LIDOPIN TOPICAL CREAM 3 % 1 LIDO-SORB 1 LIDOZION 1 LIDTOPIC MAX 3 TRANZAREL 3 ZTLIDO 3 PA; ST; QL (3 units per 1 day) Dermatological - Topical Local Anesthetics And Combinations PRILO PATCH II 3 Dermatological Antipruritics - Antihistamines doxepin topical 1 QL (45 GM per 90 Days) PRUDOXIN 1 PA; ST ZONALON 3 PA; ST Dermatological Antipruritics Other SP ANTIPRURITIC 1 Hair Growth Agents - Type Ii 5-Alpha Reductase Inhibitors finasteride oral tablet 1 mg 1 Hair Growth, Topical Hypertrichotic Agents, Eyelashes LATISSE 3 Scabicide And Pediculicide Single Agents CROTAN 3 ELIMITE 3 EURAX 3 ivermectin topical lotion 3 lindane topical shampoo 1 Last Approved Date: 09/23/2021 Formulary Version: 91
157 Drug Status Notes malathion 3 OVIDE 3 permethrin 1 SKLICE 3 spinosad 1 QL (6 bottles (1362 g) per 1 ULESFIA 3 dispensing event) Wound Care - Growth Factor Agents REGRANEX 1 BE; SPT Wound Care Combinations Other SP ANTIPRURITIC 1 Diagnostic Agents Contrast Media - Barium ENTERO VU 3 E-Z DISK 3 E-Z-CAT DRY 3 E-Z-HD BARIUM 3 E-Z-PAQUE 3 E-Z-PASTE 3 LIQUID E-Z PAQUE 3 LIQUID POLIBAR PLUS 3 READI-CAT 2 ORAL SUSPENSION 2.1 % 3 (W/V), 2.0 % (W/W) TAGITOL V 3 VARIBAR HONEY 3 VARIBAR NECTAR 3 VARIBAR PUDDING 3 VARIBAR THIN HONEY 3 VARIBAR THIN LIQUID 3 VOLUMEN 3 Contrast Media - Iodinated Ionic GASTROGRAFIN 3 MD-GASTROVIEW 3
Last Approved Date: 09/23/2021 Formulary Version: 91
158 Drug Status Notes Contrast Media - Magnetic Resonance Iron Compounds GASTROMARK 3 Diagnostic - Multiple Urine Tests CHEMSTRIP 10 MD 3 Diagnostic - Other SITZMARKS 3 Diagnostic - Therapeutic Monitoring- Toxicology-Abuse Tests TOXICOLOGY SALIVA COLLECTION 3 Diagnostic Drugs - Gastrointestinal Radiological Adjunct GLUCAGEN DIAGNOSTIC KIT 2 Diagnostic Drugs - In Vivo Other isosulfan blue 3 LYMPHAZURIN 3 Diagnostic Drugs - Metabolic Function MACRILEN 3 QL (2 units per 720 dayss) METOPIRONE 3 Drugs To Treat Erectile Dysfunction Erectile Dysfunction (Ed) Drugs - Prostaglandin, Alpha Blocker phentolam-alprostadil in water 3 Erectile Dysfunction (Ed) Drugs - Prostaglandins CAVERJECT IMPULSE 3 BE; QL (18 units per 75 days) CAVERJECT INTRACAVERNOSAL RECON BE; QL (6 injections per 1 3 SOLN prescription) CAVERJECT INTRACAVERNOSAL 3 SYRINGE BE; QL (6 injections per 1 EDEX 3 prescription) BE; QL (6 suppositories per 1 MUSE 3 prescription)
Last Approved Date: 09/23/2021 Formulary Version: 91
159 Drug Status Notes Erectile Dysfunction (Ed) Drugs- Prostaglandin, Peripheral Vasodilator papaverine-alprostadil-water 3 papav-phentolam-alprost-water 3 Erectile Dysfunction (Ed) Drugs- Sel.Cgmp Phosphodiesterase Type5 Inhib PA; ST; BE; QL (6 tablets per 1 CIALIS ORAL TABLET 10 MG, 20 MG 3 prescription) PA; ST; BE; QL (30 tablets per 1 CIALIS ORAL TABLET 2.5 MG, 5 MG 3 month) PA; ST; BE; QL (6 tablets per 1 LEVITRA 3 prescription) BE; QL (6 tablets per 1 sildenafil Benefit Exclusion prescription) PA; ST; BE; QL (6 tablets per 1 STAXYN 3 prescription) PA; ST; BE; QL (6 tablets per 1 STENDRA 3 prescription) PA; ST; SPT; QL (2 tablets per 1 tadalafil oral tablet 10 mg, 2.5 mg, 5 mg 3 day) SPT; QL (6 tablets per 1 tadalafil oral tablet 20 mg 3 prescription) PA; ST; BE; QL (18 tablets per 75 vardenafil oral tablet 10 mg, 20 mg 3 dayss) PA; ST; BE; QL (6 tablets per 1 VIAGRA 3 prescription) Eating Disorder Therapy Anorexiant Combinations QSYMIA 3 BE Anorexiant Nutritional Supplements (Diet Aids) RESVERATROL DIET 3 BE Anorexiants ADIPEX-P 3 BE benzphetamine 3 BE diethylpropion 3 BE
Last Approved Date: 09/23/2021 Formulary Version: 91
160 Drug Status Notes LOMAIRA 3 BE phendimetrazine tartrate 3 BE phentermine 3 BE REGIMEX 3 BE SUPRENZA 3 BE Anti-Obesity - Fat Absorption Decreasing Agents ALLI 3 BE XENICAL 3 PA; BE Anti-Obesity - Glucagon-Like Peptide-1 (Glp-1) Receptor Agonists BE; QL (5 pens (15ml) per 30 SAXENDA 3 days) WEGOVY 3 PA Anti-Obesity - Melanocortin 4 (Mc4) Receptor Agonist PA; BE; SPT; QL (10 ML (10 IMCIVREE 4 vials) per 25 days) Anti-Obesity - Serotonin 2C Receptor Agonists BELVIQ 2 BE BELVIQ XR 2 BE; QL (34 tablets per 34 days) Anti-Obesity-Opioid Antag/Norepinephrine And Dopamine Reuptake Inhibit CONTRAVE 2 PA; BE; QL (4 tablets per 1 day) Appetite Stimulants - Cannabinoids dronabinol 3 MARINOL 3 SYNDROS 3 Appetite Stimulants - Progestin Hormone Type MEGACE 3 MEGACE ES 3 megestrol oral suspension 400 mg/10 ml (10 ml), 1 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml) Last Approved Date: 09/23/2021 Formulary Version: 91
161 Drug Status Notes megestrol oral suspension 625 mg/5 ml (125 3 mg/ml) Electrolyte Balance-Nutritional Products Amino Acid - Carnitine Derivatives levocarnitine oral solution 1 gram/10 ml 3 levocarnitine oral tablet 1 Amino Acids, Single Ingredient, Oral (Non-Injectable) PA; ST; SP; $3-Copay; SPT; QL ENDARI 4 (6 packets per 1 Day) B-Complex Vitamin Combinations B COMPLEX 1 (WITH FOLIC ACID) 1 B COMPLEX 100 ORAL 1 b complex-vitamin c-folic acid oral tablet 400 $0 mcg B-100 COMPLEX 1 BALANCE B-100 (FOLIC ACID) 1 BALANCE B-50 (WITH FOLIC ACID) 1 BALANCED B-100 COMPLEX 1 BALANCED B-100 ORAL TABLET 1 balanced b-complex caplet p/f,no-lactose (rx) 1 B-COMPLEX $0 b-complex tablet (rx) 3 b-complex with vit c caplet (rx) 1 b-complex with vit c tablet (rx) 1 b-complex with vitamin c oral tablet 1 B-PLEX $0 BE cvs super b-complex-vit c cplt (rx) 3 DIALYVITE 3000 NL BE DIALYVITE 800 ORAL TABLET $0 DIALYVITE 800 WITH ZINC 15 NL DIALYVITE 800 WITH ZINC 50 NL DIALYVITE ORAL TABLET 100-1 MG NL BE DIALYVITE SUPREME D NL
Last Approved Date: 09/23/2021 Formulary Version: 91
162 Drug Status Notes eql super b complex tablet (rx) 1 FARBEE WITH C $0 FOLBEE AR NL FOLBEE PLUS ORAL TABLET 5 MG NL FULL SPECTRUM B-VITAMIN C 1 hm super vitamin b complex gluten-free (rx) 3 KOBEE 1 LYSIPLEX PLUS ORAL TABLET NL MYNEPHROCAPS NL MYNEPHRON NL NATURAL B-100 COMPLEX 1 NEPHROCAPS NL BE NEPHROCAPS QT NL RENAL CAPS NL BE RENA-VITE 1 RENO CAPS NL BE sm super vitamin b complex tab (rx) 1 sm vitamin b complex tablet gluten-free (rx) 1 STRESS 500 $0 STRESS FORMULA 1 STRESS FORMULA 600 C 1 STROVITE $0 BE super b complex tablet p/f (rx) 1 SUPER B COMPLEX-VITAMIN C 1 SUPER B MAXI COMPLEX 3 SUPER QUINTS 1 SUPERPLEX-T 1 SUPERVITE NL SUPPORT-500 3 BE TOTAL B/C 1 TRIPHROCAPS NL BE VIRT-CAPS NL VIRT-VITE PLUS NL VITABEE/C $0 vitamin b complex-folic acid oral tablet 0.4 mg $0
Last Approved Date: 09/23/2021 Formulary Version: 91
163 Drug Status Notes vitamin b-50 complex tablet s/f,p/f,dairy-free (rx) 1 B-Complex Vitamins B COMPLETE 1 B COMPLEX $0 B COMPLEX 1 $0 B COMPLEX-VITAMIN B12 1 B-100 COMPLEX $0 B-50 $0 B-50 COMPLEX $0 BAL B-100 1 BAL B-50 1 BALANCE B-100 $0 BALANCE B-50 $0 BALANCED B-100 COMPLEX $0 BALANCED B-150 $0 BALANCED B-50 1 BALANCED B-50 COMPLEX $0 B-COMPLEX $0 COMPLEX B-100 ORAL TABLET EXTENDED 1 RELEASE POTEN B-150 CR $0 STRESS FORMULA 1 SUPER B-50 COMPLEX PLUS $0 SUPER QUINTS B-50 1 ULTRA B-100 COMPLEX ORAL TABLET 1 vitamin b complex oral tablet 1 VITAMIN B-100 COMPLEX $0 VITAMINS B COMPLEX ORAL TABLET 1 B-Complex Vitamins And Combinations DIALYVITE ORAL TABLET 1-100-300-50 NL BE MG-MG-MCG-MG NEPHPLEX RX NL BE NEPHRO-VITE RX NL BE RENA-VITE RX NL BE
Last Approved Date: 09/23/2021 Formulary Version: 91
164 Drug Status Notes VOL-CARE RX NL VP-VITE RX NL Dietary Product - Dietary Supplements TRI-ZEL NL Diluents - Sodium Chloride sodium chloride 0.9 % injection 3 sodium chloride injection 3 Diluents - Sterile Water For Injection water for injection, sterile injection solution 3 Electrolyte Depleters - Ion Exchange Resin KALEXATE 3 KAYEXALATE 3 KIONEX 1 KIONEX (WITH SORBITOL) 1 LOKELMA ORAL POWDER IN PACKET 10 2 PA; QL (3 packets per 1 day) GRAM LOKELMA ORAL POWDER IN PACKET 5 2 PA; QL (6 packets per 1 day) GRAM SODIUM POLYSTYRENE (SORB FREE) 1 sodium polystyrene sulfonate oral 1 sodium polystyrene sulfonate rectal enema 30 1 gram/120 ml SPS (WITH SORBITOL) 1 VELTASSA 2 PA; QL (1 packet per 1 day) Minerals And Electrolytes - Calcium Replacement Combinations TL G-FOL OS 1 Minerals And Electrolytes - Calcium Replacement/Vitamin D Combinations CAL-600 WITH VITAMIN D NL CALCARB 600 WITH VITAMIN D NL CALCITRATE-VITAMIN D NL CALCIUM + D NL CALCIUM 500 + D (D3) NL
Last Approved Date: 09/23/2021 Formulary Version: 91
165 Drug Status Notes CALCIUM 500 + D ORAL TABLET 500 NL MG(1,250MG) -200 UNIT CALCIUM 500 + D ORAL NL TABLET,CHEWABLE CALCIUM 500 WITH D $0 CALCIUM 500 WITH VITAMIN D2 NL CALCIUM 600 + D(3) ORAL CAPSULE NL CALCIUM 600 + D(3) ORAL TABLET 600 MG(1,500MG) -200 UNIT, 600 MG(1,500MG) - NL 400 UNIT CALCIUM 600 WITH VITAMIN D3 NL calcium carb and citrate-vitd3 NL calcium carbonate-vitamin d2 $0 calcium carbonate-vitamin d3 oral capsule 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -500 NL unit calcium carbonate-vitamin d3 oral tablet 250-125 mg-unit, 500 mg(1,250mg) -125 unit, 500 mg(1,250mg) -200 unit, 600 mg(1,500mg) -200 NL unit, 600 mg(1,500mg) -400 unit, 600 mg(1,500mg) -800 unit calcium carbonate-vitamin d3 oral tablet 500 $0 mg(1,250mg) -400 unit calcium carbonate-vitamin d3 oral $0 tablet,chewable 500 mg(1,250mg) -400 unit calcium carbonate-vitamin d3 oral NL tablet,chewable 500-100 mg-unit CALCIUM CITRATE + NL CALCIUM CITRATE + D NL calcium citrate-vitamin d2 NL calcium citrate-vitamin d3 oral tablet NL CALCIUM CREAMIES NL CALCIUM WITH VITAMIN D NL CALCIUM+D NL CALCIUM-VITAMIN D3 NL CALTRATE WITH VITAMIN D3 NL CALVITE P AND D NL CENTRUM PRO NUTRIENTS NL
Last Approved Date: 09/23/2021 Formulary Version: 91
166 Drug Status Notes CITRACAL + D MAXIMUM NL CITRACAL PLUS D NL CITRACAL REGULAR NL CITRACAL-D3 PETITES NL CITRACAL-D3 SLOW RELEASE NL CITRUS CALCIUM-VITAMIN D3 NL DICAL-D NL HI-CAL PLUS VIT D NL LIQUID CALCIUM WITH VITAMIN D NL OS-CAL 250+D (D2) NL OS-CAL 500 + D3 NL OYSCO 500/D ORAL TABLET NL OYSCO 500/D ORAL TABLET,CHEWABLE $0 OYSCO D $0 OYST-CAL-D 500 NL OYSTER SHELL + D3 $0 OYSTER SHELL CALCIUM-VIT D2 NL OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 250-125 MG-UNIT, 500 $0 MG(1,250MG) -400 UNIT OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT, 600 NL MG(1,500MG) -200 UNIT OYSTERCAL-D $0 SUPER CALCIUM/D NL SUPER CALCIUM-VITAMIN D NL Minerals And Electrolytes - Iodine SSKI 3 STRONG IODINE ORAL 1 Minerals And Electrolytes - Iron ACCRUFER 3 PA; ST; QL (2 capsules per 1 Day) AURYXIA 4 SPT FE C PLUS NL FEOSOL ORAL TABLET 45 MG 3 FERGON ORAL TABLET 240 MG (27 MG 3 IRON)
Last Approved Date: 09/23/2021 Formulary Version: 91
167 Drug Status Notes FER-IN-SOL 3 INFED 3 BE VENOFER INTRAVENOUS SOLUTION 200 3 BE MG IRON/10 ML Minerals And Electrolytes - Iron Combinations BIFERA RX NL CENTRATEX NL CORVITA 150 NL CORVITE 150 NL CORVITE FE NL FERIVA FA (WITH QUATREFOLIC) NL FEROCON NL BE FERREX 150 FORTE 1 BE FERREX 150 FORTE PLUS 1 BE FERREX 28 1 BE FERROCITE PLUS NL FERROGELS FORTE NL BE FOCALGIN DSS NL FOLITAB 3 BE FOLIVANE-F NL FOLIVANE-PLUS NL FUSION PLUS NL FUSION SPRINKLES NL HEMATINIC PLUS VIT/MINERALS NL BE HEMATINIC/FOLIC ACID NL BE HEMATOGEN (WITH STOMACH CONC) NL BE HEMATOGEN FA NL BE HEMATOGEN FORTE NL BE HEMETAB NL HEMOCYTE-F NL IFEREX 150 FORTE 1 BE iron aspgly,ps-c-b12-fa-ca-suc NL iron fum,ag-c-b12-fa-ca-succ NL IROSPAN 24/6 NL
Last Approved Date: 09/23/2021 Formulary Version: 91
168 Drug Status Notes MAXARON FORTE NL MULTIGEN 3 BE MULTIGEN FOLIC NL BE MULTIGEN PLUS NL BE MYFERON 150 FORTE 1 BE NATALVIRT FLT NL POLY-IRON 150 FORTE 1 BE PROFERRIN-FORTE NL SIDEROL 3 BE STRESS FORMULA 1 TL ICON 1 BE TL-HEM 150 NL TRICON 1 BE TRIGELS-F FORTE NL VIRT-FEFA PLUS 3 Minerals And Electrolytes - Magnesium magnesium sulfate injection syringe 3 Minerals And Electrolytes - Potassium Combinations potassium bicarb and chloride 1 Minerals And Electrolytes - Potassium, Oral EFFER-K ORAL TABLET, EFFERVESCENT 3 10 MEQ, 20 MEQ EFFER-K ORAL TABLET, EFFERVESCENT 1 25 MEQ K-EFFERVESCENT 1 KLOR-CON 1 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 1 KLOR-CON M20 1 KLOR-CON/25 3 KLOR-CON/EF 1
Last Approved Date: 09/23/2021 Formulary Version: 91
169 Drug Status Notes K-SOL 1 K-TAB ORAL TABLET EXTENDED 3 RELEASE 10 MEQ K-TAB ORAL TABLET EXTENDED 3 $3-Copay RELEASE 8 MEQ potassium bicarb-citric acid 1 potassium chloride oral capsule, extended release 1 potassium chloride oral liquid 40 meq/15 ml 1 potassium chloride oral packet 1 potassium chloride oral tablet extended release 1 potassium chloride oral tablet,er 1 particles/crystals Minerals And Electrolytes - Zinc zinc sulfate oral capsule NL Multivitamin And Mineral Combinations ADVANCED AM-PM NL BE BACMIN NL BE CHOICE-TABS NL CONCEPT DHA 3 BE CONCEPT OB 3 BE CORVITA NL PA CORVITE NL PA CORVITE FE NL CORVITE FREE NL BE DIALYVITE 5000 NL BE DOTHELLE DHA 1 ELDERCAPS NL BE ELITE-OB 3 BE FOLIVANE-OB 1 BE MACUZIN NL MULTICHEW NL BE M-VIT NL BE NIVA-PLUS NL NUTRICAP NL BE OB COMPLETE 3 BE Last Approved Date: 09/23/2021 Formulary Version: 91
170 Drug Status Notes O-CAL F.A. NL PNV-OMEGA 1 PROTECT CARDIO 3 PROTECT IRON NL PUREFE PLUS NL REQ49+ NL BE SOFTGELS MULTIVIT-A,B,D,E,K,ZN NL STROVITE FORTE NL BE STROVITE ONE NL BE SUPERVITE (EC) NL BE SUPERVITE EC NL TARON-C DHA 1 BE THERAPEUTIC FORMULA/HEMATINICS NL BE UDAMIN SP NL BE UROSEX 3 BE V-C FORTE NL BE VIC-FORTE NL BE VIRT-C DHA 1 VIRT-PN PLUS 1 VITAL-D RX NL VOL-PLUS NL VOL-TAB RX NL ZATEAN-PN PLUS 1 Multivitamins ANIMI-3 WITH VITAMIN D NL BP VIT 3 PLUS NL DIALYVITE 800 WITH IRON NL BE ENBRACE HR 3 FORTAVIT NL BE LEVOMEFOLATE DHA 1 PNV-DHA 1 BE PNV-VP-U 1 PRENATAL-U 1 BE RULAVITE DHA 1 ULTIMATECARE ONE 1 BE Last Approved Date: 09/23/2021 Formulary Version: 91
171 Drug Status Notes VINATE CARE 1 BE VIRT-PN DHA 1 VIT 3 NL ZATEAN-PN DHA 1 Nutritional Product - Lipid Others DOJOLVI 4 PA; ST; $3-Copay; SPT Nutritional Product - Medical Condition Specific Formulation PA; ST; SP; $3-Copay; SPT; QL ENDARI 4 (6 packets per 1 Day) Pediatric Vitamins CHEWABLE MULTIVIT-A,B,D,E,K,ZN NL PED MULTIVITAMINS-A,B,D,E,K,ZN NL Pediatric Vitamins With Fluoride And Minerals Combinations MULTI-VIT WITH FLUORIDE-IRON $0 MYKIDZ IRON FLUORIDE $0 BE TRI-VIT WITH FLUORIDE AND IRON 1 BE Pediatric Vitamins With Fluoride Combinations ESCAVITE $0 ESCAVITE D $0 ESCAVITE LQ 3 FLORIVA 3 FLORIVA (FLUORIDE-VITAMIN D3) 3 FLORIVA PLUS $0 FLORIVA PLUS (WITH BIOTIN) 3 MULTI-VIT WITH FLUORIDE-IRON $0 MULTIVITAMIN WITH FLUORIDE $0 MULTI-VITAMIN WITH FLUORIDE ORAL $0 DROPS MULTI-VITAMIN WITH FLUORIDE ORAL $0 BE TABLET,CHEWABLE MULTIVITAMINS WITH FLUORIDE ORAL 1 BE TABLET,CHEWABLE 0.25 MG
Last Approved Date: 09/23/2021 Formulary Version: 91
172 Drug Status Notes MULTIVITAMINS WITH FLUORIDE ORAL 1 TABLET,CHEWABLE 0.5 MG MULTIVITAMINS WITH FLUORIDE ORAL $0 TABLET,CHEWABLE 1 MG MULTIVIT-FLUOR (VIT E ACETATE) $0 MVC-FLUORIDE ORAL 1 BE TABLET,CHEWABLE 0.25 MG, 0.5 MG MVC-FLUORIDE ORAL $0 BE TABLET,CHEWABLE 1 MG pediatric multivitamin-fl $0 BE POLY-VI-FLOR 3 POLY-VI-FLOR FS NL POLY-VI-FLOR WITH IRON 3 QUFLORA $0 QUFLORA FE 3 QUFLORA FE (FERROUS SULFATE) 3 QUFLORA PEDIATRIC $0 QUFLORA PEDIATRIC DROPS $0 TEXAVITE LQ 3 TL-FLUORIVITE NL TRIPLE VITAMIN WITH FLUORIDE NL TRI-VI-FLOR 3 TRI-VI-FLORO NL TRI-VITAMIN WITH FLUORIDE 1 BE TRI-VITE WITH FLUORIDE 1 VITAMINS A,C,D AND FLUORIDE ORAL $0 DROPS 0.25 MG FLUOR. (0.55 MG)/ML VITAMINS A,C,D AND FLUORIDE ORAL 1 DROPS 0.5 MG FLUORIDE (1.1 MG)/ML Prenatal Vitamins And Minerals ATABEX EC 3 BE BAL-CARE DHA 1 CITRANATAL 90 DHA (NEW FORMULA 2 BE CITRANATAL ASSURE 2 BE CITRANATAL B-CALM (FE GLUC) 2 CITRANATAL DHA (NEW FORMULA) 2 BE
Last Approved Date: 09/23/2021 Formulary Version: 91
173 Drug Status Notes CITRANATAL HARMONY 2 BE CITRANATAL RX (NEW FORMULA) 2 BE CLASSIC PRENATAL 1 C-NATE DHA 1 COMPLETE NATAL DHA 1 BE COMPLETENATE 1 BE DAILY PRENATAL 1 FOCALGIN 90 DHA 1 FOCALGIN CA 1 HEMENATAL OB 1 HEMENATAL OB + DHA 1 KOSHER PRENATAL PLUS IRON 3 KPN ORAL TABLET 1 MACNATAL CN DHA 1 MARNATAL-F 3 BE MAXINATE 3 BE M-NATAL PLUS 1 MYNATAL 1 BE MYNATAL PLUS 1 BE MYNATAL-Z 1 BE NEONATAL-DHA 3 NEWGEN 1 OBTREX 3 BE O-CAL FA NL BE O-CAL PRENATAL 3 BE ONE DAILY PRENATAL ORAL COMBO 1 PACK 28-800-440 MG-MCG-MG P D NATAL VITAMINS-FOLIC ACID $0 PERRY PRENATAL 1 PNV 29-1 1 pnv cmb#95-ferrous fumarate-fa $0 PNV OB+DHA 1 PNV-SELECT 1 BE PR NATAL 400 1 BE PR NATAL 400 EC 1
Last Approved Date: 09/23/2021 Formulary Version: 91
174 Drug Status Notes PR NATAL 430 1 BE PR NATAL 430 EC 1 PREFERA-OB ONE 3 BE PRENA1 CHEW 1 PRENA1 TRUE 1 PRENATABS FA 1 BE PRENATABS RX 1 BE PRENATAL COMPLETE 1 PRENATAL FORMULA ORAL TABLET 28 $0 MG IRON- 800 MCG PRENATAL LOW IRON 1 BE PRENATAL MULTIVITAMINS 1 PRENATAL ONE DAILY 1 PRENATAL ORAL TABLET 28 MG IRON- 800 1 MCG PRENATAL PLUS 1 PRENATAL PLUS (CALCIUM CARB) 1 PRENATAL PLUS WITH IRON (CA) 1 BE PRENATAL TABLET 1 prenatal vit 90-iron fum-folic 3 PRENATAL VITAMIN ORAL TABLET , 27 1 MG IRON- 0.8 MG PRENATAL VITAMIN ORAL TABLET 27 MG $0 IRON- 800 MCG, 28 MG IRON- 800 MCG PRENATAL VITAMIN PLUS LOW IRON 1 PRENATAL VITAMIN WITH MINERALS 1 prenatal vit-iron fum-folic ac $0 prenatal vits96-iron fum-folic $0 PREPLUS 1 PRETAB 1 RELNATE DHA 1 SELECT-OB + DHA 3 BE SE-NATAL 19 CHEWABLE 1 BE SE-NATAL-19 1 TRICARE 3 BE TRICARE PRENATAL 3
Last Approved Date: 09/23/2021 Formulary Version: 91
175 Drug Status Notes TRICARE PRENATAL DHA ONE 3 TRICARE PRENATAL WITH DHA 3 TRINATAL GT 1 TRINATAL RX 1 1 BE TRINATE 1 BE TRIVEEN-DUO DHA 1 TRIVEEN-TEN $0 TRUST NATAL DHA 1 BE ULTIMATECARE ONE NF 1 BE VEMAVITE-PRX-2 1 VINATE M 1 BE VINATE ONE 1 BE VIRT-ADVANCE 1 VIRT-NATE 1 VIRT-NATE DHA 1 VIRT-PN 1 VIRT-SELECT 1 VIRT-VITE GT 1 VITAFOL FE PLUS 3 VOL-NATE 1 VP-CH-PNV 1 VP-HEME OB 1 VP-HEME ONE 1 WESTGEL DHA 3 ZATEAN-CH 1 Sodium Chloride Flushes BD PRE-FILLED NORMAL SALINE 3 MONOJECT 0.9% SODIUM CHLORIDE 3 MONOJECT PREFILL ADVANCED NS 3 MONOJECT PREFILL SALINE FLUSH 3 NORMAL SALINE FLUSH 3 SALINE FLUSH 3 sodium chloride 0.9 % (flush) injection syringe 3 sodium chloride 0.9 % injection 3 SYREX SODIUM CHLORIDE 0.9 % 3 Last Approved Date: 09/23/2021 Formulary Version: 91
176 Drug Status Notes Vitamin D And Folic Acid Combinations DERMACINRX PUREFOLIX NL Vitamins - A AQUASOL A 3 Vitamins - B Preparation Combinations FABB 1 BE FOLGARD RX NL FOLGARD RX 2.2 NL FOLTABS 800 3 PRENAISSANCE NEXT 1 TL GARD RX 1 BE VIRT-VITE FORTE NL VITA-RESPA NL BE VP-GGR-B6 1 ZINGIBER 1 Vitamins - B-12 And Folic Acid Combinations FOLTRATE NL Vitamins - B-12, Cyanocobalamin And Derivatives cyanocobalamin (vitamin b-12) injection 1 BE hydroxocobalamin 3 BE NASCOBAL 3 PA; ST NEURIN-SL NL BE Vitamins - B-3, Niacin And Derivatives niacin oral tablet 500 mg 3 niacin oral tablet extended release 1,000 mg, 500 3 mg, 750 mg Vitamins - D Derivatives calcitriol intravenous solution 1 mcg/ml 3 BE calcitriol oral 1 CHILDREN'S VITAMIN D $0 cholecalciferol (vitamin d3) oral capsule 10 mcg NL (400 unit), 25 mcg (1,000 unit)
Last Approved Date: 09/23/2021 Formulary Version: 91
177 Drug Status Notes cholecalciferol (vitamin d3) oral drops 10 mcg/ml NL (400 unit/ml) cholecalciferol (vitamin d3) oral tablet 10 mcg NL (400 unit) cholecalciferol (vitamin d3) oral tablet 25 mcg $0 (1,000 unit) cholecalciferol (vitamin d3) oral tablet,chewable $0 10 mcg (400 unit) cholecalciferol (vitamin d3) oral tablet,chewable NL 25 mcg (1,000 unit) DELTA D3 NL DRISDOL 3 BE D-VI-SOL NL D-VITA NL ergocalciferol (vitamin d2) oral capsule 1,250 1 BE mcg (50,000 unit) ergocalciferol (vitamin d2) oral tablet 10 mcg $0 (400 unit) JUST D NL KIDS FIRST VITAMIN D3 NL PEDIA D-VITE ORAL DROPS NL ROCALTROL 3 VITAJOY DAILY D NL VITAL-D RX NL VITAMIN D2 1 BE VITAMIN D3 ORAL CAPSULE 10 MCG (400 NL UNIT), 25 MCG (1,000 UNIT) VITAMIN D3 ORAL TABLET 10 MCG (400 NL UNIT) VITAMIN D3 ORAL TABLET 25 MCG (1,000 $0 UNIT) VITAMIN D3 ORAL TABLET,CHEWABLE 10 $0 MCG (400 UNIT) VITAMIN D3 ORAL TABLET,CHEWABLE 25 NL MCG (1,000 UNIT) Vitamins - Folic Acid And Derivatives FA-8 3 folic acid oral capsule 0.8 mg 3 Last Approved Date: 09/23/2021 Formulary Version: 91
178 Drug Status Notes folic acid oral tablet 1 mg 1 BE folic acid oral tablet 400 mcg, 800 mcg 1 Vitamins - Folic Acid Combinations FOLGARD RX NL FOLGARD RX 2.2 NL FOLTABS 800 3 RESTORA RX NL RESTORA SPRINKLES NL VIRT-VITE FORTE NL Vitamins - K, Phytonadione And Derivatives MEPHYTON 3 BE phytonadione (vit k1) (bulk) 3 phytonadione (vitamin k1) injection syringe 3 phytonadione (vitamin k1) sublingual 3 VITAMIN K1 3 Vitamins - Paba POTABA 2 BE Endocrine Abortifacients- Progesterone Receptor Antagonist mifepristone 1 Adrenal Steroid Inhibitors ISTURISA 3 PA; BE; SPT Adrenocorticotrophic Hormones ACTHAR 4 Agents To Treat Hypoglycemia (Hyperglycemics) QL (2 bottles per 1 dispensing BAQSIMI 2 event) diazoxide 3 GLUCAGEN HYPOKIT 2 QL (1 KIT per 3 MONTHs) GLUCAGON EMERGENCY KIT (HUMAN) 3 QL (1 unit per 1 dispense) GVOKE HYPOPEN 1-PACK 2 QL (2 units per 1 dispense) GVOKE HYPOPEN 2-PACK 2 QL (2 units per 1 dispense) Last Approved Date: 09/23/2021 Formulary Version: 91
179 Drug Status Notes GVOKE PFS 1-PACK SYRINGE 2 QL (2 units per 1 dispense) GVOKE PFS 2-PACK SYRINGE 2 QL (2 units per 1 dispense) PROGLYCEM 3 QL (2 prefilled ZEGALOGUE AUTOINJECTOR 3 syringes/autoinjectors per 1 dispensing event) QL (2 prefilled ZEGALOGUE SYRINGE 3 syringes/autoinjectors per 1 dispensing event) Amyloidosis Agents- Transthyretin (Ttr) Stabilizer PA; BE; SPT; QL (1 capsule per 1 VYNDAMAX 4 day) PA; BE; SPT; QL (4 capsules per VYNDAQEL 4 1 day) Amyloidosis Agents-Ttr Suppression, Antisense Oligonucleotide-Based PA; SPT; QL (4 syringes per 28 TEGSEDI 4 Dayss) Anabolic Steroid - Single Agents ANADROL-50 3 PA OXANDRIN 3 PA oxandrolone 3 PA Androgen - Single Agents ANDRODERM 3 PA ANDROGEL 3 PA ANDROID 3 PA ANDROXY 1 PA AXIRON 3 PA DEPO-TESTOSTERONE 3 PA FORTESTA 3 PA JATENZO ORAL CAPSULE 158 MG, 237 MG 3 PA; QL (2 capsules per 1 day) JATENZO ORAL CAPSULE 198 MG 3 PA; QL (4 capsules per 1 day) METHITEST 3 PA methyltestosterone oral capsule 3 PA NATESTO 3 PA
Last Approved Date: 09/23/2021 Formulary Version: 91
180 Drug Status Notes STRIANT 3 PA; ST TESTIM 3 PA TESTONE CIK 3 PA testosterone cypionate intramuscular oil 100 1 PA mg/ml, 200 mg/ml testosterone cypionate intramuscular oil 50 2 PA mg/ml testosterone enanthate 1 PA testosterone propionate 3 testosterone transdermal gel 3 PA testosterone transdermal gel in metered-dose 3 PA pump 10 mg/0.5 gram /actuation testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %), 20.25 mg/1.25 1 PA gram (1.62 %) testosterone transdermal gel in packet 1 PA testosterone transdermal solution in metered 3 PA pump w/app TESTRED 3 PA; ST VOGELXO TRANSDERMAL GEL 3 PA VOGELXO TRANSDERMAL GEL IN 3 METERED-DOSE PUMP VOGELXO TRANSDERMAL GEL IN 3 PACKET XYOSTED 3 PA; ST Antidiuretic And Vasopressor Hormones DDAVP 3 desmopressin injection 1 desmopressin nasal solution 1 desmopressin nasal spray with pump 1 desmopressin nasal spray,non-aerosol 10 1 mcg/spray (0.1 ml) desmopressin oral 1 NOCDURNA (MEN) 3 NOCDURNA (WOMEN) 3 NOCTIVA 3 QL (1 bottle (3.8g) per 23 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
181 Drug Status Notes STIMATE 3 Antihyperglycemic - Alpha-Glucosidase Inhibitors acarbose 1 GLYSET 3 miglitol 1 PRECOSE 3 Antihyperglycemic - Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors alogliptin 3 PA; QL (1 TABLET per 1 day) JANUVIA 2 QL (1 TABLET per 1 day) NESINA 3 PA; QL (1 TABLET per 1 day) ONGLYZA 3 PA; QL (1 TABLET per 1 day) TRADJENTA 2 QL (1 TABLET per 1 day) Antihyperglycemic - Dopamine Receptor Agonists CYCLOSET 3 Antihyperglycemic - Glucocorticoid (Cortisol) Receptor Blocker (Gr-Ii) KORLYM 3 PA Antihyperglycemic - Meglitinide Analog And Biguanide Combinations repaglinide-metformin 3 Antihyperglycemic - Meglitinide Analogs nateglinide 1 PRANDIN 3 repaglinide 1 STARLIX 3 Antihyperglycemic - Sglt-2 Inhibitor And Biguanide Combinations INVOKAMET 2 QL (2 TABLETS per 1 day) INVOKAMET XR 2 QL (2 Tablets per 1 day) SEGLUROMET 3 QL (2 TABLETS per 1 DAY) SYNJARDY 2 QL (2 TABLETS per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
182 Drug Status Notes SYNJARDY XR 2 QL (2 Tablets per 1 Day) XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5- 3 PA; ST; QL (1 tablet per 1 day) 500 MG XIGDUO XR ORAL TABLET, IR - ER, 3 PA; QL (2 tablets per 1 day) BIPHASIC 24HR 2.5-1,000 MG XIGDUO XR ORAL TABLET, IR - ER, 3 PA; ST; QL (2 tablets per 1 day) BIPHASIC 24HR 5-1,000 MG Antihyperglycemic - Sglt-2 Inhibitor And Dpp-4 Inhibitor Combinations GLYXAMBI 2 QL (1 TABLET per 1 day) PA; ST; QL (1 TABLET per 1 QTERN ORAL TABLET 10-5 MG 3 Day) QTERN ORAL TABLET 5-5 MG 3 STEGLUJAN 3 QL (1 TABLET per 1 DAY) Antihyperglycemic - Sodium Glucose Cotransporter-2 (Sglt2) Inhibitors PA; ST; QL (1 TABLET per 1 FARXIGA 3 day) INVOKANA 2 QL (1 TABLET per 1 day) JARDIANCE 2 QL (1 TABLET per 1 day) STEGLATRO 3 QL (1 TABLET per 1 DAY) Antihyperglycemic - Sulfonylurea And Biguanide Combinations glipizide-metformin 1 GLUCOVANCE 3 glyburide-metformin 1 Antihyperglycemic - Sulfonylurea Derivatives AMARYL 3 chlorpropamide 3 glimepiride 1 $3-Copay glipizide (bulk) 3 glipizide oral tablet 1 $3-Copay glipizide oral tablet extended release 24hr 10 mg 1 glipizide oral tablet extended release 24hr 2.5 1 $3-Copay mg, 5 mg Last Approved Date: 09/23/2021 Formulary Version: 91
183 Drug Status Notes GLUCOTROL 3 GLUCOTROL XL 3 glyburide 1 glyburide (bulk) 3 glyburide micronized 1 GLYNASE 3 tolazamide 3 tolbutamide 3 Antihyperglycemic - Thiazolidinedione And Biguanide Combinations ACTOPLUS MET 3 ACTOPLUS MET XR 3 AVANDAMET 3 pioglitazone-metformin 1 Antihyperglycemic - Thiazolidinedione And Sulfonylurea Combinations DUETACT 3 pioglitazone-glimepiride 1 Antihyperglycemic, Amylin Analog- Type SYMLINPEN 120 3 SYMLINPEN 60 3 Antihyperglycemic, Incretin Mimetic,Glp-1 Receptor Agonist Analog-Type ADLYXIN 3 PA; ST; QL (2 Pens per 28 Days) PA; ST; QL (4 autoinjectors per 28 BYDUREON BCISE 3 Days) BYDUREON SUBCUTANEOUS PEN PA; ST; QL (4 Pens per 1 34 day 3 INJECTOR limit) BYDUREON SUBCUTANEOUS PA; ST; QL (4 VIALS per 1 3 SUSPENSION,EXTENDED REL RECON MONTH) PA; ST; QL (1 PEN per 1 BYETTA 3 MONTH) OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML), 1 2 QL (4 PENS per 28 DAYSs) MG/DOSE (2 MG/1.5 ML) Last Approved Date: 09/23/2021 Formulary Version: 91
184 Drug Status Notes OZEMPIC SUBCUTANEOUS PEN INJECTOR 2 QL (4 pens per 21 Dayss) 1 MG/DOSE (4 MG/3 ML) RYBELSUS 2 QL (1 tablet per 1 day) PA; ST; QL (4 PENS per 1 TANZEUM 3 MONTH) TRULICITY 2 QL (2 ML per 21 days) VICTOZA 2-PAK 2 QL (3 PENS per 1 MONTH) VICTOZA 3-PAK 2 QL (3 Pens per 34 days) Antihyperglycemic-Dipeptidyl Peptidase-4 Inhibit And Thiazolidinedione alogliptin-pioglitazone 3 PA; QL (1 TABLET per 1 day) OSENI 3 PA; QL (1 TABLET per 1 day) Antihyperglycemic-Dipeptidyl Peptidase-4(Dpp-4)Inhibitor And Biguanide alogliptin-metformin 3 PA; QL (2 TABLETS per 1 day) JANUMET 2 QL (2 TABLETS per 1 day) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-500 2 QL (1 TABLET per 1 day) MG JANUMET XR ORAL TABLET, ER 2 QL (2 TABLETS per 1 day) MULTIPHASE 24 HR 50-1,000 MG JENTADUETO 2 QL (2 TABLETS per 1 day) JENTADUETO XR ORAL TABLET, IR - ER, 2 QL (2 TABLETS per 1 day) BIPHASIC 24HR 2.5-1,000 MG JENTADUETO XR ORAL TABLET, IR - ER, 2 QL (1 TABLET per 1 day) BIPHASIC 24HR 5-1,000 MG KAZANO 3 PA; QL (2 TABLETS per 1 day) KOMBIGLYZE XR ORAL TABLET, ER 3 PA; QL (2 TABLETS per 1 day) MULTIPHASE 24 HR 2.5-1,000 MG KOMBIGLYZE XR ORAL TABLET, ER 3 PA; QL (1 TABLET per 1 day) MULTIPHASE 24 HR 5-1,000 MG, 5-500 MG Antihyperglycemic-Insulin, Long Acting And Glp-1 Receptor Agonist Comb SOLIQUA 100/33 3 PA; ST XULTOPHY 100/3.6 2
Last Approved Date: 09/23/2021 Formulary Version: 91
185 Drug Status Notes Antihyperglycemic-Sglt-2 Inhibitor, Dpp-4 Inhibitor And Biguanide Comb TRIJARDY XR ORAL TABLET, IR - ER, 2 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 2 MG TRIJARDY XR ORAL TABLET, IR - ER, 2 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 TAPAZOLE 3 Antithyroid Agents, Thionamides - Thiouracil Derivatives propylthiouracil 1 Bone Formation Agents - Sclerostin Inhibitor, Monoclonal Antibody EVENITY SUBCUTANEOUS SYRINGE 105 PA; ST; BE; SPT; QL (24 syringes 4 MG/1.17 ML (2520mg/28.08ml) per 720 days) EVENITY SUBCUTANEOUS SYRINGE PA; ST; BE; SPT; QL (2 syringes 4 210MG/2.34ML ( 105MG/1.17MLX2) per 30 days) Bone Formation Stimulating Agents - Parathyroid Hormone Rel Peptides PA; ST; SP; BE; SPT; QL (1 PEN TYMLOS 3 INJECTOR per 30 days) Bone Formation Stimulating Agents - Parathyroid Hormone-Type FORTEO SUBCUTANEOUS PEN INJECTOR PA; ST; SPT; QL (1 pen per 1 4 20 MCG/DOSE (600MCG/2.4ML) month) FORTEO SUBCUTANEOUS PEN INJECTOR PA; ST; $3-Copay; SPT; QL (1 4 20 MCG/DOSE (620MCG/2.48ML) pen per 1 month) PA; ST; SPT; QL (3 ML per 1 teriparatide 4 Dispense)
Last Approved Date: 09/23/2021 Formulary Version: 91
186 Drug Status Notes Bone Resorption Inhibitors - Bisphosphonate And Vitamin D Combinations FOSAMAX PLUS D ORAL TABLET 70 MG- 3 QL (4 TABLETS per 1 MONTH) 2,800 UNIT FOSAMAX PLUS D ORAL TABLET 70 MG- 3 QL (4 EA per 30 days) 5,600 UNIT Bone Resorption Inhibitors - Bisphosphonates ACTONEL ORAL TABLET 150 MG 3 QL (1 TABLET per 1 MONTH) ACTONEL ORAL TABLET 30 MG, 5 MG 3 ACTONEL ORAL TABLET 35 MG 3 QL (4 TABLETS per 1 MONTH) alendronate oral solution 1 alendronate oral tablet 10 mg, 5 mg 1 $3-Copay $3-Copay; QL (4 TABLETS per 1 alendronate oral tablet 35 mg, 70 mg 1 MONTH) alendronate oral tablet 40 mg 1 ATELVIA 3 QL (4 TABLETS per 1 MONTH) BINOSTO 3 BONIVA INTRAVENOUS 3 QL (1 ML per 30 days) BONIVA ORAL 3 QL (1 TABLET per 1 MONTH) etidronate disodium 1 FOSAMAX ORAL TABLET 70 MG 3 QL (4 TABLETS per 1 MONTH) ibandronate oral 1 QL (1 TABLET per 1 MONTH) pamidronate 3 risedronate oral tablet 150 mg 1 QL (1 TABLET per 1 MONTH) risedronate oral tablet 30 mg, 5 mg 3 risedronate oral tablet 35 mg 3 QL (4 TABLETS per 1 MONTH) risedronate oral tablet,delayed release (dr/ec) 3 QL (4 TABLETS per 1 MONTH) ZOMETA INTRAVENOUS SOLUTION 3 Calcimimetic, Parathyroid Calcium Receptor Sensitivity Enhancer cinacalcet 3 BE; SPT SENSIPAR 4 SP; BE; SPT Calcitonins calcitonin (salmon) injection 3 Last Approved Date: 09/23/2021 Formulary Version: 91
187 Drug Status Notes calcitonin (salmon) nasal 1 QL (1 BOTTLE per 1 MONTH) FORTICAL 1 QL (1 BOTTLE per 1 MONTH) MIACALCIN INJECTION 3 MIACALCIN NASAL 3 QL (1 BOTTLE per 1 MONTH) Estrogen And Progestin With Antimineralocorticoid Activity,Combination ANGELIQ 3 Estrogen And Selective Estrogen Receptor Modulator (Serm) Combinations DUAVEE 3 Estrogen-Androgen COVARYX 1 COVARYX H.S. 1 EEMT 1 EEMT HS 1 estrogens-methyltestosterone 1 Estrogen-Progestin ACTIVELLA 3 AMABELZ 1 BIJUVA 3 CLIMARA PRO 3 QL (4 PATCHES per 1 MONTH) COMBIPATCH 3 QL (8 PATCHES per 1 MONTH) estradiol-norethindrone acet 1 FEMHRT LOW DOSE 3 FYAVOLV 1 JEVANTIQUE LO 1 JINTELI 1 LOPREEZA 1 MIMVEY 1 MIMVEY LO 1 norethindrone ac-eth estradiol oral tablet 0.5-2.5 3 mg-mcg
Last Approved Date: 09/23/2021 Formulary Version: 91
188 Drug Status Notes norethindrone ac-eth estradiol oral tablet 1-5 mg- 1 mcg PREFEST 3 PREMPHASE 3 PREMPRO 3 Estrogens ALORA 3 QL (8 PATCHES per 1 MONTH) CLIMARA 3 QL (4 PATCHES per 1 MONTH) DELESTROGEN 3 DEPO-ESTRADIOL 3 DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %), 0.5 MG/0.5 3 GRAM (0.1 %), 0.75 MG/0.75 GRAM (0.1%), 1 MG/GRAM (0.1 %) DOTTI 3 ELESTRIN 3 QL (1 GM per 30 days) ENJUVIA ORAL TABLET 0.625 MG, 0.9 MG, 3 1.25 MG ESTRACE ORAL 3 estradiol oral 1 $3-Copay ESTRADIOL TRANSDERMAL PATCH 1 estradiol transdermal patch semiweekly 1 estradiol transdermal patch weekly 1 QL (4 PATCHES per 1 MONTH) estradiol valerate intramuscular oil 20 mg/ml, 40 1 mg/ml QL (1 (50G) GEL PUMP per 1 ESTROGEL 3 MONTH) estropipate 1 QL (1 CANNISTER per 1 EVAMIST 3 MONTH) MENEST 3 MENOSTAR 3 QL (4 PATCHES per 1 MONTH) MINIVELLE TRANSDERMAL PATCH 3 SEMIWEEKLY 0.025 MG/24 HR MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY 0.0375 MG/24 HR, 0.05 MG/24 3 QL (8 PATCHES per 1 MONTH) HR, 0.075 MG/24 HR, 0.1 MG/24 HR PREMARIN ORAL 2 Last Approved Date: 09/23/2021 Formulary Version: 91
189 Drug Status Notes VIVELLE-DOT 3 QL (8 PATCHES per 1 MONTH) Fertility Enhancer - Luteal Phase Supporting, Progesterone-Type CRINONE VAGINAL GEL 8 % 3 PA; $3-Copay; SPT ENDOMETRIN 3 PA; $3-Copay; SPT Fertility Enhancer - Ovulation Stimulant - Synthetic (Non-Fsh) clomiphene citrate 1 PA; $3-Copay; SPT SEROPHENE 1 PA; SPT Follicle-Stimulating And Luteinizing Hormones MENOPUR 3 PA; SP; BE; SPT Follicle-Stimulating Hormone (Fsh) FOLLISTIM AQ INJECTION 3 PA; SP; SPT FOLLISTIM AQ SUBCUTANEOUS 3 PA; SP; BE; SPT GONAL-F 4 PA; ST; SP; BE; SPT GONAL-F RFF 4 PA; ST; SP; BE; SPT GONAL-F RFF PEN 4 PA; ST GONAL-F RFF REDI-JECT 4 PA; ST; SP; BE; SPT Glucocorticoids PA; ST; BE; SPT; QL (3 capsules ALKINDI SPRINKLE 4 per 1 day) CORTEF 3 cortisone 1 DECADRON 1 DELTASONE 1 DEXABLISS 3 DEXAMETHASONE INTENSOL 1 dexamethasone oral elixir 1 dexamethasone oral solution 1 dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1 $3-Copay 1.5 mg, 6 mg dexamethasone oral tablet 2 mg, 4 mg 1 dexamethasone oral tablets,dose pack 1 dexamethasone sodium phos (pf) injection syringe 3
Last Approved Date: 09/23/2021 Formulary Version: 91
190 Drug Status Notes dexamethasone sodium phosphate injection 3 syringe DEXONTO 3 DEXPAK 10 DAY 3 DEXPAK 13 DAY 3 DEXPAK 6 DAY 3 DXEVO 3 EMFLAZA 4 PA; BE; SPT HEMADY 4 PA; ST; $3-Copay; SPT HIDEX 1 hydrocortisone oral 1 LOCORT 3 MEDROL 3 MEDROL (PAK) 3 METHYLPRED DP 1 methylprednisolone oral tablet 1 methylprednisolone oral tablets,dose pack 1 $3-Copay MILLIPRED DP 1 MILLIPRED ORAL SOLUTION 3 MILLIPRED ORAL TABLET 1 ORAPRED ODT 3 PEDIAPRED 3 prednisolone 1 prednisolone sodium phosphate oral solution 10 mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 1 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral 3 tablet,disintegrating PREDNISONE INTENSOL 1 prednisone oral solution 1 prednisone oral tablet 1 mg 1 prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 5 1 $3-Copay mg, 50 mg prednisone oral tablets,dose pack 1 RAYOS 3 PA; ST
Last Approved Date: 09/23/2021 Formulary Version: 91
191 Drug Status Notes TAPERDEX ORAL TABLETS,DOSE PACK 1.5 3 MG (21 TABS) VERIPRED 20 1 ZCORT 3 ZONACORT 3 $3-Copay Gonadotropin Inhibitor Pituitary Suppressants danazol 1 Growth Hormone Receptor Antagonists SOMAVERT SUBCUTANEOUS RECON 3 SPT SOLN 10 MG SOMAVERT SUBCUTANEOUS RECON 3 BE; SPT SOLN 15 MG, 20 MG SOMAVERT SUBCUTANEOUS RECON 3 SOLN 25 MG, 30 MG Growth Hormone Releasing Hormones (Ghrh) EGRIFTA SUBCUTANEOUS RECON SOLN 1 4 PA; SPT MG EGRIFTA SUBCUTANEOUS RECON SOLN 2 4 MG EGRIFTA SV 4 PA; ST; BE; SPT Growth Hormones GENOTROPIN 3 PA; SP; BE; SPT GENOTROPIN MINIQUICK 3 PA; SP; BE; SPT HUMATROPE 3 PA; SP; BE; SPT NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 3 PA; SP; BE; SPT 15 MG/1.5 ML (10 MG/ML), 5 MG/1.5 ML (3.3 MG/ML) NORDITROPIN FLEXPRO SUBCUTANEOUS 3 PA; SP; BE PEN INJECTOR 30 MG/3 ML (10 MG/ML) NORDITROPIN NORDIFLEX 3 PA; SP; SPT NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 4 MG/2 ML (10 MG/ML) NUTROPIN AQ NUSPIN SUBCUTANEOUS 4 PA; ST; SP; BE; SPT PEN INJECTOR 5 MG/2 ML (2.5 MG/ML)
Last Approved Date: 09/23/2021 Formulary Version: 91
192 Drug Status Notes NUTROPIN AQ SUBCUTANEOUS 4 PA; ST; SP; SPT CARTRIDGE 10 MG/2 ML (5 MG/ML) NUTROPIN AQ SUBCUTANEOUS 4 PA; ST; SP CARTRIDGE 20 MG/2 ML (10 MG/ML) OMNITROPE 4 PA; ST; SP; BE; SPT SAIZEN 4 PA; ST; SP; BE; SPT SAIZEN CLICK.EASY 4 PA; ST; SP; BE; SPT SAIZEN SAIZENPREP 4 SEROSTIM SUBCUTANEOUS RECON SOLN 4 PA; ST; SP; BE; SPT 4 MG, 5 MG, 6 MG ZOMACTON 4 PA; ST; SP; BE; SPT ZORBTIVE 4 PA; ST; SP; BE; SPT Human Chorionic Gonadotropin (Hcg) chorionic gonadotropin, human injection recon 3 PA; BE soln 12,000 unit, 6,000 unit chorionic gonadotropin, human injection recon 3 BE; SPT soln 50,000 unit chorionic gonadotropin, human intramuscular 3 BE NOVAREL INTRAMUSCULAR RECON SOLN 3 PA; BE; SPT 10,000 UNIT NOVAREL INTRAMUSCULAR RECON SOLN 3 BE 5,000 UNIT OVIDREL 1 PA; ST; BE; SPT PREGNYL 2 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 U-100 INSULIN 2 NOVOLIN 70-30 FLEXPEN U-100 2 Human Insulins - Intermediate Acting HUMULIN N NPH INSULIN KWIKPEN 2 HUMULIN N NPH U-100 INSULIN 2 NOVOLIN N FLEXPEN 3 NOVOLIN N NPH U-100 INSULIN 2
Last Approved Date: 09/23/2021 Formulary Version: 91
193 Drug Status Notes Human Insulins - Rapid Acting AFREZZA 3 Human Insulins - Short Acting HUMULIN R REGULAR U-100 INSULN 2 HUMULIN R U-500 (CONC) INSULIN 2 HUMULIN R U-500 (CONC) KWIKPEN 2 NOVOLIN R FLEXPEN 3 NOVOLIN R REGULAR U-100 INSULN 2 Insulin Analogs - Fixed Combinations HUMALOG MIX 50-50 INSULN U-100 2 HUMALOG MIX 50-50 KWIKPEN 2 HUMALOG MIX 75-25 KWIKPEN 2 HUMALOG MIX 75-25(U-100)INSULN 2 insulin asp prt-insulin aspart 2 insulin lispro protamin-lispro 2 NOVOLOG MIX 70-30 U-100 INSULN 2 NOVOLOG MIX 70-30FLEXPEN U-100 2 Insulin Analogs - Long Acting BASAGLAR KWIKPEN U-100 INSULIN 3 LANTUS SOLOSTAR U-100 INSULIN 3 LANTUS U-100 INSULIN 3 LEVEMIR FLEXTOUCH U-100 INSULN 2 LEVEMIR U-100 INSULIN 2 SEMGLEE PEN U-100 INSULIN 3 SEMGLEE U-100 INSULIN 3 TOUJEO MAX U-300 SOLOSTAR 3 TOUJEO SOLOSTAR U-300 INSULIN 3 TRESIBA FLEXTOUCH U-100 2 TRESIBA FLEXTOUCH U-200 2 TRESIBA U-100 INSULIN 2 Insulin Analogs - Rapid Acting ADMELOG SOLOSTAR U-100 INSULIN 3 ADMELOG U-100 INSULIN LISPRO 3 APIDRA SOLOSTAR U-100 INSULIN 3
Last Approved Date: 09/23/2021 Formulary Version: 91
194 Drug Status Notes APIDRA U-100 INSULIN 3 FIASP FLEXTOUCH U-100 INSULIN 2 FIASP PENFILL U-100 INSULIN 2 FIASP U-100 INSULIN 2 HUMALOG JUNIOR KWIKPEN U-100 2 HUMALOG KWIKPEN INSULIN 2 HUMALOG U-100 INSULIN 2 insulin aspart u-100 2 insulin lispro subcutaneous insulin pen 2 insulin lispro subcutaneous solution 2 LYUMJEV KWIKPEN U-100 INSULIN 3 LYUMJEV KWIKPEN U-200 INSULIN 3 LYUMJEV U-100 INSULIN 3 NOVOLOG FLEXPEN U-100 INSULIN 2 NOVOLOG PENFILL U-100 INSULIN 2 NOVOLOG U-100 INSULIN ASPART 2 Insulin Response Enhancers - Biguanides FORTAMET 3 PA; ST; EX GLUCOPHAGE 3 PA; ST GLUCOPHAGE XR 3 PA; ST GLUMETZA 3 PA; ST metformin oral solution 3 PA; ST metformin oral tablet 1 $3-Copay metformin oral tablet extended release 24 hr 500 3 PA; $3-Copay mg metformin oral tablet extended release 24 hr 750 1 $3-Copay mg metformin oral tablet extended release 24hr 1,000 3 PA mg metformin oral tablet extended release 24hr 500 1 PA mg metformin oral tablet,er gast.retention 24 hr 3 PA; ST; EX 1,000 mg metformin oral tablet,er gast.retention 24 hr 500 3 PA; ST mg
Last Approved Date: 09/23/2021 Formulary Version: 91
195 Drug Status Notes RIOMET 3 PA; ST PA; ST; QL (2 bottles per 1 RIOMET ER 3 dispense) Insulin Response Enhancers - Thiazolidinediones (Ppar-Gamma Agonists) ACTOS 3 AVANDIA ORAL TABLET 2 MG, 4 MG 3 pioglitazone 1 Insulin-Like Growth Factor-1 (Igf-1) INCRELEX 3 PA; BE; SPT Leptin Hormone Analogs PA; ST; BE; SPT; QL (34 2 ML MYALEPT 4 per 1 VIALS) Lhrh (Gnrh) Agonist Analog Pit Suppres - Central Precocious Puberty LUPRON DEPOT-PED 3 SP; SPT LUPRON DEPOT-PED (3 MONTH) 3 Lhrh (Gnrh) Agonist Analog Pituitary Supp. And Progestin Comb. LUPANETA PACK (1 MONTH) 3 SP; SPT LUPANETA PACK (3 MONTH) 3 SP; SPT Lhrh (Gnrh) Agonist Analog Pituitary Suppressants LUPRON DEPOT (3 MONTH) 3 SP; SPT INTRAMUSCULAR SYRINGE KIT 11.25 MG LUPRON DEPOT INTRAMUSCULAR 3 SP; SPT SYRINGE KIT 3.75 MG SYNAREL 3 PA; BE; SPT Lhrh (Gnrh) Antagonist, Estrogen And Progestin Combinations PA; BE; SPT; QL (1 tablet per 1 MYFEMBREE 4 day) PA; BE; SPT; QL (2 tablets per 1 ORIAHNN 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
196 Drug Status Notes Lhrh (Gnrh) Antagonists CETROTIDE 4 PA; SP; $3-Copay; SPT ganirelix 4 PA; SP; $3-Copay; SPT PA; ST; BE; SPT; QL (1 Tablet ORILISSA ORAL TABLET 150 MG 3 per 1 Day) PA; ST; BE; SPT; QL (2 Tablets ORILISSA ORAL TABLET 200 MG 3 per 1 Day) Menopausal Symptoms Suppressant - Hormonal Agents INTRAROSA 3 QL (28 inserts per 21 Days) Menopausal Symptoms Suppressant- Selective Estrogen Receptor Modulators OSPHENA 3 Menopausal Symptoms Suppressant- Ssri Antidepressant Type BRISDELLE 3 PA; ST paroxetine mesylate(menop.sym) 1 Mineralocorticoids fludrocortisone 1 Oxytocic - Ergot Alkaloids METHERGINE 1 QL (28 tablets per 180 Dayss) methylergonovine oral 3 QL (28 tablets per 180 Dayss) Parathyroid Hormones NATPARA 4 PA; BE; SPT Progestins AYGESTIN 3 hydroxyprogesterone capr(bulk) 3 medroxyprogesterone oral 1 $3-Copay norethindrone acetate 1 progesterone 1 progesterone micronized 1 PROMETRIUM 3 PROVERA 3
Last Approved Date: 09/23/2021 Formulary Version: 91
197 Drug Status Notes Prolactin Inhibitor - Ergot Derivative Dopamine Receptor Agonists cabergoline 1 Rank Ligand (Rankl) Inhibitor, Mc Antibody PROLIA 1 PA; ST; SP; BE; SPT XGEVA 4 SP; SPT Selective Estrogen Receptor Modulators (Serms) EVISTA 3 raloxifene 1 Somatostatic Agents BYNFEZIA 4 PA; ST; BE; SPT PA; ST; BE; SPT; QL (4 capsules MYCAPSSA 4 per 1 day) octreotide acetate injection solution 3 SP; BE; SPT octreotide acetate injection syringe 3 SPT SANDOSTATIN INJECTION SOLUTION 1,000 4 SP; SPT MCG/ML, 200 MCG/ML SANDOSTATIN INJECTION SOLUTION 100 4 SP; BE; SPT MCG/ML, 50 MCG/ML, 500 MCG/ML SANDOSTATIN LAR DEPOT 4 SP; SPT INTRAMUSCULAR KIT SANDOSTATIN LAR DEPOT INTRAMUSCULAR 4 SUSPENSION,EXTENDED REL RECON SIGNIFOR 4 PA; BE; SPT SOMATULINE DEPOT 4 SP; BE; SPT Thyroid Hormone Combinations - Synthetic T3 And T4 THYROLAR-1 3 THYROLAR-1/2 3 THYROLAR-1/4 3 THYROLAR-2 3 THYROLAR-3 3
Last Approved Date: 09/23/2021 Formulary Version: 91
198 Drug Status Notes Thyroid Hormones - Animal Source (Porcine) ARMOUR THYROID 2 NATURE-THROID 1 NP THYROID 1 thyroid (pork) 1 WESTHROID 1 WP THYROID 3 Thyroid Hormones - Synthetic T3 (Triiodothyronine) CYTOMEL 3 liothyronine oral 1 Thyroid Hormones - Synthetic T4 (Thyroxine) EUTHYROX 1 LEVO-T 3 levothyroxine oral capsule 3 levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 1 $3-Copay mcg, 50 mcg, 75 mcg, 88 mcg levothyroxine oral tablet 300 mcg 1 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 2 THYQUIDITY 3 PA; ST TIROSINT 3 TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150 MCG/ML, 175 3 PA MCG/ML, 200 MCG/ML, 25 MCG/ML, 50 MCG/ML, 75 MCG/ML, 88 MCG/ML TIROSINT-SOL ORAL SOLUTION 37.5 3 MCG/ML, 44 MCG/ML, 62.5 MCG/ML UNITHROID 1
Last Approved Date: 09/23/2021 Formulary Version: 91
199 Drug Status Notes Gastrointestinal Therapy Agents Antidiarrheal - Antiperistaltic Agents loperamide oral capsule 3 opium tincture 3 paregoric 3 Antidiarrheal - Gastrointestinal Chloride Channel Inhibitors FULYZAQ 3 MYTESI 3 Antidiarrheal - Tryptophan Hydroxylase Inhibitor PA; BE; SPT; QL (3 tablets per 1 XERMELO 4 day) Antidiarrheal Antiperistaltic- Anticholinergic Combinations diphenoxylate-atropine 1 LOMOTIL 3 MOTOFEN 3 Antidiarrheal Opioid Agents opium tincture 3 paregoric 3 Antiemetic - Anticholinergics scopolamine base 3 TRANSDERM-SCOP 3 Antiemetic - Antihistamines ANTIVERT ORAL TABLET 50 MG 3 meclizine oral tablet 12.5 mg 3 meclizine oral tablet 25 mg 1 Antiemetic - Antihistamine-Vitamin Combinations BONJESTA 3 PA; QL (2 tablets per 1 day) DICLEGIS 3 PA; ST; QL (4 tablets per 1 day) doxylamine-pyridoxine (vit b6) 3 PA; ST; QL (4 tablets per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
200 Drug Status Notes Antiemetic - Cannabinoid Type CESAMET 3 dronabinol 3 MARINOL 3 SYNDROS 3 Antiemetic - Dopamine (D2)/5-Ht3 Antagonists TIGAN INTRAMUSCULAR 3 TIGAN ORAL CAPSULE 300 MG 3 trimethobenzamide oral 1 Antiemetic - Phenothiazines COMPRO 3 PHENADOZ 1 PHENERGAN RECTAL 1 prochlorperazine 3 prochlorperazine maleate 1 promethazine oral 1 promethazine rectal 1 PROMETHEGAN 1 Antiemetic - Selective Serotonin 5-Ht3 Antagonists ANZEMET ORAL 3 granisetron hcl oral 3 ondansetron 1 ondansetron hcl (pf) injection syringe 3 ondansetron hcl oral 1 SANCUSO 3 QL (3 PATCHES per 3 MONTHs) SUSTOL 3 ZOFRAN ODT 3 ZOFRAN ORAL 3 ZUPLENZ 3 Antiemetic - Substance P-Neurokinin 1 (Nk1) Receptor Antagonists aprepitant oral capsule 80 mg 3 QL (3 capsules per 3 months) aprepitant oral capsule,dose pack 3 QL (3 capsules per 3 months) Last Approved Date: 09/23/2021 Formulary Version: 91
201 Drug Status Notes QL (3 CAPSULES per 3 EMEND ORAL CAPSULE 125 MG, 80 MG 3 MONTHs) EMEND ORAL CAPSULE 40 MG 3 QL (1 CAPSULE per 3 MONTHs) QL (3 CAPSULES per 3 EMEND ORAL CAPSULE,DOSE PACK 3 MONTHs) EMEND ORAL SUSPENSION FOR 3 RECONSTITUTION QL (4 CAPSULES per 1 VARUBI ORAL 3 MONTH) Antiemetic - Substance P-Neurokinin 1 And 5-Ht3 Recept Antagonist Comb AKYNZEO (NETUPITANT) 3 QL (1 CAPSULE per 3 MONTHs) Bile Acids CHOLBAM 4 PA; BE; SPT Chronic Idiopathic Const. Agents - Guanylate Cyclase-C (Gc-C) Agonists LINZESS ORAL CAPSULE 145 MCG 3 LINZESS ORAL CAPSULE 290 MCG 3 QL (1 Capsule per 1 day) LINZESS ORAL CAPSULE 72 MCG 3 PA; QL (1 EA per 1 day) TRULANCE 3 PA; ST; QL (1 tablet per 1 Day) Colonic Acidifier (Ammonia Inhibitor) ENULOSE 1 GENERLAC 1 lactulose oral solution 10 gram/15 ml 1 Digestive Enzyme Mixtures CREON 2 PANCREAZE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600- 3 6,200- 10,850 UNIT, 2,600-8,800- 15,200 UNIT, 21,000-54,700- 83,900 UNIT, 37,000-97,300- 149,900 UNIT, 4,200-14,200- 24,600 UNIT PERTZYE 3 VIOKACE 3
Last Approved Date: 09/23/2021 Formulary Version: 91
202 Drug Status Notes ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 10,000-34,000 -55,000 UNIT, 15,000- 51,000 -82,000 UNIT, 20,000-63,000- 84,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000- 3 79,000- 105,000 UNIT, 3,000-10,000- 16,000 UNIT, 40,000-126,000- 168,000 UNIT, 40,000- 136,000- 218,000 UNIT, 5,000-17,000 -27,000 UNIT, 5,000-17,000- 24,000 UNIT Digestive Enzymes SUCRAID 3 PA; BE; SPT Gallstone Solubilizing (Litholysis) Agents ACTIGALL 3 CHENODAL 4 PA; ST; $3-Copay; SPT RELTONE 4 SPT URSO 250 3 URSO FORTE 3 ursodiol oral capsule 300 mg 1 ursodiol oral tablet 1 Gastric Acid Secretion Reducers - Histamine H2-Receptor Antagonists cimetidine 3 cimetidine hcl oral 1 famotidine oral suspension 1 famotidine oral tablet 20 mg, 40 mg 1 $3-Copay nizatidine 1 PEPCID 3 ranitidine hcl oral capsule 3 ranitidine hcl oral syrup 1 ranitidine hcl oral tablet 150 mg, 300 mg 1 $3-Copay ZANTAC ORAL TABLET 3 Gastric Acid Secretion Reducing Agents - Proton Pump Inhibitors (Ppis) PA; ST; QL (2 TABLETS per 1 ACIPHEX 3 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
203 Drug Status Notes ACIPHEX SPRINKLE ORAL CAPSULE, PA; ST; QL (1 CAPSULE per 1 3 DELAYED REL SPRINKLE 10 MG day) ACIPHEX SPRINKLE ORAL CAPSULE, PA; ST; QL (3 CAPSULES per 1 3 DELAYED REL SPRINKLE 5 MG day) DEXILANT ORAL CAPSULE,BIPHASE PA; ST; QL (34 CAPSULES per 1 3 DELAYED RELEAS 30 MG MONTH) DEXILANT ORAL CAPSULE,BIPHASE PA; ST; QL (34 capsules per 1 3 DELAYED RELEAS 60 MG month) esomeprazole magnesium oral capsule,delayed PA; ST; QL (1 CAPSULE per 1 3 release(dr/ec) day) esomeprazole magnesium oral granules dr for 3 PA; ST; QL (1 packet per 1 Day) susp in packet esomeprazole strontium 3 PA; ST; QL (1 Capsule per 1 day) lansoprazole oral capsule,delayed release(dr/ec) 3 QL (1 capsule/tablet per 1 day) lansoprazole oral tablet,disintegrat, delay rel 3 QL (1 capsule per 1 day) NEXIUM 24HR ORAL TABLET,DELAYED 3 QL (1 Tablet per 1 day) RELEASE (DR/EC) NEXIUM ORAL CAPSULE,DELAYED 3 PA; ST; QL (1 Capsule per 1 day) RELEASE(DR/EC) 20 MG NEXIUM ORAL CAPSULE,DELAYED PA; ST; QL (1 CAPSULE per 1 3 RELEASE(DR/EC) 40 MG day) NEXIUM PACKET 3 PA; ST; QL (1 Packet per 1 day) omeprazole magnesium oral capsule,delayed 3 QL (4 Capsules per 1 day) release(dr/ec) omeprazole magnesium oral tablet,delayed 1 QL (4 Tablets 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) $3-Copay; QL (4 CAPSULES per 1 20 mg 1 day) omeprazole oral capsule,delayed release(dr/ec) $3-Copay; QL (2 CAPSULES per 1 40 mg 1 day) omeprazole oral tablet,delayed release (dr/ec) 1 QL (4 Tablets per 1 day) pantoprazole intravenous 3 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) $3-Copay; QL (2 TABLETS per 1 1 40 mg day)
Last Approved Date: 09/23/2021 Formulary Version: 91
204 Drug Status Notes PREVACID ORAL CAPSULE,DELAYED 3 PA; ST; QL (1 Capsule per 1 day) RELEASE(DR/EC) 15 MG PREVACID ORAL CAPSULE,DELAYED PA; ST; QL (2 CAPSULES per 1 3 RELEASE(DR/EC) 30 MG day) PREVACID SOLUTAB 3 PA; ST; QL (1 Tablet per 1 day) PRILOSEC ORAL SUSP,DELAYED RELEASE 3 PA; ST; QL (1 Packet per 1 day) FOR RECON PROTONIX ORAL GRANULES DR FOR SUSP 3 PA; ST; QL (2 Packets per 1 day) IN PACKET PROTONIX ORAL TABLET,DELAYED PA; ST; QL (1 TABLET per 1 3 RELEASE (DR/EC) 20 MG day) PROTONIX ORAL TABLET,DELAYED PA; ST; QL (2 TABLETS per 1 3 RELEASE (DR/EC) 40 MG day) PA; ST; QL (12 tablets (1 carton) rabeprazole oral capsule, delayed rel sprinkle 3 per 28 Dayss) rabeprazole oral tablet,delayed release (dr/ec) 1 PA; ST; QL (1 tablet per 1 day) Gastric Acid Secretion Reducing-Proton Pump Inhibitor And Antacid Comb OMEPPI ORAL CAPSULE 20-1.1 MG-GRAM 3 OMEPPI ORAL CAPSULE 40-1.1 MG-GRAM 1 omeprazole-sodium bicarbonate oral capsule 40- PA; ST; QL (34 CAPSULES per 1 3 1.1 mg-gram MONTH) omeprazole-sodium bicarbonate oral packet 3 PA; ST; QL (1 Packet per 1 day) PA; ST; QL (34 CAPSULES per 1 ZEGERID ORAL CAPSULE 3 MONTH) ZEGERID ORAL PACKET 3 PA; ST; QL (1 Packet per 1 day) Gastric Mucosa - Cytoprotective Prostaglandin Analogs CYTOTEC 3 misoprostol 1 Gastrointestinal - Prokinetic Agents - 5- Ht4 Receptor Agonists MOTEGRITY 3 PA; ST; QL (1 tablet per 1 day) Gastrointestinal Antiflatulents simethicone (bulk) 3
Last Approved Date: 09/23/2021 Formulary Version: 91
205 Drug Status Notes Gastrointestinal Prokinetic Agents - D2 Antagonist/5-Ht4 Agonists PA; ST; QL (1 bottle (9.8ml) per GIMOTI 3 21 days) metoclopramide hcl injection syringe 3 metoclopramide hcl oral solution 1 metoclopramide hcl oral tablet 1 $3-Copay metoclopramide hcl oral tablet,disintegrating 10 1 mg metoclopramide hcl oral tablet,disintegrating 5 3 mg METOZOLV ODT ORAL 3 TABLET,DISINTEGRATING 5 MG REGLAN ORAL 3 Gi Antispasmodic - Belladonna Alkaloids ANASPAZ 1 atropine injection solution 3 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 3 belladonna tincture (bulk) 3 ED-SPAZ 1 hyoscyamine sulfate oral 1 hyoscyamine sulfate sublingual 1 HYOSYNE 1 LEVBID 3 LEVSIN ORAL 3 LEVSIN/SL 3 methscopolamine 1 NULEV 3 OSCIMIN 1 OSCIMIN SL 1 OSCIMIN SR 3 SYMAX DUOTAB 3 SYMAX FASTABS 1 SYMAX-SL 1 SYMAX-SR 1
Last Approved Date: 09/23/2021 Formulary Version: 91
206 Drug Status Notes Gi Antispasmodic - Quaternary Ammonium Compounds GLYCATE 3 PA; ST glycopyrrolate oral tablet 1 mg, 2 mg 1 glycopyrrolate oral tablet 1.5 mg 3 propantheline 1 ROBINUL FORTE 3 ROBINUL ORAL 3 Gi Antispasmodic - Synthetic Tertiary Amines BENTYL ORAL CAPSULE 3 BENTYL ORAL TABLET 3 dicyclomine oral capsule 1 dicyclomine oral solution 3 dicyclomine oral tablet 1 Gi Antispasmodic And Benzodiazepine Combinations chlordiazepoxide-clidinium 3 LIBRAX (WITH CLIDINIUM) 3 Gi Antispasmodic And Opioid Combinations belladonna alkaloids-opium 3 PA Gi Antispasmodic Combinations Other belladonna alkaloids-opium 3 PA BELLADONNA-PHENOBARBITAL 3 chlordiazepoxide-clidinium 3 DONNATAL ORAL ELIXIR 16.2-0.1037 - 3 0.0194 MG/5 ML DONNATAL ORAL TABLET 3 LIBRAX (WITH CLIDINIUM) 3 phenobarb-hyoscy-atropine-scop 3 PHENOHYTRO ORAL ELIXIR 16.2-0.1037 - 1 0.0194 MG/5 ML PHENOHYTRO ORAL TABLET 1
Last Approved Date: 09/23/2021 Formulary Version: 91
207 Drug Status Notes Ibs Agent - Gastrointestinal Chloride Channel Activator Agents AMITIZA 3 QL (2 Capsules per 1 day) lubiprostone 3 PA; ST; QL (2 capsules per 1 Day) Ibs Agent - Guanylate Cyclase-C (Gc-C) Agonists LINZESS ORAL CAPSULE 145 MCG, 290 3 MCG LINZESS ORAL CAPSULE 72 MCG 3 PA; QL (1 EA per 1 day) TRULANCE 3 PA; ST; QL (1 tablet per 1 Day) Ibs Agent - Mixed Opioid Receptor Agonist And Antagonist VIBERZI 3 PA; QL (60 EA per 30 days) Ibs Agent - Selective 5-Ht3 Receptor Antagonists PA; ST; QL (60 TABLETS per 1 alosetron 3 MONTH) LOTRONEX 3 Ibs Agent - Selective Partial 5-Ht4 Receptor Agonists ZELNORM 3 PA; ST; QL (2 tablets per 1 Day) Inflammatory Bowel Agent - Interleukin-12 And Il-23 Inhibitors, Mc Ab PA; ST; BE; SPT; QL (1 vial per STELARA SUBCUTANEOUS SOLUTION 3 63 days) STELARA SUBCUTANEOUS SYRINGE 90 PA; ST; SP; BE; SPT; QL (1 3 MG/ML SYRINGE per 63 days) Inflammatory Bowel Agent - Aminosalicylates And Related Agents APRISO 3 ASACOL HD 3 AZULFIDINE 3 AZULFIDINE EN-TABS 3 balsalazide 1 CANASA 3
Last Approved Date: 09/23/2021 Formulary Version: 91
208 Drug Status Notes COLAZAL 3 DELZICOL 3 DIPENTUM 2 GIAZO 3 LIALDA 3 mesalamine oral capsule (with del rel tablets) 1 mesalamine oral capsule,extended release 24hr 1 mesalamine oral tablet,delayed release (dr/ec) 1 1.2 gram mesalamine oral tablet,delayed release (dr/ec) 3 800 mg mesalamine rectal enema 1 mesalamine with cleansing wipe 3 PENTASA 3 ROWASA RECTAL ENEMA KIT 3 SFROWASA 3 sulfasalazine 1 SULFAZINE 1 Inflammatory Bowel Agent - Glucocorticoids budesonide oral 3 COLOCORT 1 CORTIFOAM 3 ENTOCORT EC 3 hydrocortisone rectal 1 ORTIKOS 3 UCERIS 3 Inflammatory Bowel Agent - Janus Kinase (Jak) Inhibitors PA; ST; BE; SPT; QL (2 tablets XELJANZ ORAL TABLET 10 MG 3 per 1 Day) PA; ST; SP; BE; SPT; QL (68 XELJANZ ORAL TABLET 5 MG 3 TABLETS per 1 MONTH) XELJANZ XR ORAL TABLET EXTENDED PA; ST; SP; BE; SPT; QL (1 tablet 3 RELEASE 24 HR 11 MG per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
209 Drug Status Notes XELJANZ XR ORAL TABLET EXTENDED PA; BE; SPT; QL (1 tablet per 1 3 RELEASE 24 HR 22 MG day) Inflammatory Bowel Agent - Tumor Necrosis Factor Alpha Blockers PA; ST; SP; BE; SPT; QL (1 KIT CIMZIA 4 per 21 days) PA; ST; SP; BE; SPT; QL (1 CIMZIA POWDER FOR RECONST 4 Starter Kit per 365 days) PA; ST; SP; BE; SPT; QL (2 CIMZIA STARTER KIT 4 prefilled syrs per 28 days) PA; ST; SP; SPT; QL (1 unit per HUMIRA PEDIATRIC CROHNS START 3 274 days) PA; ST; SP; BE; SPT; QL (2 HUMIRA PEN 3 SYRINGES per 21 days) PA; ST; SP; SPT; QL (2 HUMIRA PEN CROHNS-UC-HS START 3 SYRINGES per 21 days) PA; ST; SP; SPT; QL (2 HUMIRA PEN PSOR-UVEITS-ADOL HS 3 SYRINGES per 21 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 20 3 ST; BE MG/0.4 ML, 40 MG/0.8 ML PA; ST; BE; SPT; QL (1 unit per HUMIRA(CF) PEDI CROHNS STARTER 3 274 dayss) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN 3 per 21 days) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN CROHNS-UC-HS 3 per 21 days) PA; ST; BE; SPT; QL (1 unit per HUMIRA(CF) PEN PEDIATRIC UC 3 274 Dayss) PA; ST; BE; SPT; QL (2 syringes HUMIRA(CF) PEN PSOR-UV-ADOL HS 3 per 21 days) HUMIRA(CF) SUBCUTANEOUS SYRINGE PA; ST; BE; SPT; QL (2 syringes 3 KIT 20 MG/0.2 ML, 40 MG/0.4 ML per 21 days) SIMPONI SUBCUTANEOUS PEN INJECTOR PA; ST; SP; BE; SPT; QL (1 4 100 MG/ML prefilled syrs per 28 days) SIMPONI SUBCUTANEOUS SYRINGE 100 PA; ST; SP; BE; SPT; QL (1 4 MG/ML UNIT per 21 days) Intestinal Flora Modifiers RESTORA RX NL RESTORA SPRINKLES NL
Last Approved Date: 09/23/2021 Formulary Version: 91
210 Drug Status Notes Irritable Bowel Syndrome (Ibs) Agents PA; ST; QL (60 TABLETS per 1 alosetron 3 MONTH) PA; ST; QL (60 TABLETS per 1 LOTRONEX 3 MONTH) lubiprostone 3 PA; ST; QL (2 capsules per 1 Day) VIBERZI 3 ZELNORM 3 PA; ST; QL (2 tablets per 1 Day) Laxative - Bowel Prep Kits LO-SO PREP $0 Laxative - Saline And Osmotic CITRATE OF MAGNESIA 3 CITROMA 3 CLEARLAX ORAL POWDER 1 CLEARLAX ORAL POWDER IN PACKET 3 CONSTULOSE 1 $3-Copay GAVILAX ORAL POWDER 3 GAVILAX ORAL POWDER IN PACKET 17 $0 GRAM GAVILAX ORAL POWDER IN PACKET 8.5 3 GRAM GENTLELAX 3 GIALAX 3 GLYCOLAX ORAL POWDER 3 HEALTHYLAX 3 KRISTALOSE 3 lactulose oral packet 3 lactulose oral solution 10 gram/15 ml, 20 1 gram/30 ml LAXACLEAR 3 LAXATIVE PEG 3350 ORAL POWDER 3 LAXATIVE PEG 3350 ORAL POWDER IN $0 PACKET magnesium citrate oral solution 3 MILK OF MAGNESIA 3 MILK OF MAGNESIA CONCENTRATED 3
Last Approved Date: 09/23/2021 Formulary Version: 91
211 Drug Status Notes MIRALAX ORAL POWDER $0 MIRALAX ORAL POWDER IN PACKET 3 NATURA-LAX 3 polyethylene glycol 3350 oral powder 3 polyethylene glycol 3350 oral powder in packet $0 17 gram POWDERLAX 3 PURELAX 3 SMOOTHLAX 3 sorbitol solution 3 Laxative - Saline/Osmotic Mixtures COLYTE WITH FLAVOR PACKS ORAL $0 RECON SOLN 227.1-21.5-6.36 GRAM COLYTE WITH FLAVOR PACKS ORAL 3 RECON SOLN 240-22.72-6.72 -5.84 GRAM GAVILYTE-C 1 GAVILYTE-G 1 GAVILYTE-N 1 GOLYTELY ORAL POWDER IN PACKET $0 GOLYTELY ORAL RECON SOLN 3 MOVIPREP $0 NULYTELY WITH FLAVOR PACKS 3 ORAL SALINE LAXATIVE ORAL LIQUID 3 OSMOPREP $0 peg 3350-electrolytes 1 PEG-3350 WITH FLAVOR PACKS $0 peg3350-sod sul-nacl-kcl-asb-c $0 peg-electrolyte soln 1 PHOSPHATE LAXATIVE ORAL LIQUID 3 PHOSPHATE LAXATIVE ORAL SOLUTION $0 PLENVU $0 SUCLEAR $0 SUPREP BOWEL PREP KIT 2 SUTAB $0 TRILYTE WITH FLAVOR PACKETS 1
Last Approved Date: 09/23/2021 Formulary Version: 91
212 Drug Status Notes Laxative - Stimulant ALOPHEN (BISACODYL) 1 bisacodyl oral 1 BISA-LAX (BISACODYL) 1 DUCODYL (BISACODYL) 1 DULCOLAX BOWEL PREP KIT(BICOD) $0 FLEET LAXATIVE (BISACODYL) 1 GENTLE LAXATIVE (BISACODYL) ORAL 1 LAXATIVE (BISACODYL) ORAL 1 LAXATIVE FEMININE 1 WOMAN'S LAXATIVE (BISACODYL) 1 WOMEN'S GENTLE LAXATIVE(BISAC) 3 WOMEN'S LAXATIVE (BISACODYL) 1 Laxative - Stimulant And Saline/Osmotic Combinations CLENPIQ $0 QL (320 ml per 30 days) GAVILYTE-H AND BISACODYL 1 PEG-PREP 1 PREPOPIK $0 Peptic Ulcer - Gastric Lumen Adherent Cytoprotectives CARAFATE 3 sucralfate oral suspension 1 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 3 per 365 days) PA; ST; QL (120 capsules per 365 PYLERA 3 days) Peptic Ulcer-Treatment H. Pylori- Proton Pump Inhibitor And Antibiotics amoxicil-clarithromy-lansopraz 3 OMECLAMOX-PAK 3 PREVPAC 3
Last Approved Date: 09/23/2021 Formulary Version: 91
213 Drug Status Notes PA; ST; QL (168 capsules per 365 TALICIA 3 days) Short Bowel Syndrome (Sbs) - Glucagon-Like Peptide-2 (Glp-2) Analog GATTEX 30-VIAL 3 PA; SP; BE; SPT GATTEX ONE-VIAL 3 PA; SP; SPT Short Bowel Syndrome (Sbs) Agents BYNFEZIA 4 PA; ST; BE; SPT octreotide acetate injection solution 3 BE octreotide acetate injection syringe 3 SPT SAIZEN SUBCUTANEOUS RECON SOLN 8.8 4 BE MG SANDOSTATIN INJECTION SOLUTION 1,000 4 MCG/ML, 200 MCG/ML SANDOSTATIN LAR DEPOT INTRAMUSCULAR 4 SUSPENSION,EXTENDED REL RECON ZORBTIVE 4 BE Genitourinary Therapy Bph Agent- 5-Alpha Reductase Inhib And Alpha-1 Adrenoceptor Antag Comb JALYN 3 PA; ST Cystinosis Therapy (Cystine Depleting Agents) CYSTAGON 2 PROCYSBI ORAL CAPSULE, DELAYED REL 3 PA; BE; SPT SPRINKLE PROCYSBI ORAL GRANULES DEL 4 PA; ST; BE; SPT RELEASE IN PACKET Interstitial Cystitis Agents ELMIRON 2 Kidney Stone Agents THIOLA 3 PA; BE THIOLA EC ORAL TABLET,DELAYED PA; BE; SPT; QL (20 tablets per 1 4 RELEASE (DR/EC) 100 MG day) Last Approved Date: 09/23/2021 Formulary Version: 91
214 Drug Status Notes THIOLA EC ORAL TABLET,DELAYED PA; ST; BE; SPT; QL (6 tablets 4 RELEASE (DR/EC) 300 MG per 1 day) tiopronin 3 PA; ST; BE Overactive Bladder Agents - Beta -3 Adrenergic Receptor Agonist GEMTESA 3 PA; ST; QL (1 tablet per 1 day) MYRBETRIQ ORAL TABLET EXTENDED 3 RELEASE 24 HR Phosphate Binders AURYXIA 4 SPT calcium acetate(phosphat bind) 1 ELIPHOS 1 FOSRENOL ORAL POWDER IN PACKET 4 FOSRENOL ORAL TABLET,CHEWABLE 4 SPT lanthanum 4 PHOSLYRA 4 SPT RENAGEL 4 SPT RENVELA 4 SPT sevelamer carbonate 3 sevelamer hcl 4 VELPHORO 4 SPT Phosphate Binders - Calcium-Based calcium acetate(phosphat bind) 1 ELIPHOS 1 PHOSLYRA 4 SPT Phosphate Binders - Iron-Based AURYXIA 4 SPT VELPHORO 4 Polycystic Kidney Disease - Vasopressin V2 Receptor Antagonists JYNARQUE ORAL TABLET 4 PA; BE; SPT JYNARQUE ORAL TABLETS, SEQUENTIAL PA; BE; SPT; QL (56 tablets per 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 3 28 days) MG (PM)
Last Approved Date: 09/23/2021 Formulary Version: 91
215 Drug Status Notes JYNARQUE ORAL TABLETS, SEQUENTIAL PA; BE; SPT; QL (4 blister cards 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 3 per 28 days) MG (PM), 90 MG (AM)/ 30 MG (PM) Prostatic Hypertrophy Agent - Alpha-1- Adrenoceptor Antagonists alfuzosin 3 FLOMAX 3 PA; ST RAPAFLO 3 tamsulosin 1 $3-Copay UROXATRAL 3 PA; ST Prostatic Hypertrophy Agent - Type Ii 5-Alpha Reductase Inhibitors finasteride oral tablet 5 mg 1 $3-Copay PROSCAR 3 PA; ST Prostatic Hypertrophy Agent-Sel.Cgmp Phosphodiesterase Type5 Inhibitor PA; ST; SPT; QL (2 tablets per 1 tadalafil oral tablet 2.5 mg, 5 mg 3 day) Prostatic Hypertrophy Agent-Type I And Ii 5-Alpha Reductase Inhibitors AVODART 3 PA; ST dutasteride 3 Urinary Acidifier - Phosphates K-PHOS NO 2 3 K-PHOS ORIGINAL 3 Urinary Alkalinizer - Citrates CYTRA-2 NL CYTRA-3 NL CYTRA-K NL ORACIT 3 pot,sodium citrate-citric acid NL potassium citrate oral tablet extended release 10 1 meq (1,080 mg), 5 meq (540 mg) potassium citrate-citric acid NL SHOHL'S MODIFIED 3 sodium citrate-citric acid NL Last Approved Date: 09/23/2021 Formulary Version: 91
216 Drug Status Notes TRICITRATES NL UROCIT-K 10 3 UROCIT-K 15 3 UROCIT-K 5 3 VIRTRATE-2 NL VIRTRATE-3 NL VIRTRATE-K NL Urinary Analgesics phenazopyridine oral tablet 100 mg, 200 mg 3 PYRIDIUM 3 Urinary Antibacterial - Methenamine And Salts HIPREX 3 methenamine hippurate 1 methenamine mandelate 1 UROQID-ACID NO.2 3 Urinary Antibacterial - Nitrofuran Derivatives FURADANTIN 3 MACROBID 3 MACRODANTIN 3 nitrofurantoin 1 nitrofurantoin macrocrystal oral capsule 100 mg, 1 50 mg nitrofurantoin macrocrystal oral capsule 25 mg 3 nitrofurantoin monohyd/m-cryst 1 Urinary Antibacterial - Quinolones CIPRO XR 3 ciprofloxacin (mixture) 1 Urinary Antibacterials Other fosfomycin tromethamine 3 MONUROL 3 Urinary Anti-Infective Methenamine- Antispas-Analg Combinations AZUPHEN MB 1 Last Approved Date: 09/23/2021 Formulary Version: 91
217 Drug Status Notes HYOLEV MB 1 HYOPHEN 1 PHOSPHASAL 1 UR N-C 1 URAMIT MB 1 URELLE 3 URETRON D-S 1 URIBEL 3 URIMAR-T 1 URIN DS 1 URO-458 1 UROAV-B 1 URO-MP 1 UROPHEN MB 1 USTELL 1 UTIRA-C 1 VILAMIT MB 1 VILEVEV MB 1 Urinary Anti-Infective Methenamine- Antispasmodic Combinations INDIOMIN MB 3 methen-sod phos-meth blue-hyos 1 UROGESIC-BLUE 1 UROLET MB 1 URYL 1 UTA 3 Urinary Antispasmodic - Antichol., M(3) Muscarinic Selective (Bladder) ENABLEX 3 solifenacin 3 VESICARE 3 PA; ST; QL (300 ML per 25 VESICARE LS 3 Dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
218 Drug Status Notes Urinary Antispasmodic - Anticholinergics, Non-Selective ANASPAZ 1 ED-SPAZ 1 hyoscyamine sulfate oral 1 hyoscyamine sulfate sublingual 1 HYOSYNE 1 LEVBID 3 LEVSIN ORAL 3 LEVSIN/SL 3 NULEV 3 OSCIMIN 1 OSCIMIN SL 1 OSCIMIN SR 3 SYMAX DUOTAB 3 SYMAX FASTABS 1 SYMAX-SL 1 SYMAX-SR 1 Urinary Antispasmodic - Smooth Muscle Relaxants DETROL 3 DETROL LA 3 DITROPAN XL 3 flavoxate 1 GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 100 MG/GRAM (10 3 QL (30 g (1 pump) per 30 Days) %) GELNIQUE TRANSDERMAL GEL IN 3 QL (30 g (1 pump) per 30 days) PACKET oxybutynin chloride oral syrup 1 $3-Copay oxybutynin chloride oral tablet 1 $3-Copay oxybutynin chloride oral tablet extended release 1 24hr OXYTROL 3 QL (8 PATCHES per 1 MONTH) OXYTROL FOR WOMEN 3 tolterodine oral capsule,extended release 24hr 3
Last Approved Date: 09/23/2021 Formulary Version: 91
219 Drug Status Notes tolterodine oral tablet 1 TOVIAZ 3 trospium oral tablet 3 Urinary Retention Therapy - Parasympathomimetic Agents bethanechol chloride 1 URECHOLINE 3 Gout And Hyperuricemia Therapy Gout Acute Therapy - Antimitotics colchicine 0.6 mg capsule 3 PA; ST PA; ST; QL (68 CAPSULES per 1 colchicine oral capsule 0.6 mg 3 MONTH) colchicine oral tablet 3 COLCRYS 3 GLOPERBA 3 PA; ST; QL (10 ML per 1 day) PA; ST; QL (68 CAPSULES per 1 MITIGARE 3 MONTH) Gout And Hyperuricemia - Antimitotic- Uricosuric Combinations probenecid-colchicine 1 Hyperuricemia Therapy - Uricosurics probenecid 1 Hyperuricemia Therapy - Xanthine Oxidase Inhibitors allopurinol 1 $3-Copay febuxostat 3 PA; ST ULORIC 3 PA; ST ZYLOPRIM 3 Hyperuricemia Tx - Urat1 Inhibitor And Xanthine Oxidase Inhibitor Comb DUZALLO 3 PA; ST; QL (1 tablet per 1 Day) Hematological Agents Agents To Treat Attp- Anti Von Willebrand Factor (Vwf) A1 Domain CABLIVI INJECTION KIT 4 PA; $3-Copay; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
220 Drug Status Notes CABLIVI INJECTION RECON SOLN 4 PA; SPT Agents To Treat Paroxysmal Nocturnal Hemoglobinuria (Pnh) PA; $3-Copay; SPT; QL (8 vials EMPAVELI 4 per 28 days) Anticoagulants - Citrate-Based anticoag citrate phos dextrose 3 sodium citrate 3 Anticoagulants - Coumarin COUMADIN ORAL 3 JANTOVEN 1 $3-Copay warfarin 1 $3-Copay Anti-Inhibitor Coagulation Complex FEIBA NF 4 SPT Blood Cell And Platelet Disorder Tx- Spleen Tyrosine Kinase Inhibitors PA; ST; BE; SPT; QL (2 Tablets TAVALISSE 4 per 1 Day) C1 Esterase Inhibitor Agents BERINERT INTRAVENOUS KIT 3 PA; ST; SPT CINRYZE 4 PA; ST; BE; SPT PA; ST; SP; BE; SPT; QL (20 HAEGARDA 4 vials per 30 days) RUCONEST 1 PA; ST; SP; BE; SPT Cxcr4 Chemokine Receptor Antagonists MOZOBIL 3 PA; SP; BE; SPT Direct Factor Xa Inhibitors BEVYXXA ORAL CAPSULE 40 MG 3 QL (42 tablets per 60 days) BEVYXXA ORAL CAPSULE 80 MG 3 QL (42 tablets per 60 Days) ELIQUIS DVT-PE TREAT 30D START 2 QL (1 dose pack per 365 days) ELIQUIS ORAL TABLET 2.5 MG 2 QL (68 TABLETS per 1 MONTH) ELIQUIS ORAL TABLET 5 MG 2 QL (74 tablets per 25 days) SAVAYSA 3 QL (34 TABLETS per 1 MONTH) XARELTO DVT-PE TREAT 30D START 2 QL (2 Starter Packs per 365 days) XARELTO ORAL TABLET 10 MG, 20 MG 2 QL (34 TABLETS per 1 MONTH)
Last Approved Date: 09/23/2021 Formulary Version: 91
221 Drug Status Notes XARELTO ORAL TABLET 15 MG 2 QL (48 TABLETS per 1 MONTH) XARELTO ORAL TABLET 2.5 MG 2 Erythropoietins ARANESP (IN POLYSORBATE) INJECTION 3 SP; BE; SPT SOLUTION ARANESP (IN POLYSORBATE) INJECTION 3 BE; SPT SYRINGE 10 MCG/0.4 ML ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 3 SP; BE; SPT MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 4 SP; BE; SPT 3,000 UNIT/ML, 4,000 UNIT/ML EPOGEN INJECTION SOLUTION 20,000 4 SP; SPT UNIT/2 ML MIRCERA 4 PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 4 SP; BE; SPT 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 4 SP; SPT UNIT/2 ML RETACRIT 4 BE; SPT Factor Ix Preparations ALPHANINE SD 4 SPT ALPROLIX 4 SPT BENEFIX 3 SPT IDELVION 3 SPT IXINITY 4 SPT PROFILNINE 4 SPT REBINYN 4 SPT RIXUBIS 4 SPT Factor Vii Preparations NOVOSEVEN RT 4 SPT SEVENFACT 4 SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
222 Drug Status Notes Factor Viii Preparations (Ahf) ADVATE 3 SPT ADYNOVATE 3 SPT AFSTYLA 3 SPT ELOCTATE 3 SPT ESPEROCT 3 SPT HELIXATE FS 4 SPT HEMOFIL M HIGH 4 SPT HEMOFIL M LOW 4 SPT HEMOFIL M MID 4 SPT HEMOFIL M SUPER HIGH 4 SPT HUMATE-P 4 SPT JIVI 3 SPT KOATE 4 SPT KOATE-DVI 4 SPT KOGENATE FS 3 SPT KOVALTRY 3 SPT NOVOEIGHT 3 SPT NUWIQ 4 PA; ST; BE; SPT OBIZUR 4 SPT RECOMBINATE 4 PA; ST; BE; SPT WILATE 3 SPT XYNTHA 4 PA; ST; BE; SPT XYNTHA SOLOFUSE 4 BE; SPT Factor Viii-Mimetic Agent, Monoclonal Antibody HEMLIBRA SUBCUTANEOUS SOLUTION PA; BE; SPT; QL (8 VIALS (5.6 3 105 MG/0.7 ML mL) per 28 DAYSs) HEMLIBRA SUBCUTANEOUS SOLUTION PA; BE; SPT; QL (8 VIALS (8 3 150 MG/ML mL) per 28 DAYSs) HEMLIBRA SUBCUTANEOUS SOLUTION 30 PA; BE; SPT; QL (24 VIALS (24 3 MG/ML mL) per 28 DAYSs) HEMLIBRA SUBCUTANEOUS SOLUTION 60 PA; BE; SPT; QL (8 VIALS (3.2 3 MG/0.4 ML mL) per 28 DAYSs) Factor X Preparations COAGADEX 4 SPT Last Approved Date: 09/23/2021 Formulary Version: 91
223 Drug Status Notes Factor Xiii Preparations CORIFACT 4 SPT TRETTEN 4 SPT Granulocyte Colony-Stimulating Factor (G-Csf) FULPHILA 4 $3-Copay; SPT GRANIX SUBCUTANEOUS SOLUTION 4 GRANIX SUBCUTANEOUS SYRINGE 4 BE; SPT NEULASTA 3 SP; BE; SPT NEULASTA ONPRO 4 SPT NEUPOGEN INJECTION SOLUTION 300 3 SP; BE; SPT MCG/ML NEUPOGEN INJECTION SOLUTION 480 3 SP; SPT MCG/1.6 ML NEUPOGEN INJECTION SYRINGE 3 SP; BE; SPT NIVESTYM INJECTION 4 NIVESTYM SUBCUTANEOUS 4 SPT NYVEPRIA 4 BE; SPT UDENYCA 4 BE; SPT ZARXIO 4 SP; SPT ZIEXTENZO 4 BE; SPT Granulocyte-Macrophage Colony- Stimulating Factor (Gm-Csf) LEUKINE INJECTION RECON SOLN 4 SP; BE; SPT Hematopoietic Agents - Erythroid (Rbc) Maturation Agents REBLOZYL 3 Hematorheologic Agents pentoxifylline 1 Hemostatic Systemic - Antifibrinolytic Agents AMICAR 3 aminocaproic acid oral solution 3 aminocaproic acid oral tablet 1 FIBRYGA 4 SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
224 Drug Status Notes LYSTEDA 3 RIASTAP 4 SPT tranexamic acid oral 3 Hemostatic Systemic- Von Willebrand Factor (Vwf) Preparations VONVENDI 4 SPT Hemostatic Topical Agents ferric subsulfate (bulk) solution 3 THROMBIN-JMI NASAL 3 Heparins HEP FLUSH-10 (PF) 3 heparin (porcine) injection solution 1 heparin (porcine) injection syringe 5,000 unit/ml 3 heparin flush(porcine)-0.9nacl 3 HEPARIN LOCK 1 HEPARIN LOCK FLUSH 1 heparin, porcine (pf) injection syringe 5,000 3 unit/0.5 ml heparin, porcine (pf) subcutaneous 3 Indirect Factor Xa Inhibitors ARIXTRA SUBCUTANEOUS SYRINGE 10 4 BE; SPT MG/0.8 ML, 2.5 MG/0.5 ML, 5 MG/0.4 ML ARIXTRA SUBCUTANEOUS SYRINGE 7.5 4 SPT MG/0.6 ML fondaparinux 3 BE; SPT Low Molecular Weight Heparins enoxaparin subcutaneous solution 1 enoxaparin subcutaneous syringe 1 BE FRAGMIN SUBCUTANEOUS SOLUTION 4 SPT FRAGMIN SUBCUTANEOUS SYRINGE 4 BE; SPT LOVENOX 4 BE; SPT Monoclonal Antibody - P-Selectin Inhibitors ADAKVEO 3
Last Approved Date: 09/23/2021 Formulary Version: 91
225 Drug Status Notes Platelet Aggregation Inhib - Cyclopentyl-Triazolo-Pyrimidines (Cptps) BRILINTA 3 Platelet Aggregation Inhibitor Combinations AGGRENOX 3 aspirin-dipyridamole 3 Platelet Aggregation Inhibitors - Phosphodiesterase Iii Inhibitors cilostazol 1 Platelet Aggregation Inhibitors - Quinazoline Agents AGRYLIN 3 anagrelide 1 Platelet Aggregation Inhibitors - Salicylates ADULT ASPIRIN REGIMEN 1 ADULT LOW DOSE ASPIRIN $0 ASPIR-81 1 ASPIRIN CHILDRENS 1 ASPIRIN LOW DOSE 1 ASPIRIN LOW-STRENGTH $0 aspirin oral tablet 325 mg 1 aspirin oral tablet 81 mg $0 aspirin oral tablet,chewable 1 aspirin oral tablet,delayed release (dr/ec) 325 1 mg, 81 mg ASPIR-LOW 1 ASPIR-TRIN 1 BAYER ASPIRIN 1 BAYER CHEWABLE ASPIRIN 3 CHILD ASPIRIN 1 CHILDREN'S ASPIRIN 1 DURLAZA 3 QL (1 CAPSULE per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
226 Drug Status Notes E.C. PRIN 1 ECOTRIN $0 ECOTRIN LOW STRENGTH 1 ENTERIC COATED ASPIRIN $0 HALFPRIN $0 LITE COAT ASPIRIN 1 LO-DOSE ASPIRIN $0 MINIPRIN $0 ST JOSEPH ASPIRIN 1 ST. JOSEPH ASPIRIN 1 Platelet Aggregation Inhibitors - Thienopyridine Agents clopidogrel 1 EFFIENT 3 PLAVIX 3 prasugrel 3 ticlopidine 3 Platelet Aggregation Inhibitors- Salicylates And Proton Pump Inhib Comb aspirin-omeprazole 3 PA; ST; QL (1 tablet per 1 Day) YOSPRALA 3 PA; ST; QL (1 tablet per 1 day) Platelet Aggregation Inhib-Pdesterase And Adenosine Deaminase Inhibitr dipyridamole oral 1 PERSANTINE 3 Platelet Aggregation Inhib-Protease- Activ.Receptor-1(Par-1) Antagonist ZONTIVITY 3 QL (34 TABLETS per 1 MONTH) Pnh - Complement (C3) Inhibitors PA; $3-Copay; SPT; QL (8 vials EMPAVELI 4 per 28 days) Sickle Cell Anemia Agents, Others DROXIA 3
Last Approved Date: 09/23/2021 Formulary Version: 91
227 Drug Status Notes PA; ST; SP; $3-Copay; SPT; QL ENDARI 4 (6 packets per 1 Day) SIKLOS ORAL TABLET 1,000 MG 3 PA; SPT; QL (1 tablet per 1 day) PA; BE; SPT; QL (1 tablet per 1 SIKLOS ORAL TABLET 100 MG 3 day) Sickle Hemoglobin (Hbs) Polymerization Inhibitor PA; BE; SPT; QL (3 capsules per OXBRYTA 1 1 day) Thrombin Inhibitor - Selective Direct And Reversible PRADAXA 3 QL (4 capsules per 1 day) Thrombin Inhibitor - Selective Direct And Reversible - Hirudin Type IPRIVASK 3 Thrombopoietin Receptor Agonists PA; ST; BE; QL (15 tablets per 28 DOPTELET (10 TAB PACK) 4 days) PA; ST; BE; QL (15 tablets per 28 DOPTELET (15 TAB PACK) 4 days) PA; ST; BE; QL (15 tablets per 28 DOPTELET (30 TAB PACK) 4 days) PA; SPT; QL (7 tablets per 28 MULPLETA 4 Dayss) NPLATE SUBCUTANEOUS RECON SOLN 4 PA; ST; BE; SPT 125 MCG NPLATE SUBCUTANEOUS RECON SOLN 4 PA; ST; SP; BE; SPT 250 MCG NPLATE SUBCUTANEOUS RECON SOLN 4 PA; ST; SP; SPT 500 MCG PROMACTA ORAL POWDER IN PACKET PA; BE; SPT; QL (1 packet per 1 3 12.5 MG day) PROMACTA ORAL POWDER IN PACKET 25 PA; ST; BE; SPT; QL (1 packet 3 MG per 1 day) PA; SP; BE; SPT; QL (1 tablet per PROMACTA ORAL TABLET 12.5 MG 3 1 day) PA; ST; SP; BE; SPT; QL (1 tablet PROMACTA ORAL TABLET 25 MG 3 per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
228 Drug Status Notes PA; ST; SP; BE; SPT; QL (2 PROMACTA ORAL TABLET 50 MG, 75 MG 3 tablets per 1 day) Transforming Growth Factor (Tgf) Ligands Agent REBLOZYL 3 Hepatobiliary System Treatment Agents Ahp Agents - Alas1 Degradation, Small Interfering Rna (Sirna) Based GIVLAARI 3 Farnesoid X Receptor (Fxr) Agonist, Bile Acid Analog OCALIVA 4 PA; ST; BE; SPT Ileal Bile Acid Transporter (Ibat) Inhibitor BYLVAY 3 Immunosuppressive Agents Immunosuppressive - Calcineurin Inhibitors ASTAGRAF XL 2 cyclosporine modified 1 cyclosporine oral 1 ENVARSUS XR 3 GENGRAF 1 PA; ST; BE; SPT; QL (6 capsules LUPKYNIS 4 per 1 day) NEORAL 3 PROGRAF ORAL 3 SANDIMMUNE ORAL 3 tacrolimus oral 1 Immunosuppressive - Inosine Monophosphate Dehydrogenase Inhibitors CELLCEPT ORAL CAPSULE 3 CELLCEPT ORAL SUSPENSION FOR 2 RECONSTITUTION CELLCEPT ORAL TABLET 3 Last Approved Date: 09/23/2021 Formulary Version: 91
229 Drug Status Notes mycophenolate mofetil 1 mycophenolate sodium 1 MYFORTIC 3 Immunosuppressive - Interleukin-6 (Il- 6) Receptor Inhibitors PA; $3-Copay; SPT; QL (1 syringe ENSPRYNG 4 per 28 days) Immunosuppressive - Mammalian Target Of Rapamycin (Mtor) Inhibitors everolimus (immunosuppressive) 3 RAPAMUNE 3 sirolimus oral solution 1 sirolimus oral tablet 3 ZORTRESS 3 Immunosuppressive - Purine Analogs AZASAN 3 azathioprine 1 IMURAN 3 Locomotor System Agents To Treat Periodic Paralysis - Carbonic Anhydrase Inhibitors PA; BE; SPT; QL (136 TABLETS KEVEYIS 4 per 1 MONTH) Als Agents - Benzathiazoles PA; $3-Copay; SPT; QL (2 films EXSERVAN 4 per 1 Day) RILUTEK 1 BE; SPT riluzole 1 BE BE; SPT; QL (2 multiple-dose TIGLUTIK 4 bottles (600ml) per 30 Dayss) Antimyasthenic Agent - Reversible Cholinesterase Inhibitors MESTINON ORAL 3 MESTINON TIMESPAN 3 pyridostigmine bromide oral syrup 3 pyridostigmine bromide oral tablet 30 mg 3 Last Approved Date: 09/23/2021 Formulary Version: 91
230 Drug Status Notes pyridostigmine bromide oral tablet 60 mg 1 Antimyasthenic Agents Other guanidine 1 Skeletal Muscle Relaxant - Analgesic Salicylate Combinations carisoprodol-aspirin 1 PA NORGESIC FORTE 3 PA; ST; QL (4 tablets per 1 day) orphenadrine-asa-caffeine 3 ORPHENGESIC FORTE 3 PA; ST; QL (4 tablets per 1 day) Skeletal Muscle Relaxant - Central Muscle Relaxants AMRIX 3 PA; ST baclofen oral tablet 10 mg 1 $3-Copay baclofen oral tablet 20 mg 1 baclofen oral tablet 5 mg 3 carisoprodol oral tablet 350 mg 3 PA chlorzoxazone oral tablet 250 mg 3 chlorzoxazone oral tablet 375 mg, 750 mg 3 PA; ST chlorzoxazone oral tablet 500 mg 1 cyclobenzaprine oral tablet 10 mg, 5 mg 1 $3-Copay cyclobenzaprine oral tablet 7.5 mg 3 PA; ST FEXMID 3 PA; ST LIORESAL INTRATHECAL SOLUTION 2,000 4 SP; SPT MCG/ML, 500 MCG/ML LORZONE 3 PA; ST METAXALL 1 PA; ST metaxalone 1 PA; ST methocarbamol oral 1 orphenadrine citrate oral 1 PA; ST; BE; QL (80 ML per 1 OZOBAX 1 day) PARAFON FORTE DSC 3 PA; ST ROBAXIN ORAL 3 ROBAXIN-750 3 SKELAXIN 3 PA; ST
Last Approved Date: 09/23/2021 Formulary Version: 91
231 Drug Status Notes SOMA 3 PA tizanidine oral capsule 1 tizanidine oral tablet 1 $3-Copay ZANAFLEX 3 Skeletal Muscle Relaxant - Direct Muscle Relaxants DANTRIUM ORAL CAPSULE 25 MG, 50 MG 3 dantrolene oral 1 Skeletal Muscle Relaxant - Opioid Analgesic Combinations carisoprodol-aspirin-codeine 1 PA Skeletal Muscle Relaxant, Salicylate, And Opioid Analgesic Comb. carisoprodol-aspirin-codeine 1 PA Spinal Muscular Atrophy - Motor Neuron 2 (Smn2) Splicing Modifier PA; $3-Copay; QL (80 ML per 20 EVRYSDI 3 days) Medical Supplies And Durable Medical Equipment (Dme) Medical Supplies And Dme - Blood Glucose Tests ACCU-CHEK AVIVA 3 PA; QL (7 test strips per 1 day) ACCU-CHEK GUIDE TEST STRIPS 3 PA; QL (7 test strips per 1 Day) ADVOCATE REDI-CODE 3 PA; QL (7 test strips per 1 day) ADVOCATE TEST STRIPS 3 PA; QL (7 test strips per 1 day) ASSURE 4 STRIPS 3 PA; QL (7 test strips per 1 day) BREEZE 2 TEST STRIPS 3 PA; QL (7 test strips per 1 day) CLEVER CHOICE PRO STRIP 3 PA; QL (7 test strips per 1 day) CLEVER CHOICE TEST STRIPS 3 PA; QL (7 test strips per 1 day) CONTOUR TEST STRIPS 3 PA; QL (7 test strips per 1 day) EASY TOUCH BLU LINK TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) EASY TRAK II TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) ELEMENT TEST STRIPS 3 PA; QL (7 test strips per 1 day) EVENCARE PROVIEW TEST STRIP 3 PA; ST; QL (7 strips per 1 Day)
Last Approved Date: 09/23/2021 Formulary Version: 91
232 Drug Status Notes FORA 6 CONNECT GLUCOSE STRIP 3 PA; ST; QL (7 strips per 1 Day) FORA GTEL GLUCOSE TEST STRIP 3 PA; ST; QL (7 strips per 1 day) FORTISCARE G1 TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) FREESTYLE INSULINX STRIP 2 QL (7 test strips per 1 day) FREESTYLE LITE STRIPS 2 QL (7 test strips per 1 day) FREESTYLE TEST 2 QL (7 test strips per 1 day) GOJJI BLOOD GLUCOSE TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) HARMONY GLUCOSE TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) INFINITY TEST STRIPS 3 PA; QL (7 test strips per 1 day) MICRODOT XTRA BLOOD GLUCOSE 3 PA; ST; QL (7 strips per 1 Day) ONETOUCH VERIO TEST STRIPS 2 QL (7 test strips per 1 day) PRECISION PCX PLUS TEST 3 PA; QL (7 test strips per 1 day) PRECISION PCX TEST 3 QL (7 test strips per 1 day) PRECISION POINT OF CARE TEST 3 PA; QL (7 test strips per 1 day) PRECISION Q-I-D TEST 3 QL (7 test strips per 1 day) PRECISION XTRA TEST 2 QL (7 test strips per 1 day) SURE-TEST EASYPLUS MINI STRIP 3 PA; QL (7 test strips per 1 day) TRUETEST TEST STRIPS 3 PA; QL (7 test strips per 1 day) TRUETRACK TEST 3 PA; QL (7 test strips per 1 day) VIVAGUARD INO TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) Medical Supplies And Dme - Cervical Caps FEMCAP 3 Medical Supplies And Dme - Diaphragms CAYA CONTOURED 3 ORTHO ALL-FLEX FITTING SET $0 ORTHO DIAPHRAGM ALL-FLEX 65 $0 ORTHO DIAPHRAGM ALL-FLEX 70 $0 ORTHO DIAPHRAGM ALL-FLEX 75 $0 ORTHO DIAPHRAGM ALL-FLEX 80 $0 WIDE-SEAL DIAPHRAGM 60 3 WIDE-SEAL DIAPHRAGM 65 3 WIDE-SEAL DIAPHRAGM 70 3 WIDE-SEAL DIAPHRAGM 75 3
Last Approved Date: 09/23/2021 Formulary Version: 91
233 Drug Status Notes WIDE-SEAL DIAPHRAGM 80 3 WIDE-SEAL DIAPHRAGM 85 3 WIDE-SEAL DIAPHRAGM 90 3 WIDE-SEAL DIAPHRAGM 95 3 Medical Supplies And Dme - Female Condoms FC2 FEMALE CONDOM 3 Medical Supplies And Dme - Glucose Monitoring Test Supplies DEXCOM G4 RECEIVER 2 QL (1 pack per 365 Dayss) DEXCOM G4 TRANSMITTER 2 QL (1 pack per 90 Dayss) DEXCOM G5 RECEIVER 2 QL (1 pack per 365 Dayss) DEXCOM G5 TRANSMITTER 2 QL (1 pack per 90 Dayss) QL (4 units (1 box) per 25 day DEXCOM G5-G4 SENSOR 2 rolling periods) DEXCOM G6 RECEIVER 2 QL (1 pack per 365 Dayss) QL (4 units (1 box) per 25 day DEXCOM G6 SENSOR 2 rolling periods) DEXCOM G6 TRANSMITTER 2 QL (1 pack per 90 Dayss) DEXCOM RECEIVER 2 QL (1 pack per 365 Dayss) EVERSENSE SENSOR-HOLDER 3 FREESTYLE LIBRE 10 DAY READER 2 QL (1 pack per 365 Dayss) FREESTYLE LIBRE 10 DAY SENSOR 2 QL (3 packs per 30 Dayss) FREESTYLE LIBRE 14 DAY READER 2 QL (1 pack per 365 Dayss) FREESTYLE LIBRE 14 DAY SENSOR 2 QL (2 packs per 28 Dayss) 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 HUMAPEN LUXURA HD 2 INPEN (FOR HUMALOG) 3 INPEN (FOR NOVOLOG OR FIASP) 3 NOVOFINE 30 2 NOVOFINE 32 2 NOVOFINE AUTOCOVER 2
Last Approved Date: 09/23/2021 Formulary Version: 91
234 Drug Status Notes NOVOFINE PLUS 2 NOVOPEN ECHO 3 NOVOTWIST 3 OMNIPOD DASH PDM KIT 2 QL (10 pods per 30 days) Medical Supplies And Dme - Male Condoms AIMSCO LATEX CONDOM 3 CONDOMS-PREM LUBRICATED 3 DUREX AVANTI BARE REAL FEEL 3 FANTASY CONDOM 3 KIMONO CONDOMS(NON-LUBRICATED) 3 KIMONO MAXX CONDOMS 3 KIMONO MICROTHIN AQUA LUBE CON 3 KIMONO MICROTHIN CONDOMS 3 KIMONO MICROTHIN LARGE CONDOMS 3 KIMONO TEXTURED CONDOMS 3 TRUSTEX LATEX CONDOM 3 TRUSTEX LUBRICATED CONDOMS $0 TRUSTEX NON-LUB CONDOMS 3 TRUSTEX-RIA LUB/SPERMICIDE $0 TRUSTEX-RIA LUBRICATED CONDOMS $0 TRUSTEX-RIA NON-LUB CONDOMS 3 Medical Supplies And Dme - Miscellaneous Other OMNIPOD DASH 5 PACK POD 3 OMNIPOD INSULIN REFILL 3 T:FLEX 3 T:SLIM 3 T:SLIM G4 3 Medical Supplies And Dme - Respiratory Therapy Supplies PROVENT 3 PROVENT STARTER 3
Last Approved Date: 09/23/2021 Formulary Version: 91
235 Drug Status Notes Medical Supplies And Dme - Scar Treatments CELACYN 1 SP SCAR MANAGEMENT 1 Medical Supplies And Dme - Subcutaneous Administration Supply ACCU-CHEK TENDER 3 ACCU-CHEK ULTRAFLEX 3 DELTEC COZMO CLEO INFUSION SET 3 NERIA MULTI (BI-FURCATED) 3 NERIA MULTI (TRI-FURCATED) 3 NERIA SUBCUTANEOUS INFUSION SET 10 3 X 110 MM-CM Medical Supplies And Dme - Subcutaneous Insulin Delivery Devices CEQUR SIMPLICITY 2 QL (10 patches per 25 Dayss) V-GO 20 2 QL (30 devices per 30 days) V-GO 30 2 QL (30 devices per 30 days) V-GO 40 2 QL (30 devices per 30 days) Medical Supplies And Dme-Eustachian Tube/Middle Ear Ventilator Devices EAR POPPER INFLATION DEVICE 3 Medical Supply, Fdb Superset Medical Supply, Fdb Superset ACCU-CHEK GUIDE TEST STRIPS 3 PA; QL (7 test strips per 1 Day) ACCU-CHEK TENDER 3 ACCU-CHEK ULTRAFLEX 3 AIMSCO LATEX CONDOM 3 CAYA CONTOURED 3 CEQUR SIMPLICITY 2 QL (10 patches per 25 Dayss) CONDOMS-PREM LUBRICATED 3 DELTEC COZMO CLEO INFUSION SET 3 DEXCOM G4 RECEIVER 2 QL (1 pack per 365 Dayss) DEXCOM G4 TRANSMITTER 2 QL (1 pack per 90 Dayss) DEXCOM G5 RECEIVER 2 QL (1 pack per 365 Dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
236 Drug Status Notes DEXCOM G5 TRANSMITTER 2 QL (1 pack per 90 Dayss) QL (4 units (1 box) per 25 day DEXCOM G5-G4 SENSOR 2 rolling periods) DEXCOM G6 RECEIVER 2 QL (1 pack per 365 Dayss) QL (4 units (1 box) per 25 day DEXCOM G6 SENSOR 2 rolling periods) DEXCOM G6 TRANSMITTER 2 QL (1 pack per 90 Dayss) DEXCOM RECEIVER 2 QL (1 pack per 365 Dayss) DUREX AVANTI BARE REAL FEEL 3 EAR POPPER INFLATION DEVICE 3 EASY TOUCH BLU LINK TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) EASY TRAK II TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) EVENCARE PROVIEW TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) EVERSENSE SENSOR-HOLDER 3 FANTASY CONDOM 3 FC2 FEMALE CONDOM 3 FEMCAP 3 FORA 6 CONNECT GLUCOSE STRIP 3 PA; ST; QL (7 strips per 1 Day) FORA GTEL GLUCOSE TEST STRIP 3 PA; ST; QL (7 strips per 1 day) FORTISCARE G1 TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) FREESTYLE LIBRE 10 DAY READER 2 QL (1 pack per 365 Dayss) FREESTYLE LIBRE 10 DAY SENSOR 2 QL (3 packs per 30 Dayss) FREESTYLE LIBRE 14 DAY READER 2 QL (1 pack per 365 Dayss) FREESTYLE LIBRE 14 DAY SENSOR 2 QL (2 packs per 28 Dayss) FREESTYLE LIBRE 2 READER 2 QL (1 pack per 365 days) FREESTYLE LIBRE 2 SENSOR 2 QL (2 kits per 21 days) GOJJI BLOOD GLUCOSE TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) HARMONY GLUCOSE TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) HUMAPEN LUXURA HD 2 INPEN (FOR HUMALOG) 3 INPEN (FOR NOVOLOG OR FIASP) 3 KIMONO CONDOMS(NON-LUBRICATED) 3 KIMONO MAXX CONDOMS 3 KIMONO MICROTHIN AQUA LUBE CON 3 KIMONO MICROTHIN CONDOMS 3
Last Approved Date: 09/23/2021 Formulary Version: 91
237 Drug Status Notes KIMONO MICROTHIN LARGE CONDOMS 3 KIMONO TEXTURED CONDOMS 3 MICRODOT XTRA BLOOD GLUCOSE 3 PA; ST; QL (7 strips per 1 Day) NERIA MULTI (BI-FURCATED) 3 NERIA MULTI (TRI-FURCATED) 3 NERIA SUBCUTANEOUS INFUSION SET 10 3 X 110 MM-CM NOVOFINE PLUS 2 NOVOPEN ECHO 3 NOVOTWIST 3 OMNIPOD DASH 5 PACK POD 3 OMNIPOD DASH PDM KIT 2 QL (10 pods per 30 days) OMNIPOD INSULIN REFILL 3 ONETOUCH VERIO TEST STRIPS 2 QL (7 test strips per 1 day) ORTHO ALL-FLEX FITTING SET $0 ORTHO DIAPHRAGM ALL-FLEX 65 $0 ORTHO DIAPHRAGM ALL-FLEX 70 $0 ORTHO DIAPHRAGM ALL-FLEX 75 $0 ORTHO DIAPHRAGM ALL-FLEX 80 $0 PROVENT 3 PROVENT STARTER 3 T:FLEX 3 T:SLIM 3 T:SLIM G4 3 TRUSTEX LATEX CONDOM 3 TRUSTEX LUBRICATED CONDOMS $0 TRUSTEX NON-LUB CONDOMS 3 TRUSTEX-RIA LUB/SPERMICIDE $0 TRUSTEX-RIA LUBRICATED CONDOMS $0 TRUSTEX-RIA NON-LUB CONDOMS 3 V-GO 20 2 QL (30 devices per 30 days) V-GO 30 2 QL (30 devices per 30 days) V-GO 40 2 QL (30 devices per 30 days) VIVAGUARD INO TEST STRIP 3 PA; ST; QL (7 strips per 1 Day) WIDE-SEAL DIAPHRAGM 60 3
Last Approved Date: 09/23/2021 Formulary Version: 91
238 Drug Status Notes WIDE-SEAL DIAPHRAGM 65 3 WIDE-SEAL DIAPHRAGM 70 3 WIDE-SEAL DIAPHRAGM 75 3 WIDE-SEAL DIAPHRAGM 80 3 WIDE-SEAL DIAPHRAGM 85 3 WIDE-SEAL DIAPHRAGM 90 3 WIDE-SEAL DIAPHRAGM 95 3 Metabolic Disease Enzyme Replacement Agents Metabolic Disease Enzyme Replacement, Gaucher's Disease VPRIV 3 Metabolic Disease Enzyme Replacement, Hypophosphatasia STRENSIQ SUBCUTANEOUS SOLUTION 18 3 MG/0.45 ML, 28 MG/0.7 ML STRENSIQ SUBCUTANEOUS SOLUTION 40 3 PA; SPT MG/ML, 80 MG/0.8 ML Metabolic Dx Enzyme Replacement, Severe Combined Immune Deficiency ADAGEN 3 Metabolic Modifiers Hyperparathyroid Treatment Agents - Vitamin D Analog-Type calcitriol oral 1 HECTOROL INTRAVENOUS SOLUTION 4 3 MCG/2 ML HECTOROL ORAL 3 paricalcitol oral 1 RAYALDEE 3 PA; QL (1 Tablet per 1 Day) ROCALTROL 3 ZEMPLAR INTRAVENOUS 3 ZEMPLAR ORAL CAPSULE 1 MCG, 2 MCG 3 Metabolic Modifier - Carnitine Replenisher Agents CARNITOR (SUGAR-FREE) 3 Last Approved Date: 09/23/2021 Formulary Version: 91
239 Drug Status Notes CARNITOR ORAL 3 levocarnitine (with sugar) 1 levocarnitine oral solution 100 mg/ml 3 levocarnitine oral tablet 1 Metabolic Modifier - Gaucher's Disease, Type-1, Substrate Reduction Tx PA; $3-Copay; SPT; QL (1 tablet CERDELGA 4 per 1 day) PA; SPT; QL (3 capsules per 1 miglustat 3 day) PA; ST; BE; SPT; QL (3 capsules ZAVESCA 4 per 1 day) Metabolic Modifier - Hereditary Orotic Aciduria Treatment Agents XURIDEN 4 PA; BE; SPT Metabolic Modifier - Hereditary Tyrosinemia Treatment Agents nitisinone 4 PA; ST; BE; SPT NITYR 3 PA; ST; SP; BE; SPT ORFADIN ORAL CAPSULE 4 PA; ST; BE ORFADIN ORAL SUSPENSION 3 PA; ST; BE; SPT Metabolic Modifier - Homocystinuria Treatment Agents CYSTADANE 3 Metabolic Modifier - Urea Cycle Disorder Agents-Conjugating Agents BUPHENYL ORAL POWDER 4 BUPHENYL ORAL TABLET 4 PA; BE; SPT RAVICTI 1 PA; BE; SPT sodium phenylbutyrate oral powder 3 PA; SP; SPT sodium phenylbutyrate oral tablet 3 PA; SP; BE; SPT Metabolic Modifier-Carbamoyl Phosphate Synthetase 1 (Cps 1) Activator CARBAGLU 4 PA; $3-Copay; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
240 Drug Status Notes Pharmacoenhancer - Cytochrome P450 Inhibitors TYBOST 2 QL (1 TABLET per 1 day) Pharmacological Chaperone Tx - Alpha-Galactosidase A Enzyme Stabilizer PA; $3-Copay; SPT; QL (14 GALAFOLD 3 capsules per 28 Dayss) Phenylketonuria(Pku) Tx Agents - Cofactor Of Phenylalanine Hydroxylase KUVAN 4 PA; SP; BE; SPT PA; BE; SPT; QL (90 day supply sapropterin 3 per 720 Dayss) Phenylketonuria(Pku) Tx Agents - Phenylalanine Ammonia Lyase PALYNZIQ 4 PA; ST; BE; SPT Progeria Syndrome Treatment Agents - Farnyltransferase Inhibitor PA; BE; SPT; QL (2 capsules per ZOKINVY 4 1 day) Mouth-Throat-Dental - Preparations Dental Product - Fluoride Preparations CLINPRO 5000 3 DENTA 5000 PLUS 1 DENTAGEL 1 FLORIVA (FLUORIDE-VITAMIN D3) 3 FLUORABON 2 BE FLUOR-A-DAY $0 BE FLUOR-A-DAY (WITH XYLITOL) 1 BE fluoride (sodium) dental 1 fluoride (sodium) oral drops 1 fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium 1 BE fluorid) fluoride (sodium) oral tablet,chewable 1 mg (2.2 $0 BE mg sod. fluoride)
Last Approved Date: 09/23/2021 Formulary Version: 91
241 Drug Status Notes FLUORIDEX DAILY DEFENSE DENTAL GEL 1 FLUORIDEX DAILY DEFENSE DENTAL 3 PASTE FLUORIDEX SENSITIVITY RELIEF 3 FLUORITAB ORAL DROPS $0 FLUORITAB ORAL TABLET,CHEWABLE 0.5 1 BE MG (1.1 MG SODIUM FLUORID) FLUORITAB ORAL TABLET,CHEWABLE 1 $0 BE MG (2.2 MG SOD. FLUORIDE) FLURA-DROPS $0 BE LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. 1 BE FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID) LUDENT FLUORIDE ORAL TABLET,CHEWABLE 1 MG (2.2 MG SOD. $0 BE FLUORIDE) PREVIDENT 3 PREVIDENT 5000 BOOSTER 3 PREVIDENT 5000 BOOSTER PLUS 3 PREVIDENT 5000 DRY MOUTH 3 PREVIDENT 5000 ENAMEL PROTECT 3 PREVIDENT 5000 ORTHO DEFENSE 3 PREVIDENT 5000 PLUS 3 PREVIDENT 5000 SENSITIVE 3 SF 1 SF 5000 PLUS 1 SODIUM FLUORIDE 5000 DRY MOUTH 1 SODIUM FLUORIDE 5000 PLUS 1 sodium fluoride-pot nitrate 1 Mouth And Throat - Antifungals clotrimazole mucous membrane 1 nystatin oral suspension 1 $3-Copay Mouth And Throat - Anti-Infective Mixtures DEBACTEROL 3
Last Approved Date: 09/23/2021 Formulary Version: 91
242 Drug Status Notes Mouth And Throat - Antiseptics chlorhexidine gluconate (bulk) 3 chlorhexidine gluconate mucous membrane 1 PAROEX ORAL RINSE 1 PERIDEX 3 PERIOGARD 1 Mouth And Throat - Artificial Saliva AQUORAL 3 PA; ST CAPHOSOL 3 PA; ST NEUTRASAL 3 PA; ST NUMOISYN 3 SALIVAMAX 3 PA SALIVATERX 3 PA XEROSTOMIA RELIEF 3 PA Mouth And Throat - Glucocorticoids ORALONE 1 triamcinolone acetonide dental 1 Mouth And Throat - Local Anesthetic Amides DYNAMIC 1 DYNAMIC PLUS PAK 1 lidocaine hcl mucous membrane jelly 1 lidocaine hcl mucous membrane solution 4 % (40 1 mg/ml) LIDOCAINE VISCOUS 1 PRO DNA COLLECTION 1 Mouth And Throat - Mucositis- Stomatitis Agents EPISIL 3 GELCLAIR 3 PA; ST GELX 3 PA MUGARD 3 PA; ST ORAMAGICRX 3 Mouth And Throat - Protectants GELX 3 PA Last Approved Date: 09/23/2021 Formulary Version: 91
243 Drug Status Notes MUGARD 3 PA; ST Mouth And Throat - Saliva Stimulants PA; ST; QL (3 CAPSULES per 1 cevimeline 1 day) PA; ST; QL (3 CAPSULES per 1 EVOXAC 3 day) pilocarpine hcl oral 1 SALAGEN (PILOCARPINE) 3 Periodontal Product - Tetracycline- Type, Collagenase Inhibitors doxycycline hyclate oral tablet 20 mg 1 Therapy For Drooling- Primary Or Secondary Sialorrhea-Anticholinergic CUVPOSA 3 PA Multiple Sclerosis Agents Multiple Sclerosis Agent - Cd20 Specific Monoclonal Antibody PA; BE; SPT; QL (1 pen per 28 KESIMPTA PEN 4 days) Multiple Sclerosis Agent - Interferons AVONEX (WITH ALBUMIN) 3 SP; SPT AVONEX INTRAMUSCULAR PEN 3 SP; BE; SPT INJECTOR KIT AVONEX INTRAMUSCULAR SYRINGE 3 SP; BE AVONEX INTRAMUSCULAR SYRINGE KIT 3 SP; BE; SPT BETASERON SUBCUTANEOUS KIT 3 ST; SP; BE; SPT EXTAVIA 4 PA; ST; SP; BE; SPT PLEGRIDY SUBCUTANEOUS PEN 3 SP; BE; SPT INJECTOR PLEGRIDY SUBCUTANEOUS SYRINGE 125 3 SP; BE; SPT MCG/0.5 ML PLEGRIDY SUBCUTANEOUS SYRINGE 63 3 SP; SPT MCG/0.5 ML- 94 MCG/0.5 ML REBIF (WITH ALBUMIN) 3 SP; BE; SPT REBIF REBIDOSE 3 SP; BE; SPT REBIF TITRATION PACK 3 SP; BE; SPT
Last Approved Date: 09/23/2021 Formulary Version: 91
244 Drug Status Notes Multiple Sclerosis Agent - Others PA; BE; SPT; QL (4 capsules per BAFIERTAM 4 1 Day) COPAXONE SUBCUTANEOUS SYRINGE 20 SP; BE; SPT; QL (28 syringes per 3 MG/ML 21 days) COPAXONE SUBCUTANEOUS SYRINGE 40 SP; BE; SPT; QL (12 syringes per 3 MG/ML 21 days) dimethyl fumarate oral capsule,delayed PA; BE; SPT; QL (2 capsules per 3 release(dr/ec) 120 mg, 240 mg 1 Day) BE; SPT; QL (28 syringes per 21 glatiramer subcutaneous syringe 20 mg/ml 3 days) BE; SPT; QL (12 syringes per 21 glatiramer subcutaneous syringe 40 mg/ml 3 days) GLATOPA SUBCUTANEOUS SYRINGE 20 SP; BE; SPT; QL (28 syringes per 3 MG/ML 21 days) GLATOPA SUBCUTANEOUS SYRINGE 40 3 SPT; QL (12 syringes per 21 days) MG/ML PA; SP; BE; SPT; QL (68 TECFIDERA 4 CAPSULES per 1 MONTH) PA; BE; SPT; QL (4 capsules per VUMERITY 4 1 day) Multiple Sclerosis Agent - Potassium Channel Blocker PA; SP; BE; SPT; QL (20 MG per AMPYRA 4 1 day) dalfampridine 3 PA; $3-Copay; SPT; QL (8 tablets FIRDAPSE 4 per 1 Day) PA; BE; SPT; QL (10 tablets per 1 RUZURGI 1 day) Multiple Sclerosis Agent - Purine Nucleoside Analogs PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (10 TABLET PACK) 4 per 1 year) PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (4 TABLET PACK) 4 per 1 year) PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (5 TABLET PACK) 4 per 1 year)
Last Approved Date: 09/23/2021 Formulary Version: 91
245 Drug Status Notes PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (6 TABLET PACK) 4 per 1 year) PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (7 TABLET PACK) 4 per 1 year) PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (8 TABLET PACK) 4 per 1 year) PA; ST; BE; SPT; QL (20 tablets MAVENCLAD (9 TABLET PACK) 4 per 1 year) Multiple Sclerosis Agent - Pyrimidine Synthesis Inhibitors PA; BE; SPT; QL (476 MG per 1 AUBAGIO 4 MONTH) Multiple Sclerosis Agent - Sphingosine 1-Phosphate Receptor Modulator PA; SP; $3-Copay; SPT; QL (34 GILENYA ORAL CAPSULE 0.5 MG 3 CAPSULES per 1 MONTH) PA; BE; SPT; QL (4 tablets per 1 MAYZENT ORAL TABLET 0.25 MG 3 day) PA; BE; SPT; QL (1 tablet per 1 MAYZENT ORAL TABLET 2 MG 3 day) PA; BE; SPT; QL (1 starter pack MAYZENT STARTER PACK 3 per 720 days) PA; ST; BE; SPT; QL (1 tablet per PONVORY 4 1 day) PA; ST; BE; SPT; QL (2 starter PONVORY 14-DAY STARTER PACK 4 packs per 1 Year) ZEPOSIA 4 BE; SPT; QL (1 capsule per 1 day) PA; SPT; QL (1 pack (37 capsules) ZEPOSIA STARTER KIT 4 per 365 days) PA; SPT; QL (1 pack (7 capsules) ZEPOSIA STARTER PACK 4 per 365 days) Multiple Sclerosis Agent-Interleukin-2 Receptor Modulator, Mc Antibody PA; SP; SPT; QL (1 Syringe per ZINBRYTA 4 30 Days)
Last Approved Date: 09/23/2021 Formulary Version: 91
246 Drug Status Notes Ophthalmic Agents Artificial Tears And Lubricant Combinations FRESHKOTE OPHTHALMIC (EYE) DROPS 2- 3 0.9-1.8 % Artificial Tears And Lubricant Single Agents LACRISERT 3 Miotics - Cholinesterase Inhibitors PHOSPHOLINE IODIDE 3 Miotics - Direct Acting ISOPTO CARPINE 3 MIOCHOL-E 3 MIOSTAT 1 pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 1 4 % Mydriatic And Cycloplegic Combinations CYCLOMYDRIL 3 cyclopen-tropic-phenyleph-watr 3 cyclop-trop-propa-phen-ket-wat 3 lidocaine-phenylephrn in water 1 MYDRIATIC3 (TROP-CYCLOPENT-PE) 1 PAREMYD 3 phenyleph-tropicamide in water 3 Ophth - Beta Blocker-Adrenerg- Carbonic Anhyd Inhib-Prostagladin Analog timol-brimon-dorzo-latanop(pf) 3 Ophthalmic - Adrenergic Receptor Agonist UPNEEQ (PF) 3 Ophthalmic - Adrenergic-Carbonic Anhydrase Inhibitor Combinations brimonidine-dorzolamide (pf) 3
Last Approved Date: 09/23/2021 Formulary Version: 91
247 Drug Status Notes SIMBRINZA 3 Ophthalmic - Antibacterial- Glucocorticoid Combinations BLEPHAMIDE 3 BLEPHAMIDE S.O.P. 3 gatifloxacin-dexamethasone 3 MAXITROL 3 neomycin-bacitracin-poly-hc 1 neomycin-polymyxin b-dexameth 1 neomycin-polymyxin-hc ophthalmic (eye) 1 NEO-POLYCIN HC 1 PRED-G 3 PRED-G S.O.P. 3 prednisolone acet-gatifloxacin 3 prednisolone sod ph-gatifloxac 3 prednisolone sod ph-moxiflox 3 prednisolone-moxifloxacin hcl 3 sulfacetamide-prednisolone 1 TOBRADEX 3 TOBRADEX ST 3 tobramycin-dexamethasone 1 ZYLET 3 Ophthalmic - Antibacterial- Glucocorticoid-Nsaid Combinations prednisol ace-gatiflox-bromfen 3 prednisoln sp-gatiflox-bromfen 3 prednisoln sp-moxiflox-bromfen 3 prednisolone-moxiflo-nepafenac 3 prednisolone-moxiflox-bromfen 3 Ophthalmic - Anticholinergics atropine ophthalmic (eye) drops 1 atropine ophthalmic (eye) drops, emulsion 3 atropine ophthalmic (eye) ointment 1 atropine sulfate (pf) 1 CYCLOGYL 3 Last Approved Date: 09/23/2021 Formulary Version: 91
248 Drug Status Notes cyclopentolate 1 HOMATROPAIRE 1 homatropine hbr 1 ISOPTO ATROPINE 3 MYDRIACYL 3 tropicamide 1 Ophthalmic - Antihistamines azelastine ophthalmic (eye) 1 bepotastine besilate 3 BEPREVE 3 ELESTAT 3 EMADINE 3 epinastine 1 ketotifen fumarate 3 LASTACAFT 3 olopatadine ophthalmic (eye) 1 PATADAY 3 PATADAY ONCE DAILY RELIEF 3 OPHTHALMIC (EYE) DROPS 0.2 % PATANOL 3 PAZEO 3 ZERVIATE 3 PA; ST Ophthalmic - Anti-Inflammatory, Glucocorticoids ALREX 3 dexamethasone sodium phosphate ophthalmic 1 (eye) DUREZOL 3 PA; ST; QL (1 bottle per 1 EYSUVIS 3 dispensing event) FLAREX 3 fluorometholone 1 FML FORTE 2 FML LIQUIFILM 3 FML S.O.P. 2 INVELTYS 3 Last Approved Date: 09/23/2021 Formulary Version: 91
249 Drug Status Notes LOTEMAX 3 QL (1 bottle (10ml) per 1 LOTEMAX SM 3 dispense) loteprednol etabonate ophthalmic (eye) drops,gel 3 loteprednol etabonate ophthalmic (eye) 1 drops,suspension MAXIDEX 3 OMNIPRED 3 OZURDEX 3 PRED FORTE 3 PRED MILD 2 prednisolone acetate 1 prednisolone acetate (pf) 3 prednisolone sodium phosphate ophthalmic (eye) 1 TRIESENCE (PF) 3 VEXOL 3 Ophthalmic - Anti-Inflammatory, Immunomodulators PA; ST; QL (60 vials per 25 CEQUA 3 Dayss) CYCLOSPORINE IN KLARITY 3 RESTASIS 2 RESTASIS MULTIDOSE 3 Ophthalmic - Anti-Inflammatory, Lfa-1 Antagonists XIIDRA 3 PA; ST; QL (60 units per 30 days) Ophthalmic - Anti-Inflammatory, Nsaids ACULAR 3 ACULAR LS 3 ACUVAIL (PF) 3 bromfenac 1 BROMSITE 3 QL (1 Bottle(5ml) per 34 days) diclofenac sodium ophthalmic (eye) 1 flurbiprofen sodium 1 ILEVRO 3 Last Approved Date: 09/23/2021 Formulary Version: 91
250 Drug Status Notes ketorolac ophthalmic (eye) 1 NEVANAC 3 OCUFEN 3 PROLENSA 3 Ophthalmic - Beta Blocker-Adrenergic- Carbonic Anhydrase Inhibitor Comb timolol-brimonidi-dorzolam(pf) 3 Ophthalmic - Beta Blocker-Carbonic Anhydrase Inhib-Prostagladin Analog timolol-dorzolamid-latanop(pf) 3 Ophthalmic - Beta Blockers-Adrenergic Combinations COMBIGAN 3 Ophthalmic - Beta Blockers-Carbonic Anhydrase Inhibitor Combinations COSOPT 3 COSOPT (PF) 3 dorzolamide-timolol 1 dorzolamide-timolol (pf) 3 Ophthalmic - Beta Blockers- Prostaglandin Analog Combinations timolol-latanoprost(pf) 3 Ophthalmic - Carbonic Anhydrase Inhibitors AZOPT 3 brinzolamide 3 dorzolamide 1 dorzolamide (pf) 3 TRUSOPT 3 Ophthalmic - Cystine Depleting Agents PA; $3-Copay; SPT; QL (20 ML CYSTADROPS 3 (vials) per 28 days) SP; SPT; QL (60 ML (4 bottles) CYSTARAN 3 per 28 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
251 Drug Status Notes Ophthalmic - Decongestants phenylephrine hcl ophthalmic (eye) 1 Ophthalmic - Diagnostic Agents ALTAFLUOR 1 ALTAFLUOR BENOX 3 BIOGLO 1 FLUCAINE 1 fluorescein-benoxinate 1 fluorescein-proparacaine 1 FLUROX 1 FUL-GLO OPHTHALMIC (EYE) STRIP 0.6 3 MG FUL-GLO OPHTHALMIC (EYE) STRIP 1 MG 1 GLOSTRIPS OPHTHALMIC (EYE) STRIP 1 1 MG GREEN GLO 1 Ophthalmic - Glucocorticoid-Nsaid Combinations prednisolone acetate-bromfenac 3 prednisolone acetate-nepafenac 3 prednisolone sod ph-bromfenac 3 Ophthalmic - Human Nerve Growth Factor (Hngf) PA; ST; BE; SPT; QL (8 cartons OXERVATE 4 (56 vials) per 8 weekss) Ophthalmic - Intraocular Pressure Reducing Agents, Beta-Blockers BETAGAN OPHTHALMIC (EYE) DROPS 0.5 3 % betaxolol ophthalmic (eye) 1 BETIMOL 3 BETOPTIC S 3 carteolol 1 ISTALOL 3 levobunolol ophthalmic (eye) drops 0.5 % 1 metipranolol 1 Last Approved Date: 09/23/2021 Formulary Version: 91
252 Drug Status Notes timolol maleate (pf) 3 timolol maleate ophthalmic (eye) 1 TIMOPTIC 3 TIMOPTIC OCUDOSE (PF) 3 TIMOPTIC-XE 3 Ophthalmic - Irrigation Solutions BALANCED SALT 1 BSS 1 Ophthalmic - Local Anesthetic Combinations ALTAFLUOR 1 ALTAFLUOR BENOX 3 fluorescein-benoxinate 1 FLUROX 1 Ophthalmic - Local Anesthetic Esters ALCAINE 3 ALTACAINE 1 proparacaine 1 TETCAINE 1 tetracaine hcl 1 tetracaine hcl (pf) ophthalmic (eye) 3 TETRAVISC 3 TETRAVISC FORTE 3 Ophthalmic - Local Anesthetic, Amides AKTEN (PF) 3 Ophthalmic - Macular Degeneration, Age-Related, Therapy Agents EYLEA INTRAVITREAL SYRINGE 3 Ophthalmic - Mast Cell Stabilizers ALOCRIL 3 ALOMIDE 3 cromolyn ophthalmic (eye) 1
Last Approved Date: 09/23/2021 Formulary Version: 91
253 Drug Status Notes Ophthalmic - Mydriatic-Nsaid Combinations MYDRIATIC4(TROP-PROP-PE-KTRLC) 3 tropic-proparacai-pe-ketor-wat 3 Ophthalmic - Rho Kinase Inhibitor And Prostaglandin Analog Combination PA; ST; QL (1 bottle (2.5ml) per 1 ROCKLATAN 3 dispense) Ophthalmic - Surgical Aids Other CELLUGEL 3 GELFILM OPHTHALMIC (EYE) 3 MEMBRANEBLUE 3 OCUCOAT 1 VISIONBLUE 3 Ophthalmic - Viscoelastic Agents BIOLON 1 DISCOVISC 3 DUOVISC VISCO ELASTIC 3 VISCOAT 3 Ophthalmic Antibacterial Mixtures AK-POLY-BAC 1 bacitracin-polymyxin b ophthalmic (eye) 1 neomycin-bacitracin-polymyxin 1 neomycin-polymyxin-gramicidin 1 NEO-POLYCIN 1 NEOSPORIN (NEO-POLYM-GRAMICID) 3 POLYCIN 1 polymyxin b sulf-trimethoprim 1 POLYTRIM 3 Ophthalmic Antibiotic - Aminoglycosides GENTAK OPHTHALMIC (EYE) OINTMENT 1 gentamicin ophthalmic (eye) drops 1 $3-Copay gentamicin ophthalmic (eye) ointment 1 tobramycin ophthalmic (eye) 1 Last Approved Date: 09/23/2021 Formulary Version: 91
254 Drug Status Notes TOBREX 3 Ophthalmic Antibiotic - Cephalosporins cefuroxime (pf) in 0.9% nacl 3 Ophthalmic Antibiotic - Dehydropeptidase Inhibitors bacitracin ophthalmic (eye) 1 Ophthalmic Antibiotic - Fluoroquinolones BESIVANCE 3 CILOXAN 3 ciprofloxacin hcl ophthalmic (eye) 1 $3-Copay gatifloxacin 1 levofloxacin ophthalmic (eye) 1 MOXEZA 3 moxifloxacin ophthalmic (eye) 3 OCUFLOX 3 ofloxacin ophthalmic (eye) 1 VIGAMOX 3 ZYMAXID 3 Ophthalmic Antibiotic - Macrolides AZASITE 3 erythromycin ophthalmic (eye) 1 Ophthalmic Antibiotic - Sulfonamides BLEPH-10 3 sulfacetamide sodium ophthalmic (eye) drops 1 sulfacetamide sodium ophthalmic (eye) ointment 3 Ophthalmic Antifungals NATACYN 3 Ophthalmic Antifungals - Tetraene Polyene-Type NATACYN 3 Ophthalmic Antiseptics BETADINE OPHTHALMIC PREP 3
Last Approved Date: 09/23/2021 Formulary Version: 91
255 Drug Status Notes Ophthalmic Antivirals trifluridine 1 VIROPTIC 3 ZIRGAN 3 Ophthalmic-Intraocular Press. Reducing, Sel. Alpha Adrenergic Agonists ALPHAGAN P 3 apraclonidine 1 brimonidine 1 IOPIDINE 3 Ophthalmic-Intraocular Pressure Reducing Agents, Prostaglandin Analogs bimatoprost ophthalmic (eye) 1 latanoprost 1 latanoprost (pf) 3 LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 2 QL (1 BOTTLE per 1 MONTH) % TRAVATAN Z 3 PA; ST travoprost 3 travoprost (benzalkonium) 1 VYZULTA 3 PA; QL (5 ml per 30 DAYSs) XALATAN 3 PA; ST PA; ST; QL (2.5 ml (1 bottle) per XELPROS 3 30 days) ZIOPTAN (PF) 3 Ophthalmic-Intraocular Pressure Reducing Agents, Rho Kinase Inhibitors RHOPRESSA 3 PA; ST; QL (5 ML per 1 dispense) Vascular Endothelial Growth Factor(Vegf-A And Plgf)Receptor Inhibitors EYLEA INTRAVITREAL SYRINGE 3
Last Approved Date: 09/23/2021 Formulary Version: 91
256 Drug Status Notes Organ Preservation Solutions Cardioplegic Solutions CARDIOPLEGIA DEL NIDO FORMULA 3 CARDIOPLEGIA HIGH POTASSIUM 3 CARDIOPLEGIA IND 4:1 PLASMALYT 3 CARDIOPLEGIA IND 8:1 NON-ENRCH 3 CARDIOPLEGIA INDUCTION 4:1 3 CARDIOPLEGIA INDUCTION 8:1 3 CARDIOPLEGIA MAINTENANCE 4:1 3 CARDIOPLEGIA MAINTENANCE 8:1 3 Otic (Ear) Otic (Ear) - Anti-Infective Mixtures acetic acid-aluminum acetate 1 Otic (Ear) - Anti-Infective- Glucocorticoid Combinations CIPRO HC 3 CIPRODEX 3 ciprofloxacin-dexamethasone 3 QL (28 vials (2 cartons) per 135 ciprofloxacin-fluocinolone 3 Dayss) COLY-MYCIN S 3 CORTISPORIN OTIC (EAR) 3 DROPS,SUSPENSION CORTISPORIN-TC 3 neomycin-polymyxin-hc otic (ear) 1 OTOVEL 3 QL (2 Cartons per 180 Days) Otic (Ear) - Anti-Infectives Other acetic acid otic (ear) 3 Otic (Ear) - Fluoroquinolones CETRAXAL 3 ciprofloxacin hcl otic (ear) 1 FLOXIN OTIC (EAR) 1 ofloxacin otic (ear) 1 Otic (Ear) - Glucocorticoids ACETASOL HC 1 Last Approved Date: 09/23/2021 Formulary Version: 91
257 Drug Status Notes DERMOTIC OIL 3 FLAC OTIC OIL 1 fluocinolone acetonide oil 1 hydrocortisone-acetic acid 1 Otic (Ear) - Local Anesthetic-Analgesic Combinations TREAGAN OTIC 1 Otic (Ear) - Pinna Combinations CORTANE-B 3 Renal Replacement Therapy Hemodialysis And Hemofiltrate Solutions PRISMASOL BGK HEMODIALYSIS SOLUTION CA (2.5 MEQ/L) -MG (1.5 MEQ/L), K (2 MEQ/L) -CA (3.5)-MG(1), K (2 MEQ/L) - 3 MG (1 MEQ/L), K (4 MEQ/L)-CA (2.5)-MG (1.5) Respiratory Therapy Agents 1St Generation Antihistamine- Decongestant Combinations chlorpheniramine-pseudoephed NL ED A-HIST ORAL LIQUID 3 J-TAN D PD 3 LOHIST - D 3 PROMETHAZINE VC 1 promethazine-phenylephrine 1 R-TANNA 1 1St Generation Antihistamine- Decongestant-Anticholinergic Combinations PCM LA 3 RESPA-AR 3 2Nd Generation Antihistamine- Decongestant Combinations ALLEGRA-D 12 HOUR 3 ALLEGRA-D 24 HOUR 3 Last Approved Date: 09/23/2021 Formulary Version: 91
258 Drug Status Notes CLARINEX-D 12 HOUR 3 fexofenadine-pseudoephedrine 3 SEMPREX-D 3 ZYRTEC-D 3 Antihistamine - 1St Generation - Alkylamines dexchlorpheniramine maleate 1 Antihistamine - 1St Generation - Ethanolamines ALLERGY RELIEF(DIPHENHYDRAMIN) 3 ORAL LIQUID ARBINOXA 1 carbinoxamine maleate oral liquid 1 carbinoxamine maleate oral tablet 4 mg 1 carbinoxamine maleate oral tablet 6 mg 3 PA; ST; QL (4 tablets per 1 day) clemastine oral syrup 3 clemastine oral tablet 1 DIPHEN ORAL ELIXIR 3 diphenhydramine hcl injection solution 50 mg/ml 1 diphenhydramine hcl injection syringe 1 diphenhydramine hcl oral capsule 25 mg 3 diphenhydramine hcl oral capsule 50 mg 1 diphenhydramine hcl oral elixir 3 KARBINAL ER 3 RYVENT 3 PA; ST; QL (4 tablets per 1 day) Antihistamine - 1St Generation - Phenothiazines PHENADOZ 1 PHENERGAN RECTAL 1 promethazine oral syrup 1 promethazine oral tablet 12.5 mg, 25 mg 1 $3-Copay promethazine oral tablet 50 mg 1 promethazine rectal 1 PROMETHEGAN 1
Last Approved Date: 09/23/2021 Formulary Version: 91
259 Drug Status Notes Antihistamine - 1St Generation - Piperidines cyproheptadine 2 mg/5 ml soln 1 cyproheptadine 2 mg/5 ml syrup 1 cyproheptadine 4 mg/10 ml syrp 3 cyproheptadine oral syrup 2 mg/5 ml 3 cyproheptadine oral tablet 1 Antihistamines - 1St Generation ALLERGY RELIEF(DIPHENHYDRAMIN) 3 ORAL LIQUID ARBINOXA 1 carbinoxamine maleate oral liquid 1 carbinoxamine maleate oral tablet 4 mg 1 carbinoxamine maleate oral tablet 6 mg 3 PA; ST; QL (4 tablets per 1 day) clemastine oral syrup 3 clemastine oral tablet 1 cyproheptadine 2 mg/5 ml soln 1 cyproheptadine 2 mg/5 ml syrup 1 cyproheptadine 4 mg/10 ml syrp 3 cyproheptadine oral syrup 2 mg/5 ml 3 cyproheptadine oral tablet 1 dexchlorpheniramine maleate oral solution 1 DIPHEN ORAL ELIXIR 3 diphenhydramine hcl injection solution 50 mg/ml 1 diphenhydramine hcl injection syringe 1 diphenhydramine hcl oral capsule 25 mg 3 diphenhydramine hcl oral capsule 50 mg 1 diphenhydramine hcl oral elixir 3 KARBINAL ER 3 PHENADOZ 1 PHENERGAN RECTAL 1 promethazine oral 1 promethazine rectal 1 PROMETHEGAN 1 RYVENT 3 PA; ST; QL (4 tablets per 1 day)
Last Approved Date: 09/23/2021 Formulary Version: 91
260 Drug Status Notes Antihistamines - 2Nd Generation ALLEGRA 3 ALLEGRA ODT 3 cetirizine oral solution 1 mg/ml 3 CLARINEX ORAL SYRUP 3 CLARINEX ORAL TABLET 3 fexofenadine oral tablet 3 levocetirizine oral solution 3 levocetirizine oral tablet 1 XYZAL 3 ZYRTEC ORAL TABLET 3 Antihistamines - 2Nd Generation - Piperazines cetirizine oral solution 1 mg/ml 3 levocetirizine oral solution 3 levocetirizine oral tablet 1 Antihistamines - 2Nd Generation - Piperidines ALLEGRA 3 CLARINEX ORAL SYRUP 3 Antitussives - Non-Opioid benzonatate 1 TESSALON PERLES 3 Asthma Therapy - 5-Lipoxygenase Inhibitors zileuton 3 ZYFLO 3 PA Asthma Therapy - Alpha/Beta Adrenergic Agents epinephrine injection syringe 0.1 mg/ml 3 Asthma Therapy - Inhaled Corticosteroids (Glucocorticoids) AEROSPAN 3 QL (2 INHALERS per 1 MONTH) ALVESCO 3 QL (1 INHALER per 1 MONTH)
Last Approved Date: 09/23/2021 Formulary Version: 91
261 Drug Status Notes PA; ST; QL (2 inhalers per 720 ARMONAIR DIGIHALER 3 Dayss) ARMONAIR RESPICLICK 3 QL (1 inhaler per 1 Month) ARNUITY ELLIPTA 2 ASMANEX HFA INHALATION HFA AEROSOL INHALER 100 MCG/ACTUATION, 2 200 MCG/ACTUATION ASMANEX HFA INHALATION HFA 2 QL (1 inhaler per 1 retail dispense) AEROSOL INHALER 50 MCG/ACTUATION ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 2 QL (1 INHALER per 1 MONTH) 110 MCG/ ACTUATION (30) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 2 110 MCG/ ACTUATION (7) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 2 QL (2 INHALERS per 1 MONTH) 220 MCG/ ACTUATION (120) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (14), 220 MCG/ 2 QL (2 Inhalers per 1 Month) ACTUATION (30), 220 MCG/ ACTUATION (60) budesonide inhalation suspension for 1 PA nebulization 0.25 mg/2 ml, 0.5 mg/2 ml budesonide inhalation suspension for 3 PA nebulization 1 mg/2 ml FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 2 QL (1 INHALER per 1 MONTH) MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER 2 QL (4 INHALERS per 1 MONTH) WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 2 QL (1 INHALER per 1 MONTH) 44 MCG/ACTUATION FLOVENT HFA INHALATION HFA 2 QL (2 INHALERS per 1 MONTH) AEROSOL INHALER 220 MCG/ACTUATION PULMICORT 3 PA PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 3 QL (2 INHALERS per 1 MONTH) 180 MCG/ACTUATION Last Approved Date: 09/23/2021 Formulary Version: 91
262 Drug Status Notes PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 90 3 QL (1 INHALER per 1 MONTH) MCG/ACTUATION QVAR INHALATION AEROSOL 40 3 QL (2 INHALERS per 1 MONTH) MCG/ACTUATION QVAR INHALATION AEROSOL 80 3 QL (2 inhalers per 1 Month) MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 40 3 QL (1 Inhaler per 30 days) MCG/ACTUATION QVAR REDIHALER INHALATION HFA AEROSOL BREATH ACTIVATED 80 3 QL (2 Inhalers per 30 days) MCG/ACTUATION Asthma Therapy - Interleukin-4 (Il-4) Receptor Alpha Antagonists, Mab DUPIXENT PEN SUBCUTANEOUS PEN PA; ST; SPT; QL (3 ML per 21 3 INJECTOR 200 MG/1.14 ML Dayss) DUPIXENT PEN SUBCUTANEOUS PEN PA; ST; SPT; QL (2 syringes per 3 INJECTOR 300 MG/2 ML 21 Dayss) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; SPT; QL (2 syringes 3 SYRINGE 200 MG/1.14 ML per 21 Dayss) DUPIXENT SYRINGE SUBCUTANEOUS PA; ST; BE; SPT; QL (2 syringes 3 SYRINGE 300 MG/2 ML per 21 days) Asthma Therapy - Interleukin-5 (Il-5) Receptor Alpha Antagonists, Mab PA; ST; $3-Copay; SPT; QL (1 FASENRA PEN 4 pen per 56 dayss) Asthma Therapy - Leukotriene Receptor Antagonists ACCOLATE 3 PA; ST montelukast 1 SINGULAIR ORAL GRANULES IN PACKET 3 SINGULAIR ORAL TABLET 3 ST SINGULAIR ORAL TABLET,CHEWABLE 3 ST zafirlukast 1 PA; ST Asthma Therapy - Mast Cell Stabilizers cromolyn inhalation 1
Last Approved Date: 09/23/2021 Formulary Version: 91
263 Drug Status Notes Asthma Therapy - Monoclonal Antibodies To Immunoglobulin E (Ige) PA; ST; BE; SPT; QL (1 ML per XOLAIR SUBCUTANEOUS SYRINGE 4 21 Dayss) Asthma Therapy - Xanthines ELIXOPHYLLIN 1 THEO-24 3 THEOCHRON ORAL TABLET EXTENDED 1 RELEASE 12 HR 100 MG, 200 MG theophylline oral elixir 1 theophylline oral solution 1 theophylline oral tablet extended release 1 theophylline oral tablet extended release 12 hr 1 theophylline oral tablet extended release 24 hr 1 Asthma Therapy- Monoclonal Antibody - Interleukin-5 (Il-5) Antagonists NUCALA SUBCUTANEOUS AUTO- PA; ST; BE; SPT; QL (1 syringe 4 INJECTOR per 28 days) PA; ST; BE; SPT; QL (1 syringe NUCALA SUBCUTANEOUS SYRINGE 4 per 28 days) Asthma/Copd - Phosphodiesterase-4 (Pde4) Inhibitors DALIRESP ORAL TABLET 250 MCG 3 DALIRESP ORAL TABLET 500 MCG 3 PA Asthma/Copd - Anticholinergic Agents, Inhaled Long Acting INCRUSE ELLIPTA 2 LONHALA MAGNAIR 25 MCG REFILL 3 QL (1 Refill kit per per 30 days) LONHALA MAGNAIR 25 MCG STARTER 3 QL (1 Starter kit per per 720 days) LONHALA MAGNAIR REFILL INHALATION SOLUTION FOR NEBULIZATION 25 3 MCG/ML LONHALA MAGNAIR STARTER INHALATION SOLUTION FOR 3 NEBULIZATION 25 MCG/ML SEEBRI NEOHALER 3 QL (2 CAPSULES per 1 day) SPIRIVA RESPIMAT 2 Last Approved Date: 09/23/2021 Formulary Version: 91
264 Drug Status Notes spiriva with handihaler 2 TUDORZA PRESSAIR 3 PA; ST; QL (1 carton (30 vials) YUPELRI 3 per 1 Month) Asthma/Copd - Anticholinergic Agents, Inhaled Short Acting ATROVENT HFA 3 ipratropium bromide inhalation 1 Asthma/Copd - Beta 2-Adrenergic Agents, Inhaled, Ultra-Long Acting ARCAPTA NEOHALER 3 STRIVERDI RESPIMAT 3 Asthma/Copd Therapy - Beta 2- Adrenergic Agents, Inhaled, Long Acting arformoterol 3 BROVANA 3 FORADIL AEROLIZER 2 formoterol fumarate 3 PERFOROMIST 3 SEREVENT DISKUS 2 Asthma/Copd Therapy - Beta 2- Adrenergic Agents, Inhaled, Short Acting QL (2 albuterol/levalbuterol albuterol sulfate inhalation hfa aerosol inhaler 1 inhalers per 25 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 1 mg/0.5 ml, 5 mg/ml albuterol sulfate inhalation solution for 1 $3-Copay nebulization 2.5 mg /3 ml (0.083 %) levalbuterol hcl 3 QL (2 albuterol/levalbuterol levalbuterol tartrate 3 inhalers per 25 days) PA; ST; QL (2 inhalers per 720 PROAIR DIGIHALER 3 Dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
265 Drug Status Notes QL (2 albuterol/levalbuterol PROAIR HFA 3 inhalers per 25 days) QL (2 albuterol/levalbuterol PROAIR RESPICLICK 3 inhalers per 25 days) QL (2 albuterol/levalbuterol PROVENTIL HFA 3 inhalers per 25 days) QL (2 albuterol/levalbuterol VENTOLIN HFA 2 inhalers per 25 days) XOPENEX 3 XOPENEX CONCENTRATE 3 QL (2 albuterol/levalbuterol XOPENEX HFA 3 inhalers per 25 days) Asthma/Copd Therapy - Beta Adrenergic Agents albuterol sulfate oral 1 metaproterenol 1 terbutaline oral 1 terbutaline subcutaneous 3 Asthma/Copd Therapy - Beta Adrenergic-Anticholinergic Combinations ANORO ELLIPTA 2 QL (1 inhaler per 1 month) BEVESPI AEROSPHERE 3 COMBIVENT RESPIMAT 3 QL (1 inhaler per 1 dispensing DUAKLIR PRESSAIR 3 event) DUONEB 3 ipratropium-albuterol 1 STIOLTO RESPIMAT 2 QL (1 inhaler per 1 month) UTIBRON NEOHALER 3 QL (2 CAPSULES per 1 day) Asthma/Copd Therapy - Beta Adrenergic-Glucocorticoid Combinations ADVAIR DISKUS 3 QL (1 INHALER per 1 MONTH) ADVAIR HFA 3 QL (1 INHALER per 1 MONTH) PA; ST; QL (2 inhalers per 720 AIRDUO DIGIHALER 3 Dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
266 Drug Status Notes AIRDUO RESPICLICK 3 QL (1 inhaler per 30 Days) QL (60 BLISTERS per 1 BREO ELLIPTA 2 MONTH) PA; ST; QL (11 grams per 1 budesonide-formoterol 3 dispense) DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 3 PA MCG/ACTUATION DULERA INHALATION HFA AEROSOL 3 INHALER 50-5 MCG/ACTUATION fluticasone propion-salmeterol inhalation aerosol 2 powdr breath activated fluticasone propion-salmeterol inhalation blister 1 with device PA; QL (1 INHALER per 1 SYMBICORT 2 MONTH) WIXELA INHUB 1 Asthma/Copd Tx - Beta-Adrenergic- Anticholinergic-Glucocorticoid Comb, QL (10.7 g (1 cannister) per 30 BREZTRI AEROSPHERE 3 days) TRELEGY ELLIPTA INHALATION BLISTER 2 QL (1 inhaler per 30 Days) WITH DEVICE 100-62.5-25 MCG TRELEGY ELLIPTA INHALATION BLISTER 2 QL (1 inhaler per 1 Dispense) WITH DEVICE 200-62.5-25 MCG Cystic Fibrosis - Inhaled Aminoglycosides PA; SP; SPT; QL (224 ML per 42 BETHKIS 3 days) PA; QL (28 DAY SUPPLY per 42 KITABIS PAK 2 days) PA; SP; BE; SPT; QL (280 ML TOBI 4 per 42 days) PA; SP; SPT; QL (224 CAPS per TOBI PODHALER INHALATION CAPSULE 3 42 days) TOBI PODHALER INHALATION CAPSULE, PA; SP; SPT; QL (224 EA per 56 3 W/INHALATION DEVICE days) SP; BE; SPT; QL (280 ML per 42 tobramycin in 0.225 % nacl 3 days)
Last Approved Date: 09/23/2021 Formulary Version: 91
267 Drug Status Notes PA; SPT; QL (28 day supply per tobramycin inhalation 3 42 Dayss) tobramycin with nebulizer 3 Cystic Fibrosis - Inhaled Monobactams PA; $3-Copay; SPT; QL (84 ML CAYSTON 4 per 42 days) Cystic Fibrosis - Inhaled Osmotic Agents PA; ST; SPT; QL (560 capsules BRONCHITOL 4 per 1 dispense) Cystic Fibrosis-Transmembrane Conductance Regulator (Cftr) Potentiator KALYDECO ORAL GRANULES IN PACKET 3 PA; SPT; QL (2 units per 1 day) 25 MG KALYDECO ORAL GRANULES IN PACKET PA; SP; SPT; QL (68 PACKETS 3 50 MG, 75 MG per 1 MONTH) PA; SP; SPT; QL (68 TABLETS KALYDECO ORAL TABLET 3 per 1 MONTH) Cystic Fib-Transmemb Conduct. Reg.(Cftr) Potentiator And Corrector Cmb PA; BE; SPT; QL (2 packets per 1 ORKAMBI ORAL GRANULES IN PACKET 4 Day) PA; SP; BE; SPT; QL (112 tablets ORKAMBI ORAL TABLET 100-125 MG 4 per 1 month) PA; BE; SPT; QL (112 TABLETS ORKAMBI ORAL TABLET 200-125 MG 4 per 1 MONTH) SYMDEKO ORAL TABLETS, SEQUENTIAL PA; BE; SPT; QL (2 Tablets per 1 4 100-150 MG (D)/ 150 MG (N) day) SYMDEKO ORAL TABLETS, SEQUENTIAL 4 BE 50-75 MG (D)/ 75 MG (N) TRIKAFTA ORAL TABLETS, SEQUENTIAL PA; BE; SPT; QL (1 carton per 28 4 100-50-75 MG(D) /150 MG (N) dayss) TRIKAFTA ORAL TABLETS, SEQUENTIAL PA; BE; SPT; QL (84 tablets per 4 50-25-37.5 MG (D)/75 MG (N) 21 Dayss)
Last Approved Date: 09/23/2021 Formulary Version: 91
268 Drug Status Notes Decongestant-Expectorant Combinations DONATUSSIN PEDI (REFORMULATED) 3 GILPHEX TR 3 J-MAX 3 PE-GUAI 1 RESPAIRE-30 3 TG 10PEH-380GFN 3 TUSNEL PEDIATRIC ORAL DROPS 3 Expectorants - Single Agents, General guaifenesin oral tablet 200 mg 3 IOPHEN-NR 3 ORGAN-I NR 3 Lung Surfactants CUROSURF 3 SURFAXIN 3 Mucolytics acetylcysteine 1 PA; SP; BE; SPT; QL (150 ML PULMOZYME 1 per 23 days) Nasal Antibiotics BACTROBAN NASAL 3 Nasal Anticholinergics ATROVENT 3 ipratropium bromide nasal 1 Nasal Antihistamine And Anti- Inflammatory Steroid Combinations azelastine-fluticasone 3 PA; ST DYMISTA 3 PA; ST Nasal Antihistamines ASTEPRO NASAL SPRAY,NON-AEROSOL 3 azelastine nasal 1 olopatadine nasal 3 PATANASE 3
Last Approved Date: 09/23/2021 Formulary Version: 91
269 Drug Status Notes Nasal Corticosteroids BECONASE AQ 3 PA; ST budesonide nasal 3 CHILDREN'S NASACORT 3 PA; ST FLONASE 3 PA; ST flunisolide 1 fluticasone propionate nasal 1 mometasone nasal 3 NASACORT 3 PA; ST NASONEX 3 PA; ST OMNARIS 3 PA; ST QNASL 3 PA; ST RHINOCORT AQUA 3 PA; ST triamcinolone acetonide nasal 3 VERAMYST 3 PA; ST PA; ST; SP; QL (1 bottle per 30 XHANCE 3 Days) ZETONNA 3 PA; ST Nasal Sympathomimetic Decongestants (Intranasal) ADRENALIN NASAL 3 Non-Opioid Antituss-Decongestant- Analgesic,Non-Salicylate-Expectorant DURAFLU 3 Non-Opioid Antitussive-1St Gen.Antihistamine-Decongestant Combinations ALA-HIST DM 3 BROMFED DM 3 brompheniramine-pseudoeph-dm 1 BRONKIDS 3 ED A-HIST DM ORAL LIQUID 3 LOHIST-DM 3
Last Approved Date: 09/23/2021 Formulary Version: 91
270 Drug Status Notes Non-Opioid Antitussive-Antihistamine Combinations promethazine-dm 1 Non-Opioid Antitussive-Decongestant- Expectorant Combinations GILTUSS TR 3 TG 10PEH-380GFN-15DM 3 TUSNEL DM PEDIATRIC(PSEUDOEPH) 3 TUSNEL NEW FORMULA ORAL SOLUTION 3 TUSNEL PEDIATRIC ORAL LIQUID 3 TUSSI-PRES PEDIATRIC ORAL LIQUID 3 Non-Opioid Antitussive-Expectorant Combinations dextromethorphan-guaifenesin oral syrup 3 IOPHEN DM-NR 3 TUSNEL DIABETIC 3 Opioid Antitussive-1St Generation Antihistamine Combinations hydrocodone-chlorpheniramine 1 promethazine-codeine 1 TUSSICAPS 3 TUSSIONEX PENNKINETIC ER 3 TUXARIN ER 3 TUZISTRA XR 3 VITUZ 3 ZODRYL AC 25 3 ZODRYL AC 30 3 ZODRYL AC 35 3 ZODRYL AC 40 3 ZODRYL AC 50 3 ZODRYL AC 60 3 ZODRYL AC 80 3 Z-TUSS AC 3
Last Approved Date: 09/23/2021 Formulary Version: 91
271 Drug Status Notes Opioid Antitussive-1St Generation Antihistamine-Decongestant Comb. CAPCOF 3 HISTEX-AC 3 hydrocodone-cpm-pseudoephed 1 MAR-COF BP 3 MAXI-TUSS CD 3 M-END MAX D 3 M-END PE 3 PHENYLHISTINE DH 1 POLY-TUSSIN AC 3 PROMETHAZINE VC-CODEINE 1 promethazine-phenyleph-codeine 1 PRO-RED AC (W/ DEXCHLORPHENIR) 3 PRO-RED AC (WITH PYRILAMINE) 3 RYDEX 1 ZODRYL DAC 25 3 ZODRYL DAC 30 3 ZODRYL DAC 35 3 ZODRYL DAC 40 3 ZODRYL DAC 50 3 ZODRYL DAC 60 3 ZODRYL DAC 80 3 ZUTRIPRO 3 Opioid Antitussive-Anticholinergic Combinations HYCODAN 3 PA HYDROCODONE COMPOUND 1 hydrocodone-homatropine oral syrup 5-1.5 mg/5 1 ml hydrocodone-homatropine oral syrup 5-1.5 mg/5 3 ml (5 ml) hydrocodone-homatropine oral tablet 1 HYDROMET 1 TUSSIGON 1
Last Approved Date: 09/23/2021 Formulary Version: 91
272 Drug Status Notes Opioid Antitussive-Decongestant Combinations REZIRA 3 Opioid Antitussive-Decongestant- Expectorant Combinations CHERATUSSIN DAC 1 CODITUSSIN DAC 3 GUAIFENESIN DAC 1 HYCOFENIX 3 LORTUSS EX 1 PHENYLHISTINE 1 TUSNEL C 1 VIRTUSSIN DAC 1 ZODRYL DEC 25 3 ZODRYL DEC 30 3 ZODRYL DEC 35 3 ZODRYL DEC 40 3 ZODRYL DEC 50 3 ZODRYL DEC 60 3 ZODRYL DEC 80 3 Opioid Antitussive-Expectorant Combinations CHERATUSSIN AC 1 codeine-guaifen 10-100 mg/5 ml a/f,d/f,s/f (otc) 1 codeine-guaifenesin oral liquid 10-100 mg/5 ml 1 CODITUSSIN AC 3 FLOWTUSS 3 G TUSSIN AC 1 GUAIATUSSIN AC 1 guaifen-codeine 100-10 mg/5 ml (otc) 1 guaifen-codeine 200-20 mg/10 ml outer (otc) 3 GUAIFENESIN AC 1 guaifenesin-codeine syrup (otc) 3 hydrocodone-guaifenesin 3 PA IOPHEN C-NR 1
Last Approved Date: 09/23/2021 Formulary Version: 91
273 Drug Status Notes MAR-COF CG 3 M-CLEAR WC 1 NINJACOF-XG 3 OBREDON 3 RELCOF C 1 ROBAFEN AC 1 VIRTUSSIN AC 1 Pulmonary Fibrosis Treatment Agents - Antifibrotic Therapy PA; SP; BE; QL (306 CAPSULES ESBRIET ORAL CAPSULE 4 per 1 MONTH) ESBRIET ORAL TABLET 267 MG 4 PA; BE; SPT; QL (3 tablets per 1 ESBRIET ORAL TABLET 801 MG 4 Day) Pulmonary Fibrosis Treatment Agents - Multikinase Inhibitors PA; SP; BE; SPT; QL (68 OFEV 4 TABLETS per 1 MONTH) Systemic Sympathomimetic Decongestants pseudoephedrine hcl oral tablet 60 mg 3 Vaginal Products Vaginal Antibacterial - Lincosamides CLEOCIN VAGINAL 3 clindamycin phosphate vaginal 1 CLINDESSE 3 Vaginal Antibacterial - Sulfonamides AVC VAGINAL 3 Vaginal Antifungal - Imidazoles clotrimazole vaginal 1 GYNAZOLE-1 3 MICONAZOLE-3 VAGINAL SUPPOSITORY 1 Vaginal Antifungal - Triazoles TERAZOL 3 VAGINAL CREAM 3 TERAZOL 7 3
Last Approved Date: 09/23/2021 Formulary Version: 91
274 Drug Status Notes terconazole 1 Vaginal Antiprotozoal-Antibacterial - Nitroimidazole Derivatives METROGEL VAGINAL 3 metronidazole vaginal 1 VANDAZOLE 1 Vaginal Antiseptic Mixtures FEM PH 1 RELAGARD 3 Vaginal Estrogens ESTRACE VAGINAL 3 estradiol vaginal 1 ESTRING 2 QL (1 RING per 3 MONTHs) FEMRING 2 QL (1 RING per 3 MONTHs) PREMARIN VAGINAL 3 VAGIFEM 3 YUVAFEM 1 Vaginal Progestins CRINONE VAGINAL GEL 4 % 3
Last Approved Date: 09/23/2021 Formulary Version: 91
275 Last Approved Date: 09/23/2021 Formulary Version: 91
276 Index abacavir...... 31 ACTOS...... 196 AFLURIA 2016-2017...... 64 abacavir-lamivudine...... 33 ACUICYN...... 146 AFLURIA 2016-2017 (PF)...... 64 abacavir-lamivudine-zidovudine 33 ACULAR...... 250 AFLURIA 2017-2018...... 64 ABILIFY...... 102, 109 ACULAR LS...... 250 AFLURIA 2017-2018 (PF)...... 64 ABILIFY MYCITE...... 102, 109 ACUVAIL (PF)...... 250 AFLURIA 2018-2019...... 64 ABILIFY MYCITE acyclovir...... 39, 145 AFLURIA 2018-2019 (PF)...... 64 MAINTENANCE KIT..... 102, 109 ACZONE...... 135 AFLURIA QD 2019-20(3YR ABILIFY MYCITE STARTER ADACEL(TDAP UP)(PF)...... 64 KIT...... 102, 109 ADOLESN/ADULT)(PF)...... 62 AFLURIA QD 2019-20(6- abiraterone...... 46, 48 ADAGEN...... 239 35MO)(PF)...... 64 ABSORICA...... 134 ADAKVEO...... 225 AFLURIA QD 2020-21(3YR ABSORICA LD...... 134 ADALAT CC...... 78 UP)(PF)...... 64 acamprosate...... 121 adapalene...... 138 AFLURIA QD 2020-21(6- ACANYA...... 136 ADASUVE...... 100 35MO)(PF)...... 64 acarbose...... 182 ADCIRCA...... 85 AFLURIA QD 2021-22(3YR ACCOLATE...... 263 ADDERALL...... 110 UP)(PF)...... 64 ACCRUFER...... 167 ADDERALL XR...... 110 AFLURIA QD 2021-22(6- ACCU-CHEK AVIVA...... 232 ADDYI...... 113 35MO)(PF)...... 64 ACCU-CHEK GUIDE TEST adefovir...... 37 AFLURIA QUAD 2016-2017 STRIPS...... 232, 236 ADEMPAS...... 85 (PF)...... 64 ACCU-CHEK TENDER...... 236 ADHANSIA XR...... 103 AFLURIA QUAD 2017-2018.... 64 ACCU-CHEK ULTRAFLEX...236 ADIPEX-P...... 160 AFLURIA QUAD 2017-2018 ACCUPRIL...... 68 ADLYXIN...... 184 (PF)...... 64 ACCURETIC...... 67 ADMELOG SOLOSTAR U- AFLURIA QUAD 2018-2019.... 64 acebutolol...... 76 100 INSULIN...... 194 AFLURIA QUAD 2018-2019 ACEON...... 68 ADMELOG U-100 INSULIN (PF)...... 64 acetaminophen-caff-dihydrocod... 7 LISPRO...... 194 AFLURIA QUAD 2019- acetaminophen-codeine...... 6 ADRENALIN...... 270 20(6MO UP)...... 64 ACETASOL HC...... 257 ADULT ASPIRIN REGIMEN AFLURIA QUAD 2020- acetazolamide...... 81 ...... 20, 226 2021(6MO UP)...... 64 acetic acid...... 257 ADULT LOW DOSE ASPIRIN AFLURIA QUAD 2021- acetic acid-aluminum acetate... 257 ...... 20, 226 2022(6MO UP)...... 64 acetylcysteine...... 269 ADVAIR DISKUS...... 266 AFREZZA...... 194 ACIPHEX...... 203 ADVAIR HFA...... 266 AFSTYLA...... 223 ACIPHEX SPRINKLE...... 204 ADVANCED AM-PM...... 170 AFTERA...... 133, 134 ACTEMRA...... 16 ADVATE...... 223 AGGRENOX...... 226 ACTEMRA ACTPEN...... 16 ADVOCATE REDI-CODE...... 232 AGRYLIN...... 226 ACTHAR...... 179 ADVOCATE TEST STRIPS....232 AIMOVIG AUTOINJECTOR..114 ACTHIB (PF)...... 62 ADYNOVATE...... 223 AIMOVIG AUTOINJECTOR ACTICLATE...... 44 ADZENYS ER...... 103, 111 (2 PACK)...... 114 ACTIGALL...... 203 ADZENYS XR-ODT...... 103, 111 AIMSCO LATEX CONDOM ACTIMMUNE...... 28 AEMCOLO...... 44 ...... 235, 236 ACTIQ...... 2 AEROSPAN...... 261 AIRDUO DIGIHALER...... 266 ACTIVELLA...... 188 AFEDITAB CR...... 78 AIRDUO RESPICLICK...... 267 ACTONEL...... 187 AFINITOR...... 54 AJOVY AUTOINJECTOR...... 113 ACTOPLUS MET...... 184 AFINITOR DISPERZ...... 54 AJOVY SYRINGE...... 113 ACTOPLUS MET XR...... 184 AFIRMELLE...... 126 AKLIEF...... 138 Last Approved Date: 09/23/2021 Formulary Version: 91
277 AK-POLY-BAC...... 254 ALPHAQUIN HP...... 146 ammonium lactate...... 146 AKTEN (PF)...... 253 alprazolam...... 86, 106 AMNESTEEM...... 134 AKYNZEO (NETUPITANT)...202 ALPRAZOLAM INTENSOL amoxapine...... 95 ALA-CORT...... 147 ...... 86, 106 amoxicil-clarithromy-lansopraz213 ALA-HIST DM...... 270 ALPROLIX...... 222 amoxicillin...... 25 ALA-QUIN...... 141 alprostadil...... 83 amoxicillin-pot clavulanate...... 25 ALA-SCALP...... 147 ALREX...... 249 amphetamine...... 103, 111 ALBA-DERM...... 122 ALTABAX...... 140 ampicillin...... 25 albendazole...... 25 ALTACAINE...... 253 AMPYRA...... 245 albendazole (bulk)...... 25, 122 ALTACE...... 68 AMRIX...... 231 ALBENZA...... 25 ALTAFLUOR...... 252, 253 AMZEEQ...... 135 albuterol sulfate...... 265, 266 ALTAFLUOR BENOX....252, 253 ANADROL-50...... 180 ALCAINE...... 253 ALTAVERA (28)...... 126 ANAFRANIL...... 95 alclometasone...... 147 ALTOPREV...... 73, 74 anagrelide...... 226 ALCORTIN A...... 141 ALTRENO...... 138 ANALPRAM E...... 22 ALDACTAZIDE...... 82 aluminum chloride...... 143 ANALPRAM-HC...... 22 ALDACTONE...... 68, 81 ALUNBRIG...... 47 ANALPRAM-HC SINGLES...... 22 ALDARA...... 153 ALVESCO...... 261 ANAPROX DS...... 19 ALECENSA...... 47 alvimopan...... 24 ANASPAZ...... 206, 219 alendronate...... 187 ALYACEN 1/35 (28)...... 126 anastrozole...... 49 ALFENTA...... 2 ALYACEN 7/7/7 (28)...... 131 ANCOBON...... 27 alfentanil...... 2 ALYQ...... 85 ANDRODERM...... 180 ALFERON N...... 153 AMABELZ...... 188 ANDROGEL...... 180 alfuzosin...... 216 amantadine hcl...... 98 ANDROID...... 180 ALINIA...... 29 AMARYL...... 183 ANDROXY...... 180 aliskiren...... 86 AMBIEN...... 120 ANGELIQ...... 188 ALKERAN...... 47 AMBIEN CR...... 120 ANIMI-3 WITH VITAMIN D. 171 ALKINDI SPRINKLE...... 190 ambrisentan...... 85 ANNOVERA...... 133 ALLEGRA...... 261 amcinonide...... 147 ANORO ELLIPTA...... 266 ALLEGRA ODT...... 261 AMERGE...... 115 ANTABUSE...... 121 ALLEGRA-D 12 HOUR...... 258 AMETHIA...... 125 ANTARA...... 73 ALLEGRA-D 24 HOUR...... 258 AMETHIA LO...... 125 anticoag citrate phos dextrose..221 ALLERGY AMETHYST (28)...... 126 ANTIVERT...... 200 RELIEF(DIPHENHYDRAMIN AMICAR...... 224 ANUCORT-HC...... 22 )...... 259, 260 amiloride...... 82 ANUSOL-HC...... 22 ALLI...... 161 amiloride-hydrochlorothiazide... 82 ANZEMET...... 201 allopurinol...... 220 aminocaproic acid...... 224 APEXICON E...... 147 ALOCRIL...... 253 amiodarone...... 72 APIDRA SOLOSTAR U-100 alogliptin...... 182 AMITIZA...... 208 INSULIN...... 194 alogliptin-metformin...... 185 amitriptyline...... 95 APIDRA U-100 INSULIN...... 195 alogliptin-pioglitazone...... 185 amitriptyline-chlordiazepoxide APLENZIN...... 95 ALOMIDE...... 253 ...... 94, 106 APOKYN...... 98 ALOPHEN (BISACODYL)..... 213 amlodipine...... 78 apraclonidine...... 256 ALOQUIN...... 140 amlodipine-atorvastatin...... 76 aprepitant...... 201 ALORA...... 189 amlodipine-benazepril...... 67 APRI...... 126 alosetron...... 208, 211 amlodipine-olmesartan...... 69 APRISO...... 208 ALPHAGAN P...... 256 amlodipine-valsartan...... 69 APTIOM...... 89 ALPHANINE SD...... 222 amlodipine-valsartan-hcthiazid..69 APTIVUS...... 43 Last Approved Date: 09/23/2021 Formulary Version: 91
278 APTIVUS (WITH VITAMIN ASTAGRAF XL...... 229 AVITA...... 138 E)...... 43 ASTEPRO...... 269 AVO CREAM...... 146 AQUASOL A...... 177 ATABEX EC...... 173 AVODART...... 216 AQUORAL...... 243 ATACAND...... 70 AVONEX...... 244 ARAKODA...... 28 ATACAND HCT...... 69 AVONEX (WITH ALBUMIN) 244 ARANELLE (28)...... 131 atazanavir...... 43 AXERT...... 115 ARANESP (IN ATELVIA...... 187 AXIRON...... 180 POLYSORBATE)...... 222 atenolol...... 76 AYGESTIN...... 197 ARAVA...... 17 atenolol-chlorthalidone...... 79 AYUNA...... 126 ARAZLO...... 138 ATIVAN...... 86, 106 AYVAKIT...... 56 ARBINOXA...... 259, 260 atomoxetine...... 106 AZASAN...... 15, 230 ARCALYST...... 12 atorvastatin...... 74 AZASITE...... 255 ARCAPTA NEOHALER...... 265 atovaquone...... 29 azathioprine...... 15, 230 arformoterol...... 265 atovaquone-proguanil...... 28 azelastine...... 249, 269 ARICEPT...... 124 ATRALIN...... 138 azelastine-fluticasone...... 269 ARICEPT ODT...... 124 ATRIPLA...... 33 AZELEX...... 135 ARIKAYCE...... 24 ATROPEN...... 83 AZILECT...... 97 ARIMIDEX...... 49 atropine...... 83, 206, 248 azithromycin...... 40 aripiprazole...... 102, 109 atropine sulfate (pf)...... 248 AZOPT...... 251 ARIXTRA...... 225 ATROVENT...... 269 AZOR...... 69 armodafinil...... 118 ATROVENT HFA...... 265 AZSTARYS...... 103 ARMONAIR DIGIHALER...... 262 AUBAGIO...... 246 AZULFIDINE...... 16, 208 ARMONAIR RESPICLICK.....262 AUBRA...... 126 AZULFIDINE EN-TABS...16, 208 ARMOUR THYROID...... 199 AUBRA EQ...... 126 AZUPHEN MB...... 41, 217 ARNUITY ELLIPTA...... 262 AUGMENTIN...... 25 AZURETTE (28)...... 125 AROMASIN...... 49 AUGMENTIN ES-600...... 25 B COMPLETE...... 164 ARTHROTEC 50...... 17 AUGMENTIN XR...... 25 B COMPLEX...... 164 ARTHROTEC 75...... 17 AUROVELA 1.5/30 (21)...... 126 B COMPLEX 1...... 164 ARYMO ER...... 2 AUROVELA 1/20 (21)...... 126 B COMPLEX 1 (WITH FOLIC ASACOL HD...... 208 AUROVELA 24 FE...... 126 ACID)...... 162 ASCENIV...... 61 AUROVELA FE 1.5/30 (28)....126 B COMPLEX 100...... 162 ASCOMP WITH CODEINE...... 6 AUROVELA FE 1-20 (28)...... 126 B COMPLEX-VITAMIN B12. 164 asenapine maleate...... 98, 109 AURYXIA...... 167, 215 b complex-vitamin c-folic acid ASHLYNA...... 125 AUSTEDO...... 116, 117 ...... 162, 163 ASMANEX HFA...... 262 AUVI-Q...... 79 B-100 COMPLEX...... 162, 164 ASMANEX TWISTHALER.... 262 AVALIDE...... 69 B-50...... 164 ASPIR-81...... 20, 226 AVANDAMET...... 184 B-50 COMPLEX...... 164 aspirin...... 20, 21, 226 AVANDIA...... 196 BACIIM...... 43 ASPIRIN CHILDRENS..... 20, 226 AVAPRO...... 70 bacitracin...... 43, 255 ASPIRIN LOW DOSE...... 20, 226 AVAR...... 136 bacitracin-polymyxin b...... 254 ASPIRIN LOW-STRENGTH AVAR LS...... 136 baclofen...... 231 ...... 20, 226 AVAR-E...... 136 BACMIN...... 170 aspirin-caffeine-dihydrocodein.....7 AVAR-E LS...... 136 BACTRIM...... 26 aspirin-dipyridamole...... 226 AVC VAGINAL...... 274 BACTRIM DS...... 26 aspirin-omeprazole...... 227 AVELOX...... 36 BACTROBAN...... 140 ASPIR-LOW...... 21, 226 AVELOX ABC PACK...... 36 BACTROBAN NASAL...... 269 ASPIR-TRIN...... 21, 226 AVIANE...... 126 BAFIERTAM...... 245 ASSURE 4 STRIPS...... 232 AVIDOXY...... 44 BAL B-100...... 164 Last Approved Date: 09/23/2021 Formulary Version: 91
279 BAL B-50...... 164 BENSAL HP...... 153 BIKTARVY...... 32 BALANCE B-100...... 164 BENTYL...... 207 BILTRICIDE...... 26 BALANCE B-100 (FOLIC BENZACLIN...... 136 bimatoprost...... 256 ACID)...... 162 BENZACLIN PUMP...... 136 BINOSTO...... 187 BALANCE B-50...... 164 benzalkonium chloride (bulk) BIOGLO...... 252 BALANCE B-50 (WITH ...... 60, 122, 123 BIOLON...... 254 FOLIC ACID)...... 162 BENZAMYCIN...... 136 BIONECT...... 155 BALANCED B-100...... 162 BENZAMYCINPAK...... 136 BIORPHEN...... 80 BALANCED B-100 BENZEFOAM...... 137 bisacodyl...... 213 COMPLEX...... 162, 164 BENZEFOAM ULTRA...... 137 BISA-LAX (BISACODYL)..... 213 BALANCED B-150...... 164 BENZEPRO...... 137 bisoprolol fumarate...... 76 BALANCED B-50...... 164 benznidazole...... 29 bisoprolol-hydrochlorothiazide.. 79 BALANCED B-50 COMPLEX164 benzonatate...... 261 BLANCHE...... 145 BALANCED SALT...... 253 benzoyl peroxide...... 137 BLEPH-10...... 255 BAL-CARE DHA...... 173 benzphetamine...... 160 BLEPHAMIDE...... 248 BALCOLTRA...... 126 benztropine...... 97 BLEPHAMIDE S.O.P...... 248 balsalazide...... 208 bepotastine besilate...... 249 BLISOVI 24 FE...... 126 BALVERSA...... 51 BEPREVE...... 249 BLISOVI FE 1.5/30 (28)...... 126 BALZIVA (28)...... 126 BERINERT...... 221 BLISOVI FE 1/20 (28)...... 126 BANZEL...... 91 BESER...... 147 BONIVA...... 187 BAQSIMI...... 179 BESIVANCE...... 255 BONJESTA...... 200 BARACLUDE...... 37 BETADINE OPHTHALMIC BOOSTRIX TDAP...... 62 BASAGLAR KWIKPEN U-100 PREP...... 255 bosentan...... 85 INSULIN...... 194 BETAGAN...... 252 BOSULIF...... 56 BAXDELA...... 36 betamethasone dipropionate.....147 BP 10-1...... 136 BAYER ASPIRIN...... 21, 226 betamethasone valerate...... 147 BP VIT 3 PLUS...... 171 BAYER CHEWABLE betamethasone, augmented...... 147 BP-50% UREA...... 153 ASPIRIN...... 21, 226 BETAPACE...... 72, 77 B-PLEX...... 162 B-COMPLEX...... 162, 164 BETAPACE AF...... 72, 77 BPO...... 137 b-complex with vitamin c...... 162 BETASERON...... 244 BRAFTOVI...... 50 BD PRE-FILLED NORMAL betaxolol...... 76, 252 BREEZE 2 TEST STRIPS...... 232 SALINE...... 176 bethanechol chloride...... 220 BREO ELLIPTA...... 267 BECONASE AQ...... 270 BETHKIS...... 267 BREVICON (28)...... 126 BEKYREE (28)...... 125 BETIMOL...... 252 BREXAFEMME...... 27 BELBUCA...... 11 BETOPTIC S...... 252 BREZTRI AEROSPHERE...... 267 belladonna alkaloids-opium..... 207 BEVESPI AEROSPHERE...... 266 BRIELLYN...... 126 belladonna tincture (bulk)...... 206 BEVYXXA...... 221 BRILINTA...... 226 BELLADONNA- bexarotene...... 59 brimonidine...... 256 PHENOBARBITAL...... 207 BEXSERO...... 63 brimonidine-dorzolamide (pf)...247 BELSOMRA...... 120 BEYAZ...... 126 brinzolamide...... 251 BELVIQ...... 161 BIAFINE EMULSION...... 146 BRISDELLE...... 197 BELVIQ XR...... 161 BIAXIN...... 40 BRIVIACT...... 91 benazepril...... 68 bicalutamide...... 48 BROMFED DM...... 270 benazepril-hydrochlorothiazide..67 BICILLIN C-R...... 43 bromfenac...... 250 BENEFIX...... 222 BICILLIN L-A...... 42 bromocriptine...... 97 BENICAR...... 70 BIDIL...... 86 brompheniramine-pseudoeph- BENICAR HCT...... 69 BIFERA RX...... 168 dm...... 270 BENLYSTA...... 17 BIJUVA...... 188 BROMSITE...... 250 Last Approved Date: 09/23/2021 Formulary Version: 91
280 BRONCHITOL...... 268 CALCARB 600 WITH captopril...... 68 BRONKIDS...... 270 VITAMIN D...... 165 captopril-hydrochlorothiazide....67 BROVANA...... 265 calcipotriene...... 144 CARAC...... 143 BRUKINSA...... 50, 56 calcipotriene-betamethasone....138 CARAFATE...... 213 BRYHALI...... 144, 147 calcitonin (salmon)...... 187, 188 CARBAGLU...... 240 BSS...... 253 CALCITRATE-VITAMIN D...165 carbamazepine...... 89, 108 budesonide...... 209, 262, 270 calcitriol...... 144, 177, 239 CARBATROL...... 89 budesonide-formoterol...... 267 CALCIUM + D...... 165 carbidopa...... 97 BUFFERED LIDOCAINE...... 22 CALCIUM 500 + D...... 166 carbidopa-levodopa...... 96 bumetanide...... 81 CALCIUM 500 + D (D3)...... 165 carbidopa-levodopa-entacapone 96 BUNAVAIL...... 120 CALCIUM 500 WITH D...... 166 carbinoxamine maleate.....259, 260 BUPHENYL...... 240 CALCIUM 500 WITH CARDIOPLEGIA DEL NIDO BUPRENEX...... 11 VITAMIN D2...... 166 FORMULA...... 257 buprenorphine...... 11 CALCIUM 600 + D(3)...... 166 CARDIOPLEGIA HIGH buprenorphine hcl...... 11, 121 CALCIUM 600 WITH POTASSIUM...... 257 buprenorphine-naloxone...... 121 VITAMIN D3...... 166 CARDIOPLEGIA IND 4:1 BUPROBAN...... 121 calcium acetate(phosphat bind) 215 PLASMALYT...... 257 bupropion hcl...... 95 calcium carb and citrate-vitd3..166 CARDIOPLEGIA IND 8:1 bupropion hcl (smoking deter)..121 calcium carbonate-vitamin d2.. 166 NON-ENRCH...... 257 buspirone...... 87 calcium carbonate-vitamin d3.. 166 CARDIOPLEGIA BUTALBITAL COMPOUND CALCIUM CITRATE +...... 166 INDUCTION 4:1...... 257 W/CODEINE...... 6 CALCIUM CITRATE + D...... 166 CARDIOPLEGIA BUTALBITAL COMPOUND- calcium citrate-vitamin d2...... 166 INDUCTION 8:1...... 257 CODEINE...... 6 calcium citrate-vitamin d3...... 166 CARDIOPLEGIA butalbital-acetaminop-caf-cod...... 7 CALCIUM CREAMIES...... 166 MAINTENANCE 4:1...... 257 butalbital-acetaminophen...... 11 CALCIUM WITH VITAMIN D CARDIOPLEGIA butalbital-acetaminophen-caff....12 ...... 166 MAINTENANCE 8:1...... 257 butalbital-aspirin-caffeine...... 20 CALCIUM+D...... 166 CARDIZEM...... 77 BUTISOL...... 119 CALCIUM-VITAMIN D3...... 166 CARDIZEM CD...... 77 butorphanol...... 11 CALQUENCE...... 50, 56 CARDIZEM LA...... 77 BUTRANS...... 11 CALTRATE WITH VITAMIN CARDURA...... 83 BYDUREON...... 184 D3...... 166 CARDURA XL...... 83 BYDUREON BCISE...... 184 CALVITE P AND D...... 166 carisoprodol...... 231 BYETTA...... 184 CAMBIA...... 19, 20, 114 carisoprodol-aspirin...... 231 BYLVAY...... 229 CAMILA...... 131 carisoprodol-aspirin-codeine... 232 BYNFEZIA...... 198, 214 CAMRESE...... 125 CARNITOR...... 240 BYSTOLIC...... 76 CAMRESE LO...... 125 CARNITOR (SUGAR-FREE)..239 BYVALSON...... 69 CANASA...... 208 CAROSPIR...... 68, 81 cabergoline...... 198 candesartan...... 70 carteolol...... 252 CABLIVI...... 220, 221 candesartan-hydrochlorothiazid.69 CARTIA XT...... 77 CABOMETYX...... 54 CAPACET...... 12 carvedilol...... 69 CADUET...... 76 CAPCOF...... 272 carvedilol phosphate...... 69 CAFERGOT...... 114 capecitabine...... 49 CASODEX...... 48 caffeine citrate...... 112 CAPEX...... 147 CATAPRES...... 80 CAL-600 WITH VITAMIN D. 165 CAPHOSOL...... 243 CATAPRES-TTS-1...... 80 CALAN...... 72 CAPITAL WITH CODEINE...... 7 CATAPRES-TTS-2...... 80 CALAN SR...... 79 CAPLYTA...... 99 CATAPRES-TTS-3...... 80 CAPRELSA...... 56 CAVERJECT...... 159 Last Approved Date: 09/23/2021 Formulary Version: 91
281 CAVERJECT IMPULSE...... 159 CHATEAL (28)...... 126 CIMZIA POWDER FOR CAYA CONTOURED..... 233, 236 CHATEAL EQ (28)...... 126 RECONST...... 12, 13, 210 CAYSTON...... 268 CHEMET...... 24 CIMZIA STARTER KIT CAZIANT (28)...... 131 CHEMSTRIP 10 MD...... 159 ...... 12, 13, 210 CEDAX...... 35 CHENODAL...... 203 cinacalcet...... 187 cefaclor...... 34, 35 CHERATUSSIN AC...... 273 CINRYZE...... 221 cefadroxil...... 34 CHERATUSSIN DAC...... 273 CIPRO...... 36 cefdinir...... 35 CHEWABLE MULTIVIT- CIPRO HC...... 257 cefditoren pivoxil...... 35 A,B,D,E,K,ZN...... 172 CIPRO XR...... 36, 217 cefixime...... 35 CHILD ASPIRIN...... 21, 226 CIPRODEX...... 257 cefpodoxime...... 35 CHILDREN'S ASPIRIN.....21, 226 ciprofloxacin...... 36 cefprozil...... 35 CHILDREN'S NASACORT.....270 ciprofloxacin (mixture)...... 36, 217 ceftibuten...... 35 CHILDREN'S VITAMIN D.....177 ciprofloxacin hcl...... 36, 255, 257 CEFTIN...... 35 chlordiazepoxide hcl...... 86, 106 ciprofloxacin-dexamethasone... 257 ceftriaxone...... 35 chlordiazepoxide-clidinium ciprofloxacin-fluocinolone...... 257 cefuroxime (pf) in 0.9% nacl.....255 ...... 106, 207 citalopram...... 92 cefuroxime axetil...... 35 chlorhexidine gluconate...... 243 CITRACAL + D MAXIMUM..167 CELACYN...... 146, 236 chlorhexidine gluconate (bulk) CITRACAL PLUS D...... 167 CELEBREX...... 18 ...... 60, 122, 243 CITRACAL REGULAR...... 167 celecoxib...... 18 chloroquine phosphate...... 28 CITRACAL-D3 PETITES...... 167 CELEXA...... 92 chlorothiazide...... 82 CITRACAL-D3 SLOW CELLCEPT...... 15, 229 chlorpheniramine-pseudoephed258 RELEASE...... 167 CELLUGEL...... 254 chlorpromazine...... 100 CITRANATAL 90 DHA (NEW CELONTIN...... 91 chlorpropamide...... 183 FORMULA...... 173 CEM-UREA...... 153 chlorthalidone...... 82 CITRANATAL ASSURE...... 173 CENTRATEX...... 168 chlorzoxazone...... 231 CITRANATAL B-CALM (FE CENTRUM PRO NUTRIENTS CHOICE-TABS...... 170 GLUC)...... 173 ...... 166 CHOLBAM...... 202 CITRANATAL DHA (NEW cephalexin...... 34 cholecalciferol (vitamin d3) FORMULA)...... 173 CEQUA...... 250 ...... 177, 178 CITRANATAL HARMONY... 174 CEQUR SIMPLICITY...... 236 cholestyramine (with sugar)...... 73 CITRANATAL RX (NEW CERDELGA...... 240 CHOLESTYRAMINE LIGHT...73 FORMULA)...... 174 CERVARIX VACCINE (PF)..... 63 choline,magnesium salicylate..... 20 CITRATE OF MAGNESIA..... 211 CESAMET...... 110, 201 chorionic gonadotropin, human193 CITROMA...... 211 cetirizine...... 261 CIALIS...... 160 CITRUS CALCIUM- CETRAXAL...... 257 CICLODAN...... 141 VITAMIN D3...... 167 CETROTIDE...... 197 ciclopirox...... 141 CLARAVIS...... 134 CETYLEV...... 23 ciclopirox-ure-camph-menth- CLARINEX...... 261 cevimeline...... 244 euc...... 141 CLARINEX-D 12 HOUR...... 259 CHANTIX...... 122 ciclopirox-vite-nail lacq remo.. 142 clarithromycin...... 40 CHANTIX CONTINUING CIDALEAZE...... 156 CLASSIC PRENATAL...... 174 MONTH BOX...... 122 cidofovir...... 36 CLEANSING WASH...... 136, 156 CHANTIX CONTINUING cilostazol...... 226 CLEARLAX...... 211 MONTH PAK...... 122 CILOXAN...... 255 clemastine...... 259, 260 CHANTIX STARTING CIMDUO...... 31 CLENPIQ...... 213 MONTH BOX...... 122 cimetidine...... 203 CLEOCIN...... 274 CHANTIX STARTING cimetidine hcl...... 203 CLEOCIN HCL...... 40 MONTH PAK...... 122 CIMZIA...... 12, 13, 210 CLEOCIN PEDIATRIC...... 40 Last Approved Date: 09/23/2021 Formulary Version: 91
282 CLEOCIN T...... 135 colesevelam...... 73 CORTANE-B...... 258 CLEVER CHOICE PRO...... 232 COLESTID...... 73 CORTEF...... 190 CLEVER CHOICE TEST colestipol...... 73 CORTIFOAM...... 209 STRIPS...... 232 COLOCORT...... 209 cortisone...... 190 CLIMARA...... 189 COLY-MYCIN S...... 257 CORTISPORIN...... 141, 257 CLIMARA PRO...... 188 COLYTE WITH FLAVOR CORTISPORIN-TC...... 257 CLINDACIN ETZ...... 135 PACKS...... 212 CORVITA...... 170 CLINDACIN P...... 135 COMBIGAN...... 251 CORVITA 150...... 168 CLINDAGEL...... 135 COMBIPATCH...... 188 CORVITE...... 170 clindamycin hcl...... 40 COMBIVENT RESPIMAT...... 266 CORVITE 150...... 168 clindamycin palmitate hcl...... 40 COMBIVIR...... 33 CORVITE FE...... 168, 170 clindamycin phosphate..... 135, 274 COMETRIQ...... 54 CORVITE FREE...... 170 clindamycin-benzoyl peroxide.. 136 COMPLERA...... 33 CORZIDE...... 83 clindamycin-tretinoin...... 137 COMPLETE NATAL DHA..... 174 COSENTYX...... 139 CLINDESSE...... 274 COMPLETENATE...... 174 COSENTYX (2 SYRINGES)...139 CLINPRO 5000...... 241 COMPLEX B-100...... 164 COSENTYX PEN...... 139 clobazam...... 87, 107 COMPRO...... 201 COSENTYX PEN (2 PENS).... 139 clobetasol...... 147 COMTAN...... 97 COSOPT...... 251 clobetasol-emollient...... 147 CONCEPT DHA...... 170 COSOPT (PF)...... 251 CLOBEX...... 147, 148 CONCEPT OB...... 170 COTELLIC...... 54 clocortolone pivalate...... 148 CONCEPTROL...... 134 COTEMPLA XR-ODT...... 103 CLODAN...... 148 CONCERTA...... 103 COUMADIN...... 221 CLODAN KIT...... 153 CONDOMS-PREM COVARYX...... 188 CLODERM...... 148 LUBRICATED...... 235, 236 COVARYX H.S...... 188 clomiphene citrate...... 190 CONDYLOX...... 153 COZAAR...... 70 clomipramine...... 95 CONJUPRI...... 78 CREON...... 202 clonazepam...... 86, 87, 107 CONSENSI...... 77 CRESTOR...... 74 clonidine...... 80 CONSTULOSE...... 211 CRINONE...... 190, 275 clonidine hcl...... 81, 102 CONTOUR TEST STRIPS...... 232 CRIXIVAN...... 43 clopidogrel...... 227 CONTRAVE...... 161 cromolyn...... 53, 253, 263 clorazepate dipotassium..... 86, 107 CONZIP...... 2 CROTAN...... 157 clotrimazole...... 142, 242, 274 COPAXONE...... 245 CRYSELLE (28)...... 126 clotrimazole-betamethasone..... 142 COPEGUS...... 38 CUPRIMINE...... 16, 23 clozapine...... 99, 100 COPIKTRA...... 55 CUROSURF...... 269 CLOZARIL...... 100 CORDARONE...... 72 CUTIVATE...... 148 C-NATE DHA...... 174 CORDRAN...... 148 CUVPOSA...... 244 COAGADEX...... 223 CORDRAN SP...... 148 cyanocobalamin (vitamin b-12) 177 coal tar...... 154 CORDRAN TAPE LARGE CYCLAFEM 1/35 (28)...... 126 coal tar (bulk)...... 122, 154 ROLL...... 148 CYCLAFEM 7/7/7 (28)...... 131 COARTEM...... 28 CORDRAN TAPE SMALL CYCLESSA (28)...... 131 codeine sulfate...... 2 ROLL...... 148 cyclobenzaprine...... 231 codeine-butalbital-asa-caff...... 7 COREG...... 69 CYCLOGYL...... 248 codeine-guaifenesin...... 273 COREG CR...... 69 CYCLOMYDRIL...... 247 CODITUSSIN AC...... 273 COREMINO...... 44, 135 cyclopentolate...... 249 CODITUSSIN DAC...... 273 CORGARD...... 77 cyclopen-tropic-phenyleph-watr COLAZAL...... 209 CORIFACT...... 224 ...... 247 colchicine...... 220 CORLANOR...... 83 cyclophosphamide...... 15, 47 COLCRYS...... 220 CORMAX...... 148 Last Approved Date: 09/23/2021 Formulary Version: 91
283 cyclop-trop-propa-phen-ket-wat DELESTROGEN...... 189 desvenlafaxine succinate...... 93 ...... 247 DELSTRIGO...... 33 DETROL...... 219 cycloserine...... 33 DELTA D3...... 178 DETROL LA...... 219 CYCLOSET...... 182 DELTASONE...... 190 DEXABLISS...... 190 cyclosporine...... 15, 229 DELTEC COZMO CLEO dexamethasone...... 190 CYCLOSPORINE IN INFUSION SET...... 236 DEXAMETHASONE KLARITY...... 250 DELYLA (28)...... 127 INTENSOL...... 190 cyclosporine modified...... 15, 229 DELZICOL...... 209 dexamethasone sodium phos CYMBALTA...... 93 DEMADEX...... 81 (pf)...... 190 cyproheptadine...... 260 demeclocycline...... 44 dexamethasone sodium CYRED...... 126 DEMEROL...... 2 phosphate...... 191, 249 CYRED EQ...... 126 DEMEROL (PF)...... 2 dexchlorpheniramine maleate CYSTADANE...... 240 DEMSER...... 84 ...... 259, 260 CYSTADROPS...... 251 DENAVIR...... 145 DEXCOM G4 RECEIVER CYSTAGON...... 214 DENTA 5000 PLUS...... 241 ...... 234, 236 CYSTARAN...... 251 DENTAGEL...... 241 DEXCOM G4 TRANSMITTER CYTOMEL...... 199 DEPAKENE...... 88, 108 ...... 234, 236 CYTOTEC...... 205 DEPAKOTE...... 88, 108 DEXCOM G5 RECEIVER CYTOVENE...... 35 DEPAKOTE ER...... 88, 108, 113 ...... 234, 236 CYTRA-2...... 216 DEPAKOTE SPRINKLES.88, 108 DEXCOM G5 TRANSMITTER CYTRA-3...... 216 DEPEN TITRATABS...... 16, 23 ...... 234, 237 CYTRA-K...... 216 DEPO-ESTRADIOL...... 189 DEXCOM G5-G4 SENSOR D.H.E.45...... 114 DEPO-PROVERA...... 56, 125 ...... 234, 237 DAILY PRENATAL...... 174 DEPO-SUBQ PROVERA 104. 125 DEXCOM G6 RECEIVER DAKLINZA...... 38 DEPO-TESTOSTERONE...... 180 ...... 234, 237 dalfampridine...... 245 DERMACINRX PRIZOPAK...154 DEXCOM G6 SENSOR...234, 237 DALIRESP...... 264 DERMACINRX PUREFOLIX 177 DEXCOM G6 TRANSMITTER danazol...... 192 DERMA-SMOOTHE/FS ...... 234, 237 DANTRIUM...... 232 BODY OIL...... 148 DEXCOM RECEIVER.... 234, 237 dantrolene...... 232 DERMA-SMOOTHE/FS DEXEDRINE...... 103, 111, 118 dapsone...... 28, 135 SCALP OIL...... 148 DEXEDRINE SPANSULE...... 111 DAPTACEL (DTAP DERMATOP...... 148 DEXILANT...... 204 PEDIATRIC) (PF)...... 62 DERMAZENE...... 143 dexmethylphenidate...... 103 DARAPRIM...... 28 DERMOTIC OIL...... 258 DEXONTO...... 191 DASETTA 1/35 (28)...... 127 DESCOVY...... 31 DEXPAK 10 DAY...... 191 DASETTA 7/7/7 (28)...... 131 desflurane...... 21 DEXPAK 13 DAY...... 191 DAURISMO...... 52 desipramine...... 95 DEXPAK 6 DAY...... 191 DAXBIA...... 34 desmopressin...... 181 dextroamphetamine DAYPRO...... 19 desog-e.estradiol/e.estradiol.....125 ...... 103, 104, 111, 112, 118 DAYSEE...... 125 DESOGEN...... 127 dextroamphetamine- DAYTRANA...... 103 desogestrel-ethinyl estradiol.....127 amphetamine.....104, 111, 118, 119 DAYVIGO...... 120 DESONATE...... 148 dextromethorphan-guaifenesin. 271 DDAVP...... 181 desonide...... 148 DIACOMIT...... 91 DEBACTEROL...... 242 DESOWEN...... 148 DIALYVITE...... 162, 164 DEBLITANE...... 131 desoximetasone...... 148, 149 DIALYVITE 3000...... 162 DECADRON...... 190 DESOXYN...... 111 DIALYVITE 5000...... 170 deferasirox...... 23 desvenlafaxine...... 93 DIALYVITE 800...... 162 deferiprone...... 23 desvenlafaxine fumarate...... 93 DIALYVITE 800 WITH IRON171 Last Approved Date: 09/23/2021 Formulary Version: 91
284 DIALYVITE 800 WITH ZINC DIPHEN...... 259, 260 DROXIA...... 227 15...... 162 diphenhydramine hcl.119, 259, 260 droxidopa...... 80 DIALYVITE 800 WITH ZINC diphenoxylate-atropine...... 200 DRYSOL...... 143 50...... 162 DIPROLENE (AUGMENTED)149 DRYSOL DAB-O-MATIC...... 144 DIALYVITE SUPREME D...... 162 DIPROLENE AF...... 149 DUAKLIR PRESSAIR...... 266 DIAMOX SEQUELS...... 81 dipyridamole...... 227 DUAVEE...... 188 DIASTAT...... 87, 107 DISALCID...... 21 DUCODYL (BISACODYL).... 213 DIASTAT ACUDIAL...... 87, 107 DISCOVISC...... 254 DUETACT...... 184 diazepam...... 86, 87, 88, 107 DISKETS...... 2 DUEXIS...... 17 DIAZEPAM INTENSOL... 86, 107 disopyramide phosphate...... 71 DULCOLAX BOWEL PREP diazoxide...... 179 disulfiram...... 121 KIT(BICOD)...... 213 DIBENZYLINE...... 83 DITROPAN XL...... 219 DULERA...... 267 DICAL-D...... 167 DIURIL...... 82 duloxetine...... 93, 94, 113 DICLEGIS...... 200 divalproex...... 88, 108, 113 DUOBRII...... 138 diclofenac epolamine...... 155 DIVIGEL...... 189 DUODOTE...... 23 diclofenac potassium...... 19 dofetilide...... 72 DUONEB...... 266 diclofenac sodium19, 143, 155, 250 DOJOLVI...... 172 DUOPA...... 96 diclofenac submicronized...... 19 DOLOPHINE...... 2 DUOVISC VISCO ELASTIC.. 254 diclofenac-misoprostol...... 17 DONATUSSIN PEDI DUPIXENT PEN...... 140, 263 dicloxacillin...... 42 (REFORMULATED)...... 269 DUPIXENT SYRINGE.... 140, 263 dicyclomine...... 207 donepezil...... 124 DURAFLU...... 270 didanosine...... 31 DONNATAL...... 207 DURAGESIC...... 3 diethylpropion...... 160 DOPTELET (10 TAB PACK)..228 DURAMORPH (PF)...... 3 DIFFERIN...... 138 DOPTELET (15 TAB PACK)..228 DUREX AVANTI BARE DIFICID...... 40 DOPTELET (30 TAB PACK)..228 REAL FEEL...... 235, 237 diflorasone...... 149 DORAL...... 107, 119 DUREZOL...... 249 DIFLUCAN...... 27 DORYX...... 44 DURLAZA...... 21, 226 diflunisal...... 21 dorzolamide...... 251 dutasteride...... 216 DIGITEK...... 81 dorzolamide (pf)...... 251 DUTOPROL...... 79 DIGOX...... 81 dorzolamide-timolol...... 251 DUZALLO...... 220 digoxin...... 81 dorzolamide-timolol (pf)...... 251 D-VI-SOL...... 178 dihydroergotamine...... 114 DOTHELLE DHA...... 170 D-VITA...... 178 DILANTIN...... 89 DOTTI...... 189 DVORAH...... 7 DILANTIN EXTENDED...... 89 DOVATO...... 30 DXEVO...... 191 DILANTIN INFATABS...... 89 DOVONEX...... 144 DYANAVEL XR...... 104, 111 DILANTIN KAPSEAL...... 89 doxazosin...... 84 DYAZIDE...... 82 DILANTIN-125...... 89 doxepin...... 96, 120, 157 DYMISTA...... 269 DILATRATE-SR...... 71 doxycycline hyclate...... 44, 244 DYNAMIC...... 243 DILAUDID...... 2 doxycycline monohydrate DYNAMIC PLUS PAK...... 243 DILAUDID (PF)...... 2 ...... 44, 45, 156 DYRENIUM...... 82 DILAUDID-HP (PF)...... 2 doxylamine-pyridoxine (vit b6).200 E.C. PRIN...... 21, 227 DILT-CD...... 77 D-PENAMINE...... 16, 23 E.E.S. 200...... 41 diltiazem hcl...... 77, 78 DRISDOL...... 178 E.E.S. 400...... 41 DILT-XR...... 78 DRITHOCREME HP...... 144 E.E.S. GRANULES...... 41 dimethyl fumarate...... 245 DRIZALMA SPRINKLE... 93, 112 EAR POPPER INFLATION DIOVAN...... 70 dronabinol...... 110, 161, 201 DEVICE...... 236, 237 DIOVAN HCT...... 69 drospirenone-e.estradiol-lm.fa. 127 EASY TOUCH BLU LINK DIPENTUM...... 209 drospirenone-ethinyl estradiol..127 TEST STRIP...... 232, 237 Last Approved Date: 09/23/2021 Formulary Version: 91
285 EASY TRAK II TEST STRIP ELIQUIS DVT-PE TREAT ENTOCORT EC...... 209 ...... 232, 237 30D START...... 221 ENTRESTO...... 70 EC-NAPROSYN...... 19 ELITE-OB...... 170 ENULOSE...... 202 EC-NAPROXEN...... 19 ELIXOPHYLLIN...... 264 ENVARSUS XR...... 229 econazole...... 142 ELLA...... 133 ENZOCLEAR...... 137 ECONTRA EZ...... 133, 134 ELMIRON...... 214 EPANED...... 68 ECONTRA ONE-STEP....133, 134 ELOCON...... 149 EPCLUSA...... 38 ECOTRIN...... 21, 227 ELOCTATE...... 223 EPIDIOLEX...... 88 ECOTRIN LOW STRENGTH ELURYNG...... 133 EPIDUO...... 137 ...... 21, 227 EMADINE...... 249 EPIDUO FORTE...... 137 ECOZA...... 142 EMCYT...... 51 EPIFOAM...... 152 ED A-HIST...... 258 EMEND...... 202 epinastine...... 249 ED A-HIST DM...... 270 EMFLAZA...... 191 epinephrine...... 80, 261 EDARBI...... 70 EMGALITY PEN...... 113 EPINEPHRINESNAP-V...... 80 EDARBYCLOR...... 69 EMGALITY SYRINGE..... 86, 113 EPIPEN...... 80 EDECRIN...... 81 EMOQUETTE...... 127 EPIPEN 2-PAK...... 80 EDEX...... 159 EMPAVELI...... 221, 227 EPIPEN JR...... 80 EDLUAR...... 120 EMSAM...... 92 EPIPEN JR 2-PAK...... 80 ED-SPAZ...... 206, 219 emtricitabine...... 31 EPISIL...... 243 EDURANT...... 30 emtricitabine-tenofovir (tdf)...... 31 EPITOL...... 89, 108 EEMT...... 188 EMTRIVA...... 31 EPIVIR...... 31 EEMT HS...... 188 EMULSION SB...... 146 EPIVIR HBV...... 37 efavirenz...... 30 EMVERM...... 25 eplerenone...... 68, 81 efavirenz-emtricitabin-tenofov....33 ENABLEX...... 218 EPOGEN...... 222 efavirenz-lamivu-tenofov disop...33 enalapril maleate...... 68 eprosartan...... 70 EFFER-K...... 169 enalapril-hydrochlorothiazide....67 EPZICOM...... 33 EFFEXOR XR...... 94 ENBRACE HR...... 171 EQUETRO...... 108 EFFIENT...... 227 ENBREL...... 12, 13 ergocalciferol (vitamin d2)...... 178 EFUDEX...... 143 ENBREL MINI...... 12, 13 ergoloid...... 124 EGRIFTA...... 192 ENBREL SURECLICK...... 12, 14 ERGOMAR...... 114 EGRIFTA SV...... 192 ENDARI...... 162, 172, 228 ergotamine-caffeine...... 114 ELDERCAPS...... 170 ENDOCET...... 10 ERIVEDGE...... 52 ELEMENT TEST STRIPS...... 232 ENDOMETRIN...... 190 ERLEADA...... 48 ELEPSIA XR...... 91 ENGERIX-B (HEPATITIS erlotinib...... 46 ELESTAT...... 249 B)VACCINE...... 61 ERRIN...... 131 ELESTRIN...... 189 ENGERIX-B (PF)...... 61 ERTACZO...... 142 ELETONE...... 146 ENGERIX-B PEDIATRIC (PF).61 ERY PADS...... 135 eletriptan...... 115 ENJUVIA...... 189 ERYGEL...... 136 ELIDEL...... 145 enoxaparin...... 225 ERYPED...... 41 ELIGARD...... 53 ENPRESSE...... 131 ERYPED 200...... 41 ELIGARD (3 MONTH)...... 53 ENSKYCE...... 127 ERYPED 400...... 41 ELIGARD (4 MONTH)...... 53 ENSPRYNG...... 230 ERY-TAB...... 41 ELIGARD (6 MONTH)...... 53 ENSTILAR...... 138 ERYTHROCIN (AS ELIMITE...... 157 entecavir...... 37 STEARATE)...... 41 ELINEST...... 127 ENTEREG...... 24 erythromycin...... 41, 255 ELIPHOS...... 215 ENTERIC COATED ASPIRIN erythromycin ethylsuccinate...... 41 ELIQUIS...... 221 ...... 21, 227 erythromycin stearate...... 41 ENTERO VU...... 158 erythromycin with ethanol...... 136 Last Approved Date: 09/23/2021 Formulary Version: 91
286 erythromycin-benzoyl peroxide.136 EVERSENSE SENSOR- FARBEE WITH C...... 163 ESBRIET...... 274 HOLDER...... 234, 237 FARESTON...... 58 ESCAVITE...... 172 EVISTA...... 198 FARXIGA...... 183 ESCAVITE D...... 172 EVOCLIN...... 136 FARYDAK...... 52 ESCAVITE LQ...... 172 EVOTAZ...... 32, 43 FASENRA PEN...... 263 escitalopram oxalate...... 92 EVOXAC...... 244 FAYOSIM...... 131 ESGIC...... 12 EVRYSDI...... 232 FAZACLO...... 100 esomeprazole magnesium...... 204 EVZIO...... 24 FC2 FEMALE CONDOM 234, 237 esomeprazole strontium...... 204 EXALGO ER...... 3 FE C PLUS...... 167 ESPEROCT...... 223 EXELDERM...... 142 febuxostat...... 220 ESTARYLLA...... 127 EXELON...... 124 FEIBA NF...... 221 estazolam...... 107, 119 EXELON PATCH...... 124 felbamate...... 88 ESTRACE...... 189, 275 exemestane...... 49 FELBATOL...... 88 estradiol...... 189, 275 EXFORGE...... 69 FELDENE...... 18 ESTRADIOL EXFORGE HCT...... 69 felodipine...... 78 TRANSDERMAL PATCH...... 189 EXJADE...... 23 FEM PH...... 275 estradiol valerate...... 189 EXSERVAN...... 230 FEMARA...... 49 estradiol-norethindrone acet.... 188 EXTAVIA...... 244 FEMCAP...... 233, 237 ESTRING...... 275 EXTINA...... 142 FEMCON FE...... 127 ESTROGEL...... 189 EYLEA...... 253, 256 FEMHRT LOW DOSE...... 188 estrogens-methyltestosterone....188 EYSUVIS...... 249 FEMRING...... 275 estropipate...... 189 E-Z DISK...... 158 FEMYNOR...... 127 ESTROSTEP FE-28...... 132 EZ FLU 2016-17 (AFLURIA) fenofibrate...... 73 eszopiclone...... 120 (PF)...... 64 fenofibrate micronized...... 73 ethacrynic acid...... 82 EZ FLU 2016-17 (FLUVIRIN) fenofibrate nanocrystallized...... 73 ethambutol...... 34 (PF)...... 64 fenofibric acid...... 73 ethosuximide...... 91 EZ FLU 2018- fenofibric acid (choline)...... 73 ethyl acetate...... 123 19(FLUCELVAX)(PF)...... 64 FENOGLIDE...... 73 ethyl chloride...... 155 EZ FLU16-17(FLUZON QD fenoprofen...... 19 ethynodiol diac-eth estradiol.... 127 PED)(PF)...... 64 fentanyl...... 3 etidronate disodium...... 187 EZALLOR SPRINKLE...... 74 fentanyl citrate...... 3 etodolac...... 20 E-Z-CAT DRY...... 158 FENTORA...... 3 etonogestrel-ethinyl estradiol... 133 ezetimibe...... 75 FEOSOL...... 167 etoposide...... 50 ezetimibe-simvastatin...... 76 FERGON...... 167 etravirine...... 30 E-Z-HD BARIUM...... 158 FER-IN-SOL...... 168 EUCRISA...... 140 E-Z-PAQUE...... 158 FERIVA FA (WITH EURAX...... 157 E-Z-PASTE...... 158 QUATREFOLIC)...... 168 EUTHYROX...... 199 FA-8...... 178 FEROCON...... 168 EVAMIST...... 189 FABB...... 177 FERREX 150 FORTE...... 168 EVEKEO...... 104, 112, 119 FABIOR...... 138 FERREX 150 FORTE PLUS....168 EVEKEO ODT...... 104, 112 FACTIVE...... 36 FERREX 28...... 168 EVENCARE PROVIEW TEST FALLBACK SOLO...... 133, 134 ferric subsulfate (bulk)...... 122, 225 STRIP...... 232, 237 FALMINA (28)...... 127 FERRIPROX...... 23 EVENITY...... 186 famciclovir...... 39 FERROCITE PLUS...... 168 everolimus (antineoplastic)...... 54 famotidine...... 203 FERROGELS FORTE...... 168 everolimus FAMVIR...... 39 FETZIMA...... 94 (immunosuppressive)...... 230 FANAPT...... 99 FEXMID...... 231 FANTASY CONDOM..... 235, 237 fexofenadine...... 261 Last Approved Date: 09/23/2021 Formulary Version: 91
287 fexofenadine-pseudoephedrine. 259 FLUAD 2019-2020 (65 YR FLUCELVAX QUAD 2020- FIASP FLEXTOUCH U-100 UP)(PF)...... 64 2021...... 65 INSULIN...... 195 FLUAD 2020-2021 (65 YR FLUCELVAX QUAD 2020- FIASP PENFILL U-100 UP)(PF)...... 64 2021 (PF)...... 65 INSULIN...... 195 FLUAD QUAD 2020-21(65Y FLUCELVAX QUAD 2021- FIASP U-100 INSULIN...... 195 UP)(PF)...... 64 2022 (PF)...... 65 FIBRICOR...... 73 FLUAD QUAD 2021-22(65Y fluconazole...... 27 FIBRYGA...... 224 UP)(PF)...... 64 flucytosine...... 27 FINACEA...... 136, 156 FLUARIX QUAD 2016-2017 fludrocortisone...... 197 finasteride...... 157, 216 (PF)...... 64 FLULAVAL QUAD 2016-2017 65 FINTEPLA...... 91 FLUARIX QUAD 2017-2018 FLULAVAL QUAD 2016-2017 FIORICET...... 12 (PF)...... 64 (PF)...... 65 FIORICET WITH CODEINE...... 7 FLUARIX QUAD 2018-2019 FLULAVAL QUAD 2017-2018 65 FIORINAL...... 20 (PF)...... 64 FLULAVAL QUAD 2017-2018 FIORINAL-CODEINE #3...... 7 FLUARIX QUAD 2019-2020 (PF)...... 65 FIRAZYR...... 77 (PF)...... 65 FLULAVAL QUAD 2018-2019 65 FIRDAPSE...... 245 FLUARIX QUAD 2020-2021 FLULAVAL QUAD 2018-2019 FIRMAGON...... 53 (PF)...... 65 (PF)...... 65 FIRMAGON KIT W DILUENT FLUARIX QUAD 2021-2022 FLULAVAL QUAD 2019-2020 65 SYRINGE...... 53 (PF)...... 65 FLULAVAL QUAD 2019-2020 FIRVANQ...... 36 FLUBLOK 2016-2017 (PF)...... 65 (PF)...... 65 FLAC OTIC OIL...... 258 FLUBLOK 2017-2018 (PF)...... 65 FLULAVAL QUAD 2020-2021 FLAGYL...... 29 FLUBLOK QUAD 2017-2018 (PF)...... 65 FLAREX...... 249 (PF)...... 65 FLULAVAL QUAD 2021-2022 flavoxate...... 219 FLUBLOK QUAD 2018-2019 (PF)...... 65 flecainide...... 72 (PF)...... 65 FLUMADINE...... 40 FLECTOR...... 155 FLUBLOK QUAD 2019-2020 FLUMIST QUAD 2016-2017 FLEET LAXATIVE (PF)...... 65 ...... 61, 65 (BISACODYL)...... 213 FLUBLOK QUAD 2020-2021 FLUMIST QUAD 2017-2018 FLOLIPID...... 74 (PF)...... 65 ...... 61, 65 FLOMAX...... 216 FLUBLOK QUAD 2021-2022 FLUMIST QUAD 2018-2019 FLONASE...... 270 (PF)...... 65 ...... 61, 65 FLORIVA...... 172 FLUCAINE...... 252 FLUMIST QUAD 2019-2020 FLORIVA (FLUORIDE- FLUCELVAX QUAD 2016- ...... 61, 65 VITAMIN D3)...... 172, 241 2017 (PF)...... 65 FLUMIST QUAD 2020-2021 FLORIVA PLUS...... 172 FLUCELVAX QUAD 2017- ...... 61, 65 FLORIVA PLUS (WITH 2018...... 65 FLUMIST QUAD 2021-2022 BIOTIN)...... 172 FLUCELVAX QUAD 2017- ...... 61, 66 FLOVENT DISKUS...... 262 2018 (PF)...... 65 flunisolide...... 270 FLOVENT HFA...... 262 FLUCELVAX QUAD 2018- fluocinolone...... 149 FLOWTUSS...... 273 2019...... 65 fluocinolone acetonide oil...... 258 FLOXIN...... 257 FLUCELVAX QUAD 2018- fluocinolone and shower cap.... 149 FLUAD 2016-2017 (65 YR 2019 (PF)...... 65 fluocinonide...... 149 UP)(PF)...... 64 FLUCELVAX QUAD 2019- FLUOCINONIDE-E...... 149 FLUAD 2017-2018 (65 YR 2020...... 65 fluocinonide-emollient...... 149 UP)(PF)...... 64 FLUCELVAX QUAD 2019- FLUORABON...... 241 FLUAD 2018-2019 (65 YR 2020 (PF)...... 65 FLUOR-A-DAY...... 241 UP)(PF)...... 64 Last Approved Date: 09/23/2021 Formulary Version: 91
288 FLUOR-A-DAY (WITH FLUZONE QUAD 2016-2017 FORADIL AEROLIZER...... 265 XYLITOL)...... 241 (PF)...... 66 FORANE...... 21 fluorescein-benoxinate...... 252, 253 FLUZONE QUAD 2017-2018 FORFIVO XL...... 95 fluorescein-proparacaine...... 252 (PF)...... 66 FORMADON...... 60 fluoride (sodium)...... 241 FLUZONE QUAD 2018-2019... 66 formoterol fumarate...... 265 FLUORIDEX DAILY FLUZONE QUAD 2018-2019 FORTAMET...... 195 DEFENSE...... 242 (PF)...... 66 FORTAVIT...... 171 FLUORIDEX SENSITIVITY FLUZONE QUAD 2019-2020... 66 FORTEO...... 186 RELIEF...... 242 FLUZONE QUAD 2019-2020 FORTESTA...... 180 FLUORITAB...... 242 (PF)...... 66 FORTICAL...... 188 fluorometholone...... 249 FLUZONE QUAD 2020-2021... 66 FORTISCARE G1 TEST FLUOROPLEX...... 143 FLUZONE QUAD 2020-2021 STRIP...... 233, 237 fluorouracil...... 143 (PF)...... 66 FOSAMAX...... 187 fluoxetine...... 92 FLUZONE QUAD 2021-2022 FOSAMAX PLUS D...... 187 fluphenazine decanoate...... 101 (PF)...... 66 fosamprenavir...... 43 fluphenazine hcl...... 101 FLUZONE QUAD PEDI 2016- foscarnet...... 35 FLURA-DROPS...... 242 17 (PF)...... 66 FOSCAVIR...... 35 flurandrenolide...... 149 FLUZONE QUAD PEDI 2017- fosfomycin tromethamine....26, 217 flurazepam...... 107, 119 18 (PF)...... 66 fosinopril...... 68 flurbiprofen...... 19 FLUZONE QUAD PEDI 2018- fosinopril-hydrochlorothiazide... 67 flurbiprofen sodium...... 250 19 (PF)...... 66 FOSRENOL...... 215 FLUROX...... 252, 253 FLUZONE QUAD PEDI 2019- FOTIVDA...... 56 flutamide...... 48 20 (PF)...... 66 FRAGMIN...... 225 fluticasone propionate...... 149, 270 FML FORTE...... 249 FREESTYLE INSULINX...... 233 fluticasone propion-salmeterol.267 FML LIQUIFILM...... 249 FREESTYLE LIBRE 10 DAY fluvastatin...... 74 FML S.O.P...... 249 READER...... 234, 237 FLUVIRIN 2016-2017...... 66 FOCALGIN 90 DHA...... 174 FREESTYLE LIBRE 10 DAY FLUVIRIN 2016-2017 (PF)...... 66 FOCALGIN CA...... 174 SENSOR...... 234, 237 FLUVIRIN 2017-2018...... 66 FOCALGIN DSS...... 168 FREESTYLE LIBRE 14 DAY FLUVIRIN 2017-2018 (PF)...... 66 FOCALIN...... 104 READER...... 234, 237 fluvoxamine...... 92 FOCALIN XR...... 104 FREESTYLE LIBRE 14 DAY FLUZONE HIGH-DOSE 2016- FOLBEE AR...... 163 SENSOR...... 234, 237 17 (PF)...... 66 FOLBEE PLUS...... 163 FREESTYLE LIBRE 2 FLUZONE HIGH-DOSE 2017- FOLGARD RX...... 177, 179 READER...... 234, 237 18 (PF)...... 66 FOLGARD RX 2.2...... 177, 179 FREESTYLE LIBRE 2 FLUZONE HIGH-DOSE 2018- folic acid...... 178, 179 SENSOR...... 234, 237 19 (PF)...... 66 FOLITAB...... 168 FREESTYLE LITE STRIPS.... 233 FLUZONE HIGH-DOSE 2019- FOLIVANE-F...... 168 FREESTYLE TEST...... 233 20 (PF)...... 66 FOLIVANE-OB...... 170 FRESHKOTE...... 247 FLUZONE HIGHDOSE QUAD FOLIVANE-PLUS...... 168 FROTEK...... 155 20-21 PF...... 66 FOLLISTIM AQ...... 190 FROVA...... 115 FLUZONE HIGHDOSE QUAD FOLTABS 800...... 177, 179 FUL-GLO...... 252 21-22 PF...... 66 FOLTRATE...... 177 FULL SPECTRUM B- FLUZONE INTRADERM fondaparinux...... 225 VITAMIN C...... 163 QUAD 2016-17...... 66 FORA 6 CONNECT FULPHILA...... 224 FLUZONE INTRADERM GLUCOSE STRIP...... 233, 237 FULYZAQ...... 200 QUAD 2017-18...... 66 FORA GTEL GLUCOSE TEST FURADANTIN...... 26, 217 STRIP...... 233, 237 furosemide...... 82 Last Approved Date: 09/23/2021 Formulary Version: 91
289 FUSION PLUS...... 168 GIALAX...... 211 GLYXAMBI...... 183 FUSION SPRINKLES...... 168 GIANVI (28)...... 127 GOCOVRI...... 98 FUZEON...... 30 GIAZO...... 209 GOJJI BLOOD GLUCOSE FYAVOLV...... 188 GILDAGIA...... 127 TEST STRIP...... 233, 237 FYCOMPA...... 87 GILDESS 1.5/30 (21)...... 127 GOLYTELY...... 212 G TUSSIN AC...... 273 GILDESS 1/20 (21)...... 127 GONAL-F...... 190 gabapentin...... 88 GILDESS 24 FE...... 127 GONAL-F RFF...... 190 GABITRIL...... 89 GILDESS FE 1.5/30 (28)...... 127 GONAL-F RFF PEN...... 190 GALAFOLD...... 241 GILDESS FE 1/20 (28)...... 127 GONAL-F RFF REDI-JECT....190 galantamine...... 124 GILENYA...... 246 GONITRO...... 71 GALZIN...... 23 GILOTRIF...... 46 GORDOFILM...... 153 ganciclovir sodium...... 35 GILPHEX TR...... 269 GRALISE...... 119 ganirelix...... 197 GILTUSS TR...... 271 GRALISE 30-DAY STARTER GARDASIL (PF)...... 63 GIMOTI...... 206 PACK...... 119 GARDASIL 9 (PF)...... 63 GIVLAARI...... 229 granisetron hcl...... 201 GASTROCROM...... 53 glatiramer...... 245 GRANIX...... 224 GASTROGRAFIN...... 158 GLATOPA...... 245 GRASTEK...... 60 GASTROMARK...... 159 GLEEVEC...... 56 GREEN GLO...... 252 gatifloxacin...... 255 GLEOSTINE...... 47 griseofulvin microsize...... 28 gatifloxacin-dexamethasone..... 248 glimepiride...... 183 griseofulvin ultramicrosize...... 28 GATTEX 30-VIAL...... 214 glipizide...... 183 GRIS-PEG GATTEX ONE-VIAL...... 214 glipizide (bulk)...... 122, 183 (ULTRAMICROSIZE)...... 28 GAVILAX...... 211 glipizide-metformin...... 183 GUAIATUSSIN AC...... 273 GAVILYTE-C...... 212 GLOPERBA...... 220 guaifenesin...... 269 GAVILYTE-G...... 212 GLOSTRIPS...... 252 GUAIFENESIN AC...... 273 GAVILYTE-H AND GLUCAGEN DIAGNOSTIC GUAIFENESIN DAC...... 273 BISACODYL...... 213 KIT...... 159 guanfacine...... 81, 102 GAVILYTE-N...... 212 GLUCAGEN HYPOKIT...... 179 guanidine...... 231 GAVRETO...... 59 GLUCAGON EMERGENCY GVOKE HYPOPEN 1-PACK..179 GELCLAIR...... 243 KIT (HUMAN)...... 179 GVOKE HYPOPEN 2-PACK..179 GELFILM...... 254 GLUCOPHAGE...... 195 GVOKE PFS 1-PACK GELNIQUE...... 219 GLUCOPHAGE XR...... 195 SYRINGE...... 180 GELX...... 243 GLUCOTROL...... 184 GVOKE PFS 2-PACK gemfibrozil...... 73 GLUCOTROL XL...... 184 SYRINGE...... 180 GEMMILY...... 127 GLUCOVANCE...... 183 GYNAZOLE-1...... 274 GEMTESA...... 215 GLUMETZA...... 195 GYNOL II...... 134 GENERESS FE...... 127 glutaraldehyde...... 60 HAEGARDA...... 221 GENERLAC...... 202 glyburide...... 184 HAILEY...... 127 GENGRAF...... 15, 229 glyburide (bulk)...... 122, 184 HAILEY 24 FE...... 127 GENOTROPIN...... 192 glyburide micronized...... 184 HAILEY FE 1.5/30 (28)...... 127 GENOTROPIN MINIQUICK.. 192 glyburide-metformin...... 183 halcinonide...... 149 GENTAK...... 254 GLYCATE...... 207 HALCION...... 107, 119 gentamicin...... 140, 254 GLYCOLAX...... 211 HALFPRIN...... 21, 227 GENTLE LAXATIVE glycolic acid (bulk)...... 122, 123 halobetasol propionate..... 144, 149 (BISACODYL)...... 213 glycopyrrolate...... 207 HALOG...... 149 GENTLELAX...... 211 GLYDO...... 156 HALONATE...... 152 GENVOYA...... 32 GLYNASE...... 184 haloperidol...... 100 GEODON...... 98, 109 GLYSET...... 182 haloperidol decanoate...... 100 Last Approved Date: 09/23/2021 Formulary Version: 91
290 haloperidol lactate...... 100 HPR...... 146 HUMULIN R REGULAR U- HARMONY GLUCOSE TEST HPR PLUS...... 146 100 INSULN...... 194 STRIP...... 233, 237 HPR PLUS HYDROGEL...... 146 HUMULIN R U-500 (CONC) HARVONI...... 38 HUMALOG JUNIOR INSULIN...... 194 HAVRIX (PF)...... 61 KWIKPEN U-100...... 195 HUMULIN R U-500 (CONC) HEALTHYLAX...... 211 HUMALOG KWIKPEN KWIKPEN...... 194 HEATHER...... 131 INSULIN...... 195 HYCAMTIN...... 59 HECTOROL...... 239 HUMALOG MIX 50-50 HYCODAN...... 272 HELIDAC...... 213 INSULN U-100...... 194 HYCOFENIX...... 273 HELIXATE FS...... 223 HUMALOG MIX 50-50 hydralazine...... 81 HEMADY...... 191 KWIKPEN...... 194 HYDREA...... 49 HEMANGEOL...... 77 HUMALOG MIX 75-25 HYDRO 35...... 153 HEMATINIC PLUS KWIKPEN...... 194 HYDRO 40...... 153 VIT/MINERALS...... 168 HUMALOG MIX 75-25(U- hydrochlorothiazide...... 82 HEMATINIC/FOLIC ACID.....168 100)INSULN...... 194 hydrocodone bitartrate...... 3 HEMATOGEN (WITH HUMALOG U-100 INSULIN..195 HYDROCODONE STOMACH CONC)...... 168 HUMAPEN LUXURA HD COMPOUND...... 272 HEMATOGEN FA...... 168 ...... 234, 237 hydrocodone-acetaminophen 7, 8, 9 HEMATOGEN FORTE...... 168 HUMATE-P...... 223 hydrocodone-chlorpheniramine271 HEMENATAL OB...... 174 HUMATROPE...... 192 hydrocodone-cpm-pseudoephed272 HEMENATAL OB + DHA...... 174 HUMIRA...... 12, 14, 210 hydrocodone-guaifenesin...... 273 HEMETAB...... 168 HUMIRA PEDIATRIC hydrocodone-homatropine...... 272 HEMLIBRA...... 223 CROHNS START...... 13, 14, 210 hydrocodone-ibuprofen...... 8, 9 HEMMOREX-HC...... 22 HUMIRA PEN...... 13, 14, 210 hydrocortisone.... 22, 150, 191, 209 HEMOCYTE-F...... 168 HUMIRA PEN CROHNS-UC- hydrocortisone acetate...... 22 HEMOFIL M HIGH...... 223 HS START...... 13, 14, 210 hydrocortisone butyrate...... 150 HEMOFIL M LOW...... 223 HUMIRA PEN PSOR- hydrocortisone butyr-emollient.150 HEMOFIL M MID...... 223 UVEITS-ADOL HS...... 13, 14, 210 hydrocortisone valerate...... 150 HEMOFIL M SUPER HIGH....223 HUMIRA(CF)...... 13, 14, 210 hydrocortisone-acetic acid...... 258 HEP FLUSH-10 (PF)...... 225 HUMIRA(CF) PEDI CROHNS hydrocortisone-pramoxine heparin (porcine)...... 225 STARTER...... 13, 14, 210 ...... 22, 150, 152 heparin flush(porcine)-0.9nacl. 225 HUMIRA(CF) PEN...... 13, 14, 210 HYDROMET...... 272 HEPARIN LOCK...... 225 HUMIRA(CF) PEN CROHNS- hydromorphone...... 3 HEPARIN LOCK FLUSH...... 225 UC-HS...... 13, 14, 210 hydromorphone (pf)...... 3 heparin, porcine (pf)...... 225 HUMIRA(CF) PEN hydromorphone (pf)-0.9 % nacl....3 HEPLISAV-B (PF)...... 61 PEDIATRIC UC...... 13, 14, 210 hydromorphone in 0.9 % nacl...... 3 HEPSERA...... 37 HUMIRA(CF) PEN PSOR-UV- hydromorphone in d5w (pf)...... 3 HETLIOZ...... 113 ADOL HS...... 13, 14, 210 hydroquinone...... 145 HETLIOZ LQ...... 113 HUMULIN 70/30 INSULIN hydroquinone microspheres...... 145 HEXALEN...... 47 PEN...... 193 hydroxocobalamin...... 177 HIBERIX (PF)...... 62 HUMULIN 70/30 U-100 hydroxychloroquine...... 14, 28 HI-CAL PLUS VIT D...... 167 INSULIN...... 193 hydroxyprogesterone capr(bulk) HIDEX...... 191 HUMULIN 70/30 U-100 ...... 197 HIPREX...... 41, 217 KWIKPEN...... 193 hydroxyurea...... 49 HISTEX-AC...... 272 HUMULIN N NPH INSULIN hydroxyzine hcl...... 86 HOMATROPAIRE...... 249 KWIKPEN...... 193 hydroxyzine pamoate...... 86 homatropine hbr...... 249 HUMULIN N NPH U-100 HYLATOPIC...... 146 HORIZANT...... 117 INSULIN...... 193 HYOLEV MB...... 41, 218 Last Approved Date: 09/23/2021 Formulary Version: 91
291 HYOPHEN...... 41, 218 INFED...... 168 IRESSA...... 46 hyoscyamine sulfate...... 206, 219 INFINITY TEST STRIPS...... 233 iron aspgly,ps-c-b12-fa-ca-suc. 168 HYOSYNE...... 206, 219 INFUMORPH P/F...... 3 iron fum,ag-c-b12-fa-ca-succ... 168 HYPER-SAL...... 123 INGREZZA...... 116, 117 IROSPAN 24/6...... 168 HYPOCYN...... 146 INGREZZA INITIATION ISENTRESS...... 30 HYSINGLA ER...... 3 PACK...... 116, 117 ISENTRESS HD...... 30 HYZAAR...... 69 INLYTA...... 57 ISIBLOOM...... 127 ibandronate...... 187 INNOPRAN XL...... 77 ISOCHRON...... 71 IBRANCE...... 50 INOVA...... 137 isoflurane...... 21 IBU...... 19 INOVA 4-1...... 137 isometh-dichloral- IBUDONE...... 8, 9 INOVA 8-2...... 137 acetaminophn...... 113 ibuprofen...... 19 INPEN (FOR HUMALOG) isoniazid...... 33 ibuprofen-famotidine...... 17 ...... 234, 237 ISOPTO ATROPINE...... 249 ibuprofen-oxycodone...... 10 INPEN (FOR NOVOLOG OR ISOPTO CARPINE...... 247 icatibant...... 77 FIASP)...... 234, 237 ISORDIL...... 71 ICLUSIG...... 54 INQOVI...... 59 ISORDIL TITRADOSE...... 71 icosapent ethyl...... 75 INREBIC...... 52 isosorbide dinitrate...... 71 IDELVION...... 222 INSPRA...... 68, 81 isosorbide mononitrate...... 71 IDHIFA...... 55 insulin asp prt-insulin aspart....194 isosulfan blue...... 159 IFEREX 150 FORTE...... 168 insulin aspart u-100...... 195 isotretinoin...... 134 ILARIS (PF)...... 12 insulin lispro...... 195 isoxsuprine...... 84 ILEVRO...... 250 insulin lispro protamin-lispro...194 isradipine...... 78 imatinib...... 56 INTELENCE...... 30 ISTALOL...... 252 IMBRUVICA...... 50, 57 INTERMEZZO...... 120 ISTURISA...... 179 IMCIVREE...... 161 INTRAROSA...... 197 itraconazole...... 27 imipramine hcl...... 96 INTRON A...... 52 ivermectin...... 26, 156, 157 imipramine pamoate...... 96 INTROVALE...... 127 IXINITY...... 222 imiquimod...... 153 INTUNIV ER...... 103 JADENU...... 23 IMITREX...... 115 INVEGA...... 99 JADENU SPRINKLE...... 24 IMITREX STATDOSE PEN....115 INVELTYS...... 249 JAKAFI...... 52 IMITREX STATDOSE INVIRASE...... 43 JALYN...... 214 REFILL...... 115 INVOKAMET...... 182 JANSSEN COVID-19 IMPAVIDO...... 29 INVOKAMET XR...... 182 VACCINE (EUA)...... 63 IMPEKLO...... 150 INVOKANA...... 183 JANTOVEN...... 221 IMPOYZ...... 144, 150 IODOFLEX...... 60 JANUMET...... 185 IMURAN...... 15, 230 IODOSORB...... 60 JANUMET XR...... 185 INBRIJA...... 97 IONSYS...... 3 JANUVIA...... 182 INCASSIA...... 131 IOPHEN C-NR...... 273 JARDIANCE...... 183 INCRELEX...... 196 IOPHEN DM-NR...... 271 JASMIEL (28)...... 127 INCRUSE ELLIPTA...... 264 IOPHEN-NR...... 269 JATENZO...... 180 indapamide...... 83 IOPIDINE...... 256 JENCYCLA...... 131 INDERAL LA...... 77 ipecac...... 24 JENTADUETO...... 185 INDERAL XL...... 77 IPOL...... 67 JENTADUETO XR...... 185 INDIOMIN MB...... 41, 218 ipratropium bromide...... 265, 269 JEVANTIQUE LO...... 188 INDOCIN...... 20 ipratropium-albuterol...... 266 JINTELI...... 188 indomethacin...... 20 IPRIVASK...... 228 JIVI...... 223 indomethacin submicronized...... 20 irbesartan...... 70 J-MAX...... 269 INFANRIX (DTAP) (PF)...... 62 irbesartan-hydrochlorothiazide..69 JOLESSA...... 127 Last Approved Date: 09/23/2021 Formulary Version: 91
292 JOLIVETTE...... 131 KIDS FIRST VITAMIN D3.....178 KRISTALOSE...... 211 JORNAY PM...... 104 KIMIDESS (28)...... 125 K-SOL...... 170 J-TAN D PD...... 258 KIMONO CONDOMS(NON- K-TAB...... 170 JUBLIA...... 142 LUBRICATED)...... 235, 237 KURVELO (28)...... 128 JULEBER...... 127 KIMONO MAXX CONDOMS KUVAN...... 241 JULUCA...... 30 ...... 235, 237 KYLEENA...... 125 JUNEL 1.5/30 (21)...... 127 KIMONO MICROTHIN KYNAMRO...... 72 JUNEL 1/20 (21)...... 127 AQUA LUBE CON...... 235, 237 KYNMOBI...... 98 JUNEL FE 1.5/30 (28)...... 127 KIMONO MICROTHIN l norgest/e.estradiol-e.estrad JUNEL FE 1/20 (28)...... 128 CONDOMS...... 235, 237 ...... 125, 131 JUNEL FE 24...... 128 KIMONO MICROTHIN labetalol...... 69 JUST D...... 178 LARGE CONDOMS...... 235, 238 LACRISERT...... 247 JUXTAPID...... 76 KIMONO TEXTURED lactic acid...... 146 JYNARQUE...... 215, 216 CONDOMS...... 235, 238 LACTIC ACID E...... 146 KADIAN...... 4 KINERET...... 16 lactulose...... 202, 211 KAITLIB FE...... 128 KINRIX (PF)...... 62 LAMICTAL...... 90 KALETRA...... 32 KIONEX...... 165 LAMICTAL ODT...... 90 KALEXATE...... 165 KIONEX (WITH SORBITOL) 165 LAMICTAL ODT STARTER KALLIGA...... 128 KISQALI...... 50 (BLUE)...... 90 KALYDECO...... 268 KISQALI FEMARA CO-PACK 53 LAMICTAL ODT STARTER KAPSPARGO SPRINKLE...... 76 KITABIS PAK...... 267 (GREEN)...... 90 KAPVAY...... 103 KLARON...... 136 LAMICTAL ODT STARTER KARBINAL ER...... 259, 260 KLISYRI...... 143 (ORANGE)...... 90 KARIVA (28)...... 125 KLOFENSAID II...... 155 LAMICTAL STARTER KATERZIA...... 78 KLONOPIN...... 87, 88, 107 (BLUE) KIT...... 90 KAYEXALATE...... 165 KLOR-CON...... 169 LAMICTAL STARTER KAZANO...... 185 KLOR-CON 10...... 169 (GREEN) KIT...... 90 K-EFFERVESCENT...... 169 KLOR-CON 8...... 169 LAMICTAL STARTER KEFLEX...... 34 KLOR-CON M10...... 169 (ORANGE) KIT...... 90 KELNOR 1/35 (28)...... 128 KLOR-CON M15...... 169 LAMICTAL XR...... 90 KELNOR 1-50 (28)...... 128 KLOR-CON M20...... 169 LAMICTAL XR STARTER KENALOG...... 150 KLOR-CON/25...... 169 (BLUE)...... 90 KEPPRA...... 91 KLOR-CON/EF...... 169 LAMICTAL XR STARTER KEPPRA XR...... 91 KLOXXADO...... 24 (GREEN)...... 90 KERAFOAM...... 153 KOATE...... 223 LAMICTAL XR STARTER KERENDIA...... 68 KOATE-DVI...... 223 (ORANGE)...... 90 KERYDIN...... 142 KOBEE...... 163 LAMISIL...... 26 KESIMPTA PEN...... 244 KOGENATE FS...... 223 lamivudine...... 31, 37 KETEK...... 40 KOMBIGLYZE XR...... 185 lamivudine-zidovudine...... 33 ketoconazole...... 27, 142 KORLYM...... 182 lamotrigine...... 90, 108 KETODAN...... 142 KOSELUGO...... 54 LAMPIT...... 29 KETODAN KIT...... 142 KOSHER PRENATAL PLUS lanolin (bulk)...... 122 ketoprofen...... 19 IRON...... 174 LANOXIN...... 81 ketorolac...... 18, 251 KOVALTRY...... 223 lansoprazole...... 204 ketotifen fumarate...... 249 K-PHOS NO 2...... 216 lanthanum...... 215 KEVEYIS...... 230 K-PHOS ORIGINAL...... 216 LANTUS SOLOSTAR U-100 KEVZARA...... 16 KPN...... 174 INSULIN...... 194 KHEDEZLA...... 94 KRINTAFEL...... 28 LANTUS U-100 INSULIN...... 194 Last Approved Date: 09/23/2021 Formulary Version: 91
293 lapatinib...... 45 LEVONEST (28)...... 132 LIQUID E-Z PAQUE...... 158 LARIN 1.5/30 (21)...... 128 levonorgestrel...... 133, 134 LIQUID POLIBAR PLUS...... 158 LARIN 1/20 (21)...... 128 levonorgestrel-ethinyl estrad.... 128 lisinopril...... 68 LARIN 24 FE...... 128 levonorg-eth estrad triphasic....132 lisinopril-hydrochlorothiazide....67 LARIN FE 1.5/30 (28)...... 128 LEVORA 0.15/30 (28)...... 128 LITE COAT ASPIRIN...... 21, 227 LARIN FE 1/20 (28)...... 128 LEVORA-28...... 128 lithium carbonate...... 110 LARISSIA...... 128 levorphanol tartrate...... 4 lithium citrate...... 110 LASIX...... 82 LEVO-T...... 199 LITHOBID...... 110 LASTACAFT...... 249 levothyroxine...... 199 LIVALO...... 74 latanoprost...... 256 LEVOXYL...... 199 LO LOESTRIN FE...... 125 latanoprost (pf)...... 256 LEVSIN...... 206, 219 LO MINASTRIN FE...... 128 LATISSE...... 157 LEVSIN/SL...... 206, 219 LOCOID...... 150 LATRIX...... 153 LEVULAN...... 155 LOCOID LIPOCREAM...... 150 LATUDA...... 98 LEXAPRO...... 92, 93 LOCORT...... 191 LAXACLEAR...... 211 LEXETTE...... 144, 150 LO-DOSE ASPIRIN...... 21, 227 LAXATIVE (BISACODYL)....213 LEXIVA...... 43 LODOSYN...... 97 LAXATIVE FEMININE...... 213 LIALDA...... 209 LOESTRIN 1.5/30 (21)...... 128 LAXATIVE PEG 3350...... 211 LIBRAX (WITH CLIDINIUM) LOESTRIN 1/20 (21)...... 128 LAYOLIS FE...... 128 ...... 107, 207 LOESTRIN 24 FE...... 128 LAZANDA...... 4 LICART...... 155 LOESTRIN FE 1.5/30 (28- ledipasvir-sofosbuvir...... 38 lidocaine...... 22, 157 DAY)...... 128 LEENA 28...... 132 lidocaine hcl...... 156, 157, 243 LOESTRIN FE 1/20 (28-DAY)128 leflunomide...... 17 lidocaine hcl-hydrocortison ac LOFIBRA...... 73 LENVIMA...... 57 ...... 22, 152 LOHIST - D...... 258 LESCOL...... 74 LIDOCAINE VISCOUS...... 243 LOHIST-DM...... 270 LESCOL XL...... 74 lidocaine-hydrocortisone-aloe LOKELMA...... 165 LESSINA...... 128 ...... 22, 23 LOMAIRA...... 161 LETAIRIS...... 85 lidocaine-phenylephrn in water 247 LOMEDIA 24 FE...... 128 letrozole...... 49 lidocaine-prilocaine...... 154 LOMOTIL...... 200 leucovorin calcium...... 60 lidocaine-tetracaine...... 157 LONHALA MAGNAIR LEUKERAN...... 47 LIDODERM...... 157 REFILL...... 264 LEUKINE...... 224 LIDO-K...... 157 LONHALA MAGNAIR leuprolide...... 53 LIDOPIN...... 157 STARTER...... 264 levalbuterol hcl...... 265 LIDOPRIL...... 154 LONSURF...... 49 levalbuterol tartrate...... 265 LIDO-SORB...... 157 loperamide...... 200 LEVAQUIN...... 36 LIDOZION...... 157 LOPID...... 73 LEVBID...... 206, 219 LIDTOPIC MAX...... 157 lopinavir-ritonavir...... 32 LEVEMIR FLEXTOUCH U- LILETTA...... 125 LOPREEZA...... 188 100 INSULN...... 194 LILLOW (28)...... 128 LOPRESSOR...... 76 LEVEMIR U-100 INSULIN.... 194 lindane...... 157 LOPRESSOR HCT...... 79 levetiracetam...... 91 linezolid...... 42 LOPROX...... 142 LEVITRA...... 160 LINZESS...... 202, 208 lorazepam...... 87, 107, 119 levobunolol...... 252 LIORESAL...... 231 LORAZEPAM INTENSOL87, 107 levocarnitine...... 162, 240 liothyronine...... 199 LORBRENA...... 47 levocarnitine (with sugar)...... 240 LIPITOR...... 74 LORCET (HYDROCODONE) 8, 9 levocetirizine...... 261 LIPOFEN...... 73 LORCET HD...... 8, 9 levofloxacin...... 36, 255 LIQUID CALCIUM WITH LORCET PLUS...... 8, 9 LEVOMEFOLATE DHA...... 171 VITAMIN D...... 167 LORTAB 10-325...... 8, 9 Last Approved Date: 09/23/2021 Formulary Version: 91
294 LORTAB 5-325...... 8, 9 LUXIQ...... 150 MAVENCLAD (8 TABLET LORTAB 7.5-325...... 8, 9 LUZU...... 142 PACK)...... 246 LORTAB ELIXIR...... 8, 9 LYMPHAZURIN...... 159 MAVENCLAD (9 TABLET LORTUSS EX...... 273 LYNPARZA...... 55 PACK)...... 246 LORYNA (28)...... 128 LYRICA...... 88, 112 MAVIK...... 68 LORZONE...... 231 LYRICA CR...... 112, 119 MAVYRET...... 37 losartan...... 70 LYSIPLEX PLUS...... 163 MAXALT...... 115 losartan-hydrochlorothiazide..... 69 LYSODREN...... 48 MAXALT-MLT...... 115 LOSEASONIQUE...... 125 LYSTEDA...... 225 MAXARON FORTE...... 169 LO-SO PREP...... 211 LYUMJEV KWIKPEN U-100 MAXIDEX...... 250 LOTEMAX...... 250 INSULIN...... 195 MAXINATE...... 174 LOTEMAX SM...... 250 LYUMJEV KWIKPEN U-200 MAXITROL...... 248 LOTENSIN...... 68 INSULIN...... 195 MAXI-TUSS CD...... 272 LOTENSIN HCT...... 67 LYUMJEV U-100 INSULIN....195 MAXZIDE...... 82 loteprednol etabonate...... 250 LYZA...... 131 MAXZIDE-25MG...... 82 LOTREL...... 67 MACNATAL CN DHA...... 174 MAYZENT...... 246 LOTRISONE...... 143 MACRILEN...... 159 MAYZENT STARTER PACK 246 LOTRONEX...... 208, 211 MACROBID...... 26, 217 MB HYDROGEL...... 146 lovastatin...... 74 MACRODANTIN...... 26, 217 M-CLEAR WC...... 274 LOVAZA...... 75 MACUZIN...... 170 MD-GASTROVIEW...... 158 LOVENOX...... 225 mafenide acetate...... 145 meclizine...... 200 LOW-OGESTREL (28)...... 128 magnesium citrate...... 211 meclofenamate...... 18 loxapine succinate...... 100 magnesium sulfate...... 169 MEDROL...... 191 LO-ZUMANDIMINE (28)...... 128 MALARONE...... 28 MEDROL (PAK)...... 191 LTA PRE-ATTACHED...... 22 MALARONE PEDIATRIC...... 28 medroxyprogesterone...... 125, 197 lubiprostone...... 208, 211 malathion...... 158 mefloquine...... 28 LUCEMYRA...... 120 maprotiline...... 96 MEGACE...... 161 LUDENT FLUORIDE...... 242 MAR-COF BP...... 272 MEGACE ES...... 161 LUGOLS...... 60 MAR-COF CG...... 274 megestrol...... 56, 161, 162 luliconazole...... 142 MARGESIC...... 12 MEKINIST...... 54 LUMAKRAS...... 53 MARINOL...... 110, 161, 201 MEKTOVI...... 54 LUMIGAN...... 256 MARLISSA (28)...... 128 meloxicam...... 18 LUNESTA...... 120 MARNATAL-F...... 174 meloxicam submicronized...... 18 LUPANETA PACK (1 MARPLAN...... 92 MELPAQUE HP...... 146 MONTH)...... 196 MARTEN-TAB...... 12 melphalan...... 47 LUPANETA PACK (3 MATULANE...... 47 MELQUIN 3...... 146 MONTH)...... 196 MATZIM LA...... 78 memantine...... 124 LUPKYNIS...... 229 MAVENCLAD (10 TABLET MEMBRANEBLUE...... 254 LUPRON DEPOT...... 53, 196 PACK)...... 245 MENACTRA (PF)...... 63 LUPRON DEPOT (3 MONTH) MAVENCLAD (4 TABLET M-END MAX D...... 272 ...... 53, 196 PACK)...... 245 M-END PE...... 272 LUPRON DEPOT (4 MONTH). 53 MAVENCLAD (5 TABLET MENEST...... 189 LUPRON DEPOT (6 MONTH). 53 PACK)...... 245 MENHIBRIX (PF)...... 63 LUPRON DEPOT-PED...... 196 MAVENCLAD (6 TABLET MENOMUNE - A/C/Y/W-135...63 LUPRON DEPOT-PED (3 PACK)...... 246 MENOMUNE - A/C/Y/W-135 MONTH)...... 196 MAVENCLAD (7 TABLET (PF)...... 63 LUTERA (28)...... 128 PACK)...... 246 MENOPUR...... 190 LUXAMEND...... 146 MENOSTAR...... 189 Last Approved Date: 09/23/2021 Formulary Version: 91
295 MENQUADFI (PF)...... 63 methyltestosterone...... 180 MIMVEY LO...... 188 MENTAX...... 141 metipranolol...... 252 MINASTRIN 24 FE...... 129 MENVEO A-C-Y-W-135-DIP metoclopramide hcl...... 206 MINIPRESS...... 84 (PF)...... 63 metolazone...... 83 MINIPRIN...... 21, 227 meperidine...... 4 METOPIRONE...... 159 MINITRAN...... 71 meperidine (pf)...... 4 metoprolol succinate...... 76 MINIVELLE...... 189 MEPHYTON...... 179 metoprolol su-hydrochlorothiaz. 79 MINOCIN...... 16, 17, 45 meprobamate...... 87 metoprolol ta-hydrochlorothiaz..79 minocycline...... 17, 45, 135 MEPRON...... 29 metoprolol tartrate...... 76 MINOLIRA ER...... 45, 135 mercaptopurine...... 49 METOZOLV ODT...... 206 minoxidil...... 81 mesalamine...... 209 METROCREAM...... 156 MIOCHOL-E...... 247 mesalamine with cleansing wipe METROGEL...... 156 MIOSTAT...... 247 ...... 209 METROGEL VAGINAL...... 275 MIRALAX...... 212 MESNEX...... 60 METROLOTION...... 156 MIRAPEX...... 98 MESTINON...... 230 metronidazole...... 29, 156, 275 MIRAPEX ER...... 98 MESTINON TIMESPAN...... 230 metyrosine...... 84 MIRCERA...... 222 METADATE CD...... 104 mexiletine...... 72 MIRCETTE (28)...... 125 METADATE ER...... 104 MIACALCIN...... 188 MIRENA...... 125 metaproterenol...... 266 MIBELAS 24 FE...... 129 mirtazapine...... 92 METAXALL...... 231 MICARDIS...... 70 MIRVASO...... 156 metaxalone...... 231 MICARDIS HCT...... 69 misoprostol...... 205 metformin...... 195 MICONAZOLE-3...... 274 MITIGARE...... 220 methadone...... 4 MICRODOT XTRA BLOOD M-M-R II (PF)...... 61, 66, 67 METHADONE INTENSOL...... 4 GLUCOSE...... 233, 238 M-NATAL PLUS...... 174 METHADOSE...... 4 MICROGESTIN 1.5/30 (21).... 129 MOBIC...... 18 methamphetamine...... 112 MICROGESTIN 1/20 (21)...... 129 modafinil...... 118 methazolamide...... 81 MICROGESTIN 24 FE...... 129 MODERIBA...... 39 methenamine hippurate...... 41, 217 MICROGESTIN FE 1.5/30 (28) MODERIBA DOSE PACK...... 39 methenamine mandelate..... 41, 217 ...... 129 MODERNA COVID-19 methen-sod phos-meth blue- MICROGESTIN FE 1/20 (28)..129 VACCINE (EUA)...... 63 hyos...... 41, 218 MICROZIDE...... 83 MODICON (28)...... 129 METHERGINE...... 197 midazolam...... 22, 107, 119, 120 moexipril...... 68 methimazole...... 186 midazolam (pf)...... 21, 107 moexipril-hydrochlorothiazide... 67 METHITEST...... 180 midazolam in 0.9 % sod chlorid molindone...... 100 methocarbamol...... 231 ...... 21, 107 mometasone...... 150, 270 methotrexate sodium...... 14, 48 midodrine...... 80 MONDOXYNE NL...... 45 methotrexate sodium (pf)...... 14, 48 mifepristone...... 179 MONODOX...... 45 methoxsalen...... 144 MIGERGOT...... 114 MONOJECT 0.9% SODIUM methscopolamine...... 206 miglitol...... 182 CHLORIDE...... 176 methyclothiazide...... 83 miglustat...... 240 MONOJECT PREFILL methyldopa...... 81 MIGRANAL...... 114 ADVANCED NS...... 176 methyldopa- MILI...... 129 MONOJECT PREFILL hydrochlorothiazide...... 80 MILK OF MAGNESIA...... 211 SALINE FLUSH...... 176 methylergonovine...... 197 MILK OF MAGNESIA MONO-LINYAH...... 129 METHYLIN...... 104, 118 CONCENTRATED...... 211 MONONESSA (28)...... 129 methylphenidate hcl.. 104, 105, 118 MILLIPRED...... 191 montelukast...... 263 METHYLPRED DP...... 191 MILLIPRED DP...... 191 MONUROL...... 26, 217 methylprednisolone...... 191 MIMVEY...... 188 MORGIDOX...... 45 Last Approved Date: 09/23/2021 Formulary Version: 91
296 morphine...... 4, 5 MYFEMBREE...... 196 NATURA-LAX...... 212 morphine (pf)...... 4 MYFERON 150 FORTE...... 169 NATURE-THROID...... 199 morphine concentrate...... 4 MYFORTIC...... 230 NAVELBINE...... 59 MOTEGRITY...... 205 MYKIDZ IRON FLUORIDE...172 NAYZILAM...... 88, 107 MOTOFEN...... 200 MYLERAN...... 47 NEBUPENT...... 41 MOVANTIK...... 24 MYNATAL...... 174 NEBUSAL...... 123 MOVIPREP...... 212 MYNATAL PLUS...... 174 NECON 0.5/35 (28)...... 129 MOXATAG...... 25 MYNATAL-Z...... 174 NECON 1/35 (28)...... 129 MOXEZA...... 255 MYNEPHROCAPS...... 163 NECON 1/50 (28)...... 129 moxifloxacin...... 36, 255 MYNEPHRON...... 163 NECON 10/11 (28)...... 126 MOZOBIL...... 221 MYORISAN...... 134 NECON 7/7/7 (28)...... 132 MS CONTIN...... 5 MYRBETRIQ...... 215 nefazodone...... 93 MUGARD...... 243, 244 MYSOLINE...... 87 neomycin...... 24 MULPLETA...... 228 MYTESI...... 200 neomycin-bacitracin-poly-hc....248 MULTAQ...... 72 MYZILRA...... 132 neomycin-bacitracin-polymyxin254 MULTICHEW...... 170 nabumetone...... 18 neomycin-polymyxin b- MULTIGEN...... 169 nadolol...... 77 dexameth...... 248 MULTIGEN FOLIC...... 169 nadolol-bendroflumethiazide...... 83 neomycin-polymyxin-gramicidin MULTIGEN PLUS...... 169 naftifine...... 141 ...... 254 MULTI-VIT WITH NAFTIN...... 141 neomycin-polymyxin-hc.... 248, 257 FLUORIDE-IRON...... 172 nalbuphine...... 11 NEONATAL-DHA...... 174 MULTIVITAMIN WITH NALFON...... 19 NEO-POLYCIN...... 254 FLUORIDE...... 172 NALOCET...... 10 NEO-POLYCIN HC...... 248 MULTI-VITAMIN WITH naloxone...... 24 NEORAL...... 16, 229 FLUORIDE...... 172 naltrexone...... 24 NEOSPORIN (NEO-POLYM- MULTIVITAMINS WITH NAMENDA...... 124 GRAMICID)...... 254 FLUORIDE...... 172, 173 NAMENDA TITRATION PAK NEPHPLEX RX...... 164 MULTIVIT-FLUOR (VIT E ...... 124 NEPHROCAPS...... 163 ACETATE)...... 173 NAMENDA XR...... 124 NEPHROCAPS QT...... 163 mupirocin...... 140 NAMZARIC...... 124 NEPHRO-VITE RX...... 164 mupirocin calcium...... 140 NAPRELAN CR...... 19 NEPTAZANE...... 81 MUSE...... 159 NAPROSYN...... 19 NERIA...... 236, 238 MVC-FLUORIDE...... 173 naproxen...... 19, 20 NERIA MULTI (BI- M-VIT...... 170 naproxen sodium...... 20 FURCATED)...... 236, 238 MY CHOICE...... 133, 134 naproxen-esomeprazole...... 18 NERIA MULTI (TRI- MY WAY...... 133, 134 naratriptan...... 115 FURCATED)...... 236, 238 MYALEPT...... 196 NARCAN...... 24 NERLYNX...... 46 MYAMBUTOL...... 34 NARDIL...... 92 NESINA...... 182 MYCAPSSA...... 198 NASACORT...... 270 NEUAC...... 136 MYCOBUTIN...... 34, 44 NASCOBAL...... 177 NEULASTA...... 224 mycophenolate mofetil...... 15, 230 NASONEX...... 270 NEULASTA ONPRO...... 224 mycophenolate sodium...... 230 NATACYN...... 255 NEUPOGEN...... 224 MYDAYIS...... 105, 111 NATALVIRT FLT...... 169 NEUPRO...... 98 MYDRIACYL...... 249 NATAZIA...... 131 NEURIN-SL...... 177 MYDRIATIC3 (TROP- nateglinide...... 182 NEURONTIN...... 88 CYCLOPENT-PE)...... 247 NATESTO...... 180 NEUTRASAL...... 243 MYDRIATIC4(TROP-PROP- NATPARA...... 197 NEVANAC...... 251 PE-KTRLC)...... 254 NATURAL B-100 COMPLEX 163 nevirapine...... 30 Last Approved Date: 09/23/2021 Formulary Version: 91
297 NEW DAY...... 133, 134 NIVA-PLUS...... 170 NOVOFINE AUTOCOVER.... 234 NEWGEN...... 174 NIVATOPIC PLUS...... 146 NOVOFINE PLUS...... 235, 238 NEXAVAR...... 54 NIVESTYM...... 224 NOVOLIN 70/30 U-100 NEXIUM...... 204 nizatidine...... 203 INSULIN...... 193 NEXIUM 24HR...... 204 NIZORAL...... 142 NOVOLIN 70-30 FLEXPEN NEXIUM PACKET...... 204 NOCDURNA (MEN)...... 181 U-100...... 193 NEXLETOL...... 72 NOCDURNA (WOMEN)...... 181 NOVOLIN N FLEXPEN...... 193 NEXLIZET...... 75 NOCTIVA...... 181 NOVOLIN N NPH U-100 NEXPLANON...... 124 NODOLOR...... 113 INSULIN...... 193 NEXT CHOICE...... 133 NOLIX...... 150 NOVOLIN R FLEXPEN...... 194 NEXT CHOICE ONE DOSE NORA-BE...... 131 NOVOLIN R REGULAR U- ...... 133, 134 NORCO...... 8, 9 100 INSULN...... 194 NEXTSTELLIS...... 129 NORDETTE (28)...... 129 NOVOLOG FLEXPEN U-100 niacin...... 75, 177 NORDITROPIN FLEXPRO.... 192 INSULIN...... 195 NIACOR...... 75 NORDITROPIN NORDIFLEX192 NOVOLOG MIX 70-30 U-100 NIASPAN EXTENDED- noreth-ethinyl estradiol-iron.... 129 INSULN...... 194 RELEASE...... 75 norethindrone (contraceptive).. 131 NOVOLOG MIX 70- nicardipine...... 78 norethindrone acetate...... 197 30FLEXPEN U-100...... 194 NICODERM CQ...... 121 norethindrone ac-eth estradiol NOVOLOG PENFILL U-100 NICORELIEF...... 121 ...... 129, 188, 189 INSULIN...... 195 NICORETTE...... 121 norethindrone-e.estradiol-iron. 129 NOVOLOG U-100 INSULIN nicotine...... 121 NORGESIC FORTE...... 231 ASPART...... 195 nicotine (polacrilex)...... 121 norgestimate-ethinyl estradiol NOVOPEN ECHO...... 235, 238 NICOTROL...... 121 ...... 129, 132 NOVOSEVEN RT...... 222 NICOTROL NS...... 122 norgestrel-ethinyl estradiol...... 129 NOVOTWIST...... 235, 238 NIFEDICAL XL...... 78 NORINYL 1/35 (28)...... 129 NOXAFIL...... 27 nifedipine...... 78 NORINYL 1+50 (28)...... 129 NP THYROID...... 199 NIKKI (28)...... 129 NORITATE...... 156 NPLATE...... 228 NILANDRON...... 48 NORLYDA...... 131 NTS STEP 1...... 122 nilutamide...... 48 NORLYROC...... 131 NUBEQA...... 48 nimodipine...... 79 NORMAL SALINE FLUSH.... 176 NUCALA...... 264 NINJACOF-XG...... 274 NORPACE...... 71 NUCYNTA...... 5 NINLARO...... 56 NORPACE CR...... 71 NUCYNTA ER...... 5 nisoldipine...... 78 NORPRAMIN...... 96 NUEDEXTA...... 119 nitazoxanide...... 29 NOR-Q-D...... 131 NULEV...... 206, 219 nitisinone...... 240 NORTHERA...... 80 NULYTELY WITH FLAVOR NITRO-BID...... 71 NORTREL 0.5/35 (28)...... 129 PACKS...... 212 NITRO-DUR...... 71 NORTREL 1/35 (21)...... 129 NUMOISYN...... 2, 243 nitrofurantoin...... 26, 217 NORTREL 1/35 (28)...... 129 NUPLAZID...... 102 nitrofurantoin macrocrystal26, 217 NORTREL 7/7/7 (28)...... 132 NURTEC ODT...... 114 nitrofurantoin monohyd/m-cryst nortriptyline...... 96 NUTRICAP...... 170 ...... 26, 217 NORVASC...... 78 NUTROPIN AQ...... 193 nitroglycerin...... 71 NORVIR...... 43 NUTROPIN AQ NUSPIN...... 192 NITROLINGUAL...... 71 NOURIANZ...... 96 NUVARING...... 133 NITROMIST...... 71 NOVAREL...... 193 NUVIGIL...... 118 NITROSTAT...... 71 NOVOEIGHT...... 223 NUWIQ...... 223 NITRO-TIME...... 71 NOVOFINE 30...... 234 NUZYRA...... 25, 45 NITYR...... 240 NOVOFINE 32...... 234 Last Approved Date: 09/23/2021 Formulary Version: 91
298 NUZYRA (7 DAY WITH omeprazole-sodium bicarbonate ORLADEYO...... 84 LOAD DOSE)...... 24, 45 ...... 205 orphenadrine citrate...... 231 NUZYRA (7 DAY)...... 24, 45 OMNARIS...... 270 orphenadrine-asa-caffeine...... 231 NYAMYC...... 141 OMNIPOD DASH 5 PACK ORPHENGESIC FORTE...... 231 NYATA...... 141 POD...... 235, 238 ORSYTHIA...... 130 NYMALIZE...... 79 OMNIPOD DASH PDM KIT ORTHO ALL-FLEX FITTING nystatin...... 27, 141, 242 ...... 235, 238 SET...... 233, 238 nystatin (bulk)...... 27, 122 OMNIPOD INSULIN REFILL ORTHO DIAPHRAGM ALL- nystatin-triamcinolone...... 143 ...... 235, 238 FLEX 65...... 233, 238 NYSTOP...... 141 OMNIPRED...... 250 ORTHO DIAPHRAGM ALL- NYVEPRIA...... 224 OMNITROPE...... 193 FLEX 70...... 233, 238 OB COMPLETE...... 170 ondansetron...... 201 ORTHO DIAPHRAGM ALL- OBIZUR...... 223 ondansetron hcl...... 201 FLEX 75...... 233, 238 OBREDON...... 274 ondansetron hcl (pf)...... 201 ORTHO DIAPHRAGM ALL- OBTREX...... 174 ONE DAILY PRENATAL...... 174 FLEX 80...... 233, 238 O-CAL F.A...... 171 ONETOUCH VERIO TEST ORTHO EVRA...... 133 O-CAL FA...... 174 STRIPS...... 233, 238 ORTHO MICRONOR...... 131 O-CAL PRENATAL...... 174 ONEXTON...... 136 ORTHO TRI-CYCLEN (28).... 132 OCALIVA...... 229 ONFI...... 88, 107 ORTHO TRI-CYCLEN LO OCELLA...... 129 ONGENTYS...... 97 (28)...... 132 octreotide acetate...... 198, 214 ONGLYZA...... 182 ORTHO-CEPT (28)...... 130 OCUCOAT...... 254 ONUREG...... 49 ORTHO-CYCLEN (28)...... 130 OCUFEN...... 251 ONZETRA XSAIL...... 115 ORTHO-NOVUM 1/35 (28).... 130 OCUFLOX...... 255 OPANA...... 5 ORTHO-NOVUM 7/7/7 (28)... 132 ODACTRA...... 60 OPANA ER...... 5 ORTIKOS...... 209 ODEFSEY...... 33 OPCICON ONE-STEP.....133, 134 OS-CAL 250+D (D2)...... 167 ODOMZO...... 52 opium tincture...... 200 OS-CAL 500 + D3...... 167 OFEV...... 57, 274 OPSUMIT...... 85 OSCIMIN...... 206, 219 ofloxacin...... 36, 255, 257 OPTION-2...... 133, 134 OSCIMIN SL...... 206, 219 OGESTREL (28)...... 129 ORACEA...... 45, 156 OSCIMIN SR...... 206, 219 OGIVRI...... 59 ORACIT...... 216 oseltamivir...... 39, 40 OKEBO...... 45 ORAL SALINE LAXATIVE... 212 OSENI...... 185 olanzapine...... 101, 109 ORALAIR...... 60 OSMOLEX ER...... 98 olanzapine-fluoxetine..95, 101, 109 ORALONE...... 243 OSMOPREP...... 212 olmesartan...... 70 ORAMAGICRX...... 243 OSPHENA...... 197 olmesartan-amlodipin-hcthiazid.69 ORAP...... 100 OTEZLA...... 17, 144 olmesartan-hydrochlorothiazide.70 ORA-PLUS...... 123 OTEZLA STARTER...... 17, 145 olopatadine...... 249, 269 ORAPRED ODT...... 191 OTOVEL...... 257 OLUMIANT...... 16 ORAVIG...... 27 OTREXUP (PF)...... 14, 15 OLUX...... 151 ORENCIA...... 15 OVACE...... 145 OLUX-E...... 151 ORENCIA CLICKJECT...... 15 OVACE PLUS...... 145 OLYSIO...... 37 ORENITRAM...... 84 OVCON-35 (28)...... 130 OMECLAMOX-PAK...... 213 ORFADIN...... 240 OVIDE...... 158 omega-3 acid ethyl esters...... 75 ORGAN-I NR...... 269 OVIDREL...... 193 OMEPPI...... 205 ORGOVYX...... 53 OXANDRIN...... 180 omeprazole...... 204 ORIAHNN...... 196 oxandrolone...... 180 omeprazole magnesium...... 204 ORILISSA...... 197 oxaprozin...... 20 ORKAMBI...... 268 OXAYDO...... 5 Last Approved Date: 09/23/2021 Formulary Version: 91
299 oxazepam...... 87, 107 PALFORZIA LEVEL 11 PEG-3350 WITH FLAVOR OXBRYTA...... 228 MAINTENANCE...... 62 PACKS...... 212 oxcarbazepine...... 89 paliperidone...... 99 peg3350-sod sul-nacl-kcl-asb-c 212 OXERVATE...... 252 PALYNZIQ...... 241 PEGANONE...... 89 oxiconazole...... 142 PAMELOR...... 96 PEGASYS...... 37 OXISTAT...... 142 pamidronate...... 187 PEGASYS PROCLICK...... 37 OXSORALEN ULTRA...... 144 PANCREAZE...... 202 peg-electrolyte soln...... 212 OXTELLAR XR...... 89 PANDEL...... 151 PEGINTRON...... 37 oxybutynin chloride...... 219 PANLOR(ACETAM-CAFF- PEGINTRON REDIPEN...... 37 oxycodone...... 5 DIHYDROCOD)...... 7 PEG-PREP...... 213 oxycodone-acetaminophen...... 10 PANRETIN...... 143 PE-GUAI...... 269 oxycodone-aspirin...... 10 pantoprazole...... 204 PEMAZYRE...... 51 OXYCONTIN...... 5 papaverine-alprostadil-water... 160 penicillamine...... 17, 23 oxymorphone...... 6 papav-phentolam-alprost-water160 penicillin g procaine...... 42 OXYTROL...... 219 PARAFON FORTE DSC...... 231 penicillin v potassium...... 42 OXYTROL FOR WOMEN...... 219 PARAGARD T 380A...... 125 PENLAC...... 142 OYSCO 500/D...... 167 paregoric...... 200 PENNSAID...... 155 OYSCO D...... 167 PAREMYD...... 247 PENTACEL (PF)...... 62 OYST-CAL-D 500...... 167 paricalcitol...... 239 PENTACEL ACTHIB OYSTER SHELL + D3...... 167 PARLODEL...... 97 COMPONENT (PF)...... 63 OYSTER SHELL CALCIUM- PARNATE...... 92 pentamidine...... 41 VIT D2...... 167 PAROEX ORAL RINSE...... 243 PENTASA...... 209 OYSTER SHELL CALCIUM- paromomycin...... 24 pentazocine-naloxone...... 11 VIT D3...... 167 paroxetine hcl...... 93 pentoxifylline...... 224 OYSTERCAL-D...... 167 paroxetine PEPCID...... 203 OZEMPIC...... 184, 185 mesylate(menop.sym)...... 197 PERCOCET...... 10 OZOBAX...... 231 PASER...... 33 PERFOROMIST...... 265 OZURDEX...... 250 PATADAY...... 249 PERIDEX...... 243 P D NATAL VITAMINS- PATADAY ONCE DAILY perindopril erbumine...... 68 FOLIC ACID...... 174 RELIEF...... 249 PERIOGARD...... 243 PACERONE...... 72 PATANASE...... 269 permethrin...... 158 PACNEX...... 137 PATANOL...... 249 permethrin (bulk)...... 122 PACNEX HP...... 137 PAXIL...... 93 perphenazine...... 101 PACNEX LP...... 137 PAXIL CR...... 93 perphenazine-amitriptyline...... 94 PALFORZIA (LEVEL 1)...... 62 PAZEO...... 249 PERRY PRENATAL...... 174 PALFORZIA (LEVEL 2)...... 62 PCE...... 41 PERSANTINE...... 227 PALFORZIA (LEVEL 3)...... 62 PCM LA...... 258 PERTZYE...... 202 PALFORZIA (LEVEL 4)...... 62 PED MULTIVITAMINS- PEXEVA...... 93 PALFORZIA (LEVEL 5)...... 62 A,B,D,E,K,ZN...... 172 PFIZER COVID-19 VACCINE PALFORZIA (LEVEL 6)...... 62 PEDIA D-VITE...... 178 (EUA)...... 63 PALFORZIA (LEVEL 7)...... 62 PEDIADERM HC...... 152 PHENADOZ...... 201, 259, 260 PALFORZIA (LEVEL 8)...... 62 PEDIAPRED...... 191 phenazopyridine...... 217 PALFORZIA (LEVEL 9)...... 62 PEDIARIX...... 61, 62 phendimetrazine tartrate...... 161 PALFORZIA (LEVEL 10)...... 62 PEDIARIX (PF)...... 61, 62 phenelzine...... 92 PALFORZIA (LEVEL 11 UP- pediatric multivitamin-fl...... 173 PHENERGAN...... 201, 259, 260 DOSE)...... 62 PEDVAX HIB (PF)...... 63 phenobarb-hyoscy-atropine- PALFORZIA INITIAL DOSE... 62 peg 3350-electrolytes...... 212 scop...... 207 PEG 3350-GRX...... 122, 123 phenobarbital...... 87, 119 Last Approved Date: 09/23/2021 Formulary Version: 91
300 PHENOHYTRO...... 207 PNV-SELECT...... 174 PRANDIN...... 182 phenoxybenzamine...... 84 PNV-VP-U...... 171 prasugrel...... 227 phentermine...... 161 podofilox...... 153 PRAVACHOL...... 74 phentolam-alprostadil in water 159 POLYCIN...... 254 pravastatin...... 74 phenylephrine hcl...... 252 polyethylene glycol 3350...... 212 praziquantel...... 26 phenyleph-tropicamide in water polyethylene glycol 400 (bulk) prazosin...... 84 ...... 247 ...... 122, 123 PRECISION PCX PLUS TEST233 PHENYLHISTINE...... 273 POLY-IRON 150 FORTE...... 169 PRECISION PCX TEST...... 233 PHENYLHISTINE DH...... 272 polymyxin b sulf-trimethoprim..254 PRECISION POINT OF CARE PHENYTEK...... 89 polysorbate 20 (bulk)...... 122, 123 TEST...... 233 phenytoin...... 89 polysorbate 40...... 123 PRECISION Q-I-D TEST...... 233 phenytoin sodium extended...... 89 polysorbate 60...... 123 PRECISION XTRA TEST...... 233 PHEXXI...... 124 polysorbate 80...... 123 PRECOSE...... 182 PHILITH...... 130 POLYTRIM...... 254 PRED FORTE...... 250 PHOSLYRA...... 215 POLY-TUSSIN AC...... 272 PRED MILD...... 250 PHOSPHASAL...... 41, 218 POLY-VI-FLOR...... 173 PRED-G...... 248 PHOSPHATE LAXATIVE...... 212 POLY-VI-FLOR FS...... 173 PRED-G S.O.P...... 248 PHOSPHOLINE IODIDE...... 247 POLY-VI-FLOR WITH IRON.173 prednicarbate...... 151 PHRENILIN FORTE(WITH POMALYST...... 59 prednisol ace-gatiflox-bromfen.248 CAFFEINE)...... 12 PONSTEL...... 18 prednisoln sp-gatiflox-bromfen 248 phytonadione (vit k1) (bulk)...... 179 PONVORY...... 246 prednisoln sp-moxiflox-bromfen phytonadione (vitamin k1)...... 179 PONVORY 14-DAY ...... 248 PICATO...... 143 STARTER PACK...... 246 prednisolone...... 191 PIFELTRO...... 30 PORTIA 28...... 130 prednisolone acetate...... 250 pilocarpine hcl...... 244, 247 posaconazole...... 27 prednisolone acetate (pf)...... 250 pimecrolimus...... 145 pot,sodium citrate-citric acid....216 prednisolone acetate-bromfenac pimozide...... 100 POTABA...... 179 ...... 252 PIMTREA (28)...... 126 potassium bicarb and chloride. 169 prednisolone acetate-nepafenac252 pindolol...... 77 potassium bicarb-citric acid..... 170 prednisolone acet-gatifloxacin. 248 pioglitazone...... 196 potassium chloride...... 170 prednisolone sod ph-bromfenac252 pioglitazone-glimepiride...... 184 potassium citrate...... 216 prednisolone sod ph-gatifloxac.248 pioglitazone-metformin...... 184 potassium citrate-citric acid..... 216 prednisolone sod ph-moxiflox...248 PIQRAY...... 55 potassium hydroxide...... 137 prednisolone sodium phosphate PIRMELLA...... 130, 132 POTEN B-150 CR...... 164 ...... 191, 250 piroxicam...... 18 POTIGA...... 91 prednisolone-moxiflo-nepafenac PLAN B ONE-STEP...... 133, 134 POWDERLAX...... 212 ...... 248 PLAQUENIL...... 14, 28 PR CREAM...... 155 prednisolone-moxifloxacin hcl..248 PLAVIX...... 227 PR NATAL 400...... 174 prednisolone-moxiflox-bromfen 248 PLEGRIDY...... 244 PR NATAL 400 EC...... 174 prednisone...... 191 PLENVU...... 212 PR NATAL 430...... 175 PREDNISONE INTENSOL.....191 PLIXDA...... 138 PR NATAL 430 EC...... 175 PREFERA-OB ONE...... 175 PNEUMOVAX-23...... 63 PRADAXA...... 228 PREFEST...... 189 PNV 29-1...... 174 pralidoxime...... 23 pregabalin...... 88, 89, 112, 119 pnv cmb#95-ferrous fumarate-fa PRALUENT PEN...... 75 PREGNYL...... 193 ...... 174 PRAMCORT...... 23 PREMARIN...... 189, 275 PNV OB+DHA...... 174 pramipexole...... 98 PREMPHASE...... 189 PNV-DHA...... 171 PRAMOSONE...... 152 PREMPRO...... 189 PNV-OMEGA...... 171 PRAMOSONE E...... 152 PRENA1 CHEW...... 175 Last Approved Date: 09/23/2021 Formulary Version: 91
301 PRENA1 TRUE...... 175 PREVNAR 13 (PF)...... 63 PROMETHAZINE VC...... 258 PRENAISSANCE NEXT...... 177 PREVPAC...... 213 PROMETHAZINE VC- PRENATABS FA...... 175 PREVYMIS...... 36 CODEINE...... 272 PRENATABS RX...... 175 PREZCOBIX...... 32, 43 promethazine-codeine...... 271 PRENATAL...... 175 PREZISTA...... 43 promethazine-dm...... 271 PRENATAL COMPLETE...... 175 PRIALT...... 2 promethazine-phenyleph- PRENATAL FORMULA...... 175 PRIFTIN...... 34, 44 codeine...... 272 PRENATAL LOW IRON...... 175 PRILO PATCH II...... 157 promethazine-phenylephrine.... 258 PRENATAL PRILOSEC...... 205 PROMETHEGAN.... 201, 259, 260 MULTIVITAMINS...... 175 primaquine...... 28 PROMETRIUM...... 197 PRENATAL ONE DAILY...... 175 primidone...... 87 propafenone...... 72 PRENATAL PLUS...... 175 PRIMLEV...... 10 propantheline...... 207 PRENATAL PLUS PRIMSOL...... 26 proparacaine...... 253 (CALCIUM CARB)...... 175 PRINIVIL...... 68 propranolol...... 77 PRENATAL PLUS WITH PRISMASOL BGK...... 258 propranolol-hydrochlorothiazid. 83 IRON (CA)...... 175 PRISTIQ...... 94 propylthiouracil...... 186 PRENATAL TABLET...... 175 PRO DNA COLLECTION...... 243 PROQUAD (PF)...... 61, 66, 67 prenatal vit 90-iron fum-folic... 175 PROAIR DIGIHALER...... 265 PRO-RED AC (W/ PRENATAL VITAMIN...... 175 PROAIR HFA...... 266 DEXCHLORPHENIR)...... 272 PRENATAL VITAMIN PLUS PROAIR RESPICLICK...... 266 PRO-RED AC (WITH LOW IRON...... 175 probenecid...... 220 PYRILAMINE)...... 272 PRENATAL VITAMIN WITH probenecid-colchicine...... 220 PROSCAR...... 216 MINERALS...... 175 PROCARDIA...... 78 PROTECT CARDIO...... 171 prenatal vit-iron fum-folic ac....175 PROCARDIA XL...... 78 PROTECT IRON...... 171 prenatal vits96-iron fum-folic...175 PROCENTRA...... 112 PROTONIX...... 205 PRENATAL-U...... 171 prochlorperazine...... 201 PROTOPIC...... 145 PREPLUS...... 175 prochlorperazine maleate.101, 201 protriptyline...... 96 PREPOPIK...... 213 PROCRIT...... 222 PROVENT...... 235, 238 PRESTALIA...... 67 PROCTOCORT...... 22, 151 PROVENT STARTER..... 235, 238 PRETAB...... 175 PROCTOFOAM HC...... 23 PROVENTIL HFA...... 266 pretomanid...... 34 PROCTO-MED HC...... 22, 151 PROVERA...... 197 PREVACID...... 205 PROCTO-PAK...... 22, 151 PROVIGIL...... 118 PREVACID SOLUTAB...... 205 PROCTOSOL HC...... 22, 151 PROZAC...... 93 PREVALITE...... 73 PROCTOZONE-HC...... 22, 151 PROZAC WEEKLY...... 93 PREVIDENT...... 242 PROCYSBI...... 214 PRUCLAIR...... 146 PREVIDENT 5000 BOOSTER 242 PROFENO...... 20 PRUDOXIN...... 157 PREVIDENT 5000 BOOSTER PROFERRIN-FORTE...... 169 PRUTECT...... 146 PLUS...... 242 PROFILNINE...... 222 pseudoephedrine hcl...... 274 PREVIDENT 5000 DRY progesterone...... 197 PSORCON...... 151 MOUTH...... 242 progesterone micronized...... 197 PULMICORT...... 262 PREVIDENT 5000 ENAMEL PROGLYCEM...... 180 PULMICORT FLEXHALER PROTECT...... 242 PROGRAF...... 229 ...... 262, 263 PREVIDENT 5000 ORTHO PROLATE...... 10, 11 PULMOSAL...... 123 DEFENSE...... 242 PROLENSA...... 251 PULMOZYME...... 269 PREVIDENT 5000 PLUS...... 242 PROLEUKIN...... 52 PUREFE PLUS...... 171 PREVIDENT 5000 PROLIA...... 198 PURELAX...... 212 SENSITIVE...... 242 PROMACTA...... 228, 229 PURIXAN...... 49 PREVIFEM...... 130 promethazine...... 201, 259, 260 PYLERA...... 213 Last Approved Date: 09/23/2021 Formulary Version: 91
302 pyrazinamide...... 33 ranitidine hcl...... 203 RENA-VITE...... 163 PYRIDIUM...... 217 ranolazine...... 71 RENA-VITE RX...... 164 pyridostigmine bromide.... 230, 231 RAPAFLO...... 216 RENO CAPS...... 163 pyrimethamine...... 28 RAPAMUNE...... 230 RENVELA...... 215 pyrithione zinc (bulk)...... 122 rasagiline...... 97 repaglinide...... 182 QBRELIS...... 68 RASUVO (PF)...... 15 repaglinide-metformin...... 182 QBREXZA...... 141 RAVICTI...... 240 REPATHA PUSHTRONEX...... 75 QDOLO...... 6 RAYALDEE...... 239 REPATHA SURECLICK...... 75 QELBREE...... 106 RAYOS...... 191 REPATHA SYRINGE...... 75 QINLOCK...... 57 RAZADYNE...... 124 REPREXAIN...... 8, 9 QMIIZ ODT...... 18 RAZADYNE ER...... 124 REQ49+...... 171 QNASL...... 270 REA LO 39...... 153 REQUIP...... 98 QSYMIA...... 160 REA LO 40...... 154 REQUIP XL...... 98 QTERN...... 183 REACT...... 133, 134 RESCRIPTOR...... 30, 31 QUADRACEL (PF)...... 62 READI-CAT 2...... 158 RESPA-AR...... 258 QUALAQUIN...... 28 REBETOL...... 39 RESPAIRE-30...... 269 QUARTETTE...... 131 REBIF (WITH ALBUMIN)..... 244 RESTASIS...... 250 QUASENSE...... 130 REBIF REBIDOSE...... 244 RESTASIS MULTIDOSE...... 250 quazepam...... 108, 120 REBIF TITRATION PACK..... 244 RESTORA RX...... 179, 210 QUDEXY XR...... 90 REBINYN...... 222 RESTORA SPRINKLES..179, 210 QUESTRAN...... 73 REBLOZYL...... 224, 229 RESTORIL...... 108, 120 QUESTRAN LIGHT...... 73 RECEDO...... 155 RESVERATROL DIET...... 160 quetiapine...... 101, 109 RECLIPSEN (28)...... 130 RETACRIT...... 222 QUFLORA...... 173 RECOMBINATE...... 223 RETEVMO...... 59 QUFLORA FE...... 173 RECOMBIVAX HB...... 61 RETIN-A...... 138 QUFLORA FE (FERROUS RECOMBIVAX HB (PF)...... 61 RETIN-A MICRO...... 138 SULFATE)...... 173 REDITREX (PF)...... 15 RETIN-A MICRO PUMP...... 138 QUFLORA PEDIATRIC...... 173 REFISSA...... 155 RETROVIR...... 31 QUFLORA PEDIATRIC REGIMEX...... 161 REVATIO...... 85 DROPS...... 173 REGLAN...... 206 REVLIMID...... 59 QUILLICHEW ER...... 105 REGRANEX...... 158 REXULTI...... 102 QUILLIVANT XR...... 105 RELADOR PAK...... 155 REYATAZ...... 43, 44 quinapril...... 68 RELADOR PAK PLUS...... 155 REYVOW...... 116 quinapril-hydrochlorothiazide....68 RELAFEN DS...... 18 REZIRA...... 273 quinidine gluconate...... 71 RELAGARD...... 275 REZUROCK...... 17 quinidine sulfate...... 72 RELCOF C...... 274 RHEUMATREX...... 15 quinine sulfate...... 29 RELENZA DISKHALER...... 40 RHINOCORT AQUA...... 270 QUIT 2...... 122 RELEXXII...... 105 RHOFADE...... 156 QUIT 4...... 122 RELISTOR...... 24 RHOPRESSA...... 256 QVAR...... 263 RELNATE DHA...... 175 RIASTAP...... 225 QVAR REDIHALER...... 263 RELPAX...... 115 RIBASPHERE...... 39 rabeprazole...... 205 RELTONE...... 203 RIBASPHERE RIBAPAK...... 39 RAGWITEK...... 60 REMERON...... 92 ribavirin...... 39, 44 RAJANI...... 130 REMERON SOLTAB...... 92 RIDAURA...... 15 raloxifene...... 198 REMEVEN...... 154 rifabutin...... 34, 44 ramelteon...... 113 remifentanil...... 22 RIFADIN...... 34, 44 ramipril...... 68 RENAGEL...... 215 RIFAMATE...... 34 RANEXA...... 71 RENAL CAPS...... 163 rifampin...... 34, 44 Last Approved Date: 09/23/2021 Formulary Version: 91
303 RIFATER...... 34 RYBELSUS...... 185 selegiline hcl...... 97 RILUTEK...... 230 RYDAPT...... 57 selenium sulfide...... 145 riluzole...... 230 RYDEX...... 272 SELZENTRY...... 29 rimantadine...... 40 RYTARY...... 96 SEMGLEE PEN U-100 RINVOQ...... 16 RYTHMOL...... 72 INSULIN...... 194 RIOMET...... 196 RYTHMOL SR...... 72 SEMGLEE U-100 INSULIN....194 RIOMET ER...... 196 RYVENT...... 259, 260 SEMPREX-D...... 259 risedronate...... 187 SABRIL...... 89 SE-NATAL 19 CHEWABLE...175 RISPERDAL...... 99, 109 SAFYRAL...... 130 SE-NATAL-19...... 175 RISPERDAL M-TAB...... 99, 109 SAIZEN...... 193, 214 SENSIPAR...... 187 risperidone...... 99, 109 SAIZEN CLICK.EASY...... 193 SEREVENT DISKUS...... 265 RITALIN...... 105 SAIZEN SAIZENPREP...... 193 SERNIVO...... 151 RITALIN LA...... 105 SALACYN...... 154 SEROPHENE...... 190 ritonavir...... 44 SALAGEN (PILOCARPINE).. 244 SEROQUEL...... 101, 109 rivastigmine...... 124 SALEX...... 154 SEROQUEL XR...... 101, 109 rivastigmine tartrate...... 124 salicylic acid...... 154 SEROSTIM...... 193 RIVELSA...... 131 salicylic acid-ceramides no.1... 154 sertraline...... 93 RIXUBIS...... 222 SALIMEZ...... 154 SETLAKIN...... 130 rizatriptan...... 115 SALIMEZ FORTE...... 154 sevelamer carbonate...... 215 ROBAFEN AC...... 274 SALINE FLUSH...... 176 sevelamer hcl...... 215 ROBAXIN...... 231 SALIVAMAX...... 243 SEVENFACT...... 222 ROBAXIN-750...... 231 SALIVATERX...... 243 sevoflurane...... 21 ROBINUL...... 207 salsalate...... 21 SEYSARA...... 45, 135 ROBINUL FORTE...... 207 SALVAX...... 154 SF...... 242 ROCALTROL...... 178, 239 SAMSCA...... 82 SF 5000 PLUS...... 242 ROCKLATAN...... 254 SANCUSO...... 201 SFROWASA...... 209 ropinirole...... 98 SANDIMMUNE...... 16, 229 SHAROBEL...... 131 ROSADAN...... 156 SANDOSTATIN...... 198, 214 SHINGRIX (PF)...... 67 ROSULA...... 136 SANDOSTATIN LAR DEPOT SHOHL'S MODIFIED...... 216 ROSULA CLEANSING ...... 198, 214 SIDEROL...... 169 CLOTHS...... 136 SANTYL...... 146 SIGNIFOR...... 198 rosuvastatin...... 74 SAPHRIS...... 98, 109 SIKLOS...... 228 ROSZET...... 76 sapropterin...... 241 sildenafil...... 160 ROTARIX...... 61, 67 SARAFEM...... 93 sildenafil (pulm.hypertension) ROTATEQ VACCINE...... 61, 67 SAVAYSA...... 221 ...... 85, 86 ROWASA...... 209 SAVELLA...... 94 SILENOR...... 120 ROWEEPRA...... 91 SAXENDA...... 161 SILIQ...... 139 ROXICODONE...... 6 SCALACORT...... 151 SILVADENE...... 145 ROXYBOND...... 6 SCALACORT DK...... 151 silver nitrate...... 140 ROZEREM...... 113 scopolamine base...... 200 silver nitrate applicators...... 153 ROZLYTREK...... 57 SEASONIQUE...... 126 silver sulfadiazine...... 145 R-TANNA...... 258 SEB-PREV...... 145 SIMBRINZA...... 248 RUBRACA...... 55 SECONAL SODIUM...... 119 simethicone (bulk)...... 122, 205 RUCONEST...... 221 SECTRAL...... 77 SIMLIYA (28)...... 126 rufinamide...... 91 SECUADO...... 98 SIMPESSE...... 126 RUKOBIA...... 29 SEEBRI NEOHALER...... 264 SIMPONI...... 13, 14, 210 RULAVITE DHA...... 171 SEGLUROMET...... 182 simvastatin...... 74 RUZURGI...... 245 SELECT-OB + DHA...... 175 SINEMET...... 96 Last Approved Date: 09/23/2021 Formulary Version: 91
304 SINEMET CR...... 96 SORILUX...... 144 STRESS FORMULA163, 164, 169 SINGULAIR...... 263 SORINE...... 72, 77 STRESS FORMULA 600 C.....163 sirolimus...... 230 sotalol...... 72, 77 STRIANT...... 181 SIRTURO...... 33 SOTALOL AF...... 72, 77 STRIBILD...... 32 SITAVIG...... 39 SOTYLIZE...... 72, 77 STRIVERDI RESPIMAT...... 265 SITZMARKS...... 159 SOVALDI...... 38 STROMECTOL...... 26 SIVEXTRO...... 42 SP ANTIPRURITIC...... 157, 158 STRONG IODINE...... 167 SKELAXIN...... 231 SP SCAR MANAGEMENT STROVITE...... 163 SKLICE...... 158 ...... 146, 236 STROVITE FORTE...... 171 SKYLA...... 125 SPECTRACEF...... 35 STROVITE ONE...... 171 SKYRIZI...... 139 spinosad...... 158 SUBOXONE...... 121 SLYND...... 131 SPIRIVA RESPIMAT...... 264 SUBSYS...... 6 SMOOTHLAX...... 212 spiriva with handihaler...... 265 SUBVENITE...... 90 sodium chloride...... 123, 165 spironolactone...... 68, 81 SUBVENITE STARTER sodium chloride 0.9 %...... 165, 176 spironolacton-hydrochlorothiaz. 82 (BLUE) KIT...... 90, 108 sodium chloride 0.9 % (flush)...176 SPORANOX...... 27 SUBVENITE STARTER sodium citrate...... 221 SPRINTEC (28)...... 130 (GREEN) KIT...... 90, 108 sodium citrate-citric acid...... 216 SPRITAM...... 91 SUBVENITE STARTER SODIUM FLUORIDE 5000 SPRIX...... 18 (ORANGE) KIT...... 90, 108 DRY MOUTH...... 242 SPRYCEL...... 57 SUCLEAR...... 212 SODIUM FLUORIDE 5000 SPS (WITH SORBITOL)...... 165 SUCRAID...... 203 PLUS...... 242 SRONYX...... 130 sucralfate...... 213 sodium fluoride-pot nitrate...... 242 SSD...... 145 sufentanil citrate...... 22 sodium hydroxide (bulk)...... 123 SSKI...... 167 sufentanil citrate (pf)...... 22 sodium lactate (bulk)...... 123 SSS 10-5...... 136 SULAR...... 78 sodium phenylbutyrate...... 240 ST JOSEPH ASPIRIN...... 21, 227 sulconazole...... 142 SODIUM POLYSTYRENE ST. JOSEPH ASPIRIN...... 21, 227 sulfacetamide sodium...... 145, 255 (SORB FREE)...... 165 STALEVO 100...... 96 sulfacetamide sodium (acne).... 136 sodium polystyrene sulfonate....165 STALEVO 125...... 96 sulfacetamide sodium-sulfur.....136 sofosbuvir-velpatasvir...... 38 STALEVO 150...... 96 sulfacetamide sod-sulfur-urea SOFTGELS MULTIVIT- STALEVO 200...... 96 ...... 136, 156 A,B,D,E,K,ZN...... 171 STALEVO 50...... 96 sulfacetamide-prednisolone...... 248 SOJOURN...... 21 STALEVO 75...... 96 SULFACLEANSE 8-4...... 136 SOLARAZE...... 143 STARLIX...... 182 sulfadiazine...... 44 solifenacin...... 218 stavudine...... 31 sulfamethoxazole-trimethoprim.. 26 SOLIQUA 100/33...... 185 STAXYN...... 160 SULFAMYLON...... 145 SOLODYN...... 45, 135 STEGLATRO...... 183 sulfasalazine...... 17, 209 SOLOSEC...... 29 STEGLUJAN...... 183 SULFATRIM...... 26 SOLOXIDE...... 45 STELARA...... 139, 208 SULFAZINE...... 17, 209 SOLTAMOX...... 58 STENDRA...... 160 sulindac...... 18 SOMA...... 232 STIMATE...... 182 sumatriptan...... 115 SOMATULINE DEPOT...... 198 STIOLTO RESPIMAT...... 266 sumatriptan succinate...... 115 SOMAVERT...... 192 STIVARGA...... 54 SUMAVEL DOSEPRO...... 115 SONAFINE...... 146 STOP SMOKING AID...... 122 SUMAXIN...... 137 SONATA...... 120 STRATTERA...... 106 SUNOSI...... 118 SOOLANTRA...... 156 STRENSIQ...... 239 SUPER B COMPLEX- sorbitol...... 123, 212 streptomycin...... 24 VITAMIN C...... 163 SORIATANE...... 144 STRESS 500...... 163 SUPER B MAXI COMPLEX.. 163 Last Approved Date: 09/23/2021 Formulary Version: 91
305 SUPER B-50 COMPLEX SYNJARDY XR...... 183 TAYTULLA...... 130 PLUS...... 164 SYNTHROID...... 199 tazarotene...... 138, 144, 155 SUPER CALCIUM/D...... 167 SYPRINE...... 23 TAZORAC...... 144 SUPER CALCIUM-VITAMIN SYREX SODIUM CHLORIDE TAZTIA XT...... 78 D...... 167 0.9 %...... 176 TAZVERIK...... 51 SUPER QUINTS...... 163 T:FLEX...... 235, 238 TDVAX...... 62 SUPER QUINTS B-50...... 164 T:SLIM...... 235, 238 TECFIDERA...... 245 SUPERPLEX-T...... 163 T:SLIM G4...... 235, 238 TECHNIVIE...... 38 SUPERVITE...... 163 TABLOID...... 49 TEGRETOL...... 89, 108 SUPERVITE (EC)...... 171 TABRECTA...... 57 TEGRETOL XR...... 89, 108 SUPERVITE EC...... 171 TACLONEX...... 138 TEGSEDI...... 180 SUPPORT-500...... 163 tacrolimus...... 145, 229 TEKTURNA...... 86 SUPRAX...... 35 tadalafil...... 160, 216 TEKTURNA HCT...... 86 SUPRENZA...... 161 tadalafil (pulm. hypertension).... 86 telmisartan...... 70 SUPREP BOWEL PREP KIT.. 212 TAFINLAR...... 50 telmisartan-amlodipine...... 69 SURE-TEST EASYPLUS TAGITOL V...... 158 telmisartan-hydrochlorothiazid.. 70 MINI...... 233 TAGRISSO...... 46 temazepam...... 108, 120 SURFAXIN...... 269 TAKE ACTION...... 133, 134 TEMIXYS...... 31 SURMONTIL...... 96 TAKHZYRO...... 84 TEMODAR...... 47 SUSTIVA...... 31 TALICIA...... 214 TEMOVATE...... 151 SUSTOL...... 201 TALTZ AUTOINJECTOR...... 139 temozolomide...... 47 SUTAB...... 212 TALTZ AUTOINJECTOR (2 TENCON...... 12 SUTENT...... 57 PACK)...... 139 TENEX...... 81 SYEDA...... 130 TALTZ AUTOINJECTOR (3 TENIVAC (PF)...... 62 SYLATRON...... 52 PACK)...... 140 tenofovir disoproxil fumarate32, 37 SYLATRON 4-PACK...... 52 TALTZ SYRINGE...... 140 TENORETIC 100...... 79 SYMAX DUOTAB...... 206, 219 TALTZ SYRINGE (2 PACK).. 140 TENORETIC 50...... 79 SYMAX FASTABS...... 206, 219 TALTZ SYRINGE (3 PACK).. 140 TENORMIN...... 76 SYMAX-SL...... 206, 219 TALWIN...... 11 TEPMETKO...... 58 SYMAX-SR...... 206, 219 TALZENNA...... 55, 56 TERAZOL 3...... 274 SYMBICORT...... 267 TAMIFLU...... 40 TERAZOL 7...... 274 SYMBYAX...... 95, 101, 109 tamoxifen...... 58 terazosin...... 84 SYMDEKO...... 268 tamsulosin...... 216 terbinafine hcl...... 26 SYMFI...... 33 TANZEUM...... 185 terbutaline...... 266 SYMFI LO...... 33 TAPAZOLE...... 186 terconazole...... 275 SYMJEPI...... 80 TAPERDEX...... 192 teriparatide...... 186 SYMLINPEN 120...... 184 TARCEVA...... 46 TERRELL...... 21 SYMLINPEN 60...... 184 TARGADOX...... 45 TERSI FOAM...... 145 SYMPAZAN...... 88, 108 TARGRETIN...... 59, 143 TESSALON PERLES...... 261 SYMPROIC...... 24 TARINA 24 FE...... 130 TESTIM...... 181 SYMTUZA...... 32 TARINA FE 1/20 (28)...... 130 TESTONE CIK...... 181 SYNALAR...... 151 TARINA FE 1-20 EQ (28)...... 130 testosterone...... 181 SYNALAR OINTMENT KIT..152 TARKA...... 67 testosterone cypionate...... 181 SYNALAR TS...... 153 TARON-C DHA...... 171 testosterone enanthate...... 181 SYNALGOS-DC...... 7 TASIGNA...... 58 testosterone propionate...... 181 SYNAREL...... 196 TASMAR...... 97 TESTRED...... 181 SYNDROS...... 110, 161, 201 tavaborole...... 142 tetanus,diphtheria tox ped(pf).....62 SYNJARDY...... 182 TAVALISSE...... 221 TETCAINE...... 253 Last Approved Date: 09/23/2021 Formulary Version: 91
306 tetrabenazine...... 116, 117 tinidazole...... 29 TOXICOLOGY SALIVA tetracaine hcl...... 253 tiopronin...... 215 COLLECTION...... 159 tetracaine hcl (pf)...... 253 TIROSINT...... 199 TRACLEER...... 85 tetracycline...... 45 TIROSINT-SOL...... 199 TRADJENTA...... 182 TETRAVISC...... 253 TIVICAY...... 30 tramadol...... 6 TETRAVISC FORTE...... 253 TIVICAY PD...... 30 tramadol-acetaminophen...... 11 TEXACORT...... 151 TIVORBEX...... 20 trandolapril...... 68 TEXAVITE LQ...... 173 tizanidine...... 232 trandolapril-verapamil...... 67 TG 10PEH-380GFN...... 269 TL GARD RX...... 177 tranexamic acid...... 225 TG 10PEH-380GFN-15DM..... 271 TL G-FOL OS...... 165 TRANSDERM-SCOP...... 200 THALOMID...... 28, 59 TL ICON...... 169 TRANXENE T-TAB...... 87, 108 THEO-24...... 264 TL-FLUORIVITE...... 173 tranylcypromine...... 92 THEOCHRON...... 264 TL-HEM 150...... 169 TRANZAREL...... 157 theophylline...... 264 TOBI...... 267 TRAVATAN Z...... 256 THERAPEUTIC TOBI PODHALER...... 267 travoprost...... 256 FORMULA/HEMATINICS..... 171 TOBRADEX...... 248 travoprost (benzalkonium)...... 256 THERMAZENE...... 145 TOBRADEX ST...... 248 trazodone...... 93 THIOLA...... 214 tobramycin...... 254, 268 TREAGAN OTIC...... 258 THIOLA EC...... 214, 215 tobramycin in 0.225 % nacl...... 267 TRECATOR...... 34 thioridazine...... 101 tobramycin with nebulizer...... 268 TRELEGY ELLIPTA...... 267 thiothixene...... 101 tobramycin-dexamethasone...... 248 TRELSTAR...... 53 THROMBIN-JMI...... 225 TOBREX...... 255 TRELSTAR DEPOT...... 53 THYQUIDITY...... 199 TODAY CONTRACEPTIVE TRELSTAR LA...... 53 thyroid (pork)...... 199 SPONGE...... 134 TREMFYA...... 139 THYROLAR-1...... 198 TOFRANIL...... 96 TRESIBA FLEXTOUCH U- THYROLAR-1/2...... 198 TOLAK...... 143 100...... 194 THYROLAR-1/4...... 198 tolazamide...... 184 TRESIBA FLEXTOUCH U- THYROLAR-2...... 198 tolbutamide...... 184 200...... 194 THYROLAR-3...... 198 tolmetin...... 18 TRESIBA U-100 INSULIN...... 194 TIADYLT ER...... 78 TOLSURA...... 27 tretinoin...... 138 tiagabine...... 89 tolterodine...... 219, 220 tretinoin (antineoplastic)...... 58 TIAZAC...... 78 tolvaptan...... 82 tretinoin (emollient)...... 155 TIBSOVO...... 55 TOPAMAX...... 90 TRETIN-X CREAM KIT...... 138 ticlopidine...... 227 TOPICORT...... 151, 152 TRETTEN...... 224 TIGAN...... 201 topiramate...... 90 TREXALL...... 15, 49 TIGLUTIK...... 230 TOPOSAR...... 51 TREXIMET...... 116 TIKOSYN...... 72 TOPROL XL...... 76 TREZIX...... 7 TILIA FE...... 132 toremifene...... 58 TRI FEMYNOR...... 132 timol-brimon-dorzo-latanop(pf)247 torsemide...... 82 triamcinolone acetonide timolol maleate...... 77, 253 TOSYMRA...... 116 ...... 152, 243, 270 timolol maleate (pf)...... 253 TOTAL B/C...... 163 triamterene...... 82 timolol-brimonidi-dorzolam(pf) 251 TOUJEO MAX U-300 triamterene-hydrochlorothiazid..82 timolol-dorzolamid-latanop(pf) 251 SOLOSTAR...... 194 TRIANEX...... 152 timolol-latanoprost(pf)...... 251 TOUJEO SOLOSTAR U-300 triazolam...... 108, 120 TIMOPTIC...... 253 INSULIN...... 194 TRIBENZOR...... 69 TIMOPTIC OCUDOSE (PF)... 253 TOVET EMOLLIENT...... 152 TRICARE...... 175 TIMOPTIC-XE...... 253 TOVIAZ...... 220 TRICARE PRENATAL...... 175 TINDAMAX...... 29 Last Approved Date: 09/23/2021 Formulary Version: 91
307 TRICARE PRENATAL DHA TRIVEEN-DUO DHA...... 176 TUSNEL NEW FORMULA.... 271 ONE...... 176 TRIVEEN-TEN...... 176 TUSNEL PEDIATRIC..... 269, 271 TRICARE PRENATAL WITH TRI-VI-FLOR...... 173 TUSSICAPS...... 271 DHA...... 176 TRI-VI-FLORO...... 173 TUSSIGON...... 272 TRI-CHLOR...... 154 TRI-VIT WITH FLUORIDE TUSSIONEX PENNKINETIC trichloroacetic acid...... 154 AND IRON...... 172 ER...... 271 TRICITRATES...... 217 TRI-VITAMIN WITH TUSSI-PRES PEDIATRIC...... 271 TRICON...... 169 FLUORIDE...... 173 TUXARIN ER...... 271 TRICOR...... 73 TRI-VITE WITH FLUORIDE. 173 TUZISTRA XR...... 271 TRIDERM...... 152 TRIVORA (28)...... 132 TWINRIX...... 61 TRIDESILON...... 152 TRI-VYLIBRA...... 132 TWINRIX (PF)...... 61 TRIESENCE (PF)...... 250 TRI-VYLIBRA LO...... 132 TWIRLA...... 133 TRI-ESTARYLLA...... 132 TRI-ZEL...... 165 TWYNSTA...... 69 trifluoperazine...... 101 TRIZIVIR...... 33 TYBOST...... 241 trifluridine...... 256 TROKENDI XR...... 90 TYDEMY...... 130 TRIGELS-F FORTE...... 169 tropicamide...... 249 TYKERB...... 46 TRIGLIDE...... 73 tropic-proparacai-pe-ketor-wat 254 TYLENOL-CODEINE #3...... 7 trihexyphenidyl...... 97 trospium...... 220 TYLENOL-CODEINE #4...... 7 TRIJARDY XR...... 186 TRUETEST TEST STRIPS...... 233 TYMLOS...... 186 TRIKAFTA...... 268 TRUETRACK TEST...... 233 TYVASO...... 84 TRIKLO...... 75 TRULANCE...... 202, 208 TYVASO INSTITUTIONAL TRI-LEGEST FE...... 132 TRULICITY...... 185 START KIT...... 84, 85 TRILEPTAL...... 89 TRUMENBA...... 63 TYVASO REFILL KIT...... 84, 85 TRI-LINYAH...... 132 TRUSELTIQ...... 51 TYVASO STARTER KIT....84, 85 TRILIPIX...... 73 TRUSOPT...... 251 TYZEKA...... 37 TRI-LO-ESTARYLLA...... 132 TRUST NATAL DHA...... 176 UBRELVY...... 114 TRI-LO-MARZIA...... 132 TRUSTEX LATEX CONDOM UCERIS...... 209 TRI-LO-MILI...... 132 ...... 235, 238 UDAMIN SP...... 171 TRI-LO-SPRINTEC...... 132 TRUSTEX LUBRICATED UDENYCA...... 224 TRILYTE WITH FLAVOR CONDOMS...... 235, 238 UKONIQ...... 54 PACKETS...... 212 TRUSTEX NON-LUB ULESFIA...... 158 trimethobenzamide...... 201 CONDOMS...... 235, 238 ULORIC...... 220 trimethoprim...... 26 TRUSTEX-RIA ULTIMATECARE ONE...... 171 TRI-MILI...... 132 LUB/SPERMICIDE...... 235, 238 ULTIMATECARE ONE NF....176 TRIMPEX...... 26 TRUSTEX-RIA ULTIVA...... 22 TRINATAL GT...... 176 LUBRICATED CONDOMS ULTRA B-100 COMPLEX...... 164 TRINATAL RX 1...... 176 ...... 235, 238 ULTRACET...... 11 TRINATE...... 176 TRUSTEX-RIA NON-LUB ULTRAM...... 6 TRINESSA (28)...... 132 CONDOMS...... 235, 238 ULTRAM ER...... 6 TRINESSA LO...... 132 TRUVADA...... 31 ULTRASAL-ER...... 154 TRI-NORINYL (28)...... 132 TUDORZA PRESSAIR...... 265 ULTRAVATE...... 144, 152 TRINTELLIX...... 94 TUKYSA...... 50 ULTRAVATE X...... 152 TRIPHROCAPS...... 163 TULANA...... 131 UNITHROID...... 199 TRIPLE VITAMIN WITH TURALIO...... 58 UPNEEQ (PF)...... 247 FLUORIDE...... 173 TUSNEL C...... 273 UPTRAVI...... 83 TRI-PREVIFEM (28)...... 132 TUSNEL DIABETIC...... 271 UR N-C...... 42, 218 TRI-SPRINTEC (28)...... 132 TUSNEL DM URAMIT MB...... 42, 218 TRIUMEQ...... 32 PEDIATRIC(PSEUDOEPH)....271 URECHOLINE...... 220 Last Approved Date: 09/23/2021 Formulary Version: 91
308 URE-K...... 154 VANOXIDE-HC...... 137 VFEND...... 27 URELLE...... 42, 218 VAQTA (PF)...... 61 V-GO 20...... 236, 238 URETRON D-S...... 42, 218 vardenafil...... 160 V-GO 30...... 236, 238 URIBEL...... 42, 218 varenicline...... 122 V-GO 40...... 236, 238 URIMAR-T...... 42, 218 VARIBAR HONEY...... 158 VIAGRA...... 160 URIN DS...... 42, 218 VARIBAR NECTAR...... 158 VIBERZI...... 208, 211 URO-458...... 42, 218 VARIBAR PUDDING...... 158 VIBRAMYCIN...... 45 UROAV-B...... 42, 218 VARIBAR THIN HONEY...... 158 VIC-FORTE...... 171 UROCIT-K 10...... 217 VARIBAR THIN LIQUID...... 158 VICODIN...... 8, 9 UROCIT-K 15...... 217 VARIVAX (PF)...... 61, 67 VICODIN ES...... 8, 9 UROCIT-K 5...... 217 VARUBI...... 202 VICODIN HP...... 8, 9 UROGESIC-BLUE...... 42, 218 VASCEPA...... 75 VICTOZA 2-PAK...... 185 UROLET MB...... 42, 218 VASERETIC...... 68 VICTOZA 3-PAK...... 185 URO-MP...... 42, 218 VASOTEC...... 68 VIDEX 2 GRAM PEDIATRIC.. 31 UROPHEN MB...... 42, 218 VAXELIS (PF)...... 61, 62, 63 VIDEX 4 GRAM PEDIATRIC.. 31 UROQID-ACID NO.2...... 41, 217 V-C FORTE...... 171 VIDEX EC...... 32 UROSEX...... 171 VCF CONTRACEPTIVE VIEKIRA PAK...... 39 UROXATRAL...... 216 FILM...... 134 VIEKIRA XR...... 39 URSO 250...... 203 VCF CONTRACEPTIVE GEL 134 VIENVA...... 130 URSO FORTE...... 203 VECAMYL...... 83 vigabatrin...... 89 ursodiol...... 203 VECTICAL...... 144 VIGADRONE...... 89 URYL...... 42, 218 VELIVET TRIPHASIC VIGAMOX...... 255 USTELL...... 42, 218 REGIMEN (28)...... 132 VIIBRYD...... 94 UTA...... 42, 218 VELPHORO...... 215 VILAMIT MB...... 42, 218 UTIBRON NEOHALER...... 266 VELTASSA...... 165 VILEVEV MB...... 42, 218 UTIRA-C...... 42, 218 VEMAVITE-PRX-2...... 176 VIMOVO...... 18 VAGIFEM...... 275 VEMLIDY...... 37 VIMPAT...... 88 VAGINAL CONTRACEPTIVE VENCLEXTA...... 49 VINATE CARE...... 172 FILM...... 134 VENCLEXTA STARTING VINATE M...... 176 VAGINAL CONTRACEPTIVE PACK...... 49 VINATE ONE...... 176 FOAM...... 134 venlafaxine...... 94 VIOKACE...... 202 valacyclovir...... 39 VENNGEL ONE...... 155 VIORELE (28)...... 126 VALCHLOR...... 143 VENOFER...... 168 VIRACEPT...... 44 VALCYTE...... 35 VENTAVIS...... 85 VIRAMUNE...... 31 valganciclovir...... 35 VENTOLIN HFA...... 266 VIRAMUNE XR...... 31 VALIUM...... 87, 108 VERAMYST...... 270 VIRASAL...... 154 valproic acid...... 88, 109 verapamil...... 72, 79 VIRAZOLE...... 44 valproic acid (as sodium salt) VERDESO...... 152 VIREAD...... 32, 37 ...... 88, 109 VERELAN...... 79 VIROPTIC...... 256 valproic acid (bulk)...... 88 VERELAN PM...... 79 VIRT-ADVANCE...... 176 valsartan...... 70 VERIPRED 20...... 192 VIRT-C DHA...... 171 valsartan-hydrochlorothiazide... 70 VERQUVO...... 71 VIRT-CAPS...... 163 VALTOCO...... 88, 108 VERSACLOZ...... 100 VIRT-FEFA PLUS...... 169 VALTREX...... 39 VERZENIO...... 50 VIRT-NATE...... 176 VANCOCIN...... 36 VESICARE...... 218 VIRT-NATE DHA...... 176 vancomycin...... 37 VESICARE LS...... 218 VIRT-PN...... 176 VANDAZOLE...... 275 VESTURA (28)...... 130 VIRT-PN DHA...... 172 VANOS...... 152 VEXOL...... 250 VIRT-PN PLUS...... 171 Last Approved Date: 09/23/2021 Formulary Version: 91
309 VIRTRATE-2...... 217 VOSEVI...... 38 WIDE-SEAL DIAPHRAGM 95 VIRTRATE-3...... 217 VOTRIENT...... 58 ...... 234, 239 VIRTRATE-K...... 217 VP-CH-PNV...... 176 WILATE...... 223 VIRT-SELECT...... 176 VP-GGR-B6...... 177 WINLEVI...... 135 VIRTUSSIN AC...... 274 VP-HEME OB...... 176 WIXELA INHUB...... 267 VIRTUSSIN DAC...... 273 VP-HEME ONE...... 176 WOMAN'S LAXATIVE VIRT-VITE FORTE...... 177, 179 VPRIV...... 239 (BISACODYL)...... 213 VIRT-VITE GT...... 176 VP-VITE RX...... 165 WOMEN'S GENTLE VIRT-VITE PLUS...... 163 VRAYLAR...... 102, 109, 110 LAXATIVE(BISAC)...... 213 VISCOAT...... 254 VTOL LQ...... 12 WOMEN'S LAXATIVE VISIONBLUE...... 254 VUMERITY...... 245 (BISACODYL)...... 213 VISTARIL...... 86 VUSION...... 142 WP THYROID...... 199 VISTIDE...... 36 VYFEMLA (28)...... 130 WYMZYA FE...... 130 VISTOGARD...... 59 VYLEESI...... 113 WYNZORA...... 139 VIT 3...... 172 VYLIBRA...... 130 XADAGO...... 97 VITABEE/C...... 163 VYNDAMAX...... 180 XALATAN...... 256 VITAFOL FE PLUS...... 176 VYNDAQEL...... 180 XALIX...... 154 VITAJOY DAILY D...... 178 VYTORIN 10-10...... 76 XALKORI...... 48 VITAL-D RX...... 171, 178 VYTORIN 10-20...... 76 XANAX...... 87, 108 vitamin b complex...... 164 VYTORIN 10-40...... 76 XANAX XR...... 87, 108 vitamin b complex-folic acid VYTORIN 10-80...... 76 XARELTO...... 221, 222 ...... 162, 163, 164 VYVANSE...... 105, 106 XARELTO DVT-PE TREAT VITAMIN B-100 COMPLEX..164 VYZULTA...... 256 30D START...... 221 VITAMIN D2...... 178 WAKIX...... 118 XATMEP...... 15, 49 VITAMIN D3...... 178 warfarin...... 221 XCOPRI...... 92 VITAMIN K1...... 179 water for injection, sterile...... 165 XCOPRI MAINTENANCE VITAMINS A,C,D AND WEGOVY...... 161 PACK...... 92 FLUORIDE...... 173 WELCHOL...... 73 XCOPRI TITRATION PACK....92 VITAMINS B COMPLEX...... 164 WELLBUTRIN SR...... 95 XELJANZ...... 16, 209 VITA-RESPA...... 177 WELLBUTRIN XL...... 95 XELJANZ XR...... 16, 209, 210 VITEKTA...... 30 WERA (28)...... 130 XELODA...... 49 VITRAKVI...... 59 WESTGEL DHA...... 176 XELPROS...... 256 VITUZ...... 271 WESTHROID...... 199 XENAZINE...... 116, 117 VIVAGUARD INO TEST WIDE-SEAL DIAPHRAGM 60 XENICAL...... 161 STRIP...... 233, 238 ...... 233, 238 XENLETA...... 43 VIVELLE-DOT...... 190 WIDE-SEAL DIAPHRAGM 65 XEPI...... 141 VIVLODEX...... 18 ...... 233, 239 XERAC AC...... 144 VIZIMPRO...... 46 WIDE-SEAL DIAPHRAGM 70 XERESE...... 145 VOGELXO...... 181 ...... 233, 239 XERMELO...... 200 VOL-CARE RX...... 165 WIDE-SEAL DIAPHRAGM 75 XEROSTOMIA RELIEF...... 243 VOL-NATE...... 176 ...... 233, 239 XGEVA...... 198 VOL-PLUS...... 171 WIDE-SEAL DIAPHRAGM 80 XHANCE...... 270 VOL-TAB RX...... 171 ...... 234, 239 XIFAXAN...... 44 VOLTAREN...... 155 WIDE-SEAL DIAPHRAGM 85 XIGDUO XR...... 183 VOLTAREN-XR...... 19 ...... 234, 239 XIIDRA...... 250 VOLUMEN...... 158 WIDE-SEAL DIAPHRAGM 90 XILAPAK...... 153 VONVENDI...... 225 ...... 234, 239 XIMINO...... 45, 135 voriconazole...... 28 XODOL 10/300...... 8, 9 Last Approved Date: 09/23/2021 Formulary Version: 91
310 XODOL 5/300...... 8, 9 ZELAPAR...... 97 ZODRYL AC 80...... 271 XODOL 7.5/300...... 8, 9 ZELBORAF...... 50 ZODRYL DAC 25...... 272 XOFLUZA...... 40 ZELNORM...... 208, 211 ZODRYL DAC 30...... 272 XOLAIR...... 264 ZEMBRACE SYMTOUCH..... 116 ZODRYL DAC 35...... 272 XOLEGEL...... 142 ZEMPLAR...... 239 ZODRYL DAC 40...... 272 XOPENEX...... 266 ZENATANE...... 135 ZODRYL DAC 50...... 272 XOPENEX CONCENTRATE. 266 ZENCHENT (28)...... 130 ZODRYL DAC 60...... 272 XOPENEX HFA...... 266 ZENCHENT FE...... 130 ZODRYL DAC 80...... 272 XOSPATA...... 52 ZENCIA...... 137 ZODRYL DEC 25...... 273 XPOVIO...... 51, 58 ZENPEP...... 203 ZODRYL DEC 30...... 273 XTAMPZA ER...... 6 ZENZEDI...... 106, 112, 119 ZODRYL DEC 35...... 273 XTANDI...... 48 ZEOSA...... 130 ZODRYL DEC 40...... 273 XULANE...... 133 ZEPATIER...... 38 ZODRYL DEC 50...... 273 XULTOPHY 100/3.6...... 185 ZEPOSIA...... 246 ZODRYL DEC 60...... 273 XURIDEN...... 240 ZEPOSIA STARTER KIT...... 246 ZODRYL DEC 80...... 273 XYLON 10...... 8, 9 ZEPOSIA STARTER PACK... 246 ZOFRAN...... 201 XYNTHA...... 223 ZERIT...... 32 ZOFRAN ODT...... 201 XYNTHA SOLOFUSE...... 223 ZERVIATE...... 249 ZOHYDRO ER...... 6 XYOSTED...... 181 ZESTORETIC...... 68 ZOKINVY...... 241 XYREM...... 117 ZESTRIL...... 68 ZOLADEX...... 53 XYWAV...... 117 ZETIA...... 75 ZOLINZA...... 52 XYZAL...... 261 ZETONNA...... 270 zolmitriptan...... 116 YASMIN (28)...... 130 ZIAC...... 79 ZOLOFT...... 93 YAZ (28)...... 130 ZIAGEN...... 32 zolpidem...... 120 YONSA...... 46, 48 ZIANA...... 137 ZOLPIMIST...... 120 YOSPRALA...... 227 zidovudine...... 32 ZOMACTON...... 193 YUPELRI...... 265 ZIEXTENZO...... 224 ZOMETA...... 187 YUVAFEM...... 275 zileuton...... 261 ZOMIG...... 116 zafirlukast...... 263 ZILXI...... 156 ZOMIG ZMT...... 116 zaleplon...... 120 ZINBRYTA...... 246 ZONACORT...... 192 ZAMICET...... 8, 9 zinc sulfate...... 170 ZONALON...... 157 ZANAFLEX...... 232 ZINGIBER...... 177 ZONEGRAN...... 91 ZANTAC...... 203 ZIOPTAN (PF)...... 256 zonisamide...... 91 ZARAH...... 130 ziprasidone hcl...... 99, 110 ZONTIVITY...... 227 ZARONTIN...... 91 ZIPSOR...... 19 ZORBTIVE...... 193, 214 ZARXIO...... 224 ZIRGAN...... 256 ZORTRESS...... 230 ZATEAN-CH...... 176 ZITHRANOL-RR...... 144 ZORVOLEX...... 19 ZATEAN-PN DHA...... 172 ZITHROMAX...... 41 ZOSTAVAX (PF)...... 61, 67 ZATEAN-PN PLUS...... 171 ZITHROMAX TRI-PAK...... 41 ZOVIA 1/35E (28)...... 130 ZAVESCA...... 240 ZITHROMAX Z-PAK...... 41 ZOVIA 1/50E (28)...... 131 ZCORT...... 192 ZMAX...... 41 ZOVIRAX...... 39, 145 ZEBETA...... 76 ZOCOR...... 75 ZTLIDO...... 157 ZEBUTAL...... 12 ZODRYL AC 25...... 271 Z-TUSS AC...... 271 ZEGALOGUE ZODRYL AC 30...... 271 ZUBSOLV...... 121 AUTOINJECTOR...... 180 ZODRYL AC 35...... 271 ZUMANDIMINE (28)...... 131 ZEGALOGUE SYRINGE...... 180 ZODRYL AC 40...... 271 ZUPLENZ...... 201 ZEGERID...... 205 ZODRYL AC 50...... 271 ZUTRIPRO...... 272 ZEJULA...... 56 ZODRYL AC 60...... 271 ZYBAN...... 121 Last Approved Date: 09/23/2021 Formulary Version: 91
311 ZYCLARA...... 153 ZYDELIG...... 55 ZYFLO...... 261 ZYKADIA...... 48 ZYLET...... 248 ZYLOPRIM...... 220 ZYMAXID...... 255 ZYPITAMAG...... 75 ZYPRAM...... 23 ZYPREXA...... 101, 102, 110 ZYPREXA RELPREVV...... 102 ZYPREXA ZYDIS...... 102, 110 ZYRTEC...... 261 ZYRTEC-D...... 259 ZYTIGA...... 46, 48 ZYVOX...... 42
Last Approved Date: 09/23/2021 Formulary Version: 91
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