Preferred Drug List (PDL)
Hawaii Effective Date: 7/1/2021
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UnitedHealthcare Community Plan complies with applicable Federal civil rights laws and does not discriminate, exclude people, or treat people differently because of: Race Color National Origin Age Disability Sex
UnitedHealthcare Community Plan provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
UnitedHealthcare Community Plan provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, contact us toll-free at 1-888-980-8728 (TTY: 711).
If you believe that UnitedHealthcare Community Plan has failed to provide these services or discriminated in another way, you can file a grievance with: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608 Salt Lake City, UTAH 84130 [email protected]
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator UnitedHealthcare is available to help you.
You can also file a grievance with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CSHI15MC3966014_000 (English) Do you need help in another language? We will get you a free interpreter. Call 1-888-980-8728 to tell us which language you speak. (TTY: 711). (Cantonese) 您需要其它語言嗎？如有需要, 請致電 1-888-980-8728, 我們會提供免費翻譯服務 (TTY: 711). (Chuukese) En mi niit alilis lon pwal eu kapas? Sipwe angei emon chon chiaku ngonuk ese kamo. Kokori 1-888- 980-8728 omw kopwe ureni kich meni kapas ka ani. (TTY: 711).
(French) Avez-vous besoin d'aide dans une autre langue? Nous pouvons vous fournir gratuitement des services d'un interprète. Appelez le 1-888-980-8728 pour nous indiquer quelle langue vous parlez. (TTY: 711).
(German) Brauchen Sie Hilfe in einer andereren Sprache? Wir koennen Ihnen gern einen kostenlosen Dolmetscher besorgen. Bitte rufen Sie uns an unter 1-888-980-8728 und sagen Sie uns Bescheid, welche Sprache Sie sprechen. (TTY: 711). (Hawaiian) Makemake `oe i kokua i pili kekahi `olelo o na `aina `e? Makemake la maua i ki`i `oe mea unuhi manuahi. E kelepona 1-888-980-8728 `oe ia la kaua a e ha`ina `oe ia la maua mea `olelo o na `aina `e. (TTY: 711).
(Ilocano) Masapulyo kadi ti tulong iti sabali a pagsasao? Ikkandakayo iti libre nga paraipatarus. Awaganyo ti 1-888-980-8728 tapno ibagayo kadakami no ania ti pagsasao nga ar-aramatenyo. (TTY: 711).
(Japanese) 貴方は、他の言語に、助けを必要としていますか ? 私たちは、貴方のために、無料で 通訳を用意で きます。電話番号の、1-888-980-8728 に、電話して、私たちに貴方の話されている言語を 申し出てください。 (TTY: 711). (Korean) 다른언어로 도움이 필요하십니까? 저희가 무료로 통역을 제공합니다. 1-888-980-8728 로 전화해서 사용하는 언어를 알려주십시요 (TTY: 711). (Mandarin) 您需要其它语言吗？如有需要,请致电 1-888-980-8728, 我们会提供免费翻译服务 (TTY: 711). (Marshallese) Kwoj aikuij ke jiban kin juon bar kajin? Kim naj lewaj juon am dri ukok eo ejjelok wonen. Kirtok 1-888-980-8728 im kwalok non kim kajin ta eo kwo melele im kenono kake. (TTY: 711).
(Samoan) E te mana'o mia se fesosoani i se isi gagana? Matou te fesosoani e ave atu fua se faaliliu upu mo oe. Vili mai i le numera lea 1-888-980-8728 pea e mana'o mia se fesosoani mo se faaliliu upu. (TTY: 711).
(Spanish) ¿Necesita ayuda en otro idioma? Nosotros le ayudaremos a conseguir un intérprete gratuito. Llame al 1-888-980-8728 y diganos que idioma habla. (TTY: 711).
(Tagalog) Kailangan ba ninyo ng tulong sa ibang lengguwahe? Ikukuha namin kayo ng libreng tagasalin. Tumawag sa 1-888-980-8728 para sabihin kung anong lengguwahe ang nais ninyong gamitin. (TTY: 711).
(Tongan) 'Oku ke fiema'u tokoni 'iha lea makehe? Te mau malava 'o 'oatu ha fakatonulea ta'etotongi. Telefoni ki he 1-888-980-8728 'o fakaha mai pe koe ha 'ae lea fakafonua 'oku ke ngaue'aki. (TTY: 711).
(Vietnamese) Bạn có cần giúp đỡ bằng ngôn ngữ khác không ? Chúng tôi se yêu cầu một người thông dịch viên miễn phí cho bạn. Gọi 1-888-980-8728 nói cho chúng tôi biết bạn dùng ngôn ngữ nào. (TTY: 711).
(Visayan) Gakinahanglan ka ba ug tabang sa imong pinulongan? Amo kang mahatagan ug libre nga maghuhubad. Tawag sa 1-888-980-8728 aron magpahibalo kung unsa ang imong sinulti-han. (TTY: 711).
UnitedHealthcare Community Plan List of Preferred Drugs
Frequently Asked Questions (FAQ) Find answers here to questions you have about this UnitedHealthcare Community Plan List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question and answer.
1 What drugs are on the Preferred Drug List? (We call the Preferred Drug List the “Drug List” for short.) The drugs on Preferred Drug List that starts on page <3> are the drugs covered by UnitedHealthcare Community Plan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”
UnitedHealthcare will cover all medically necessary drugs if: · your doctor or other prescriber says you need them to get better or stay healthy, and · you fill the prescription at a UnitedHealthcare Community Plan network pharmacy. UnitedHealthcare may have additional steps to access certain drugs (see question <#5> below). You can also see an up-to-date drug list on our website at
2 Does the Drug List ever change? Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: · a cheaper drug comes along that works as well as a drug on the Drug List now, or · we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: · Decide to require or not require prior approval for a drug. (Prior approval is permission from UnitedHealthcare Community Plan before you can get a drug.) · Add or change the amount of a drug you can get (called “quantity limits”). · Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)
Questions 3, 4, and 7 below have more information on what happens when the Drug List changes. You can always check the up-to-date Drug List online at
3 What happens when another drug comes along that works as well as a drug on the Drug List now? If you are taking a drug that is removed because another drug that works just as well is available, we will tell you. You will get a letter letting you know about the change. We will also tell you what alternate drugs are available to you. Contact your doctor or other prescriber to make sure another drug will work for you.
4 What happens when we find out a drug is not safe? If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. Contact your doctor or other prescriber and ask about your other options.
5 Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases your doctor must do something before you can get the drug. For example: · Prior approval (or prior authorization): For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. · Quantity limits: Sometimes UnitedHealthcare limits the amount of a drug you can get. · Step therapy: Sometimes UnitedHealthcare requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables on pages <3 – 168>. You can also get more information by visiting our website at
6 How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The Preferred Drug List on pages <3-– 168> has a column labeled “Requirements and Limits.”
7 What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you before the restriction is added. This gives you time to talk to your doctor or other prescriber about what to do next.
8 How can you find a drug on the Drug List? There are two ways to find a drug: · You can search by medical condition. To search by medical condition, find the section labeled “List of drugs by medical condition” on pages <1–2>. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents. That is where you will find drugs that treat heart conditions. · You can also search for drugs alphabetically. To search alphabetically, go to the
10 What if you just joined UnitedHealthcare Community Plan and can’t find your drug on the Drug List or have a problem getting your drug? We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of UnitedHealthcare. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead, or whether to request an exception.
11 Can you ask for an exception to cover your drug? Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to cover a drug that is not on the Drug List. Your doctor can also ask us to change the rules on your drug. · For example, we may limit the amount of a drug we will cover. If your drug has a limit, your doctor can ask us to change the limit and cover more. · Other examples: Your doctor can ask us to drop step therapy restrictions or prior approval requirements.
12 How long does it take to get an exception? First, we must receive some information from your doctor supporting your request for an exception. After we receive the information, we will give you a decision on your exception request within the timeframes required by the state, generally within 24 hours.
13 How can you ask for an exception? To ask for an exception, you can do one of two things: - Call Member Services. A Member Services representative will work with you and your doctor to help ask for an exception. - Call your doctor and ask them to request an exception by calling the Prior Notification Service at <1-800-310-6826>, or they can fax a request to<866-940- 7328>.
14 What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA). In most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand name drug is medically necessary, you will need to ask your doctor to submit for prior approval.
15 What are OTC drugs? OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs are preferred.
16 Does UnitedHealthcare cover OTC non-drug products? UnitedHealthcare covers some OTC non-drug products when they are written as prescriptions by your provider. You can read the UnitedHealthcare Community Plan Drug List to see what OTC non- drug products are covered.
17 What is a Specialty Pharmacy Medication? A specialty pharmacy medication is a drug that generally has one or more of the following characteristics: • It’s used by a small number of people • It treats rare, chronic, and/or potentially life-threatening diseases • It has special storage or handling requirements such as needing to be refrigerated • It may need close monitoring, ongoing clinical support and management, and complete patient education and engagement • It’s a high cost medication • It may not be available at retail pharmacies • It may be oral, injectable, or inhaled
Specialty pharmacy medications are available through our specialty pharmacy network. If you have questions, call Member Services at <1-888-980-8728, TTY 711>.
List of Preferred Drugs The List of Preferred Drugs that begins
Utilization Management Restrictions
PA - Prior approval (or prior authorization) For some drugs, your doctor or other prescriber must get approval from UnitedHealthcare Community Plan before you fill your prescription. If you don’t get approval, UnitedHealthcare may not cover the drug. QL - Quantity limits Sometimes UnitedHealthcare Community Plan limits the amount of a drug you can get. ST - Step therapy Sometimes UnitedHealthcare Community Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then your doctor can ask for approval to cover the second. Other special requirements for coverage
SP – Specialty Pharmacy Drug needs to be accessed through a network Specialty Pharmacy. Specialty Pharmacy Drugs may require extra handling, provider coordination or patient education that can’t be done at a network retail pharmacy.
Drug Tiers
The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.
Tier Name Drug Tier Tier 1 Generic Tier 2 Brand
[ABBREVIATIONS]
OTC = Over the Counter PA = Prior Authorization required QL = Quantity Limit ST = Step Therapy SP = Specialty Pharmacy
[You can find information on what the symbols and abbreviations in this table mean by going to page <3>] Preguntas frecuentes Encuentre aquí las respuestas a sus preguntas sobre esta Lista de Medicamentos Preferidos de UnitedHealthcare Community Plan. Puede leer todas las preguntas frecuentes para obtener más información o buscar una pregunta y su respuesta.
1. ¿Qué medicamentos están en la Lista de Medicamentos Preferidos? (Para abreviar, denominamos a esta lista “Lista de Medicamentos”). Los medicamentos de la Lista de Medicamentos Preferidos que comienza en la página <3> son los medicamentos cubiertos por UnitedHealthcare Community Plan. Estos medicamentos están disponibles en farmacias dentro de nuestra red. Una farmacia se encuentra en nuestra red si tenemos un acuerdo con ella para que trabaje con nosotros y le proporcione servicios. A estas farmacias las denominamos “farmacias de la red”.
UnitedHealthcare Community Plan cubrirá todos los medicamentos médicamente necesarios si: · su médico u otro profesional que receta dice que los necesita para mejorarse o mantenerse en buen estado de salud, y · usted surte una receta en una farmacia de la red de UnitedHealthcare Community Plan. UnitedHealthcare Community Plan puede requerir pasos adicionales para tener acceso a determinados medicamentos (vea la pregunta <#5> a continuación). También puede ver una lista de medicamentos actualizada en nuestro sitio web en
2. ¿Cambia alguna vez la Lista de Medicamentos Preferidos? Sí. UnitedHealthcare Community Plan puede agregar o quitar medicamentos de la Lista de Medicamentos Preferidos durante el año. Por lo general, la Lista de Medicamentos Preferidos solo cambiará si: · aparece un medicamento más económico que funciona igual que un medicamento que está actualmente en la Lista de Medicamentos Preferidos, o · si tomamos conocimiento de que un medicamento no es seguro. También podemos cambiar nuestras reglas sobre los medicamentos. Por ejemplo, podríamos: · Decidir exigir o no exigir aprobación previa para un medicamento. (Aprobación previa es un permiso de UnitedHealthcare Community Plan antes de que usted pueda obtener un medicamento). · Agregar o cambiar la cantidad de un medicamento que puede obtener (denominados “límites de cantidad”). · Agregar o cambiar las restricciones de terapia escalonada de un medicamento. (Terapia escalonada significa que usted debe probar un medicamento antes de que cubramos otro medicamento). Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que sucede cuando cambia la Lista de Medicamentos Preferidos. Siempre puede consultar la Lista de Medicamentos Preferidos actualizada en Internet en
3. ¿Qué sucede cuando aparece otro medicamento que funciona igual que un medicamento que está actualmente en la Lista de Medicamentos Preferidos? Si está tomando un medicamento que se retira porque otro medicamento que funciona igual está disponible, se lo informaremos. Recibirá una carta que le informará sobre el cambio. También le informaremos qué medicamentos alternativos están disponibles para usted. Comuníquese con su médico u otro profesional que receta para asegurarse de que otro medicamento sea adecuado para usted.
4. ¿Qué sucede cuando averiguamos que un medicamento no es seguro? Si la Administración de Medicamentos y Alimentos (FDA) anuncia que un medicamento que usted está tomando no es seguro, lo quitaremos inmediatamente de la Lista de Medicamentos Preferidos. También le enviaremos una carta para informarle al respecto. Comuníquese con su médico u otro profesional que receta para preguntarle sobre sus otras opciones.
5. ¿Se aplican restricciones o límites a la cobertura de medicamentos? ¿O se requiere tomar alguna medida a fin de obtener determinados medicamentos? Sí, algunos medicamentos tienen reglas de cobertura o tienen límites sobre la cantidad que usted puede obtener. En algunos casos, su médico debe hacer algo antes de que usted pueda obtener el medicamento. Por ejemplo: · Aprobación previa (o preautorización): Para algunos medicamentos, su médico u otro profesional que receta debe obtener aprobación de UnitedHealthcare Community Plan antes de que usted pueda surtir su receta. Si no obtiene la aprobación, es posible que UnitedHealthcare Community Plan no cubra el medicamento. · Límites de cantidad: A veces, UnitedHealthcare Community Plan limita la cantidad de un medicamento que usted puede obtener. · Terapia escalonada: A veces, UnitedHealthcare Community Plan requiere que usted haga una terapia escalonada. Esto significa que deberá probar los medicamentos en un determinado orden para su condición médica. Usted podría tener que probar un medicamento antes de que cubramos otro medicamento. Si su médico considera que el primer medicamento no es adecuado para usted, cubriremos el segundo. Puede averiguar si su medicamento tiene requisitos o límites adicionales consultando las tablas de las páginas <3 – 168>. También puede obtener más información visitando nuestro sitio web en
6. ¿Cómo sabrá si el medicamento que desea está sujeto a límites o si debe tomar medidas adicionales para poder obtenerlo? La Lista de Medicamentos Preferidos en las páginas <3-168> tiene una columna denominada “Requisitos y límites”.
7. ¿Qué sucede si cambiamos nuestras reglas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos un requisito de preautorización (aprobación), límites de cantidad o restricciones de terapia escalonada a un medicamento. Si agregamos un requisito de aprobación previa, límites de cantidad o restricciones de terapia escalonada a un medicamento, se lo informaremos. Le informaremos antes de que se agregue la restricción. Esto le da tiempo para hablar con su médico u otro profesional que receta sobre qué hacer a continuación.
8. ¿Cómo puede buscar un medicamento en la Lista de Medicamentos Preferidos? Hay dos formas de buscar un medicamento: · Puede buscar por condición médica. Para buscar por condición médica, encuentre la sección “Lista de medicamentos por condición médica” en las páginas <1– 2>. Los medicamentos en esta sección están agrupados en categorías según el tipo de condiciones médicas para cuyo tratamiento se utilizan. Por ejemplo, si usted tiene una condición cardíaca, debe buscar en la categoría Agentes cardiovasculares. Allí es donde encontrará los medicamentos que tratan las condiciones cardíacas. · También puede buscar medicamentos por orden alfabético. Para buscar por orden alfabético, vaya a la sección <Índice alfabético de medicamentos cubiertos> que comienza en la página <169>. Encuentre el nombre de su medicamento. Al lado del medicamento está el número de página donde se encuentra.
9. ¿Qué debe hacer si el medicamento que desea tomar no está en la Lista de Medicamentos Preferidos? Si su medicamento no aparece en la Lista de Medicamentos Preferidos, llame al Departamento de Servicio al Cliente y pregunte al respecto. Si UnitedHealthcare Community Plan no incluye su medicamento dentro de los medicamentos preferidos del plan, usted tiene dos opciones: · Solicite al Departamento de Servicio al Cliente una lista de medicamentos que sean similares al que usted desea tomar. Luego muestre la lista a su médico u otro profesional que receta. Este puede recetar un medicamento que aparezca en la Lista de Medicamentos Preferidos que sea como el que desea tomar. O · Puede solicitar al plan de salud que haga una excepción y cubra su medicamento. Consulte la pregunta 11 para obtener más información sobre las excepciones. 10. ¿Qué sucede si acaba de inscribirse en UnitedHealthcare Community Plan y su medicamento no aparece en la Lista de Medicamentos Preferidos o tiene problemas para obtener su medicamento? Podemos ayudar. Podemos cubrir un suministro temporal de 30 días de su medicamento durante los primeros 90 días de su membresía en UnitedHealthcare Community Plan. Esto le dará tiempo para hablar con su médico u otro profesional que receta. Este puede ayudarle a decidir si hay un medicamento similar en la Lista de Medicamentos Preferidos que usted puede tomar en lugar del otro, o si debe solicitar una excepción.
11. ¿Puede solicitar una excepción para cubrir su medicamento? Sí. Su médico puede solicitar a UnitedHealthcare Community Plan que haga una excepción y cubra un medicamento que no aparece en la Lista de Medicamentos Preferidos. Su médico también puede solicitarnos que cambiemos las reglas sobre su medicamento. · Por ejemplo, podemos limitar la cantidad de un medicamento que cubriremos. Si su medicamento tiene un límite, su médico puede pedirnos que cambiemos el límite y cubramos una cantidad mayor. · Otros ejemplos: Su médico puede solicitarnos que dejemos de lado las restricciones de terapia escalonada o los requisitos de aprobación previa.
12. ¿Cuánto tiempo demora conseguir una excepción? Primero, debemos recibir más información de su médico que respalde su solicitud de una excepción. Después de que recibamos la información, le daremos una decisión sobre su solicitud de excepción dentro los plazos requeridos por el estado, por lo general, dentro de las 24 horas.
13. ¿Cómo puede solicitar una excepción? Para solicitar una excepción, puede hacer una de estas dos cosas: - Llame al Departamento de Servicio al Cliente. Un representante de dicho departamento trabajará con usted y con su médico para ayudarle a solicitar una excepción. - Llame a su médico y pídale que solicite una excepción llamando al Servicio de Prenotificación al <1-800-310-6826>, o puede enviar una solicitud por fax al <866-940-7328>.
14. ¿Qué son los medicamentos genéricos? Los medicamentos genéricos están compuestos por los mismos ingredientes activos que los medicamentos de marca. Por lo general, cuestan menos que el medicamento de marca y no tienen nombres muy conocidos. Los medicamentos genéricos están aprobados por la Administración de Medicamentos y Alimentos (FDA). En la mayoría de los casos, UnitedHealthcare Community Plan cubre los medicamentos genéricos primero. Si su médico considera que un medicamento de marca es médicamente necesario, deberá pedirle a su médico que envíe una solicitud de aprobación previa.
15. ¿Qué son los medicamentos sin receta? OTC son las siglas en inglés de “sin receta” (over-the-counter). UnitedHealthcare Community Plan considera algunos medicamentos sin receta como medicamentos preferidos si su proveedor extiende una receta para estos. Puede consultar la Lista de Medicamentos Preferidos de UnitedHealthcare Community Plan para ver qué medicamentos sin receta son los preferidos.
16. ¿Cubre UnitedHealthcare Community Plan productos sin receta que no son medicamentos? UnitedHealthcare Community Plan cubre algunos productos sin receta que no son medicamentos si su proveedor extiende una receta para estos. Puede consultar la Lista de Medicamentos Preferidos de UnitedHealthcare Community Plan para ver qué productos sin receta que no son medicamentos están cubiertos.
17. ¿Qué es un medicamento de farmacia especializada? Un medicamento de farmacia especializada es un medicamento que, por lo general, tiene una o más de las siguientes características: • Es utilizado por una cantidad reducida de personas • Trata enfermedades raras, crónicas o potencialmente mortales • Tiene requisitos de almacenamiento o manipulación especiales, como la necesidad de estar refrigerado • Es posible que requiera control de cerca, apoyo y manejo clínicos continuos, y educación y compromiso totales del paciente • Es un medicamento de alto costo • Es posible que no esté disponible en farmacias de venta al por menor • Puede ser de administración oral, inyectable o inhalable
Los medicamentos de farmacia especializada están disponibles a través de nuestra red de farmacias especializadas. Si tiene alguna pregunta, llame al Departamento de Servicio al Cliente al <1-888-980- 8728, TTY 711>.
Lista de Medicamentos Preferidos La Lista de Medicamentos Preferidos que comienza
Restricciones de administración de la utilización
PA - Aprobación previa (o preautorización) Para algunos medicamentos, su médico u otro profesional que receta debe obtener la aprobación de UnitedHealthcare Community Plan antes de que usted pueda surtir su receta. Si no obtiene la aprobación, es posible que UnitedHealthcare Community Plan no cubra el medicamento. QL – Límites de cantidad A veces, UnitedHealthcare Community Plan limita la cantidad de un medicamento que usted puede obtener. ST – Terapia escalonada A veces, UnitedHealthcare Community Plan requiere que usted haga una terapia escalonada. Esto significa que deberá probar los medicamentos en un determinado orden para su condición médica. Usted podría tener que probar un medicamento antes de que cubramos otro medicamento. Si su médico considera que el primer medicamento no es adecuado para usted, su médico puede solicitar la aprobación de la cobertura del segundo.
Otros requisitos especiales de cobertura
SP – Farmacia especializada Se debe acceder a los medicamentos a través de una farmacia especializada de la red. Los medicamentos de farmacia especializada pueden requerir manejo adicional, coordinación de proveedores o educación del paciente que no se puede realizar en una farmacia de venta al por menor de la red.
[ABREVIATURAS]
OTC = Sin receta PA = Se requiere Preautorización QL = Límite de cantidad ST = Terapia escalonada SP = Farmacia especializada Table of Contents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions...... 3 Anesthetics - Drugs for Numbing...... 13 Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence...... 13 Antibacterials...... 15 Antibacterials - Drugs to Treat Bacterial Infections...... 16 Anticonvulsants - Drugs to Treat Seizures...... 20 Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia...... 23 Antidepressants - Drugs to Treat Depression...... 24 Antiemetics - Drugs to Treat Nausea and Vomiting...... 26 Antifungals - Drugs to Treat Fungal Infections...... 27 Antigout Agents - Drugs to Treat Gout...... 30 Antimigraine Agents - Drugs to Treat Migraines...... 30 Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis...... 31 Antimycobacterials - Drugs to Treat Infections...... 31 Antineoplastics - Drugs to Treat Cancer...... 32 Antiparasitics - Drugs to Treat Parasitic Infections...... 36 Antiparkinson Agents - Drugs to Treat Parkinson's Disease...... 38 Antipsychotics - Drugs to Treat Mood Disorders...... 39 Antispasticity Agents...... 40 Antivirals - Drugs to Treat Viral Infections...... 40 Anxiolytics - Drugs to Treat Anxiety...... 44 Bipolar Agents - Drugs to Treat Mood Disorders...... 45 Blood Glucose Regulators - Drugs to Regulate Blood Sugar...... 45 Blood Products and Modifiers...... 48 Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders...... 49 Cardiovascular Agents...... 50 Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions...... 51 Central Nervous System Agents...... 56 Central Nervous System Agents - Drugs to Treat Nerve Conditions...... 56 Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions...... 59 Dermatological Agents - Drugs to Treat Skin Conditions...... 60 Electrolytes/Minerals/Metals/Vitamins...... 66 Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions...... 80 Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...... 97 Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...... 98 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones...... 99 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones...... 100 Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones...... 101 1 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones...... 101 Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones...... 108 Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones...... 108 Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones...... 108 Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones...... 109 Immunological Agents...... 109 Immunological Agents - Drugs that Stimulate or Suppress the Immune System...... 109 Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease...... 113 Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions...... 113 Metabolic Bone Disease Agents - Other...... 114 Miscellaneous Therapeutic Agents...... 114 Ophthalmic Agents - Drugs to Treat Eye Conditions...... 121 Otic Agents - Drugs to Treat Ear Conditions...... 127 Regulators - Drugs to Regulate Blood Sugar...... 128 Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions...... 129 Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm...... 149 Sleep Disorder Agents - Drugs for Sedation and Sleep...... 150 Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies...... 150
2 Preferred Agents Non-Preferred Agents Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions Analgesics - Miscellaneous Analgesics 8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL 8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL 8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen childrens - Tier 1; QL acetaminophen childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 3 Preferred Agents Non-Preferred Agents acetaminophen ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650 mg/20.3ml - Tier 1; QL acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic for PANADOL CHILDRENS) - Tier 1; QL acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL acetaminophen oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 120 mg (generic for FEVERALL CHILDRENS) - Tier 1; QL acetaminophen rectal suppository 650 mg (generic for FEVERALL ADULTS) - Tier 1; QL apra (generic for MEDI-TABS CHILDRENS) - Tier 1; QL arthritis pain oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QL bac (generic for BAC) - Tier 1; QL betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1; QL butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON) - Tier 1; QL butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 4 Preferred Agents Non-Preferred Agents butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL butalbital-aspirin-caffeine - Tier 1; QL capsaicin external cream 0.025 % (generic for DERMACINRX PENETRAL) - Tier 1; QL CASTIVA WARMING - Tier 2; QL childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier 1; QL childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL childrens tactinal (generic for MAPAP CHILDRENS) - Tier 1; QL childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL DERMACINRX PENETRAL (brand for sure result sr relief) - Tier 2; QL ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL EXCEDRIN EXTRA STRENGTH (brand for sb pain relief x-str) - Tier 2 EXCEDRIN MIGRAINE (brand for sb pain relief x-str) - Tier 2 fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier 1; QL fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL FEVERALL INFANTS - Tier 2; QL FEVERALL JUNIOR STRENGTH - Tier 2; QL headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1; QL infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1; QL liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 5 Preferred Agents Non-Preferred Agents liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL mapap acetaminophen extra str (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL mapap oral capsule - Tier 1; QL migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL non-aspirin (generic for PHARBETOL) - Tier 1; QL non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL non-aspirin childrens (generic for PANADOL CHILDRENS) - Tier 1; QL non-aspirin extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL pain & fever child (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief childrens oral tablet chewable 160 mg (generic for MAPAP CHILDRENS) - Tier 1; QL pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain relief oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 6 Preferred Agents Non-Preferred Agents pain relief oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain relief oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain relief regular st (generic for PHARBETOL) - Tier 1; QL pain relief regular strength (generic for PHARBETOL) - Tier 1; QL pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever childrens oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP ACETAMINOPHEN EXTRA STR) - Tier 1 pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever ex st oral tablet extended release 650 mg (generic for TYLENOL 8 HOUR) - Tier 1; QL pain reliever extra strength oral tablet 250-250-65 mg (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain reliever extra strength oral tablet 500 mg (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL pain reliever infants oral suspension 160 mg/5ml (generic for PANADOL CHILDRENS) - Tier 1; QL pain reliever oral tablet (generic for PHARBETOL) - Tier 1; QL pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1 PANADOL CHILDRENS (brand for pain relief childrens) - Tier 2; QL PANADOL EXTRA STRENGTH (brand for hm pain relief extra strength) - Tier 2; QL PANADOL INFANTS (brand for pain relief childrens) - Tier 2; QL PHARBETOL EXTRA STRENGTH (brand for hm pain relief extra strength) - Tier 2; QL PHARBETOL ORAL TABLET 325 MG (brand for pain reliever) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 7 Preferred Agents Non-Preferred Agents sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier 1; QL sb pain reliever ex st (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1; QL tactinal extra strength (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL TENCON (brand for butalbital-acetaminophen) - Tier 2; QL TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for pain relief childrens) - Tier 2; QL TYLENOL ORAL TABLET 325 MG (brand for pain reliever) - Tier 2; QL TYLENOL ORAL TABLET 500 MG (brand for hm pain relief extra strength) - Tier 2; QL TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for cvs pain relief childrens) - Tier 2; QL TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for mapap arthritis pain) - Tier 2; QL Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory Drugs addaprin (generic for ADDAPRIN) - Tier 1; QL ADVIL JUNIOR STRENGTH (brand for sm ibuprofen jr) - Tier 2; QL ADVIL ORAL TABLET (brand for qc ibuprofen) - Tier 2; QL ALEVE ORAL TABLET (brand for eq all day pain relief) - Tier 2; QL all day pain relief (generic for MEDIPROXEN) - Tier 1; QL all day relief (generic for MEDIPROXEN) - Tier 1; QL aspirin childrens (generic for ST JOSEPH LOW DOSE) - Tier 1; QL aspirin ec (generic for BAYER ASPIRIN) - Tier 1; QL aspirin ec oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1; QL aspirin oral (generic for ST JOSEPH LOW DOSE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 8 Preferred Agents Non-Preferred Agents ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for aspirin low dose) - Tier 2; QL aspirin rectal - Tier 1 BAYER ASPIRIN (brand for gnp aspirin) - Tier 2; QL celecoxib oral capsule 100 mg, 200 mg, 400 mg (generic for CELEBREX) - Tier 1; PA; QL celecoxib oral capsule 50 mg (generic for CELEBREX) - Tier 1; QL childrens aspirin low strength (generic for ST JOSEPH LOW DOSE) - Tier 1; QL childrens aspirin oral tablet chewable 81 mg (generic for ST JOSEPH LOW DOSE) - Tier 1; QL diclofenac potassium (generic for CATAFLAM) - Tier 1; QL diclofenac sodium er - Tier 1; QL diclofenac sodium external gel 1 % (generic for ASPERCREME ARTHRITIS PAIN) - Tier 1; PA; Brand OTC and Generic; QL diclofenac sodium oral - Tier 1; QL ec-naproxen (generic for EC-NAPROSYN) - Tier 1; QL enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL etodolac - Tier 1; QL h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ibu (generic for IBU) - Tier 1; QL ibu-200 (generic for ADDAPRIN) - Tier 1; QL ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen ib oral tablet 200 mg (generic for ADDAPRIN) - Tier 1; QL ibuprofen ib oral tablet chewable 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS ADVIL) - Tier 1; QL ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 9 Preferred Agents Non-Preferred Agents ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS ADVIL) - Tier 1; QL ibuprofen oral tablet 200 mg (generic for ADDAPRIN) - Tier 1; QL ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier 1; QL indomethacin er - Tier 1; QL indomethacin oral capsule 25 mg, 50 mg - Tier 1; QL INFANTS ADVIL (brand for px infants profen ib) - Tier 2; QL infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; QL ketoprofen oral - Tier 1; QL ketorolac tromethamine intramuscular - Tier 1; QL ketorolac tromethamine oral - Tier 1; QL ketorolac tromethamine solution 30 mg/ml injection - Tier 1; QL KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION - Tier 2; QL mediproxen (generic for MEDIPROXEN) - Tier 1; QL meloxicam oral tablet (generic for MOBIC) - Tier 1; QL MOTRIN CHILDRENS (brand for eql ibuprofen junior strength) - Tier 2; QL MOTRIN IB ORAL TABLET (brand for qc ibuprofen) - Tier 2; QL MOTRIN INFANTS DROPS (brand for px infants profen ib) - Tier 2; QL nabumetone oral (generic for RELAFEN) - Tier 1; QL naproxen oral - Tier 1; QL naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier 1; QL oxaprozin (generic for DAYPRO) - Tier 1; QL piroxicam oral (generic for FELDENE) - Tier 1; QL provil (generic for ADDAPRIN) - Tier 1; QL salsalate oral - Tier 1; QL sb aspirin oral tablet delayed release (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL ST JOSEPH LOW DOSE (brand for sb childrens aspirin) - Tier 2; QL sulindac oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 10 Preferred Agents Non-Preferred Agents Opioid Analgesics, Long-acting - Opioid Pain Relievers buprenorphine transdermal (generic for BUTRANS) - Tier 1; PA; QL HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 100 mcg/hr (generic for NUCYNTA ER - Tier 2; PA; QL DURAGESIC-100) - Tier 1; PA; QL OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL fentanyl transdermal patch 72 hour 12 mcg/hr (generic for ZOHYDRO ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL DURAGESIC-12) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 25 mcg/hr (generic for DURAGESIC-25) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 50 mcg/hr (generic for DURAGESIC-50) - Tier 1; PA; QL fentanyl transdermal patch 72 hour 75 mcg/hr (generic for DURAGESIC-75) - Tier 1; PA; QL hydrocodone bitartrate er oral capsule extended release 12 hour (generic for ZOHYDRO ER) - Tier 1; PA; QL morphine sulfate er oral tablet extended release (generic for MS CONTIN) - Tier 1; PA; QL oxymorphone hcl er - Tier 1; PA; QL Opioid Analgesics, Short-acting - Opioid Pain Relievers acetaminophen-codeine - Tier 1; QL apap-caff-dihydrocodeine oral capsule (generic for TREZIX) - Tier 1; PA; acetaminophen-codeine #2 - Tier 1; QL QL acetaminophen-codeine #3 - Tier 1; QL TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL acetaminophen-codeine #4 - Tier 1; QL ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL butorphanol tartrate nasal - Tier 1; QL codeine sulfate - Tier 1; QL endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 11 Preferred Agents Non-Preferred Agents fentanyl citrate (pf) - Tier 1; QL hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1; QL hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5- 325 mg - Tier 1; QL hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL hydromorphone hcl rectal - Tier 1; QL morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml - Tier 1; QL morphine sulfate (pf) injection solution 2 mg/ml - Tier 1; QL morphine sulfate (pf) intravenous solution 2 mg/ml - Tier 1; QL morphine sulfate injection solution 2 mg/ml, 4 mg/ml - Tier 1; QL morphine sulfate intravenous solution 50 mg/ml - Tier 1; QL morphine sulfate oral - Tier 1; QL morphine sulfate rectal - Tier 1; QL OXAYDO ORAL TABLET 5 MG (brand for oxycodone hcl) - Tier 2; QL oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QL oxycodone hcl oral solution - Tier 1; QL oxycodone hcl oral tablet 10 mg, 20 mg - Tier 1; QL oxycodone hcl oral tablet 15 mg, 30 mg (generic for ROXICODONE) - Tier 1; QL oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL oxycodone-aspirin - Tier 1; QL pentazocine-naloxone hcl - Tier 1; QL tramadol hcl oral tablet 50 mg (generic for ULTRAM) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 12 Preferred Agents Non-Preferred Agents Anesthetics - Drugs for Numbing Local Anesthetics 7T LIDO - Tier 2; QL anecream external cream (generic for ANECREAM) - Tier 1; QL blue tube/ aloe (generic for ANECREAM) - Tier 1; QL glydo (generic for GLYDO) - Tier 1; QL lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QL lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; DX2RX; QL lidocaine hcl external cream 3 % - Tier 1; QL lidocaine hcl urethral/mucosal (generic for GLYDO) - Tier 1; QL lidocaine viscous hcl - Tier 1; QL lidocaine-prilocaine external cream - Tier 1; QL lidopin external cream 3 % - Tier 1; QL LMX 4 (brand for blue tube/ aloe) - Tier 2; QL Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence Alcohol Deterrents/Anti-craving - Antidotes/Deterrents/Protectants acamprosate calcium - Tier 1; QL disulfiram oral tablet 250 mg - Tier 1; QL disulfiram oral tablet 500 mg - Tier 1 naltrexone hcl oral - Tier 1; DX2RX VIVITROL - Tier 2; DX2RX; QL Opioid Dependence Treatments - Antidotes/Deterrents/Protectants buprenorphine hcl sublingual - Tier 1; DX2RX; QL BUNAVAIL - Tier 2; PA; QL buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 8-2 mg SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG (brand for (generic for SUBOXONE) - Tier 1; DX2RX; QL buprenorphine hcl-naloxone hcl) - Tier 2; PA; QL buprenorphine hcl-naloxone hcl sublingual tablet sublingual - Tier 1; SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 8-2 MG (brand for DX2RX; QL buprenorphine hcl-naloxone hcl) - Tier 2; DX2RX; QL ZUBSOLV - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 13 Preferred Agents Non-Preferred Agents Opioid Reversal Agents - Antidotes/Deterrents/Protectants naloxone hcl injection - Tier 1; QL NARCAN - Tier 2; QL Smoking Cessation Agents - Deterrents bupropion hcl er (smoking det) - Tier 1 CHANTIX - Tier 2; QL CHANTIX CONTINUING MONTH PAK - Tier 2; QL CHANTIX STARTING MONTH PAK - Tier 2; QL habitrol (generic for HABITROL) - Tier 1; QL mini nicotine (generic for KLS QUIT2) - Tier 1; QL NICODERM CQ (brand for eq nicotine step 3) - Tier 2; QL NICORETTE (brand for eq nicotine polacrilex) - Tier 2; QL NICORETTE MINI (brand for ra mini nicotine) - Tier 2; QL NICORETTE STARTER KIT (brand for eq nicotine polacrilex) - Tier 2; QL nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine mini (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 14 Preferred Agents Non-Preferred Agents nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1; QL nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1; QL nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; QL nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL nicotine step 1 (generic for HABITROL) - Tier 1; QL nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for NICODERM CQ) - Tier 1; QL nicotine transdermal patch 24 hour 21 mg/24hr (generic for HABITROL) - Tier 1; QL nicotine transdermal system (generic for NICODERM CQ) - Tier 1; QL NICOTROL - Tier 2; QL NICOTROL NS - Tier 2; QL quit2 (generic for KLS QUIT2) - Tier 1; QL quit4 (generic for KLS QUIT4) - Tier 1; QL THRIVE (brand for eq nicotine polacrilex) - Tier 2; QL Antibacterials Antibacterials, Other methenamine hippurate (generic for HIPREX) - Tier 1; QL nitrofurantoin - Tier 1; Members >= 8 years of age will require PA; QL; AL nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL nitrofurantoin monohydrate macrocrystals (generic for MACROBID) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 15 Preferred Agents Non-Preferred Agents Antibacterials - Drugs to Treat Bacterial Infections Aminoglycosides - Antibiotics amikacin sulfate injection solution 500 mg/2ml - Tier 1; QL gentamicin sulfate external - Tier 1; QL neomycin sulfate oral - Tier 1; QL paromomycin sulfate oral - Tier 1; QL Antibacterials, Other - Antibiotics antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL CLEOCIN VAGINAL SUPPOSITORY - Tier 2; PA; QL antiseptic (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 CLINDESSE - Tier 2; PA; QL bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1; QL FLAGYL (brand for metronidazole) - Tier 2; PA; QL bacitracin zinc external - Tier 1; QL METROGEL (brand for metronidazole) - Tier 2; PA bacitracin zinc first aid - Tier 1; QL VANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QL BETADINE OPHTHALMIC PREP (brand for povidone-iodine) - Tier 2 XENLETA ORAL - Tier 2; PA; QL CENTANY (brand for mupirocin) - Tier 2; QL clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) - Tier 1; QL clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL double antibiotic (generic for POLYSPORIN) - Tier 1 first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg- unit (generic for NEOSPORIN ORIGINAL) - Tier 1; QL first aid antiseptic external solution 10 % (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 FIRVANQ - Tier 2; DX2RX; QL linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA; QL linezolid oral tablet (generic for ZYVOX) - Tier 1; PA medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL metronidazole external (generic for ROSADAN) - Tier 1 metronidazole oral tablet - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 16 Preferred Agents Non-Preferred Agents metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL mupirocin external (generic for CENTANY) - Tier 1; QL NEOSPORIN ORIGINAL (brand for triple antibiotic) - Tier 2; QL NORITATE - Tier 2; PA poly bacitracin (generic for POLYSPORIN) - Tier 1 POLYSPORIN (brand for kp double antibiotic) - Tier 2 povidone iodine (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 povidone-iodine external solution (generic for SCRUB CARE POVIDONE-IODINE) - Tier 1 POVIDONE-IODINE OPHTHALMIC - Tier 2 rosadan external cream (generic for ROSADAN) - Tier 1 rosadan external gel (generic for ROSADAN) - Tier 1 SCRUB CARE POVIDONE-IODINE (brand for sb povidone-iodine) - Tier 2 trimethoprim oral - Tier 1; QL triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1; QL vandazole (generic for VANDAZOLE) - Tier 1; QL Beta-Lactam, Cephalosporins - Antibiotics cefaclor - Tier 1; QL cefadroxil - Tier 1; QL cefazolin sodium injection solution reconstituted 1 gm - Tier 1; QL cefdinir - Tier 1; QL cefprozil - Tier 1; QL ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 500 mg - Tier 1; QL cefuroxime axetil - Tier 1; QL cephalexin oral capsule 250 mg, 500 mg - Tier 1; QL cephalexin oral capsule 750 mg (generic for KEFLEX) - Tier 1 cephalexin oral suspension reconstituted - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 17 Preferred Agents Non-Preferred Agents Beta-Lactam, Penicillins - Antibiotics amoxicillin oral capsule - Tier 1; QL amoxicillin oral suspension reconstituted - Tier 1; QL amoxicillin oral tablet 875 mg - Tier 1; QL amoxicillin oral tablet chewable - Tier 1; QL amoxicillin-potassium clavulanate oral (generic for AUGMENTIN) - Tier 1; QL ampicillin - Tier 1; QL dicloxacillin sodium - Tier 1; QL penicillin v potassium - Tier 1; QL piperacillin sod-tazobactam so intravenous solution reconstituted 4.5 (4-0.5) gm - Tier 1; QL Macrolides - Antibiotics azithromycin oral suspension reconstituted (generic for ZITHROMAX) - Tier 1; QL azithromycin oral tablet (generic for ZITHROMAX) - Tier 1; QL clarithromycin er - Tier 1; QL clarithromycin oral - Tier 1; QL DIFICID - Tier 2; PA; QL E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; QL ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; QL erythromycin base - Tier 1; QL erythromycin ethylsuccinate oral (generic for E.E.S. GRANULES) - Tier 1; QL erythromycin oral (generic for ERY-TAB) - Tier 1; QL Quinolones - Antibiotics CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL MOXEZA (brand for moxifloxacin hcl (2x day)) - Tier 2; PA; QL ciprofloxacin hcl oral - Tier 1; QL VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL levofloxacin oral tablet (generic for LEVAQUIN) - Tier 1; QL XEPI - Tier 2; PA; QL ofloxacin oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 18 Preferred Agents Non-Preferred Agents Sulfonamides - Antibiotics silver sulfadiazine external (generic for SSD) - Tier 1; QL ssd (generic for SSD) - Tier 1; QL sulfacetamide sodium ophthalmic (generic for BLEPH-10) - Tier 1; QL sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1; QL sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL Tetracyclines - Antibiotics doxycycline hyclate oral capsule (generic for MORGIDOX) - Tier 1; ORACEA (brand for doxycycline) - Tier 2; PA QL; AL SOLODYN (brand for minocycline hcl er) - Tier 2; PA doxycycline hyclate oral tablet 100 mg - Tier 1; QL; AL XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL doxycycline hyclate oral tablet 20 mg - Tier 1 doxycycline monohydrate oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; QL doxycycline monohydrate oral capsule 50 mg - Tier 1; QL minocycline hcl oral capsule 100 mg (generic for MINOCIN) - Tier 1; QL minocycline hcl oral capsule 50 mg - Tier 1; QL mondoxyne nl oral capsule 100 mg (generic for MONDOXYNE NL) - Tier 1; QL morgidox oral (generic for MORGIDOX) - Tier 1; QL; AL NUZYRA ORAL - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 19 Preferred Agents Non-Preferred Agents Anticonvulsants - Drugs to Treat Seizures Anticonvulsants, Other - Seizure Control Drugs KEPPRA ORAL SOLUTION (brand for levetiracetam) - Tier 2; BRIVIACT INTRAVENOUS - Tier 2; PA Maximum age of 9 years for solution; QL; AL BRIVIACT ORAL - Tier 2; PA; QL KEPPRA ORAL TABLET (brand for levetiracetam) - Tier 2; QL XCOPRI - Tier 2; PA; QL levetiracetam oral solution (generic for KEPPRA) - Tier 1; Maximum XCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 50 & age of 9 years for solution; QL; AL 200 MG - Tier 2; PA; QL levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL NAYZILAM - Tier 2; PA; QL phenobarbital oral tablet - Tier 1; QL roweepra (generic for ROWEEPRA) - Tier 1; QL Calcium Channel Modifying Agents - Seizure Control Drugs CELONTIN - Tier 2; QL ethosuximide oral (generic for ZARONTIN) - Tier 1; QL ZARONTIN (brand for ethosuximide) - Tier 2; QL ZONEGRAN (brand for zonisamide) - Tier 2; QL zonisamide oral (generic for ZONEGRAN) - Tier 1; QL Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure Control Drugs clobazam (generic for ONFI) - Tier 1; DX2RX; QL SYMPAZAN - Tier 2; PA; QL DIASTAT ACUDIAL (brand for diazepam) - Tier 2 VALTOCO 10 MG DOSE - Tier 2; PA; QL DIASTAT PEDIATRIC (brand for diazepam) - Tier 2; QL VALTOCO 15 MG DOSE - Tier 2; PA; QL diazepam rectal gel 10 mg, 20 mg (generic for DIASTAT ACUDIAL) - VALTOCO 20 MG DOSE - Tier 2; PA; QL Tier 1 VALTOCO 5 MG DOSE - Tier 2; PA; QL diazepam rectal gel 2.5 mg (generic for DIASTAT PEDIATRIC) - Tier 1; QL gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL GABITRIL (brand for tiagabine hcl) - Tier 2; PA; QL; AL MYSOLINE (brand for primidone) - Tier 2; QL NEURONTIN ORAL CAPSULE (brand for gabapentin) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 20 Preferred Agents Non-Preferred Agents NEURONTIN ORAL TABLET (brand for gabapentin) - Tier 2; QL ONFI (brand for clobazam) - Tier 2; DX2RX; QL phenobarbital oral elixir - Tier 1; QL primidone oral (generic for MYSOLINE) - Tier 1; QL SABRIL ORAL PACKET (brand for vigabatrin) - Tier 2; SP; QL tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL; AL valproic acid oral - Tier 1; QL vigabatrin oral packet (generic for VIGADRONE) - Tier 1; SP; QL vigadrone (generic for VIGADRONE) - Tier 1; SP; QL Glutamate Reducing Agents - Seizure Control Drugs felbamate oral suspension (generic for FELBATOL) - Tier 1; Members FYCOMPA - Tier 2; PA; QL >= 8 years of age will require PA; QL; AL felbamate oral tablet (generic for FELBATOL) - Tier 1; QL FELBATOL ORAL SUSPENSION (brand for felbamate) - Tier 2; Members >= 8 years of age will require PA; QL; AL FELBATOL ORAL TABLET (brand for felbamate) - Tier 2; QL LAMICTAL ORAL TABLET (brand for lamotrigine) - Tier 2; QL LAMICTAL ORAL TABLET CHEWABLE (brand for lamotrigine) - Tier 2; Members >= 8 years of age will require PA; QL; AL LAMICTAL STARTER (brand for lamotrigine starter kit-green) - Tier 2; QL lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; Members >= 8 years of age will require PA; QL; AL lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1; QL lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; QL lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; QL subvenite (generic for SUBVENITE) - Tier 1; QL subvenite starter kit-blue (generic for SUBVENITE STARTER KIT- BLUE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 21 Preferred Agents Non-Preferred Agents subvenite starter kit-green (generic for SUBVENITE STARTER KIT- GREEN) - Tier 1; QL subvenite starter kit-orange (generic for SUBVENITE STARTER KIT- ORANGE) - Tier 1; QL TOPAMAX (brand for topiramate) - Tier 2; QL TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; Members >= 8 years of age will require PA; QL; AL topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - Tier 1; Members >= 8 years of age will require PA; QL; AL topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL Sodium Channel Agents - Seizure Control Drugs BANZEL - Tier 2; DX2RX; QL APTIOM - Tier 2; PA; QL carbamazepine er (generic for CARBATROL) - Tier 1; QL VIMPAT INTRAVENOUS - Tier 2; PA carbamazepine oral - Tier 1; QL VIMPAT ORAL - Tier 2; PA; QL; AL CARBATROL (brand for carbamazepine er) - Tier 2; QL DILANTIN (brand for phenytoin sodium extended) - Tier 2; QL DILANTIN INFATABS (brand for phenytoin) - Tier 2; QL epitol (generic for EPITOL) - Tier 1; QL oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1; Maximum age of 9 years for solution; QL; AL oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL PHENYTEK (brand for phenytoin sodium extended) - Tier 2; QL phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1; QL phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) - Tier 1; QL phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL rufinamide (generic for BANZEL) - Tier 1; DX2RX; QL TEGRETOL (brand for carbamazepine) - Tier 2; QL TEGRETOL-XR (brand for carbamazepine er) - Tier 2; QL TRILEPTAL ORAL SUSPENSION (brand for oxcarbazepine) - Tier 2; Maximum age of 9 years for solution; QL; AL TRILEPTAL ORAL TABLET (brand for oxcarbazepine) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 22 Preferred Agents Non-Preferred Agents Antidementia Agents - Drugs to Treat Alzheimer's Disease and Dementia Cholinesterase Inhibitors - Alzheimer's Disease and Dementia Drugs donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1; Members <18 years of age will require PA; QL; AL donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; ST; Members <18 years of age will require PA; QL; AL donepezil hcl oral tablet dispersible 10 mg - Tier 1; QL donepezil hcl oral tablet dispersible 5 mg - Tier 1; PA; QL galantamine hydrobromide oral solution - Tier 1; QL; AL galantamine hydrobromide oral tablet 12 mg, 8 mg - Tier 1; QL; AL galantamine hydrobromide oral tablet 4 mg - Tier 1; Members <18 years of age will require PA; QL; AL rivastigmine (generic for EXELON) - Tier 1; Members <18 years of age will require PA; QL; AL rivastigmine tartrate - Tier 1; QL; AL N-methyl-D-aspartate (NMDA) Receptor Antagonist - Alzheimer's Disease and Dementia Drugs memantine hcl oral solution 2 mg/ml - Tier 1; QL memantine hcl oral tablet (generic for NAMENDA) - Tier 1; Members <18 years of age will require PA; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 23 Preferred Agents Non-Preferred Agents Antidepressants - Drugs to Treat Depression Antidepressants, Other - Antidepressants APLENZIN - Tier 2; QL bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg (generic for WELLBUTRIN XL) - Tier 1; QL BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG - Tier 2; QL bupropion hcl oral - Tier 1; QL FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; QL mirtazapine oral tablet 15 mg, 30 mg (generic for REMERON) - Tier 1; Tabs (not soltabs); QL mirtazapine oral tablet 45 mg, 7.5 mg - Tier 1; QL mirtazapine oral tablet dispersible (generic for REMERON SOLTAB) - Tier 1; QL olanzapine-fluoxetine hcl (generic for SYMBYAX) - Tier 1; QL; AL perphenazine-amitriptyline - Tier 1 Monoamine Oxidase Inhibitors - Antidepressants EMSAM - Tier 2; QL MARPLAN - Tier 2; QL phenelzine sulfate oral (generic for NARDIL) - Tier 1; QL tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 24 Preferred Agents Non-Preferred Agents SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitors) citalopram hydrobromide (generic for CELEXA) - Tier 1; QL CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL DESVENLAFAXINE ER - Tier 2; QL PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL desvenlafaxine succinate er (generic for PRISTIQ) - Tier 1; QL duloxetine hcl oral (generic for CYMBALTA) - Tier 1; QL escitalopram oxalate (generic for LEXAPRO) - Tier 1; QL FETZIMA - Tier 2; QL FETZIMA TITRATION - Tier 2; QL fluoxetine hcl oral (generic for PROZAC) - Tier 1; QL fluvoxamine maleate - Tier 1; QL fluvoxamine maleate er - Tier 1; QL maprotiline hcl - Tier 1; QL nefazodone hcl - Tier 1; QL paroxetine hcl (generic for PAXIL) - Tier 1; QL paroxetine hcl er (generic for PAXIL CR) - Tier 1; QL PAXIL ORAL SUSPENSION - Tier 2; QL PEXEVA - Tier 2; QL sertraline hcl oral (generic for ZOLOFT) - Tier 1; QL trazodone hcl oral - Tier 1; QL TRINTELLIX - Tier 2; QL venlafaxine hcl - Tier 1; QL venlafaxine hcl er (generic for EFFEXOR XR) - Tier 1; QL VIIBRYD - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 25 Preferred Agents Non-Preferred Agents Tricyclics - Antidepressants amitriptyline hcl oral - Tier 1; QL amoxapine - Tier 1; QL clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; QL desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL doxepin hcl oral capsule - Tier 1; QL doxepin hcl oral concentrate - Tier 1; QL imipramine hcl oral - Tier 1; QL imipramine pamoate - Tier 1; QL nortriptyline hcl oral (generic for PAMELOR) - Tier 1; QL protriptyline hcl - Tier 1; QL trimipramine maleate oral - Tier 1; QL Antiemetics - Drugs to Treat Nausea and Vomiting Antiemetics, Other - Nausea and Vomiting Drugs anti-nausea - Tier 1 BONINE (brand for ra motion sickness relief) - Tier 2 compro (generic for COMPRO) - Tier 1 formula em - Tier 1 meclizine hcl oral tablet 12.5 mg - Tier 1; QL meclizine hcl oral tablet 25 mg (generic for TRAVEL-EASE) - Tier 1; QL meclizine hcl oral tablet chewable (generic for BONINE) - Tier 1 metoclopramide hcl oral solution - Tier 1; QL motion sickness relief oral tablet chewable 25 mg (generic for BONINE) - Tier 1 motion-time (generic for BONINE) - Tier 1 nausea control - Tier 1 nausea relief - Tier 1 perphenazine oral - Tier 1 prochlorperazine (generic for COMPRO) - Tier 1 travel ease (generic for BONINE) - Tier 1 trimethobenzamide hcl oral (generic for TIGAN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 26 Preferred Agents Non-Preferred Agents Emetogenic Therapy Adjuncts - Nausea and Vomiting Drugs aprepitant (generic for EMEND) - Tier 1; QL AKYNZEO ORAL - Tier 2; PA; QL dronabinol (generic for MARINOL) - Tier 1; PA; QL EMEND INTRAVENOUS (brand for fosaprepitant dimeglumine) - Tier 2; ondansetron hcl oral (generic for ZOFRAN) - Tier 1; QL PA ondansetron odt - Tier 1; QL EMEND ORAL (brand for aprepitant) - Tier 2; PA; QL VARUBI (180 MG DOSE) - Tier 2; QL Antifungals - Drugs to Treat Fungal Infections Antifungals - Fungal Infection Drugs 3 day (generic for MONISTAT 3) - Tier 1 DIFLUCAN (brand for fluconazole) - Tier 2; PA; QL 3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1 GYNAZOLE-1 - Tier 2; PA 3-day vaginal vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) - Tier 1 af spray powder (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 antifungal (tolnaftate) (generic for TINACTIN) - Tier 1; QL antifungal external cream 1 % (generic for TINACTIN) - Tier 1; QL antifungal external cream 2 % (generic for CAVILON) - Tier 1 antifungal foot care (generic for LAMISIL AT) - Tier 1; QL antifungal miconazole (generic for CAVILON) - Tier 1 antifungal tolnaftate (generic for TINACTIN) - Tier 1; QL atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; QL athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) - Tier 1; QL athletes foot external aerosol powder 2 % (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1; QL athletes foot powder spray (generic for CRUEX PRESCRIPTION STRENGTH) - Tier 1 athletes foot spray (generic for TINACTIN) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 27 Preferred Agents Non-Preferred Agents athletes foot spray external aerosol 2 % (generic for LOTRIMIN AF) - Tier 1 CAVILON (brand for miconazole nitrate) - Tier 2 ciclodan (generic for CICLODAN) - Tier 1; QL ciclopirox external solution (generic for CICLODAN) - Tier 1; QL clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1 clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1; QL clotrimazole external (generic for DESENEX) - Tier 1; QL clotrimazole mouth/throat - Tier 1; QL clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL CRUEX PRESCRIPTION STRENGTH (brand for athletes foot powder spray) - Tier 2 DESENEX JOCK ITCH (brand for athletes foot powder spray) - Tier 2 fluconazole oral (generic for DIFLUCAN) - Tier 1; QL foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; QL fungi-guard (generic for TINACTIN) - Tier 1; QL griseofulvin microsize oral - Tier 1; QL griseofulvin ultramicrosize - Tier 1; QL GYNE-LOTRIMIN (brand for clotrimazole-7) - Tier 2; QL GYNE-LOTRIMIN 3 (brand for cvs clotrimazole 3) - Tier 2 itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1; QL jock itch max st (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1 ketoconazole external cream - Tier 1; QL ketoconazole external shampoo - Tier 1; QL ketoconazole oral - Tier 1; QL LAMISIL AT EXTERNAL CREAM (brand for gnp terbinafine hydrochloride) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 28 Preferred Agents Non-Preferred Agents LAMISIL AT JOCK ITCH (brand for gnp terbinafine hydrochloride) - Tier 2; QL micaderm (generic for CAVILON) - Tier 1 miconazole 3 - Tier 1; QL miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBO PACK APP) - Tier 1; QL miconazole 3 combo pack app (generic for MONISTAT 3 COMBO PACK APP) - Tier 1; QL miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for MONISTAT 3 COMBINATION PACK) - Tier 1; QL miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL miconazole 7 vaginal suppository 100 mg - Tier 1 miconazole antifungal (generic for CAVILON) - Tier 1 miconazole nitrate external (generic for CAVILON) - Tier 1 miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL nyamyc (generic for NYAMYC) - Tier 1; QL nystatin external - Tier 1; QL nystatin mouth/throat - Tier 1; QL nystatin oral - Tier 1; QL nystop (generic for NYAMYC) - Tier 1; QL terbinafine hcl external (generic for LAMISIL AT) - Tier 1; QL terbinafine hcl oral (generic for LAMISIL) - Tier 1; QL terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT) - Tier 1; QL terconazole vaginal cream - Tier 1; QL TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier 2 TINACTIN EXTERNAL CREAM (brand for sm antifungal tolnaftate) - Tier 2; QL tinaspore (generic for BLIS-TO-SOL) - Tier 1 tolnaftate antifungal (generic for TINACTIN) - Tier 1; QL tolnaftate external cream (generic for TINACTIN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 29 Preferred Agents Non-Preferred Agents voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL
Antigout Agents - Drugs to Treat Gout Antigout Agents - Gout Drugs allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL COLCHICINE ORAL CAPSULE - Tier 2; PA; QL MITIGARE (brand for colchicine) - Tier 2; QL colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL probenecid - Tier 1; QL COLCRYS (brand for colchicine) - Tier 2; PA; QL Antimigraine Agents - Drugs to Treat Migraines Ergot Alkaloids - Migraine Drugs dihydroergotamine mesylate injection (generic for D.H.E. 45) - Tier 1; QL ergotamine-caffeine (generic for CAFERGOT) - Tier 1; QL MIGERGOT - Tier 2; QL Prophylactic - Migraine Drugs AIMOVIG - Tier 2; PA; QL AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; EMGALITY - Tier 2; PA; QL QL EMGALITY (300 MG DOSE) - Tier 2; PA; QL REYVOW - Tier 2; PA; QL NURTEC - Tier 2; PA; QL UBRELVY - Tier 2; PA; QL Serotonin (5-HT) 1b/1d Receptor Agonists - Migraine Drugs naratriptan hcl (generic for AMERGE) - Tier 1; ST; QL rizatriptan benzoate - Tier 1; QL sumatriptan nasal (generic for IMITREX) - Tier 1; QL sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) - Tier 1; QL sumatriptan succinate subcutaneous (generic for IMITREX) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 30 Preferred Agents Non-Preferred Agents Antimyasthenic Agents - Drugs to Treat Myasthenia Gravis Parasympathomimetics - Myasthenia Gravis Drugs pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1; QL pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) - Tier 1; QL Antimycobacterials - Drugs to Treat Infections Antimycobacterials, Other - Miscellaneous Anti-Infectives dapsone oral - Tier 1; QL rifabutin (generic for MYCOBUTIN) - Tier 1; QL Antituberculars - Tuberculosis Drugs cycloserine oral - Tier 1; QL ethambutol hcl oral tablet 100 mg - Tier 1 ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1; QL isoniazid oral - Tier 1; QL PASER - Tier 2; QL PRIFTIN - Tier 2; QL pyrazinamide oral - Tier 1; QL rifampin oral - Tier 1; QL SIRTURO - Tier 2; QL TRECATOR - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 31 Preferred Agents Non-Preferred Agents Antineoplastics - Drugs to Treat Cancer Alkylating Agents - Chemotherapy Agents cyclophosphamide oral capsule - Tier 1 CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2 GLEOSTINE - Tier 2 LEUKERAN - Tier 2 MATULANE - Tier 2; SP; QL melphalan (generic for ALKERAN) - Tier 1 MYLERAN - Tier 2 temozolomide - Tier 1; PA; SP; QL Antiandrogens - Hormone Suppressants abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL XTANDI ORAL CAPSULE - Tier 2; PA; SP; QL bicalutamide (generic for CASODEX) - Tier 1; QL YONSA - Tier 2; PA; SP; QL ERLEADA - Tier 2; PA; SP; QL ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL flutamide - Tier 1; QL NUBEQA - Tier 2; PA; SP; QL Antiangiogenic Agents - Chemotherapy Agents POMALYST - Tier 2; PA; SP; QL REVLIMID - Tier 2; PA; SP; QL THALOMID - Tier 2; PA; SP; QL Antiestrogens/Modifiers - Chemotherapy Agents tamoxifen citrate oral - Tier 1; QL toremifene citrate (generic for FARESTON) - Tier 1; QL Antimetabolites - Chemotherapy Agents capecitabine (generic for XELODA) - Tier 1; SP; QL XELODA (brand for capecitabine) - Tier 2; PA; SP; QL DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2 DROXIA ORAL CAPSULE 400 MG - Tier 2; QL hydroxyurea oral (generic for HYDREA) - Tier 1; QL mercaptopurine oral - Tier 1; QL TABLOID - Tier 2; SP
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 32 Preferred Agents Non-Preferred Agents Antineoplastics, Other - Chemotherapy Agents leucovorin calcium oral tablet 10 mg - Tier 1 KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL LONSURF - Tier 2; PA; SP; QL KISQALI (400 MG DOSE) TABLET THERAPY PACK 200 MG ORAL - NINLARO - Tier 2; PA; SP; QL Tier 2; PA; QL PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL KISQALI (400 MG DOSE) TABLET THERAPY PACK 200 MG ORAL - PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL Tier 2; PA; SP; QL PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) TABLET THERAPY PACK 200 MG ORAL - ROZLYTREK - Tier 2; PA; SP; QL Tier 2; PA; QL VERZENIO - Tier 2; PA; SP; QL KISQALI (600 MG DOSE) TABLET THERAPY PACK 200 MG ORAL - ZOLINZA - Tier 2; PA; SP; QL Tier 2; PA; SP; QL ZYKADIA - Tier 2; PA; SP; QL Aromatase Inhibitors, 3rd Generation - Chemotherapy Agents anastrozole oral (generic for ARIMIDEX) - Tier 1; QL exemestane (generic for AROMASIN) - Tier 1; QL letrozole oral (generic for FEMARA) - Tier 1; QL Enzyme Inhibitors - Chemotherapy Agents BALVERSA - Tier 2; PA; SP; QL etoposide oral - Tier 1 RUBRACA - Tier 2; PA; SP; QL ZEJULA - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 33 Preferred Agents Non-Preferred Agents Molecular Target Inhibitors - Chemotherapy Agents AFINITOR DISPERZ - Tier 2; PA; SP; QL LORBRENA - Tier 2; PA; SP; QL AFINITOR ORAL TABLET 10 MG - Tier 2; PA; SP; QL ALECENSA - Tier 2; PA; SP; QL ALUNBRIG - Tier 2; PA; SP; QL BOSULIF - Tier 2; PA; SP; QL BRUKINSA - Tier 2; PA; SP; QL CABOMETYX - Tier 2; PA; SP; QL CALQUENCE - Tier 2; PA; SP; QL CAPRELSA - Tier 2; PA; SP; QL COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL COTELLIC - Tier 2; PA; SP; QL DAURISMO - Tier 2; PA; SP; QL ERIVEDGE - Tier 2; PA; SP; QL erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL everolimus oral tablet 2.5 mg, 5 mg, 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP; QL FARYDAK - Tier 2; PA; SP; QL GILOTRIF - Tier 2; PA; SP; QL IBRANCE - Tier 2; PA; SP; QL ICLUSIG ORAL TABLET 15 MG, 45 MG - Tier 2; PA; SP; QL IDHIFA - Tier 2; PA; SP; QL imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 34 Preferred Agents Non-Preferred Agents IMBRUVICA - Tier 2; PA; SP; QL INLYTA - Tier 2; PA; SP; QL IRESSA - Tier 2; PA; SP; QL JAKAFI - Tier 2; PA; SP; QL lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL LYNPARZA - Tier 2; PA; SP; QL MEKINIST - Tier 2; PA; SP; QL NEXAVAR - Tier 2; PA; SP; QL ODOMZO - Tier 2; PA; SP; QL RYDAPT - Tier 2; PA; SP; QL SPRYCEL - Tier 2; PA; SP; QL STIVARGA - Tier 2; PA; SP; QL SUTENT - Tier 2; PA; SP; QL TAFINLAR - Tier 2; PA; SP; QL TASIGNA - Tier 2; PA; SP; QL TIBSOVO - Tier 2; PA; SP; QL TURALIO - Tier 2; PA; SP; QL VENCLEXTA - Tier 2; PA; SP; QL VENCLEXTA STARTING PACK - Tier 2; PA; SP; QL VITRAKVI - Tier 2; PA; SP; QL VOTRIENT - Tier 2; PA; SP; QL XALKORI - Tier 2; PA; SP; QL ZELBORAF - Tier 2; PA; SP; QL ZYDELIG - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 35 Preferred Agents Non-Preferred Agents Monoclonal Antibodies - Chemotherapy Agents HERCEPTIN - Tier 2; PA RITUXAN - Tier 2; PA Monoclonal Antibodies/Antibody-Drug Conjugate - Chemotherapy Agents AVASTIN - Tier 2; PA Retinoids - Chemotherapy Agents bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL PANRETIN - Tier 2; PA TARGRETIN EXTERNAL - Tier 2; PA; SP; QL tretinoin oral - Tier 1; SP; QL Treatment Adjuncts - Supportive Chemotherapy Drugs MESNEX ORAL - Tier 2; SP; QL Antiparasitics - Drugs to Treat Parasitic Infections Anthelmintics - Worm Infection Drugs albendazole oral (generic for ALBENZA) - Tier 1; DX2RX; QL ivermectin oral (generic for STROMECTOL) - Tier 1; QL praziquantel oral (generic for BILTRICIDE) - Tier 1; DX2RX; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 36 Preferred Agents Non-Preferred Agents Antiprotozoals - Protozoal Infection Drugs ALINIA ORAL SUSPENSION RECONSTITUTED - Tier 2; Members ARAKODA - Tier 2; PA; QL >= 8 years of age will require PA; QL; AL atovaquone oral (generic for MEPRON) - Tier 1; PA; QL BENZNIDAZOLE - Tier 2; DX2RX; QL chloroquine phosphate oral - Tier 1; QL hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; QL IMPAVIDO - Tier 2; PA; QL KRINTAFEL - Tier 2; QL mefloquine hcl - Tier 1; QL nitazoxanide (generic for ALINIA) - Tier 1; DX2RX; QL pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1 primaquine phosphate - Tier 1 pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL Pediculicides/Scabicides - Scabies and Lice Drugs crotan - Tier 1; QL lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing max strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice killing maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice maximum strength (generic for RID LICE KILLING SHAMPOO) - Tier 1 lice treatment - Tier 1 lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 37 Preferred Agents Non-Preferred Agents lice treatment external liquid 1 % (generic for NIX CREME RINSE) - Tier 1 lice treatment external shampoo 0.33-4 % (generic for RID LICE KILLING SHAMPOO) - Tier 1 malathion (generic for OVIDE) - Tier 1; QL permethrin external (generic for ELIMITE) - Tier 1; QL RID LICE KILLING SHAMPOO (brand for eq lice killing max st) - Tier 2 sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1 spinosad (generic for NATROBA) - Tier 1; QL Antiparkinson Agents - Drugs to Treat Parkinson's Disease Anticholinergics - Parkinson's Disease Drugs benztropine mesylate oral - Tier 1; QL trihexyphenidyl hcl - Tier 1; QL Antiparkinson Agents, Other - Parkinson's Disease Drugs amantadine hcl oral capsule - Tier 1; QL amantadine hcl oral syrup - Tier 1; QL entacapone (generic for COMTAN) - Tier 1; QL tolcapone (generic for TASMAR) - Tier 1; QL Dopamine Agonists - Parkinson's Disease Drugs pramipexole dihydrochloride (generic for MIRAPEX) - Tier 1; QL ropinirole hcl - Tier 1; QL Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors - Parkinson's Disease Drugs carbidopa-levodopa (generic for SINEMET) - Tier 1; QL carbidopa-levodopa er - Tier 1; QL Monoamine Oxidase B (MAO-B) Inhibitors - Parkinson's Disease Drugs selegiline hcl oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 38 Preferred Agents Non-Preferred Agents Antipsychotics - Drugs to Treat Mood Disorders 1st Generation/Typical - Mood Disorder Drugs chlorpromazine hcl injection - Tier 1 chlorpromazine hcl oral - Tier 1 fluphenazine decanoate injection - Tier 1 fluphenazine hcl - Tier 1 HALDOL DECANOATE (brand for haloperidol decanoate) - Tier 2 haloperidol decanoate intramuscular (generic for HALDOL DECANOATE) - Tier 1 haloperidol lactate oral - Tier 1 haloperidol oral - Tier 1 loxapine succinate - Tier 1 molindone hcl - Tier 1 pimozide - Tier 1; QL; AL prochlorperazine maleate oral - Tier 1 thioridazine hcl oral - Tier 1 thiothixene - Tier 1 trifluoperazine hcl - Tier 1 2nd Generation/Atypical - Mood Disorder Drugs ABILIFY MAINTENA - Tier 2 ABILIFY (brand for aripiprazole) - Tier 2; PA ABILIFY MYCITE - Tier 2 aripiprazole (generic for ABILIFY) - Tier 1; PA ARISTADA INITIO - Tier 2 FANAPT - Tier 2; PA ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 1064 GEODON ORAL CAPSULE 40 MG, 80 MG (brand for ziprasidone hcl) - MG/3.9ML - Tier 2; QL Tier 2; PA ARISTADA INTRAMUSCULAR PREFILLED SYRINGE 441 olanzapine oral (generic for ZYPREXA) - Tier 1; PA MG/1.6ML, 662 MG/2.4ML, 882 MG/3.2ML - Tier 2 paliperidone er (generic for INVEGA) - Tier 1; PA; QL; AL CAPLYTA - Tier 2; QL; AL quetiapine fumarate (generic for SEROQUEL) - Tier 1; PA GEODON ORAL CAPSULE 20 MG, 60 MG (brand for ziprasidone hcl) quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; PA - Tier 2 RISPERDAL CONSTA - Tier 2; PA INVEGA (brand for paliperidone er) - Tier 2; QL; AL RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; PA; INVEGA SUSTENNA - Tier 2 Members >= 8 years of age will require PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 39 Preferred Agents Non-Preferred Agents INVEGA TRINZA - Tier 2 RISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; PA; QL LATUDA - Tier 2 risperidone oral solution (generic for RISPERDAL) - Tier 1; PA; Members NUPLAZID - Tier 2; QL >= 8 years of age will require PA PERSERIS - Tier 2 risperidone oral tablet (generic for RISPERDAL) - Tier 1; PA; QL REXULTI - Tier 2 risperidone oral tablet dispersible - Tier 1; PA VRAYLAR - Tier 2 SAPHRIS (brand for asenapine maleate) - Tier 2; PA SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA ziprasidone hcl (generic for GEODON) - Tier 1; PA ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA ZYPREXA RELPREVV - Tier 2; PA ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA Treatment-Resistant - Mood Disorder Drugs CLOZARIL (brand for clozapine) - Tier 2; PA Antispasticity Agents XEOMIN - Tier 2; PA Antivirals - Drugs to Treat Viral Infections Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral Drugs valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL Anti-hepatitis B (HBV) Agents - Hepatitis B Drugs BARACLUDE ORAL SOLUTION - Tier 2; SP; QL entecavir (generic for BARACLUDE) - Tier 1; SP; QL EPIVIR HBV ORAL SOLUTION - Tier 2; SP; QL lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 40 Preferred Agents Non-Preferred Agents Anti-hepatitis C (HCV) Agents, Direct Acting Agents - Hepatitis C Drugs MAVYRET - Tier 2; PA; Preferred for Genotypes 1, 2, 3, 4, 5,& 6; SP; EPCLUSA (brand for sofosbuvir-velpatasvir) - Tier 2; PA; SP; QL QL HARVONI (brand for ledipasvir-sofosbuvir) - Tier 2; PA; SP; QL SOFOSBUVIR-VELPATASVIR - Tier 2; PA; SP; QL LEDIPASVIR-SOFOSBUVIR - Tier 2; PA; SP; QL ZEPATIER - Tier 2; PA; SP; QL SOVALDI - Tier 2; PA; SP; QL VIEKIRA PAK - Tier 2; PA; SP; QL VOSEVI - Tier 2; PA; SP; QL Anti-hepatitis C (HCV) Agents, Other - Hepatitis C Drugs INTRON A - Tier 2; PA; SP; QL PEGASYS - Tier 2; PA; SP; QL ribavirin oral - Tier 1; PA; QL Antiherpetic Agents - Herpes Drugs ABREVA (brand for docosanol) - Tier 2; QL acyclovir oral - Tier 1; QL docosanol external (generic for ABREVA) - Tier 1; QL trifluridine - Tier 1; QL valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL Anti-HIV Agents, Integrase Inhibitors (INSTI) - HIV Drugs DOVATO - Tier 2; QL GENVOYA - Tier 2; QL ISENTRESS HD - Tier 2; QL ISENTRESS ORAL PACKET - Tier 2 ISENTRESS ORAL TABLET - Tier 2; QL ISENTRESS ORAL TABLET CHEWABLE - Tier 2; QL STRIBILD - Tier 2; QL TIVICAY - Tier 2; QL TIVICAY PD - Tier 2; QL; AL TRIUMEQ - Tier 2 TYBOST - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 41 Preferred Agents Non-Preferred Agents Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI) - HIV Drugs COMPLERA - Tier 2; QL ATRIPLA (brand for efavirenz-emtricitab-tenofovir) - Tier 2; PA; QL DELSTRIGO - Tier 2; QL SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL EDURANT - Tier 2; QL SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL efavirenz (generic for SUSTIVA) - Tier 1; QL efavirenz-emtricitab-tenofovir (generic for ATRIPLA) - Tier 1; QL efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; QL INTELENCE - Tier 2; QL JULUCA - Tier 2; QL nevirapine - Tier 1; QL nevirapine er - Tier 1; QL ODEFSEY - Tier 2; QL PIFELTRO - Tier 2; QL VIRAMUNE (brand for nevirapine) - Tier 2; QL
Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI) - HIV Drugs abacavir sulfate (generic for ZIAGEN) - Tier 1; QL abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL abacavir-lamivudine-zidovudine (generic for TRIZIVIR) - Tier 1; QL BIKTARVY - Tier 2; QL CIMDUO - Tier 2; QL DESCOVY - Tier 2; QL emtricitabine (generic for EMTRIVA) - Tier 1; QL emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; QL EMTRIVA ORAL SOLUTION - Tier 2; QL lamivudine oral solution (generic for EPIVIR) - Tier 1; QL lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 42 Preferred Agents Non-Preferred Agents lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; QL stavudine - Tier 1; QL TEMIXYS - Tier 2; QL tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL VIREAD ORAL POWDER - Tier 2; QL VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; QL zidovudine (generic for RETROVIR) - Tier 1; QL Anti-HIV Agents, Other - HIV Drugs FUZEON - Tier 2; QL SELZENTRY - Tier 2; QL VOCABRIA - Tier 2; QL Anti-HIV Agents, Protease Inhibitors - HIV Drugs APTIVUS - Tier 2; QL KALETRA ORAL SOLUTION (brand for lopinavir-ritonavir) - Tier 2; PA; atazanavir sulfate (generic for REYATAZ) - Tier 1; QL QL CRIXIVAN - Tier 2; QL REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA; EVOTAZ - Tier 2; QL QL fosamprenavir calcium (generic for LEXIVA) - Tier 1; QL INVIRASE - Tier 2 KALETRA ORAL TABLET 100-25 MG - Tier 2; QL KALETRA ORAL TABLET 200-50 MG - Tier 2 LEXIVA ORAL SUSPENSION - Tier 2 lopinavir-ritonavir (generic for KALETRA) - Tier 1; QL NORVIR ORAL PACKET - Tier 2; QL NORVIR ORAL SOLUTION - Tier 2; QL PREZCOBIX - Tier 2; QL PREZISTA - Tier 2; QL REYATAZ ORAL PACKET - Tier 2; Members >= 8 years of age will require PA; QL; AL ritonavir (generic for NORVIR) - Tier 1; QL SYMTUZA - Tier 2; QL VIRACEPT - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 43 Preferred Agents Non-Preferred Agents Anti-Influenza Agents - Flu Drugs oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QL TAMIFLU ORAL CAPSULE (brand for oseltamivir phosphate) - Tier 2; PA; oseltamivir phosphate oral suspension reconstituted (generic for QL TAMIFLU) - Tier 1; QL; AL TAMIFLU ORAL SUSPENSION RECONSTITUTED (brand for oseltamivir RELENZA DISKHALER - Tier 2; QL phosphate) - Tier 2; PA; QL; AL rimantadine hcl - Tier 1; QL XOFLUZA (40 MG DOSE) - Tier 2; PA; QL XOFLUZA (80 MG DOSE) - Tier 2; PA; QL Anxiolytics - Drugs to Treat Anxiety Anxiolytics, Other - Anxiety Drugs buspirone hcl oral - Tier 1; QL hydroxyzine hcl oral - Tier 1; QL meprobamate - Tier 1; QL Benzodiazepines - Anxiety Drugs alprazolam er (generic for XANAX XR) - Tier 1; QL alprazolam intensol - Tier 1; QL alprazolam oral (generic for XANAX) - Tier 1; QL alprazolam xr (generic for XANAX XR) - Tier 1; QL chlordiazepoxide hcl - Tier 1; QL clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL clorazepate dipotassium - Tier 1; QL diazepam intensol (generic for DIAZEPAM INTENSOL) - Tier 1; QL diazepam oral (generic for VALIUM) - Tier 1; QL KLONOPIN (brand for clonazepam) - Tier 2; QL lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1; QL lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM INTENSOL) - Tier 1; QL lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL oxazepam - Tier 1; QL temazepam oral capsule 22.5 mg (generic for RESTORIL) - Tier 1; QL triazolam - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 44 Preferred Agents Non-Preferred Agents Bipolar Agents - Drugs to Treat Mood Disorders Mood Stabilizers - Mood Disorder Drugs DEPAKOTE (brand for divalproex sodium) - Tier 2; Minimum age of 2 years; QL DEPAKOTE SPRINKLES (brand for divalproex sodium) - Tier 2; Members >= 8 years of age will require PA; QL; AL divalproex sodium oral capsule delayed release sprinkle (generic for DEPAKOTE SPRINKLES) - Tier 1; Members >= 8 years of age will require PA; QL; AL divalproex sodium oral tablet delayed release (generic for DEPAKOTE) - Tier 1; Minimum age of 2 years; QL EQUETRO - Tier 2 lithium - Tier 1 lithium carbonate er (generic for LITHOBID) - Tier 1 lithium carbonate oral - Tier 1 LITHOBID (brand for lithium carbonate er) - Tier 2 Blood Glucose Regulators - Drugs to Regulate Blood Sugar Antidiabetic Agents - Diabetic Drugs acarbose oral (generic for PRECOSE) - Tier 1; QL BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL ADLYXIN - Tier 2; ST; QL BYETTA 10 MCG PEN - Tier 2; PA; QL ADLYXIN STARTER PACK - Tier 2; ST; QL BYETTA 5 MCG PEN - Tier 2; PA; QL ALOGLIPTIN BENZOATE - Tier 2; ST; QL GLYXAMBI - Tier 2; PA; QL ALOGLIPTIN-METFORMIN HCL - Tier 2; ST; QL INVOKAMET - Tier 2; PA; QL ALOGLIPTIN-PIOGLITAZONE - Tier 2; ST; QL INVOKAMET XR - Tier 2; PA; QL FARXIGA - Tier 2; PA; QL INVOKANA - Tier 2; PA; QL glimepiride (generic for AMARYL) - Tier 1; QL JANUMET - Tier 2; PA; QL glipizide er (generic for GLUCOTROL XL) - Tier 1; QL JANUMET XR - Tier 2; PA; QL glipizide ir (generic for GLUCOTROL) - Tier 1; QL JANUVIA - Tier 2; PA; QL glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL JARDIANCE - Tier 2; PA; QL glyburide micronized (generic for GLYNASE) - Tier 1; QL JENTADUETO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 45 Preferred Agents Non-Preferred Agents glyburide oral - Tier 1; QL JENTADUETO XR - Tier 2; PA; QL glyburide-metformin - Tier 1; QL KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; ST; QL metformin hcl er - Tier 1; QL KOMBIGLYZE XR - Tier 2; PA; QL metformin hcl er (osm) (generic for FORTAMET) - Tier 1; PA; QL NESINA (brand for alogliptin benzoate) - Tier 2; PA; ST; QL metformin hcl oral tablet - Tier 1; QL ONGLYZA - Tier 2; PA; QL nateglinide - Tier 1; QL OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; ST; QL pioglitazone hcl (generic for ACTOS) - Tier 1; QL OZEMPIC SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML - repaglinide - Tier 1; QL Tier 2; PA; QL SEGLUROMET - Tier 2; ST; QL QTERN - Tier 2; PA; QL SOLIQUA - Tier 2; ST; QL RYBELSUS - Tier 2; PA; QL STEGLATRO - Tier 2; ST; QL STEGLUJAN - Tier 2; PA; QL SYMLINPEN 120 - Tier 2; PA; QL SYNJARDY - Tier 2; PA; QL SYMLINPEN 60 - Tier 2; PA; QL SYNJARDY XR - Tier 2; PA; QL TRULICITY - Tier 2; ST; QL TRADJENTA - Tier 2; PA; QL VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML TRIJARDY XR - Tier 2; PA; QL SUBCUTANEOUS - Tier 2; ST; QL VICTOZA SOLUTION PEN-INJECTOR 18 MG/3ML SUBCUTANEOUS - Tier 2; PA; QL XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 10-500 MG, 5-500 MG - Tier 2; PA XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG - Tier 2; PA; QL XULTOPHY - Tier 2; PA; QL Glycemic Agents - Diabetic Drugs BAQSIMI ONE PACK - Tier 2; QL GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; PA; QL BAQSIMI TWO PACK - Tier 2; QL GLUCAGEN HYPOKIT - Tier 2; QL GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED - Tier 2; QL glucagon emergency kit 1 mg injection - Tier 1; QL glucose oral tablet chewable 4 gm (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL GVOKE HYPOPEN 1-PACK - Tier 2; QL GVOKE HYPOPEN 2-PACK - Tier 2; QL GVOKE PFS - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 46 Preferred Agents Non-Preferred Agents soft glucose (generic for DEX4 QUICK DISSOLVE GLUCOSE) - Tier 1; QL Insulins - Diabetic Drugs ADMELOG (brand for insulin lispro) - Tier 2; QL AFREZZA - Tier 2; PA; QL ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; APIDRA SOLOSTAR - Tier 2; PA; QL PA; QL APIDRA VIAL - Tier 2; PA; QL BASAGLAR KWIKPEN - Tier 2; QL FIASP - Tier 2; PA; QL HUMALOG MIX 50/50 - Tier 2; QL FIASP FLEXTOUCH - Tier 2; PA; QL HUMALOG MIX 75/25 - Tier 2; QL HUMALOG (brand for insulin lispro) - Tier 2; PA; QL HUMULIN 70/30 VIAL - Tier 2; QL HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) - HUMULIN N VIAL - Tier 2; QL Tier 2; PA; QL HUMULIN R VIAL - Tier 2; QL HUMALOG KWIKPEN (brand for insulin lispro (1 unit dial)) - Tier 2; PA; INSULIN ASPART PROT & ASPART - Tier 2; QL QL NOVOLIN 70/30 RELION - Tier 2; QL HUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QL NOVOLIN 70/30 VIAL - Tier 2; QL NOVOLIN N RELION - Tier 2; QL HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) - NOVOLIN N VIAL - Tier 2; QL Tier 2; PA; QL NOVOLIN R RELION - Tier 2; QL HUMULIN 70/30 KWIKPEN - Tier 2; PA; QL NOVOLIN R VIAL - Tier 2; QL HUMULIN N KWIKPEN - Tier 2; PA; QL SEMGLEE - Tier 2; QL HUMULIN R U-500 KWIKPEN - Tier 2; PA; QL HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QL INSULIN ASP PROT & ASP FLEXPEN - Tier 2; PA; QL INSULIN ASPART - Tier 2; PA; QL INSULIN LISPRO - Tier 2; PA; QL INSULIN LISPRO (1 UNIT DIAL) - Tier 2; PA; QL LANTUS SOLOSTAR - Tier 2; PA; QL LANTUS U-100 VIAL - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 47 Preferred Agents Non-Preferred Agents LEVEMIR U-100 FLEXTOUCH - Tier 2; PA; QL LEVEMIR U-100 VIAL - Tier 2; PA; QL NOVOLIN 70/30 FLEXPEN - Tier 2; PA; QL NOVOLIN N FLEXPEN - Tier 2; PA; QL NOVOLIN R FLEXPEN - Tier 2; PA; QL NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp flexpen) - Tier 2; PA; QL NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier 2; PA; QL NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QL TOUJEO MAX SOLOSTAR - Tier 2; PA; QL TOUJEO SOLOSTAR - Tier 2; PA; QL TRESIBA - Tier 2; PA; QL TRESIBA FLEXTOUCH - Tier 2; PA; QL
Blood Products and Modifiers Blood Products and Modifiers, Other NYVEPRIA - Tier 2; PA; SP
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 48 Preferred Agents Non-Preferred Agents Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders Anticoagulants - Blood Thinners ELIQUIS - Tier 2; QL PRADAXA - Tier 2; PA; QL ELIQUIS DVT/PE STARTER PACK - Tier 2; QL enoxaparin sodium (generic for LOVENOX) - Tier 1; QL heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml - Tier 1 heparin sodium (porcine) injection solution 20000 unit/ml - Tier 1; QL heparin sodium (porcine) injection solution prefilled syringe - Tier 1; QL heparin sodium (porcine) pf - Tier 1 jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1 SAVAYSA - Tier 2; QL warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1 XARELTO - Tier 2; QL XARELTO STARTER PACK - Tier 2; QL Blood Formation Modifiers - Blood Formation Drugs anagrelide hcl (generic for AGRYLIN) - Tier 1 DOPTELET - Tier 2; PA; SP; QL ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QL EPOGEN - Tier 2; PA; SP; QL LEUKINE - Tier 2; PA; SP; QL FULPHILA - Tier 2; PA; SP; QL MOZOBIL - Tier 2; PA; SP; QL GRANIX - Tier 2; PA; SP; QL MULPLETA - Tier 2; PA; SP; QL MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100 NEULASTA - Tier 2; PA; SP; QL MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier 2; NEULASTA ONPRO - Tier 2; PA; SP; QL PA; QL PROMACTA ORAL PACKET 25 MG - Tier 2; PA; SP; QL NEUPOGEN - Tier 2; PA; SP; QL PROMACTA ORAL TABLET - Tier 2; PA; SP; QL NIVESTYM - Tier 2; PA; SP; QL RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; PA; SP; QL 500 MCG - Tier 2; PA RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA; SP PROCRIT - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 49 Preferred Agents Non-Preferred Agents ZARXIO - Tier 2; PA; SP; QL UDENYCA - Tier 2; PA; SP; QL ZIEXTENZO - Tier 2; PA; SP Hemostasis Agents - Drugs to Stop Bleeding aminocaproic acid oral (generic for AMICAR) - Tier 1; QL ADVATE INTRAVENOUS SOLUTION RECONSTITUTED 1500 UNIT, HEMLIBRA - Tier 2; PA; SP; QL 4000 UNIT - Tier 2; PA tranexamic acid oral (generic for LYSTEDA) - Tier 1; DX2RX; QL HEMOFIL M - Tier 2; PA HUMATE-P - Tier 2; PA KOATE - Tier 2; PA KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT - Tier 2; PA NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 500 UNIT - Tier 2; PA RECOMBINATE - Tier 2; PA WILATE - Tier 2; PA XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 500 UNIT - Tier 2; PA
Platelet Modifying Agents - Platelet Modifying Drugs BRILINTA - Tier 2; DX2RX; QL CABLIVI - Tier 2; PA; SP; QL cilostazol - Tier 1; QL clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QL dipyridamole oral - Tier 1; QL prasugrel hcl (generic for EFFIENT) - Tier 1; DX2RX; QL Cardiovascular Agents Cardiovascular Agents, Other NEXLIZET - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 50 Preferred Agents Non-Preferred Agents Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions Alpha-adrenergic Agonists - Blood Pressure Drugs clonidine hcl oral - Tier 1; QL guanfacine hcl - Tier 1; QL methyldopa - Tier 1; QL midodrine hcl - Tier 1; QL Alpha-adrenergic Blocking Agents - Blood Pressure Drugs doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL Angiotensin II Receptor Antagonists - Blood Pressure Drugs losartan potassium oral (generic for COZAAR) - Tier 1; QL EDARBI - Tier 2; PA; QL Angiotensin-Converting Enzyme (ACE) Inhibitors - Blood Pressure Drugs benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL captopril oral - Tier 1; QL enalapril maleate oral (generic for VASOTEC) - Tier 1; QL EPANED - Tier 2; Members >= 8 years of age will require PA; QL; AL fosinopril sodium - Tier 1; QL lisinopril oral (generic for PRINIVIL) - Tier 1; QL quinapril hcl (generic for ACCUPRIL) - Tier 1; QL ramipril (generic for ALTACE) - Tier 1; QL trandolapril - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 51 Preferred Agents Non-Preferred Agents Antiarrhythmics - Heart Regulation Drugs amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) - BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL Tier 1; QL BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL disopyramide phosphate (generic for NORPACE) - Tier 1; QL MULTAQ - Tier 2; PA; QL dofetilide (generic for TIKOSYN) - Tier 1; QL NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL flecainide acetate - Tier 1; QL PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL mexiletine hcl oral - Tier 1; QL RYTHMOL SR (brand for propafenone hcl er) - Tier 2; PA; QL NORPACE CR - Tier 2; QL TIKOSYN (brand for dofetilide) - Tier 2; PA; QL propafenone hcl - Tier 1; QL quinidine gluconate er - Tier 1; QL quinidine sulfate - Tier 1; QL sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL sotalol hcl oral (generic for BETAPACE) - Tier 1; QL Beta-adrenergic Blocking Agents - Blood Pressure Drugs acebutolol hcl oral - Tier 1; QL HEMANGEOL - Tier 2; PA; QL atenolol oral (generic for TENORMIN) - Tier 1; QL betaxolol hcl oral - Tier 1; QL bisoprolol fumarate oral - Tier 1; QL carvedilol (generic for COREG) - Tier 1; QL labetalol hcl oral - Tier 1; QL metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL metoprolol tartrate oral tablet 100 mg, 50 mg (generic for LOPRESSOR) - Tier 1; QL metoprolol tartrate oral tablet 25 mg - Tier 1; QL propranolol hcl er (generic for INDERAL LA) - Tier 1; DX2RX; QL propranolol hcl oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 52 Preferred Agents Non-Preferred Agents Calcium Channel Blocking Agents - Blood Pressure Drugs amlodipine besylate oral (generic for NORVASC) - Tier 1; QL cartia xt (generic for CARTIA XT) - Tier 1; QL diltiazem hcl er - Tier 1; QL diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL diltiazem hcl er coated beads oral capsule extended release 24 hour (generic for CARTIA XT) - Tier 1; QL diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL dilt-xr - Tier 1; QL felodipine er - Tier 1; QL nifedipine er (generic for AFEDITAB CR) - Tier 1; QL nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1; QL nifedipine oral (generic for PROCARDIA) - Tier 1; QL nimodipine oral - Tier 1; QL NYMALIZE - Tier 2; QL taztia xt (generic for TAZTIA XT) - Tier 1; QL tiadylt er (generic for TAZTIA XT) - Tier 1; QL verapamil hcl er oral tablet extended release (generic for CALAN SR) - Tier 1; QL verapamil hcl oral - Tier 1; QL Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs amiloride-hydrochlorothiazide - Tier 1; QL BIDIL - Tier 2; PA; QL atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL CORLANOR - Tier 2; PA; QL benazepril-hydrochlorothiazide - Tier 1; QL EDARBYCLOR - Tier 2; PA; QL bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL captopril-hydrochlorothiazide - Tier 1; QL digitek (generic for DIGITEK) - Tier 1; QL digox (generic for DIGITEK) - Tier 1; QL digoxin oral (generic for DIGITEK) - Tier 1; QL enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL ENTRESTO - Tier 2; PA; QL fosinopril sodium-hctz - Tier 1; QL lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 53 Preferred Agents Non-Preferred Agents losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL methyldopa-hydrochlorothiazide - Tier 1; QL pentoxifylline er - Tier 1; QL propranolol-hctz - Tier 1; QL quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL ranolazine er (generic for RANEXA) - Tier 1; ST; QL spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL triamterene-hctz (generic for MAXZIDE-25) - Tier 1; QL VYNDAMAX - Tier 2; PA; SP; QL VYNDAQEL - Tier 2; PA; SP; QL Diuretics, Carbonic Anhydrase Inhibitors - Cardiac Drugs methazolamide oral - Tier 1; QL Diuretics, Loop - Cardiac Drugs bumetanide oral (generic for BUMEX) - Tier 1; QL furosemide oral solution 10 mg/ml - Tier 1; QL furosemide oral tablet (generic for LASIX) - Tier 1; QL torsemide - Tier 1; QL Diuretics, Potassium-sparing - Cardiac Drugs amiloride hcl oral - Tier 1; QL spironolactone oral (generic for ALDACTONE) - Tier 1; QL Diuretics, Thiazide - Cardiac Drugs chlorthalidone - Tier 1; QL DIURIL - Tier 2; QL hydrochlorothiazide oral - Tier 1; QL indapamide - Tier 1; QL metolazone - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 54 Preferred Agents Non-Preferred Agents Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QL fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; ST; QL fenofibrate oral tablet 160 mg, 54 mg - Tier 1; PA; ST; QL gemfibrozil oral (generic for LOPID) - Tier 1; QL Dyslipidemics, HMG CoA Reductase Inhibitors - Cholesterol Control Drugs atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL lovastatin oral - Tier 1; QL; AL rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL simvastatin oral (generic for ZOCOR) - Tier 1; QL Dyslipidemics, Other - Miscellaneous Cholesterol Control Drugs cholestyramine light oral powder (generic for PREVALITE) - Tier 1; NEXLETOL - Tier 2; PA; QL Only the bulk products are covered (cans) Individual packets are not PRALUENT - Tier 2; PA; NDC starting w/72733 Preferred w/PA; SP; QL covered; QL cholestyramine oral powder (generic for QUESTRAN) - Tier 1; Only the bulk products are covered (cans) Individual packets are not covered; QL ezetimibe (generic for ZETIA) - Tier 1; PA; QL niacin (antihyperlipidemic) (generic for NIACOR) - Tier 1; QL niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; QL niacor (generic for NIACOR) - Tier 1; QL omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL prevalite oral powder (generic for PREVALITE) - Tier 1; Only the bulk products are covered (cans) Individual packets are not covered; QL REPATHA - Tier 2; PA; NDC starting w/72511 Preferred w/PA; SP; QL Vasodilators, Direct-acting Arterial - Chest Pain Drugs hydralazine hcl oral - Tier 1; QL minoxidil oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 55 Preferred Agents Non-Preferred Agents Vasodilators, Direct-acting Arterial/Venous - Chest Pain Drugs isosorbide dinitrate - Tier 1; QL isosorbide mononitrate - Tier 1; QL isosorbide mononitrate er - Tier 1; QL minitran (generic for MINITRAN) - Tier 1; QL NITRO-BID - Tier 2; QL NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR (brand for nitroglycerin) - Tier 2; QL nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL nitroglycerin transdermal (generic for MINITRAN) - Tier 1; QL nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QL RECTIV - Tier 2; DX2RX; QL Central Nervous System Agents Fibromyalgia Agents ZEPOSIA - Tier 2; PA; SP; QL Multiple Sclerosis Agents BAFIERTAM - Tier 2; PA; SP; QL KESIMPTA - Tier 2; PA Central Nervous System Agents - Drugs to Treat Nerve Conditions Attention Deficit Hyperactivity Disorder Agents, Amphetamines - ADHD Drugs ADDERALL (brand for amphetamine-dextroamphetamine) - Tier 2; ADZENYS XR-ODT - Tier 2; PA; QL; AL DX2RX; QL; AL DYANAVEL XR - Tier 2; PA; QL; AL amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1; EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; QL; AL DX2RX; QL; AL EVEKEO ODT - Tier 2; PA; QL; AL amphetamine-dextroamphetamine er (generic for ADDERALL XR) - MYDAYIS - Tier 2; PA; QL; AL Tier 1; DX2RX; QL; AL VYVANSE - Tier 2; PA; QL; AL ZENZEDI - Tier 2; PA; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 56 Preferred Agents Non-Preferred Agents Attention Deficit Hyperactivity Disorder Agents, Non- amphetamines - ADHD Drugs atomoxetine hcl (generic for STRATTERA) - Tier 1; DX2RX; QL; AL APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; PA; QL; AL CONCERTA (brand for methylphenidate hcl er) - Tier 2; QL; AL COTEMPLA XR-ODT - Tier 2; PA; QL; AL guanfacine hcl er (generic for INTUNIV) - Tier 1; DX2RX; QL; AL DAYTRANA - Tier 2; PA; QL; AL methylphenidate hcl er (cd) - Tier 1; DX2RX; QL; AL FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL; AL methylphenidate hcl er (la) oral capsule extended release 24 hour 20 JORNAY PM - Tier 2; PA; QL mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; DX2RX; QL; AL KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL; AL methylphenidate hcl er oral tablet extended release 10 mg, 20 mg - METHYLIN ORAL SOLUTION 10 MG/5ML (brand for methylphenidate Tier 1; DX2RX; QL; AL hcl) - Tier 2; PA; QL; AL methylphenidate hcl er oral tablet extended release 18 mg, 27 mg, 36 METHYLIN ORAL SOLUTION 5 MG/5ML (brand for methylphenidate hcl) mg, 54 mg (generic for CONCERTA) - Tier 1; QL; AL - Tier 2; PA; QL methylphenidate hcl er oral tablet extended release 24 hour - Tier 1; STRATTERA (brand for atomoxetine hcl) - Tier 2; DX2RX; QL; AL DX2RX; Mallinckrodt and Kremers Urban labelers; QL; AL methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; DX2RX; QL; AL RITALIN (brand for methylphenidate hcl) - Tier 2; DX2RX; QL; AL
Central Nervous System, Other - Miscellaneous Central Nervous System Drugs ALLI - Tier 2; QL AUSTEDO - Tier 2; PA; SP; QL caffeine citrate oral - Tier 1; QL; AL INGREZZA ORAL CAPSULE 40 MG, 80 MG - Tier 2; PA; SP; QL INGREZZA ORAL CAPSULE THERAPY PACK - Tier 2; PA; SP; QL NUEDEXTA - Tier 2; DX2RX; QL riluzole (generic for RILUTEK) - Tier 1; QL tetrabenazine (generic for XENAZINE) - Tier 1; DX2RX; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 57 Preferred Agents Non-Preferred Agents Fibromyalgia Agents - Drugs to Treat Muscle and Soft Tissue Pain LYRICA (brand for pregabalin) - Tier 2; QL pregabalin oral (generic for LYRICA) - Tier 1; QL Multiple Sclerosis Agents - Multiple Sclerosis Drugs AUBAGIO - Tier 2; DX2RX; SP; QL AVONEX PEN - Tier 2; PA; SP; QL COPAXONE (brand for glatiramer acetate) - Tier 2; DX2RX; SP; QL AVONEX PREFILLED - Tier 2; PA; SP; QL dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; DX2RX; SP; BETASERON - Tier 2; PA; SP; QL QL EXTAVIA - Tier 2; PA; SP; QL dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL DX2RX; SP; QL MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL GILENYA ORAL CAPSULE 0.25 MG - Tier 2; PA; SP; QL MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL GILENYA ORAL CAPSULE 0.5 MG - Tier 2; DX2RX; SP; QL MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL glatiramer acetate (generic for GLATOPA) - Tier 1; DX2RX; SP; QL MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL glatopa (generic for GLATOPA) - Tier 1; DX2RX; SP; QL MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL MAYZENT - Tier 2; PA; SP; QL MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL PLEGRIDY INTRAMUSCULAR - Tier 2; SP; QL REBIF - Tier 2; PA; SP; QL PLEGRIDY STARTER PACK - Tier 2; DX2RX; SP; QL REBIF REBIDOSE - Tier 2; PA; SP; QL PLEGRIDY SUBCUTANEOUS - Tier 2; DX2RX; SP; QL REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL REBIF TITRATION PACK - Tier 2; PA; SP; QL TECFIDERA (brand for dimethyl fumarate) - Tier 2; DX2RX; SP; QL TYSABRI - Tier 2; PA VUMERITY - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 58 Preferred Agents Non-Preferred Agents Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions cavarest (generic for CAVAREST) - Tier 1 chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier 1; QL DENTA 5000 PLUS (brand for sodium fluoride 5000 plus) - Tier 2; QL DENTAGEL (brand for sodium fluoride) - Tier 2 easygel - Tier 1 fluoridex daily renewal - Tier 1 oralone (generic for ORALONE) - Tier 1; QL periogard (generic for PERIOGARD) - Tier 1; QL pilocarpine hcl oral (generic for SALAGEN) - Tier 1; QL PREVIDENT 5000 DRY MOUTH (brand for sodium fluoride) - Tier 2 PREVIDENT 5000 PLUS (brand for sodium fluoride 5000 plus) - Tier 2; QL PREVIDENT DENTAL (brand for sodium fluoride) - Tier 2 sf (generic for CAVAREST) - Tier 1 sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride 5000 ppm dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1; QL sodium fluoride dental gel (generic for CAVAREST) - Tier 1 triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 59 Preferred Agents Non-Preferred Agents Dermatological Agents - Drugs to Treat Skin Conditions accutane (generic for ACCUTANE) - Tier 1; PA; QL ABSORICA (brand for isotretinoin) - Tier 2; PA; QL acitretin (generic for SORIATANE) - Tier 1; PA; QL ABSORICA LD - Tier 2; PA; QL acne (generic for CLEARSKIN) - Tier 1 ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL acne control cleanser (generic for CLEARSKIN) - Tier 1 ACZONE EXTERNAL GEL 7.5 % (brand for dapsone) - Tier 2; PA; QL acne medication 10 external lotion - Tier 1 ALDARA (brand for imiquimod) - Tier 2; PA; QL acne medication 5 external lotion - Tier 1 AMZEEQ - Tier 2; PA; QL acne treatment external cream 10 % (generic for CLEARSKIN) - Tier 1 ATRALIN (brand for tretinoin) - Tier 2; PA; QL adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE BENZACLIN (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL WASH) - Tier 1 BENZACLIN WITH PUMP (brand for clindamycin phos-benzoyl perox) - advanced acne spot treat (generic for CLEAN & CLEAR ACNE Tier 2; PA; QL SCRUB) - Tier 1 BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL CARAC (brand for fluorouracil) - Tier 2; PA; QL advanced healing external ointment (generic for FLANDERS CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL BUTTOCKS) - Tier 1 CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL; alclometasone dipropionate external ointment - Tier 1; QL AL ALOE VESTA DAILY MOISTURIZER - Tier 2 DIFFERIN EXTERNAL GEL 0.3 % (brand for adapalene) - Tier 2; PA; QL; amcinonide external ointment - Tier 1 AL ammonium lactate external (generic for AL12) - Tier 1; QL DIFFERIN EXTERNAL LOTION - Tier 2; PA; QL; AL amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL DOVONEX (brand for calcipotriene) - Tier 2; PA; ST; QL arthritis pain relieving - Tier 1; QL DUPIXENT - Tier 2; PA; SP; QL astringent solution (generic for DOMEBORO) - Tier 1 EFUDEX (brand for fluorouracil) - Tier 2; PA; QL AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2 ELIDEL (brand for pimecrolimus) - Tier 2; PA; ST; Minimum age of 2 AVAR-E GREEN (brand for sss 10-5) - Tier 2 years; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 60 Preferred Agents Non-Preferred Agents AVITA EXTERNAL CREAM (brand for tretinoin) - Tier 2; ST; QL ENSTILAR - Tier 2; PA; QL azelaic acid external (generic for FINACEA) - Tier 1; QL EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) - EPIDUO FORTE - Tier 2; PA; QL Tier 1; QL FABIOR (brand for tazarotene) - Tier 2; PA; QL beauty 360 pure glycerin - Tier 1 FINACEA (brand for azelaic acid) - Tier 2; PA; QL BENZAC AC WASH (brand for benzoyl peroxide wash) - Tier 2; QL LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL betamethasone dipropionate aug (generic for DIPROLENE AF) - Tier MIRVASO - Tier 2; PA; QL 1; QL OLUX (brand for clobetasol propionate) - Tier 2; PA; QL betamethasone dipropionate external lotion - Tier 1 OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL betamethasone dipropionate external ointment - Tier 1; QL ONEXTON - Tier 2; PA; QL betamethasone valerate external cream - Tier 1; QL PROTOPIC EXTERNAL OINTMENT 0.03 % (brand for tacrolimus) - Tier betamethasone valerate external lotion - Tier 1 2; PA; ST; Minimum age of 2 years; QL; AL betamethasone valerate external ointment - Tier 1; QL PROTOPIC EXTERNAL OINTMENT 0.1 % (brand for tacrolimus) - Tier 2; boro-packs (generic for DOMEBORO) - Tier 1 PA; ST; Minimum age of 16 years; QL; AL BOUDREAUXS BUTT PASTE EXTERNAL OINTMENT 40 % (brand QBREXZA - Tier 2; PA; QL for cvs diaper rash) - Tier 2; QL RETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL bp 10-1 - Tier 1 RETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; PA; QL bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1 RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere calamine external lotion , 8-8 % - Tier 1 pump) - Tier 2; PA; QL; AL calamine-zinc oxide external lotion - Tier 1 RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL calcipotriene external cream (generic for DOVONEX) - Tier 1; ST; QL RHOFADE - Tier 2; PA; QL calcipotriene external ointment (generic for CALCITRENE) - Tier 1; SERNIVO - Tier 2; PA; QL ST; QL SILIQ - Tier 2; PA; SP; QL calcipotriene external solution - Tier 1; QL SOOLANTRA - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 61 Preferred Agents Non-Preferred Agents calcitriol external (generic for VECTICAL) - Tier 1; ST; QL SORILUX (brand for calcipotriene) - Tier 2; PA; QL capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1; QL TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL capsaicin hp (generic for ZOSTRIX HP) - Tier 1; QL TALTZ - Tier 2; PA; SP; QL capzix (generic for ZOSTRIX HP) - Tier 1; QL TAZORAC EXTERNAL CREAM - Tier 2; PA; QL; AL cerovel (generic for CEROVEL) - Tier 1; QL TAZORAC EXTERNAL GEL 0.1 % - Tier 2; PA; QL claravis (generic for AMNESTEEM) - Tier 1; PA; QL TEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QL clearskin (generic for CLEARSKIN) - Tier 1 TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QL clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1; TREMFYA - Tier 2; PA; SP; QL QL VANOS (brand for fluocinonide) - Tier 2; PA; QL clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier VECTICAL (brand for calcitriol) - Tier 2; PA; ST; QL 1; QL VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL clindamycin phosphate external solution - Tier 1; QL ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL clobetasol prop emollient base - Tier 1; QL ZYCLARA (brand for imiquimod pump) - Tier 2; PA; QL clobetasol propionate e - Tier 1; QL clobetasol propionate external solution - Tier 1; QL clotrimazole-betamethasone - Tier 1; QL corn & callus remover (generic for COMPOUND W) - Tier 1 COSENTYX - Tier 2; PA; SP; QL daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH) - Tier 1 diaper rash external ointment (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene treatment) - Tier 2; QL; AL DR SMITHS ADULT BARRIER EXTERNAL OINTMENT - Tier 2; QL DR SMITHS DIAPER - Tier 2; QL ery - Tier 1 erythromycin external gel (generic for ERYGEL) - Tier 1 erythromycin external solution - Tier 1; QL EUCRISA - Tier 2; ST; QL flanders buttocks (generic for FLANDERS BUTTOCKS) - Tier 1 fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) - Tier 1; QL fluocinolone acetonide external cream 0.025 % (generic for SYNALAR) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 62 Preferred Agents Non-Preferred Agents fluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide external solution (generic for SYNALAR) - Tier 1; QL fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP) - Tier 1; QL fluocinonide external solution - Tier 1; QL fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL fluorouracil external solution - Tier 1 fluticasone propionate external cream - Tier 1; QL fluticasone propionate external ointment - Tier 1; QL glycerin external - Tier 1 glycerin external liquid 99.5 % - Tier 1 gormel - Tier 1; QL gormel 10 (generic for NUTRAPLUS) - Tier 1; QL halobetasol propionate external cream - Tier 1; QL hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1 hydrocortisone anti-itch external cream 0.5 % - Tier 1; QL hydrocortisone butyrate external ointment - Tier 1; QL hydrocortisone butyrate external solution - Tier 1; QL hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL hydrocortisone external cream 1 % (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL hydrocortisone external lotion 2.5 % - Tier 1; QL hydrocortisone external ointment 0.5 % - Tier 1 hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH RELIEF MAX STR) - Tier 1; QL hydrocortisone external ointment 2.5 % - Tier 1; QL hydrocortisone plus external cream 1 % (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrocortisone-aloe - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 63 Preferred Agents Non-Preferred Agents hydrocortisone-aloe max st (generic for CORTIZONE-10 INTENSIVE HEALING) - Tier 1 hydrolatum (generic for FLANDERS BUTTOCKS) - Tier 1 ILUMYA - Tier 2; PA; SP; QL imiquimod external cream 5 % (generic for ALDARA) - Tier 1; QL instacort 5 - Tier 1; QL isotretinoin oral (generic for AMNESTEEM) - Tier 1; PA; QL LAC-HYDRIN FIVE - Tier 2; QL medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1 methoxsalen rapid - Tier 1 moisturel - Tier 1 mometasone furoate external - Tier 1; QL myorisan (generic for AMNESTEEM) - Tier 1; PA; QL NEUTROGENA OIL-FREE ACNE WASH (brand for eql apricot scrub) - Tier 2 NUTRAPLUS (brand for urea 10 hydrating) - Tier 2; QL ointment base (generic for FLANDERS BUTTOCKS) - Tier 1 PANOXYL (brand for bp wash) - Tier 2 pimecrolimus (generic for ELIDEL) - Tier 1; ST; Minimum age of 2 years; QL; AL podofilox external - Tier 1; QL prednicarbate external cream - Tier 1; QL REGRANEX - Tier 2; DX2RX; QL renewal soothing bath (generic for AVEENO BABY BATH TREATMENT) - Tier 1 SANTYL - Tier 2; QL scalp relief (generic for PSORIASIN) - Tier 1 selenium sulfide external lotion - Tier 1; QL sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1 sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR-E EMOLLIENT) - Tier 1 sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1 sulfacetamide sodium-sulfur external suspension 10-5 % - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 64 Preferred Agents Non-Preferred Agents sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for SUMADAN WASH) - Tier 1; QL sulfamez wash - Tier 1 SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; QL tacrolimus external ointment 0.03 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 2 years; QL; AL tacrolimus external ointment 0.1 % (generic for PROTOPIC) - Tier 1; ST; Minimum age of 16 years; QL; AL THERASEAL HAND PROTECTION - Tier 2; QL tretinoin external cream (generic for AVITA) - Tier 1; ST; QL triamcinolone acetonide external cream - Tier 1; QL triamcinolone acetonide external lotion 0.025 % - Tier 1 triamcinolone acetonide external lotion 0.1 % - Tier 1; QL triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier 1; QL triderm (generic for TRIDERM) - Tier 1; QL urea 20 intensive hydrating - Tier 1; QL urea external lotion (generic for CEROVEL) - Tier 1; QL ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL ureacin-20 - Tier 1; QL wart remover external liquid 17 % (generic for COMPOUND W) - Tier 1 wart remover maximum strength external liquid (generic for COMPOUND W) - Tier 1 zaclir cleansing - Tier 1 zenatane (generic for ACCUTANE) - Tier 1; PA; QL zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT PASTE) - Tier 1; QL ZOSTRIX HP (brand for capzix) - Tier 2; QL ZYCLARA PUMP EXTERNAL CREAM 3.75 % (brand for imiquimod pump) - Tier 2; QL Dermatological Agents - Skin Agents ZILXI - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 65 Preferred Agents Non-Preferred Agents Electrolytes/Minerals/Metals/Vitamins Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs BPROTECTED PEDIA IRON (brand for ferrous sulfate) - Tier 2; QL cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM) - Tier 1; QL calcium 500/d oral tablet (generic for RA HI CAL) - Tier 1; QL calcium 500/vitamin d3 - Tier 1 calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL calcium 600/vit d/minerals oral tablet 600-200 mg-unit - Tier 1; QL calcium 600/vit d/minerals oral tablet chewable 600-400 mg-unit - Tier 1 calcium 600/vitamin d - Tier 1 calcium 600/vitamin d-3 - Tier 1; QL calcium 600+d oral tablet 600-200 mg-unit, 600-400 mg-unit - Tier 1; QL calcium 600+d oral tablet 600-400 mg-unit - Tier 1 calcium carb-cholecalciferol oral tablet 600-400 mg-unit - Tier 1; QL calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1; QL calcium carbonate-vitamin d oral tablet 600-200 mg-unit - Tier 1; QL calcium carbonate-vitamin d oral tablet 600-400 mg-unit - Tier 1 calcium carbonate-vitamin d3 - Tier 1; QL calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1 calcium citrate + d oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 66 Preferred Agents Non-Preferred Agents calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1 calcium citrate +d3 (generic for CALCITRATE) - Tier 1 calcium citrate plus vit d - Tier 1; QL calcium citrate+d oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate+d3 oral tablet 315-250 mg-unit (generic for CALCITRATE) - Tier 1 calcium citrate+d3 w/magne (generic for ADVANCED CALCIUM/D/MAGNESIUM) - Tier 1; QL calcium citrate-vit d - Tier 1; QL calcium citrate-vitamin d oral tablet 315-200 mg-unit - Tier 1; QL calcium fast dissolution - Tier 1; QL calcium high potency - Tier 1; QL calcium high potency/vitamin d - Tier 1; QL calcium oral tablet 1500 (600 ca) mg - Tier 1; QL calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1; QL calcium plus 600 +d - Tier 1; QL calcium plus vitamin d oral tablet 500-5 mg-mcg (generic for OYSCO 500+D) - Tier 1; QL calcium plus vitamin d oral tablet 600-200 mg-unit - Tier 1; QL calcium plus vitamin d oral tablet 600-400 mg-unit - Tier 1 calcium plus vitamin d3 - Tier 1; QL calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier 1 calcium/minerals/vitamin d - Tier 1 calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5 mg - Tier 1 calcium-vitamin d oral tablet 600-400 mg-unit - Tier 1; QL calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1; QL CARBAGLU - Tier 2; PA; SP; QL effer-k oral tablet effervescent 25 meq - Tier 1; QL electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL ENFAMIL ENFALYTE (brand for cvs pediatric electrolyte) - Tier 2; QL ferate (generic for FERATE) - Tier 1 FER-IN-SOL (brand for ferrous sulfate) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 67 Preferred Agents Non-Preferred Agents ferocon (generic for TRICON) - Tier 1 ferosul (generic for FEROSUL) - Tier 1; QL ferotrinsic (generic for TRICON) - Tier 1 ferretts - Tier 1 ferrex 150 (generic for FERREX 150) - Tier 1 ferric x-150 (generic for FERREX 150) - Tier 1 ferrous fumarate oral tablet 324 (106 fe) mg (generic for FERROCITE) - Tier 1 ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 ferrous gluconate oral tablet 324 (37.5 fe) mg - Tier 1 ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; QL ferrous sulfate oral elixir - Tier 1 ferrous sulfate oral solution 75 (15 fe) mg/ml (generic for BPROTECTED PEDIA IRON) - Tier 1; QL ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL ferrous sulfate oral tablet delayed release - Tier 1; QL fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; QL fluoritab (generic for NAFRINSE DROPS) - Tier 1; QL folic acid oral tablet 1 mg - Tier 1; QL folic acid oral tablet 400 mcg, 800 mcg - Tier 1 foltrin (generic for TRICON) - Tier 1 hi cal (generic for RA HI CAL) - Tier 1; QL iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1 iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1 iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL iron supplement - Tier 1 iron supplement childrens (generic for BPROTECTED PEDIA IRON) - Tier 1; QL klor-con (generic for KLOR-CON) - Tier 1; QL klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL klor-con/ef - Tier 1; QL K-PHOS - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 68 Preferred Agents Non-Preferred Agents K-PHOS-NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL k-prime - Tier 1; QL magnesium oxide oral tablet 400 (241.3 mg) mg (generic for MAGNESIUM-OXIDE) - Tier 1 magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1 myferon 150 (generic for FERREX 150) - Tier 1 myferon 150 forte (generic for IFEREX 150 FORTE) - Tier 1 nafrinse (generic for NAFRINSE) - Tier 1; QL nafrinse drops (generic for NAFRINSE DROPS) - Tier 1; QL NU-IRON (brand for polysaccharide iron complex) - Tier 2 oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL OS-CAL CALCIUM + D3 (brand for sm calcium/vitamin d) - Tier 2; QL oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium 500 + d - Tier 1; QL oyster shell calcium oral tablet 500 mg (generic for OYSTERCAL) - Tier 1; QL oyster shell calcium plus d oral tablet 500-200 mg-unit (generic for OYSCO 500+D) - Tier 1; QL oyster shell calcium/d oral tablet 250-125 mg-unit - Tier 1; QL oyster shell calcium/d oral tablet 250-250 mg-unit, 500-400 mg-unit - Tier 1 oyster shell calcium/d oral tablet 500-200 mg-unit (generic for RA HI CAL) - Tier 1; QL oyster shell calcium/vit d - Tier 1 oyster shell calcium/vitamin d oral tablet (generic for OYSCO 500+D) - Tier 1; QL ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) - Tier 1; QL ped electrolyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1; QL PEDIALYTE FREEZER POPS (brand for cvs pediatric electrolyte) - Tier 2; QL PEDIALYTE ORAL SOLUTION (brand for cvs pediatric electrolyte) - Tier 2; QL PEDIALYTE SINGLES (brand for cvs pediatric electrolyte) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 69 Preferred Agents Non-Preferred Agents pediatric electrolyte oral solution (generic for ORALYTE FREEZER POPS) - Tier 1; QL PHOSPHA 250 NEUTRAL (brand for virt-phos 250 neutral) - Tier 2; QL phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL poly-iron 150 (generic for FERREX 150) - Tier 1 poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide iron complex (generic for FERREX 150) - Tier 1 polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1 polysaccharide-iron complex (generic for FERREX 150) - Tier 1 potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL potassium chloride er oral capsule extended release 10 meq - Tier 1; QL potassium chloride er oral tablet extended release (generic for KLOR- CON 10) - Tier 1; QL potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) - Tier 1; QL potassium citrate er oral tablet extended release 10 meq (1080 mg) (generic for UROCIT-K 10) - Tier 1; QL potassium citrate er oral tablet extended release 15 meq (1620 mg) (generic for UROCIT-K 15) - Tier 1 potassium citrate er oral tablet extended release 5 meq (540 mg) (generic for UROCIT-K 5) - Tier 1 PREVIDENT MOUTH/THROAT (brand for sodium fluoride) - Tier 2 REHYDRALYTE (brand for cvs pediatric electrolyte) - Tier 2; QL sod citrate-citric acid - Tier 1 sodium chloride (pf) - Tier 1; QL sodium chloride intravenous solution 0.45 %, 0.9 % - Tier 1; QL sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1 sodium fluoride oral solution 1.1 (0.5 f) mg/ml - Tier 1; QL sodium fluoride oral tablet chewable - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 70 Preferred Agents Non-Preferred Agents TRICON (brand for ferocon) - Tier 2 virt-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1; QL zinc chelated oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL Electrolyte/Mineral/Metal Modifiers CHEMET - Tier 2; QL deferasirox (generic for EXJADE) - Tier 1; PA; SP; QL deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP; QL LOKELMA - Tier 2; PA; QL sps - Tier 1; QL VELTASSA - Tier 2; PA; QL Phosphate Binders - Phosphate-Removing Agents calcium acetate (phos binder) oral tablet (generic for CALPHRON) - AURYXIA - Tier 2; PA; QL Tier 1; QL VELPHORO - Tier 2; PA; QL calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; QL Vitamins a-25 - Tier 1; QL animal shapes complete (generic for CEROVITE JR) - Tier 1; QL animal shapes kids first (generic for DINO-LIFE) - Tier 1; QL animal shapes/iron (generic for CEROVITE JR) - Tier 1; QL AQUADEKS - Tier 2; DX2RX; QL aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL ATABEX OB - Tier 2; PA; QL b complex oral capsule - Tier 1 b complex vitamins - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 71 Preferred Agents Non-Preferred Agents b-1 - Tier 1; QL b6 - Tier 1; QL b-complex oral tablet - Tier 1 b-complex with b-12 - Tier 1 b-complex/b-12 oral - Tier 1 biocel (generic for LYSIPLEX PLUS) - Tier 1; QL b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL BPROTECTED PEDIA D-VITE (brand for vitamin d infant) - Tier 2; QL BPROTECTED PEDIA POLY-VITE/FE (brand for poly-vitamin/iron) - Tier 2; QL BPROTECTED VITAMIN C (brand for ascorbic acid) - Tier 2; QL c 250 oral tablet - Tier 1; QL c 500/rose hips (generic for PUREWAY-C) - Tier 1; QL c-1000/rose hips - Tier 1; QL calcidol (generic for CALCIDOL) - Tier 1; QL cerovite jr (generic for CEROVITE JR) - Tier 1; QL chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1; QL chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL child chewable vitamins/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL childrens chewable vitamins (generic for DINO-LIFE) - Tier 1; QL childrens chewables/ex c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL childrens chewables/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL childrens complete oral tablet chewable 18 mg (generic for CEROVITE JR) - Tier 1; QL childrens vitamins/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL childrens vitamins/iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL classic prenatal - Tier 1; PA; QL CO-NATAL FA (brand for pretab) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 72 Preferred Agents Non-Preferred Agents cyanocobalamin injection solution 1000 mcg/ml - Tier 1; QL CYANOCOBALAMIN INJECTION SOLUTION 2000 MCG/ML - Tier 2; QL d 1000 oral tablet (generic for VITAMIN D-1000 MAX ST) - Tier 1 d 400 oral tablet - Tier 1; QL d 400 oral tablet chewable (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 d 5000 oral tablet (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 d3 high potency oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 d3 oral capsule 10 mcg (400 unit), 50 mcg (2000 ut) - Tier 1; QL d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 d3 super strength - Tier 1; QL d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1 d3-50 (generic for D3-50) - Tier 1; QL daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 DECARA ORAL CAPSULE 1.25 MG (50000 UT) (brand for vitamin d3) - Tier 2; QL DECARA ORAL CAPSULE 250 MCG (10000 UT) (brand for vitamin d3) - Tier 2 DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2 DIALYVITE 800 ORAL TABLET (brand for renal vitamin) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 73 Preferred Agents Non-Preferred Agents DIALYVITE VITAMIN D 5000 (brand for d-3-5) - Tier 2 dino-life (generic for DINO-LIFE) - Tier 1; QL dino-life w/extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL D-VI-SOL (brand for vitamin d infant) - Tier 2; QL d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL e-400-clear (generic for ESTER-E) - Tier 1; QL ENFAMIL EXPECTA - Tier 2; PA; QL ergocalciferol oral (generic for DRISDOL) - Tier 1; QL essential one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 essentials (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 fruity c - Tier 1; QL full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; QL healthy hair/skin/nails (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 INATAL GT - Tier 2; PA; QL little ones childrens (generic for DINO-LIFE) - Tier 1; QL lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL M-NATAL PLUS - Tier 2; PA; QL multi vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multi vitamin w/d-3 (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamin-folic acid (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamins essential (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL MULTIPRO - Tier 2; QL multi-vit/iron/fluoride - Tier 1; PA; QL multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; PA; QL multivitamin/fluoride oral solution (generic for FLORIVA PLUS) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 74 Preferred Agents Non-Preferred Agents multivitamin/fluoride oral tablet chewable 0.25 mg, 0.5 mg, 1 mg (generic for QUFLORA PEDIATRIC) - Tier 1; PA; QL multi-vitamin/fluoride/iron - Tier 1; PA; QL multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL mynephrocaps (generic for MYNEPHRON) - Tier 1 MYNEPHRON (brand for reno caps) - Tier 2 natural vitamin e (generic for ESTER-E) - Tier 1; QL NEOMULTIVITE (brand for thera-tabs) - Tier 2 NEONATAL COMPLETE - Tier 2; PA; QL NEONATAL PLUS (brand for one vite womens plus) - Tier 2; PA; QL NEONATAL VITAMIN (brand for prenatal vitamin) - Tier 2; PA; QL nephro vitamins (generic for DIALYVITE 800) - Tier 1; QL NEPHRO-VITE (brand for renal vitamin) - Tier 2; QL niacin er oral capsule extended release 250 mg - Tier 1; QL niacin er oral capsule extended release 500 mg - Tier 1 niacin er oral tablet extended release - Tier 1 niacin oral tablet 100 mg, 250 mg, 50 mg - Tier 1 NIVA-PLUS (brand for one vite womens plus) - Tier 2; PA; QL NOVAMV PEDIATRIC MULTI-VITAMIN - Tier 2; QL nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL O-CAL PRENATAL - Tier 2; PA; QL once daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 once daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one daily plus iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL ONE VITE WOMENS - Tier 2; PA; QL ONE VITE WOMENS PLUS - Tier 2; PA; QL one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 one-daily multi-vitamin oral tablet (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 75 Preferred Agents Non-Preferred Agents one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL ONEVITE - Tier 2; PA; QL pediavit - Tier 1; QL phytonadione injection solution 10 mg/ml - Tier 1; QL phytonadione oral (generic for MEPHYTON) - Tier 1; QL pnv tabs 29-1 (generic for PRENATABS RX) - Tier 1; PA; QL PRENATABS RX (brand for thrivite rx) - Tier 2; PA; QL prenatal formula oral tablet 28-0.8 mg - Tier 1; PA; QL prenatal low iron (generic for NEONATAL VITAMIN) - Tier 1; PA; QL prenatal multi+dha - Tier 1; PA; QL prenatal multivitamins - Tier 1; PA; QL prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier 1; PA; QL prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1; PA; QL prenatal oral tablet 28-0.8 mg - Tier 1; PA; QL prenatal plus iron (generic for PRENATABS RX) - Tier 1; PA; QL prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1; PA; QL prenatal vitamins oral tablet 28-0.8 mg - Tier 1; PA; QL prenatal/iron - Tier 1; PA; QL PRENATAL-U - Tier 2; PA; QL PRENATRIX (brand for one vite womens plus) - Tier 2; PA; QL PRENATRYL (brand for one vite womens plus) - Tier 2; PA; QL PRENATVITE RX - Tier 2; PA; QL preplus (generic for NEONATAL PLUS) - Tier 1; PA; QL PRETAB - Tier 2; PA; QL PRONUTRIENTS VITAMIN D3 (brand for gnp d 1000) - Tier 2 pyridoxine hcl oral - Tier 1; QL QUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML (brand for multi-vitamin/fluoride) - Tier 2; PA; QL radiance platinum vitamin d3 (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 76 Preferred Agents Non-Preferred Agents RENAL (brand for reno caps) - Tier 2 RENAL MULTIVITAMIN FORMULA (brand for renal vitamin) - Tier 2; QL renal-vite (generic for DIALYVITE 800) - Tier 1; QL rena-vite (generic for DIALYVITE 800) - Tier 1; QL SLO-NIACIN (brand for hm niacin) - Tier 2 stress formula - Tier 1 stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL tab-a-vite (generic for LYSIPLEX PLUS) - Tier 1 tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 tab-a-vite/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) - Tier 1; QL thera (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1 thiamine hcl oral - Tier 1; QL thiamine mononitrate oral - Tier 1; QL THRIVITE 19 - Tier 2; PA; QL THRIVITE RX - Tier 2; PA; QL TRICARE (brand for one vite womens plus) - Tier 2; PA; QL TRINATE - Tier 2; PA; QL tri-vite pediatric (generic for BPROTECTED PEDIA TRI-VITE) - Tier 1; QL tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; PA; QL UDAMIN SP (brand for thrivite 19) - Tier 2; PA; QL v-c forte (generic for VIC-FORTE) - Tier 1; QL vic-forte (generic for VIC-FORTE) - Tier 1; QL VINATE II - Tier 2; PA; QL VINATE ONE - Tier 2; PA; QL virt-caps (generic for MYNEPHRON) - Tier 1 vit c/rose hips - Tier 1; QL vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL vitamin a oral capsule 2400 mcg (8000 ut), 3 mg (10000 ut) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 77 Preferred Agents Non-Preferred Agents vitamin b-1 - Tier 1; QL vitamin b-12 er oral tablet extended release 1000 mcg - Tier 1 vitamin b12 oral tablet extended release 1000 mcg - Tier 1 vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1 vitamin b-6 - Tier 1; QL vitamin b-6 er - Tier 1; QL vitamin c cr oral tablet extended release 500 mg (generic for ENDUR- C) - Tier 1; QL vitamin c er oral tablet extended release 1500 mg - Tier 1; QL vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN C) - Tier 1; QL vitamin c oral tablet 1000 mg, 250 mg - Tier 1; QL vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; QL vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; QL vitamin c/rose hips oral tablet 1000 mg - Tier 1; QL vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL vitamin c-rose hips oral tablet (generic for PUREWAY-C) - Tier 1; QL vitamin d (cholecalciferol) oral tablet 10 mcg (400 unit) - Tier 1; QL vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) (generic for DRISDOL) - Tier 1; QL vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier 1; QL vitamin d oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL vitamin d oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 78 Preferred Agents Non-Preferred Agents vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1; QL vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d-3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D 5000) - Tier 1 vitamin d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS VITAMIN D3) - Tier 1 vitamin d3 oral capsule 250 mcg (10000 ut) (generic for DECARA) - Tier 1 vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QL vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; QL vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D- VITE) - Tier 1; QL vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1; QL vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE PLATINUM VITAMIN D3) - Tier 1 vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000 MAX ST) - Tier 1 vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) - Tier 1; QL vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for HEALTHY KIDS VITAMIN D3) - Tier 1 vitamin d3 oral tablet chewable 25 mcg, 25 mcg (1000 ut) (generic for KIDS FIRST VITAMIN D3 GUMMIES) - Tier 1 vitamin d-400 - Tier 1; QL vitamin e oral capsule 400 unit (generic for ESTER-E) - Tier 1; QL vitamin k1 injection solution 10 mg/ml - Tier 1; QL vitamin-b complex - Tier 1 vitamins acd-fluoride - Tier 1; PA; QL vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL VITATHELY WITH GINGER (brand for one vite womens plus) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 79 Preferred Agents Non-Preferred Agents weekly-d (generic for D3-50) - Tier 1; QL WESTAB PLUS - Tier 2; PA; QL WEST-VITE W/FOLIC ACID - Tier 2; QL womens prenatal+dha - Tier 1; PA; QL zoo friends gummies (generic for ALIVE GUMMIES FOR CHILDREN) - Tier 1; QL zoo friends plus extra c (generic for DINO-LIFE W/EXTRA C) - Tier 1; QL zoo friends plus iron (generic for LAND BEFORE TIME MULTIVITAMIN) - Tier 1; QL ZYVANA - Tier 2; QL Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; QL dicyclomine hcl oral capsule - Tier 1; QL dicyclomine hcl oral solution - Tier 1 dicyclomine hcl oral tablet - Tier 1; QL ED-SPAZ - Tier 2; QL glycopyrrolate oral tablet 1 mg, 2 mg - Tier 1 hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL hyoscyamine sulfate oral - Tier 1; QL hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL hyosyne - Tier 1; QL LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL NULEV (brand for hyoscyamine sulfate) - Tier 2; QL oscimin (generic for LEVSIN) - Tier 1; QL oscimin sr (generic for LEVBID) - Tier 1; QL SYMAX-SR (brand for hyoscyamine sulfate er) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 80 Preferred Agents Non-Preferred Agents Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal Drugs abatinex (generic for ABATINEX) - Tier 1 OMECLAMOX-PAK - Tier 2; PA acid gone (generic for ACID GONE) - Tier 1 PYLERA - Tier 2; PA acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1 RELISTOR - Tier 2; PA; QL acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1 SYMPROIC - Tier 2; PA; QL acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier 1 acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) - Tier 1 acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1 adult 50+ probiotic (generic for RESTORA) - Tier 1; QL adult probiotic (generic for RESTORA) - Tier 1; QL advanced antacid max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL almacone double strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; QL alumina-magnesia-simethicone (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid & gas relief (generic for MINTOX) - Tier 1; QL antacid advanced (generic for MINTOX) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 81 Preferred Agents Non-Preferred Agents antacid advanced max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas (generic for MINTOX) - Tier 1; QL antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas max strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid anti-gas reg strength (generic for MINTOX) - Tier 1; QL antacid calcium (generic for CAL-GEST ANTACID) - Tier 1 antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1 antacid extra (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid extra strength oral suspension (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid extra strength oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 antacid extra strength oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid fast relief (generic for MINTOX) - Tier 1; QL antacid i (generic for MINTOX) - Tier 1; QL antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid liquid (generic for MINTOX) - Tier 1; QL antacid m (generic for MINTOX) - Tier 1; QL antacid maximum (generic for TUMS ULTRA 1000) - Tier 1 antacid maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid maximum strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml (generic for MINTOX) - Tier 1; QL antacid oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 82 Preferred Agents Non-Preferred Agents antacid oral tablet chewable 500 mg (generic for CAL-GEST ANTACID) - Tier 1 antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid plus anti-gas relief (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid regular strength oral suspension (generic for MINTOX) - Tier 1; QL antacid regular strength oral tablet chewable (generic for CAL-GEST ANTACID) - Tier 1 antacid supreme - Tier 1 antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS ULTRA 1000) - Tier 1 antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/anti-gas max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL antacid/antigas oral suspension 200-200-20 mg/5ml (generic for MINTOX) - Tier 1; QL antacid/gas relief max st (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal anti-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) - Tier 1 anti-diarrheal oral liquid 1 mg/5ml - Tier 1 anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1 anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH) - Tier 1 biotinex (generic for ABATINEX) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 83 Preferred Agents Non-Preferred Agents bismatrol maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; QL bismuth (generic for SOOTHE) - Tier 1; QL bismuth subsalicylate oral suspension (generic for SOOTHE) - Tier 1 bismuth subsalicylate oral tablet chewable (generic for SOOTHE) - Tier 1; QL calcium antacid (generic for CAL-GEST ANTACID) - Tier 1 calcium antacid ex st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium antacid extra strength (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 calcium carbonate antacid oral suspension - Tier 1; QL calcium carbonate antacid oral tablet - Tier 1 calcium carbonate antacid oral tablet chewable (generic for CAL- GEST ANTACID) - Tier 1 calcium carbonate oral tablet chewable 500 mg (generic for CAL- GEST ANTACID) - Tier 1 cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1 chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 childrens soothe - Tier 1 comfort gel (generic for MINTOX) - Tier 1; QL comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL digestive probiotic capsule oral (generic for RESTORA) - Tier 1; QL dairy aid (generic for LACTAID) - Tier 1 dairy relief ex st - Tier 1 dairy relief fast acting oral tablet 9000 unit (generic for LACTAID FAST ACT) - Tier 1 dairy relief oral tablet 3000 unit (generic for LACTAID) - Tier 1 diamode (generic for IMODIUM A-D) - Tier 1 diarrhea (generic for SOOTHE) - Tier 1 diarrhea relief (generic for SOOTHE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 84 Preferred Agents Non-Preferred Agents digestive probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 diotame instydose (generic for SOOTHE) - Tier 1 diphenoxylate-atropine oral liquid - Tier 1 diphenoxylate-atropine oral tablet (generic for LOMOTIL) - Tier 1; QL floranex tablet oral (generic for FLORANEX) - Tier 1 FLORANEX TABLET ORAL (brand for acidophilus/l-sporogenes) - Tier 2 foaming antacid oral tablet chewable 80-20 mg - Tier 1 freeze dried acidophilus (generic for ABATINEX) - Tier 1 gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief drops infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief extra strength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief infants (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief infants drops (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral capsule 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief oral suspension (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 gas relief oral tablet chewable - Tier 1 gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA STRENGTH) - Tier 1 gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1 GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for simethicone extra strength) - Tier 2 GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for goodsense gas relief) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 85 Preferred Agents Non-Preferred Agents GAS-X ULTRA STRENGTH (brand for sb anti-gas) - Tier 2 GATTEX - Tier 2; PA; SP; QL GAVISCON EXTRA RELIEF FORMULA (brand for cvs heartburn relief ex st) - Tier 2 GAVISCON EXTRA STRENGTH (brand for cvs heartburn relief) - Tier 2 GAVISCON ORAL SUSPENSION - Tier 2 GELUSIL - Tier 2 geri-lanta (generic for MINTOX) - Tier 1; QL geri-lanta supreme - Tier 1 geri-mox (generic for MINTOX) - Tier 1; QL geri-pectate (generic for SOOTHE) - Tier 1 heartburn antacid (generic for ACID GONE) - Tier 1 heartburn antacid ex st (generic for ACID GONE) - Tier 1 heartburn relief ex st (generic for GAVISCON EXTRA RELIEF FORMULA) - Tier 1 heartburn relief oral tablet chewable 160-105 mg (generic for ACID GONE) - Tier 1 HELIDAC THERAPY - Tier 2 IMODIUM A-D ORAL TABLET (brand for hm anti-diarrheal) - Tier 2 IMODIUM MULTI-SYMPTOM RELIEF (brand for hm anti-diarrheal anti-gas) - Tier 2 infant gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants gas relief (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 infants simethicone (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 LACTAID (brand for dairy relief) - Tier 2 LACTAID FAST ACT ORAL TABLET (brand for dairy digestive ultra) - Tier 2 lactase enzyme (generic for LACTAID) - Tier 1 lactase enzyme ultra str (generic for LACTAID FAST ACT) - Tier 1 lactase fast acting (generic for LACTAID FAST ACT) - Tier 1 lactobacillus oral tablet (generic for FLORANEX) - Tier 1 LACTOJEN - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 86 Preferred Agents Non-Preferred Agents lacto-pectin (generic for RESTORA) - Tier 1; QL lactose fast acting relief oral tablet (generic for LACTAID FAST ACT) - Tier 1 long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1 loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QL loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1 MAALOX - Tier 2 MAALOX CHILDRENS (brand for childrens pepto) - Tier 2 MAALOX MAX ORAL SUSPENSION (brand for sm antacid advanced max st) - Tier 2; QL MAALOX MULTI SYMPTOM MAX ST (brand for sm antacid advanced max st) - Tier 2; QL mag-al plus (generic for MINTOX) - Tier 1; QL mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL magnesium oxide oral tablet 400 mg - Tier 1 magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1 MAOX (brand for magnesium oxide) - Tier 2 mega probiotic (generic for RESTORA) - Tier 1; QL meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1 metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL mi-acid gas relief - Tier 1 milantex (generic for MINTOX) - Tier 1; QL milantex extra strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mintox maximum strength (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL mintox plus - Tier 1 MOTEGRITY - Tier 2; ST; QL MOVANTIK - Tier 2; DX2RX; ST; QL MYTESI - Tier 2; DX2RX; QL peptic relief (generic for SOOTHE) - Tier 1; QL PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for cvs anti-diarrheal) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 87 Preferred Agents Non-Preferred Agents PHAZYME (brand for goodsense gas relief) - Tier 2 PHAZYME ULTRA STRENGTH (brand for sb anti-gas) - Tier 2 pink bismuth maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) - Tier 1 pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1 pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL pink-bismuth (generic for SOOTHE) - Tier 1; QL pro-biotic blend (generic for RESTORA) - Tier 1; QL probiotic colon care (generic for RESTORA) - Tier 1; QL probiotic complex (generic for RESTORA) - Tier 1; QL probiotic maximum strength (generic for RESTORA) - Tier 1; QL probiotic oral capsule (generic for RESTORA) - Tier 1; QL probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1 probiotic pearls ex st (generic for RESTORA) - Tier 1; QL RESTORA (brand for folika probiotic) - Tier 2; QL RESTORA RX - Tier 2 RISAQUAD (brand for folika probiotic) - Tier 2; QL RISAQUAD-2 (brand for folika probiotic) - Tier 2; QL saccharomyces boulardii (generic for FLORASTOR) - Tier 1 senior probiotic (generic for RESTORA) - Tier 1; QL simeped (generic for LITTLE REMEDIES FOR TUMMYS) - Tier 1 simethicone oral (generic for GAS-X EXTRA STRENGTH) - Tier 1 simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier 1 smooth antacid ex st oral tablet chewable 750 mg (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 smooth antacid extra st (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier 1 sodium bicarbonate oral tablet - Tier 1 soothe maximum strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 soothe oral suspension (generic for SOOTHE) - Tier 1 soothe oral tablet (generic for SOOTHE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 88 Preferred Agents Non-Preferred Agents soothe oral tablet chewable (generic for SOOTHE) - Tier 1; QL stomach relief extra strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max st oral suspension 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief max strength (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527 mg/30ml (generic for SOOTHE) - Tier 1 stomach relief oral tablet 262 mg (generic for SOOTHE) - Tier 1 stomach relief oral tablet chewable 262 mg (generic for SOOTHE) - Tier 1; QL stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) - Tier 1 surelac (generic for LACTAID) - Tier 1 TRULANCE - Tier 2; DX2RX; ST; QL TUMS (brand for ra antacid) - Tier 2 TUMS CHEWY BITES (brand for cvs smooth antacid extra st) - Tier 2 TUMS E-X 750 (brand for cvs smooth antacid extra st) - Tier 2 TUMS EXTRA STRENGTH 750 (brand for cvs smooth antacid extra st) - Tier 2 TUMS LASTING EFFECTS (brand for ra antacid) - Tier 2 TUMS SMOOTHIES (brand for cvs smooth antacid extra st) - Tier 2 TUMS ULTRA 1000 (brand for qc antacid ultra strength) - Tier 2 ultra dairy digestive (generic for LACTAID FAST ACT) - Tier 1 ursodiol oral capsule - Tier 1; QL ursodiol oral tablet (generic for URSO 250) - Tier 1 VISBIOME HIGH POTENCY ORAL CAPSULE (brand for folika probiotic) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 89 Preferred Agents Non-Preferred Agents Histamine2 (H2) Receptor Antagonists - Ulcer and Stomach Acid Drugs acid controller (generic for PEPCID AC) - Tier 1; QL acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL cimetidine hcl oral solution 300 mg/5ml - Tier 1; QL cimetidine oral (generic for TAGAMET HB) - Tier 1; QL famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL; AL famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL famotidine oral tablet 20 mg (generic for MM ACID-PEP MAXIMUM STRENGTH) - Tier 1; QL famotidine oral tablet 40 mg (generic for PEPCID) - Tier 1; QL famotidine orig st (generic for PEPCID AC) - Tier 1; QL heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1; QL Irritable Bowel Syndrome Agents - Bowel Treatment Drugs LUBIPROSTONE - Tier 2; DX2RX; ST; QL AMITIZA (brand for lubiprostone) - Tier 2; DX2RX; ST; QL LINZESS - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 90 Preferred Agents Non-Preferred Agents Laxatives - Drugs to treat Constipation bisacodyl ec (generic for GNP BISA-LAX) - Tier 1; QL bisacodyl laxative (generic for THE MAGIC BULLET) - Tier 1; QL bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; QL bisa-lax (generic for GNP BISA-LAX) - Tier 1; QL citrate of magnesia (generic for CITROMA) - Tier 1 citroma (generic for CITROMA) - Tier 1 CITRUCEL - Tier 2 c-lax laxative (generic for GNP BISA-LAX) - Tier 1; QL clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL COLACE (brand for docqlace) - Tier 2; QL col-rite oral capsule 250 mg - Tier 1; QL constulose - Tier 1; QL daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 docu - Tier 1; QL docusate calcium (generic for SURFAK) - Tier 1 docusate mini (generic for DOCUSOL MINI) - Tier 1; QL docusate sodium oral capsule (generic for DOK) - Tier 1; QL docusate sodium oral liquid 50 mg/5ml - Tier 1; QL docusate sodium oral syrup - Tier 1 DOCUSOL MINI (brand for docusate mini) - Tier 2; QL docuzen (generic for SENEXON-S) - Tier 1 dok oral capsule (generic for DOK) - Tier 1; QL dss (generic for DOK) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 91 Preferred Agents Non-Preferred Agents ducodyl (generic for GNP BISA-LAX) - Tier 1; QL easy-lax plus (generic for SENEXON-S) - Tier 1 enema (generic for FLEET ENEMA) - Tier 1 enema disposable (generic for FLEET ENEMA) - Tier 1 enema mineral oil (generic for FLEET OIL) - Tier 1 enema ready-to-use (generic for FLEET ENEMA) - Tier 1 enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for FLEET ENEMA) - Tier 1 ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL enulose - Tier 1; QL EVAC (brand for natural psyllium seed) - Tier 2 EX-LAX ULTRA (brand for sm gentle laxative) - Tier 2; QL fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL fiber laxative (generic for FIBERCON) - Tier 1 fiber laxative + calcium (generic for FIBERCON) - Tier 1 fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber oral powder 30.9 % - Tier 1 fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber oral tablet 625 mg (generic for FIBERCON) - Tier 1 fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 fiber therapy oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1 fiber therapy oral tablet 625 mg (generic for FIBERCON) - Tier 1 fiber-caps (generic for FIBERCON) - Tier 1 FIBERCON (brand for eql fiber laxative) - Tier 2 fiber-lax (generic for FIBERCON) - Tier 1 FLEET BISACODYL - Tier 2; QL FLEET ENEMA (brand for cvs enema ready-to-use) - Tier 2 FLEET OIL (brand for enema mineral oil) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 92 Preferred Agents Non-Preferred Agents FLEET PEDIATRIC (brand for enema pediatric) - Tier 2 gavilax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL gavilyte-c - Tier 1; QL gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL generlac - Tier 1; QL gentle laxative (generic for GNP BISA-LAX) - Tier 1; QL gentle laxative womens (generic for GNP BISA-LAX) - Tier 1; QL gentlelax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL geri-kot (generic for SENNO) - Tier 1 glycerin (adult) rectal suppository 2 gm - Tier 1 glycerin (infants & children) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin (pediatric) rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin adult rectal suppository 2 gm - Tier 1 glycerin child rectal suppository 1 gm (generic for PEDIA-LAX) - Tier 1 glycerin child rectal suppository 1.2 gm - Tier 1 glycerin childrens (generic for PEDIA-LAX) - Tier 1 glycerin pediatric rectal suppository 1.2 gm - Tier 1 glycolax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL KONSYL DAILY FIBER ORAL POWDER 100 % - Tier 2 konsyl daily fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL lactulose encephalopathy - Tier 1; QL lactulose oral solution - Tier 1; QL laxacin (generic for SENEXON-S) - Tier 1 laxaclear (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL laxative max str - Tier 1 laxative maximum strength oral tablet 25 mg - Tier 1 laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL laxative oral tablet delayed release 5 mg (generic for GNP BISA-LAX) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 93 Preferred Agents Non-Preferred Agents laxative pills (generic for SENNA SMOOTH) - Tier 1 laxative pills max st - Tier 1 laxative pills oral tablet 25 mg - Tier 1 laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) - Tier 1; QL laxative regular strength (generic for SENNA SMOOTH) - Tier 1 magnesium citrate oral solution (generic for CITROMA) - Tier 1 milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1 mineral oil enema (generic for FLEET OIL) - Tier 1 mineral oil heavy oral - Tier 1 mineral oil oral oil - Tier 1 MINERAL OIL ORAL OIL - Tier 2 mineral oil rectal enema (generic for FLEET OIL) - Tier 1 MIRALAX ORAL POWDER (brand for peg 3350) - Tier 2; ONLY powder bottle; QL mm clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL mm stool softener laxative (generic for DOK) - Tier 1; QL natural daily fiber (generic for METAMUCIL) - Tier 1 natural fiber laxative oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1 natural fiber oral powder 28.3 % (generic for METAMUCIL) - Tier 1; QL natural fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1 natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH TEXTURE) - Tier 1 natural fiber supplement oral powder (generic for EVAC) - Tier 1 natural laxative (generic for SENNO) - Tier 1 natural laxative/stool soft (generic for SENEXON-S) - Tier 1 natural senna laxative (generic for SENNO) - Tier 1 natural vegetable (generic for HYDROCIL) - Tier 1 natural vegetable fiber (generic for METAMUCIL) - Tier 1 natural vegetable laxative (generic for SENNO) - Tier 1 natura-lax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL p col-rite (generic for SENEXON-S) - Tier 1 PEDIA-LAX ORAL LIQUID - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 94 Preferred Agents Non-Preferred Agents PEDIA-LAX RECTAL SUPPOSITORY 1 GM (brand for glycerin (infants & children)) - Tier 2 peg 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR PACK) - Tier 1; QL PERDIEM OVERNIGHT RELIEF (brand for laxative regular strength) - Tier 2 PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML (brand for eql milk of magnesia) - Tier 2 polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL psyldex - Tier 1 purelax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier 1 saline enema (generic for FLEET ENEMA) - Tier 1 sb docusate sodium/senna (generic for SENEXON-S) - Tier 1 senexon-s (generic for SENEXON-S) - Tier 1 senna lax (generic for SENNO) - Tier 1 senna laxative (generic for SENNO) - Tier 1 senna oral liquid - Tier 1 senna oral syrup - Tier 1 senna oral tablet (generic for SENNO) - Tier 1 senna plus oral tablet (generic for SENEXON-S) - Tier 1 senna s (generic for SENEXON-S) - Tier 1 senna smooth (generic for SENNA SMOOTH) - Tier 1 senna-docusate sodium (generic for SENEXON-S) - Tier 1 senna-lax (generic for SENNO) - Tier 1 senna-plus (generic for SENEXON-S) - Tier 1 senna-s (generic for SENEXON-S) - Tier 1 senna-tabs (generic for SENNO) - Tier 1 senna-time (generic for SENNO) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 95 Preferred Agents Non-Preferred Agents senna-time s (generic for SENEXON-S) - Tier 1 sennazon - Tier 1 senno (generic for SENNO) - Tier 1 SENOKOT (brand for cvs senna) - Tier 2 SENOKOT S (brand for stool softener laxative) - Tier 2 silace oral liquid - Tier 1; QL silace oral syrup - Tier 1 smooth lax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL soluble fiber therapy - Tier 1 sorbitol oral - Tier 1 stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener laxative oral capsule (generic for DOK) - Tier 1; QL stool softener oral capsule 100 mg (generic for DOK) - Tier 1; QL stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1 stool softener oral capsule 250 mg - Tier 1; QL stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier 1 stool softener oral tablet 8.6-50 mg (generic for SENEXON-S) - Tier 1 stool softener pls laxative (generic for SENEXON-S) - Tier 1 stool softener plus laxative (generic for SENEXON-S) - Tier 1 stool softener/laxative (generic for SENEXON-S) - Tier 1 stool softener/stimulant (generic for SENEXON-S) - Tier 1 the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL vegetable lax+stool softener (generic for SENEXON-S) - Tier 1 womans laxative (generic for GNP BISA-LAX) - Tier 1; QL womens gentle laxative (generic for GNP BISA-LAX) - Tier 1; QL womens laxative (generic for GNP BISA-LAX) - Tier 1; QL Protectants - Ulcer and Stomach Acid Drugs misoprostol oral (generic for CYTOTEC) - Tier 1; QL sucralfate oral suspension (generic for CARAFATE) - Tier 1; Members 10 years of age up to 65 years of age will require PA; QL sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 96 Preferred Agents Non-Preferred Agents Proton Pump Inhibitors - Ulcer and Stomach Acid Drugs acid reducer oral capsule delayed release - Tier 1; QL ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1; DEXILANT - Tier 2; PA; QL Members >= 2 years of age will require PA; QL; AL esomeprazole magnesium oral capsule delayed release (generic for lansoprazole oral capsule delayed release 15 mg, 30 mg (generic for NEXIUM) - Tier 1; PA; QL PREVACID) - Tier 1; QL NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for sm lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg esomeprazole magnesium) - Tier 2; PA; QL (generic for PREVACID SOLUTAB) - Tier 1; Members >= 2 years of NEXIUM ORAL PACKET 10 MG, 20 MG, 40 MG (brand for esomeprazole age will require PA; QL; AL magnesium) - Tier 2; PA; Members >= 2 years of age will require PA; QL; NEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; Members >= 2 years AL of age will require PA; QL; AL omeprazole magnesium oral tablet delayed release (generic for omeprazole magnesium oral capsule delayed release - Tier 1; QL PRILOSEC OTC) - Tier 1; PA; QL omeprazole oral tablet delayed release 20 mg - Tier 1; PA; QL omeprazole oral capsule delayed release 10 mg, 20 mg, 20.6 (20 pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA; base) mg, 40 mg - Tier 1; QL QL pantoprazole sodium oral tablet delayed release (generic for PREVACID (brand for lansoprazole) - Tier 2; PA; QL PROTONIX) - Tier 1; QL PRILOSEC - Tier 2; PA; QL PREVACID 24HR (brand for lansoprazole) - Tier 2; QL ZEGERID (brand for omeprazole-sodium bicarbonate) - Tier 2; PA; QL Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment CHOLBAM - Tier 2; PA; SP; QL CERDELGA - Tier 2; PA; SP; QL CREON - Tier 2; QL ORFADIN (brand for nitisinone) - Tier 2; PA; SP; QL CYSTAGON - Tier 2; SP; QL PANCREAZE - Tier 2; PA; QL NITYR - Tier 2; DX2RX; SP; QL VIOKACE ORAL TABLET 10440-39150 UNIT - Tier 2; PA; QL RAVICTI - Tier 2; PA; SP; QL ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL sapropterin dihydrochloride (generic for KUVAN) - Tier 1; DX2RX; SP; ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000- QL 32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 3000-10000 UNIT, sodium phenylbutyrate oral (generic for BUPHENYL) - Tier 1; DX2RX; 40000-126000 UNIT, 5000-24000 UNIT - Tier 2; PA; QL SP; QL STRENSIQ - Tier 2; PA; SP; QL TEGSEDI - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 97 Preferred Agents Non-Preferred Agents Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions Antispasmodics, Urinary - Bladder Control Drugs oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL DETROL (brand for tolterodine tartrate) - Tier 2; PA; ST; QL oxybutynin chloride oral - Tier 1; QL DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL; AL OXYTROL FOR WOMEN - Tier 2; QL DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL tolterodine tartrate (generic for DETROL) - Tier 1; ST; QL ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 7.5 MG trospium chloride - Tier 1; ST; QL (brand for darifenacin hydrobromide er) - Tier 2; PA; QL MYRBETRIQ - Tier 2; PA; QL TOVIAZ - Tier 2; PA; QL VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL Benign Prostatic Hypertrophy Agents - Prostate Drugs alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL; AL tamsulosin hcl (generic for FLOMAX) - Tier 1; QL terazosin hcl - Tier 1; QL Genitourinary Agents, Other - Miscellaneous Bladder, Genital, and Kidney Conditions Drugs azo (generic for PHENAZO) - Tier 1 CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL azo tabs (generic for PHENAZO) - Tier 1 DEPEN TITRATABS (brand for penicillamine) - Tier 2; DX2RX; SP; QL bethanechol chloride oral - Tier 1 ELMIRON - Tier 2; DX2RX; QL penicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1; DX2RX; SP; QL phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1 phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier 1; QL phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 98 Preferred Agents Non-Preferred Agents PHOSPHASAL (brand for urin ds) - Tier 2; QL PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QL SHUR-SEAL CONTRACEPTIVE - Tier 2; GE urin ds (generic for PHOSPHASAL) - Tier 1; QL urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1 UTIRA-C (brand for urin ds) - Tier 2; QL VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM - Tier 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Hormone Replacement/Modifying Drugs DECADRON ORAL TABLET 0.5 MG, 0.75 MG (brand for dexamethasone) - Tier 2 DECADRON ORAL TABLET 4 MG, 6 MG (brand for dexamethasone) - Tier 2; QL dexamethasone oral elixir - Tier 1; QL dexamethasone oral solution - Tier 1; QL dexamethasone oral tablet 0.5 mg, 0.75 mg (generic for DECADRON) - Tier 1 dexamethasone oral tablet 1 mg, 2 mg - Tier 1 dexamethasone oral tablet 1.5 mg - Tier 1; QL dexamethasone oral tablet 4 mg, 6 mg (generic for DECADRON) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 99 Preferred Agents Non-Preferred Agents fludrocortisone acetate oral - Tier 1; QL hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) - Tier 1; QL methylprednisolone oral (generic for MEDROL) - Tier 1; QL MILLIPRED - Tier 2; QL prednisolone oral solution - Tier 1; QL prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1 prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml (generic for PEDIAPRED) - Tier 1; QL prednisone oral solution - Tier 1; QL prednisone oral tablet - Tier 1; QL prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) - Tier 1 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Hormone Replacement/Modifying Drugs chorionic gonadotropin intramuscular (generic for NOVAREL) - Tier 1; GENOTROPIN - Tier 2; PA; SP; QL DX2RX; Diagnosis Required for Hypogonadism or Cryptorchidism; HUMATROPE INJECTION SOLUTION RECONSTITUTED 12 MG, 24 Infertility diagnosis is a Plan Exclusion MG, 6 MG - Tier 2; PA; SP; QL DDAVP RHINAL TUBE - Tier 2; QL NORDITROPIN FLEXPRO - Tier 2; PA; SP; QL desmopressin ace spray refrig - Tier 1; QL NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP; QL desmopressin acetate oral (generic for DDAVP) - Tier 1; QL NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP; QL desmopressin acetate spray - Tier 1; QL NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP; QL INCRELEX - Tier 2; PA; SP; QL OMNITROPE - Tier 2; PA; SP; QL NOCDURNA - Tier 2; PA; QL SAIZEN - Tier 2; PA; SP; QL novarel intramuscular solution reconstituted 10000 unit (generic for NOVAREL) - Tier 1; DX2RX; Diagnosis Required for Hypogonadism or Cryptorchidism; Infertility diagnosis is a Plan Exclusion
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 100 Preferred Agents Non-Preferred Agents NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT - Tier 2; DX2RX; Diagnosis Required for Hypogonadism or Cryptorchidism; Infertility diagnosis is a Plan Exclusion OVIDREL - Tier 2; DX2RX; Diagnosis Required for Hypogonadism or Cryptorchidism; Infertility diagnosis is a Plan Exclusion pregnyl (generic for NOVAREL) - Tier 1; DX2RX; Diagnosis Required for Hypogonadism or Cryptorchidism; Infertility diagnosis is a Plan Exclusion ZOMACTON - Tier 2; PA; SP; QL ZOMACTON (FOR ZOMA-JET 10) - Tier 2; PA; SP; QL Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Hormone Replacement/Modifying Drugs KORLYM - Tier 2; PA; SP; QL Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones Androgens - Hormone Replacement/Modifying Drugs danazol oral - Tier 1; QL testosterone cypionate intramuscular (generic for DEPO- TESTOSTERONE) - Tier 1; QL testosterone enanthate intramuscular - Tier 1 testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO PUMP) - Tier 1; PA; QL testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) (generic for ANDROGEL) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 101 Preferred Agents Non-Preferred Agents Estrogens - Hormone Replacement/Modifying Drugs afirmelle (generic for AFIRMELLE) - Tier 1; QL; GE ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL altavera (generic for ALTAVERA) - Tier 1; QL; GE ALORA (brand for estradiol) - Tier 2; PA; QL alyacen 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE ANGELIQ - Tier 2; PA; QL alyacen 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE CLIMARA (brand for estradiol) - Tier 2; PA; QL apri (generic for APRI) - Tier 1; QL; GE CLIMARA PRO - Tier 2; PA; QL aranelle - Tier 1; QL; GE COMBIPATCH - Tier 2; PA; QL aubra (generic for AFIRMELLE) - Tier 1; QL; GE DIVIGEL - Tier 2; PA; QL aubra eq (generic for AFIRMELLE) - Tier 1; QL; GE ELESTRIN - Tier 2; PA aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE ESTRACE (brand for estradiol) - Tier 2; PA; QL aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE estradiol transdermal patch twice weekly (generic for ALORA) - Tier 1; aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE PA; QL aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE aviane (generic for AFIRMELLE) - Tier 1; QL; GE estradiol-norethindrone acet oral tablet 1-0.5 mg (generic for MIMVEY) - ayuna (generic for ALTAVERA) - Tier 1; QL; GE Tier 1; PA; QL azurette (generic for AZURETTE) - Tier 1; QL; GE ESTRING - Tier 2; PA; QL balziva (generic for BALZIVA) - Tier 1; QL; GE ESTROGEL - Tier 2; PA; QL bekyree (generic for AZURETTE) - Tier 1; QL; GE EVAMIST - Tier 2; PA; QL blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG (brand for blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE norethindrone-eth estradiol) - Tier 2; PA; QL briellyn (generic for BALZIVA) - Tier 1; QL; GE FEMRING - Tier 2; PA; QL caziant - Tier 1; QL fyavolv - Tier 1; PA; QL chateal (generic for ALTAVERA) - Tier 1; QL; GE jinteli - Tier 1; PA; QL chateal eq (generic for ALTAVERA) - Tier 1; QL; GE MENEST - Tier 2; PA; QL cryselle-28 - Tier 1; QL; GE mimvey (generic for MIMVEY) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 102 Preferred Agents Non-Preferred Agents cyclafem 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE MINIVELLE (brand for estradiol) - Tier 2; PA; QL cyclafem 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE PREFEST - Tier 2; PA; QL cyred (generic for APRI) - Tier 1; QL; GE PREMARIN VAGINAL - Tier 2; PA; QL cyred eq (generic for APRI) - Tier 1; QL; GE VAGIFEM (brand for estradiol) - Tier 2; PA; QL dasetta 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL dasetta 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE delyla (generic for AFIRMELLE) - Tier 1; QL; GE DEPO-ESTRADIOL - Tier 2; QL desogestrel-ethinyl estradiol (generic for AZURETTE) - Tier 1; QL; GE DUAVEE - Tier 2; QL elinest - Tier 1; QL; GE eluryng (generic for ELURYNG) - Tier 1; QL; GE emoquette (generic for APRI) - Tier 1; QL; GE enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; GE enskyce (generic for APRI) - Tier 1; QL; GE estarylla (generic for ESTARYLLA) - Tier 1; QL; GE estradiol oral (generic for ESTRACE) - Tier 1; QL estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL estradiol vaginal (generic for ESTRACE) - Tier 1; QL ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL; GE etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GE falmina (generic for AFIRMELLE) - Tier 1; QL; GE femynor (generic for ESTARYLLA) - Tier 1; QL; GE hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE iclevia (generic for ICLEVIA) - Tier 1; QL introvale (generic for ICLEVIA) - Tier 1; QL isibloom (generic for APRI) - Tier 1; QL; GE jolessa (generic for ICLEVIA) - Tier 1; QL juleber (generic for APRI) - Tier 1; QL; GE junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE junel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 103 Preferred Agents Non-Preferred Agents junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) - Tier 1; QL; GE kalliga (generic for APRI) - Tier 1; QL; GE kariva (generic for AZURETTE) - Tier 1; QL; GE kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; GE kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; GE kurvelo (generic for ALTAVERA) - Tier 1; QL; GE larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE larissia (generic for AFIRMELLE) - Tier 1; QL; GE leena - Tier 1; QL; GE lessina (generic for AFIRMELLE) - Tier 1; QL; GE levonest (generic for ENPRESSE-28) - Tier 1; QL; GE levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg (generic for ICLEVIA) - Tier 1; QL levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for AFIRMELLE) - Tier 1; QL; GE levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for ALTAVERA) - Tier 1; QL; GE levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL; GE levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; GE lillow (generic for ALTAVERA) - Tier 1; QL; GE low-ogestrel - Tier 1; QL; GE lutera (generic for AFIRMELLE) - Tier 1; QL; GE marlissa (generic for ALTAVERA) - Tier 1; QL; GE MENOSTAR - Tier 2; QL microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE mili (generic for ESTARYLLA) - Tier 1; QL; GE mono-linyah (generic for ESTARYLLA) - Tier 1; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 104 Preferred Agents Non-Preferred Agents necon 0.5/35 (28) - Tier 1; QL; GE norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE 1/20) - Tier 1; QL; GE norethindrone acet-ethinyl est (generic for AUROVELA 1/20) - Tier 1; QL; GE norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; GE norgestimate-ethinyl estradiol triphasic oral tablet 0.18/0.215/0.25 mg- 35 mcg (generic for TRI FEMYNOR) - Tier 1; QL; GE nortrel 0.5/35 (28) - Tier 1; QL; GE nortrel 1/35 (21) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 1/35 (28) (generic for CYCLAFEM 1/35) - Tier 1; QL; GE nortrel 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE nylia 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE nymyo (generic for ESTARYLLA) - Tier 1; QL; GE orsythia (generic for AFIRMELLE) - Tier 1; QL; GE philith (generic for BALZIVA) - Tier 1; QL; GE pimtrea (generic for AZURETTE) - Tier 1; QL; GE pirmella 1/35 (generic for CYCLAFEM 1/35) - Tier 1; QL; GE pirmella 7/7/7 (generic for CYCLAFEM 7/7/7) - Tier 1; QL; GE portia-28 (generic for ALTAVERA) - Tier 1; QL; GE PREMARIN ORAL TABLET 0.3 MG, 0.625 MG, 0.9 MG, 1.25 MG - Tier 2; QL; AL PREMARIN ORAL TABLET 0.45 MG - Tier 2; QL PREMPHASE - Tier 2; QL PREMPRO - Tier 2; QL previfem (generic for ESTARYLLA) - Tier 1; QL; GE reclipsen (generic for APRI) - Tier 1; QL; GE setlakin (generic for ICLEVIA) - Tier 1; QL simliya (generic for AZURETTE) - Tier 1; QL; GE sprintec 28 (generic for ESTARYLLA) - Tier 1; QL; GE sronyx (generic for AFIRMELLE) - Tier 1; QL; GE tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; GE tilia fe - Tier 1; QL; GE tri femynor (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 105 Preferred Agents Non-Preferred Agents tri-legest fe - Tier 1; QL; GE tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-mili (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-nymyo (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-previfem (generic for TRI FEMYNOR) - Tier 1; QL; GE tri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL; GE trivora (28) (generic for ENPRESSE-28) - Tier 1; QL; GE tri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL; GE tyblume - Tier 1; QL; GE velivet - Tier 1; QL vienva (generic for AFIRMELLE) - Tier 1; QL; GE viorele (generic for AZURETTE) - Tier 1; QL; GE volnea (generic for AZURETTE) - Tier 1; QL; GE vyfemla (generic for BALZIVA) - Tier 1; QL; GE vylibra (generic for ESTARYLLA) - Tier 1; QL; GE wera - Tier 1; QL; GE xulane - Tier 1; QL; GE yuvafem (generic for YUVAFEM) - Tier 1; QL zafemy - Tier 1; QL; GE zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL; GE zovia 1/35e (28) (generic for KELNOR 1/35) - Tier 1; QL; GE Progestins - Hormone Replacement/Modifying Drugs aftera (generic for AFTERA) - Tier 1; QL; GE DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL camila (generic for CAMILA) - Tier 1; QL; GE deblitane (generic for CAMILA) - Tier 1; QL; GE econtra ez (generic for AFTERA) - Tier 1; QL; GE econtra one-step (generic for AFTERA) - Tier 1; QL; GE errin (generic for CAMILA) - Tier 1; QL; GE heather (generic for CAMILA) - Tier 1; QL; GE incassia (generic for CAMILA) - Tier 1; QL; GE jencycla (generic for CAMILA) - Tier 1; QL; GE KYLEENA - Tier 2; QL levonorgestrel (generic for AFTERA) - Tier 1; QL; GE LILETTA (52 MG) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 106 Preferred Agents Non-Preferred Agents lyleq (generic for CAMILA) - Tier 1; QL; GE lyza (generic for CAMILA) - Tier 1; QL; GE medroxyprogesterone acetate intramuscular (generic for DEPO- PROVERA) - Tier 1; QL; GE medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1; QL megestrol acetate oral suspension 40 mg/ml - Tier 1; QL megestrol acetate oral tablet - Tier 1; QL MIRENA (52 MG) - Tier 2; QL my choice (generic for AFTERA) - Tier 1; QL; GE my way (generic for AFTERA) - Tier 1; QL; GE new day (generic for AFTERA) - Tier 1; QL; GE NEXPLANON - Tier 2; QL nora-be (generic for CAMILA) - Tier 1; QL; GE norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL norethindrone oral (generic for CAMILA) - Tier 1; QL; GE norlyda (generic for CAMILA) - Tier 1; QL; GE norlyroc (generic for CAMILA) - Tier 1; QL; GE opcicon one-step (generic for AFTERA) - Tier 1; QL; GE option 2 (generic for AFTERA) - Tier 1; QL; GE PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; GE progesterone oral (generic for PROMETRIUM) - Tier 1; DX2RX; QL react (generic for AFTERA) - Tier 1; QL; GE sharobel (generic for CAMILA) - Tier 1; QL; GE SKYLA - Tier 2; QL take action (generic for AFTERA) - Tier 1; QL; GE tulana (generic for CAMILA) - Tier 1; QL; GE Selective Estrogen Receptor Modifying Agents - Hormone Replacement/Modifying Drugs raloxifene hcl (generic for EVISTA) - Tier 1; QL OSPHENA - Tier 2; PA; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 107 Preferred Agents Non-Preferred Agents Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Thyroid Replacement Drugs euthyrox (generic for EUTHYROX) - Tier 1; QL levo-t (generic for EUTHYROX) - Tier 1; QL levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL levoxyl (generic for EUTHYROX) - Tier 1; QL liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL unithroid (generic for EUTHYROX) - Tier 1; QL Hormonal Agents, Suppressant (Adrenal) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Adrenal) - Hormone Suppressants LYSODREN - Tier 2; PA; QL Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones Hormonal Agents, Suppressant (Pituitary) - Hormone Suppressants cabergoline - Tier 1; QL FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL EGRIFTA SV - Tier 2; DX2RX; SP; QL LUPANETA PACK - Tier 2; PA; SP; QL leuprolide acetate injection - Tier 1; PA; SP; QL ORIAHNN - Tier 2; PA; QL LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL SUPPRELIN LA - Tier 2; PA LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL SYNAREL - Tier 2; PA LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2; TRIPTODUR - Tier 2; PA; SP; QL PA; SP; QL ZOLADEX - Tier 2; PA LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2; PA; SP; QL LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL octreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 108 Preferred Agents Non-Preferred Agents ORILISSA - Tier 2; PA; QL SIGNIFOR - Tier 2; PA; SP; QL SOMAVERT - Tier 2; PA; SP; QL Hormonal Agents, Suppressant (Thyroid) - Drugs to Suppress Thyroid Hormones Antithyroid Agents - Thyroid Suppressing Drugs methimazole oral (generic for TAPAZOLE) - Tier 1; QL propylthiouracil oral - Tier 1; QL Immunological Agents Immunomodulators ENSPRYNG - Tier 2; SP; QL Immunological Agents - Drugs that Stimulate or Suppress the Immune System Angioedema Agents - Drugs to Treat Swelling Underneath the Skin HAEGARDA - Tier 2; PA; SP; QL BERINERT - Tier 2; PA; SP; QL icatibant acetate (generic for FIRAZYR) - Tier 1; PA; SP; QL FIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QL RUCONEST - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 109 Preferred Agents Non-Preferred Agents Immune Suppressants - Immune System Drugs AZASAN - Tier 2; QL ORENCIA CLICKJECT - Tier 2; PA; SP; QL azathioprine oral (generic for IMURAN) - Tier 1; QL ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL CIMZIA - Tier 2; PA; SP; QL OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 cyclosporine intravenous (generic for SANDIMMUNE) - Tier 1 MG/0.4ML, 15 MG/0.4ML, 20 MG/0.4ML, 25 MG/0.4ML - Tier 2; PA; QL cyclosporine modified oral capsule 100 mg (generic for GENGRAF) - OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 12.5 Tier 1; QL MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML - Tier 2; PA cyclosporine modified oral capsule 25 mg (generic for GENGRAF) - RASUVO - Tier 2; PA; QL Tier 1 REDITREX - Tier 2; PA; QL cyclosporine modified oral capsule 50 mg - Tier 1; QL SIMPONI - Tier 2; PA; SP; QL cyclosporine modified oral solution (generic for GENGRAF) - Tier 1 SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL STELARA INTRAVENOUS - Tier 2; PA ENBREL - Tier 2; PA; SP; QL STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg (generic for XELJANZ ORAL TABLET - Tier 2; PA; SP; QL ZORTRESS) - Tier 1 XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 11 MG - gengraf oral capsule 100 mg (generic for GENGRAF) - Tier 1; QL Tier 2; PA; SP; QL gengraf oral capsule 25 mg (generic for GENGRAF) - Tier 1 XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR 22 MG - gengraf oral solution (generic for GENGRAF) - Tier 1 Tier 2; PA; QL HUMIRA PEN-PEDIATRIC UC START - Tier 2; PA; SP; QL HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML - Tier 2; PA; SP; QL HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 110 Preferred Agents Non-Preferred Agents KINERET - Tier 2; PA; SP; QL LUPKYNIS - Tier 2; SP; QL methotrexate oral - Tier 1 methotrexate sodium (pf) - Tier 1 methotrexate sodium injection solution - Tier 1 methotrexate sodium oral - Tier 1 mycophenolate mofetil oral capsule (generic for CELLCEPT) - Tier 1; QL mycophenolate mofetil oral suspension reconstituted (generic for CELLCEPT) - Tier 1; QL mycophenolate mofetil oral tablet (generic for CELLCEPT) - Tier 1 mycophenolate sodium (generic for MYFORTIC) - Tier 1; QL OLUMIANT - Tier 2; PA; SP; QL SANDIMMUNE ORAL SOLUTION - Tier 2 sirolimus oral solution (generic for RAPAMUNE) - Tier 1 sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1; QL sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1 tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1 tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QL ZORTRESS ORAL TABLET 1 MG - Tier 2 Immunomodulators - Immune System Drugs ILARIS - Tier 2; PA; SP; QL ACTEMRA ACTPEN - Tier 2; PA; SP; QL KEVZARA - Tier 2; PA; SP; QL ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL leflunomide oral (generic for ARAVA) - Tier 1; QL RINVOQ - Tier 2; PA; SP; QL OTEZLA - Tier 2; PA; SP; QL SYNAGIS - Tier 2; SP; QL XOLAIR - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 111 Preferred Agents Non-Preferred Agents Vaccines ADACEL - Tier 2; QL ASTRAZENECA COVID-19 VACCINE - Tier 2; QL BEXSERO - Tier 2; QL BOOSTRIX - Tier 2; QL DAPTACEL - Tier 2; QL DIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; QL ENGERIX-B - Tier 2; QL GARDASIL 9 - Tier 2; QL HAVRIX - Tier 2; QL HEPLISAV-B - Tier 2; QL; AL HYPERTET S/D - Tier 2; QL INFANRIX - Tier 2; QL JANSSEN COVID-19 VACCINE - Tier 2; QL MENACTRA - Tier 2; QL MENQUADFI - Tier 2; QL MENVEO - Tier 2; QL M-M-R II - Tier 2; QL PNEUMOVAX 23 - Tier 2; QL PREVNAR 13 - Tier 2; QL RECOMBIVAX HB - Tier 2; QL SHINGRIX - Tier 2; QL; AL TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL TENIVAC - Tier 2; QL TETANUS-DIPHTHERIA TOXOIDS TD - Tier 2; QL TRUMENBA - Tier 2; QL TWINRIX - Tier 2; QL VAQTA - Tier 2; QL VARIVAX - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 112 Preferred Agents Non-Preferred Agents Inflammatory Bowel Disease Agents - Drugs to Treat Inflammatory Bowel Disease Aminosalicylates - Inflammatory Bowel Disease Drugs balsalazide disodium (generic for COLAZAL) - Tier 1; QL APRISO (brand for mesalamine er) - Tier 2; PA; QL mesalamine oral capsule delayed release 400 mg (generic for ASACOL HD (brand for mesalamine) - Tier 2; PA; QL DELZICOL) - Tier 1; QL COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL mesalamine rectal - Tier 1; QL DELZICOL (brand for mesalamine) - Tier 2; PA; QL SFROWASA - Tier 2; QL DIPENTUM - Tier 2; PA; QL LIALDA (brand for mesalamine) - Tier 2; PA; QL PENTASA - Tier 2; PA; QL Glucocorticoids - Drugs to Treat Inflammation budesonide oral (generic for ENTOCORT EC) - Tier 1; DX2RX; QL CORTIFOAM - Tier 2; PA; QL hydrocortisone (perianal) external cream 2.5 % (generic for PROCTO- PROCTOFOAM HC - Tier 2; PA MED HC) - Tier 1; QL hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA) - Tier 1 procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL Sulfonamides - Antibiotics sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL; AL Metabolic Bone Disease Agents - Drugs to Treat Bone Conditions Metabolic Bone Disease Agents - Osteoporosis (Bone Loss) Drugs alendronate sodium - Tier 1; QL TERIPARATIDE (RECOMBINANT) - Tier 2; PA; SP; QL calcitonin (salmon) nasal (generic for MIACALCIN) - Tier 1; QL cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL TYMLOS - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 113 Preferred Agents Non-Preferred Agents Metabolic Bone Disease Agents - Other calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL calcitriol oral solution (generic for ROCALTROL) - Tier 1; Members >= 8 years of age will require PA; QL; AL Miscellaneous Therapeutic Agents ACCU-CHEK AVIVA DEVICE (brand for glucose control) - Tier 2; QL ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for goodsense blood ACCU-CHEK COMPACT PLUS CONTROL (brand for glucose control) glucose) - Tier 2; PA; QL - Tier 2; QL ACCU-CHEK COMPACT PLUS (brand for goodsense blood glucose) - ACCU-CHEK GUIDE CONTROL (brand for glucose control) - Tier 2; Tier 2; PA; QL QL ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite ACCU-CHEK MULTICLIX LANCETS (brand for preferred plus lancets device/lancets) - Tier 2; PA; QL thin) - Tier 2; QL ACCU-CHEK GUIDE TEST STRIPS (brand for kroger blood glucose) - ACCU-CHEK SMARTVIEW CONTROL (brand for glucose control) - Tier 2; PA; QL Tier 2; QL ACCU-CHEK MULTICLIX LANCETS (brand for preferred plus lancets ACCUTREND GLUCOSE CONTROL (brand for glucose control) - Tier thin) - Tier 2; PA; QL 2; QL ACCU-CHEK SMARTVIEW (brand for goodsense blood glucose) - Tier 2; PA; QL ACE AEROSOL CLOUD ENHANCER (brand for pillow mask/pediatric) ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite - Tier 2; QL device/lancets) - Tier 2; PA; QL ADULT AEROSOL MASK - Tier 2; QL AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; AERIVA CONCENTRATOR NEBULIZER - Tier 2; QL PA; QL ALCOHOL PREP PADS PAD , 70 % - Tier 2; QL CONTOUR NEXT TEST STRIPS (brand for goodsense blood glucose) - antifungal external powder (generic for DESENEX) - Tier 1; QL Tier 2; PA; QL athletes foot external powder 2 % (generic for DESENEX) - Tier 1; QL CONTOUR TEST STRIPS (brand for goodsense blood glucose) - Tier 2; AXONA (brand for pro-critic) - Tier 2 PA; QL BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier DYSPORT - Tier 2; PA 2; QL FREESTYLE PRECISION NEO TEST (brand for goodsense blood BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL glucose) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 114 Preferred Agents Non-Preferred Agents BD ULTRA-FINE PEN NEEDLES (brand for 1st tier unifine pentips) - INSULIN PEN NEEDLES 32G X 6 MM (brand for 1st tier unifine pentips) - Tier 2; QL Tier 2; PA; QL BREATHE EASE HUMIDIFIER - Tier 2; QL MYOBLOC - Tier 2; PA BREATHE EASE NEB MASK/CHILD - Tier 2; QL NOVOTWIST PEN NEEDLE (brand for pro comfort pen needles) - Tier 2; BREATHE EASE NEB MASK/INFANT - Tier 2; QL PA; QL BUBBLES THE FISH II PEDI MASK (brand for pillow mask/pediatric) - ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for kroger Tier 2; QL blood glucose) - Tier 2; PA; QL CARETOUCH 2 CPAP HOSE HANGER (brand for pillow ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for kroger blood mask/pediatric) - Tier 2; QL glucose) - Tier 2; PA; QL CARETOUCH CONTROL SOL LEVEL 2 (brand for glucose control) - PRECISION LINK (brand for kroger blood glucose) - Tier 2; PA; QL Tier 2; QL PRECISION PCX PLUS TEST (brand for goodsense blood glucose) - Tier 2; PA; QL CARETOUCH CPAP & BIPAP HOSE (brand for pillow mask/pediatric) PRECISION POINT OF CARE TEST (brand for goodsense blood - Tier 2; QL glucose) - Tier 2; PA; QL CARETOUCH CPAP MASK WIPES (brand for pillow mask/pediatric) - PRECISION QID MONITOR (brand for diatrue plus blood glucose) - Tier Tier 2; QL 2; PA; QL CARETOUCH CPAP PRE-WASH SOLN (brand for pillow PRECISION QID TEST (brand for goodsense blood glucose) - Tier 2; PA; mask/pediatric) - Tier 2; QL QL CARETOUCH CPAP TUBE BRUSH (brand for pillow mask/pediatric) - PRECISION SOF-TACT MONITOR (brand for diatrue plus blood glucose) Tier 2; QL - Tier 2; PA; QL CARETOUCH UNIVERSL CPAP FILTER (brand for pillow PRECISION XTRA BLOOD GLUCOSE (brand for goodsense blood mask/pediatric) - Tier 2; QL glucose) - Tier 2; PA; QL CAYA - Tier 2; QL PRECISION XTRA DEVICE (brand for diatrue plus blood glucose) - Tier CHEMSTRIP 10 MD - Tier 2 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 115 Preferred Agents Non-Preferred Agents CHEMSTRIP 10/SG - Tier 2 PRECISION XTRA MONITOR (brand for diatrue plus blood glucose) - CHEMSTRIP 2 GP - Tier 2 Tier 2; PA; QL CHEMSTRIP 5 OB - Tier 2 TRUETRACK TEST (brand for goodsense blood glucose) - Tier 2; PA; QL CHEMSTRIP 7 - Tier 2 CHEMSTRIP 9 - Tier 2 CHEMSTRIP K (brand for ketone test) - Tier 2; QL CHEMSTRIP UGK - Tier 2; QL COMFORT TOUCH ALCOHOL PREP (brand for alcohol prep) - Tier 2; QL COMPRESSOR NEBULIZER - Tier 2; QL CONDOMS - Tier 2; QL COOL MIST HUMIDIFER - Tier 2; QL DESENEX EXTERNAL POWDER (brand for athletes foot) - Tier 2; QL EASIVENT (brand for breathe ease large) - Tier 2; QL EASIVENT MASK LARGE (brand for breathe ease large) - Tier 2; QL EASIVENT MASK MEDIUM (brand for breathe ease large) - Tier 2; QL EASIVENT MASK SMALL (brand for breathe ease large) - Tier 2; QL EASYMAX 15 LEVEL 2 CONTROL (brand for glucose control) - Tier 2; QL EASYMAX 15 LEVEL 2-3 CONTROL (brand for glucose control) - Tier 2; QL GLUCOSE CONTROL SOLUTIONS (brand for glucose control) - Tier 2; QL EBASE CONTROLLER KIT (brand for pillow mask/pediatric) - Tier 2; QL FILTER AIR PP - Tier 2; QL GELFOAM SPONGE - Tier 2 GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION (brand for glucose control) - Tier 2; QL INSPIREASE (brand for breathe ease large) - Tier 2; QL INSPIREASE RESERVOIR BAGS - Tier 2; QL INSULIN PEN NEEDLES 29G X 12.7MM , 30G X 8 MM (brand for sure comfort pen needles) - Tier 2; QL INSULIN PEN NEEDLES 29G X 12MM , 31G X 5 MM , 31G X 6 MM , 31G X 8 MM - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 116 Preferred Agents Non-Preferred Agents INSULIN PEN NEEDLES 32G X 4 MM (brand for freds pharmacy unifine pentips) - Tier 2; QL INSULIN SYRINGES 27G X 1/2" 1 ML (brand for insulin syringe) - Tier 2; QL INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (brand for reality insulin syringe) - Tier 2; QL INSULIN SYRINGES 28G X 5/16" 1 ML, 29G X 5/16" 1 ML, 30G X 3/8" 0.5 ML - Tier 2; QL INSULIN SYRINGES 29G X 1/2" 0.3 ML (brand for topcare ultra comfort ins syr) - Tier 2; QL INSULIN SYRINGES 29G X 1/2" 0.5 ML, 31G X 5/16" 0.3 ML (brand for ultra-comfort insulin syringe) - Tier 2; QL INSULIN SYRINGES 29G X 1/2" 1 ML, 31G X 5/16" 0.5 ML (brand for gnp insulin syringe) - Tier 2; QL INSULIN SYRINGES 30G X 1/2" 0.3 ML, 31G X 15/64" 0.3 ML (brand for techlite insulin syringe) - Tier 2; QL INSULIN SYRINGES 30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML (brand for sure comfort insulin syringe) - Tier 2; QL INSULIN SYRINGES 30G X 5/16" 0.3 ML (brand for kroger insulin syringe) - Tier 2; QL INSULIN SYRINGES 30G X 5/16" 0.5 ML (brand for preferred plus insulin syringe) - Tier 2; QL INSULIN SYRINGES 30G X 5/16" 1 ML, 31G X 5/16" 1 ML (brand for healthwise insulin syr/needle) - Tier 2; QL INSULIN SYRINGES 31G X 15/64" 0.5 ML (brand for global easy glide insulin syr) - Tier 2; QL KETO-DIASTIX - Tier 2; QL KETONE CARE - Tier 2; QL KETONE TEST - Tier 2; QL KETOSTIX (brand for ketone test) - Tier 2; QL LANCETS (brand for preferred plus lancets thin) - Tier 2; QL LOTRIMIN AF EXTERNAL POWDER (brand for athletes foot) - Tier 2; QL MASK VORTEX/CHILD/FROG - Tier 2; QL MASK VORTEX/TODDLER/LADYBUG - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 117 Preferred Agents Non-Preferred Agents MEDISENSE GLUCOSE KETONE CONTR (brand for glucose control) - Tier 2; QL MEDISENSE HI/MID/LOW CONTROL (brand for glucose control) - Tier 2; QL MEDISENSE HIGH/LOW CONTROL (brand for glucose control) - Tier 2; QL MEDISENSE MID CONTROL (brand for glucose control) - Tier 2; QL methergine (generic for METHERGINE) - Tier 1; QL methylergonovine maleate oral (generic for METHERGINE) - Tier 1; QL miconazorb af (generic for DESENEX) - Tier 1; QL MICRODOT PEN NEEDLE 31G X 6 MM (brand for true comfort pro pen needles) - Tier 2; QL MICRODOT PEN NEEDLE 32G X 4 MM (brand for freds pharmacy unifine pentips) - Tier 2; QL MINI COMPRESSOR (brand for elite compressor nebulizer) - Tier 2; QL MYCOZYL AP (brand for athletes foot) - Tier 2; QL NEODOT THERMOMETER - Tier 2; QL NEUTEK 2TEK CONTROL (brand for glucose control) - Tier 2; QL OMNIFLEX DIAPHRAGM - Tier 2; QL; GE ONETOUCH ULTRA (brand for goodsense blood glucose) - Tier 2; QL for non-insulin dependent members: allow twice daily testing; QL ONETOUCH ULTRA 2 KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; QL ONETOUCH ULTRA CONTROL (brand for glucose control) - Tier 2; QL ONETOUCH ULTRA MINI KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; QL ONETOUCH VERIO KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; QL ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; QL ONETOUCH VERIO IN VITRO SOLUTION (brand for glucose control) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 118 Preferred Agents Non-Preferred Agents ONETOUCH VERIO TEST STRIPS (brand for goodsense blood glucose) - Tier 2; QL for non-insulin dependent members: allow twice daily testing; QL ONETOUCH VERIO IQ SYSTEM (brand for kroger blood glucose) - Tier 2; QL ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for kroger blood glucose) - Tier 2; QL ONETOUCH VERIO SYNC SYSTEM (brand for kroger blood glucose) - Tier 2; QL PARAGARD INTRAUTERINE COPPER - Tier 2; QL PARI ALTERA NEBULIZER HANDSET (brand for pillow mask/pediatric) - Tier 2; QL PARI ALTERA NEBULIZER SYSTEM (brand for elite compressor nebulizer) - Tier 2; QL PARI BABY CONVERSION KIT (brand for pillow mask/pediatric) - Tier 2; QL PARI ERAPID NEBULIZER HANDSET (brand for pillow mask/pediatric) - Tier 2; QL PARI ERAPID NEBULIZER SYSTEM (brand for elite compressor nebulizer) - Tier 2; QL PARI LC PLUS NEB SET PED MASK (brand for elite compressor nebulizer) - Tier 2; QL PARI LC PLUS NEBULIZER (brand for elite compressor nebulizer) - Tier 2; QL PARI LC PLUS VIOS PRO NEB (brand for elite compressor nebulizer) - Tier 2; QL PARI LC SPRINT NEBULIZER SET (brand for elite compressor nebulizer) - Tier 2; QL PARI SINUS AEROSOL SYSTEM (brand for elite compressor nebulizer) - Tier 2; QL PARI TREK S W/12V DC ADAPTOR (brand for elite compressor nebulizer) - Tier 2; QL PARI VIOS PRO LC PLUS SYSTEM (brand for elite compressor nebulizer) - Tier 2; QL PARI VIOS PRO LC SPRINT SYSTEM (brand for elite compressor nebulizer) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 119 Preferred Agents Non-Preferred Agents PARI VORTEX ADULT MASK (brand for pillow mask/pediatric) - Tier 2; QL PEDIATRIC COMPRESSOR NEBULIZER - Tier 2; QL PRECISION GLUCOSE CONTROL (brand for glucose control) - Tier 2; QL PRECISION GLUCOSE CONTROL SOLN (brand for glucose control) - Tier 2; QL PRECISION GLUCOSE KETONE CONTR (brand for glucose control) - Tier 2; QL PRECISION GLUCOSE/KETONE CONTR (brand for glucose control) - Tier 2; QL PREMIUM CONDOMS LUBRICATED - Tier 2; QL PRO-CRITIC - Tier 2 PRONEB ULTRA FILTER SET (brand for pillow mask/pediatric) - Tier 2; QL QUINTET CONTROL HIGH/NORMAL (brand for glucose control) - Tier 2; QL REPLACEMENT FILTERS - Tier 2; QL RUZURGI - Tier 2; PA; SP; QL SOLARTEK GLUCOSE CONTROL (brand for glucose control) - Tier 2; QL TRUECONTROL GLUCOSE CONT LEV 0 (brand for glucose control) - Tier 2; QL TRUECONTROL GLUCOSE CONT LEV 1 (brand for glucose control) - Tier 2; QL TUBING/WING TIP - Tier 2; QL VAPORIZER WARM STEAM - Tier 2; QL VIOS AEROSOL DELIVERY SYSTEM (brand for elite compressor nebulizer) - Tier 2; QL VIOS LC PLUS (brand for elite compressor nebulizer) - Tier 2; QL VIOS LC PLUS DELUXE (brand for elite compressor nebulizer) - Tier 2; QL VIOS LC PLUS PEDIATRIC (brand for elite compressor nebulizer) - Tier 2; QL VIOS LC SPRINT (brand for elite compressor nebulizer) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 120 Preferred Agents Non-Preferred Agents VIOS LC SPRINT PEDIATRIC (brand for elite compressor nebulizer) - Tier 2; QL VISTOGARD - Tier 2; QL WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL WIDE-SEAL DIAPHRAGM 65 - Tier 2; QL WIDE-SEAL DIAPHRAGM 70 - Tier 2; QL WIDE-SEAL DIAPHRAGM 75 - Tier 2; QL WIDE-SEAL DIAPHRAGM 80 - Tier 2; QL WIDE-SEAL DIAPHRAGM 85 - Tier 2; QL WIDE-SEAL DIAPHRAGM 90 - Tier 2; QL WIDE-SEAL DIAPHRAGM 95 - Tier 2; QL ZEASORB-AF (brand for athletes foot) - Tier 2; QL Ophthalmic Agents - Drugs to Treat Eye Conditions Ophthalmic Agents, Other - Miscellaneous Eye Drugs ak-poly-bac (generic for POLYCIN) - Tier 1 CEQUA - Tier 2; PA; QL ALTACAINE (brand for tetracaine hcl) - Tier 2 RESTASIS - Tier 2; PA; QL altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1 RESTASIS MULTIDOSE - Tier 2; PA; QL altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL TOBRADEX ST - Tier 2; PA; QL altafrin (generic for ALTAFRIN) - Tier 1 ZYLET - Tier 2; PA; QL altalube (generic for ALTALUBE) - Tier 1; QL artificial eye (generic for ALTALUBE) - Tier 1; QL artificial tears ophthalmic ointment (generic for ALTALUBE) - Tier 1; QL artificial tears ophthalmic solution (generic for GENTEAL TEARS) - Tier 1 artificial tears ophthalmic solution 1.4 % - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 121 Preferred Agents Non-Preferred Agents astringent eye drops (generic for VISINE-AC) - Tier 1; QL atropine sulfate ophthalmic ointment - Tier 1 atropine sulfate ophthalmic solution 1 % (generic for ISOPTO ATROPINE) - Tier 1; QL bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1 bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1; QL BIOLLE TEARS (brand for lubricant eye drops pf) - Tier 2 carboxymethylcellulose sodium ophthalmic (generic for ULTRA FRESH) - Tier 1; QL cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) - Tier 1; QL CYSTARAN - Tier 2; DX2RX; SP; QL dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL eye drops advanced relief (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye drops allergy relief (generic for VISINE-AC) - Tier 1; QL eye drops long lasting (generic for SYSTANE) - Tier 1; QL eye drops ophthalmic solution 0.05-0.1-1-1 % (generic for VISINE ADVANCED RELIEF) - Tier 1; QL eye lubricant (generic for ALTALUBE) - Tier 1; QL for sty relief (generic for ALTALUBE) - Tier 1; QL GENTEAL SEVERE - Tier 2; QL GENTEAL TEARS (brand for sm artificial tears) - Tier 2 GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) - Tier 2 GENTEAL TEARS NIGHT-TIME (brand for artificial eye) - Tier 2; QL GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2 GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; QL HYPOTEARS (brand for artificial eye) - Tier 2; QL ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; QL lubricant drops fast act (generic for SYSTANE) - Tier 1; QL lubricant drops long last (generic for SYSTANE) - Tier 1; QL lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; QL lubricant drops ophthalmic solution (generic for SYSTANE COMPLETE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 122 Preferred Agents Non-Preferred Agents lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for SYSTANE HYDRATION PF) - Tier 1; QL lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE TEARS) - Tier 1 lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA FRESH) - Tier 1; QL lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE COMPLETE) - Tier 1; QL lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1 lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricant eye pm (generic for ALTALUBE) - Tier 1; QL lubricant pm (generic for ALTALUBE) - Tier 1; QL lubricating eye drop (generic for BIOLLE TEARS) - Tier 1 lubricating eye drops ophthalmic solution 0.4-0.3 % (generic for SYSTANE) - Tier 1; QL lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL lubricating plus (generic for BIOLLE TEARS) - Tier 1 lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1 lubricating tears (generic for SYSTANE) - Tier 1; QL lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1 MURO 128 OPHTHALMIC OINTMENT (brand for cvs sodium chloride) - Tier 2 MURO 128 OPHTHALMIC SOLUTION 5 % (brand for sodium chloride (hypertonic)) - Tier 2; QL natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier 1 neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1 neomycin-polymyxin-dexameth ophthalmic ointment (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1 (generic for MAXITROL) - Tier 1; QL neomycin-polymyxin-gramicidin - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 123 Preferred Agents Non-Preferred Agents neo-polycin (generic for NEO-POLYCIN) - Tier 1 neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1 polycin (generic for POLYCIN) - Tier 1 polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1; QL polyvinyl alcohol ophthalmic - Tier 1 PRED-G S.O.P. - Tier 2 PURALUBE (brand for artificial eye) - Tier 2; QL pure & gentle lubricant - Tier 1 REFRESH LACRI-LUBE (brand for artificial eye) - Tier 2; QL REFRESH P.M. (brand for artificial eye) - Tier 2; QL REFRESH PLUS (brand for lubricant eye drops pf) - Tier 2 REFRESH TEARS (brand for lubricant eye drops) - Tier 2; QL relief eye drops (generic for VISINE-AC) - Tier 1; QL restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1 restore pm (generic for ALTALUBE) - Tier 1; QL sodium chloride (hypertonic) ophthalmic ointment (generic for ALTACHLORE) - Tier 1 sodium chloride (hypertonic) ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE) - Tier 1 sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) - Tier 1; QL sulfacetamide-prednisolone ophthalmic solution - Tier 1 SYSTANE (brand for cvs lubricant eye drops) - Tier 2; QL SYSTANE COMPLETE (brand for cvs lubricant drops) - Tier 2; QL SYSTANE CONTACTS (brand for sm artificial tears) - Tier 2 SYSTANE HYDRATION PF (brand for goodsense lubricant eye drops) - Tier 2; QL SYSTANE NIGHTTIME (brand for artificial eye) - Tier 2; QL SYSTANE OVERNIGHT THERAPY - Tier 2; QL SYSTANE PRESERVATIVE FREE (brand for goodsense lubricant eye drops) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 124 Preferred Agents Non-Preferred Agents SYSTANE ULTRA (brand for cvs lubricant eye drops) - Tier 2; QL SYSTANE ULTRA PF (brand for goodsense lubricant eye drops) - Tier 2; QL TEARS AGAIN (brand for artificial eye) - Tier 2; QL TEARS AGAIN ADVANCED EYELID OPHTHALMIC (brand for sm artificial tears) - Tier 2 tears pure (generic for GENTEAL TEARS) - Tier 1 tetracaine hcl ophthalmic (generic for ALTACAINE) - Tier 1 TOBRADEX OPHTHALMIC OINTMENT - Tier 2; QL tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1 ultra fresh (generic for ULTRA FRESH) - Tier 1; QL ultra fresh pm (generic for ALTALUBE) - Tier 1; QL ultra lubricant drop (generic for SYSTANE) - Tier 1; QL ultra lubricating eye drops (generic for SYSTANE) - Tier 1; QL VISINE ADVANCED RELIEF (brand for eye drops advanced relief) - Tier 2; QL VISTA GEL DRY EYE RELIEF - Tier 2; QL VISTA MEIBO TEARS (brand for cvs lubricant drops) - Tier 2; QL VISTA TEARS (brand for cvs lubricant eye drops) - Tier 2; QL XIIDRA - Tier 2; PA; QL Ophthalmic Anti-allergy Agents - Allergy, Infection and Inflammation Drugs azelastine hcl ophthalmic - Tier 1; ST cromolyn sodium ophthalmic - Tier 1; QL eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE COMFORT) - Tier 1 NAPHCON-A (brand for allergy eye) - Tier 2 olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; QL PATADAY OPHTHALMIC SOLUTION 0.1 % (brand for eye allergy itch/redness rel) - Tier 2; QL PATADAY OPHTHALMIC SOLUTION 0.2 % (brand for olopatadine hcl) - Tier 2; QL redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR EYES REDNESS RELIEF) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 125 Preferred Agents Non-Preferred Agents VASOCLEAR-A - Tier 2; QL VISINE (brand for allergy eye) - Tier 2 Ophthalmic Antibiotics - Drugs to treat Eye Infections bacitracin ophthalmic - Tier 1; QL AZASITE - Tier 2; PA; QL ciprofloxacin hcl ophthalmic (generic for CILOXAN) - Tier 1; QL BESIVANCE - Tier 2; PA; QL erythromycin ophthalmic - Tier 1; QL CILOXAN (brand for ciprofloxacin hcl) - Tier 2; PA; QL gentak - Tier 1; QL ZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL gentamicin sulfate ophthalmic - Tier 1; QL ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL tobramycin ophthalmic (generic for TOBREX) - Tier 1; QL Ophthalmic Antiglaucoma Agents - Glaucoma Drugs acetazolamide er - Tier 1; QL ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL acetazolamide oral - Tier 1; QL AZOPT (brand for brinzolamide) - Tier 2; PA; QL apraclonidine hcl - Tier 1; QL BETIMOL - Tier 2; PA; QL betaxolol hcl ophthalmic - Tier 1; QL BETOPTIC-S - Tier 2; PA; QL brimonidine tartrate ophthalmic - Tier 1; QL COMBIGAN - Tier 2; PA; QL carteolol hcl - Tier 1; QL COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA; QL dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier ISTALOL (brand for timolol maleate) - Tier 2; PA; QL 1; QL SIMBRINZA - Tier 2; PA; QL dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL levobunolol hcl - Tier 1; QL TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL PHOSPHOLINE IODIDE - Tier 2 TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL pilocarpine hcl ophthalmic (generic for ISOPTO CARPINE) - Tier 1; QL timolol maleate ophthalmic solution (generic for TIMOPTIC) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 126 Preferred Agents Non-Preferred Agents Ophthalmic Anti-Inflammatories - Allergy, Infection and Inflammation Drugs ALAWAY (brand for ketotifen fumarate) - Tier 2; QL ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA ALAWAY CHILDRENS ALLERGY (brand for ketotifen fumarate) - Tier ACUVAIL - Tier 2; PA; QL 2; QL ILEVRO - Tier 2; PA; QL allergy eye drops (generic for ALAWAY) - Tier 1; QL NEVANAC - Tier 2; PA; QL CLARITIN EYE (brand for ketotifen fumarate) - Tier 2; QL PROLENSA - Tier 2; PA; QL dexamethasone sodium phosphate ophthalmic - Tier 1 diclofenac sodium ophthalmic - Tier 1; QL eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) - Tier 1; QL fluorometholone (generic for FML LIQUIFILM) - Tier 1 flurbiprofen sodium - Tier 1; QL ketorolac tromethamine ophthalmic solution 0.4 % (generic for ACULAR LS) - Tier 1 ketorolac tromethamine ophthalmic solution 0.5 % (generic for ACULAR) - Tier 1; QL ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1; QL prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1; QL prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL prednisolone sodium phosphate ophthalmic - Tier 1 ZADITOR (brand for ketotifen fumarate) - Tier 2; QL Ophthalmic Prostaglandin and Prostamide Analogs - Glaucoma Drugs latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QL TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QL XALATAN (brand for latanoprost) - Tier 2; PA; QL ZIOPTAN - Tier 2; PA; QL Otic Agents - Drugs to Treat Ear Conditions ofloxacin otic - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 127 Preferred Agents Non-Preferred Agents Otic Agents - Drugs for the Ear acetic acid otic - Tier 1; QL ciprofloxacin-dexamethasone (generic for CIPRODEX) - Tier 1; DX2RX; QL CLEARCANAL EARWAX SOFTENER (brand for qc ear wax removal) - Tier 2 ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear drops earwax aid (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 ear wax removal system (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 earwax removal kit otic solution 6.5 % (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1 hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1 neomycin-polymyxin-hc otic - Tier 1; QL Regulators - Drugs to Regulate Blood Sugar Insulins - Diabetic Drugs LYUMJEV - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 128 Preferred Agents Non-Preferred Agents Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions Antihistamines - Allergy Drugs allergy oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL allergy relief oral tablet extended release 12 mg (generic for CHLOR- TRIMETON ALLERGY) - Tier 1; QL chlorpheniramine maleate er (generic for CHLOR-TRIMETON ALLERGY) - Tier 1; QL CHLOR-TRIMETON ALLERGY (brand for cvs allergy relief) - Tier 2; QL CHLOR-TRIMETON ORAL SYRUP (brand for ed chlorped jr) - Tier 2; QL ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1; QL Antihistamines - Drugs to Treat Allergies ALAVERT (brand for allergy relief) - Tier 2; QL all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1; QL allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1; QL allergy antihistamine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy medication (generic for BANOPHEN) - Tier 1; QL allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 129 Preferred Agents Non-Preferred Agents allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL allergy rel child (loratadine) (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1; QL allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER- TEC) - Tier 1; QL aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL anti-hist allergy (generic for BANOPHEN) - Tier 1; QL aurodryl allergy childrens (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL azelastine hcl nasal solution 137 mcg/spray - Tier 1; QL azelastine hcl solution 0.1 % nasal - Tier 1; QL banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 130 Preferred Agents Non-Preferred Agents banophen oral tablet (generic for BANOPHEN) - Tier 1; QL BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for gnp allergy antihistamine) - Tier 2; QL BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE (brand for diphenhydramine hcl) - Tier 2; QL BENADRYL ALLERGY ORAL TABLET (brand for qc allergy relief) - Tier 2; QL cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS) - Tier 1; QL cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1; QL childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL CLARITIN ALLERGY CHILDRENS (brand for gnp loratadine childrens) - Tier 2; QL CLARITIN ORAL TABLET (brand for qc loratadine allergy relief) - Tier 2; QL CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand for allergy relief) - Tier 2; QL clemastine fumarate oral syrup - Tier 1; QL clemastine fumarate oral tablet 2.68 mg - Tier 1; QL complete allergy (generic for BANOPHEN) - Tier 1; QL complete allergy medicine oral capsule (generic for BANOPHEN) - Tier 1; QL complete allergy relief (generic for BANOPHEN) - Tier 1; QL cyproheptadine hcl oral - Tier 1; QL DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine fumarate) - Tier 2; QL diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphen - Tier 1; QL di-phen - Tier 1; QL diphenhist (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 131 Preferred Agents Non-Preferred Agents diphenhydramine hcl oral elixir - Tier 1; QL diphenhydramine hcl oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; QL diphenhydramine hcl oral tablet chewable (generic for BENADRYL ALLERGY CHILDRENS) - Tier 1; QL dye-free allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL geri-dryl (generic for BANOPHEN) - Tier 1; QL h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL hydroxyzine pamoate oral - Tier 1; QL indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; QL levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY 24HR) - Tier 1; QL liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL loradamed (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine allergy relief oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL loratadine childrens oral solution 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine childrens oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine oral syrup 5 mg/5ml (generic for CLARITIN ALLERGY CHILDRENS) - Tier 1; QL loratadine oral tablet (generic for KLS ALLERCLEAR) - Tier 1; QL loratadine oral tablet dispersible 10 mg (generic for ALAVERT) - Tier 1; QL m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL mm cetirizine hcl (generic for KLS ALLER-TEC) - Tier 1; QL NARAMIN (brand for gnp allergy antihistamine) - Tier 2; QL pharbedryl (generic for BANOPHEN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 132 Preferred Agents Non-Preferred Agents promethazine hcl injection solution 25 mg/ml (generic for PHENERGAN) - Tier 1; QL promethazine hcl oral - Tier 1; QL promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL promethegan - Tier 1; QL sb allergy medicine oral tablet (generic for BANOPHEN) - Tier 1; QL siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL total allergy (generic for BANOPHEN) - Tier 1; QL total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL TRIAMINIC ALLERCHEWS (brand for allergy relief) - Tier 2; QL ZYRTEC ALLERGY ORAL TABLET (brand for sm all day allergy) - Tier 2; QL Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung Drugs 24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; QL ALVESCO - Tier 2; PA; QL aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL ASMANEX (120 METERED DOSES) - Tier 2; PA; QL allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) - ASMANEX (14 METERED DOSES) - Tier 2; PA; QL Tier 1; QL ASMANEX (30 METERED DOSES) - Tier 2; PA; QL ARNUITY ELLIPTA - Tier 2; QL ASMANEX (60 METERED DOSES) - Tier 2; PA; QL ASMANEX HFA INHALATION AEROSOL 100 MCG/ACT, 200 ASMANEX (7 METERED DOSES) - Tier 2; PA; QL MCG/ACT - Tier 2; Members >= 8 years of age will require PA; QL; AL ASMANEX HFA INHALATION AEROSOL 50 MCG/ACT - Tier 2; PA; budesonide inhalation (generic for PULMICORT) - Tier 1; Members >= Members >= 8 years of age will require PA; QL; AL 5 years of age will require PA; QL; AL FLOVENT DISKUS - Tier 2; PA; QL FLOVENT HFA - Tier 2; QL; AL OMNARIS - Tier 2; PA; QL fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL PULMICORT FLEXHALER - Tier 2; PA; QL ZETONNA - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 133 Preferred Agents Non-Preferred Agents NASACORT ALLERGY 24HR (brand for nasal allergy 24 hour) - Tier 2; QL NASACORT ALLERGY 24HR CHILDREN (brand for nasal allergy 24 hour) - Tier 2; QL nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; QL nasal allergy nasal aerosol 55 mcg/act (generic for KLS ALLER- CORT) - Tier 1; QL nasal allergy spray (generic for KLS ALLER-CORT) - Tier 1; QL QVAR REDIHALER - Tier 2; QL Antileukotrienes - Asthma/Lung Drugs montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL Bronchodilators, Anticholinergic - Asthma/Lung Drugs ATROVENT HFA - Tier 2; QL SEEBRI NEOHALER - Tier 2; PA; QL INCRUSE ELLIPTA - Tier 2; QL SPIRIVA HANDIHALER - Tier 2; PA; QL ipratropium bromide inhalation - Tier 1; QL SPIRIVA RESPIMAT - Tier 2; PA; QL ipratropium bromide nasal - Tier 1; QL TUDORZA PRESSAIR - Tier 2; PA; QL Bronchodilators, Sympathomimetic - Asthma/Lung Drugs albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation AUVI-Q (brand for epinephrine) - Tier 2; PA; QL (generic for PROAIR HFA) - Tier 1; QL BROVANA - Tier 2; PA; QL ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL MCG/ACT INHALATION - Tier 2; QL EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, PERFOROMIST - Tier 2; PA; QL 2.5 mg/0.5ml - Tier 1; QL PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25 PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL mg/3ml - Tier 1; Members >= 8 years of age will require PA; QL; AL SEREVENT DISKUS - Tier 2; PA; QL ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5% VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL INHALATION - Tier 2; QL XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 134 Preferred Agents Non-Preferred Agents albuterol sulfate oral syrup - Tier 1; QL epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier 1; QL levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; ST; QL STRIVERDI RESPIMAT - Tier 2; QL SYMJEPI - Tier 2; QL Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis CAYSTON - Tier 2; DX2RX; SP; QL BETHKIS (brand for tobramycin) - Tier 2; DX2RX; SP; QL KALYDECO - Tier 2; PA; SP; QL KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL ORKAMBI - Tier 2; PA; SP; QL TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL SYMDEKO - Tier 2; PA; SP; QL TOBI PODHALER - Tier 2; PA; SP; QL tobramycin inhalation nebulization solution 300 mg/4ml (generic for tobramycin nebulization solution 300 mg/5ml inhalation (generic for BETHKIS) - Tier 1; DX2RX; SP; QL KITABIS PAK) - Tier 1; PA; SP; QL TRIKAFTA - Tier 2; PA; SP; QL TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION - Tier 2; PA; SP; QL Mast Cell Stabilizers - Drugs for the Lungs cromolyn sodium inhalation - Tier 1; QL cromolyn sodium nasal (generic for NASALCROM) - Tier 1; QL NASALCROM (brand for cromolyn sodium) - Tier 2; QL Phosphodiesterase Inhibitors, Airways Disease - Drugs for the Lungs ELIXOPHYLLIN - Tier 2; QL THEO-24 - Tier 2; QL theophylline - Tier 1; QL theophylline er - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 135 Preferred Agents Non-Preferred Agents Pulmonary Antihypertensives - Asthma/Lung Drugs ADEMPAS - Tier 2; DX2RX; SP; QL LETAIRIS (brand for ambrisentan) - Tier 2; DX2RX; SP; QL ambrisentan (generic for LETAIRIS) - Tier 1; DX2RX; SP; QL TRACLEER 62.5 MG, 125 MG (brand for bosentan) - Tier 2; DX2RX; SP; bosentan (generic for TRACLEER) - Tier 1; DX2RX; SP; QL QL OPSUMIT - Tier 2; DX2RX; SP; QL sildenafil citrate oral suspension reconstituted (generic for REVATIO) - Tier 1; DX2RX; SP; QL sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; DX2RX; SP; QL TRACLEER 32 MG - Tier 2; DX2RX; SP; QL; AL Pulmonary Fibrosis Agents - Drugs to treat Pulmonary Fibrosis ESBRIET - Tier 2; PA; SP; QL OFEV - Tier 2; PA; SP; QL Respiratory Tract Agents, Other - Asthma/Lung Drugs 12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL 12 hour decongestant (generic for SUDAFED SINUS CONGESTION ADVAIR HFA - Tier 2; PA; QL 12HR) - Tier 1 AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour mucus relief oral tablet extended release 12 hour 1200 mg PA; QL (generic for EQ MUCUS ER) - Tier 1; QL; AL AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal decongestant (generic for SUDAFED SINUS PA; QL CONGESTION 12HR) - Tier 1 AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2; 12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) - PA; QL Tier 1 ANORO ELLIPTA - Tier 2; PA; QL 12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 BEVESPI AEROSPHERE - Tier 2; PA; QL 4-WAY FAST ACTING (brand for gnp nasal spray fast acting) - Tier 2 BREO ELLIPTA - Tier 2; PA; QL 4-WAY MENTHOL (brand for gnp nasal spray fast acting) - Tier 2 DULERA - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 136 Preferred Agents Non-Preferred Agents acetylcysteine inhalation - Tier 1 SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA; adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG ST; QL; AL DM CHILD) - Tier 1 TRELEGY ELLIPTA - Tier 2; PA; QL ADVIL COLD/SINUS (brand for sm cold & sinus relief) - Tier 2; AL AFRIN NODRIP ORIGINAL (brand for qc no drip nasal relief) - Tier 2 AFRIN SALINE NASAL MIST (brand for hm saline nasal spray) - Tier 2 AFRIN SINUS (brand for qc no drip nasal relief) - Tier 2 ALAVERT ALLERGY/SINUS (brand for allergy relief d-12) - Tier 2; AL all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL all day allergy d-12 (generic for KLS ALLER-TEC D) - Tier 1; QL; AL all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allerclear d-24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy & congestion (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy complete-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief d oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy relief d-24 (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief/nasal decong (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief/nasal decongest oral tablet extended release 12 hour (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief/nasal decongest oral tablet extended release 24 hour (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLER-TEC D) - Tier 1; QL; AL allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 137 Preferred Agents Non-Preferred Agents allergy relief-d oral tablet extended release 24 hour 10-240 mg (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL allergy/congestion relief (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 altarussin (generic for DIABETIC TUSSIN EX) - Tier 1; AL altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL altarussin-pe - Tier 1; AL anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1 aprodine - Tier 1; AL AYR (brand for hm saline nasal spray) - Tier 2 AYR NASAL MIST ALLERGY/SINUS - Tier 2 AYR SALINE NASAL DROPS - Tier 2 BABY AYR SALINE (brand for hm saline nasal spray) - Tier 2 benzonatate oral capsule 100 mg (generic for TESSALON PERLES) - Tier 1; QL; AL benzonatate oral capsule 200 mg - Tier 1; QL; AL cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier 1; QL; AL chest congest/cough child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 chest congestion relief dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL chest congestion relief oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL chest congestion relief oral tablet (generic for XPECT) - Tier 1 childrens cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL childrens cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 138 Preferred Agents Non-Preferred Agents childrens mucus relief cough (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 CLARITIN-D 12 HOUR (brand for allergy relief d-12) - Tier 2; AL CLARITIN-D 24 HOUR (brand for ra allergy relf & nasal decong) - Tier 2; AL cold & allergy (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; AL cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold & sinus relief oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL COMBIVENT RESPIMAT - Tier 2; QL CORICIDIN HBP COUGH/COLD (brand for sb cold & cough hbp) - Tier 2; AL cough & chest congestion (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough dm (generic for DELSYM) - Tier 1; QL; AL cough dm childrens (generic for DELSYM) - Tier 1; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 139 Preferred Agents Non-Preferred Agents cough dm er (generic for DELSYM) - Tier 1; QL; AL cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH) - Tier 1; AL cough/chest congestion dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL cough/chest dm childrens oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1; AL decongestant 12hour max st (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 DELSYM (brand for eq cough dm) - Tier 2; QL; AL DELSYM CGH/CHEST CONG DM CHILD (brand for gnp tussin dm max) - Tier 2 DELSYM COUGH CHILDRENS (brand for eq cough dm) - Tier 2; QL; AL DELSYM COUGH/CHEST CONGEST DM (brand for gnp tussin dm max) - Tier 2 desgen dm oral liquid (generic for DESGEN DM) - Tier 1; AL dextromethorphan polistirex er (generic for DELSYM) - Tier 1; QL; AL dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL DIABETIC TUSSIN MAX ST (brand for hm tussin adult dm) - Tier 2; AL dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL DIMETAPP COLD RELIEF CHILDRENS (brand for ra cold/cough dm) - Tier 2; QL; AL DIMETAPP COLD/ALLERGY (brand for rynex pe) - Tier 2; AL DIMETAPP DM COLD/COUGH (brand for ra cold/cough dm) - Tier 2; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 140 Preferred Agents Non-Preferred Agents dm maximum adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 DRISTAN SPRAY (brand for qc no drip nasal relief) - Tier 2 ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; QL; AL ed bron gp - Tier 1; AL ENDACOF-DM (brand for ra cold/cough dm) - Tier 2; QL; AL ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1 FASENRA PEN - Tier 2; PA; SP; QL fluticasone-salmeterol inhalation aerosol powder breath activated 100- 50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose (generic for WIXELA INHUB) - Tier 1; PA; QL FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT - Tier 2; QL g tussin ac - Tier 1; QL; AL genaphed (generic for SUDOGEST) - Tier 1; QL geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 guaiatussin ac - Tier 1; QL; AL guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL guaifenesin ac - Tier 1; QL; AL guaifenesin er (generic for EQ MUCUS ER) - Tier 1; QL; AL guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1 guaifenesin-codeine - Tier 1; QL; AL guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL hydrocodone-homatropine (generic for HYCODAN) - Tier 1; QL; AL hydromet (generic for HYCODAN) - Tier 1; QL; AL ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1; AL ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL COLD/SINUS) - Tier 1; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 141 Preferred Agents Non-Preferred Agents ipratropium-albuterol - Tier 1; QL liquibid (generic for XPECT) - Tier 1 long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 lorata-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL lorata-dine d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL loratadine-d (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL loratadine-d 24hr (generic for KLS ALLERCLEAR D-24HR) - Tier 1; AL maxi-tuss ac - Tier 1; QL; AL maxi-tuss gmx (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL maxi-tuss pe max - Tier 1; AL m-clear wc - Tier 1; QL; AL medifin 400 (generic for XPECT) - Tier 1 meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML (brand for gnp tussin dm max) - Tier 2 MUCINEX CHILDRENS STUFFY NOSE (brand for qc no drip nasal relief) - Tier 2 MUCINEX COUGH CHILDRENS (brand for gnp tussin dm max) - Tier 2 MUCINEX D (brand for mucus relief d) - Tier 2; AL MUCINEX D MAX STRENGTH (brand for pseudoephedrine- guaifenesin er) - Tier 2; AL MUCINEX DM (brand for mucus relief dm) - Tier 2; QL; AL MUCINEX FAST-MAX DM MAX (brand for gnp tussin dm max) - Tier 2 MUCINEX MAXIMUM STRENGTH (brand for guaifenesin er) - Tier 2; QL; AL MUCINEX SINUS-MAX CLEAR & COOL (brand for qc no drip nasal relief) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 142 Preferred Agents Non-Preferred Agents MUCINEX SINUS-MAX SINUS/ALLRGY (brand for qc no drip nasal relief) - Tier 2 mucus & cough relief child (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus & cough relief childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus d (generic for MUCINEX D) - Tier 1; AL mucus d extended release (generic for MUCINEX D) - Tier 1; AL mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus extended release oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1 mucus relief cough children (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief cough childrens (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief d max strength (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL mucus relief d oral tablet extended release 12 hour 60-600 mg (generic for MUCINEX D) - Tier 1; AL mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm oral liquid (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 mucus relief dm oral tablet extended release 12 hour 30-600 mg (generic for MUCINEX DM) - Tier 1; QL; AL mucus relief er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 143 Preferred Agents Non-Preferred Agents mucus relief max strength oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL mucus relief oral tablet (generic for XPECT) - Tier 1 mucus-d (generic for MUCINEX D) - Tier 1; AL mucus-dm (generic for MUCINEX DM) - Tier 1; QL; AL mucus-er oral tablet extended release 12 hour 1200 mg (generic for EQ MUCUS ER) - Tier 1; QL; AL nasal decongestant 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant 12hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL nasal decongestant oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 nasal decongestant pe max st (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nasal decongestant spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal four (generic for 4-WAY FAST ACTING) - Tier 1 nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) - Tier 1 NASAL MOIST NASAL SOLUTION (brand for hm saline nasal spray) - Tier 2 nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal relief moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray anti-drip (generic for GILTUSS SEVERE SINUS) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 144 Preferred Agents Non-Preferred Agents nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray fast acting (generic for 4-WAY FAST ACTING) - Tier 1 nasal spray moisturizing (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1 nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1 nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1 NEO-SYNEPHRINE COLD/ALLRG MILD - Tier 2 NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for gnp nasal spray fast acting) - Tier 2 NEO-SYNEPHRINE COLD/ALLRGY REG - Tier 2 no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1 no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 nohist-lq (generic for ED A-HIST) - Tier 1; QL; AL non-pseudo sinus decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal decongest (generic for 4-WAY FAST ACTING) - Tier 1 nose drops nasal solution 1 % (generic for 4-WAY FAST ACTING) - Tier 1 NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA; SP; QL NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2; PA; SP; QL OCEAN FOR KIDS (brand for hm saline nasal spray) - Tier 2 OCEAN NASAL SPRAY (brand for hm saline nasal spray) - Tier 2 pharbinex (generic for XPECT) - Tier 1 phenylephrine hcl oral (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 promethazine vc - Tier 1; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 145 Preferred Agents Non-Preferred Agents promethazine vc/codeine - Tier 1; QL; AL promethazine-codeine - Tier 1; QL; AL promethazine-dm - Tier 1; QL; AL promethazine-phenyleph-codeine - Tier 1; QL; AL promethazine-phenylephrine - Tier 1; QL; AL pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL pseudoephedrine-bromphen-dm - Tier 1; QL; AL pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1; AL PULMOZYME - Tier 2; DX2RX; SP; QL refenesen 400 (generic for XPECT) - Tier 1 robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL ROBITUSSIN 12 HOUR COUGH (brand for eq cough dm) - Tier 2; QL; AL ROBITUSSIN 12 HOUR COUGH CHILD (brand for eq cough dm) - Tier 2; QL; AL ROBITUSSIN CHILD COUGH/COLD LA - Tier 2; AL ROBITUSSIN CHILDRENS COUGH LA - Tier 2; AL ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG/20ML (brand for gnp tussin dm max) - Tier 2 ROBITUSSIN NIGHTTIME COUGH - Tier 2; AL ROBITUSSIN PEAK COLD MULTI-SYM (brand for hm tussin adult multi-symptom) - Tier 2; AL rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL rynex pe (generic for DIMETAPP COLD/ALLERGY) - Tier 1; AL rynex pse - Tier 1; AL saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1 sb mucus relief (generic for XPECT) - Tier 1 siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1; AL siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 146 Preferred Agents Non-Preferred Agents sinus 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1 sinus pe decongestant (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sinus relief ext st (generic for 4-WAY FAST ACTING) - Tier 1 sinus relief extra strength (generic for 4-WAY FAST ACTING) - Tier 1 sinus/congestion relief pe (generic for SUDAFED PE SINUS CONGESTION) - Tier 1 sodium chloride inhalation nebulization solution 0.9 % - Tier 1; QL STIOLTO RESPIMAT - Tier 2; QL SUDAFED (brand for decongestant) - Tier 2; QL SUDAFED CHILDRENS (brand for gnp suphedrin) - Tier 2; QL SUDAFED CONGESTION (brand for decongestant) - Tier 2; QL SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for px nasal decongestant pe) - Tier 2 SUDAFED PE SINUS CONGESTION (brand for px nasal decongestant pe) - Tier 2 SUDAFED SINUS CONGESTION (brand for decongestant) - Tier 2; QL SUDAFED SINUS CONGESTION 12HR (brand for sinus 12 hour) - Tier 2 sudogest 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrin (generic for SUDAFED CHILDRENS) - Tier 1; QL suphedrine maximum strength (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL suphedrine oral tablet extended release 12 hour 120 mg (generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1 tab tussin (generic for XPECT) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 147 Preferred Agents Non-Preferred Agents tussin adult dm oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin adult multi-symptom (generic for DESGEN DM) - Tier 1; AL tussin cf cough & cold oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1; AL tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1; AL tussin cf oral liquid 30-10-100 mg/5ml - Tier 1 tussin cf oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier 1; AL tussin chest congestion oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin cough dm sugar free (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin cough long acting (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough long-acting (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough oral syrup (generic for WAL-TUSSIN COUGH) - Tier 1; AL tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin dm cough/chest cong (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1 tussin dm max oral liquid 10-200 mg/5ml (generic for DIABETIC TUSSIN MAX ST) - Tier 1; AL tussin dm max st (generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 148 Preferred Agents Non-Preferred Agents tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL tussin maximum strength oral syrup 15 mg/5ml (generic for WAL- TUSSIN COUGH) - Tier 1; AL tussin mucus+chest congestion oral syrup (generic for DIABETIC TUSSIN EX) - Tier 1; AL tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; AL tussin oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) - Tier 1; AL virtussin a/c - Tier 1; QL; AL virtussin ac w/alc - Tier 1; QL; AL virtussin dac - Tier 1; QL; AL wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL XPECT (brand for refenesen 400) - Tier 2 ZYRTEC-D ALLERGY & CONGESTION (brand for all day allergy d) - Tier 2; QL; AL Skeletal Muscle Relaxants - Drugs to Treat Muscle Tension and Spasm Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm baclofen oral - Tier 1; QL chlorzoxazone oral tablet 250 mg, 500 mg - Tier 1; QL cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL dantrolene sodium oral - Tier 1; QL methocarbamol oral - Tier 1; QL orphenadrine citrate er - Tier 1; QL tizanidine hcl oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 149 Preferred Agents Non-Preferred Agents Sleep Disorder Agents - Drugs for Sedation and Sleep GABA Receptor Modulators - Drugs for Sleeping temazepam oral capsule 15 mg, 30 mg, 7.5 mg (generic for AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QL RESTORIL) - Tier 1; QL AMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PA zaleplon - Tier 1; QL LUNESTA ORAL TABLET 1 MG (brand for eszopiclone) - Tier 2; PA; QL zolpidem tartrate oral (generic for AMBIEN) - Tier 1; QL LUNESTA ORAL TABLET 2 MG, 3 MG (brand for eszopiclone) - Tier 2; PA zolpidem tartrate sublingual - Tier 1; PA; QL Sleep Disorders, Other - Drugs for Sleeping armodafinil (generic for NUVIGIL) - Tier 1; DX2RX; QL ROZEREM (brand for ramelteon) - Tier 2; PA; QL SILENOR (brand for doxepin hcl) - Tier 2; PA; QL Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs prenatal gummy oral tablet chewable 0.4-25 mg (generic for ALIVE PRENATAL) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 150 Prior Authorization / Class Criteria
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy 151 Index of Drugs 12 hour allergy-d...... 136 ACCU-CHEK AVIVA PLUS TEST STRIPS 114 acetaminophen oral tablet 500 mg...... 4 12 hour decongestant...... 136 ACCU-CHEK COMPACT PLUS...... 114 acetaminophen oral tablet chewable 160 12 hour mucus relief oral tablet extended ACCU-CHEK COMPACT PLUS mg...... 4 release 12 hour 1200 mg...... 136 CONTROL...... 114 acetaminophen rectal suppository 120 mg.... 4 12 hour nasal decongestant...... 136 ACCU-CHEK FASTCLIX LANCET KIT...... 114 acetaminophen rectal suppository 650 mg.... 4 12 hour nasal relief spray...... 136 ACCU-CHEK GUIDE CONTROL...... 114 acetaminophen-codeine...... 11 12 hour nasal spray...... 136 ACCU-CHEK GUIDE TEST STRIPS...... 114 acetaminophen-codeine #2...... 11 24 hour nasal allergy...... 133 ACCU-CHEK MULTICLIX LANCETS...... 114 acetaminophen-codeine #3...... 11 3 day...... 27 ACCU-CHEK SMARTVIEW...... 114 acetaminophen-codeine #4...... 11 3 day vaginal...... 27 ACCU-CHEK SMARTVIEW CONTROL.... 114 acetazolamide er...... 126 3-day vaginal vaginal cream 2 %...... 27 ACCU-CHEK SOFTCLIX LANCET acetazolamide oral...... 126 4-WAY FAST ACTING...... 136 DEVICE KIT...... 114 acetic acid otic...... 128 4-WAY MENTHOL...... 136 accutane...... 60 acetylcysteine inhalation...... 136 7T LIDO...... 13 ACCUTREND GLUCOSE CONTROL...... 114 acid controller...... 90 8 hour arthritis pain reliever...... 3 ACE AEROSOL CLOUD ENHANCER...... 114 acid gone...... 81 8 hour arthritis relief...... 3 acebutolol hcl oral...... 52 acid reducer oral capsule delayed release...97 8 hour pain relief oral tablet extended acetaminophen 8 hour...... 3 acid reducer oral tablet 10 mg...... 90 release 650 mg...... 3 acetaminophen 8 hours...... 3 acid reducer oral tablet 200 mg...... 90 8 hour pain reliever...... 3 acetaminophen 8hr arth pain...... 3 acidophilus lactobacillus oral...... 81 8 hr arthritis pain relief...... 3 acetaminophen 8hr musc ache...... 3 acidophilus oral capsule , 10 mg...... 81 8hr arthritis pain relief...... 3 acetaminophen childrens...... 3 acidophilus probiotic oral capsule 10 mg..... 81 8hr muscle aches & pain...... 3 acetaminophen childrens oral suspension acidophilus probiotic oral tablet , 0.5 mg.....81 a-25...... 71 160 mg/5ml...... 3 acidophilus/l-sporogenes...... 81 abacavir sulfate...... 42 acetaminophen childrens oral tablet ACIPHEX...... 97 abacavir sulfate-lamivudine...... 42 chewable 160 mg...... 3 acitretin...... 60 abacavir-lamivudine-zidovudine...... 42 acetaminophen er...... 3 acne...... 60 abatinex...... 81 acetaminophen ex st oral liquid 500 acne control cleanser...... 60 ABILIFY...... 39 mg/15ml...... 3 acne medication 10 external lotion...... 60 ABILIFY MAINTENA...... 39 acetaminophen ex st oral tablet 500 mg...... 3 acne medication 5 external lotion...... 60 ABILIFY MYCITE...... 39 acetaminophen extra strength...... 4 acne treatment external cream 10 %...... 60 abiraterone acetate...... 32 acetaminophen infants oral suspension ACTEMRA ACTPEN...... 111 ABREVA...... 41 160 mg/5ml...... 4 ACTEMRA SUBCUTANEOUS...... 111 ABSORICA...... 60 acetaminophen oral liquid 500 mg/15ml...... 4 ACTIVELLA...... 102 ABSORICA LD...... 60 acetaminophen oral solution 160 mg/5ml, ACULAR LS...... 127 acamprosate calcium...... 13 325 mg/10.15ml, 650 mg/20.3ml...... 4 ACUVAIL...... 127 ACANYA...... 60 acetaminophen oral suspension 160 acyclovir oral...... 41 acarbose oral...... 45 mg/5ml, 650 mg/20.3ml...... 4 ACZONE EXTERNAL GEL 7.5 %...... 60 ACCU-CHEK AVIVA DEVICE...... 114 acetaminophen oral tablet 325 mg...... 4 ADACEL...... 112
152 addaprin...... 8 AJOVY SUBCUTANEOUS SOLUTION all day allergy-d...... 137 ADDERALL...... 56 PREFILLED SYRINGE...... 114 all day pain relief...... 8 ADEMPAS...... 136 ak-poly-bac...... 121 all day relief...... 8 ADLYXIN...... 45 AKYNZEO ORAL...... 27 allerclear...... 129 ADLYXIN STARTER PACK...... 45 ala-cort...... 60 allerclear d-12hr...... 137 ADMELOG...... 47 ALAVERT...... 129 allerclear d-24hr...... 137 ADMELOG SOLOSTAR...... 47 ALAVERT ALLERGY/SINUS...... 137 aller-cort...... 133 adult 50+ probiotic...... 81 ALAWAY...... 127 allergy & congestion...... 137 ADULT AEROSOL MASK...... 114 ALAWAY CHILDRENS ALLERGY...... 127 allergy 24hour indoor/outdoor...... 129 adult probiotic...... 81 albendazole oral...... 36 allergy antihistamine...... 129 adult tussin cough & chest...... 137 albuterol sulfate hfa aerosol solution 108 allergy childrens...... 129 adv acne spot treatment...... 60 (90 base) mcg/act inhalation...... 134 allergy complete-d...... 137 ADVAIR DISKUS...... 137 ALBUTEROL SULFATE HFA AEROSOL allergy eye drops...... 127 ADVAIR HFA...... 137 SOLUTION 108 (90 BASE) MCG/ACT allergy medication...... 129 advanced acne spot treat...... 60 INHALATION...... 134 allergy oral capsule 25 mg...... 129 advanced antacid max st...... 81 albuterol sulfate inhalation nebulization allergy oral liquid 12.5 mg/5ml...... 129 advanced healing external ointment ...... 60 solution (2.5 mg/3ml) 0.083%, 2.5 allergy oral tablet 25 mg...... 130 ADVATE INTRAVENOUS SOLUTION mg/0.5ml...... 134 allergy oral tablet extended release 12 mg 129 RECONSTITUTED 1500 UNIT, 4000 UNIT.50 albuterol sulfate inhalation nebulization allergy rel child (loratadine)...... 130 ADVIL COLD/SINUS...... 137 solution 0.63 mg/3ml, 1.25 mg/3ml...... 134 allergy relief (cetirizine) oral tablet 10 mg.. 130 ADVIL JUNIOR STRENGTH...... 8 ALBUTEROL SULFATE NEBULIZATION allergy relief adult...... 130 ADVIL ORAL TABLET...... 8 SOLUTION (5 MG/ML) 0.5% INHALATION allergy relief cetirizine...... 130 ADZENYS XR-ODT...... 56 ...... 134 allergy relief child...... 130 AERIVA CONCENTRATOR NEBULIZER. 114 albuterol sulfate nebulization solution (5 allergy relief childrens oral liquid 12.5 af spray powder...... 27 mg/ml) 0.5% inhalation...... 134 mg/5ml...... 130 AFINITOR DISPERZ...... 34 albuterol sulfate oral syrup...... 134 allergy relief childrens oral syrup 5 mg/5ml 130 AFINITOR ORAL TABLET 10 MG...... 34 alclometasone dipropionate external allergy relief d oral tablet extended release afirmelle...... 102 ointment...... 60 12 hour...... 137 AFREZZA...... 47 ALCOHOL PREP PADS PAD , 70 %...... 114 allergy relief d-12...... 137 AFRIN NODRIP ORIGINAL...... 137 ALDARA...... 60 allergy relief d-24...... 137 AFRIN SALINE NASAL MIST...... 137 ALECENSA...... 34 allergy relief oral capsule 25 mg...... 130 AFRIN SINUS...... 137 alendronate sodium...... 113 allergy relief oral liquid 12.5 mg/5ml, 25 aftera...... 106 ALEVE ORAL TABLET...... 8 mg/10ml...... 130 AIMOVIG...... 30 alfuzosin hcl er...... 98 allergy relief oral tablet 10 mg...... 130 AIRDUO RESPICLICK 113/14...... 137 ALINIA ORAL SUSPENSION allergy relief oral tablet 25 mg...... 130 AIRDUO RESPICLICK 232/14...... 137 RECONSTITUTED...... 37 allergy relief oral tablet chewable 12.5 mg.130 AIRDUO RESPICLICK 55/14...... 137 all day allergy d...... 137 allergy relief oral tablet dispersible 10 mg..130 AJOVY SUBCUTANEOUS SOLUTION all day allergy d-12...... 137 allergy relief oral tablet extended release AUTO-INJECTOR...... 30 all day allergy oral tablet 10 mg...... 129 12 hour 5-120 mg...... 137
153 allergy relief oral tablet extended release altarussin dm...... 138 anecream external cream...... 13 12 mg...... 129 altarussin-pe...... 138 anefrin spray...... 138 allergy relief(cetirizine)...... 130 altavera...... 102 ANGELIQ...... 102 allergy relief/indoor/outdoor oral tablet 10 alum & mag hydroxide-simeth...... 81 animal shapes complete...... 71 mg...... 130 alumina-magnesia-simethicone...... 81 animal shapes kids first...... 71 allergy relief/nasal decong...... 137 ALUNBRIG...... 34 animal shapes/iron...... 71 allergy relief/nasal decongest oral tablet ALVESCO...... 133 ANORO ELLIPTA...... 138 extended release 12 hour...... 137 alyacen 1/35...... 102 antacid & anti-gas oral suspension 200- allergy relief/nasal decongest oral tablet alyacen 7/7/7...... 102 200-20 mg/5ml...... 81 extended release 24 hour...... 137 amantadine hcl oral capsule...... 38 antacid & anti-gas oral suspension 400- allergy relief-d oral tablet extended release amantadine hcl oral syrup...... 38 400-40 mg/5ml...... 81 12 hour 5-120 mg...... 137 AMBIEN...... 150 antacid & gas relief...... 81 allergy relief-d oral tablet extended release AMBIEN CR...... 150 antacid advanced...... 81 24 hour 10-240 mg...... 137 ambrisentan...... 136 antacid advanced max st...... 81 allergy relief-d12...... 138 amcinonide external ointment...... 60 antacid anti-gas...... 82 allergy spray 24 hour nasal aerosol...... 133 amikacin sulfate injection solution 500 antacid anti-gas ex st oral suspension 400- allergy/congestion relief...... 138 mg/2ml...... 16 400-40 mg/5ml...... 82 aller-tec...... 130 amiloride hcl oral...... 54 antacid anti-gas max strength...... 82 aller-tec d...... 138 amiloride-hydrochlorothiazide...... 53 antacid anti-gas reg strength...... 82 ALLI...... 57 aminocaproic acid oral...... 50 antacid calcium...... 82 allopurinol oral...... 30 amiodarone hcl oral tablet 200 mg, 400 mg.52 antacid calcium rich...... 82 almacone double strength...... 81 AMITIZA...... 90 antacid extra...... 82 ALOE VESTA DAILY MOISTURIZER...... 60 amitriptyline hcl oral...... 26 antacid extra strength oral suspension...... 82 ALOGLIPTIN BENZOATE...... 45 amlodipine besylate oral...... 53 antacid extra strength oral tablet chewable ALOGLIPTIN-METFORMIN HCL...... 45 ammonium lactate external...... 60 160-105 mg...... 82 ALOGLIPTIN-PIOGLITAZONE...... 45 amnesteem...... 60 antacid extra strength oral tablet chewable ALORA...... 102 amoxapine...... 26 750 mg...... 82 ALPHAGAN P...... 126 amoxicillin oral capsule...... 18 antacid fast relief...... 82 alprazolam er...... 44 amoxicillin oral suspension reconstituted.....18 antacid i...... 82 alprazolam intensol...... 44 amoxicillin oral tablet 875 mg...... 18 antacid iii...... 82 alprazolam oral...... 44 amoxicillin oral tablet chewable...... 18 antacid kids...... 82 alprazolam xr...... 44 amoxicillin-potassium clavulanate oral...... 18 antacid liquid...... 82 ALTACAINE...... 121 amphetamine-dextroamphetamine...... 56 antacid m...... 82 altachlore ophthalmic ointment...... 121 amphetamine-dextroamphetamine er...... 56 antacid maximum...... 82 altachlore ophthalmic solution...... 121 ampicillin...... 18 antacid maximum strength...... 82 altafrin...... 121 AMZEEQ...... 60 antacid maximum strength oral tablet altalube...... 121 anagrelide hcl...... 49 chewable 1000 mg...... 82 altamist spray...... 138 ANASPAZ...... 80 antacid oral suspension 200-200-20 altarussin...... 138 anastrozole oral...... 33 mg/5ml, 400-400-40 mg/10ml...... 82
154 antacid oral suspension 400-400-40 apra...... 4 ASMANEX (60 METERED DOSES)...... 133 mg/5ml...... 82 apraclonidine hcl...... 126 ASMANEX (7 METERED DOSES)...... 133 antacid oral tablet chewable 1000 mg...... 82 aprepitant...... 27 ASMANEX HFA INHALATION AEROSOL antacid oral tablet chewable 500 mg...... 82 apri...... 102 100 MCG/ACT, 200 MCG/ACT...... 133 antacid oral tablet chewable 750 mg...... 83 APRISO...... 113 ASMANEX HFA INHALATION AEROSOL antacid plus antigas...... 83 aprodine...... 138 50 MCG/ACT...... 133 antacid plus anti-gas relief...... 83 APTENSIO XR...... 57 aspirin childrens...... 8 antacid regular strength oral suspension..... 83 APTIOM...... 22 aspirin ec...... 8 antacid regular strength oral tablet APTIVUS...... 43 aspirin ec oral tablet 325 mg...... 8 chewable...... 83 AQUADEKS...... 71 aspirin oral...... 8 antacid supreme...... 83 aqueous vitamin d...... 71 ASPIRIN ORAL TABLET DELAYED antacid ultra strength oral tablet chewable ARAKODA...... 37 RELEASE 81 MG...... 8 1000 mg...... 83 aranelle...... 102 aspirin rectal...... 9 antacid/anti-gas...... 83 ARANESP (ALBUMIN FREE)...... 49 ASTRAZENECA COVID-19 VACCINE...... 112 antacid/anti-gas max st...... 83 aripiprazole...... 39 astringent eye drops...... 121 antacid/antigas oral suspension 200-200- ARISTADA INITIO...... 39 astringent solution...... 60 20 mg/5ml...... 83 ARISTADA INTRAMUSCULAR ATABEX OB...... 71 antacid/gas relief max st...... 83 PREFILLED SYRINGE 1064 MG/3.9ML...... 39 atazanavir sulfate...... 43 antibiotic...... 16 ARISTADA INTRAMUSCULAR atenolol oral...... 52 anti-diarr/ant-gas...... 83 PREFILLED SYRINGE 441 MG/1.6ML, atenolol-chlorthalidone...... 53 anti-diarrheal anti-gas...... 83 662 MG/2.4ML, 882 MG/3.2ML...... 39 atheletes foot...... 27 anti-diarrheal oral liquid 1 mg/5ml...... 83 armodafinil...... 150 athletes foot (terbinafine)...... 27 anti-diarrheal oral suspension 262 mg/15ml 83 ARNUITY ELLIPTA...... 133 athletes foot (tolnaftate) external cream 1 anti-diarrheal oral tablet 2 mg...... 83 arthritis pain oral tablet extended release %...... 27 antifungal (tolnaftate)...... 27 650 mg...... 4 athletes foot external aerosol powder 2 %... 27 antifungal external cream 1 %...... 27 arthritis pain relief oral tablet extended athletes foot external cream 1 %...... 27 antifungal external cream 2 %...... 27 release 650 mg...... 4 athletes foot external powder 2 %...... 114 antifungal external powder...... 114 arthritis pain reliever oral...... 4 athletes foot powder spray...... 27 antifungal foot care...... 27 arthritis pain relieving...... 60 athletes foot spray...... 27 antifungal miconazole...... 27 artificial eye...... 121 athletes foot spray external aerosol 2 %...... 27 antifungal tolnaftate...... 27 artificial tears ophthalmic ointment...... 121 atomoxetine hcl...... 57 anti-gas oral capsule 180 mg...... 83 artificial tears ophthalmic solution ...... 121 atorvastatin calcium oral...... 55 anti-hist allergy...... 130 artificial tears ophthalmic solution 1.4 %.... 121 atovaquone oral...... 37 anti-nausea...... 26 ASACOL HD...... 113 ATRALIN...... 60 antiseptic...... 16 ascomp-codeine...... 11 ATRIPLA...... 42 apap-caff-dihydrocodeine oral capsule...... 11 ascorbic acid oral tablet 500 mg...... 71 atropine sulfate ophthalmic ointment...... 122 APIDRA SOLOSTAR...... 47 ASMANEX (120 METERED DOSES)...... 133 atropine sulfate ophthalmic solution 1 %....122 APIDRA VIAL...... 47 ASMANEX (14 METERED DOSES)...... 133 ATROVENT HFA...... 134 APLENZIN...... 24 ASMANEX (30 METERED DOSES)...... 133 AUBAGIO...... 58
155 aubra...... 102 b-1...... 71 BENZAC AC WASH...... 61 aubra eq...... 102 b6...... 72 BENZACLIN...... 61 aurodryl allergy childrens...... 130 BABY AYR SALINE...... 138 BENZACLIN WITH PUMP...... 61 aurophen childrens...... 4 baby basics diaper rash...... 61 BENZAMYCIN...... 61 aurovela 1.5/30...... 102 bac...... 4 BENZNIDAZOLE...... 37 aurovela 1/20...... 102 bacitracin external...... 16 benzonatate oral capsule 100 mg...... 138 aurovela fe 1.5/30...... 102 bacitracin ophthalmic...... 126 benzonatate oral capsule 200 mg...... 138 aurovela fe 1/20...... 102 bacitracin zinc external...... 16 benztropine mesylate oral...... 38 AURYXIA...... 71 bacitracin zinc first aid...... 16 BERINERT...... 109 AUSTEDO...... 57 bacitracin-polymyxin b ophthalmic...... 122 BESIVANCE...... 126 AUVI-Q...... 135 bacitra-neomycin-polymyxin-hc...... 122 BETADINE OPHTHALMIC PREP...... 16 AVAR-E EMOLLIENT...... 60 baclofen oral...... 149 betamethasone dipropionate aug...... 61 AVAR-E GREEN...... 60 BAFIERTAM...... 56 betamethasone dipropionate external lotion 61 AVASTIN...... 36 balsalazide disodium...... 113 betamethasone dipropionate external aviane...... 102 BALVERSA...... 33 ointment...... 61 AVITA EXTERNAL CREAM...... 60 balziva...... 102 betamethasone valerate external cream...... 61 AVONEX PEN...... 58 banophen oral capsule 25 mg...... 130 betamethasone valerate external lotion...... 61 AVONEX PREFILLED...... 58 banophen oral tablet...... 130 betamethasone valerate external ointment.. 61 AXONA...... 114 BANZEL...... 22 BETAPACE...... 52 AYR...... 138 BAQSIMI ONE PACK...... 46 BETAPACE AF...... 52 AYR NASAL MIST ALLERGY/SINUS...... 138 BAQSIMI TWO PACK...... 46 BETASERON...... 58 AYR SALINE NASAL DROPS...... 138 BARACLUDE ORAL SOLUTION...... 40 betatemp childrens...... 4 ayuna...... 102 BASAGLAR KWIKPEN...... 47 betaxolol hcl ophthalmic...... 126 AZASAN...... 110 BAYER ASPIRIN...... 9 betaxolol hcl oral...... 52 AZASITE...... 126 b-complex oral tablet ...... 72 bethanechol chloride oral...... 98 azathioprine oral...... 110 b-complex with b-12...... 72 BETHKIS...... 135 azelaic acid external...... 61 b-complex/b-12 oral...... 72 BETIMOL...... 126 azelastine hcl nasal solution 137 BD AUTOSHIELD DUO PEN NEEDLES... 114 BETOPTIC-S...... 126 mcg/spray...... 130 BD ULTRA-FINE INSULIN SYRINGES..... 114 BEVESPI AEROSPHERE...... 138 azelastine hcl ophthalmic...... 125 BD ULTRA-FINE PEN NEEDLES...... 114 bexarotene...... 36 azelastine hcl solution 0.1 % nasal...... 130 beauty 360 pure glycerin...... 61 BEXSERO...... 112 azithromycin oral suspension reconstituted. 18 bekyree...... 102 bicalutamide...... 32 azithromycin oral tablet...... 18 BENADRYL ALLERGY CHILDRENS BIDIL...... 53 azo...... 98 ORAL LIQUID...... 131 BIKTARVY...... 42 azo tabs...... 98 BENADRYL ALLERGY CHILDRENS biocel...... 72 AZOPT...... 126 ORAL TABLET CHEWABLE...... 131 BIOLLE TEARS...... 122 azurette...... 102 BENADRYL ALLERGY ORAL TABLET.....131 biotinex...... 83 b complex oral capsule...... 71 benazepril hcl oral...... 51 bisacodyl ec...... 91 b complex vitamins...... 71 benazepril-hydrochlorothiazide...... 53 bisacodyl laxative...... 91
156 bisacodyl rectal...... 91 budesonide oral...... 113 calamine-zinc oxide external lotion...... 61 bisa-lax...... 91 bumetanide oral...... 54 calcidol...... 72 bismatrol maximum strength...... 83 BUNAVAIL...... 13 calcipotriene external cream...... 61 bismatrol oral tablet chewable...... 84 buprenorphine hcl sublingual...... 13 calcipotriene external ointment...... 61 bismuth...... 84 buprenorphine hcl-naloxone hcl sublingual calcipotriene external solution...... 61 bismuth subsalicylate oral suspension...... 84 film 2-0.5 mg, 8-2 mg...... 13 calcitonin (salmon) nasal...... 113 bismuth subsalicylate oral tablet chewable.. 84 buprenorphine hcl-naloxone hcl sublingual calcitriol external...... 61 bisoprolol fumarate oral...... 52 tablet sublingual...... 13 calcitriol oral capsule...... 114 bisoprolol-hydrochlorothiazide...... 53 buprenorphine transdermal...... 11 calcitriol oral solution...... 114 blisovi fe 1.5/30...... 102 bupropion hcl er (smoking det)...... 14 calcium 500/d oral tablet...... 66 blisovi fe 1/20...... 102 bupropion hcl er (sr)...... 24 calcium 500/vitamin d3...... 66 blue tube/ aloe...... 13 bupropion hcl er (xl) oral tablet extended calcium 600 oral tablet 1500 (600 ca) mg.... 66 BONINE...... 26 release 24 hour 150 mg, 300 mg...... 24 calcium 600/vit d/minerals oral tablet 600- BOOSTRIX...... 112 BUPROPION HCL ER (XL) ORAL TABLET 200 mg-unit...... 66 boro-packs...... 61 EXTENDED RELEASE 24 HOUR 450 MG..24 calcium 600/vit d/minerals oral tablet bosentan...... 136 bupropion hcl oral...... 24 chewable 600-400 mg-unit...... 66 BOSULIF...... 34 buspirone hcl oral...... 44 calcium 600/vitamin d...... 66 BOUDREAUXS BUTT PASTE EXTERNAL butalbital-acetaminophen oral tablet 50- calcium 600/vitamin d-3...... 66 OINTMENT 40 %...... 61 325 mg...... 4 calcium 600+d oral tablet 600-200 mg-unit, bp 10-1...... 61 butalbital-apap-caff-cod oral capsule 50- 600-400 mg-unit...... 66 bp wash external liquid 2.5 %...... 61 325-40-30 mg...... 11 calcium 600+d oral tablet 600-400 mg-unit..66 b-plex plus...... 72 butalbital-apap-caffeine oral capsule 50- calcium acetate (phos binder) oral tablet..... 71 BPROTECTED PEDIA D-VITE...... 72 325-40 mg...... 4 calcium acetate oral tablet 667 mg...... 71 BPROTECTED PEDIA IRON...... 66 butalbital-apap-caffeine oral tablet...... 4 calcium antacid...... 84 BPROTECTED PEDIA POLY-VITE/FE...... 72 butalbital-asa-caff-codeine...... 11 calcium antacid ex st...... 84 BPROTECTED VITAMIN C...... 72 butalbital-aspirin-caffeine...... 5 calcium antacid extra strength...... 84 BREATHE EASE HUMIDIFIER...... 115 butorphanol tartrate nasal...... 11 calcium carb-cholecalciferol oral tablet BREATHE EASE NEB MASK/CHILD...... 115 BYDUREON BCISE AUTOINJECTOR...... 45 600-400 mg-unit...... 66 BREATHE EASE NEB MASK/INFANT...... 115 BYETTA 10 MCG PEN...... 45 calcium carbonate antacid oral suspension. 84 BREO ELLIPTA...... 138 BYETTA 5 MCG PEN...... 45 calcium carbonate antacid oral tablet...... 84 briellyn...... 102 c 250 oral tablet...... 72 calcium carbonate antacid oral tablet BRILINTA...... 50 c 500/rose hips...... 72 chewable...... 84 brimonidine tartrate ophthalmic...... 126 c-1000/rose hips...... 72 calcium carbonate oral tablet 1500 (600 BRIVIACT INTRAVENOUS...... 20 cabergoline...... 108 ca) mg...... 66 BRIVIACT ORAL...... 20 CABLIVI...... 50 calcium carbonate oral tablet chewable BROVANA...... 135 CABOMETYX...... 34 1250 (500 ca) mg...... 66 BRUKINSA...... 34 caffeine citrate oral...... 57 calcium carbonate oral tablet chewable BUBBLES THE FISH II PEDI MASK...... 115 cal mag zinc +d3...... 66 500 mg...... 84 budesonide inhalation...... 133 calamine external lotion , 8-8 %...... 61
157 calcium carbonate-vitamin d oral tablet calcium-vitamin d oral tablet 600-400 mg- CAYSTON...... 135 600-200 mg-unit...... 66 unit...... 67 caziant...... 102 calcium carbonate-vitamin d oral tablet calcium-vitamin d3 oral tablet 600-400 mg- cefaclor...... 17 600-400 mg-unit...... 66 unit...... 67 cefadroxil...... 17 calcium carbonate-vitamin d3...... 66 cal-gest antacid...... 84 cefazolin sodium injection solution calcium cit plus vit d-3...... 66 CALQUENCE...... 34 reconstituted 1 gm...... 17 calcium citrate + d oral tablet 315-250 mg- camila...... 106 cefdinir...... 17 unit...... 66 capecitabine...... 32 cefprozil...... 17 calcium citrate + d3 maximum...... 66 CAPLYTA...... 39 ceftriaxone sodium injection solution calcium citrate +d3...... 67 CAPRELSA...... 34 reconstituted 1 gm, 2 gm, 500 mg...... 17 calcium citrate plus vit d...... 67 capsaicin external cream 0.025 %...... 5 cefuroxime axetil...... 17 calcium citrate+d oral tablet 315-250 mg- capsaicin external cream 0.1 %...... 62 celecoxib oral capsule 100 mg, 200 mg, unit...... 67 capsaicin hp...... 62 400 mg...... 9 calcium citrate+d3 oral tablet 315-250 mg- captopril oral...... 51 celecoxib oral capsule 50 mg...... 9 unit...... 67 captopril-hydrochlorothiazide...... 53 CELONTIN...... 20 calcium citrate+d3 w/magne...... 67 capzix...... 62 CENTANY...... 16 calcium citrate-vit d...... 67 CARAC...... 62 cephalexin oral capsule 250 mg, 500 mg.....17 calcium citrate-vitamin d oral tablet 315- CARBAGLU...... 67 cephalexin oral capsule 750 mg...... 17 200 mg-unit...... 67 carbamazepine er...... 22 cephalexin oral suspension reconstituted.... 17 calcium fast dissolution...... 67 carbamazepine oral...... 22 CEQUA...... 122 calcium high potency...... 67 CARBATROL...... 22 CERDELGA...... 97 calcium high potency/vitamin d...... 67 carbidopa-levodopa...... 38 cerovel...... 62 calcium oral tablet 1500 (600 ca) mg...... 67 carbidopa-levodopa er...... 38 cerovite jr...... 72 calcium oyster shell oral tablet 1250 (500 carboxymethylcellulose sodium ophthalmic cetiri-d...... 138 ca) mg...... 67 ...... 122 cetirizine hcl oral solution...... 131 calcium plus 600 +d...... 67 CARETOUCH 2 CPAP HOSE HANGER... 115 cetirizine hcl oral tablet...... 131 calcium plus vitamin d oral tablet 500-5 CARETOUCH CONTROL SOL LEVEL 2.. 115 cetirizine-pseudoephedrine er...... 138 mg-mcg...... 67 CARETOUCH CPAP & BIPAP HOSE...... 115 CHANTIX...... 14 calcium plus vitamin d oral tablet 600-200 CARETOUCH CPAP MASK WIPES...... 115 CHANTIX CONTINUING MONTH PAK...... 14 mg-unit...... 67 CARETOUCH CPAP PRE-WASH SOLN.. 115 CHANTIX STARTING MONTH PAK...... 14 calcium plus vitamin d oral tablet 600-400 CARETOUCH CPAP TUBE BRUSH...... 115 chateal...... 102 mg-unit...... 67 CARETOUCH UNIVERSL CPAP FILTER. 115 chateal eq...... 102 calcium plus vitamin d3...... 67 carteolol hcl...... 126 CHEMET...... 71 calcium soft chews oral tablet chewable cartia xt...... 53 CHEMSTRIP 10 MD...... 115 500-200-40 mg-unt-mcg...... 67 carvedilol...... 52 CHEMSTRIP 10/SG...... 115 calcium/minerals/vitamin d...... 67 CASTIVA WARMING...... 5 CHEMSTRIP 2 GP...... 116 calcium-magnesium-zinc oral tablet 333- cavarest...... 59 CHEMSTRIP 5 OB...... 116 133-5 mg, 333.33-133.33-5 mg...... 67 CAVILON...... 28 CHEMSTRIP 7...... 116 CAYA...... 115 CHEMSTRIP 9...... 116
158 CHEMSTRIP K...... 116 chlorpromazine hcl oral...... 39 CLEARCANAL EARWAX SOFTENER...... 128 CHEMSTRIP UGK...... 116 chlorthalidone...... 54 clearlax oral powder 17 gm/scoop...... 91 chest congest/cough child...... 138 CHLOR-TRIMETON ALLERGY...... 129 clearskin...... 62 chest congestion relief dm...... 138 CHLOR-TRIMETON ORAL SYRUP...... 129 clemastine fumarate oral syrup...... 131 chest congestion relief oral syrup...... 138 chlorzoxazone oral tablet 250 mg, 500 mg 149 clemastine fumarate oral tablet 2.68 mg.... 131 chest congestion relief oral tablet...... 138 CHOLBAM...... 97 CLEOCIN VAGINAL SUPPOSITORY...... 16 chewable c...... 72 cholestyramine light oral powder...... 55 CLIMARA...... 102 chewable c with rose hips...... 72 cholestyramine oral powder...... 55 CLIMARA PRO...... 102 chewable childrens vitamin...... 72 chorionic gonadotropin intramuscular...... 100 clindamycin hcl oral capsule 150 mg, 300 chewy not chalky flavor...... 84 ciclodan...... 28 mg...... 16 child chewable vitamins/iron...... 72 ciclopirox external solution...... 28 clindamycin palmitate hcl...... 16 childrens acetaminophen...... 5 cilostazol...... 50 clindamycin phosphate external gel...... 62 childrens allergy oral liquid 12.5 mg/5ml.... 131 CILOXAN...... 126 clindamycin phosphate external lotion...... 62 childrens animal shapes...... 72 CIMDUO...... 42 clindamycin phosphate external solution..... 62 childrens apap...... 5 cimetidine hcl oral solution 300 mg/5ml...... 90 clindamycin phosphate vaginal...... 16 childrens aspirin low strength...... 9 cimetidine oral...... 90 CLINDESSE...... 16 childrens aspirin oral tablet chewable 81 CIMZIA...... 110 clobazam...... 20 mg...... 9 cinacalcet hcl...... 113 clobetasol prop emollient base...... 62 childrens chewable vitamins...... 72 CIPRO ORAL SUSPENSION clobetasol propionate e...... 62 childrens chewables/ex c...... 72 RECONSTITUTED...... 18 clobetasol propionate external solution...... 62 childrens chewables/iron...... 72 ciprofloxacin hcl ophthalmic...... 126 CLOBEX...... 62 childrens cold & allergy...... 138 ciprofloxacin hcl oral...... 18 CLOBEX SPRAY...... 62 childrens complete oral tablet chewable 18 ciprofloxacin-dexamethasone...... 128 clomipramine hcl oral...... 26 mg...... 72 citalopram hydrobromide...... 25 clonazepam oral tablet...... 44 childrens cough...... 138 citrate of magnesia...... 91 clonidine hcl oral...... 51 childrens loratadine...... 131 citroma...... 91 clopidogrel bisulfate oral...... 50 childrens mucus relief cough...... 138 CITRUCEL...... 91 clorazepate dipotassium...... 44 childrens non-aspirin...... 5 claravis...... 62 clotrimazole 3...... 28 childrens silapap...... 5 clarithromycin er...... 18 clotrimazole 7...... 28 childrens soothe...... 84 clarithromycin oral...... 18 clotrimazole external...... 28 childrens tactinal...... 5 CLARITIN ALLERGY CHILDRENS...... 131 clotrimazole mouth/throat...... 28 childrens vitamins/extra c...... 72 CLARITIN EYE...... 127 clotrimazole vaginal...... 28 childrens vitamins/iron...... 72 CLARITIN ORAL TABLET...... 131 clotrimazole-betamethasone...... 62 childs non-aspirin...... 5 CLARITIN REDITABS ORAL TABLET CLOZARIL...... 40 chlordiazepoxide hcl...... 44 DISPERSIBLE 10 MG...... 131 codeine sulfate...... 11 chlorhexidine gluconate mouth/throat...... 59 CLARITIN-D 12 HOUR...... 139 COLACE...... 91 chloroquine phosphate oral...... 37 CLARITIN-D 24 HOUR...... 139 COLAZAL...... 113 chlorpheniramine maleate er...... 129 classic prenatal...... 72 COLCHICINE ORAL CAPSULE...... 30 chlorpromazine hcl injection...... 39 c-lax laxative...... 91 colchicine oral tablet...... 30
159 COLCRYS...... 30 CORICIDIN HBP COUGH/COLD...... 139 CYCLOPHOSPHAMIDE ORAL TABLET.....32 cold & allergy...... 139 CORLANOR...... 53 cycloserine oral...... 31 cold & allergy childrens oral elixir 1-15 corn & callus remover...... 62 cyclosporine intravenous...... 110 mg/5ml...... 139 CORTIFOAM...... 113 cyclosporine modified oral capsule 100 mg110 cold & cough childrens oral liquid 2.5-1-5 COSENTYX...... 62 cyclosporine modified oral capsule 25 mg. 110 mg/5ml...... 139 COSOPT...... 126 cyclosporine modified oral capsule 50 mg. 110 cold & cough dm childrens oral liquid 2.5-1- COSOPT PF...... 126 cyclosporine modified oral solution...... 110 5 mg/5ml...... 139 COTELLIC...... 34 cyclosporine oral...... 110 cold & sinus relief oral tablet 30-200 mg.... 139 COTEMPLA XR-ODT...... 57 CYMBALTA...... 25 cold/cough...... 139 cough & chest congestion...... 139 cyproheptadine hcl oral...... 131 cold/cough childrens...... 139 cough & cold...... 139 cyred...... 103 cold/cough dm childrens oral liquid 2.5-1-5 cough & cold hbp...... 139 cyred eq...... 103 mg/5ml...... 139 cough childrens...... 139 CYSTAGON...... 97 cold/cough dm oral liquid 2.5-1-5 mg/5ml.. 139 cough dm...... 139 CYSTARAN...... 122 col-rite oral capsule 250 mg...... 91 cough dm childrens...... 139 d 1000 oral tablet...... 73 COMBIGAN...... 126 cough dm er...... 139 d 400 oral tablet...... 73 COMBIPATCH...... 102 cough relief oral syrup 15 mg/5ml...... 140 d 400 oral tablet chewable...... 73 COMBIVENT RESPIMAT...... 139 cough/chest congestion dm...... 140 d 5000 oral tablet...... 73 COMETRIQ (100 MG DAILY DOSE)...... 34 cough/chest dm childrens oral liquid...... 140 d3 high potency oral capsule 25 mcg (1000 COMETRIQ (140 MG DAILY DOSE)...... 34 cough/cold hbp...... 140 ut)...... 73 COMETRIQ (60 MG DAILY DOSE)...... 34 CREON...... 97 d3 oral capsule 10 mcg (400 unit), 50 mcg comfort gel...... 84 CRIXIVAN...... 43 (2000 ut)...... 73 comfort gel antacid anti-gas oral cromolyn sodium inhalation...... 135 d3 oral capsule 125 mcg (5000 ut)...... 73 suspension 400-400-40 mg/5ml...... 84 cromolyn sodium nasal...... 135 d3 oral capsule 25 mcg (1000 ut)...... 73 COMFORT TOUCH ALCOHOL PREP...... 116 cromolyn sodium ophthalmic...... 125 d3 super strength...... 73 COMPLERA...... 42 crotan...... 37 d-3-5...... 73 complete allergy...... 131 CRUEX PRESCRIPTION STRENGTH...... 28 d3-50...... 73 complete allergy medicine oral capsule..... 131 cryselle-28...... 102 daily acne wash...... 62 complete allergy relief...... 131 CUPRIMINE...... 98 daily fiber oral capsule 0.52 gm...... 91 COMPRESSOR NEBULIZER...... 116 cyanocobalamin injection solution 1000 daily multiple vitamins...... 73 compro...... 26 mcg/ml...... 72 daily multivitamins/iron...... 73 CO-NATAL FA...... 72 CYANOCOBALAMIN INJECTION daily vitamin formula+iron...... 73 CONCERTA...... 57 SOLUTION 2000 MCG/ML...... 73 daily vitamins...... 73 CONDOMS...... 116 cyclafem 1/35...... 102 daily vite...... 73 constulose...... 91 cyclafem 7/7/7...... 103 daily vites...... 73 CONTOUR NEXT TEST STRIPS...... 116 cyclobenzaprine hcl oral tablet 10 mg, 5 daily-vite...... 73 CONTOUR TEST STRIPS...... 116 mg...... 149 dairy aid...... 84 COOL MIST HUMIDIFER...... 116 cyclopentolate hcl ophthalmic solution 1 %122 dairy relief ex st...... 84 COPAXONE...... 58 cyclophosphamide oral capsule...... 32 dairy relief fast acting oral tablet 9000 unit...84
160 dairy relief oral tablet 3000 unit...... 84 DERMACINRX PENETRAL...... 5 diclofenac potassium...... 9 danazol oral...... 101 DESCOVY...... 42 diclofenac sodium er...... 9 dantrolene sodium oral...... 149 DESENEX EXTERNAL POWDER...... 116 diclofenac sodium external gel 1 %...... 9 dapsone oral...... 31 DESENEX JOCK ITCH...... 28 diclofenac sodium ophthalmic...... 127 DAPTACEL...... 112 desgen dm oral liquid...... 140 diclofenac sodium oral...... 9 dasetta 1/35...... 103 desipramine hcl oral...... 26 dicloxacillin sodium...... 18 dasetta 7/7/7...... 103 desmopressin ace spray refrig...... 100 dicyclomine hcl oral capsule...... 80 DAURISMO...... 34 desmopressin acetate oral...... 100 dicyclomine hcl oral solution...... 80 DAYHIST ALLERGY 12 HOUR RELIEF....131 desmopressin acetate spray...... 100 dicyclomine hcl oral tablet...... 80 DAYTRANA...... 57 desogestrel-ethinyl estradiol...... 103 DIFFERIN EXTERNAL CREAM...... 62 DDAVP RHINAL TUBE...... 100 DESVENLAFAXINE ER...... 25 DIFFERIN EXTERNAL GEL 0.1 %...... 62 deblitane...... 106 desvenlafaxine succinate er...... 25 DIFFERIN EXTERNAL GEL 0.3 %...... 62 DECADRON ORAL TABLET 0.5 MG, 0.75 DETROL...... 98 DIFFERIN EXTERNAL LOTION...... 62 MG...... 99 DETROL LA...... 98 DIFICID...... 18 DECADRON ORAL TABLET 4 MG, 6 MG...99 dexamethasone oral elixir...... 99 DIFLUCAN...... 28 DECARA ORAL CAPSULE 1.25 MG dexamethasone oral solution...... 99 digestive probiotic capsule oral...... 84 (50000 UT)...... 73 dexamethasone oral tablet 0.5 mg, 0.75 digestive probiotic oral capsule 250 mg...... 84 DECARA ORAL CAPSULE 250 MCG mg...... 99 digitek...... 53 (10000 UT)...... 73 dexamethasone oral tablet 1 mg, 2 mg...... 99 digox...... 53 DECARA ORAL CAPSULE 625 MCG dexamethasone oral tablet 1.5 mg...... 99 digoxin oral...... 53 (25000 UT)...... 73 dexamethasone oral tablet 4 mg, 6 mg...... 99 dihydroergotamine mesylate injection...... 30 decongestant 12hour max st...... 140 dexamethasone sodium phosphate DILANTIN...... 22 deep sea nasal spray...... 140 ophthalmic...... 127 DILANTIN INFATABS...... 22 deferasirox...... 71 DEXILANT...... 97 diltiazem hcl er...... 53 deferasirox granules...... 71 dextromethorphan polistirex er...... 140 diltiazem hcl er beads...... 53 DELSTRIGO...... 42 dextromethorphan-guaifenesin oral syrup..140 diltiazem hcl er coated beads oral capsule DELSYM...... 140 DIABETIC TUSSIN MAX ST...... 140 extended release 24 hour...... 53 DELSYM CGH/CHEST CONG DM CHILD 140 DIALYVITE 800 ORAL TABLET...... 73 diltiazem hcl oral...... 53 DELSYM COUGH CHILDRENS...... 140 DIALYVITE VITAMIN D 5000...... 73 dilt-xr...... 53 DELSYM COUGH/CHEST CONGEST DM140 diamode...... 84 dimaphen dm cold/cough...... 140 delyla...... 103 diaper rash external ointment...... 62 DIMETAPP COLD RELIEF CHILDRENS.. 140 DELZICOL...... 113 diarrhea...... 84 DIMETAPP COLD/ALLERGY...... 140 DENTA 5000 PLUS...... 59 diarrhea relief...... 84 DIMETAPP DM COLD/COUGH...... 140 DENTAGEL...... 59 DIASTAT ACUDIAL...... 20 dimethyl fumarate oral...... 58 DEPAKOTE...... 45 DIASTAT PEDIATRIC...... 20 dimethyl fumarate starter pack...... 58 DEPAKOTE SPRINKLES...... 45 diazepam intensol...... 44 dino-life...... 74 DEPEN TITRATABS...... 98 diazepam oral...... 44 dino-life w/extra c...... 74 DEPO-ESTRADIOL...... 103 diazepam rectal gel 10 mg, 20 mg...... 20 diotame instydose...... 85 DEPO-SUBQ PROVERA 104...... 106 diazepam rectal gel 2.5 mg...... 20 DIPENTUM...... 113
161 diphedryl allergy...... 131 donepezil hcl oral tablet dispersible 5 mg.... 23 E.E.S. GRANULES...... 18 diphen...... 131 DOPTELET...... 49 e-400-clear...... 74 di-phen...... 131 DORZOLAMIDE HCL SOLUTION 2 % ear drops...... 128 diphenhist...... 131 OPHTHALMIC...... 126 ear drops earwax aid...... 128 diphenhydramine hcl oral capsule...... 131 dorzolamide hcl solution 2 % ophthalmic... 126 ear wax kit...... 128 diphenhydramine hcl oral elixir...... 131 dorzolamide hcl-timolol mal...... 126 ear wax removal...... 128 diphenhydramine hcl oral liquid 12.5 double antibiotic...... 16 ear wax removal drops...... 128 mg/5ml...... 132 DOVATO...... 41 ear wax removal kit...... 128 diphenhydramine hcl oral tablet...... 132 DOVONEX...... 62 ear wax removal system...... 128 diphenhydramine hcl oral tablet chewable. 132 doxazosin mesylate oral...... 51 earwax removal...... 128 diphenoxylate-atropine oral liquid...... 85 doxepin hcl oral capsule...... 26 earwax removal drops...... 128 diphenoxylate-atropine oral tablet...... 85 doxepin hcl oral concentrate...... 26 earwax removal kit otic solution 6.5 %...... 128 DIPHTHERIA-TETANUS TOXOIDS DT.... 112 doxycycline hyclate oral capsule...... 19 EASIVENT...... 116 dipyridamole oral...... 50 doxycycline hyclate oral tablet 100 mg...... 19 EASIVENT MASK LARGE...... 116 disopyramide phosphate...... 52 doxycycline hyclate oral tablet 20 mg...... 19 EASIVENT MASK MEDIUM...... 116 disulfiram oral tablet 250 mg...... 13 doxycycline monohydrate oral capsule 100 EASIVENT MASK SMALL...... 116 disulfiram oral tablet 500 mg...... 13 mg...... 19 easygel...... 59 DITROPAN XL...... 98 doxycycline monohydrate oral capsule 50 easy-lax plus...... 92 DIURIL...... 54 mg...... 19 EASYMAX 15 LEVEL 2 CONTROL...... 116 divalproex sodium oral capsule delayed DR SMITHS ADULT BARRIER EASYMAX 15 LEVEL 2-3 CONTROL...... 116 release sprinkle...... 45 EXTERNAL OINTMENT...... 62 EBASE CONTROLLER KIT...... 116 divalproex sodium oral tablet delayed DR SMITHS DIAPER...... 62 ec-naproxen...... 9 release...... 45 DRISTAN SPRAY...... 141 econtra ez...... 106 DIVIGEL...... 103 dronabinol...... 27 econtra one-step...... 106 dm maximum adult...... 140 DROXIA ORAL CAPSULE 200 MG, 300 ED A-HIST ORAL LIQUID...... 141 docosanol external...... 41 MG...... 32 ed bron gp...... 141 docu...... 91 DROXIA ORAL CAPSULE 400 MG...... 32 ed chlorped jr...... 129 docusate calcium...... 91 dry-eye relief nighttime...... 122 ed-apap...... 5 docusate mini...... 91 dss...... 91 EDARBI...... 51 docusate sodium oral capsule...... 91 DUAVEE...... 103 EDARBYCLOR...... 53 docusate sodium oral liquid 50 mg/5ml...... 91 ducodyl...... 91 ED-SPAZ...... 80 docusate sodium oral syrup...... 91 DULERA...... 141 EDURANT...... 42 DOCUSOL MINI...... 91 duloxetine hcl oral...... 25 efavirenz...... 42 docuzen...... 91 DUPIXENT...... 62 efavirenz-emtricitab-tenofovir...... 42 dofetilide...... 52 D-VI-SOL...... 74 efavirenz-lamivudine-tenofovir...... 42 dok oral capsule...... 91 d-vite pediatric...... 74 effer-k oral tablet effervescent 25 meq...... 67 donepezil hcl oral tablet 10 mg, 5 mg...... 23 DYANAVEL XR...... 56 EFUDEX...... 62 donepezil hcl oral tablet 23 mg...... 23 dye-free allergy relief...... 132 EGRIFTA SV...... 108 donepezil hcl oral tablet dispersible 10 mg.. 23 DYSPORT...... 116 electrolyte solution...... 67
162 ELESTRIN...... 103 ENSTILAR...... 62 essentials...... 74 ELIDEL...... 62 entacapone...... 38 estarylla...... 103 elinest...... 103 entecavir...... 40 ESTRACE...... 103 ELIQUIS...... 49 enteric aspirin...... 9 estradiol oral...... 103 ELIQUIS DVT/PE STARTER PACK...... 49 ENTRESTO...... 53 estradiol transdermal patch twice weekly...103 ELIXOPHYLLIN...... 135 enulose...... 92 estradiol transdermal patch weekly...... 103 ELMIRON...... 98 EPANED...... 51 estradiol vaginal...... 103 eluryng...... 103 EPCLUSA...... 41 estradiol-norethindrone acet oral tablet 1- EMEND INTRAVENOUS...... 27 ephrine nose drops...... 141 0.5 mg...... 103 EMEND ORAL...... 27 EPIDUO...... 62 ESTRING...... 103 EMGALITY...... 30 EPIDUO FORTE...... 62 ESTROGEL...... 103 EMGALITY (300 MG DOSE)...... 30 epinephrine injection solution auto-injector 135 ethambutol hcl oral tablet 100 mg...... 31 emoquette...... 103 EPIPEN 2-PAK...... 135 ethambutol hcl oral tablet 400 mg...... 31 EMSAM...... 24 EPIPEN JR 2-PAK...... 135 ethosuximide oral...... 20 emtricitabine...... 42 epitol...... 22 ethynodiol diac-eth estradiol...... 103 emtricitabine-tenofovir df...... 42 EPIVIR HBV ORAL SOLUTION...... 40 etodolac...... 9 EMTRIVA ORAL SOLUTION...... 42 EPOGEN...... 49 etonogestrel-ethinyl estradiol...... 103 ENABLEX ORAL TABLET EXTENDED EQUETRO...... 45 etoposide oral...... 33 RELEASE 24 HOUR 7.5 MG...... 98 ergocalciferol oral...... 74 EUCRISA...... 62 enalapril maleate oral...... 51 ergotamine-caffeine...... 30 euthyrox...... 108 enalapril-hydrochlorothiazide...... 53 ERIVEDGE...... 34 EVAC...... 92 ENBREL...... 110 ERLEADA...... 32 EVAMIST...... 103 ENDACOF-DM...... 141 erlotinib hcl...... 34 EVEKEO...... 56 endocet oral tablet 10-325 mg, 5-325 mg, errin...... 106 EVEKEO ODT...... 56 7.5-325 mg...... 11 ery...... 62 everolimus oral tablet 0.25 mg, 0.5 mg, enema...... 92 ERYPED 200...... 18 0.75 mg...... 110 enema disposable...... 92 ERYTHROCIN STEARATE...... 18 everolimus oral tablet 2.5 mg, 5 mg, 7.5 enema mineral oil...... 92 erythromycin base...... 18 mg...... 34 enema ready-to-use...... 92 erythromycin ethylsuccinate oral...... 18 EVOTAZ...... 43 enema rectal enema 16-6 gm/133ml, 19-7 erythromycin external gel...... 62 EXCEDRIN EXTRA STRENGTH...... 5 gm/118ml...... 92 erythromycin external solution...... 62 EXCEDRIN MIGRAINE...... 5 ENEMEEZ MINI...... 92 erythromycin ophthalmic...... 126 exemestane...... 33 ENFAMIL ENFALYTE...... 67 erythromycin oral...... 18 EX-LAX ULTRA...... 92 ENFAMIL EXPECTA...... 74 ESBRIET...... 136 EXTAVIA...... 58 ENGERIX-B...... 112 escitalopram oxalate...... 25 eye drops advanced relief...... 122 enoxaparin sodium...... 49 esomeprazole magnesium oral capsule eye drops allergy relief...... 122 enpresse-28...... 103 delayed release...... 97 eye drops long lasting...... 122 enskyce...... 103 esomeprazole magnesium oral packet...... 97 eye drops ophthalmic solution 0.05 %...... 125 ENSPRYNG...... 109 essential one daily...... 74
163 eye drops ophthalmic solution 0.05-0.1-1-1 fentanyl transdermal patch 72 hour 25 fiber laxative oral tablet 500 mg...... 92 %...... 122 mcg/hr...... 11 fiber oral capsule 0.52 gm...... 92 eye itch relief ophthalmic solution 0.025 % 127 fentanyl transdermal patch 72 hour 50 fiber oral powder 28.3 %...... 92 eye lubricant...... 122 mcg/hr...... 11 fiber oral powder 30.9 %...... 92 ezetimibe...... 55 fentanyl transdermal patch 72 hour 75 fiber oral powder 48.57 %...... 92 FABIOR...... 62 mcg/hr...... 11 fiber oral powder 58.6 %...... 92 falmina...... 103 ferate...... 67 fiber oral tablet 500 mg...... 92 famotidine oral suspension reconstituted FER-IN-SOL...... 67 fiber oral tablet 625 mg...... 92 40 mg/5ml...... 90 ferocon...... 67 fiber therapy oral capsule 0.52 gm...... 92 famotidine oral tablet 10 mg...... 90 ferosul...... 68 fiber therapy oral powder 28.3 %...... 92 famotidine oral tablet 20 mg...... 90 ferotrinsic...... 68 fiber therapy oral tablet 500 mg...... 92 famotidine oral tablet 40 mg...... 90 ferretts...... 68 fiber therapy oral tablet 625 mg...... 92 famotidine orig st...... 90 ferrex 150...... 68 fiber-caps...... 92 FANAPT...... 39 ferric x-150...... 68 FIBERCON...... 92 FARXIGA...... 45 ferrous fumarate oral tablet 324 (106 fe) fiber-lax...... 92 FARYDAK...... 34 mg...... 68 FILTER AIR PP...... 116 FASENRA PEN...... 141 ferrous gluconate oral tablet 240 (27 fe) mg 68 FINACEA...... 62 fast relief laxative...... 92 ferrous gluconate oral tablet 324 (37.5 fe) finasteride oral tablet 5 mg...... 98 felbamate oral suspension...... 21 mg...... 68 FIRAZYR...... 109 felbamate oral tablet...... 21 ferrous gluconate oral tablet 324 (38 fe) mg 68 first aid antibiotic external ointment 3.5- FELBATOL ORAL SUSPENSION...... 21 ferrous sulfate oral elixir...... 68 400-5000 , 3.5-400-5000 mg-unit...... 16 FELBATOL ORAL TABLET...... 21 ferrous sulfate oral solution 75 (15 fe) first aid antiseptic external solution 10 %..... 16 felodipine er...... 53 mg/ml...... 68 FIRVANQ...... 16 FEMHRT LOW DOSE ORAL TABLET 0.5- ferrous sulfate oral tablet 325 (65 fe) mg..... 68 FLAGYL...... 16 2.5 MG-MCG...... 103 ferrous sulfate oral tablet delayed release... 68 flanders buttocks...... 62 FEMRING...... 103 FETZIMA...... 25 flecainide acetate...... 52 femynor...... 103 FETZIMA TITRATION...... 25 FLEET BISACODYL...... 92 fenofibrate micronized oral capsule 134 fever reducer/pain reliever...... 5 FLEET ENEMA...... 92 mg, 200 mg, 67 mg...... 55 fever reducing childrens...... 5 FLEET OIL...... 92 fenofibrate oral capsule 134 mg, 200 mg, feverall adults...... 5 FLEET PEDIATRIC...... 92 67 mg...... 55 feverall childrens...... 5 floranex tablet oral...... 85 fenofibrate oral tablet 160 mg, 54 mg...... 55 FEVERALL INFANTS...... 5 FLORANEX TABLET ORAL...... 85 FENSOLVI (6 MONTH)...... 108 FEVERALL JUNIOR STRENGTH...... 5 FLOVENT DISKUS...... 133 fentanyl citrate (pf)...... 11 fe-vite iron...... 68 FLOVENT HFA...... 133 fentanyl transdermal patch 72 hour 100 FIASP...... 47 fluconazole oral...... 28 mcg/hr...... 11 FIASP FLEXTOUCH...... 47 fludrocortisone acetate oral...... 99 fentanyl transdermal patch 72 hour 12 fiber laxative...... 92 fluocinolone acetonide body...... 62 mcg/hr...... 11 fiber laxative + calcium...... 92 fluocinolone acetonide external cream fiber laxative oral capsule 0.52 gm...... 92 0.025 %...... 62
164 fluocinolone acetonide external ointment.....62 fosinopril sodium-hctz...... 53 gavilax oral powder...... 93 fluocinolone acetonide external solution...... 63 FREESTYLE PRECISION NEO TEST...... 116 gavilyte-c...... 93 fluocinolone acetonide scalp...... 63 freeze dried acidophilus...... 85 gavilyte-n with flavor pack...... 93 fluocinonide external solution...... 63 fruity c...... 74 GAVISCON EXTRA RELIEF FORMULA..... 86 fluoridex daily renewal...... 59 full spectrum b/vitamin c...... 74 GAVISCON EXTRA STRENGTH...... 86 fluoritab...... 68 FULPHILA...... 49 GAVISCON ORAL SUSPENSION...... 86 fluorometholone...... 127 fungi-guard...... 28 GELFOAM SPONGE...... 116 fluorouracil external cream 5 %...... 63 furosemide oral solution 10 mg/ml...... 54 GELUSIL...... 86 fluorouracil external solution...... 63 furosemide oral tablet...... 54 gemfibrozil oral...... 55 fluoxetine hcl oral...... 25 FUZEON...... 43 genaphed...... 141 fluphenazine decanoate injection...... 39 fyavolv...... 103 generlac...... 93 fluphenazine hcl...... 39 FYCOMPA...... 21 gengraf oral capsule 100 mg...... 110 flurbiprofen sodium...... 127 g tussin ac...... 141 gengraf oral capsule 25 mg...... 110 flutamide...... 32 gabapentin oral capsule...... 20 gengraf oral solution...... 110 fluticasone propionate external cream...... 63 gabapentin oral tablet...... 20 GENOTROPIN...... 100 fluticasone propionate external ointment..... 63 GABITRIL...... 20 gentak...... 126 fluticasone propionate nasal...... 133 galantamine hydrobromide oral solution...... 23 gentamicin sulfate external...... 16 fluticasone-salmeterol inhalation aerosol galantamine hydrobromide oral tablet 12 gentamicin sulfate ophthalmic...... 126 powder breath activated 100-50 mcg/dose, mg, 8 mg...... 23 GENTEAL SEVERE...... 122 250-50 mcg/dose, 500-50 mcg/dose...... 141 galantamine hydrobromide oral tablet 4 mg.23 GENTEAL TEARS...... 122 FLUTICASONE-SALMETEROL GARDASIL 9...... 112 GENTEAL TEARS MODERATE PF...... 122 INHALATION AEROSOL POWDER gas relief antiflatuent...... 85 GENTEAL TEARS NIGHT-TIME...... 122 BREATH ACTIVATED 113-14 MCG/ACT, gas relief drops infants...... 85 GENTEAL TEARS PF...... 122 232-14 MCG/ACT, 55-14 MCG/ACT...... 141 gas relief extra strength...... 85 GENTEAL TEARS SEVERE DAY/NIGHT. 122 fluvoxamine maleate...... 25 gas relief extstrength...... 85 gentle laxative...... 93 fluvoxamine maleate er...... 25 gas relief infants...... 85 gentle laxative womens...... 93 foaming antacid oral tablet chewable 80-20 gas relief infants drops...... 85 gentlelax...... 93 mg...... 85 gas relief oral capsule 125 mg...... 85 GENVOYA...... 41 FOCALIN...... 57 gas relief oral suspension...... 85 GEODON ORAL CAPSULE 20 MG, 60 folic acid oral tablet 1 mg...... 68 gas relief oral tablet chewable...... 85 MG...... 39 folic acid oral tablet 400 mcg, 800 mcg...... 68 gas relief oral tablet chewable 125 mg...... 85 GEODON ORAL CAPSULE 40 MG, 80 foltrin...... 68 gas relief ultra strength...... 85 MG...... 39 foot & sneaker...... 28 gas relief ultstrength...... 85 geri-dryl...... 132 foot care (terbinafine)...... 28 GAS-X EXTRA STRENGTH ORAL geri-kot...... 93 for sty relief...... 122 CAPSULE...... 85 geri-lanta...... 86 FORFIVO XL...... 24 GAS-X EXTRA STRENGTH ORAL geri-lanta supreme...... 86 formula em...... 26 TABLET CHEWABLE...... 85 geri-mox...... 86 fosamprenavir calcium...... 43 GAS-X ULTRA STRENGTH...... 85 geri-pectate...... 86 fosinopril sodium...... 51 GATTEX...... 86 geri-tussin dm...... 141
165 GILENYA ORAL CAPSULE 0.25 MG...... 58 gormel...... 63 heartburn relief ex st...... 86 GILENYA ORAL CAPSULE 0.5 MG...... 58 gormel 10...... 63 heartburn relief oral tablet 10 mg...... 90 GILOTRIF...... 34 GRANIX...... 49 heartburn relief oral tablet 200 mg...... 90 giltuss severe sinus...... 141 griseofulvin microsize oral...... 28 heartburn relief oral tablet chewable 160- glatiramer acetate...... 58 griseofulvin ultramicrosize...... 28 105 mg...... 86 glatopa...... 58 guaiatussin ac...... 141 heather...... 106 GLEOSTINE...... 32 guaicon dms...... 141 h-e-b aspirin...... 9 glimepiride...... 45 guaifenesin ac...... 141 h-e-b childrens allergy...... 132 glipizide er...... 45 guaifenesin er...... 141 HELIDAC THERAPY...... 86 glipizide ir...... 45 guaifenesin oral tablet 400 mg...... 141 HEMANGEOL...... 52 glipizide xl...... 45 guaifenesin-codeine...... 141 HEMLIBRA...... 50 GLUCAGEN HYPOKIT...... 46 guaifenesin-dm oral syrup...... 141 HEMOFIL M...... 50 GLUCAGON EMERGENCY INJECTION guanfacine hcl...... 51 hemorrhoidal rectal suppository 0.25-3- SOLUTION RECONSTITUTED...... 46 guanfacine hcl er...... 57 85.5 %...... 63 glucagon emergency kit 1 mg injection...... 46 GVOKE HYPOPEN 1-PACK...... 46 heparin sodium (porcine) injection solution GLUCAGON EMERGENCY KIT 1 MG GVOKE HYPOPEN 2-PACK...... 46 1000 unit/ml, 10000 unit/ml, 5000 unit/ml.... 49 INJECTION...... 46 GVOKE PFS...... 46 heparin sodium (porcine) injection solution GLUCOSE CONTROL SOLUTION IN GYNAZOLE-1...... 28 20000 unit/ml...... 49 VITRO SOLUTION...... 116 GYNE-LOTRIMIN...... 28 heparin sodium (porcine) injection solution GLUCOSE CONTROL SOLUTIONS...... 116 GYNE-LOTRIMIN 3...... 28 prefilled syringe...... 49 glucose oral tablet chewable 4 gm...... 46 habitrol...... 14 heparin sodium (porcine) pf...... 49 glyburide micronized...... 45 HAEGARDA...... 109 HEPLISAV-B...... 112 glyburide oral...... 45 hailey 1.5/30...... 103 HERCEPTIN...... 36 glyburide-metformin...... 46 hailey fe 1.5/30...... 103 hi cal...... 68 glycerin (adult) rectal suppository 2 gm...... 93 hailey fe 1/20...... 103 HUMALOG...... 47 glycerin (infants & children) rectal HALDOL DECANOATE...... 39 HUMALOG JUNIOR KWIKPEN...... 47 suppository 1 gm...... 93 halobetasol propionate external cream...... 63 HUMALOG KWIKPEN...... 47 glycerin (pediatric) rectal suppository 1 gm..93 haloperidol decanoate intramuscular...... 39 HUMALOG MIX 50/50...... 47 glycerin adult rectal suppository 2 gm...... 93 haloperidol lactate oral...... 39 HUMALOG MIX 50/50 KWIKPEN...... 47 glycerin child rectal suppository 1 gm...... 93 haloperidol oral...... 39 HUMALOG MIX 75/25...... 47 glycerin child rectal suppository 1.2 gm...... 93 HARVONI...... 41 HUMALOG MIX 75/25 KWIKPEN...... 47 glycerin childrens...... 93 HAVRIX...... 112 HUMATE-P...... 50 glycerin external...... 63 headache formula...... 5 HUMATROPE INJECTION SOLUTION glycerin external liquid 99.5 %...... 63 headache relief...... 5 RECONSTITUTED 12 MG, 24 MG, 6 MG. 100 glycerin pediatric rectal suppository 1.2 gm. 93 headache relief extra str...... 5 HUMIRA PEN-PEDIATRIC UC START..... 110 glycolax...... 93 healthy hair/skin/nails...... 74 HUMIRA PEN-PSOR/UVEIT STARTER....110 glycopyrrolate oral tablet 1 mg, 2 mg...... 80 heartburn antacid...... 86 HUMIRA SUBCUTANEOUS PEN- glydo...... 13 heartburn antacid ex st...... 86 INJECTOR KIT 40 MG/0.4ML, 40 GLYXAMBI...... 46 heartburn prevention oral tablet 10 mg...... 90 MG/0.8ML, 80 MG/0.8ML...... 110
166 HUMIRA SUBCUTANEOUS PREFILLED hydrocortisone/aloe...... 63 ibuprofen oral tablet 200 mg...... 10 SYRINGE KIT 10 MG/0.1ML, 20 hydrocortisone/aloe max str...... 63 ibuprofen oral tablet 400 mg, 600 mg, 800 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, hydrocortisone-acetic acid...... 128 mg...... 10 80 MG/0.8ML, 80 MG/0.8ML & hydrocortisone-aloe...... 63 icatibant acetate...... 109 40MG/0.4ML...... 110 hydrocortisone-aloe max st...... 63 iclevia...... 103 HUMULIN 70/30 KWIKPEN...... 47 hydrolatum...... 64 ICLUSIG ORAL TABLET 15 MG, 45 MG.....34 HUMULIN 70/30 VIAL...... 47 hydromet...... 141 IDHIFA...... 34 HUMULIN N KWIKPEN...... 47 hydromorphone hcl oral...... 12 iferex 150 forte...... 68 HUMULIN N VIAL...... 47 hydromorphone hcl rectal...... 12 ILARIS...... 111 HUMULIN R U-500 KWIKPEN...... 47 hydroxychloroquine sulfate oral...... 37 ILEVRO...... 127 HUMULIN R U-500 VIAL hydroxyurea oral...... 32 ILUMYA...... 64 (CONCENTRATED)...... 47 hydroxyzine hcl oral...... 44 imatinib mesylate...... 34 HUMULIN R VIAL...... 47 hydroxyzine pamoate oral...... 132 IMBRUVICA...... 34 hydralazine hcl oral...... 55 hyoscyamine sulfate er...... 80 imipramine hcl oral...... 26 hydrochlorothiazide oral...... 54 hyoscyamine sulfate oral...... 80 imipramine pamoate...... 26 hydrocodone bitartrate er oral capsule hyoscyamine sulfate sl...... 80 imiquimod external cream 5 %...... 64 extended release 12 hour...... 11 hyoscyamine sulfate sublingual...... 80 IMODIUM A-D ORAL TABLET...... 86 hydrocodone-acetaminophen oral solution hyosyne...... 80 IMODIUM MULTI-SYMPTOM RELIEF...... 86 7.5-325 mg/15ml...... 12 HYPERTET S/D...... 112 IMPAVIDO...... 37 hydrocodone-acetaminophen oral tablet HYPOTEARS...... 122 INATAL GT...... 74 10-325 mg, 5-325 mg, 7.5-325 mg...... 12 HYSINGLA ER...... 11 incassia...... 106 hydrocodone-homatropine...... 141 IBRANCE...... 34 INCRELEX...... 100 hydrocortisone (perianal) external cream ibu...... 9 INCRUSE ELLIPTA...... 134 2.5 %...... 113 ibu-200...... 9 indapamide...... 54 hydrocortisone anti-itch external cream 0.5 ibuprofen childrens oral tablet chewable indomethacin er...... 10 %...... 63 100 mg...... 9 indomethacin oral capsule 25 mg, 50 mg.... 10 hydrocortisone butyrate external ointment... 63 ibuprofen cold & sinus...... 141 indoor/outdoor allergy rlf...... 132 hydrocortisone butyrate external solution.... 63 ibuprofen cold/sinus oral tablet 30-200 mg 141 INFANRIX...... 112 hydrocortisone external cream 0.5 %, 2.5 ibu-profen cold/sinus oral tablet 30-200 mg infant gas relief...... 86 %...... 63 ...... 141 INFANTS ADVIL...... 10 hydrocortisone external cream 1 %...... 63 ibuprofen ib childrens...... 9 infants gas relief...... 86 hydrocortisone external lotion 2.5 %...... 63 ibuprofen ib oral tablet 200 mg...... 9 infants ibuprofen...... 10 hydrocortisone external ointment 0.5 %...... 63 ibuprofen ib oral tablet chewable 100 mg...... 9 infants pain & fever...... 5 hydrocortisone external ointment 1 %...... 63 ibuprofen infants oral suspension 50 infants pain relief drops...... 5 hydrocortisone external ointment 2.5 %...... 63 mg/1.25ml...... 9 infants pain/fever...... 5 hydrocortisone oral tablet 10 mg, 20 mg, 5 ibuprofen jr oral tablet 100 mg...... 9 infants simethicone...... 86 mg...... 100 ibuprofen junior...... 9 INGREZZA ORAL CAPSULE 40 MG, 80 hydrocortisone plus external cream 1 %...... 63 ibuprofen junior strength...... 9 MG...... 57 hydrocortisone rectal enema 100 mg/60ml 113 ibuprofen oral suspension 100 mg/5ml...... 10
167 INGREZZA ORAL CAPSULE THERAPY introvale...... 103 jencycla...... 106 PACK...... 57 INVEGA...... 39 JENTADUETO...... 46 INLYTA...... 35 INVEGA SUSTENNA...... 39 JENTADUETO XR...... 46 INSPIREASE...... 116 INVEGA TRINZA...... 39 jinteli...... 103 INSPIREASE RESERVOIR BAGS...... 116 INVIRASE...... 43 jock itch external cream 1 %...... 28 instacort 5...... 64 INVOKAMET...... 46 jock itch max st...... 28 INSULIN ASP PROT & ASP FLEXPEN...... 47 INVOKAMET XR...... 46 jock itch spray powder...... 28 INSULIN ASPART...... 47 INVOKANA...... 46 jolessa...... 103 INSULIN ASPART PROT & ASPART...... 47 ipratropium bromide inhalation...... 134 JORNAY PM...... 57 INSULIN LISPRO...... 47 ipratropium bromide nasal...... 134 juleber...... 103 INSULIN LISPRO (1 UNIT DIAL)...... 47 ipratropium-albuterol...... 141 JULUCA...... 42 INSULIN PEN NEEDLES 29G X 12.7MM , IRESSA...... 35 junel 1.5/30...... 103 30G X 8 MM...... 116 iron oral tablet 240 (27 fe) mg...... 68 junel 1/20...... 103 INSULIN PEN NEEDLES 29G X 12MM , iron oral tablet 325 (65 fe) mg...... 68 junel fe oral tablet 1.5-30 mg-mcg...... 103 31G X 5 MM , 31G X 6 MM , 31G X 8 MM.116 iron supplement...... 68 junel fe oral tablet 1-20 mg-mcg...... 103 INSULIN PEN NEEDLES 32G X 4 MM...... 116 iron supplement childrens...... 68 KALETRA ORAL SOLUTION...... 43 INSULIN PEN NEEDLES 32G X 6 MM...... 117 ISENTRESS HD...... 41 KALETRA ORAL TABLET 100-25 MG...... 43 INSULIN SYRINGES 27G X 1/2" 1 ML...... 117 ISENTRESS ORAL PACKET...... 41 KALETRA ORAL TABLET 200-50 MG...... 43 INSULIN SYRINGES 28G X 1/2" 0.5 ML, ISENTRESS ORAL TABLET...... 41 kalliga...... 104 28G X 1/2" 1 ML...... 117 ISENTRESS ORAL TABLET CHEWABLE.. 41 KALYDECO...... 135 INSULIN SYRINGES 28G X 5/16" 1 ML, isibloom...... 103 KAPVAY...... 57 29G X 5/16" 1 ML, 30G X 3/8" 0.5 ML...... 117 isoniazid oral...... 31 kariva...... 104 INSULIN SYRINGES 29G X 1/2" 0.3 ML...117 ISOPTO ATROPINE...... 122 KAZANO...... 46 INSULIN SYRINGES 29G X 1/2" 0.5 ML, isosorbide dinitrate...... 56 kelnor 1/35...... 104 31G X 5/16" 0.3 ML...... 117 isosorbide mononitrate...... 56 kelnor 1/50...... 104 INSULIN SYRINGES 29G X 1/2" 1 ML, isosorbide mononitrate er...... 56 KEPPRA ORAL SOLUTION...... 20 31G X 5/16" 0.5 ML...... 117 isotretinoin oral...... 64 KEPPRA ORAL TABLET...... 20 INSULIN SYRINGES 30G X 1/2" 0.3 ML, ISTALOL...... 126 KESIMPTA...... 56 31G X 15/64" 0.3 ML...... 117 itraconazole oral...... 28 ketoconazole external cream...... 28 INSULIN SYRINGES 30G X 1/2" 0.5 ML, ivermectin oral...... 36 ketoconazole external shampoo...... 28 30G X 1/2" 1 ML...... 117 JAKAFI...... 35 ketoconazole oral...... 28 INSULIN SYRINGES 30G X 5/16" 0.3 ML.117 JANSSEN COVID-19 VACCINE...... 112 KETO-DIASTIX...... 117 INSULIN SYRINGES 30G X 5/16" 0.5 ML.117 jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 KETONE CARE...... 117 INSULIN SYRINGES 30G X 5/16" 1 ML, mg, 3 mg, 4 mg, 5 mg, 7.5 mg...... 49 KETONE TEST...... 117 31G X 5/16" 1 ML...... 117 jantoven oral tablet 6 mg...... 49 ketoprofen oral...... 10 INSULIN SYRINGES 31G X 15/64" 0.5 ML JANUMET...... 46 ketorolac tromethamine intramuscular...... 10 ...... 117 JANUMET XR...... 46 ketorolac tromethamine ophthalmic INTELENCE...... 42 JANUVIA...... 46 solution 0.4 %...... 127 INTRON A...... 41 JARDIANCE...... 46
168 ketorolac tromethamine ophthalmic LACTAID...... 86 LATUDA...... 40 solution 0.5 %...... 127 LACTAID FAST ACT ORAL TABLET...... 86 laxacin...... 93 ketorolac tromethamine oral...... 10 lactase enzyme...... 86 laxaclear...... 93 ketorolac tromethamine solution 30 mg/ml lactase enzyme ultra str...... 86 laxative max str...... 93 injection...... 10 lactase fast acting...... 86 laxative maximum strength oral tablet 25 KETOROLAC TROMETHAMINE lactobacillus oral tablet...... 86 mg...... 93 SOLUTION 30 MG/ML INJECTION...... 10 LACTOJEN...... 86 laxative oral powder 17 gm/scoop...... 93 KETOSTIX...... 117 lacto-pectin...... 86 laxative oral tablet delayed release 5 mg.....93 ketotifen fumarate ophthalmic...... 127 lactose fast acting relief oral tablet...... 87 laxative pills...... 93 KEVZARA...... 111 lactulose encephalopathy...... 93 laxative pills max st...... 94 KINERET...... 110 lactulose oral solution...... 93 laxative pills oral tablet 25 mg...... 94 KISQALI (200 MG DOSE)...... 33 LAMICTAL ORAL TABLET...... 21 laxative rectal suppository 10 mg...... 94 KISQALI (400 MG DOSE) TABLET LAMICTAL ORAL TABLET CHEWABLE..... 21 laxative regular strength...... 94 THERAPY PACK 200 MG ORAL...... 33 LAMICTAL STARTER...... 21 LEDIPASVIR-SOFOSBUVIR...... 41 KISQALI (600 MG DOSE) TABLET LAMISIL AT EXTERNAL CREAM...... 28 leena...... 104 THERAPY PACK 200 MG ORAL...... 33 LAMISIL AT JOCK ITCH...... 28 leflunomide oral...... 111 KITABIS PAK...... 135 lamivudine oral solution...... 42 LENVIMA (10 MG DAILY DOSE)...... 35 KLONOPIN...... 44 lamivudine oral tablet 100 mg...... 40 LENVIMA (12 MG DAILY DOSE)...... 35 klor-con...... 68 lamivudine oral tablet 150 mg, 300 mg...... 42 LENVIMA (14 MG DAILY DOSE)...... 35 klor-con 10...... 68 lamivudine-zidovudine...... 42 LENVIMA (18 MG DAILY DOSE)...... 35 klor-con m10...... 68 lamotrigine oral tablet...... 21 LENVIMA (20 MG DAILY DOSE)...... 35 klor-con m20...... 68 lamotrigine oral tablet chewable...... 21 LENVIMA (24 MG DAILY DOSE)...... 35 klor-con/ef...... 68 lamotrigine starter kit-blue...... 21 LENVIMA (4 MG DAILY DOSE)...... 35 KOATE...... 50 lamotrigine starter kit-green...... 21 LENVIMA (8 MG DAILY DOSE)...... 35 KOGENATE FS INTRAVENOUS KIT 1000 lamotrigine starter kit-orange...... 21 lessina...... 104 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT.....50 LANCETS...... 117 LETAIRIS...... 136 KOMBIGLYZE XR...... 46 lansoprazole oral capsule delayed release letrozole oral...... 33 KONSYL DAILY FIBER ORAL POWDER 15 mg, 30 mg...... 97 leucovorin calcium oral tablet 10 mg...... 33 100 %...... 93 lansoprazole oral tablet delayed release LEUKERAN...... 32 konsyl daily fiber oral powder 28.3 %...... 93 dispersible 15 mg, 30 mg...... 97 LEUKINE...... 49 KORLYM...... 101 LANTUS SOLOSTAR...... 47 leuprolide acetate injection...... 108 K-PHOS...... 68 LANTUS U-100 VIAL...... 47 levalbuterol hcl inhalation...... 135 K-PHOS-NEUTRAL...... 68 lapatinib ditosylate...... 35 LEVBID...... 80 k-prime...... 69 larin 1.5/30...... 104 LEVEMIR U-100 FLEXTOUCH...... 47 KRINTAFEL...... 37 larin 1/20...... 104 LEVEMIR U-100 VIAL...... 48 kurvelo...... 104 larin fe 1.5/30...... 104 levetiracetam oral solution...... 20 KYLEENA...... 106 larin fe 1/20...... 104 levetiracetam oral tablet...... 20 labetalol hcl oral...... 52 larissia...... 104 levobunolol hcl...... 126 LAC-HYDRIN FIVE...... 64 latanoprost ophthalmic...... 127 levocetirizine dihydrochloride oral tablet.... 132
169 levofloxacin oral tablet...... 18 liquid acetaminophen...... 5 losartan potassium-hctz...... 53 levonest...... 104 liquid allergy relief...... 132 LOTRIMIN AF EXTERNAL POWDER...... 117 levonorgest-eth estrad 91-day oral tablet liquid pain relief...... 5 lovastatin oral...... 55 0.15-0.03 mg...... 104 lisinopril oral...... 51 low-ogestrel...... 104 levonorgestrel...... 106 lisinopril-hydrochlorothiazide...... 53 loxapine succinate...... 39 levonorgestrel-ethinyl estrad oral tablet lithium...... 45 LUBIPROSTONE...... 90 0.1-20 mg-mcg...... 104 lithium carbonate er...... 45 lubricant drops fast act...... 122 levonorgestrel-ethinyl estrad oral tablet lithium carbonate oral...... 45 lubricant drops long last...... 122 0.15-30 mg-mcg...... 104 LITHOBID...... 45 lubricant drops ophthalmic gel 0.25-0.3 %. 122 levonorg-eth estrad triphasic...... 104 little ones childrens...... 74 lubricant drops ophthalmic solution...... 122 levora 0.15/30 (28)...... 104 LMX 4...... 13 lubricant eye drops (pf) ophthalmic solution levo-t...... 108 LOKELMA...... 71 0.4-0.3 %...... 122 levothyroxine sodium oral tablet...... 108 long acting nasal spray...... 142 lubricant eye drops (pf) ophthalmic solution levoxyl...... 108 long lasting antacid...... 87 0.5 %...... 123 LEXIVA ORAL SUSPENSION...... 43 long lasting nasal spray...... 142 lubricant eye drops ophthalmic solution LIALDA...... 113 LONSURF...... 33 0.4-0.3 %...... 123 lice killing...... 37 loperamide hcl oral capsule...... 87 lubricant eye drops ophthalmic solution 0.5 lice killing max st...... 37 loperamide hcl oral tablet...... 87 %...... 123 lice killing max strength...... 37 lopinavir-ritonavir...... 43 lubricant eye drops ophthalmic solution 0.6 lice killing maximum strength...... 37 loradamed...... 132 %...... 123 lice maximum strength...... 37 lorata-d...... 142 lubricant eye drops pf...... 123 lice treatment...... 37 loratadine allergy relief oral tablet 10 mg... 132 lubricant eye nighttime...... 123 lice treatment creme rinse...... 37 loratadine allergy relief oral tablet lubricant eye ophthalmic solution 0.4-0.3 % lice treatment external liquid 1 %...... 37 dispersible 10 mg...... 132 ...... 123 lice treatment external shampoo 0.33-4 %...38 loratadine childrens oral solution 5 mg/5ml 132 lubricant eye pm...... 123 lidocaine external cream 4 %...... 13 loratadine childrens oral syrup 5 mg/5ml... 132 lubricant pm...... 123 lidocaine external patch 5 %...... 13 lorata-dine d...... 142 lubricating eye drop...... 123 lidocaine hcl external cream 3 %...... 13 loratadine d 12hr...... 142 lubricating eye drops ophthalmic solution lidocaine hcl urethral/mucosal...... 13 loratadine oral syrup 5 mg/5ml...... 132 0.4-0.3 %...... 123 lidocaine viscous hcl...... 13 loratadine oral tablet...... 132 lubricating eye/overnight...... 123 lidocaine-prilocaine external cream...... 13 loratadine oral tablet dispersible 10 mg..... 132 lubricating plus...... 123 lidopin external cream 3 %...... 13 loratadine-d...... 142 lubricating plus eye drops...... 123 LILETTA (52 MG)...... 106 loratadine-d 12hr...... 142 lubricating tears...... 123 lillow...... 104 loratadine-d 24hr...... 142 lubricating tears eye drops...... 123 linezolid oral suspension reconstituted...... 16 lorazepam intensol...... 44 LUMIGAN...... 127 linezolid oral tablet...... 16 lorazepam oral concentrate 2 mg/ml...... 44 LUNESTA ORAL TABLET 1 MG...... 150 LINZESS...... 90 lorazepam oral tablet...... 44 LUNESTA ORAL TABLET 2 MG, 3 MG.....150 liothyronine sodium oral...... 108 LORBRENA...... 35 LUPANETA PACK...... 108 liquibid...... 142 losartan potassium oral...... 51 LUPKYNIS...... 111
170 LUPRON DEPOT (1-MONTH)...... 108 MASK VORTEX/TODDLER/LADYBUG.....117 MEKINIST...... 35 LUPRON DEPOT (3-MONTH)...... 108 MATULANE...... 32 meloxicam oral tablet...... 10 LUPRON DEPOT (4-MONTH) MAVENCLAD (10 TABS)...... 58 melphalan...... 32 INTRAMUSCULAR KIT 30MG...... 108 MAVENCLAD (4 TABS)...... 58 memantine hcl oral solution 2 mg/ml...... 23 LUPRON DEPOT (6-MONTH) MAVENCLAD (5 TABS)...... 58 memantine hcl oral tablet...... 23 INTRAMUSCULAR KIT 45MG...... 108 MAVENCLAD (6 TABS)...... 58 MENACTRA...... 112 LUPRON DEPOT-PED (1-MONTH)...... 108 MAVENCLAD (7 TABS)...... 58 MENEST...... 104 LUPRON DEPOT-PED (3-MONTH)...... 108 MAVENCLAD (8 TABS)...... 58 MENOSTAR...... 104 lutera...... 104 MAVENCLAD (9 TABS)...... 58 MENQUADFI...... 112 LUXIQ...... 64 MAVYRET...... 41 MENVEO...... 112 lyleq...... 106 maxi-tuss ac...... 142 meprobamate...... 44 LYNPARZA...... 35 maxi-tuss gmx...... 142 mercaptopurine oral...... 32 LYRICA...... 58 maxi-tuss pe max...... 142 mesalamine oral capsule delayed release lysiplex plus oral tablet...... 74 MAYZENT...... 58 400 mg...... 113 LYSODREN...... 108 m-clear wc...... 142 mesalamine rectal...... 113 LYUMJEV...... 128 m-dryl...... 132 MESNEX ORAL...... 36 lyza...... 107 meclizine hcl oral tablet 12.5 mg...... 26 metformin hcl er...... 46 MAALOX...... 87 meclizine hcl oral tablet 25 mg...... 26 metformin hcl er (osm)...... 46 MAALOX CHILDRENS...... 87 meclizine hcl oral tablet chewable...... 26 metformin hcl oral tablet...... 46 MAALOX MAX ORAL SUSPENSION...... 87 medicated spot...... 64 methazolamide oral...... 54 MAALOX MULTI SYMPTOM MAX ST...... 87 medifin 400...... 142 methenamine hippurate...... 15 mag-al plus...... 87 medi-first triple antibiotic...... 16 methergine...... 118 mag-al plus xs...... 87 mediproxen...... 10 methimazole oral...... 109 magnesium citrate oral solution...... 94 MEDISENSE GLUCOSE KETONE methocarbamol oral...... 149 magnesium oxide oral tablet 400 (241.3 CONTR...... 117 methotrexate oral...... 111 mg) mg...... 69 MEDISENSE HI/MID/LOW CONTROL...... 118 methotrexate sodium (pf)...... 111 magnesium oxide oral tablet 400 mg...... 87 MEDISENSE HIGH/LOW CONTROL...... 118 methotrexate sodium injection solution...... 111 magnesium oxide oral tablet 420 mg...... 87 MEDISENSE MID CONTROL...... 118 methotrexate sodium oral...... 111 magnesium-oxide...... 69 medroxyprogesterone acetate methoxsalen rapid...... 64 malathion...... 38 intramuscular...... 107 methyldopa...... 51 MAOX...... 87 medroxyprogesterone acetate oral...... 107 methyldopa-hydrochlorothiazide...... 54 mapap acetaminophen extra str...... 6 mefloquine hcl...... 37 methylergonovine maleate oral...... 118 mapap arthritis pain...... 6 mega probiotic...... 87 METHYLIN ORAL SOLUTION 10 MG/5ML. 57 mapap childrens...... 6 megestrol acetate oral suspension 40 METHYLIN ORAL SOLUTION 5 MG/5ML... 57 mapap oral capsule...... 6 mg/ml...... 107 methylphenidate hcl er (cd)...... 57 maprotiline hcl...... 25 megestrol acetate oral tablet...... 107 methylphenidate hcl er (la) oral capsule marlissa...... 104 meijer allergy relief-d...... 142 extended release 24 hour 20 mg, 30 mg, MARPLAN...... 24 meijer antacid...... 87 40 mg...... 57 MASK VORTEX/CHILD/FROG...... 117 meijer anti-diarrheal...... 87
171 methylphenidate hcl er oral tablet extended microgestin fe 1.5/30...... 104 mm cetirizine hcl...... 132 release 10 mg, 20 mg...... 57 microgestin fe 1/20...... 104 mm clearlax...... 94 methylphenidate hcl er oral tablet extended midodrine hcl...... 51 mm stool softener laxative...... 94 release 18 mg, 27 mg, 36 mg, 54 mg...... 57 MIGERGOT...... 30 M-M-R II...... 112 methylphenidate hcl er oral tablet extended migraine formula...... 6 M-NATAL PLUS...... 74 release 24 hour...... 57 migraine relief...... 6 moisturel...... 64 methylphenidate hcl oral tablet...... 57 milantex...... 87 molindone hcl...... 39 methylprednisolone oral...... 100 milantex extra strength...... 87 mometasone furoate external...... 64 metoclopramide hcl oral solution...... 26 mili...... 104 mondoxyne nl oral capsule 100 mg...... 19 metoclopramide hcl oral tablet...... 87 milk of magnesia...... 94 mono-linyah...... 104 metolazone...... 54 MILLIPRED...... 100 montelukast sodium oral...... 134 metoprolol succinate er...... 52 mimvey...... 104 morgidox oral...... 19 metoprolol tartrate oral tablet 100 mg, 50 mineral oil enema...... 94 morphine sulfate (concentrate) oral mg...... 52 mineral oil heavy oral...... 94 solution 100 mg/5ml, 20 mg/ml...... 12 metoprolol tartrate oral tablet 25 mg...... 52 MINERAL OIL ORAL OIL...... 94 morphine sulfate (pf) injection solution 2 METROGEL...... 16 mineral oil oral oil ...... 94 mg/ml...... 12 metronidazole external...... 16 mineral oil rectal enema ...... 94 morphine sulfate (pf) intravenous solution 2 metronidazole oral tablet...... 16 MINI COMPRESSOR...... 118 mg/ml...... 12 metronidazole vaginal...... 16 mini nicotine...... 14 morphine sulfate er oral tablet extended mexiletine hcl oral...... 52 minitran...... 56 release...... 11 mi-acid gas relief...... 87 MINIVELLE...... 104 morphine sulfate injection solution 2 mg/ml, micaderm...... 29 minocycline hcl oral capsule 100 mg...... 19 4 mg/ml...... 12 miconazole 3...... 29 minocycline hcl oral capsule 50 mg...... 19 morphine sulfate intravenous solution 50 miconazole 3 applicator vaginal kit 200 & 2 minoxidil oral...... 55 mg/ml...... 12 mg-% (9gm)...... 29 mintox maximum strength...... 87 morphine sulfate oral...... 12 miconazole 3 combo pack app...... 29 mintox plus...... 87 morphine sulfate rectal...... 12 miconazole 3 combo pack vaginal kit 200 & MIRALAX ORAL POWDER...... 94 MOTEGRITY...... 87 2 mg-% (9gm)...... 29 MIRCERA INJECTION SOLUTION motion sickness relief oral tablet chewable miconazole 7 day treatment...... 29 PREFILLED SYRINGE 100 MCG/0.3ML, 25 mg...... 26 miconazole 7 vaginal cream 2 %...... 29 200 MCG/0.3ML, 50 MCG/0.3ML, 75 motion-time...... 26 miconazole 7 vaginal suppository 100 mg... 29 MCG/0.3ML...... 49 MOTRIN CHILDRENS...... 10 miconazole antifungal...... 29 MIRENA (52 MG)...... 107 MOTRIN IB ORAL TABLET...... 10 miconazole nitrate external...... 29 mirtazapine oral tablet 15 mg, 30 mg...... 24 MOTRIN INFANTS DROPS...... 10 miconazole nitrate vaginal...... 29 mirtazapine oral tablet 45 mg, 7.5 mg...... 24 MOVANTIK...... 87 miconazorb af...... 118 mirtazapine oral tablet dispersible...... 24 MOXEZA...... 18 MICRODOT PEN NEEDLE 31G X 6 MM...118 MIRVASO...... 64 MOZOBIL...... 49 MICRODOT PEN NEEDLE 32G X 4 MM...118 misoprostol oral...... 96 m-pap...... 6 microgestin 1.5/30...... 104 MITIGARE...... 30 MUCINEX CHILDRENS FREEFROM microgestin 1/20...... 104 mm arthritis pain...... 6 ORAL LIQUID 5-100 MG/5ML...... 142
172 MUCINEX CHILDRENS STUFFY NOSE...142 MULPLETA...... 49 nabumetone oral...... 10 MUCINEX COUGH CHILDRENS...... 142 MULTAQ...... 52 nafrinse...... 69 MUCINEX D...... 142 multi vitamin...... 74 nafrinse drops...... 69 MUCINEX D MAX STRENGTH...... 142 multi vitamin w/d-3...... 74 naloxone hcl injection...... 14 MUCINEX DM...... 142 multiple vitamin-folic acid...... 74 naltrexone hcl oral...... 13 MUCINEX FAST-MAX DM MAX...... 142 multiple vitamins essential...... 74 NAPHCON-A...... 125 MUCINEX MAXIMUM STRENGTH...... 142 multiple vitamins/iron...... 74 naproxen oral...... 10 MUCINEX SINUS-MAX CLEAR & COOL.. 142 MULTIPRO...... 74 naproxen sodium oral tablet 220 mg...... 10 MUCINEX SINUS-MAX SINUS/ALLRGY.. 142 multi-vit/iron/fluoride...... 74 NARAMIN...... 132 mucus & cough relief child...... 143 multi-vitamin...... 74 naratriptan hcl...... 30 mucus & cough relief childrens...... 143 multi-vitamin/fluoride...... 74 NARCAN...... 14 mucus d...... 143 multivitamin/fluoride oral solution...... 74 NASACORT ALLERGY 24HR...... 133 mucus d extended release...... 143 multivitamin/fluoride oral tablet chewable NASACORT ALLERGY 24HR CHILDREN 134 mucus d max st er...... 143 0.25 mg, 0.5 mg, 1 mg...... 74 nasal allergy 24 hour...... 134 mucus dm...... 143 multi-vitamin/fluoride/iron...... 75 nasal allergy nasal aerosol 55 mcg/act...... 134 mucus er oral tablet extended release 12 multi-vitamin/iron...... 75 nasal allergy spray...... 134 hour 1200 mg...... 143 mupirocin external...... 17 nasal decongestant 12 hour...... 144 mucus extended release oral tablet MURO 128 OPHTHALMIC OINTMENT.....123 nasal decongestant 12hr...... 144 extended release 12 hour 1200 mg...... 143 MURO 128 OPHTHALMIC SOLUTION 5 nasal decongestant max st...... 144 mucus relief chest oral tablet 400 mg...... 143 %...... 123 nasal decongestant oral tablet 30 mg...... 144 mucus relief cough children...... 143 my choice...... 107 nasal decongestant oral tablet extended mucus relief cough childrens...... 143 my way...... 107 release 12 hour 120 mg...... 144 mucus relief d max strength...... 143 mycophenolate mofetil oral capsule...... 111 nasal decongestant pe max st...... 144 mucus relief d oral tablet extended release mycophenolate mofetil oral suspension nasal decongestant pe oral tablet 10 mg... 144 12 hour 60-600 mg...... 143 reconstituted...... 111 nasal decongestant spray...... 144 mucus relief dm max oral liquid...... 143 mycophenolate mofetil oral tablet...... 111 nasal four...... 144 mucus relief dm oral liquid...... 143 mycophenolate sodium...... 111 nasal mist nasal solution...... 144 mucus relief dm oral tablet extended MYCOZYL AP...... 118 NASAL MOIST NASAL SOLUTION...... 144 release 12 hour 30-600 mg...... 143 MYDAYIS...... 56 nasal moisturizing spray...... 144 mucus relief er oral tablet extended release myferon 150...... 69 nasal relief...... 144 12 hour 1200 mg...... 143 myferon 150 forte...... 69 nasal relief moisturizing...... 144 mucus relief max st...... 143 MYLERAN...... 32 nasal spray...... 144 mucus relief max strength oral tablet mynephrocaps...... 75 nasal spray 12 hour...... 144 extended release 12 hour 1200 mg...... 143 MYNEPHRON...... 75 nasal spray anti-drip...... 144 mucus relief oral tablet...... 144 MYOBLOC...... 118 nasal spray extra moist...... 144 mucus-d...... 144 myorisan...... 64 nasal spray extra moisturizing...... 145 mucus-dm...... 144 MYRBETRIQ...... 98 nasal spray fast acting...... 145 mucus-er oral tablet extended release 12 MYSOLINE...... 20 nasal spray moisturizing...... 145 hour 1200 mg...... 144 MYTESI...... 87 nasal spray no drip...... 145
173 nasal spray saline...... 145 neo-polycin hc...... 124 NICORETTE MINI...... 14 nasal spray sinus...... 145 NEOSPORIN ORIGINAL...... 17 NICORETTE STARTER KIT...... 14 NASALCROM...... 135 NEO-SYNEPHRINE COLD/ALLRG MILD. 145 nicotine gum mouth/throat gum 2 mg...... 14 nateglinide...... 46 NEO-SYNEPHRINE COLD/ALLRGY EXT.145 nicotine gum mouth/throat gum 4 mg...... 14 natural daily fiber...... 94 NEO-SYNEPHRINE COLD/ALLRGY REG 145 nicotine gum mouth/throat lozenge 2 mg..... 14 natural fiber laxative oral powder 58.6 %..... 94 nephro vitamins...... 75 nicotine gum mouth/throat lozenge 4 mg..... 14 natural fiber oral capsule 0.52 gm...... 94 NEPHRO-VITE...... 75 nicotine mini...... 14 natural fiber oral powder 28.3 %...... 94 NESINA...... 46 nicotine mouth/throat gum 2 mg...... 14 natural fiber oral powder 48.57 %...... 94 NEULASTA...... 49 nicotine mouth/throat gum 4 mg...... 14 natural fiber oral powder 58.6 %...... 94 NEULASTA ONPRO...... 49 nicotine mouth/throat lozenge 2 mg...... 14 natural fiber supplement oral powder...... 94 NEUPOGEN...... 49 nicotine mouth/throat lozenge 4 mg...... 15 natural laxative...... 94 NEURONTIN ORAL CAPSULE...... 20 nicotine polacrilex mini...... 15 natural laxative/stool soft...... 94 NEURONTIN ORAL TABLET...... 20 nicotine polacrilex mouth/throat...... 15 natural senna laxative...... 94 NEUTEK 2TEK CONTROL...... 118 nicotine step 1...... 15 natural tears pf...... 123 NEUTROGENA OIL-FREE ACNE WASH... 64 nicotine step 2...... 15 natural vegetable...... 94 NEVANAC...... 127 nicotine step 3...... 15 natural vegetable fiber...... 94 nevirapine...... 42 nicotine transdermal patch 24 hour 14 natural vegetable laxative...... 94 nevirapine er...... 42 mg/24hr, 7 mg/24hr...... 15 natural vitamin e...... 75 new day...... 107 nicotine transdermal patch 24 hour 21 natura-lax...... 94 NEXAVAR...... 35 mg/24hr...... 15 nausea control...... 26 NEXIUM ORAL CAPSULE DELAYED nicotine transdermal system...... 15 nausea relief...... 26 RELEASE...... 97 NICOTROL...... 15 NAYZILAM...... 20 NEXIUM ORAL PACKET 10 MG, 20 MG, NICOTROL NS...... 15 necon 0.5/35 (28)...... 104 40 MG...... 97 nifedipine er...... 53 nefazodone hcl...... 25 NEXIUM ORAL PACKET 2.5 MG, 5 MG..... 97 nifedipine er osmotic release...... 53 NEODOT THERMOMETER...... 118 NEXLETOL...... 55 nifedipine oral...... 53 NEOMULTIVITE...... 75 NEXLIZET...... 50 nighttime dry-eye relief...... 124 neomycin sulfate oral...... 16 NEXPLANON...... 107 nimodipine oral...... 53 neomycin-bacitracin zn-polymyx...... 123 niacin (antihyperlipidemic)...... 55 NINLARO...... 33 neomycin-polymyxin-dexameth ophthalmic niacin er (antihyperlipidemic)...... 55 nitazoxanide...... 37 ointment...... 123 niacin er oral capsule extended release NITRO-BID...... 56 neomycin-polymyxin-dexameth ophthalmic 250 mg...... 75 NITRO-DUR TRANSDERMAL PATCH 24 suspension 3.5-10000-0.1 ...... 123 niacin er oral capsule extended release HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 neomycin-polymyxin-gramicidin...... 123 500 mg...... 75 MG/HR, 0.6 MG/HR...... 56 neomycin-polymyxin-hc otic...... 128 niacin er oral tablet extended release...... 75 nitrofurantoin...... 15 NEONATAL COMPLETE...... 75 niacin oral tablet 100 mg, 250 mg, 50 mg.... 75 nitrofurantoin macrocrystal...... 15 NEONATAL PLUS...... 75 niacor...... 55 nitrofurantoin monohydrate macrocrystals... 15 NEONATAL VITAMIN...... 75 NICODERM CQ...... 14 nitroglycerin sublingual...... 56 neo-polycin...... 123 NICORETTE...... 14 nitroglycerin transdermal...... 56
174 nitroglycerin translingual...... 56 NOVAMV PEDIATRIC MULTI-VITAMIN...... 75 NUWIQ INTRAVENOUS KIT 1000 UNIT, NITYR...... 97 novarel intramuscular solution 2000 UNIT, 500 UNIT...... 50 NIVA-PLUS...... 75 reconstituted 10000 unit...... 100 NUZYRA ORAL...... 19 NIVESTYM...... 49 NOVAREL INTRAMUSCULAR SOLUTION nyamyc...... 29 no drip nasal relief...... 145 RECONSTITUTED 5000 UNIT...... 100 nylia 7/7/7...... 105 no drip nasal spray...... 145 NOVOLIN 70/30 FLEXPEN...... 48 NYMALIZE...... 53 NOCDURNA...... 100 NOVOLIN 70/30 RELION...... 48 nymyo...... 105 nohist-lq...... 145 NOVOLIN 70/30 VIAL...... 48 nystatin external...... 29 non-aspirin...... 6 NOVOLIN N FLEXPEN...... 48 nystatin mouth/throat...... 29 non-aspirin 8 hour...... 6 NOVOLIN N RELION...... 48 nystatin oral...... 29 non-aspirin childrens...... 6 NOVOLIN N VIAL...... 48 nystop...... 29 non-aspirin extra strength...... 6 NOVOLIN R FLEXPEN...... 48 NYVEPRIA...... 48 non-aspirin jr strength...... 6 NOVOLIN R RELION...... 48 O-CAL PRENATAL...... 75 non-aspirin pain relief...... 6 NOVOLIN R VIAL...... 48 OCEAN FOR KIDS...... 145 non-pseudo sinus decongestant...... 145 NOVOLOG FLEXPEN...... 48 OCEAN NASAL SPRAY...... 145 nora-be...... 107 NOVOLOG MIX 70/30 FLEXPEN...... 48 octreotide acetate...... 108 NORDITROPIN FLEXPRO...... 100 NOVOLOG MIX 70/30 VIAL...... 48 ODEFSEY...... 42 norethin ace-eth estrad-fe oral tablet...... 105 NOVOLOG PENFILL...... 48 ODOMZO...... 35 norethindrone acetate oral...... 107 NOVOLOG U-100 VIAL...... 48 OFEV...... 136 norethindrone acet-ethinyl est...... 105 NOVOTWIST PEN NEEDLE...... 118 ofloxacin ophthalmic...... 126 norethindrone oral...... 107 NPLATE SUBCUTANEOUS SOLUTION ofloxacin oral...... 18 norgestimate-eth estradiol...... 105 RECONSTITUTED 250 MCG, 500 MCG.....49 ofloxacin otic...... 127 norgestimate-ethinyl estradiol triphasic oral NUBEQA...... 32 ointment base...... 64 tablet 0.18/0.215/0.25 mg-35 mcg...... 105 NUCALA SUBCUTANEOUS SOLUTION olanzapine oral...... 40 NORITATE...... 17 AUTO-INJECTOR...... 145 olanzapine-fluoxetine hcl...... 24 norlyda...... 107 NUCALA SUBCUTANEOUS SOLUTION olopatadine hcl ophthalmic...... 125 norlyroc...... 107 PREFILLED SYRINGE...... 145 OLUMIANT...... 111 NORPACE...... 52 NUCYNTA ER...... 11 OLUX...... 64 NORPACE CR...... 52 NUEDEXTA...... 57 OLUX-E...... 64 nortrel 0.5/35 (28)...... 105 NU-IRON...... 69 OMECLAMOX-PAK...... 87 nortrel 1/35 (21)...... 105 NULEV...... 80 omega-3-acid ethyl esters...... 55 nortrel 1/35 (28)...... 105 NUPLAZID...... 40 omeprazole magnesium oral capsule nortrel 7/7/7...... 105 NURTEC...... 30 delayed release...... 97 nortriptyline hcl oral...... 26 NUTRAPLUS...... 64 omeprazole magnesium oral tablet delayed NORVIR ORAL PACKET...... 43 nutrifac zx...... 75 release...... 97 NORVIR ORAL SOLUTION...... 43 NUTROPIN AQ NUSPIN 10...... 101 omeprazole oral capsule delayed release nose drops extstrength...... 145 NUTROPIN AQ NUSPIN 20...... 101 10 mg, 20 mg, 20.6 (20 base) mg, 40 mg.... 97 nose drops nasal decongest...... 145 NUTROPIN AQ NUSPIN 5...... 101 omeprazole oral tablet delayed release 20 nose drops nasal solution 1 %...... 145 mg...... 97
175 OMNARIS...... 134 ORENCIA CLICKJECT...... 111 OXYCONTIN...... 11 OMNIFLEX DIAPHRAGM...... 118 ORENCIA SUBCUTANEOUS...... 111 oxymorphone hcl er...... 11 OMNITROPE...... 101 ORFADIN...... 97 OXYTROL FOR WOMEN...... 98 once daily...... 75 ORIAHNN...... 108 oysco 500+d...... 69 once daily/iron...... 75 ORILISSA...... 108 oyster shell calcium 500 + d...... 69 ondansetron hcl oral...... 27 ORKAMBI...... 135 oyster shell calcium oral tablet 500 mg...... 69 ondansetron odt...... 27 orphenadrine citrate er...... 149 oyster shell calcium plus d oral tablet 500- one daily...... 75 orsythia...... 105 200 mg-unit...... 69 one daily plus iron...... 75 OS-CAL CALCIUM + D3...... 69 oyster shell calcium/d oral tablet 250-125 ONE VITE WOMENS...... 75 oscimin...... 80 mg-unit...... 69 ONE VITE WOMENS PLUS...... 75 oscimin sr...... 80 oyster shell calcium/d oral tablet 250-250 one-daily multi vitamins...... 75 oseltamivir phosphate oral capsule...... 44 mg-unit, 500-400 mg-unit...... 69 one-daily multi-vitamin oral tablet...... 75 oseltamivir phosphate oral suspension oyster shell calcium/d oral tablet 500-200 one-daily multi-vitamin/iron...... 75 reconstituted...... 44 mg-unit...... 69 one-daily/iron...... 76 OSENI...... 46 oyster shell calcium/vit d...... 69 ONETOUCH ULTRA...... 118 OSPHENA...... 107 oyster shell calcium/vitamin d oral tablet...... 69 ONETOUCH ULTRA 2 KIT W/DEVICE..... 118 OTEZLA...... 111 OZEMPIC SUBCUTANEOUS SOLUTION ONETOUCH ULTRA CONTROL...... 118 OTREXUP SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML...... 46 ONETOUCH ULTRA MINI KIT W/DEVICE 118 AUTO-INJECTOR 10 MG/0.4ML, 15 p col-rite...... 94 ONETOUCH VERIO FLEX SYSTEM KIT MG/0.4ML, 20 MG/0.4ML, 25 MG/0.4ML...111 PACERONE...... 52 W/DEVICE...... 118 OTREXUP SUBCUTANEOUS SOLUTION pain & fever child...... 6 ONETOUCH VERIO IN VITRO SOLUTION AUTO-INJECTOR 12.5 MG/0.4ML, 17.5 pain & fever childrens oral suspension 160 ...... 118 MG/0.4ML, 22.5 MG/0.4ML...... 111 mg/5ml...... 6 ONETOUCH VERIO IQ SYSTEM...... 119 OVIDREL...... 101 pain & fever infants...... 6 ONETOUCH VERIO KIT W/DEVICE...... 118 oxaprozin...... 10 pain relief childrens...... 6 ONETOUCH VERIO REFLECT KIT OXAYDO ORAL TABLET 5 MG...... 12 pain relief childrens oral tablet chewable W/DEVICE...... 119 oxazepam...... 44 160 mg...... 6 ONETOUCH VERIO SYNC SYSTEM...... 119 oxcarbazepine oral suspension...... 22 pain relief extra st...... 6 ONETOUCH VERIO TEST STRIPS...... 118 oxcarbazepine oral tablet...... 22 pain relief extra strength...... 6 ONEVITE...... 76 oxybutynin chloride er...... 98 pain relief infants oral suspension 160 ONEXTON...... 64 oxybutynin chloride oral...... 98 mg/5ml...... 6 ONFI...... 21 oxycodone hcl oral concentrate 100 pain relief oral liquid 500 mg/15ml...... 6 ONGLYZA...... 46 mg/5ml...... 12 pain relief oral tablet 325 mg...... 6 opcicon one-step...... 107 oxycodone hcl oral solution...... 12 pain relief oral tablet 500 mg...... 6 OPSUMIT...... 136 oxycodone hcl oral tablet 10 mg, 20 mg...... 12 pain relief oral tablet extended release 650 option 2...... 107 oxycodone hcl oral tablet 15 mg, 30 mg...... 12 mg...... 7 ORACEA...... 19 oxycodone-acetaminophen oral tablet 10- pain relief regular st...... 7 oralone...... 59 325 mg, 5-325 mg, 7.5-325 mg...... 12 pain relief regular strength...... 7 oralyte freezer pops...... 69 oxycodone-aspirin...... 12 pain relief/rapid burst...... 7
176 pain relieve child dye-free...... 7 PARI VIOS PRO LC SPRINT SYSTEM.....119 perphenazine-amitriptyline...... 24 pain reliever childrens oral suspension 160 PARI VORTEX ADULT MASK...... 119 PERSERIS...... 40 mg/5ml...... 7 paromomycin sulfate oral...... 16 PEXEVA...... 25 pain reliever ex st oral liquid 500 mg/15ml.....7 paroxetine hcl...... 25 pharbedryl...... 132 pain reliever ex st oral tablet 500 mg...... 7 paroxetine hcl er...... 25 PHARBETOL EXTRA STRENGTH...... 7 pain reliever ex st oral tablet extended PASER...... 31 PHARBETOL ORAL TABLET 325 MG...... 7 release 650 mg...... 7 PATADAY OPHTHALMIC SOLUTION 0.1 pharbinex...... 145 pain reliever extra strength oral tablet 250- %...... 125 PHAZYME...... 87 250-65 mg...... 7 PATADAY OPHTHALMIC SOLUTION 0.2 PHAZYME ULTRA STRENGTH...... 88 pain reliever extra strength oral tablet 500 %...... 125 phenazo oral tablet 200 mg...... 98 mg...... 7 PAXIL ORAL SUSPENSION...... 25 phenazo oral tablet 95 mg...... 98 pain reliever infants oral suspension 160 ped electrolyte freeze pop...... 69 phenazopyridine hcl oral tablet 100 mg...... 98 mg/5ml...... 7 ped electrolyte freezer pops...... 69 phenazopyridine hcl oral tablet 200 mg...... 98 pain reliever oral tablet...... 7 PEDIA-LAX ORAL LIQUID...... 94 phenelzine sulfate oral...... 24 pain reliever plus...... 7 PEDIA-LAX RECTAL SUPPOSITORY 1 phenobarbital oral elixir...... 21 pain-off...... 7 GM...... 94 phenobarbital oral tablet...... 20 paliperidone er...... 40 PEDIALYTE FREEZER POPS...... 69 phenylephrine hcl ophthalmic...... 124 PANADOL CHILDRENS...... 7 PEDIALYTE ORAL SOLUTION...... 69 phenylephrine hcl oral...... 145 PANADOL EXTRA STRENGTH...... 7 PEDIALYTE SINGLES...... 69 PHENYTEK...... 22 PANADOL INFANTS...... 7 PEDIATRIC COMPRESSOR NEBULIZER 120 phenytoin infatabs...... 22 PANCREAZE...... 97 pediatric electrolyte oral solution...... 69 phenytoin oral suspension 125 mg/5ml...... 22 PANOXYL...... 64 pediavit...... 76 phenytoin oral tablet chewable...... 22 PANRETIN...... 36 peg 3350 oral powder...... 95 phenytoin sodium extended...... 22 pantoprazole sodium oral packet...... 97 peg 3350-kcl-na bicarb-nacl...... 95 philith...... 105 pantoprazole sodium oral tablet delayed PEGASYS...... 41 PHILLIPS MILK OF MAGNESIA ORAL release...... 97 penicillamine oral tablet...... 98 SUSPENSION 400 MG/5ML...... 95 PARAGARD INTRAUTERINE COPPER... 119 penicillin v potassium...... 18 PHOSPHA 250 NEUTRAL...... 70 PARI ALTERA NEBULIZER HANDSET.... 119 pentamidine isethionate inhalation...... 37 PHOSPHASAL...... 98 PARI ALTERA NEBULIZER SYSTEM...... 119 PENTASA...... 113 PHOSPHOLINE IODIDE...... 126 PARI BABY CONVERSION KIT...... 119 pentazocine-naloxone hcl...... 12 phosphorous...... 70 PARI ERAPID NEBULIZER HANDSET..... 119 pentoxifylline er...... 54 phospho-trin 250 neutral...... 70 PARI ERAPID NEBULIZER SYSTEM...... 119 peptic relief...... 87 phytonadione injection solution 10 mg/ml.... 76 PARI LC PLUS NEB SET PED MASK...... 119 PEPTO-BISMOL ORAL SUSPENSION phytonadione oral...... 76 PARI LC PLUS NEBULIZER...... 119 524 MG/30ML...... 87 PIFELTRO...... 42 PARI LC PLUS VIOS PRO NEB...... 119 PERDIEM OVERNIGHT RELIEF...... 95 pilocarpine hcl ophthalmic...... 126 PARI LC SPRINT NEBULIZER SET...... 119 PERFOROMIST...... 135 pilocarpine hcl oral...... 59 PARI SINUS AEROSOL SYSTEM...... 119 periogard...... 59 pimecrolimus...... 64 PARI TREK S W/12V DC ADAPTOR...... 119 permethrin external...... 38 pimozide...... 39 PARI VIOS PRO LC PLUS SYSTEM...... 119 perphenazine oral...... 26 pimtrea...... 105
177 pink bismuth maximum strength...... 88 potassium chloride er oral tablet extended prednisolone sodium phosphate pink bismuth oral suspension 262 mg/15ml. 88 release...... 70 ophthalmic...... 127 pink bismuth oral tablet 262 mg...... 88 potassium chloride oral packet...... 70 prednisolone sodium phosphate oral pink bismuth oral tablet chewable 262 mg... 88 potassium chloride oral solution 20 solution 15 mg/5ml...... 100 pink-bismuth...... 88 meq/15ml (10%), 40 meq/15ml (20%)...... 70 prednisolone sodium phosphate oral pioglitazone hcl...... 46 potassium citrate er oral tablet extended solution 6.7 (5 base) mg/5ml...... 100 piperacillin sod-tazobactam so intravenous release 10 meq (1080 mg)...... 70 prednisone oral solution...... 100 solution reconstituted 4.5 (4-0.5) gm...... 18 potassium citrate er oral tablet extended prednisone oral tablet...... 100 PIQRAY (200 MG DAILY DOSE)...... 33 release 15 meq (1620 mg)...... 70 prednisone oral tablet therapy pack 10 mg PIQRAY (250 MG DAILY DOSE)...... 33 potassium citrate er oral tablet extended (21)...... 100 PIQRAY (300 MG DAILY DOSE)...... 33 release 5 meq (540 mg)...... 70 prednisone oral tablet therapy pack 10 mg pirmella 1/35...... 105 povidone iodine...... 17 (48), 5 mg (21), 5 mg (48)...... 100 pirmella 7/7/7...... 105 povidone-iodine external solution...... 17 PREFEST...... 105 piroxicam oral...... 10 POVIDONE-IODINE OPHTHALMIC...... 17 pregabalin oral...... 58 PLAN B ONE-STEP...... 107 PRADAXA...... 49 pregnyl...... 101 PLEGRIDY INTRAMUSCULAR...... 58 PRALUENT...... 55 PREMARIN ORAL TABLET 0.3 MG, 0.625 PLEGRIDY STARTER PACK...... 58 pramipexole dihydrochloride...... 38 MG, 0.9 MG, 1.25 MG...... 105 PLEGRIDY SUBCUTANEOUS...... 58 prasugrel hcl...... 50 PREMARIN ORAL TABLET 0.45 MG...... 105 PNEUMOVAX 23...... 112 praziquantel oral...... 36 PREMARIN VAGINAL...... 105 pnv tabs 29-1...... 76 prazosin hcl oral...... 51 PREMIUM CONDOMS LUBRICATED...... 120 podofilox external...... 64 PRECISION GLUCOSE CONTROL...... 120 PREMPHASE...... 105 poly bacitracin...... 17 PRECISION GLUCOSE CONTROL SOLN120 PREMPRO...... 105 polycin...... 124 PRECISION GLUCOSE KETONE CONTR120 PRENATABS RX...... 76 polyethylene glycol 3350 oral powder...... 95 PRECISION GLUCOSE/KETONE CONTR120 prenatal formula oral tablet 28-0.8 mg...... 76 polyethylene glycol 3350-grx oral powder ..95 PRECISION LINK...... 120 prenatal gummy oral tablet chewable 0.4- poly-iron 150...... 70 PRECISION PCX PLUS TEST...... 120 25 mg...... 150 poly-iron 150 forte...... 70 PRECISION POINT OF CARE TEST...... 120 prenatal low iron...... 76 polymyxin b-trimethoprim...... 124 PRECISION QID MONITOR...... 120 prenatal multi+dha...... 76 polysaccharide iron complex...... 70 PRECISION QID TEST...... 120 prenatal multivitamins...... 76 polysaccharide iron forte...... 70 PRECISION SOF-TACT MONITOR...... 120 prenatal oral tablet 27-0.8 mg...... 76 polysaccharide-iron complex...... 70 PRECISION XTRA BLOOD GLUCOSE.....120 prenatal oral tablet 27-1 mg...... 76 POLYSPORIN...... 17 PRECISION XTRA DEVICE...... 120 prenatal oral tablet 28-0.8 mg...... 76 polyvinyl alcohol ophthalmic...... 124 PRECISION XTRA MONITOR...... 120 prenatal plus iron...... 76 POMALYST...... 32 PRED-G S.O.P...... 124 prenatal vitamin plus low iron...... 76 portia-28...... 105 prednicarbate external cream...... 64 prenatal vitamins oral tablet 28-0.8 mg...... 76 potassium chloride crys er...... 70 prednisolone acetate ophthalmic...... 127 prenatal/iron...... 76 potassium chloride er oral capsule prednisolone acetate p-f...... 127 PRENATAL-U...... 76 extended release 10 meq...... 70 prednisolone oral solution...... 100 PRENATRIX...... 76 PRENATRYL...... 76
178 PRENATVITE RX...... 76 promethazine hcl injection solution 25 pyridostigmine bromide oral solution...... 31 preplus...... 76 mg/ml...... 132 pyridostigmine bromide oral tablet 60 mg.... 31 PRETAB...... 76 promethazine hcl oral...... 133 pyridoxine hcl oral...... 76 PREVACID...... 97 promethazine hcl rectal...... 133 pyrimethamine oral...... 37 PREVACID 24HR...... 97 promethazine vc...... 145 QBREXZA...... 64 prevalite oral powder...... 55 promethazine vc/codeine...... 145 QTERN...... 46 PREVIDENT 5000 DRY MOUTH...... 59 promethazine-codeine...... 146 quetiapine fumarate...... 40 PREVIDENT 5000 PLUS...... 59 promethazine-dm...... 146 quetiapine fumarate er...... 40 PREVIDENT DENTAL...... 59 promethazine-phenyleph-codeine...... 146 QUFLORA PEDIATRIC ORAL SOLUTION PREVIDENT MOUTH/THROAT...... 70 promethazine-phenylephrine...... 146 0.5 MG/ML...... 76 previfem...... 105 promethegan...... 133 quinapril hcl...... 51 PREVNAR 13...... 112 PRONEB ULTRA FILTER SET...... 120 quinapril-hydrochlorothiazide...... 54 PREZCOBIX...... 43 PRONUTRIENTS VITAMIN D3...... 76 quinidine gluconate er...... 52 PREZISTA...... 43 propafenone hcl...... 52 quinidine sulfate...... 52 PRIFTIN...... 31 propranolol hcl er...... 52 QUINTET CONTROL HIGH/NORMAL...... 120 PRILOSEC...... 97 propranolol hcl oral...... 52 quit2...... 15 primaquine phosphate...... 37 propranolol-hctz...... 54 quit4...... 15 primidone oral...... 21 propylthiouracil oral...... 109 QVAR REDIHALER...... 134 PRISTIQ...... 25 PROTOPIC EXTERNAL OINTMENT 0.03 radiance platinum vitamin d3...... 76 PROAIR HFA...... 135 %...... 64 raloxifene hcl...... 107 probenecid...... 30 PROTOPIC EXTERNAL OINTMENT 0.1 % 64 ramipril...... 51 pro-biotic blend...... 88 protriptyline hcl...... 26 ranolazine er...... 54 probiotic colon care...... 88 PROVENTIL HFA...... 135 RASUVO...... 111 probiotic complex...... 88 provil...... 10 RAVICTI...... 97 probiotic maximum strength...... 88 pseudoephedrine hcl 12 hr...... 146 react...... 107 probiotic oral capsule ...... 88 pseudoephedrine hcl er...... 146 ready-to-use enema rectal enema ...... 95 probiotic oral capsule 250 mg...... 88 pseudoephedrine hcl oral tablet 30 mg...... 146 REBIF...... 58 probiotic pearls ex st...... 88 pseudoephedrine-bromphen-dm...... 146 REBIF REBIDOSE...... 58 prochlorperazine...... 26 pseudoephedrine-guaifenesin er...... 146 REBIF REBIDOSE TITRATION PACK...... 58 prochlorperazine maleate oral...... 39 psyldex...... 95 REBIF TITRATION PACK...... 58 PROCRIT...... 49 PULMICORT FLEXHALER...... 134 reclipsen...... 105 PRO-CRITIC...... 120 PULMOZYME...... 146 RECOMBINATE...... 50 PROCTOFOAM HC...... 113 PURALUBE...... 124 RECOMBIVAX HB...... 112 procto-med hc...... 113 pure & gentle lubricant...... 124 RECTIV...... 56 proctozone-hc...... 113 purelax oral powder...... 95 REDITREX...... 111 progesterone oral...... 107 PYLERA...... 88 redness relief ophthalmic solution 0.012- PROLENSA...... 127 pyrazinamide oral...... 31 0.2 %...... 125 PROMACTA ORAL PACKET 25 MG...... 49 PYRIDIUM...... 99 refenesen 400...... 146 PROMACTA ORAL TABLET...... 49 pyridostigmine bromide er...... 31 REFRESH LACRI-LUBE...... 124
179 REFRESH P.M...... 124 RID LICE KILLING SHAMPOO...... 38 RUZURGI...... 120 REFRESH PLUS...... 124 rifabutin...... 31 RYBELSUS...... 46 REFRESH TEARS...... 124 rifampin oral...... 31 RYDAPT...... 35 REGRANEX...... 64 riluzole...... 57 rynex dm...... 146 REHYDRALYTE...... 70 rimantadine hcl...... 44 rynex pe...... 146 RELENZA DISKHALER...... 44 RINVOQ...... 111 rynex pse...... 146 relief eye drops...... 124 RISAQUAD...... 88 RYTHMOL SR...... 52 RELISTOR...... 88 RISAQUAD-2...... 88 SABRIL ORAL PACKET...... 21 RENAL...... 76 RISPERDAL CONSTA...... 40 saccharomyces boulardii...... 88 RENAL MULTIVITAMIN FORMULA...... 77 RISPERDAL ORAL SOLUTION...... 40 SAIZEN...... 101 renal-vite...... 77 RISPERDAL ORAL TABLET...... 40 saline enema...... 95 rena-vite...... 77 risperidone oral solution...... 40 saline mist spray...... 146 renewal soothing bath...... 64 risperidone oral tablet...... 40 saline nasal spray...... 146 repaglinide...... 46 risperidone oral tablet dispersible...... 40 salsalate oral...... 10 REPATHA...... 55 RITALIN...... 57 SANDIMMUNE ORAL SOLUTION...... 111 REPLACEMENT FILTERS...... 120 ritonavir...... 43 SANTYL...... 64 RESTASIS...... 124 RITUXAN...... 36 SAPHRIS...... 40 RESTASIS MULTIDOSE...... 124 rivastigmine...... 23 sapropterin dihydrochloride...... 97 RESTORA...... 88 rivastigmine tartrate...... 23 SAVAYSA...... 49 RESTORA RX...... 88 rizatriptan benzoate...... 30 sb allergy medicine oral tablet...... 133 restore plus lubricant eye...... 124 robafen cf multi-symptom cold...... 146 sb arthritis pain relief...... 7 restore pm...... 124 ROBITUSSIN 12 HOUR COUGH...... 146 sb aspirin oral tablet delayed release...... 10 RETACRIT INJECTION SOLUTION 10000 ROBITUSSIN 12 HOUR COUGH CHILD.. 146 sb docusate sodium/senna...... 95 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, ROBITUSSIN CHILD COUGH/COLD LA...146 sb lice killing max st...... 38 4000 UNIT/ML, 40000 UNIT/ML...... 49 ROBITUSSIN CHILDRENS COUGH LA....146 sb mucus relief...... 146 RETACRIT INJECTION SOLUTION 20000 ROBITUSSIN COUGH+CHEST CONG sb pain reliever childrens...... 8 UNIT/ML...... 49 DM ORAL LIQUID 20-400 MG/20ML...... 146 sb pain reliever ex st...... 8 RETIN-A EXTERNAL CREAM...... 64 ROBITUSSIN NIGHTTIME COUGH...... 146 scalp relief...... 64 RETIN-A EXTERNAL GEL...... 64 ROBITUSSIN PEAK COLD MULTI-SYM...146 SCRUB CARE POVIDONE-IODINE...... 17 RETIN-A MICRO GEL 0.04 %, 0.1 %...... 64 ropinirole hcl...... 38 SEEBRI NEOHALER...... 134 RETIN-A MICRO PUMP EXTERNAL GEL rosadan external cream...... 17 SEGLUROMET...... 46 0.06 %...... 64 rosadan external gel...... 17 selegiline hcl oral...... 38 REVLIMID...... 32 rosuvastatin calcium...... 55 selenium sulfide external lotion...... 64 REXULTI...... 40 roweepra...... 20 SELZENTRY...... 43 REYATAZ ORAL CAPSULE...... 43 ROZEREM...... 150 SEMGLEE...... 48 REYATAZ ORAL PACKET...... 43 ROZLYTREK...... 33 senexon-s...... 95 REYVOW...... 30 RUBRACA...... 33 senior probiotic...... 88 RHOFADE...... 64 RUCONEST...... 109 senna lax...... 95 ribavirin oral...... 41 rufinamide...... 22 senna laxative...... 95
180 senna oral liquid...... 95 siltussin-dm alcohol free...... 146 sodium chloride ophthalmic solution 5 %... 124 senna oral syrup...... 95 silver sulfadiazine external...... 19 sodium fluoride 5000 plus...... 59 senna oral tablet...... 95 SIMBRINZA...... 126 sodium fluoride 5000 ppm dental cream...... 59 senna plus oral tablet...... 95 simeped...... 88 sodium fluoride dental cream...... 59 senna s...... 95 simethicone oral...... 88 sodium fluoride dental gel...... 59 senna smooth...... 95 simethicone ultra strength...... 88 sodium fluoride mouth/throat...... 70 senna-docusate sodium...... 95 simliya...... 105 sodium fluoride oral solution 1.1 (0.5 f) senna-lax...... 95 SIMPONI...... 111 mg/ml...... 70 senna-plus...... 95 simvastatin oral...... 55 sodium fluoride oral tablet chewable...... 70 senna-s...... 95 sinus 12 hour...... 146 sodium phenylbutyrate oral...... 97 senna-tabs...... 95 sinus congestion max strength...... 147 SOFOSBUVIR-VELPATASVIR...... 41 senna-time...... 95 sinus nasal spray...... 147 soft glucose...... 46 senna-time s...... 95 sinus pe decongestant...... 147 SOLARTEK GLUCOSE CONTROL...... 120 sennazon...... 96 sinus relief ext st...... 147 SOLIQUA...... 46 senno...... 96 sinus relief extra strength...... 147 SOLODYN...... 19 SENOKOT...... 96 sinus/congestion relief pe...... 147 soluble fiber therapy...... 96 SENOKOT S...... 96 sirolimus oral solution...... 111 SOMAVERT...... 109 SEREVENT DISKUS...... 135 sirolimus oral tablet 0.5 mg, 1 mg...... 111 SOOLANTRA...... 64 SERNIVO...... 64 sirolimus oral tablet 2 mg...... 111 soothe maximum strength...... 88 SEROQUEL...... 40 SIRTURO...... 31 soothe oral suspension...... 88 SEROQUEL XR...... 40 SKYLA...... 107 soothe oral tablet...... 88 sertraline hcl oral...... 25 SKYRIZI (150 MG DOSE)...... 111 soothe oral tablet chewable...... 88 setlakin...... 105 SLO-NIACIN...... 77 sorbitol oral...... 96 sf...... 59 smooth antacid ex st oral tablet chewable SORILUX...... 64 sf 5000 plus...... 59 750 mg...... 88 sotalol hcl (af)...... 52 SFROWASA...... 113 smooth antacid extra st...... 88 sotalol hcl oral...... 52 sharobel...... 107 smooth lax oral powder...... 96 SOVALDI...... 41 SHINGRIX...... 112 sod citrate-citric acid...... 70 spinosad...... 38 SHUR-SEAL CONTRACEPTIVE...... 99 sodium bicarbonate oral tablet...... 88 SPIRIVA HANDIHALER...... 134 SIGNIFOR...... 109 sodium chloride (hypertonic) ophthalmic SPIRIVA RESPIMAT...... 134 silace oral liquid...... 96 ointment...... 124 spironolactone oral...... 54 silace oral syrup...... 96 sodium chloride (hypertonic) ophthalmic spironolactone-hctz...... 54 siladryl allergy...... 133 solution...... 124 sprintec 28...... 105 sildenafil citrate oral suspension sodium chloride (pf)...... 70 SPRYCEL...... 35 reconstituted...... 136 sodium chloride inhalation nebulization sps...... 71 sildenafil citrate oral tablet 20 mg...... 136 solution 0.9 %...... 147 sronyx...... 105 SILENOR...... 150 sodium chloride intravenous solution 0.45 ssd...... 19 SILIQ...... 64 %, 0.9 %...... 70 sss 10-5 external cream...... 64 siltussin sa...... 146 sodium chloride ophthalmic ointment 5 %..124 ST JOSEPH LOW DOSE...... 10
181 stavudine...... 43 SUBOXONE SUBLINGUAL FILM 2-0.5 sumatriptan succinate oral...... 30 STEGLATRO...... 46 MG, 8-2 MG...... 13 sumatriptan succinate refill...... 30 STEGLUJAN...... 46 subvenite...... 21 sumatriptan succinate subcutaneous...... 30 STELARA INTRAVENOUS...... 111 subvenite starter kit-blue...... 21 suphedrin...... 147 STELARA SUBCUTANEOUS...... 111 subvenite starter kit-green...... 21 suphedrine maximum strength...... 147 stimulant laxative oral tablet 8.6-50 mg...... 96 subvenite starter kit-orange...... 22 suphedrine oral tablet 30 mg...... 147 STIOLTO RESPIMAT...... 147 sucralfate oral suspension...... 96 suphedrine oral tablet extended release 12 STIVARGA...... 35 sucralfate oral tablet...... 96 hour 120 mg...... 147 stomach relief extra strength...... 89 SUDAFED...... 147 SUPPRELIN LA...... 109 stomach relief max st oral suspension 525 SUDAFED CHILDRENS...... 147 sure result sr relief...... 8 mg/15ml...... 89 SUDAFED CONGESTION...... 147 surelac...... 89 stomach relief max strength...... 89 SUDAFED PE CONGESTION ORAL SUTENT...... 35 stomach relief oral suspension 1050 TABLET 10 MG...... 147 SYMAX-SR...... 80 mg/30ml, 525 mg/15ml...... 89 SUDAFED PE SINUS CONGESTION...... 147 SYMBICORT...... 147 stomach relief oral suspension 262 SUDAFED SINUS CONGESTION...... 147 SYMDEKO...... 135 mg/15ml, 525 mg/30ml, 527 mg/30ml...... 89 SUDAFED SINUS CONGESTION 12HR...147 SYMFI...... 42 stomach relief oral tablet 262 mg...... 89 sudogest 12 hour...... 147 SYMFI LO...... 42 stomach relief oral tablet chewable 262 mg.89 sudogest maximum strength...... 147 SYMJEPI...... 135 stomach relief plus...... 89 sudogest oral tablet 30 mg...... 147 SYMLINPEN 120...... 46 stomach relief ultra...... 89 sulfacetamide sodium ophthalmic...... 19 SYMLINPEN 60...... 46 stool softener laxative oral capsule...... 96 sulfacetamide sodium-sulfur external SYMPAZAN...... 21 stool softener oral capsule 100 mg...... 96 cream 10-5 %...... 64 SYMPROIC...... 89 stool softener oral capsule 240 mg...... 96 sulfacetamide sodium-sulfur external liquid SYMTUZA...... 43 stool softener oral capsule 250 mg...... 96 9-4.5 %...... 64 SYNAGIS...... 111 stool softener oral capsule 50 mg...... 96 sulfacetamide sodium-sulfur external lotion SYNAREL...... 109 stool softener oral tablet 8.6-50 mg...... 96 10-5 %...... 64 SYNJARDY...... 46 stool softener pls laxative...... 96 sulfacetamide sodium-sulfur external SYNJARDY XR...... 46 stool softener plus laxative...... 96 suspension 10-5 %...... 64 SYSTANE...... 124 stool softener/laxative...... 96 sulfacetamide sod-sulfur wash external SYSTANE COMPLETE...... 124 stool softener/stimulant...... 96 liquid 9-4.5 %...... 64 SYSTANE CONTACTS...... 124 STRATTERA...... 57 sulfacetamide-prednisolone ophthalmic SYSTANE HYDRATION PF...... 124 STRENSIQ...... 97 solution...... 124 SYSTANE NIGHTTIME...... 124 stress formula...... 77 sulfamethoxazole-trimethoprim oral...... 19 SYSTANE OVERNIGHT THERAPY...... 124 stress formula/iron...... 77 sulfamez wash...... 65 SYSTANE PRESERVATIVE FREE...... 124 STRIBILD...... 41 sulfasalazine oral...... 113 SYSTANE ULTRA...... 124 STRIVERDI RESPIMAT...... 135 sulfatrim pediatric...... 19 SYSTANE ULTRA PF...... 125 SUBOXONE SUBLINGUAL FILM 12-3 sulindac oral...... 10 tab tussin...... 147 MG, 4-1 MG...... 13 SUMADAN WASH...... 65 tab-a-vite...... 77 sumatriptan nasal...... 30 tab-a-vite/beta carotene...... 77
182 tab-a-vite/iron...... 77 TENIVAC...... 112 TIMOPTIC...... 126 TABLOID...... 32 tenofovir disoproxil fumarate...... 43 TIMOPTIC-XE...... 126 TACLONEX...... 65 terazosin hcl...... 98 TINACTIN EXTERNAL AEROSOL...... 29 tacrolimus external ointment 0.03 %...... 65 terbinafine hcl external...... 29 TINACTIN EXTERNAL CREAM...... 29 tacrolimus external ointment 0.1 %...... 65 terbinafine hcl oral...... 29 tinaspore...... 29 tacrolimus oral capsule 0.5 mg, 5 mg...... 111 terbinafine hydrochloride external cream 1 TIVICAY...... 41 tacrolimus oral capsule 1 mg...... 111 %...... 29 TIVICAY PD...... 41 tactinal extra strength...... 8 terconazole vaginal cream...... 29 tizanidine hcl oral...... 149 TAFINLAR...... 35 TERIPARATIDE (RECOMBINANT)...... 113 TOBI NEBULIZER...... 135 take action...... 107 testosterone cypionate intramuscular...... 101 TOBI PODHALER...... 135 TALTZ...... 65 testosterone enanthate intramuscular...... 101 TOBRADEX OPHTHALMIC OINTMENT... 125 TAMIFLU ORAL CAPSULE...... 44 testosterone transdermal gel 12.5 mg/act TOBRADEX ST...... 125 TAMIFLU ORAL SUSPENSION (1%)...... 101 tobramycin inhalation nebulization solution RECONSTITUTED...... 44 testosterone transdermal gel 25 mg/2.5gm 300 mg/4ml...... 135 tamoxifen citrate oral...... 32 (1%), 50 mg/5gm (1%)...... 101 tobramycin nebulization solution 300 tamsulosin hcl...... 98 TETANUS-DIPHTHERIA TOXOIDS TD.... 112 mg/5ml inhalation...... 135 TARGRETIN EXTERNAL...... 36 tetrabenazine...... 57 TOBRAMYCIN NEBULIZATION tarina fe 1/20...... 105 tetracaine hcl ophthalmic...... 125 SOLUTION 300 MG/5ML INHALATION.... 135 tarina fe 1/20 eq...... 105 THALOMID...... 32 tobramycin ophthalmic...... 126 TASIGNA...... 35 the magic bullet...... 96 tobramycin-dexamethasone...... 125 TAZORAC EXTERNAL CREAM...... 65 THEO-24...... 135 tolcapone...... 38 TAZORAC EXTERNAL GEL 0.1 %...... 65 theophylline...... 135 tolnaftate antifungal...... 29 taztia xt...... 53 theophylline er...... 135 tolnaftate external cream...... 29 TDVAX...... 112 thera...... 77 tolterodine tartrate...... 98 TEARS AGAIN...... 125 THERASEAL HAND PROTECTION...... 65 TOPAMAX...... 22 TEARS AGAIN ADVANCED EYELID thera-tabs...... 77 TOPAMAX SPRINKLE...... 22 OPHTHALMIC...... 125 thiamine hcl oral...... 77 TOPICORT SPRAY...... 65 tears pure...... 125 thiamine mononitrate oral...... 77 topiramate oral capsule sprinkle...... 22 TECFIDERA...... 58 thioridazine hcl oral...... 39 topiramate oral tablet...... 22 TEGRETOL...... 22 thiothixene...... 39 toremifene citrate...... 32 TEGRETOL-XR...... 22 THRIVE...... 15 torsemide...... 54 TEGSEDI...... 97 THRIVITE 19...... 77 total allergy...... 133 temazepam oral capsule 15 mg, 30 mg, THRIVITE RX...... 77 total allergy medicine...... 133 7.5 mg...... 150 tiadylt er...... 53 TOUJEO MAX SOLOSTAR...... 48 temazepam oral capsule 22.5 mg...... 44 tiagabine hcl...... 21 TOUJEO SOLOSTAR...... 48 TEMIXYS...... 43 TIBSOVO...... 35 TOVIAZ...... 98 TEMOVATE...... 65 TIKOSYN...... 52 TRACLEER 32 MG...... 136 temozolomide...... 32 tilia fe...... 105 TRACLEER 62.5 MG, 125 MG...... 136 TENCON...... 8 timolol maleate ophthalmic solution...... 126 TRADJENTA...... 46
183 tramadol hcl oral tablet 50 mg...... 12 tri-linyah...... 106 tussin cf cough & cold oral liquid 5-10-100 trandolapril...... 51 trimethobenzamide hcl oral...... 26 mg/5ml...... 148 tranexamic acid oral...... 50 trimethoprim oral...... 17 tussin cf multi-symptom cold...... 148 tranylcypromine sulfate...... 24 tri-mili...... 106 tussin cf oral liquid 30-10-100 mg/5ml...... 148 TRAVATAN Z...... 127 trimipramine maleate oral...... 26 tussin cf oral liquid 5-10-100 mg/5ml...... 148 travel ease...... 26 TRINATE...... 77 tussin chest congestion oral syrup 100 trazodone hcl oral...... 25 TRINTELLIX...... 25 mg/5ml...... 148 TRECATOR...... 31 tri-nymyo...... 106 tussin cough dm sugar free...... 148 TRELEGY ELLIPTA...... 147 triple antibiotic...... 17 tussin cough long acting...... 148 TREMFYA...... 65 triple antibiotic original...... 17 tussin cough long-acting...... 148 TRESIBA...... 48 tri-previfem...... 106 tussin cough oral syrup...... 148 TRESIBA FLEXTOUCH...... 48 TRIPTODUR...... 109 tussin cough/chest congest oral syrup 100- tretinoin external cream...... 65 tri-sprintec...... 106 10 mg/5ml...... 148 tretinoin oral...... 36 TRIUMEQ...... 41 tussin cough/chest dm max oral liquid 10- TREZIX...... 12 tri-vite pediatric...... 77 200 mg/5ml...... 148 tri femynor...... 105 tri-vite/fluoride oral solution 0.25 mg/ml...... 77 tussin dm cough/chest cong...... 148 triamcinolone acetonide external cream...... 65 trivora (28)...... 106 tussin dm cough/chest oral syrup 10-100 triamcinolone acetonide external lotion tri-vylibra...... 106 mg/5ml...... 148 0.025 %...... 65 trospium chloride...... 98 tussin dm max adult...... 148 triamcinolone acetonide external lotion 0.1 TRUECONTROL GLUCOSE CONT LEV 0120 tussin dm max daytime...... 148 %...... 65 TRUECONTROL GLUCOSE CONT LEV 1120 tussin dm max oral liquid 10-200 mg/5ml...148 triamcinolone acetonide external ointment TRUETRACK TEST...... 120 tussin dm max st...... 148 0.025 %, 0.1 %, 0.5 %...... 65 TRULANCE...... 89 tussin dm oral syrup 100-10 mg/5ml...... 148 triamcinolone acetonide mouth/throat...... 59 TRULICITY...... 46 tussin maximum strength oral syrup 15 TRIAMINIC ALLERCHEWS...... 133 TRUMENBA...... 112 mg/5ml...... 149 triamterene-hctz...... 54 TRUSOPT...... 126 tussin mucus+chest congestion oral syrup 149 triazolam...... 44 TUBING/WING TIP...... 120 tussin multi-symptom cold cf...... 149 TRICARE...... 77 TUDORZA PRESSAIR...... 134 tussin oral syrup 100 mg/5ml...... 149 TRICON...... 70 tulana...... 107 TWINRIX...... 112 triderm...... 65 TUMS...... 89 tyblume...... 106 tri-estarylla...... 105 TUMS CHEWY BITES...... 89 TYBOST...... 41 trifluoperazine hcl...... 39 TUMS E-X 750...... 89 TYLENOL ORAL SUSPENSION 160 trifluridine...... 41 TUMS EXTRA STRENGTH 750...... 89 MG/5ML...... 8 trihexyphenidyl hcl...... 38 TUMS LASTING EFFECTS...... 89 TYLENOL ORAL TABLET 325 MG...... 8 TRIJARDY XR...... 46 TUMS SMOOTHIES...... 89 TYLENOL ORAL TABLET 500 MG...... 8 TRIKAFTA...... 135 TUMS ULTRA 1000...... 89 TYLENOL ORAL TABLET CHEWABLE tri-legest fe...... 105 TURALIO...... 35 160 MG...... 8 TRILEPTAL ORAL SUSPENSION...... 22 tussin adult dm oral liquid 10-200 mg/5ml..147 TYLENOL ORAL TABLET EXTENDED TRILEPTAL ORAL TABLET...... 22 tussin adult multi-symptom...... 148 RELEASE 650 MG...... 8
184 TYMLOS...... 113 VECTICAL...... 65 VIRAMUNE...... 42 TYSABRI...... 58 vegetable lax+stool softener...... 96 VIREAD ORAL POWDER...... 43 UBRELVY...... 30 velivet...... 106 VIREAD ORAL TABLET 150 MG, 200 MG, UDAMIN SP...... 77 VELPHORO...... 71 250 MG...... 43 UDENYCA...... 49 VELTASSA...... 71 virt-caps...... 77 ultra dairy digestive...... 89 VELTIN...... 65 virt-phos 250 neutral...... 71 ultra fresh...... 125 VENCLEXTA...... 35 virtussin a/c...... 149 ultra fresh pm...... 125 VENCLEXTA STARTING PACK...... 35 virtussin ac w/alc...... 149 ultra lubricant drop...... 125 venlafaxine hcl...... 25 virtussin dac...... 149 ultra lubricating eye drops...... 125 venlafaxine hcl er...... 25 VISBIOME HIGH POTENCY ORAL unithroid...... 108 VENTOLIN HFA...... 135 CAPSULE...... 89 urea 20 intensive hydrating...... 65 verapamil hcl er oral tablet extended VISINE...... 126 urea external lotion...... 65 release...... 53 VISINE ADVANCED RELIEF...... 125 ureacin-10...... 65 verapamil hcl oral...... 53 VISTA GEL DRY EYE RELIEF...... 125 ureacin-20...... 65 VERZENIO...... 33 VISTA MEIBO TEARS...... 125 urin ds...... 99 VESICARE...... 98 VISTA TEARS...... 125 urinary pain relief oral tablet 95 mg...... 99 vic-forte...... 77 VISTOGARD...... 121 ursodiol oral capsule...... 89 VICTOZA SOLUTION PEN-INJECTOR 18 vit c/rose hips...... 77 ursodiol oral tablet...... 89 MG/3ML SUBCUTANEOUS...... 46 vita s forte...... 77 UTIRA-C...... 99 VIEKIRA PAK...... 41 vitacel...... 77 VAGIFEM...... 106 vienva...... 106 vitamin a oral capsule 2400 mcg (8000 ut), valacyclovir hcl oral...... 41 vigabatrin oral packet...... 21 3 mg (10000 ut)...... 77 valganciclovir hcl oral tablet...... 40 vigadrone...... 21 vitamin b-1...... 77 valproic acid oral...... 21 VIGAMOX...... 18 vitamin b-12 er oral tablet extended VALTOCO 10 MG DOSE...... 21 VIIBRYD...... 25 release 1000 mcg...... 78 VALTOCO 15 MG DOSE...... 21 VIMPAT INTRAVENOUS...... 22 vitamin b12 oral tablet extended release VALTOCO 20 MG DOSE...... 21 VIMPAT ORAL...... 22 1000 mcg...... 78 VALTOCO 5 MG DOSE...... 21 VINATE II...... 77 vitamin b-12 tr oral tablet extended release VANCOCIN...... 17 VINATE ONE...... 77 1000 mcg...... 78 vandazole...... 17 VIOKACE ORAL TABLET 10440-39150 vitamin b-6...... 78 VANOS...... 65 UNIT...... 97 vitamin b-6 er...... 78 VAPORIZER WARM STEAM...... 120 viorele...... 106 vitamin c cr oral tablet extended release VAQTA...... 112 VIOS AEROSOL DELIVERY SYSTEM...... 120 500 mg...... 78 VARIVAX...... 112 VIOS LC PLUS...... 120 vitamin c er oral tablet extended release VARUBI (180 MG DOSE)...... 27 VIOS LC PLUS DELUXE...... 120 1500 mg...... 78 VASOCLEAR-A...... 125 VIOS LC PLUS PEDIATRIC...... 120 vitamin c oral liquid 500 mg/5ml...... 78 v-c forte...... 77 VIOS LC SPRINT...... 120 vitamin c oral tablet 1000 mg, 250 mg...... 78 VCF VAGINAL CONTRACEPTIVE VIOS LC SPRINT PEDIATRIC...... 120 vitamin c oral tablet 500 mg...... 78 VAGINAL FOAM...... 99 VIRACEPT...... 43
185 vitamin c oral tablet chewable 100 mg, 250 vitamin-b complex...... 79 womans laxative...... 96 mg...... 78 vitamins acd-fluoride...... 79 womens gentle laxative...... 96 vitamin c oral tablet chewable 500 mg...... 78 vitamins complete childrens...... 79 womens laxative...... 96 vitamin c/acerola...... 78 VITATHELY WITH GINGER...... 79 womens prenatal+dha...... 80 vitamin c/rose hips oral tablet 1000 mg...... 78 VITRAKVI...... 35 XALATAN...... 127 vitamin c/rose hips oral tablet 500 mg...... 78 VIVELLE-DOT...... 106 XALKORI...... 35 vitamin c-rose hips oral tablet...... 78 VIVITROL...... 13 XARELTO...... 49 vitamin d (cholecalciferol) oral tablet 10 VOCABRIA...... 43 XARELTO STARTER PACK...... 49 mcg (400 unit)...... 78 volnea...... 106 XCOPRI...... 20 vitamin d (cholecalciferol) oral tablet 25 voriconazole oral tablet...... 29 XCOPRI (250 MG DAILY DOSE) ORAL mcg (1000 ut)...... 78 VOSEVI...... 41 TABLET THERAPY PACK 50 & 200 MG.....20 vitamin d (ergocalciferol) oral capsule 1.25 VOTRIENT...... 35 XCOPRI (350 MG DAILY DOSE)...... 20 mg (50000 ut)...... 78 VRAYLAR...... 40 XELJANZ ORAL TABLET...... 111 vitamin d oral capsule 25 mcg (1000 ut)...... 78 VUMERITY...... 58 XELJANZ XR ORAL TABLET EXTENDED vitamin d oral liquid...... 78 vyfemla...... 106 RELEASE 24 HOUR 11 MG...... 111 vitamin d oral tablet 25 mcg (1000 ut)...... 78 vylibra...... 106 XELJANZ XR ORAL TABLET EXTENDED vitamin d oral tablet 50 mcg (2000 ut)...... 78 VYNDAMAX...... 54 RELEASE 24 HOUR 22 MG...... 111 vitamin d oral tablet chewable 10 mcg (400 VYNDAQEL...... 54 XELODA...... 32 unit)...... 78 VYVANSE...... 56 XENLETA ORAL...... 17 vitamin d3 oral capsule 1.25 mg (50000 ut). 78 warfarin sodium oral tablet 1 mg, 10 mg, 2 XEOMIN...... 40 vitamin d3 oral capsule 125 mcg (5000 ut).. 79 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg...... 49 XEPI...... 18 vitamin d-3 oral capsule 125 mcg (5000 ut). 79 warfarin sodium oral tablet 6 mg...... 49 XIGDUO XR ORAL TABLET EXTENDED vitamin d3 oral capsule 25 mcg (1000 ut).... 79 wart remover external liquid 17 %...... 65 RELEASE 24 HOUR 10-1000 MG, 10-500 vitamin d3 oral capsule 250 mcg (10000 ut) 79 wart remover maximum strength external MG, 5-500 MG...... 46 vitamin d3 oral capsule 50 mcg (2000 ut).... 79 liquid...... 65 XIGDUO XR ORAL TABLET EXTENDED vitamin d-3 oral capsule 50 mcg (2000 ut)... 79 weekly-d...... 79 RELEASE 24 HOUR 2.5-1000 MG, 5-1000 vitamin d3 oral liquid 10 mcg/ml...... 79 wera...... 106 MG...... 46 vitamin d3 oral tablet 10 mcg (400 unit)...... 79 WESTAB PLUS...... 80 XIIDRA...... 125 vitamin d3 oral tablet 125 mcg (5000 ut)...... 79 WEST-VITE W/FOLIC ACID...... 80 XIMINO...... 19 vitamin d3 oral tablet 25 mcg (1000 ut)...... 79 WIDE-SEAL DIAPHRAGM 60...... 121 XOFLUZA (40 MG DOSE)...... 44 vitamin d-3 oral tablet 25 mcg (1000 ut)...... 79 WIDE-SEAL DIAPHRAGM 65...... 121 XOFLUZA (80 MG DOSE)...... 44 vitamin d3 oral tablet 50 mcg (2000 ut)...... 79 WIDE-SEAL DIAPHRAGM 70...... 121 XOLAIR...... 111 vitamin d3 oral tablet chewable 10 mcg WIDE-SEAL DIAPHRAGM 75...... 121 XOPENEX HFA...... 135 (400 unit)...... 79 WIDE-SEAL DIAPHRAGM 80...... 121 XPECT...... 149 vitamin d3 oral tablet chewable 25 mcg, 25 WIDE-SEAL DIAPHRAGM 85...... 121 XTANDI ORAL CAPSULE...... 32 mcg (1000 ut)...... 79 WIDE-SEAL DIAPHRAGM 90...... 121 xulane...... 106 vitamin d-400...... 79 WIDE-SEAL DIAPHRAGM 95...... 121 XULTOPHY...... 46 vitamin e oral capsule 400 unit...... 79 WILATE...... 50 XYNTHA INTRAVENOUS KIT 1000 UNIT, vitamin k1 injection solution 10 mg/ml...... 79 wixela inhub...... 149 2000 UNIT, 500 UNIT...... 50
186 YONSA...... 32 ZONEGRAN...... 20 yuvafem...... 106 zonisamide oral...... 20 zaclir cleansing...... 65 zoo friends gummies...... 80 ZADITOR...... 127 zoo friends plus extra c...... 80 zafemy...... 106 zoo friends plus iron...... 80 zaleplon...... 150 ZORTRESS ORAL TABLET 1 MG...... 111 ZARONTIN...... 20 ZOSTRIX HP...... 65 ZARXIO...... 50 zovia 1/35 (28)...... 106 ZAVESCA...... 97 zovia 1/35e (28)...... 106 ZEASORB-AF...... 121 ZUBSOLV...... 13 ZEGERID...... 97 ZYCLARA...... 65 ZEJULA...... 33 ZYCLARA PUMP EXTERNAL CREAM ZELBORAF...... 35 3.75 %...... 65 zenatane...... 65 ZYDELIG...... 35 ZENPEP ORAL CAPSULE DELAYED ZYKADIA...... 33 RELEASE PARTICLES 10000-32000 ZYLET...... 125 UNIT, 15000-47000 UNIT, 20000-63000 ZYMAXID...... 126 UNIT, 3000-10000 UNIT, 40000-126000 ZYPREXA ORAL...... 40 UNIT, 5000-24000 UNIT...... 97 ZYPREXA RELPREVV...... 40 ZENZEDI...... 56 ZYPREXA ZYDIS...... 40 ZEPATIER...... 41 ZYRTEC ALLERGY ORAL TABLET...... 133 ZEPOSIA...... 56 ZYRTEC-D ALLERGY & CONGESTION...149 ZETONNA...... 134 ZYTIGA...... 32 ZIANA...... 65 ZYVANA...... 80 zidovudine...... 43 ZIEXTENZO...... 50 ZILXI...... 65 zinc chelated oral tablet 50 mg...... 71 zinc oral tablet 50 mg...... 71 zinc oxide external ointment 40 %...... 65 ZIOPTAN...... 127 ziprasidone hcl...... 40 ZOHYDRO ER...... 11 ZOLADEX...... 109 ZOLINZA...... 33 zolpidem tartrate oral...... 150 zolpidem tartrate sublingual...... 150 ZOMACTON...... 101 ZOMACTON (FOR ZOMA-JET 10)...... 101
187