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Mutual of Omaha Rx (PDP) 2021 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Formulary ID Number: 21129, Version 4

This formulary was updated on 3/1/2021. For more recent information or other questions, please contact Mutual of Omaha RxSM (PDP) Customer Service at 1.855.864.6797 or, for TTY users, 1.800.716.3231, 24 hours a day, 7 days a week, or visit MutualofOmahaRx.com.

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Omaha Health Insurance Company (Omaha Life and Health Insurance Company in California). When it says “plan” or “our plan,” it means Mutual of Omaha Rx.

This document includes a list of the drugs (formulary) for our plan, which is current as of March 1, 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1.855.864.6797 (TTY: 1.800.716.3231).

F00OMR1AW3 CRP2101_004084.3 S7126_F00OMR1A_C This drug list was updated in March 2021 What is the Mutual of Omaha Rx Formulary? A formulary is a list of covered drugs selected by Mutual of Omaha Rx in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Mutual of Omaha Rx will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Mutual of Omaha Rx network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the formulary (drug list) change? Most changes in drug coverage happen on January 1, but Mutual of Omaha Rx may add or remove drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these changes. Changes that can affect you this year: In the cases below , you will be affected by coverage changes during the year: • New generic drugs. We may immediately remove a brand-name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand-name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you are currently taking that brand-name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand -name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Mutual of Omaha Rx Formulary?”

• Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

• Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to the market to replace a brand-name drug currently on the formulary; or add new restrictions to the brand-name drug or move it to a different cost-sharing tier or both. Or we may make changes based on new clinical guidelines . If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30 -day supply of the drug. o If we make these other changes, you or your prescriber can ask us to make an exception and continue to cover the brand-name drug for you. The notice we provide you will also include information on how to request an exception, and you can also find information in the section below entitled “How do I request an exception to the Mutual of Omaha Rx Formulary?”

Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2021 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2021 coverage year except as described above. This means these This drug list was updated in March 2021 i drugs will remain available at the same cost-sharing and with no new restrictions for those members taking them for the remainder of the coverage year. You will not get direct notice this year about changes that do not affect you. However, on January 1 of the next year, such changes would affect you, and it is imp ortant to check the Drug List for the new benefit year for any changes to drugs.

The enclosed formulary is current as of March 1, 2021. To get updated information about the drugs covered by Mutual of Omaha Rx, please contact us. Our contact information appears on the front and back cover pages. If there are additional changes made to the formulary that affect you an d are not mentioned above, you will be notified in writing of these changes within a reasonable period of time from when the changes are made.

How do I use the formulary? There are two ways to find your drug within the formulary:

Medical C ondition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 71. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug i n the firs t column of the list.

What are generic drugs? Mutual of Omaha Rx covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs.

Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Mutual of Omaha Rx requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Mutual of Omaha Rx before you fill your prescriptions. If you don’t get approval, Mutual of Omaha Rx may not cover the drug.

• Quantity Limits: For certain drugs, Mutual of Omaha Rx limits the amount of the drug that Mutual of Omaha Rx will cover. For example, Mutual of Omaha Rx provides two inhalers (17 grams) for a 1-month supply per prescription for ADVAIR® HFA. This may be in addition to a standard 1-month or 3-month supply.

• Step Therapy: In some cases, Mutual of Omaha Rx requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if

This drug list was updated in March 2021 ii Drug A and Drug B both treat your medical condition, Mutual of Omaha Rx may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Mutual of Omaha Rx will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Mutual of Omaha Rx to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section “How do I request an exception to the Mutual of Omaha Rx Formulary?” below for information about how to request an exception.

What if my drug is not on the f ormulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Mutual of Omaha Rx does not cover your drug, you have two options: • You can ask Customer Service for a list of similar drugs that are covered by Mutual of Omaha Rx. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Mutual of Omaha Rx.

• You can ask Mutual of Omaha Rx to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Mutual of Omaha Rx Formulary? You can ask Mutual of Omaha Rx to make an exception to our coverage rules. There are several type s of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost -sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Mutual of Omaha Rx limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Mutual of Omaha Rx will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception , you should submit a statement from your prescriber or physician supporting your request. Generally, This drug list was updated in March 2021 iii we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a drug that is not on our formulary, or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.

Other times when we will cover a temporary 30-day transition supply (or less, if you have a prescription written for fewer days) include: • When you leave a long-term care facility • When you are discharged from a hospital • When you leave a skilled nursing facility • When you cancel hospice care • When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized If you are entering a long-term care facility , we will cover a 31-day transition supply.

The plan will send you a letter within 3 business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.

For more information For more detailed information about your Mutual of Omaha Rx prescription drug coverage, please review your Evid ence of Coverage and other plan materials.

If you have questions about Mutual of Omaha Rx, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048. Or, visit http://www.medicare.gov.

This drug list was updated in March 2021 iv Mutual of Omaha Rx’s Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Mutual of Omaha Rx. If you have trouble finding your drug in the list, turn to the Index that begins on page 71.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., JANUMET®) and generic drugs are listed in lowercase italics (e.g., omeprazole).

The information in the Requirements/Limits column tells you if Mutua l of Omaha Rx has any special requirements for coverage of your drug.

B/D PA: Part B or Part D Prior Authorization. This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the de termination.

HRM: High-Risk Medication. These medications will require prior authorization for patients 65 years of age or older. Medical experts have determined that these drugs may cause more side effects in those patients. If you are 65 or over and taking one or more of these drugs, ask your doctor if there are safer alternatives available.

LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult the Pharmacy Directory or call Customer Service at 1.855.864.6797, 24 hours a day, 7 days a week. TTY users should call 1.800.716.3231.

MO: Mail-Order Drug. This prescription drug is available through our home delivery pharmacy service, as well as through our retail network pharmacies. Consider using mail order for your long-term medications (the kind you take regularly, such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics).

PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug tha t we will cover.

SI: Select Insulin. We provide additional coverage of this insulin medication in the Deductible, Initial Coverage and Coverage Gap Stages. Please refer to Chapter 4 in our Evidence of Coverage for more information.

ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

Your costs The amount you pay for a covered drug will depend on: • Your coverage stage. Mutual of Omaha Rx has different stages of coverage. In each stage, the amount you pay for a drug may change. However, for select Tier 3 insulins, your copay will be the same in all stages until you reach the Catastrophic Coverage stage. These insulins are This drug list was updated in March 2021 v identified in the Drug List by the abbreviation “SI.” If you receive “Extra Help”, you do not qualify for this program and your Low Income Subsidy (LIS) benefit will apply.

• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayment or coinsurance amount. The “Drug Tiers” chart below explains what types of drugs are included in each tier and shows how costs may change with each tier.

The Evidence of Coverage has more information about the plan’s coverage stages and lists the copayment and coinsurance amounts for each tier.

If you qualify for Extra Help If you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may be lower. Please refer to the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider)” to find out what your costs are or you may contact Customer Service for more information. Drug Tiers Tier Description Tier 1: This tier includes commonly prescribed generic drugs. Use Tier 1 drugs for the Preferred lowest copayments. Generic Drugs Tier 2: This tier includes generic drugs. Use Tier 2 drugs to keep your copayments low. Generic Drugs Tier 3: This tier includes most of the plan’s covered insulins, preferred brand-name drugs Preferred as well as generic drugs. Drugs in this tier will generally have lower copayments Brand Drugs than non-preferred drugs. Tier 4: This tier includes non-preferred brand-name drugs as well as generic drugs. Non-Preferred There may be lower -cost alternatives for you. Ask your doctor if switching to a Drugs lower-cost generic or preferred brand drug may be right for you. Drugs in this tier are limited to u p to a 30-day supply from either your local retail network pharmacy or from our network home delivery service. Tier 5: This tier includes very high-cost brand-name and generic drugs. To learn more Specialty about medications in this tier, you may contact a pharmacist at the numbers Tier Drugs listed on the front and back covers of this document. Drugs in this tier are limited to up to a 30-day supply from either your local retail network pharmacy or from our network home delivery service. Key The abbreviations listed below may appear on the following pages in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. You can find information on what the symbols and abbreviations on these tables mean by going to page v.

B/D PA: Part B or Part D Prior Authorization PA: Prior Authorization HRM: High-Risk Medication QL: Quantity Limit LA: Limited Availability SI: Select Insulin MO: Mail-Order Drug ST: Step Therapy

This drug list was updated in March 2021 vi Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits ANTI - INFECTIVES micafungin 5

ANTIFUNGAL AGENTS NOXAFIL ORAL 5 PA; MO; QL SUSPENSION (840 per 30 ABELCET 4 B/D PA; MO days) AMBISOME 5 B/D PA; MO nystatin oral 2 MO amphotericin b 4 B/D PA; MO suspension caspofungin 5 B/D PA nystatin oral tablet 2 MO clotrimazole mucous 3 MO posaconazole oral 5 PA; MO; QL membrane tablet,delayed (93 per 28 release (dr/ec) days) CRESEMBA 5 PA INTRAVENOUS terbinafine hcl oral 2 MO CRESEMBA ORAL 5 PA; MO voriconazole 4 PA; MO intravenous fluconazole in nacl 4 PA; MO (iso-osm) voriconazole oral 5 PA; MO intravenous suspension for piggyback 200 reconstitution mg/100 ml voriconazole oral 5 PA; MO fluconazole in nacl 4 PA tablet 200 mg (iso-osm) voriconazole oral 4 PA; MO intravenous tablet 50 mg piggyback 400 mg/200 ml ANTIVIRALS fluconazole oral 3 MO abacavir oral 3 MO; QL (900 suspension for solution per 30 days) reconstitution abacavir oral tablet 4 MO; QL (60 fluconazole oral 2 MO per 30 days) tablet abacavir-lamivudine 4 MO; QL (30 flucytosine 5 MO per 30 days) griseofulvin 4 MO abacavir- 5 MO; QL (60 microsize lamivudine- per 30 days) zidovudine griseofulvin 4 MO ultramicrosize acyclovir oral 2 MO capsule itraconazole oral 3 MO; QL (120 capsule per 30 days) acyclovir oral 3 MO suspension 200 mg/5 itraconazole oral 3 MO ml solution acyclovir oral tablet 2 MO ketoconazole oral 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 1 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits acyclovir sodium 4 B/D PA; MO EDURANT 4 MO; QL (60 intravenous solution per 30 days) amantadine hcl oral 4 MO efavirenz oral 5 MO; QL (120 capsule capsule 200 mg per 30 days) amantadine hcl oral 2 MO efavirenz oral 3 MO; QL (180 solution capsule 50 mg per 30 days) amantadine hcl oral 4 MO efavirenz oral tablet 5 MO; QL (30 tablet per 30 days) APTIVUS 4 MO; QL (120 efavirenz- 5 MO; QL (30 per 30 days) emtricitabin-tenofov per 30 days) APTIVUS (WITH 4 QL (300 per efavirenz-lamivu- 4 MO; QL (30 VITAMIN E) 30 days) tenofov disop oral per 30 days)

atazanavir oral 4 MO; QL (30 tablet 400-300-300

capsule 150 mg, 300 per 30 days) mg mg efavirenz-lamivu- 4 MO atazanavir oral 4 MO; QL (60 tenofov disop oral

capsule 200 mg per 30 days) tablet 600-300-300 mg ATRIPLA 5 MO; QL (30

per 30 days) emtricitabine 3 MO; QL (30 per 30 days) BARACLUDE 5 MO; QL (600

ORAL SOLUTION per 30 days) emtricitabine- 5 MO; QL (30 tenofovir (tdf) per 30 days) BIKTARVY 5 MO EMTRIVA ORAL 3 MO; QL (30 cidofovir 4 B/D PA; MO CAPSULE per 30 days) CIMDUO 4 MO EMTRIVA ORAL 3 MO; QL (720 COMPLERA 4 MO; QL (30 SOLUTION per 30 days) per 30 days) entecavir 4 MO; QL (30 CRIXIVAN ORAL 4 MO; QL (90 per 30 days) CAPSULE 200 MG per 30 days) EPCLUSA ORAL 5 PA; MO; QL DELSTRIGO 4 MO TABLET 200-50 (56 per 28 MG days) DESCOVY 5 MO; QL (30 per 30 days) EPCLUSA ORAL 5 PA; MO; QL TABLET 400-100 (28 per 28 didanosine oral 4 MO; QL (30 MG days) capsule,delayed per 30 days) release(dr/ec) 250 EPIVIR HBV 4 MO mg, 400 mg ORAL SOLUTION DOVATO 5 MO EVOTAZ 4 MO; QL (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 2 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits famciclovir oral 3 MO; QL (60 ISENTRESS ORAL 5 MO; QL (120 tablet 125 mg, 250 per 30 days) TABLET per 30 days)

mg ISENTRESS ORAL 5 MO; QL (180 famciclovir oral 3 MO; QL (21 TABLET,CHEWAB per 30 days) tablet 500 mg per 30 days) LE 100 MG fosamprenavir 5 MO; QL (120 ISENTRESS ORAL 3 MO; QL (180 per 30 days) TABLET,CHEWAB per 30 days)

FUZEON 5 MO; QL (60 LE 25 MG SUBCUTANEOUS per 30 days) JULUCA 5 MO

RECON SOLN KALETRA ORAL 3 MO; QL (300 ganciclovir sodium 4 B/D PA; MO TABLET 100-25 per 30 days)

GENVOYA 5 MO; QL (30 MG per 30 days) KALETRA ORAL 5 MO; QL (180

HARVONI ORAL 5 PA; MO; QL TABLET 200-50 per 30 days)

PELLETS IN (28 per 28 MG PACKET 33.75-150 days) lamivudine oral 3 MO; QL (900 MG solution per 30 days) HARVONI ORAL 5 PA; MO lamivudine oral 4 MO; QL (30 PELLETS IN tablet 100 mg per 30 days) PACKET 45-200 lamivudine oral 3 MO; QL (60

MG tablet 150 mg per 30 days)

HARVONI ORAL 5 PA; MO lamivudine oral 3 MO; QL (30 TABLET 45-200 tablet 300 mg per 30 days) MG lamivudine- 3 MO; QL (60

HARVONI ORAL 5 PA; MO; QL zidovudine per 30 days) TABLET 90-400 (28 per 28 MG days) LEXIVA ORAL 4 MO; QL (1680 SUSPENSION per 30 days) INTELENCE ORAL 5 MO; QL (120 TABLET 100 MG per 30 days) lopinavir-ritonavir 4 MO INTELENCE ORAL 5 MO; QL (60 nevirapine oral 3 QL (1200 per TABLET 200 MG per 30 days) suspension 30 days) INTELENCE ORAL 4 MO; QL (180 nevirapine oral 3 MO; QL (60 TABLET 25 MG per 30 days) tablet per 30 days) INVIRASE ORAL 5 MO; QL (120 nevirapine oral 4 MO; QL (90 TABLET per 30 days) tablet extended per 30 days) release 24 hr 100 mg ISENTRESS HD 5 MO nevirapine oral 4 MO; QL (30

ISENTRESS ORAL 5 MO; QL (60 tablet extended per 30 days)

POWDER IN per 30 days) release 24 hr 400 mg PACKET

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 3 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits NORVIR ORAL 4 MO REYATAZ ORAL 5 MO; QL (240 POWDER IN POWDER IN per 30 days) PACKET PACKET NORVIR ORAL 3 MO; QL (450 ribavirin oral 3 MO SOLUTION per 30 days) capsule ODEFSEY 5 MO; QL (30 ribavirin oral tablet 3 MO per 30 days) 200 mg oseltamivir oral 3 MO; QL (168 rimantadine 4 MO

capsule 30 mg per 365 days) ritonavir 3 MO; QL (360 oseltamivir oral 3 MO; QL (84 per 30 days)

capsule 45 mg, 75 per 365 days) RUKOBIA 4 MO mg SELZENTRY 4 MO

oseltamivir oral 3 MO; QL (1080 ORAL SOLUTION suspension for per 365 days) reconstitution SELZENTRY 5 MO; QL (60 ORAL TABLET per 30 days)

PIFELTRO 4 MO 150 MG, 75 MG

PREVYMIS 5 SELZENTRY 4 MO; QL (120

INTRAVENOUS ORAL TABLET 25 per 30 days) PREVYMIS ORAL 5 MO; QL (30 MG

per 30 days) SELZENTRY 5 MO; QL (120 PREZCOBIX 4 MO; QL (30 ORAL TABLET per 30 days) per 30 days) 300 MG PREZISTA ORAL 5 MO; QL (360 stavudine oral 4 MO; QL (60 SUSPENSION per 30 days) capsule per 30 days) PREZISTA ORAL 3 MO; QL (240 STRIBILD 5 MO; QL (30 TABLET 150 MG per 30 days) per 30 days) PREZISTA ORAL 5 MO; QL (60 SYMFI 4 MO

TABLET 600 MG per 30 days) SYMFI LO 4 MO; QL (30 PREZISTA ORAL 3 MO; QL (480 per 30 days)

TABLET 75 MG per 30 days) SYMTUZA 4 MO

PREZISTA ORAL 5 MO; QL (30 SYNAGIS 5 MO; LA TABLET 800 MG per 30 days) TEMIXYS 4 MO RELENZA 4 MO; QL (60 DISKHALER per 180 days) tenofovir disoproxil 3 MO; QL (30 fumarate per 30 days) RETROVIR 3 MO INTRAVENOUS TIVICAY ORAL 3 MO; QL (60 TABLET 10 MG per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 4 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits TIVICAY ORAL 5 MO; QL (60 cefadroxil oral 4 MO TABLET 25 MG, 50 per 30 days) suspension for MG reconstitution 250 TIVICAY PD 5 MO; QL (180 mg/5 ml, 500 mg/5

per 30 days) ml

TRIUMEQ 5 MO; QL (30 cefadroxil oral tablet 4 MO per 30 days) cefazolin in dextrose 4 MO

TROGARZO 5 MO; LA (iso-os) intravenous piggyback 1 gram/50 TRUVADA 5 MO; QL (30 ml, 2 gram/50 ml per 30 days) CEFAZOLIN IN 4 valacyclovir oral 3 MO; QL (120 DEXTROSE (ISO- tablet 1 gram per 30 days) OS) valacyclovir oral 3 MO; QL (60 INTRAVENOUS tablet 500 mg per 30 days) PIGGYBACK 2 GRAM/100 ML valganciclovir 5 MO cefazolin injection 4 MO VEMLIDY 5 MO recon soln 1 gram, VIRACEPT ORAL 4 MO; QL (270 500 mg TABLET 250 MG per 30 days) cefazolin injection 4 VIRACEPT ORAL 4 MO; QL (120 recon soln 10 gram, TABLET 625 MG per 30 days) 100 gram, 300 g VIREAD ORAL 5 MO; QL (225 cefazolin 4 POWDER per 30 days) intravenous VIREAD ORAL 5 MO; QL (30 cefdinir oral capsule 2 MO TABLET 150 MG, per 30 days) cefdinir oral 3 MO 200 MG, 250 MG suspension for zidovudine oral 3 MO; QL (180 reconstitution capsule per 30 days) CEFEPIME IN 4 MO zidovudine oral 3 MO; QL (1800 DEXTROSE 5 % syrup per 30 days) cefepime in 4 zidovudine oral 2 MO; QL (60 dextrose,iso-osm tablet per 30 days) intravenous piggyback 1 gram/50 CEPHALOSPORINS ml cefaclor oral capsule 3 MO cefepime in 4 MO cefadroxil oral 2 MO dextrose,iso-osm capsule intravenous piggyback 2 gram/100 ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 5 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits cefepime injection 4 MO cefuroxime sodium 4 PA cefixime 4 MO intravenous recon soln 7.5 gram cefoxitin in dextrose, 4 PA

iso-osm cephalexin oral 2 MO capsule 250 mg, 500 cefoxitin intravenous 4 PA; MO mg recon soln 1 gram, 2

gram cephalexin oral 2 MO suspension for cefoxitin intravenous 4 PA reconstitution recon soln 10 gram SUPRAX ORAL 4 CEFTAZIDIME IN 4 PA SUSPENSION FOR D5W RECONSTITUTIO ceftazidime injection 4 PA; MO N 500 MG/5 ML recon soln 1 gram, 2 tazicef injection 4 PA gram recon soln 1 gram ceftazidime injection 4 PA tazicef injection 4 PA; MO recon soln 6 gram recon soln 2 gram, 6 ceftriaxone in 4 MO gram dextrose,iso-os tazicef intravenous 4 PA ceftriaxone injection 4 MO TEFLARO 4 PA; MO recon soln 1 gram, 2 gram, 250 mg, 500 ERYTHROMYCINS / OTHER mg MACROLIDES ceftriaxone injection 4 azithromycin 4 PA; MO recon soln 10 gram intravenous CEFTRIAXONE 4 azithromycin oral 3 MO INJECTION packet RECON SOLN 100 azithromycin oral 4 MO GRAM suspension for ceftriaxone 4 MO reconstitution intravenous azithromycin oral 2 MO cefuroxime axetil 3 MO tablet oral tablet clarithromycin 4 MO cefuroxime sodium 4 PA; MO erythrocin (as 4 MO injection recon soln stearate) oral tablet 750 mg 250 mg cefuroxime sodium 4 PA; MO ERYTHROCIN 4 PA; MO intravenous recon INTRAVENOUS soln 1.5 gram RECON SOLN 500 MG You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 6 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits erythromycin 4 MO chloroquine 4 MO ethylsuccinate oral phosphate oral suspension for tablet 500 mg

reconstitution clindamycin hcl 2 MO

erythromycin 4 MO CLINDAMYCIN IN 4 PA ethylsuccinate oral 0.9 % SOD CHLOR tablet clindamycin in 5 % 4 PA; MO

erythromycin oral 4 MO dextrose MISCELLANEOUS clindamycin 2 MO ANTIINFECTIVES pediatric albendazole 5 MO clindamycin 4 PA; MO ALINIA ORAL 5 MO; QL (360 phosphate injection SUSPENSION FOR per 30 days) clindamycin 4 PA; MO RECONSTITUTIO phosphate N intravenous solution ALINIA ORAL 5 MO; QL (14 600 mg/4 ml TABLET per 30 days) COARTEM 4 MO; QL (24 amikacin injection 4 PA; MO per 30 days) solution 1,000 mg/4 colistin 4 PA; MO ml, 500 mg/2 ml (colistimethate na) ARIKAYCE 5 PA; MO; LA dapsone oral 3 MO atovaquone 5 MO DAPTOMYCIN 5 MO atovaquone- 3 MO INTRAVENOUS proguanil oral tablet RECON SOLN 350 250-100 mg MG atovaquone- 2 MO daptomycin 5 MO proguanil oral tablet intravenous recon 62.5-25 mg soln 500 mg aztreonam 4 PA; MO EMVERM 5 MO BENZNIDAZOLE 4 MO ertapenem 4 MO CAPASTAT 4 ethambutol oral 2 MO tablet 100 mg CAYSTON 5 PA; MO; LA; QL (84 per 28 ethambutol oral 4 MO days) tablet 400 mg chloroquine 2 MO gentamicin in nacl 4 PA; MO phosphate oral (iso-osm) tablet 250 mg intravenous piggyback 100 mg/100 ml You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 7 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits GENTAMICIN IN 2 PA; MO linezolid-0.9% 4 PA NACL (ISO-OSM) sodium chloride INTRAVENOUS mefloquine 2 MO PIGGYBACK 100 MG/50 ML meropenem 4 MO GENTAMICIN IN 2 PA MEROPENEM- 4 MO NACL (ISO-OSM) 0.9% SODIUM INTRAVENOUS CHLORIDE PIGGYBACK 120 INTRAVENOUS MG/100 ML PIGGYBACK 1 GRAM/50 ML gentamicin in nacl 2 PA; MO (iso-osm) MEROPENEM- 4 intravenous 0.9% SODIUM piggyback 60 mg/50 CHLORIDE ml, 80 mg/50 ml INTRAVENOUS PIGGYBACK 500

gentamicin in nacl 2 PA MG/50 ML (iso-osm) intravenous metro i.v. 2 PA; MO piggyback 80 metronidazole in 2 PA; MO mg/100 ml nacl (iso-os) gentamicin injection 2 PA; MO metronidazole oral 2 MO solution 40 mg/ml tablet gentamicin sulfate 2 PA; MO NEBUPENT 4 B/D PA; MO; (ped) (pf) QL (1 per 28 hydroxychloroquine 3 MO days) imipenem-cilastatin 4 MO neomycin 2 MO IMPAVIDO 5 PA; MO paromomycin 4 MO isoniazid oral 4 MO PASER 4 MO solution pentamidine 3 B/D PA; MO; isoniazid oral tablet 2 MO inhalation QL (1 per 28 days) ivermectin oral 3 MO pentamidine 3 MO

linezolid in dextrose 4 PA injection 5% praziquantel 3 MO linezolid oral 5 MO; QL (1800 suspension for per 30 days) PRIFTIN 4 MO reconstitution PRIMAQUINE 3 MO linezolid oral tablet 4 MO; QL (60 pyrazinamide 4 MO per 30 days) pyrimethamine 5 PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 8 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits quinine sulfate 3 PA; MO; QL VANCOMYCIN 4 (42 per 30 INTRAVENOUS days) RECON SOLN 250

rifabutin 4 MO MG

rifampin intravenous 2 MO vancomycin oral 4 PA; MO; QL capsule 125 mg (40 per 10 rifampin oral 4 MO days) SIRTURO ORAL 5 PA; MO; LA vancomycin oral 5 PA; MO; QL TABLET 100 MG capsule 250 mg (80 per 10 SIRTURO ORAL 5 PA; LA days) TABLET 20 MG XIFAXAN ORAL 4 PA; MO; QL STREPTOMYCIN 4 PA; MO TABLET 200 MG (9 per 30 days) SYNERCID 5 XIFAXAN ORAL 4 PA; MO; QL TABLET 550 MG (90 per 30 tigecycline 5 PA days)

tobramycin in 0.225 5 B/D PA; MO; PENICILLINS % nacl QL (280 per 28 days) amoxicillin oral 2 MO capsule tobramycin sulfate 4 PA injection recon soln amoxicillin oral 2 MO suspension for tobramycin sulfate 2 PA; MO reconstitution injection solution 10 mg/ml amoxicillin oral 2 MO tablet tobramycin sulfate 4 PA; MO injection solution 40 amoxicillin oral 2 MO mg/ml tablet,chewable 125 mg, 250 mg TRECATOR 4 MO amoxicillin-pot 2 MO VANCOMYCIN IN 4 clavulanate oral 0.9 % SODIUM suspension for CHL reconstitution 200- INTRAVENOUS 28.5 mg/5 ml, 600- PIGGYBACK 42.9 mg/5 ml VANCOMYCIN 4 amoxicillin-pot 3 MO INJECTION clavulanate oral vancomycin 4 MO suspension for intravenous recon reconstitution 250- soln 1,000 mg, 10 62.5 mg/5 ml, 400- gram, 5 gram, 500 57 mg/5 ml mg, 750 mg

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 9 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits amoxicillin-pot 2 MO nafcillin intravenous 4 PA; MO clavulanate oral recon soln 2 gram

tablet penicillin g 4 PA; MO amoxicillin-pot 4 MO potassium

clavulanate oral penicillin g procaine 2 PA; MO tablet extended release 12 hr penicillin g sodium 4 PA; MO amoxicillin-pot 2 MO penicillin v 2 MO clavulanate oral potassium tablet,chewable pfizerpen-g 4 PA ampicillin oral 2 MO PIPERACILLIN- 4 MO capsule 500 mg TAZOBACTAM ampicillin sodium 4 PA; MO INTRAVENOUS injection RECON SOLN 13.5 GRAM ampicillin sodium 4 PA intravenous piperacillin- 4 MO tazobactam

ampicillin-sulbactam 4 PA; MO intravenous recon

injection recon soln soln 2.25 gram,

1.5 gram, 3 gram 3.375 gram, 4.5 ampicillin-sulbactam 4 PA gram, 40.5 gram injection recon soln

15 gram QUINOLONES ciprofloxacin hcl 2 MO ampicillin-sulbactam 4 PA oral intravenous recon soln 1.5 gram ciprofloxacin in 5 % 4 PA; MO dextrose ampicillin-sulbactam 4 PA; MO intravenous recon levofloxacin in d5w 4 PA soln 3 gram intravenous piggyback 250 BICILLIN L-A 4 PA; MO mg/50 ml dicloxacillin 2 MO levofloxacin in d5w 4 PA; MO nafcillin in dextrose 4 PA; MO intravenous iso-osm intravenous piggyback 500 piggyback 2 mg/100 ml, 750 gram/100 ml mg/150 ml nafcillin injection 5 PA; MO levofloxacin 4 PA; MO recon soln 10 gram intravenous nafcillin injection 4 PA; MO levofloxacin oral 4 MO recon soln 2 gram solution

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 10 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits levofloxacin oral 2 MO methenamine 3 MO tablet mandelate SULFA'S / RELATED AGENTS nitrofurantoin 3 MO sulfadiazine 4 MO nitrofurantoin 3 MO macrocrystal oral sulfamethoxazole- 4 PA; MO capsule 100 mg, 25 trimethoprim mg intravenous nitrofurantoin 2 MO sulfamethoxazole- 2 MO macrocrystal oral trimethoprim oral capsule 50 mg TETRACYCLINES nitrofurantoin 4 MO doxy-100 4 PA; MO monohyd/m-cryst doxycycline hyclate 4 PA trimethoprim 2 MO intravenous ANTINEOPLASTIC / doxycycline hyclate 3 MO IMMUNOSUPPRESSANT oral capsule DRUGS doxycycline hyclate 3 MO oral tablet 100 mg, ADJUNCTIVE AGENTS 20 mg, 50 mg KEPIVANCE 5 MO doxycycline 3 MO KHAPZORY 4 B/D PA monohydrate oral capsule 100 mg, 50 leucovorin calcium 2 B/D PA; MO mg injection recon soln 100 mg, 200 mg, 350 doxycycline 3 MO mg, 50 mg monohydrate oral suspension for leucovorin calcium 2 B/D PA reconstitution injection recon soln 500 mg doxycycline 3 MO monohydrate oral leucovorin calcium 3 MO tablet oral minocycline oral 2 MO levoleucovorin 5 B/D PA capsule calcium intravenous recon soln 50 mg morgidox oral 3 MO capsule 100 mg levoleucovorin 4 B/D PA calcium intravenous tetracycline 4 MO solution URINARY TRACT AGENTS mesna 4 B/D PA; MO methenamine 4 MO MESNEX ORAL 5 MO hippurate VISTOGARD 5 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 11 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits XGEVA 5 B/D PA; MO; ALECENSA 5 PA; MO; QL QL (1.7 per 28 (240 per 30 days) days) ANTINEOPLASTIC / ALIMTA 5 B/D PA; MO IMMUNOSUPPRESSANT DRUGS ALIQOPA 4 B/D PA; MO; abiraterone oral 4 PA; MO; QL LA tablet 250 mg (120 per 30 ALUNBRIG ORAL 5 PA; MO; QL days) TABLET 180 MG, (30 per 30 abiraterone oral 4 PA; MO; QL 90 MG days) tablet 500 mg (60 per 30 ALUNBRIG ORAL 5 PA; MO; QL days) TABLET 30 MG (60 per 30 ABRAXANE 5 B/D PA; MO days) ADCETRIS 4 B/D PA; MO ALUNBRIG ORAL 5 PA; MO; QL TABLETS,DOSE (30 per 30

adriamycin 3 B/D PA; MO PACK days) intravenous recon soln 10 mg anastrozole 2 MO adriamycin 3 B/D PA ARRANON 5 B/D PA intravenous solution ARSENIC 4 B/D PA adrucil intravenous 4 B/D PA TRIOXIDE solution 2.5 gram/50 INTRAVENOUS ml SOLUTION 1 MG/ML AFINITOR 5 PA; MO; QL DISPERZ ORAL (150 per 30 arsenic trioxide 4 B/D PA; MO TABLET FOR days) intravenous solution SUSPENSION 2 2 mg/ml MG ARZERRA 5 B/D PA; MO AFINITOR 5 PA; MO; QL AVASTIN 3 B/D PA; MO DISPERZ ORAL (90 per 30 TABLET FOR days) AYVAKIT 5 PA; MO; LA; SUSPENSION 3 QL (30 per 30 MG days) AFINITOR 5 PA; MO; QL azacitidine 5 B/D PA; MO DISPERZ ORAL (60 per 30 azathioprine 2 B/D PA; MO TABLET FOR days) azathioprine sodium 3 B/D PA SUSPENSION 5 MG BALVERSA 5 PA; MO; LA AFINITOR ORAL 5 PA; MO; QL BAVENCIO 5 B/D PA; MO; TABLET 10 MG (30 per 30 LA days) BELEODAQ 5 B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 12 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits BENDEKA 4 B/D PA; MO carboplatin 4 B/D PA; MO

BESPONSA 5 B/D PA; MO; intravenous solution LA carmustine 5 B/D PA; MO bexarotene 5 PA; MO cisplatin intravenous 3 B/D PA; MO

bicalutamide 3 MO solution

BLENREP 4 PA; MO cladribine 4 B/D PA; MO

bleomycin 4 B/D PA; MO clofarabine 5 B/D PA

BLINCYTO 5 B/D PA; MO COMETRIQ ORAL 5 PA; MO; QL INTRAVENOUS CAPSULE 100 (56 per 28

KIT MG/DAY(80 MG days) X1-20 MG X1) BORTEZOMIB 4 B/D PA; MO COMETRIQ ORAL 5 PA; MO; QL BOSULIF ORAL 5 PA; MO; QL CAPSULE 140 (112 per 28 TABLET 100 MG (90 per 30 MG/DAY(80 MG days) days) X1-20 MG X3) BOSULIF ORAL 5 PA; MO; QL COMETRIQ ORAL 5 PA; MO; QL TABLET 400 MG, (30 per 30 CAPSULE 60 (84 per 28 500 MG days) MG/DAY (20 MG X days) BRAFTOVI ORAL 5 PA; MO; LA; 3/DAY) CAPSULE 75 MG QL (180 per COPIKTRA 5 PA; MO; LA; 30 days) QL (60 per 30 BRUKINSA 5 PA; MO; LA days) busulfan 5 B/D PA COTELLIC 5 PA; MO; LA; QL (63 per 28 CABOMETYX 5 PA; MO; LA; days) ORAL TABLET 20 QL (30 per 30 MG, 60 MG days) cyclophosphamide 3 B/D PA; MO intravenous recon CABOMETYX 5 PA; MO; LA; soln ORAL TABLET 40 QL (60 per 30 MG days) cyclophosphamide 3 B/D PA; MO oral capsule CALQUENCE 5 PA; MO; LA; QL (60 per 30 cyclosporine 4 B/D PA days) intravenous CAPRELSA ORAL 5 PA; LA; QL cyclosporine 3 B/D PA; MO TABLET 100 MG (60 per 30 modified days) cyclosporine oral 3 B/D PA; MO CAPRELSA ORAL 5 PA; LA; QL capsule TABLET 300 MG (30 per 30 CYRAMZA 5 B/D PA; MO days) cytarabine 4 B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 13 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits cytarabine (pf) 2 B/D PA; MO doxorubicin 2 B/D PA; MO injection solution intravenous recon 100 mg/5 ml (20 soln 50 mg

mg/ml) doxorubicin 2 B/D PA; MO cytarabine (pf) 4 B/D PA; MO intravenous solution

injection solution 2 doxorubicin, peg- 5 B/D PA; MO gram/20 ml (100 liposomal mg/ml) DROXIA 3 MO cytarabine (pf) 4 B/D PA injection solution 20 ELLENCE 4 B/D PA; MO mg/ml INTRAVENOUS SOLUTION 50

dacarbazine 2 B/D PA; MO MG/25 ML

dactinomycin 3 B/D PA ELZONRIS 5 PA; MO; LA

DARZALEX 5 B/D PA; MO; EMCYT 4 MO LA EMPLICITI 4 B/D PA; MO DARZALEX 5 B/D PA; MO FASPRO epirubicin 4 B/D PA; MO intravenous solution daunorubicin 2 B/D PA intravenous solution ERBITUX 5 B/D PA; MO DAURISMO ORAL 5 PA; MO; QL ERIVEDGE 5 PA; MO; QL TABLET 100 MG (30 per 30 (30 per 30 days) days) DAURISMO ORAL 5 PA; MO; QL ERLEADA 4 PA; MO; QL TABLET 25 MG (60 per 30 (120 per 30 days) days) decitabine 5 B/D PA; MO erlotinib oral tablet 5 PA; MO; QL 100 mg, 150 mg (30 per 30

docetaxel 5 B/D PA days) intravenous solution 160 mg/16 ml (10 erlotinib oral tablet 5 PA; MO; QL mg/ml), 20 mg/2 ml 25 mg (60 per 30 (10 mg/ml) days) docetaxel 5 B/D PA; MO ERWINAZE 5 B/D PA; MO intravenous solution ETOPOPHOS 4 B/D PA; MO 160 mg/8 ml (20 mg/ml), 20 mg/ml (1 etoposide 2 B/D PA; MO ml), 80 mg/4 ml (20 intravenous mg/ml), 80 mg/8 ml everolimus 5 PA; MO; QL (10 mg/ml) (antineoplastic) (30 per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 14 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits everolimus 5 B/D PA; MO; gemcitabine 3 B/D PA (immunosuppressive QL (60 per 30 intravenous recon ) oral tablet 0.25 mg, days) soln 2 gram

0.75 mg gemcitabine 3 B/D PA; MO everolimus 5 B/D PA; MO; intravenous solution (immunosuppressive QL (120 per 1 gram/26.3 ml (38 ) oral tablet 0.5 mg 30 days) mg/ml), 200 mg/5.26

EVOMELA 5 B/D PA; MO ml (38 mg/ml)

exemestane 4 MO GEMCITABINE 3 B/D PA INTRAVENOUS FARYDAK 5 PA; MO; QL SOLUTION 100 (6 per 21 days) MG/ML FIRMAGON KIT W 4 B/D PA; MO gemcitabine 3 B/D PA DILUENT intravenous solution SYRINGE 2 gram/52.6 ml (38 floxuridine 4 B/D PA mg/ml) fludarabine 3 B/D PA; MO gengraf oral capsule 4 B/D PA; MO intravenous recon 100 mg, 25 mg soln gengraf oral solution 4 B/D PA; MO fludarabine 3 B/D PA GILOTRIF 5 PA; MO; QL intravenous solution (30 per 30 fluorouracil 2 B/D PA; MO days) intravenous solution HALAVEN 5 B/D PA; MO 1 gram/20 ml, 500

mg/10 ml HERCEPTIN 5 B/D PA; MO HYLECTA fluorouracil 4 B/D PA; MO

intravenous solution HERCEPTIN 5 B/D PA; MO 2.5 gram/50 ml, 5 INTRAVENOUS gram/100 ml RECON SOLN 150 MG flutamide 4 MO hydroxyurea 2 MO FOLOTYN 5 B/D PA; MO IBRANCE 5 PA; MO; QL fulvestrant 5 B/D PA; MO (21 per 28 GAVRETO 4 PA; MO; LA; days) QL (120 per ICLUSIG ORAL 5 PA; MO 30 days) TABLET 10 MG, 30 GAZYVA 5 B/D PA; MO MG gemcitabine 3 B/D PA; MO ICLUSIG ORAL 5 PA; MO; QL intravenous recon TABLET 15 MG (60 per 30 soln 1 gram, 200 mg days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 15 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits ICLUSIG ORAL 5 PA; MO; QL INQOVI 5 PA; MO; QL TABLET 45 MG (30 per 30 (5 per 28 days)

days) INREBIC 5 PA; MO; LA; idarubicin 4 B/D PA; MO QL (120 per

IDHIFA 5 PA; MO; LA; 30 days) QL (30 per 30 IRESSA 4 PA; MO; QL days) (30 per 30

ifosfamide 4 B/D PA; MO days) intravenous recon irinotecan 4 B/D PA; MO soln intravenous solution ifosfamide 4 B/D PA; MO 100 mg/5 ml, 40

intravenous solution mg/2 ml 1 gram/20 ml irinotecan 4 B/D PA

ifosfamide 4 B/D PA intravenous solution intravenous solution 300 mg/15 ml, 500

3 gram/60 ml mg/25 ml

imatinib oral tablet 5 PA; MO; QL ISTODAX 5 B/D PA; MO 100 mg (180 per 30 IXEMPRA 5 B/D PA; MO

days) JAKAFI 5 PA; MO; QL imatinib oral tablet 5 PA; MO; QL (60 per 30 400 mg (60 per 30 days)

days) JEVTANA 4 B/D PA; MO

IMBRUVICA 5 PA; MO; QL KADCYLA 5 PA; MO ORAL CAPSULE (120 per 30 140 MG days) KEYTRUDA 5 PA; MO INTRAVENOUS

IMBRUVICA 5 PA; MO; QL SOLUTION ORAL CAPSULE (30 per 30 70 MG days) KISQALI FEMARA 4 PA; MO; QL CO-PACK ORAL (49 per 28

IMBRUVICA 5 PA; MO; QL TABLET 200 days)

ORAL TABLET (30 per 30 MG/DAY(200 MG

days) X 1)-2.5 MG

IMFINZI 4 B/D PA; MO; KISQALI FEMARA 4 PA; MO; QL

LA CO-PACK ORAL (70 per 28 INFUGEM 4 B/D PA TABLET 400 days) INLYTA ORAL 5 PA; MO; QL MG/DAY(200 MG

TABLET 1 MG (180 per 30 X 2)-2.5 MG days) INLYTA ORAL 5 PA; MO; QL TABLET 5 MG (120 per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 16 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits KISQALI FEMARA 4 PA; MO; QL leuprolide 4 MO CO-PACK ORAL (91 per 28 subcutaneous kit

TABLET 600 days) LIBTAYO 5 PA; MO; LA MG/DAY(200 MG X 3)-2.5 MG LONSURF ORAL 5 PA; MO; QL TABLET 15-6.14 (100 per 28

KISQALI ORAL 5 PA; MO; QL MG days) TABLET 200 (21 per 28 MG/DAY (200 MG days) LONSURF ORAL 5 PA; MO; QL X 1) TABLET 20-8.19 (80 per 28 MG days) KISQALI ORAL 5 PA; MO; QL TABLET 400 (42 per 28 LORBRENA ORAL 5 PA; MO; QL MG/DAY (200 MG days) TABLET 100 MG (30 per 30 X 2) days) KISQALI ORAL 5 PA; MO; QL LORBRENA ORAL 5 PA; MO; QL TABLET 600 (63 per 28 TABLET 25 MG (90 per 30 MG/DAY (200 MG days) days) X 3) LUMOXITI 4 PA; MO; LA KYPROLIS 5 B/D PA; MO LUPRON DEPOT 5 PA; MO lapatinib 5 PA; MO; QL LUPRON DEPOT 5 PA; MO (180 per 30 (3 MONTH) days) LUPRON DEPOT 5 PA; MO LENVIMA ORAL 5 PA; MO; QL (4 MONTH) CAPSULE 10 (30 per 30 MG/DAY (10 MG X days) LUPRON DEPOT 5 PA; MO 1), 4 MG (6 MONTH) LENVIMA ORAL 5 PA; MO; QL LUPRON DEPOT- 5 PA; MO CAPSULE 12 (90 per 30 PED MG/DAY (4 MG X days) LUPRON DEPOT- 5 PA; MO 3), 18 MG/DAY (10 PED (3 MONTH) MG X 1-4 MG X2), LYNPARZA ORAL 5 PA; MO; QL 24 MG/DAY(10 MG TABLET (120 per 30 X 2-4 MG X 1) days) LENVIMA ORAL 5 PA; MO; QL LYSODREN 5 MO CAPSULE 14 (60 per 30 MG/DAY(10 MG X days) MARQIBO 5 B/D PA; MO 1-4 MG X 1), 20 MATULANE 5 MO MG/DAY (10 MG X 2), 8 MG/DAY (4 megestrol oral 4 PA; MO MG X 2) suspension 400 mg/10 ml (40 letrozole 2 MO mg/ml), 625 mg/5 ml LEUKERAN 4 MO (125 mg/ml)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 17 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits megestrol oral tablet 4 PA; MO NERLYNX 5 PA; MO; LA MEKINIST ORAL 5 PA; MO; QL NEXAVAR 5 PA; MO; LA; TABLET 0.5 MG (90 per 30 QL (120 per days) 30 days) MEKINIST ORAL 5 PA; MO; QL nilutamide 5 PA; MO

TABLET 2 MG (30 per 30 NINLARO 5 PA; MO; QL

days) (3 per 28 days)

MEKTOVI 5 PA; MO; LA; NIPENT 4 B/D PA; MO QL (180 per 30 days) NUBEQA 4 PA; MO; LA; QL (120 per

melphalan 3 B/D PA; MO 30 days)

melphalan hcl 5 B/D PA NULOJIX 5 B/D PA; MO

mercaptopurine 2 MO octreotide acetate 5 PA; MO methotrexate sodium 3 B/D PA; MO injection solution methotrexate sodium 3 B/D PA 1,000 mcg/ml, 500

(pf) injection recon mcg/ml soln octreotide acetate 3 PA; MO

methotrexate sodium 3 B/D PA; MO injection solution (pf) injection 100 mcg/ml, 200

solution mcg/ml, 50 mcg/ml

mitomycin 4 B/D PA; MO octreotide acetate 5 PA; MO

intravenous injection syringe 100 mcg/ml (1 ml), 500 mitoxantrone 2 B/D PA; MO mcg/ml (1 ml) MONJUVI 4 PA; MO; LA octreotide acetate 3 PA; MO mycophenolate 3 B/D PA injection syringe 50 mofetil (hcl) mcg/ml (1 ml) mycophenolate 3 B/D PA; MO ODOMZO 5 PA; MO; LA; mofetil oral capsule QL (30 per 30 days) mycophenolate 5 B/D PA; MO mofetil oral ONCASPAR 5 B/D PA; MO suspension for ONIVYDE 5 B/D PA; MO reconstitution ONUREG 4 PA; MO; QL mycophenolate 3 B/D PA; MO (14 per 28 mofetil oral tablet days) mycophenolate 4 B/D PA; MO OPDIVO 5 PA; MO sodium oxaliplatin 4 B/D PA; MO MYLOTARG 4 B/D PA; MO; intravenous recon LA soln 100 mg You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 18 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits oxaliplatin 4 B/D PA RITUXAN 5 PA; MO intravenous recon RITUXAN 4 PA; MO

soln 50 mg HYCELA

oxaliplatin 4 B/D PA; MO ROMIDEPSIN 5 B/D PA; MO

intravenous solution INTRAVENOUS 100 mg/20 ml, 50 SOLUTION mg/10 ml (5 mg/ml) ROZLYTREK 4 PA; MO; QL

oxaliplatin 4 B/D PA ORAL CAPSULE (150 per 30

intravenous solution 100 MG days) 200 mg/40 ml ROZLYTREK 4 PA; MO; QL

paclitaxel 4 B/D PA; MO ORAL CAPSULE (90 per 30 PADCEV 4 B/D PA; MO 200 MG days) PEMAZYRE 4 PA; MO; LA RUBRACA 5 PA; MO; LA; PERJETA 5 B/D PA; MO QL (120 per 30 days) PHESGO 5 PA; MO

SUBCUTANEOUS RYDAPT 5 PA; MO; QL SOLUTION 1,200 (240 per 30

MG-600MG- 30000 days) UNIT/15ML SANDIMMUNE 3 B/D PA; MO

PIQRAY 5 PA; MO ORAL SOLUTION

POLIVY 5 PA; MO SARCLISA 4 PA; MO; LA

POMALYST 5 PA; MO; LA; SIGNIFOR 5 PA; MO QL (21 per 28 SIMULECT 3 B/D PA days) INTRAVENOUS PORTRAZZA 4 B/D PA; MO RECON SOLN 10 MG POTELIGEO 5 PA; MO SIMULECT 3 B/D PA; MO PROGRAF 3 B/D PA; MO INTRAVENOUS INTRAVENOUS RECON SOLN 20 PROGRAF ORAL 3 B/D PA; MO MG GRANULES IN sirolimus oral 5 B/D PA; MO PACKET solution PURIXAN 5 sirolimus oral tablet 3 B/D PA; MO QINLOCK 5 PA; MO; LA 0.5 mg RETEVMO 5 PA; MO; LA sirolimus oral tablet 4 B/D PA; MO 1 mg REVLIMID 5 PA; MO; LA; QL (28 per 28 sirolimus oral tablet 5 B/D PA; MO days) 2 mg SOLTAMOX 4 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 19 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits SOMATULINE 5 PA; MO TASIGNA ORAL 5 PA; MO; QL DEPOT CAPSULE 50 MG (120 per 30

SPRYCEL ORAL 5 PA; MO; QL days) TABLET 100 MG, (30 per 30 TAZVERIK 4 PA; MO; LA

140 MG, 50 MG, 80 days) TECENTRIQ 5 B/D PA; MO;

MG LA

SPRYCEL ORAL 5 PA; MO; QL TEMODAR 5 B/D PA; MO TABLET 20 MG, 70 (60 per 30 INTRAVENOUS MG days) temsirolimus 5 B/D PA; MO STIVARGA 5 PA; MO; QL (84 per 28 THALOMID ORAL 5 PA; MO; QL days) CAPSULE 100 MG, (30 per 30 50 MG days) SUTENT 5 PA; MO; QL (30 per 30 THALOMID ORAL 5 PA; MO; QL days) CAPSULE 150 MG, (60 per 30 200 MG days) SYLVANT 5 B/D PA; MO thiotepa injection 5 B/D PA

SYNRIBO 4 B/D PA; MO recon soln 100 mg

TABLOID 4 MO thiotepa injection 5 B/D PA; MO TABRECTA 5 PA; MO recon soln 15 mg tacrolimus oral 3 B/D PA; MO TIBSOVO 5 PA; MO TAFINLAR 5 PA; MO; QL toposar 4 B/D PA; MO (120 per 30 topotecan 4 B/D PA

days) intravenous recon TAGRISSO 5 PA; MO; LA; soln QL (30 per 30 topotecan 4 B/D PA; MO

days) intravenous solution TALZENNA ORAL 5 PA; MO; QL 4 mg/4 ml (1 mg/ml)

CAPSULE 0.25 MG (90 per 30 toremifene 5 MO days) TREANDA 4 B/D PA; MO

TALZENNA ORAL 5 PA; MO; QL INTRAVENOUS

CAPSULE 1 MG (30 per 30 RECON SOLN days) TRELSTAR 5 B/D PA; MO

tamoxifen 2 MO INTRAMUSCULA TARGRETIN 5 PA; MO R SUSPENSION TOPICAL FOR

TASIGNA ORAL 5 PA; MO; QL RECONSTITUTIO

CAPSULE 150 MG, (112 per 28 N 200 MG days) tretinoin 5 MO (antineoplastic) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 20 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits TRISENOX 4 B/D PA; MO vinblastine 2 B/D PA; MO INTRAVENOUS intravenous solution SOLUTION 2 vincasar pfs 2 B/D PA; MO MG/ML vincristine 2 B/D PA; MO TRODELVY 4 PA; MO; LA vinorelbine 3 B/D PA; MO TUKYSA ORAL 5 PA; MO; LA; TABLET 150 MG QL (120 per VITRAKVI ORAL 4 PA; MO; LA; 30 days) CAPSULE 100 MG QL (60 per 30 days) TUKYSA ORAL 5 PA; MO; LA TABLET 50 MG VITRAKVI ORAL 4 PA; MO; LA; CAPSULE 25 MG QL (180 per

TURALIO 5 PA; MO; LA; 30 days) QL (120 per 30 days) VITRAKVI ORAL 4 PA; MO; LA; SOLUTION QL (300 per

TYKERB 5 PA; MO; LA; 30 days) QL (180 per 30 days) VIZIMPRO 5 PA; MO; QL (30 per 30

UNITUXIN 5 B/D PA; MO days)

valrubicin 5 B/D PA; MO VOTRIENT 5 PA; MO; QL VALSTAR 4 B/D PA; MO (120 per 30

VANTAS 4 PA; MO days)

VECTIBIX 5 B/D PA; MO VYXEOS 5 B/D PA; MO

VELCADE 5 B/D PA; MO XALKORI 5 PA; MO; QL (60 per 30 VENCLEXTA 4 PA; MO; LA; days) ORAL TABLET 10 QL (60 per 30

MG days) XATMEP 4 B/D PA; MO

VENCLEXTA 5 PA; MO; LA; XERMELO 5 PA; MO; LA; ORAL TABLET QL (120 per QL (90 per 30

100 MG 30 days) days)

VENCLEXTA 5 PA; MO; LA; XOSPATA 5 PA; MO; LA ORAL TABLET 50 QL (30 per 30 XPOVIO 4 PA; MO; LA

MG days) XTANDI 4 PA; MO; QL VENCLEXTA 5 PA; MO; LA; (120 per 30 STARTING PACK QL (42 per 30 days)

days) YERVOY 5 B/D PA; MO

VERZENIO 5 PA; MO; LA; YONDELIS 5 B/D PA; MO QL (60 per 30 days) ZALTRAP 4 B/D PA; MO ZANOSAR 4 B/D PA; MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 21 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits ZEJULA 5 PA; MO; LA; carbamazepine oral 4 MO QL (90 per 30 capsule, er days) multiphase 12 hr ZELBORAF 5 PA; MO; QL carbamazepine oral 4 MO (240 per 30 suspension 100 mg/5 days) ml ZEPZELCA 4 PA; MO carbamazepine oral 4 MO

ZIRABEV 5 B/D PA; MO tablet

ZOLADEX 4 B/D PA; MO carbamazepine oral 4 MO tablet extended ZOLINZA 5 PA; MO; QL release 12 hr (120 per 30

days) carbamazepine oral 3 MO tablet,chewable ZORTRESS ORAL 5 B/D PA; MO

TABLET 1 MG CELONTIN ORAL 4 MO CAPSULE 300 MG ZYDELIG 5 PA; MO; QL

(60 per 30 clobazam oral 3 PA; MO; QL

days) suspension (480 per 30 days) ZYKADIA ORAL 5 PA; MO; QL

TABLET (150 per 30 clobazam oral tablet 4 PA; MO; QL days) (60 per 30 days) AUTONOMIC / CNS DRUGS, clonazepam oral 2 MO; QL (90 NEUROLOGY / PSYCH tablet 0.5 mg, 1 mg per 30 days) ANTICONVULSANTS clonazepam oral 2 MO; QL (300 tablet 2 mg per 30 days) APTIOM ORAL 4 MO; QL (180 TABLET 200 MG per 30 days) clonazepam oral 4 MO; QL (90 tablet,disintegrating per 30 days) APTIOM ORAL 4 MO; QL (90 0.125 mg, 0.25 mg, TABLET 400 MG per 30 days) 0.5 mg, 1 mg APTIOM ORAL 4 MO; QL (60 clonazepam oral 4 MO; QL (300 TABLET 600 MG, per 30 days) tablet,disintegrating per 30 days) 800 MG 2 mg BANZEL 5 PA; MO DIACOMIT 4 PA; MO; LA BRIVIACT 4 diazepam rectal 3 MO INTRAVENOUS DILANTIN 30 MG 4 MO BRIVIACT ORAL 4 MO; QL (600 SOLUTION per 30 days) divalproex oral 4 MO capsule, delayed rel BRIVIACT ORAL 4 MO; QL (60 sprinkle TABLET per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 22 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits divalproex oral 4 MO lamotrigine oral 3 MO tablet extended tablets,dose pack

release 24 hr levetiracetam in nacl 3 divalproex oral 2 MO (iso-os) intravenous tablet,delayed piggyback 1,000 release (dr/ec) mg/100 ml, 1,500

EPIDIOLEX 5 PA; MO; LA mg/100 ml

epitol 2 MO levetiracetam in nacl 3 MO (iso-os) intravenous ethosuximide 3 MO piggyback 500 felbamate 4 MO mg/100 ml FINTEPLA 4 PA; MO; LA levetiracetam 3 MO intravenous fosphenytoin 2 MO levetiracetam oral 3 MO FYCOMPA ORAL 4 PA; MO; QL solution 100 mg/ml SUSPENSION (720 per 30 days) levetiracetam oral 3 solution 500 mg/5 ml FYCOMPA ORAL 4 PA; MO; QL (5 ml) TABLET 10 MG, 12 (30 per 30 MG, 8 MG days) levetiracetam oral 2 MO tablet FYCOMPA ORAL 4 PA; MO; QL TABLET 2 MG, 4 (60 per 30 NAYZILAM 4 PA; MO; QL MG, 6 MG days) (10 per 30 days) gabapentin oral 2 MO; QL (270 capsule 100 mg, 400 per 30 days) oxcarbazepine 3 MO mg phenobarbital oral 3 PA; MO; gabapentin oral 2 MO; QL (360 elixir HRM; QL capsule 300 mg per 30 days) (1500 per 30 days) gabapentin oral 4 MO; QL (2160 solution 250 mg/5 ml per 30 days) phenobarbital oral 3 PA; MO; tablet HRM; QL gabapentin oral 2 MO; QL (180 (120 per 30 tablet 600 mg per 30 days) days) gabapentin oral 2 MO; QL (120 phenobarbital 3 MO tablet 800 mg per 30 days) sodium injection lamotrigine oral 2 MO solution 130 mg/ml tablet phenobarbital 3 lamotrigine oral 2 MO sodium injection tablet, chewable solution 65 mg/ml dispersible

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 23 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits phenytoin oral 2 MO valproate sodium 2 MO

suspension 125 mg/5 valproic acid 2 MO ml valproic acid (as 2 MO

phenytoin oral 2 MO sodium salt) oral

tablet,chewable solution 250 mg/5 ml

phenytoin sodium 2 MO VALTOCO 4 PA; MO; QL

extended (10 per 30 phenytoin sodium 2 MO days)

intravenous solution vigabatrin 5 PA; MO; LA; pregabalin oral 3 MO; QL (90 QL (180 per capsule 100 mg, 150 per 30 days) 30 days) mg, 200 mg, 25 mg, vigadrone 5 PA; MO; LA;

50 mg, 75 mg QL (180 per pregabalin oral 3 MO; QL (60 30 days)

capsule 225 mg, 300 per 30 days) VIMPAT 4 MO

mg INTRAVENOUS

pregabalin oral 3 MO; QL (900 VIMPAT ORAL 4 MO; QL (1200

solution per 30 days) SOLUTION per 30 days)

primidone 2 MO VIMPAT ORAL 4 MO; QL (60 roweepra 2 MO TABLET per 30 days) rufinamide 5 PA; MO XCOPRI 4 PA; MO SPRITAM 4 MO XCOPRI 4 PA; MO subvenite 3 MO MAINTENANCE PACK subvenite starter 3 MO

(blue) kit XCOPRI 4 PA; MO TITRATION PACK subvenite starter 3 MO

(green) kit zonisamide 3 PA; MO subvenite starter 3 MO ANTIPARKINSONISM AGENTS (orange) kit APOKYN 5 PA; MO; LA; SYMPAZAN 4 PA; MO; QL QL (60 per 30 (60 per 30 days) days) benztropine injection 4 MO tiagabine 4 MO benztropine oral 3 PA; MO; topiramate oral 2 PA; MO HRM capsule, sprinkle bromocriptine 4 MO topiramate oral 2 PA; MO carbidopa 5 MO tablet

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 24 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits carbidopa-levodopa 2 MO sumatriptan 3 MO; QL (8 per oral tablet succinate 28 days) carbidopa-levodopa 3 MO subcutaneous

oral tablet extended cartridge release sumatriptan 3 MO; QL (8 per

carbidopa-levodopa 4 MO succinate 28 days) oral subcutaneous pen

tablet,disintegrating injector

carbidopa-levodopa- 4 MO sumatriptan 3 MO; QL (8 per

entacapone succinate 28 days) subcutaneous entacapone 3 MO solution NEUPRO 4 MO sumatriptan 3 MO; QL (8 per pramipexole oral 2 MO succinate 28 days) tablet subcutaneous syringe 6 mg/0.5 ml rasagiline 4 MO MISCELLANEOUS ropinirole oral tablet 2 MO NEUROLOGICAL THERAPY RYTARY 4 ST; MO dalfampridine 5 PA; MO; QL selegiline hcl 3 MO (60 per 30

MIGRAINE / CLUSTER HEADACHE days) THERAPY dimethyl fumarate 5 PA; MO; QL oral capsule,delayed (14 per 30 AIMOVIG 3 PA; MO; QL release(dr/ec) 120 days) AUTOINJECTOR (1 per 30 days) mg dihydroergotamine 2 MO dimethyl fumarate 5 PA; MO; QL injection oral capsule,delayed (120 per 180 dihydroergotamine 4 MO; QL (8 per release(dr/ec) 120 days) nasal 28 days) mg (14)- 240 mg ergotamine-caffeine 3 MO (46) rizatriptan 3 MO; QL (36 dimethyl fumarate 5 PA; MO; QL per 28 days) oral capsule,delayed (60 per 30 release(dr/ec) 240 days) sumatriptan nasal 4 MO; QL (18 mg spray,non-aerosol per 28 days) 20 mg/actuation donepezil oral tablet 2 MO; QL (69 10 mg per 30 days) sumatriptan nasal 4 MO; QL (36 spray,non-aerosol 5 per 28 days) donepezil oral tablet 2 MO; QL (30 mg/actuation 5 mg per 30 days) sumatriptan 2 MO; QL (18 donepezil oral 2 MO; QL (69 succinate oral per 28 days) tablet,disintegrating per 30 days) 10 mg You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 25 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits donepezil oral 2 MO; QL (30 OCREVUS 5 PA; MO; LA

tablet,disintegrating per 30 days) RADICAVA 5 PA; MO 5 mg rivastigmine 4 MO; QL (30

FIRDAPSE 5 PA; MO; LA per 30 days)

galantamine oral 4 MO; QL (30 rivastigmine tartrate 4 MO; QL (60

capsule,ext rel. per 30 days) per 30 days) pellets 24 hr TECFIDERA ORAL 5 PA; MO; LA;

galantamine oral 4 MO; QL (200 CAPSULE,DELAY QL (14 per 30

solution per 30 days) ED days) galantamine oral 4 MO; QL (60 RELEASE(DR/EC) tablet per 30 days) 120 MG glatiramer 5 PA; MO; QL TECFIDERA ORAL 5 PA; MO; LA; subcutaneous (30 per 30 CAPSULE,DELAY QL (120 per syringe 20 mg/ml days) ED 180 days) glatiramer 5 PA; MO; QL RELEASE(DR/EC) subcutaneous (12 per 28 120 MG (14)- 240

syringe 40 mg/ml days) MG (46)

glatopa 5 PA; MO; QL TECFIDERA ORAL 5 PA; MO; LA;

subcutaneous (30 per 30 CAPSULE,DELAY QL (60 per 30

syringe 20 mg/ml days) ED days) RELEASE(DR/EC) glatopa 5 PA; MO; QL 240 MG subcutaneous (12 per 28

syringe 40 mg/ml days) tetrabenazine oral 5 PA; MO; QL tablet 12.5 mg (240 per 30 LEMTRADA 5 PA; MO days) memantine oral 4 PA; MO tetrabenazine oral 5 PA; MO; QL capsule,sprinkle,er tablet 25 mg (120 per 30 24hr days) memantine oral 4 PA; MO; QL TYSABRI 5 PA; MO; LA solution (300 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY memantine oral 3 PA; MO; QL tablet (60 per 30 baclofen oral 3 MO days) cyclobenzaprine oral 4 PA; MO; MEMANTINE 3 PA; MO; QL tablet 10 mg, 5 mg HRM ORAL (98 per 28 dantrolene oral 4 MO TABLETS,DOSE days)

PACK LIORESAL 5 B/D PA; MO INTRATHECAL NAMZARIC 3 PA; MO SOLUTION 2,000 NUEDEXTA 5 PA; MO MCG/ML

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 26 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits LIORESAL 3 B/D PA buprenorphine hcl 3 PA; MO INTRATHECAL sublingual SOLUTION 50 duramorph (pf) 4 MO; QL (4000

MCG/ML injection solution 0.5 per 30 days) LIORESAL 3 B/D PA; MO mg/ml INTRATHECAL duramorph (pf) 4 QL (2000 per SOLUTION 500 injection solution 1 30 days)

MCG/ML mg/ml

neostigmine 3 MO endocet oral tablet 3 MO; QL (360 methylsulfate 10-325 mg, 5-325 per 30 days)

intravenous solution mg, 7.5-325 mg 0.5 mg/ml endocet oral tablet 4 MO; QL (360

neostigmine 3 2.5-325 mg per 30 days) methylsulfate intravenous solution fentanyl citrate (pf) 3 MO; QL (400 1 mg/ml injection solution per 30 days) pyridostigmine 5 MO FENTANYL 3 QL (400 per bromide oral syrup CITRATE (PF) 30 days) INTRAVENOUS

pyridostigmine 3 MO SYRINGE 100

bromide oral tablet MCG/2 ML (50

60 mg MCG/ML)

pyridostigmine 3 MO fentanyl citrate 5 PA; MO; QL bromide oral tablet buccal lozenge on a (120 per 30

extended release handle days)

regonol 3 fentanyl transdermal 4 PA; MO; QL revonto 3 patch 72 hour 100 (10 per 30

tizanidine oral tablet 2 MO mcg/hr, 12 mcg/hr, days) 25 mcg/hr, 50 NARCOTIC ANALGESICS mcg/hr, 75 mcg/hr acetaminophen- 2 MO; QL (4500 hydrocodone- 4 QL (5550 per codeine oral solution per 30 days) acetaminophen oral 30 days) 120-12 mg/5 ml solution 10-325

acetaminophen- 2 MO; QL (360 mg/15 ml(15 ml) codeine oral tablet per 30 days) hydrocodone- 4 MO; QL (5550 300-15 mg, 300-30 acetaminophen oral per 30 days) mg solution 7.5-325

acetaminophen- 2 MO; QL (180 mg/15 ml codeine oral tablet per 30 days) hydrocodone- 3 MO; QL (360 300-60 mg acetaminophen oral per 30 days) tablet 10-325 mg, 5- 325 mg, 7.5-325 mg You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 27 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits hydrocodone- 3 MO; QL (50 methadone intensol 4 PA; MO; QL ibuprofen oral tablet per 30 days) (90 per 30 7.5-200 mg days) HYDROMORPHO 4 QL (300 per methadone oral 4 PA; MO; QL NE (PF) 30 days) concentrate (90 per 30 INJECTION days) SOLUTION 1 methadone oral 3 PA; MO; QL

MG/ML solution 10 mg/5 ml (600 per 30 hydromorphone (pf) 4 MO; QL (240 days)

injection solution 10 per 30 days) methadone oral 3 PA; MO; QL

(mg/ml) (5 ml), 10 solution 5 mg/5 ml (1200 per 30

mg/ml days)

hydromorphone (pf) 4 QL (150 per methadone oral 2 PA; MO; QL

injection solution 2 30 days) tablet 10 mg (120 per 30

mg/ml days)

HYDROMORPHO 4 QL (75 per 30 methadone oral 2 PA; MO; QL

NE (PF) days) tablet 5 mg (240 per 30 INJECTION days) SOLUTION 4 MG/ML methadose oral 4 PA; MO; QL concentrate (90 per 30

hydromorphone 4 QL (300 per days) injection solution 1 30 days) mg/ml morphine (pf) 4 QL (4000 per injection solution 0.5 30 days)

hydromorphone 4 MO; QL (150 mg/ml injection solution 2 per 30 days) mg/ml morphine (pf) 4 MO; QL (2000 injection solution 1 per 30 days)

hydromorphone 4 MO; QL (300 mg/ml injection syringe 1 per 30 days) mg/ml morphine 3 MO; QL (900 concentrate oral per 30 days)

hydromorphone 4 QL (150 per solution injection syringe 2 30 days) mg/ml MORPHINE 4 MO; QL (1000 INJECTION per 30 days)

hydromorphone oral 2 MO; QL (2400 SOLUTION 2

liquid per 30 days) MG/ML

hydromorphone oral 3 MO; QL (180 morphine injection 4 MO; QL (1000

tablet per 30 days) syringe 2 mg/ml per 30 days)

methadone injection 4 QL (150 per morphine injection 4 MO; QL (500

solution 30 days) syringe 4 mg/ml per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 28 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits morphine 4 MO; QL (200 buprenorphine- 2 MO; QL (60 intravenous solution per 30 days) naloxone sublingual per 30 days) 10 mg/ml film 12-3 mg morphine 4 QL (1000 per buprenorphine- 2 MO; QL (360 intravenous syringe 30 days) naloxone sublingual per 30 days) 2 mg/ml film 2-0.5 mg morphine 4 QL (500 per buprenorphine- 2 MO; QL (90 intravenous syringe 30 days) naloxone sublingual per 30 days) 4 mg/ml film 4-1 mg, 8-2 mg morphine oral 3 MO; QL (900 butorphanol nasal 2 MO; QL (10 solution per 30 days) per 28 days) morphine oral tablet 3 MO; QL (180 celecoxib 3 MO; QL (60 per 30 days) per 30 days) morphine oral tablet 3 PA; MO; QL diclofenac potassium 2 MO

extended release (120 per 30 diclofenac sodium 2 MO

days) oral tablet,delayed oxycodone oral 3 MO; QL (360 release (dr/ec) 75 capsule per 30 days) mg oxycodone oral 4 MO; QL (180 diclofenac sodium 4 MO; QL (300 concentrate per 30 days) topical drops per 28 days) oxycodone oral 4 MO; QL (1200 diclofenac sodium 2 MO; QL (1000 solution per 30 days) topical gel 1 % per 28 days) oxycodone oral 3 MO; QL (180 diflunisal 4 MO

tablet 10 mg, 15 mg, per 30 days) etodolac oral 2 MO

20 mg, 30 mg capsule

oxycodone oral 3 MO; QL (360 etodolac oral tablet 2 MO tablet 5 mg per 30 days) ibu 1 MO oxycodone- 3 MO; QL (360 acetaminophen oral per 30 days) ibuprofen oral 2 MO tablet 10-325 mg, suspension 2.5-325 mg, 5-325 ibuprofen oral tablet 2 MO mg, 7.5-325 mg 400 mg, 600 mg, 800 oxycodone-aspirin 4 MO; QL (360 mg per 30 days) meloxicam oral 1 MO; QL (30 oxymorphone oral 3 PA; MO; QL tablet per 30 days) tablet extended (90 per 30 naloxone injection 2 MO release 12 hr days) solution NON-NARCOTIC ANALGESICS naloxone injection 2 MO syringe

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 29 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits naltrexone 2 MO amoxapine 4 MO naproxen oral 2 MO aripiprazole oral 5 MO suspension solution naproxen oral tablet 1 MO aripiprazole oral 4 MO; QL (30

NARCAN NASAL 3 MO tablet per 30 days) SPRAY,NON- aripiprazole oral 5 MO; QL (60 AEROSOL 4 tablet,disintegrating per 30 days)

MG/ACTUATION asenapine maleate 4 MO; QL (60 oxaprozin 3 MO per 30 days) salsalate 3 MO atomoxetine oral 3 MO; QL (60

SUBOXONE 4 MO; QL (60 capsule 10 mg, 18 per 30 days)

SUBLINGUAL per 30 days) mg, 25 mg, 40 mg FILM 12-3 MG atomoxetine oral 3 MO; QL (30

SUBOXONE 4 MO; QL (360 capsule 100 mg, 60 per 30 days)

SUBLINGUAL per 30 days) mg, 80 mg FILM 2-0.5 MG bupropion hcl oral 2 MO; QL (180

SUBOXONE 4 MO; QL (90 tablet per 30 days) SUBLINGUAL per 30 days) bupropion hcl oral 3 MO; QL (90 FILM 4-1 MG, 8-2 tablet extended per 30 days) MG release 24 hr 150 mg sulindac 2 MO bupropion hcl oral 3 MO; QL (30

TRAMADOL 3 MO; QL (120 tablet extended per 30 days)

ORAL TABLET per 30 days) release 24 hr 300 mg 100 MG bupropion hcl oral 3 MO; QL (60

tramadol oral tablet 2 MO; QL (240 tablet sustained- per 30 days)

50 mg per 30 days) release 12 hr

VIVITROL 5 MO buspirone 2 MO

CAPLYTA 5 MO; QL (30 PSYCHOTHERAPEUTIC DRUGS per 30 days) ABILIFY 4 MO; QL (1 per chlorpromazine 4 MO MAINTENA 28 days) citalopram oral 3 MO ADASUVE 4 LA solution alprazolam oral 3 MO; QL (90 citalopram oral 1 MO; QL (30 tablet 0.25 mg, 0.5 per 30 days) tablet per 30 days) mg, 1 mg clomipramine 4 PA; MO; alprazolam oral 3 MO; QL (150 HRM tablet 2 mg per 30 days) amitriptyline 2 PA; MO; HRM You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 30 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits clorazepate 4 PA; MO; diazepam oral 2 PA; MO; dipotassium oral HRM; QL concentrate HRM; QL tablet 15 mg, 3.75 (180 per 30 (240 per 30 mg days) days) clorazepate 4 PA; MO; diazepam oral 2 PA; MO; dipotassium oral HRM; QL solution 5 mg/5 ml HRM; QL tablet 7.5 mg (360 per 30 (1 mg/ml) (1200 per 30 days) days) clozapine oral tablet 3 MO diazepam oral tablet 2 PA; MO; clozapine oral 4 MO HRM; QL tablet,disintegrating (120 per 30 days) desipramine 4 MO doxepin oral capsule 3 PA; MO; desvenlafaxine 4 MO; QL (30 HRM succinate per 30 days) doxepin oral 3 PA; MO; dextroamphetamine 4 MO concentrate HRM oral capsule,

extended release DRIZALMA 4 MO; QL (60 SPRINKLE ORAL per 30 days) dextroamphetamine 4 MO CAPSULE, oral solution DELAYED REL dextroamphetamine 2 MO SPRINKLE 20 MG, oral tablet 30 MG, 60 MG dextroamphetamine- 3 MO; QL (30 DRIZALMA 4 MO; QL (90 amphetamine oral per 30 days) SPRINKLE ORAL per 30 days) capsule,extended CAPSULE, release 24hr 10 mg, DELAYED REL 15 mg SPRINKLE 40 MG dextroamphetamine- 3 MO; QL (60 duloxetine oral 3 MO; QL (60 amphetamine oral per 30 days) capsule,delayed per 30 days) capsule,extended release(dr/ec) 20 release 24hr 20 mg, mg, 30 mg, 60 mg 25 mg, 30 mg, 5 mg duloxetine oral 3 MO; QL (90 diazepam injection 2 PA; HRM capsule,delayed per 30 days) solution release(dr/ec) 40 mg diazepam injection 2 PA; MO; EMSAM 4 MO; QL (30 syringe HRM per 30 days) diazepam intensol 2 PA; MO; escitalopram oxalate 4 MO; QL (600 HRM; QL oral solution per 30 days) (240 per 30 escitalopram oxalate 2 MO; QL (30 days) oral tablet per 30 days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 31 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits FANAPT ORAL 4 MO; QL (60 fluvoxamine oral 3 MO; QL (60 TABLET per 30 days) tablet 50 mg per 30 days) FANAPT ORAL 4 MO; QL (8 per haloperidol 2 MO

TABLETS,DOSE 28 days) haloperidol 4 MO

PACK decanoate

FETZIMA ORAL 4 ST; MO; QL haloperidol lactate 2 MO CAPSULE,EXT (28 per 28 injection REL 24HR DOSE days) PACK haloperidol lactate 2 MO oral FETZIMA ORAL 4 ST; MO; QL CAPSULE,EXTEN (30 per 30 HETLIOZ 5 PA; MO; QL DED RELEASE 24 days) (30 per 30 HR days) fluoxetine oral 1 MO; QL (30 imipramine hcl 3 PA; MO; capsule 10 mg per 30 days) HRM fluoxetine oral 1 MO INVEGA 4 MO; QL (0.75 capsule 20 mg SUSTENNA per 28 days) INTRAMUSCULA

fluoxetine oral 1 MO; QL (60 R SYRINGE 117

capsule 40 mg per 30 days) MG/0.75 ML

fluoxetine oral 2 MO INVEGA 4 MO; QL (1 per

solution SUSTENNA 28 days) fluoxetine oral tablet 2 MO; QL (30 INTRAMUSCULA 10 mg per 30 days) R SYRINGE 156

fluoxetine oral tablet 2 MO MG/ML 20 mg, 60 mg INVEGA 4 MO; QL (1.5

fluphenazine 4 MO SUSTENNA per 28 days)

decanoate INTRAMUSCULA R SYRINGE 234 fluphenazine hcl 4 MO MG/1.5 ML injection INVEGA 4 MO; QL (0.25 fluphenazine hcl oral 2 MO SUSTENNA per 28 days) concentrate INTRAMUSCULA fluphenazine hcl oral 4 MO R SYRINGE 39 elixir MG/0.25 ML fluphenazine hcl oral 2 MO INVEGA 4 MO; QL (0.5 tablet SUSTENNA per 28 days) INTRAMUSCULA fluvoxamine oral 3 MO; QL (90 R SYRINGE 78 tablet 100 mg per 30 days) MG/0.5 ML fluvoxamine oral 3 MO; QL (30 tablet 25 mg per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 32 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits INVEGA TRINZA 4 MO; QL (0.88 lorazepam oral 2 PA; MO; INTRAMUSCULA per 28 days) tablet 0.5 mg, 1 mg HRM; QL (90 R SYRINGE 273 per 30 days)

MG/0.875 ML lorazepam oral 2 PA; MO; INVEGA TRINZA 4 MO; QL (1.32 tablet 2 mg HRM; QL INTRAMUSCULA per 28 days) (150 per 30 R SYRINGE 410 days)

MG/1.315 ML loxapine succinate 3 MO

INVEGA TRINZA 4 MO; QL (1.76 maprotiline 2 MO INTRAMUSCULA per 28 days) R SYRINGE 546 MARPLAN 4 MO; QL (180 MG/1.75 ML per 30 days) INVEGA TRINZA 4 MO; QL (2.63 methylphenidate hcl 3 MO INTRAMUSCULA per 28 days) oral capsule, er R SYRINGE 819 biphasic 30-70 MG/2.625 ML methylphenidate hcl 4 MO LATUDA ORAL 4 MO; QL (30 oral capsule,er TABLET 120 MG, per 30 days) biphasic 50-50 20 MG, 40 MG, 60 methylphenidate hcl 4 MO; QL (900 MG oral solution 10 per 30 days) LATUDA ORAL 4 MO; QL (60 mg/5 ml TABLET 80 MG per 30 days) methylphenidate hcl 4 MO; QL (1800 lithium carbonate 2 MO oral solution 5 mg/5 per 30 days) ml lithium citrate oral 3 MO solution 8 meq/5 ml methylphenidate hcl 4 MO; QL (90 oral tablet per 30 days) lorazepam injection 4 PA; MO; solution HRM mirtazapine oral 2 MO; QL (30 tablet per 30 days) lorazepam injection 4 PA; MO; syringe 2 mg/ml HRM mirtazapine oral 3 MO; QL (30 tablet,disintegrating per 30 days) lorazepam injection 4 PA; HRM syringe 4 mg/ml modafinil oral tablet 3 PA; MO; QL 100 mg (30 per 30

lorazepam intensol 3 PA; MO; days) HRM; QL (150 per 30 modafinil oral tablet 3 PA; MO; QL days) 200 mg (60 per 30 days) lorazepam oral 3 PA; MO; concentrate HRM; QL molindone 3 MO (150 per 30 nefazodone 4 MO days) nortriptyline 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 33 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits NUPLAZID ORAL 4 PA; MO; QL quetiapine oral 2 MO; QL (60 CAPSULE (30 per 30 tablet 300 mg, 400 per 30 days) days) mg NUPLAZID ORAL 4 PA; MO; QL quetiapine oral 4 MO; QL (30 TABLET 10 MG (30 per 30 tablet extended per 30 days) days) release 24 hr 150

olanzapine 4 MO; QL (30 mg, 200 mg intramuscular per 30 days) quetiapine oral 4 MO; QL (60

olanzapine oral 3 MO; QL (30 tablet extended per 30 days)

tablet per 30 days) release 24 hr 300 mg, 400 mg, 50 mg olanzapine oral 4 MO; QL (30

tablet,disintegrating per 30 days) ramelteon 3 MO; QL (30 per 30 days) paliperidone oral 4 MO; QL (30

tablet extended per 30 days) REXULTI 4 MO; QL (30

release 24hr 1.5 mg, per 30 days) 3 mg RISPERDAL 4 MO; QL (2 per

paliperidone oral 4 MO; QL (60 CONSTA 28 days) tablet extended per 30 days) risperidone oral 4 MO release 24hr 6 mg solution paliperidone oral 5 MO; QL (30 risperidone oral 2 MO; QL (60 tablet extended per 30 days) tablet 0.25 mg, 0.5 per 30 days) release 24hr 9 mg mg, 1 mg, 2 mg, 3

paroxetine hcl oral 2 MO; QL (30 mg tablet 10 mg, 20 mg, per 30 days) risperidone oral 2 MO; QL (120 40 mg tablet 4 mg per 30 days) paroxetine hcl oral 2 MO; QL (60 risperidone oral 4 MO; QL (60 tablet 30 mg per 30 days) tablet,disintegrating per 30 days) PAXIL ORAL 4 MO; QL (900 0.25 mg, 0.5 mg, 1

SUSPENSION per 30 days) mg, 2 mg, 3 mg

perphenazine 4 MO risperidone oral 4 MO; QL (120 tablet,disintegrating per 30 days) PERSERIS 4 MO; QL (1 per 4 mg 28 days) SAPHRIS 4 MO; QL (60 phenelzine 3 MO per 30 days) pimozide 4 MO SECUADO 4 MO; QL (30 protriptyline 4 MO per 30 days) quetiapine oral 2 MO; QL (90 sertraline oral 4 MO tablet 100 mg, 200 per 30 days) concentrate mg, 25 mg, 50 mg sertraline oral tablet 1 MO; QL (60 100 mg, 50 mg per 30 days) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 34 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits sertraline oral tablet 1 MO; QL (30 ziprasidone mesylate 4 QL (60 per 30 25 mg per 30 days) days) thioridazine 4 MO zolpidem oral tablet 2 MO; QL (30

thiothixene 4 MO per 30 days)

tranylcypromine 4 MO ZYPREXA 4 PA; MO; QL RELPREVV (2 per 28 days) trazodone 2 MO INTRAMUSCULA trifluoperazine 3 MO R SUSPENSION FOR trimipramine 4 PA; MO; RECONSTITUTIO HRM N 210 MG TRINTELLIX 4 MO; QL (30 ZYPREXA 4 PA; MO per 30 days) RELPREVV venlafaxine oral 2 MO; QL (30 INTRAMUSCULA capsule,extended per 30 days) R SUSPENSION release 24hr 150 mg, FOR 37.5 mg RECONSTITUTIO N 300 MG, 405 MG venlafaxine oral 2 MO; QL (90 capsule,extended per 30 days) CARDIOVASCULAR,

release 24hr 75 mg HYPERTENSION / LIPIDS venlafaxine oral 2 MO; QL (90

tablet per 30 days) ANTIARRHYTHMIC AGENTS adenosine 3 VERSACLOZ 5 amiodarone 2 B/D PA; MO VIIBRYD ORAL 3 MO; QL (30 intravenous solution TABLET per 30 days) amiodarone 2 B/D PA VIIBRYD ORAL 3 MO; QL (30 intravenous syringe TABLETS,DOSE per 30 days) PACK 10 MG (7)- amiodarone oral 2 MO 20 MG (23) tablet 100 mg, 200 mg VRAYLAR ORAL 4 MO; QL (30 CAPSULE per 30 days) amiodarone oral 4 MO tablet 400 mg VRAYLAR ORAL 4 MO; QL (7 per CAPSULE,DOSE 30 days) dofetilide 4 MO

PACK flecainide 2 MO

XYREM 5 PA; MO; LA; lidocaine (pf) 2 MO QL (540 per intravenous solution 30 days) lidocaine (pf) 2

ziprasidone hcl 4 MO; QL (60 intravenous syringe per 30 days) mexiletine 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 35 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits MULTAQ 4 MO atenolol- 2 MO

pacerone oral tablet 2 MO chlorthalidone 100 mg, 200 mg benazepril 1 MO propafenone oral 4 MO benazepril- 2 MO capsule,extended hydrochlorothiazide

release 12 hr BIDIL 3 MO

propafenone oral 2 MO bisoprolol fumarate 2 MO tablet 150 mg, 225 mg bisoprolol- 1 MO hydrochlorothiazide propafenone oral 4 MO tablet 300 mg bumetanide injection 4 MO quinidine sulfate 2 MO bumetanide oral 2 MO oral tablet BYSTOLIC 4 MO sorine oral tablet 2 MO candesartan oral 2 MO; QL (60 120 mg, 160 mg, 80 tablet 16 mg, 4 mg, 8 per 30 days) mg mg sorine oral tablet 2 candesartan oral 2 MO; QL (30 240 mg tablet 32 mg per 30 days) sotalol af 2 MO candesartan- 2 MO sotalol oral tablet 2 MO hydrochlorothiazid 120 mg, 160 mg, 80 cartia xt oral 2 MO mg capsule,extended sotalol oral tablet 4 MO release 24hr 120 mg, 240 mg 180 mg, 240 mg SOTYLIZE 4 MO cartia xt oral 3 MO capsule,extended ANTIHYPERTENSIVE THERAPY release 24hr 300 mg acebutolol 2 MO carvedilol 1 MO amiloride 3 MO chlorthalidone oral 2 MO amiloride- 2 MO tablet 25 mg, 50 mg hydrochlorothiazide clonidine 4 MO; QL (4 per amlodipine 1 MO 28 days) amlodipine- 2 MO clonidine hcl oral 2 MO benazepril tablet amlodipine- 2 MO DEMSER 4 PA; MO valsartan diltiazem hcl 4 atenolol 1 MO intravenous recon soln

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 36 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits diltiazem hcl 4 MO felodipine 3 MO

intravenous solution fosinopril 2 MO

diltiazem hcl oral 3 MO fosinopril- 2 MO capsule,extended hydrochlorothiazide release 12 hr furosemide injection 4 MO diltiazem hcl oral 2 MO capsule,extended furosemide oral 2 MO release 24 hr 120 solution 10 mg/ml, mg, 240 mg, 300 mg 40 mg/5 ml (8 mg/ml) diltiazem hcl oral 3 MO capsule,extended furosemide oral 1 MO release 24 hr 180 tablet mg, 360 mg, 420 mg hydralazine injection 4 MO diltiazem hcl oral 2 MO hydralazine oral 2 MO capsule,extended release 24hr 120 mg, hydrochlorothiazide 1 MO 240 mg, 300 mg indapamide 2 MO diltiazem hcl oral 3 MO irbesartan 1 MO; QL (30 capsule,extended per 30 days) release 24hr 180 mg, irbesartan- 2 MO; QL (30 360 mg hydrochlorothiazide per 30 days) diltiazem hcl oral 2 MO labetalol 3 tablet intravenous syringe diltiazem hcl oral 3 MO 20 mg/4 ml (5 tablet extended mg/ml) release 24 hr labetalol oral 2 MO dilt-xr 2 MO lisinopril 1 MO doxazosin oral tablet 2 MO; QL (30 lisinopril- 1 MO 1 mg, 2 mg, 4 mg per 30 days) hydrochlorothiazide doxazosin oral tablet 2 MO; QL (60 losartan 1 MO; QL (30 8 mg per 30 days) per 30 days) enalapril maleate 2 MO losartan- 1 MO; QL (30 enalaprilat 3 hydrochlorothiazide per 30 days) intravenous solution mannitol 20 % 3 enalapril- 2 MO mannitol 25 % 3 MO hydrochlorothiazide intravenous solution eplerenone 4 MO methyldopa 4 MO epoprostenol 3 B/D PA; MO metolazone 3 MO (glycine)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 37 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits metoprolol succinate 2 MO quinapril- 2 MO

metoprolol ta- 3 MO hydrochlorothiazide hydrochlorothiaz ramipril 1 MO metoprolol tartrate 2 MO spironolactone oral 2 MO intravenous solution tablet 100 mg, 50 mg metoprolol tartrate 1 MO spironolactone oral 1 MO oral tablet 25 mg metyrosine 5 PA; MO spironolacton- 2 MO

minoxidil oral 2 MO hydrochlorothiaz

nifedipine oral tablet 3 MO telmisartan 2 MO extended release terazosin oral 2 MO; QL (30

nifedipine oral tablet 3 MO capsule 1 mg, 2 mg, per 30 days)

extended release 5 mg 24hr terazosin oral 2 MO; QL (60

nimodipine 4 MO capsule 10 mg per 30 days)

olmesartan 2 MO timolol maleate oral 4 MO

olmesartan- 2 MO torsemide oral 2 MO hydrochlorothiazide treprostinil sodium 5 PA; MO; LA osmitrol 15 % 3 triamterene 3 MO osmitrol 20 % 3 triamterene- 2 MO phentolamine 3 hydrochlorothiazid

injection recon soln oral capsule 37.5-25 mg pindolol 4 MO triamterene- 2 MO prazosin 2 MO hydrochlorothiazid propranolol 2 oral tablet intravenous UPTRAVI 4 PA; MO; LA propranolol oral 3 MO valsartan 2 MO; QL (30 capsule,extended per 30 days) release 24 hr valsartan- 2 MO; QL (30 propranolol oral 2 MO hydrochlorothiazide per 30 days) solution verapamil 2 MO propranolol oral 2 MO intravenous solution tablet verapamil 2 propranolol- 4 MO intravenous syringe hydrochlorothiazid quinapril 2 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 38 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits verapamil oral 2 MO ELIQUIS DVT-PE 3 MO; QL (74 capsule, 24 hr er TREAT 30D per 30 days) pellet ct START verapamil oral 2 MO enoxaparin 4 MO capsule,ext rel. subcutaneous pellets 24 hr 120 mg, solution

180 mg, 240 mg enoxaparin 4 MO; QL (28 verapamil oral 3 MO subcutaneous per 28 days) capsule,ext rel. syringe 100 mg/ml, pellets 24 hr 360 mg 150 mg/ml verapamil oral tablet 1 MO enoxaparin 4 MO; QL (22.4

verapamil oral tablet 2 MO subcutaneous per 28 days)

extended release syringe 120 mg/0.8 ml, 80 mg/0.8 ml

COAGULATION THERAPY enoxaparin 4 MO; QL (16.8 aminocaproic acid 3 MO subcutaneous per 28 days)

BRILINTA 4 MO; QL (60 syringe 30 mg/0.3

per 30 days) ml, 60 mg/0.6 ml

CABLIVI 5 PA; MO; LA enoxaparin 4 MO; QL (11.2

INJECTION KIT subcutaneous per 28 days) syringe 40 mg/0.4 ml CEPROTIN (BLUE 3 MO

BAR) fondaparinux 5 MO subcutaneous CEPROTIN 3 MO syringe 10 mg/0.8 (GREEN BAR) ml, 5 mg/0.4 ml, 7.5 cilostazol 2 MO mg/0.6 ml clopidogrel oral 4 MO fondaparinux 3 MO tablet 300 mg subcutaneous syringe 2.5 mg/0.5 clopidogrel oral 1 MO; QL (30 ml tablet 75 mg per 30 days) heparin (porcine) in 4 dipyridamole oral 4 MO 5 % dex intravenous DOPTELET (10 5 PA; MO; LA parenteral solution TAB PACK) 20,000 unit/500 ml (40 unit/ml) DOPTELET (15 5 PA; MO; LA TAB PACK) heparin (porcine) in 4 MO 5 % dex intravenous DOPTELET (30 5 PA; MO; LA parenteral solution TAB PACK) 25,000 unit/250 ELIQUIS 3 MO; QL (60 ml(100 unit/ml), per 30 days) 25,000 unit/500 ml (50 unit/ml) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 39 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits heparin (porcine) in 3 PROMACTA 5 PA; MO; LA; nacl (pf) ORAL POWDER IN QL (180 per

heparin (porcine) 4 MO PACKET 30 days) injection cartridge PROMACTA 5 PA; MO; LA;

heparin (porcine) 3 MO ORAL TABLET QL (30 per 30

injection solution 12.5 MG, 25 MG, 50 days) MG heparin (porcine) 4 MO

injection syringe PROMACTA 5 PA; MO; LA;

5,000 unit/ml ORAL TABLET 75 QL (60 per 30 MG days) HEPARIN(PORCIN 4

E) IN 0.45% NACL warfarin 1 MO INTRAVENOUS LIPID/CHOLESTEROL LOWERING PARENTERAL AGENTS SOLUTION 12,500

UNIT/250 ML atorvastatin 1 MO; QL (30 per 30 days) heparin(porcine) in 4 MO

0.45% nacl cholestyramine (with 3 MO

intravenous sugar) parenteral solution cholestyramine light 3 MO 25,000 unit/250 ml, colesevelam oral 3 MO 25,000 unit/500 ml powder in packet heparin, porcine (pf) 4 MO colesevelam oral 4 MO injection solution tablet 1,000 unit/ml ezetimibe 3 MO; QL (30 heparin, porcine (pf) 3 MO per 30 days) injection solution 5,000 unit/0.5 ml ezetimibe- 3 MO; QL (30 simvastatin per 30 days) heparin, porcine (pf) 3 MO injection syringe fenofibrate 3 MO; QL (30 5,000 unit/0.5 ml micronized oral per 30 days) capsule 134 mg, 200 HEPARIN, 3 mg PORCINE (PF) SUBCUTANEOUS fenofibrate 3 MO; QL (60 micronized oral per 30 days) jantoven 1 MO capsule 67 mg NPLATE 5 MO fenofibrate 3 MO; QL (30 pentoxifylline 2 MO nanocrystallized per 30 days) PRADAXA 4 MO; QL (60 oral tablet 145 mg per 30 days) fenofibrate 3 MO; QL (60

prasugrel 4 MO nanocrystallized per 30 days) oral tablet 48 mg You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 40 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits fenofibrate oral 3 MO; QL (30 digitek oral tablet 3 MO; QL (30 tablet 160 mg per 30 days) 125 mcg (0.125 mg) per 30 days) fenofibrate oral 3 MO; QL (60 digitek oral tablet 3 MO tablet 54 mg per 30 days) 250 mcg (0.25 mg) fluvastatin oral 4 MO; QL (30 digox oral tablet 125 2 MO; QL (30 capsule 20 mg per 30 days) mcg (0.125 mg) per 30 days) fluvastatin oral 4 MO; QL (60 digox oral tablet 250 2 MO capsule 40 mg per 30 days) mcg (0.25 mg) gemfibrozil 2 MO; QL (60 digoxin oral solution 3 MO per 30 days) 50 mcg/ml (0.05

icosapent ethyl 4 MO mg/ml)

lovastatin oral tablet 1 MO; QL (30 digoxin oral tablet 2 MO; QL (30

10 mg per 30 days) 125 mcg (0.125 mg) per 30 days)

lovastatin oral tablet 1 MO; QL (60 digoxin oral tablet 2 MO

20 mg, 40 mg per 30 days) 250 mcg (0.25 mg)

niacin oral tablet 4 MO dobutamine in d5w 3 B/D PA; MO extended release 24 intravenous

hr parenteral solution 1,000 mg/250 ml pravastatin 1 MO; QL (30 (4,000 mcg/ml), 250 per 30 days) mg/250 ml (1 mg/ml) prevalite 3 MO dobutamine in d5w 3 B/D PA REPATHA 4 PA; QL (3 per intravenous 28 days) parenteral solution 500 mg/250 ml REPATHA 4 PA; QL (3.5 (2,000 mcg/ml) PUSHTRONEX per 28 days) dobutamine 3 B/D PA REPATHA 4 PA; QL (3 per intravenous solution SURECLICK 28 days) 250 mg/20 ml (12.5 rosuvastatin 2 MO; QL (30 mg/ml) per 30 days) dopamine in 5 % 3 B/D PA simvastatin oral 1 MO; QL (30 dextrose intravenous tablet per 30 days) solution 200 mg/250 ml (800 mcg/ml), VASCEPA 4 MO 400 mg/250 ml MISCELLANEOUS (1,600 mcg/ml), 400 CARDIOVASCULAR AGENTS mg/500 ml (800 mcg/ml), 800 CORLANOR ORAL 4 PA; MO; QL mg/500 ml (1,600 TABLET (60 per 30 mcg/ml) days)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 41 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits dopamine in 5 % 3 B/D PA; MO nitroglycerin in 5 % 3 B/D PA; MO dextrose intravenous dextrose intravenous solution 800 mg/250 solution 25 mg/250 ml (3,200 mcg/ml) ml (100 mcg/ml) dopamine 3 B/D PA nitroglycerin 2 MO intravenous solution sublingual 200 mg/5 ml (40 nitroglycerin 2 MO

mg/ml) transdermal patch dopamine 3 B/D PA; MO 24 hour

intravenous solution nitroglycerin 2 MO 400 mg/10 ml (40 translingual

mg/ml) spray,non-aerosol ENTRESTO 3 MO; QL (60 per 30 days) DERMATOLOGICALS/TOPICA

LANOXIN ORAL 4 MO L THERAPY TABLET 62.5 MCG ANTIPSORIATIC / (0.0625 MG) ANTISEBORRHEIC milrinone 3 B/D PA; MO acitretin 4 MO milrinone in 5 % 3 B/D PA; MO calcipotriene scalp 3 MO; QL (120 dextrose per 30 days) ranolazine 3 MO; QL (60 calcipotriene topical 4 MO; QL (120 per 30 days) cream per 30 days) VYNDAMAX 4 PA; MO calcipotriene topical 4 MO; QL (120 NITRATES ointment per 30 days)

isosorbide dinitrate 4 MO selenium sulfide 2 MO

oral tablet 10 mg, 20 topical lotion mg, 40 mg, 5 mg SKYRIZI 5 PA; MO; QL

isosorbide dinitrate 3 MO SUBCUTANEOUS (1 per 28 days)

oral tablet 30 mg SYRINGE KIT

isosorbide 2 MO STELARA 5 PA; MO

mononitrate INTRAVENOUS

nitro-bid 3 MO STELARA 5 PA; MO; QL SUBCUTANEOUS (0.5 per 28 nitroglycerin in 5 % 3 B/D PA SOLUTION days) dextrose intravenous

solution 100 mg/250 STELARA 5 PA; MO; QL ml (400 mcg/ml), 50 SUBCUTANEOUS (0.5 per 28

mg/250 ml (200 SYRINGE 45 days)

mcg/ml) MG/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 42 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits STELARA 5 PA; MO; QL lidocaine (pf) 4 MO SUBCUTANEOUS (1 per 28 days) injection solution 10 SYRINGE 90 mg/ml (1 %), 5 MG/ML mg/ml (0.5 %) TALTZ 5 PA; MO; QL lidocaine (pf) 2 AUTOINJECTOR (1 per 28 days) injection solution 15

TALTZ 5 PA; MO; QL mg/ml (1.5 %) AUTOINJECTOR (2 per 28 days) lidocaine (pf) 2 MO (2 PACK) injection solution 20 TALTZ 5 PA; MO; QL mg/ml (2 %), 40

AUTOINJECTOR (3 per 28 days) mg/ml (4 %) (3 PACK) lidocaine hcl 2 MO TALTZ SYRINGE 5 PA; MO; QL injection solution 10 (1 per 28 days) mg/ml (1 %), 5 mg/ml (0.5 %)

MISCELLANEOUS lidocaine hcl 4 MO

DERMATOLOGICALS injection solution 20 ammonium lactate 2 MO mg/ml (2 %) DUPIXENT PEN 5 PA; MO; QL lidocaine hcl 2 MO (8 per 28 days) laryngotracheal DUPIXENT 5 PA; MO; QL lidocaine hcl mucous 3 MO; QL (60 SYRINGE (4.56 per 28 membrane jelly per 30 days)

SUBCUTANEOUS days) lidocaine hcl mucous 3 MO; QL (60 SYRINGE 200 membrane jelly in per 30 days)

MG/1.14 ML applicator

DUPIXENT 5 PA; MO; QL lidocaine hcl mucous 2 MO

SYRINGE (8 per 28 days) membrane solution 4 SUBCUTANEOUS % (40 mg/ml) SYRINGE 300 MG/2 ML lidocaine topical 2 PA; MO; QL adhesive (90 per 30

fluorouracil topical 4 MO patch,medicated 5 % days) cream 5 % lidocaine topical 4 MO; QL (50

fluorouracil topical 4 MO ointment per 30 days) solution lidocaine viscous 2 MO glydo 3 MO; QL (60 per 30 days) lidocaine-prilocaine 3 MO; QL (30 topical cream per 30 days) imiquimod topical 3 MO; QL (12 cream in packet 5 % per 28 days) methoxsalen 5 MO PANRETIN 5 MO podofilox 4 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 43 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits REGRANEX 5 MO isotretinoin 4 MO SANTYL 3 MO metronidazole 4 MO

silver sulfadiazine 2 MO topical cream

ssd 3 MO metronidazole 4 MO topical gel 0.75 % tacrolimus topical 3 PA; MO; QL

(100 per 30 metronidazole 2 MO

days) topical gel 1 %

UVADEX 4 B/D PA metronidazole 2 MO topical gel with VALCHLOR 5 PA; MO pump ZTLIDO 3 PA; MO; QL metronidazole 4 MO (90 per 30 topical lotion days) rosadan topical 4 MO THERAPY FOR ACNE cream claravis 4 MO rosadan topical gel 4 MO clindamycin 3 MO; QL (120 tazarotene 3 PA; MO phosphate topical per 30 days) TAZORAC 3 PA; MO gel TOPICAL CREAM CLINDAMYCIN 3 MO; QL (120 0.05 % PHOSPHATE per 30 days) tretinoin topical 4 PA; MO TOPICAL GEL, cream 0.025 %, 0.05 ONCE DAILY %, 0.1 % clindamycin 3 MO; QL (120 tretinoin topical 3 PA; MO phosphate topical per 30 days) topical gel 0.01 % lotion tretinoin topical 4 PA; MO clindamycin 3 MO topical gel 0.025 %, phosphate topical 0.05 % solution

clindamycin 2 MO TOPICAL ANTIBACTERIALS phosphate topical gentamicin topical 3 MO

swab mafenide acetate 2 MO

ery pads 4 MO mupirocin 2 MO

erythromycin with 2 MO sulfacetamide 4 MO

ethanol topical gel sodium (acne)

erythromycin with 2 MO SULFAMYLON 4 MO

ethanol topical TOPICAL CREAM solution

erythromycin- 4 MO TOPICAL ANTIFUNGALS benzoyl peroxide You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 44 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits ciclopirox topical 3 MO; QL (90 acyclovir topical 4 PA; MO; QL cream per 28 days) ointment (30 per 30

ciclopirox topical 3 MO; QL (45 days) gel per 28 days) DENAVIR 4 MO ciclopirox topical 3 MO; QL (120 TOPICAL CORTICOSTEROIDS shampoo per 28 days) alclometasone 4 MO ciclopirox topical 2 MO topical cream solution alclometasone 2 MO ciclopirox topical 4 MO; QL (60 topical ointment suspension per 28 days) beser 3 MO clotrimazole topical 2 MO; QL (45 betamethasone 4 MO cream per 28 days) dipropionate clotrimazole topical 2 MO; QL (30 betamethasone 2 MO solution per 28 days) valerate topical clotrimazole- 3 MO; QL (45 cream betamethasone per 28 days) betamethasone 4 MO topical cream valerate topical clotrimazole- 4 MO; QL (60 lotion betamethasone per 28 days) betamethasone 2 MO topical lotion valerate topical econazole 4 MO; QL (85 ointment per 28 days) betamethasone, 2 MO ketoconazole topical 2 MO; QL (60 augmented topical cream per 28 days) cream ketoconazole topical 2 MO; QL (120 betamethasone, 4 MO shampoo per 28 days) augmented topical nyamyc 3 MO gel nystatin topical 2 MO; QL (30 betamethasone, 4 MO cream per 28 days) augmented topical lotion nystatin topical 2 MO; QL (30 ointment per 28 days) betamethasone, 4 MO augmented topical nystatin topical 3 MO ointment powder clobetasol scalp 4 MO; QL (100 nystatin- 4 MO; QL (60 per 28 days) triamcinolone per 28 days) clobetasol topical 4 MO; QL (120 nystop 3 MO cream per 28 days) TOPICAL ANTIVIRALS clobetasol topical 4 MO; QL (120 gel per 28 days) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 45 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits clobetasol topical 4 MO; QL (120 halobetasol 4 MO ointment per 28 days) propionate topical

clobetasol-emollient 2 MO; QL (120 cream topical cream per 28 days) halobetasol 4 MO

desonide topical 4 MO propionate topical

cream ointment

desonide topical 4 MO hydrocortisone 2 MO

lotion topical cream 1 %, 2.5 % desonide topical 4 MO

ointment hydrocortisone 4 MO topical lotion 2.5 % desoximetasone 4 MO

topical cream hydrocortisone 2 MO topical ointment 2.5 desoximetasone 4 MO % topical gel hydrocortisone 2 MO desoximetasone 4 MO valerate topical topical ointment cream fluocinolone 4 MO hydrocortisone 4 MO fluocinolone and 4 MO valerate topical shower cap ointment fluocinonide topical 2 MO; QL (120 mometasone topical 2 MO cream 0.05 % per 30 days) prednicarbate 4 MO fluocinonide topical 2 MO; QL (120 topical ointment gel per 30 days) triamcinolone 2 MO fluocinonide topical 2 MO; QL (120 acetonide topical ointment per 30 days) cream fluocinonide topical 4 MO; QL (120 triamcinolone 3 MO solution per 30 days) acetonide topical lotion fluocinonide-e 2 MO; QL (120 per 30 days) triamcinolone 2 MO acetonide topical fluocinonide- 2 MO; QL (120 ointment emollient per 30 days) triderm topical 2 MO fluticasone 3 MO cream propionate topical cream TOPICAL SCABICIDES / PEDICULICIDES fluticasone 3 MO propionate topical lindane topical 4 MO ointment shampoo malathion 4 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 46 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits permethrin topical 3 MO disulfiram 3 MO

cream FERRIPROX (2 5 PA DIAGNOSTICS / TIMES A DAY) MISCELLANEOUS AGENTS FERRIPROX ORAL 5 PA; MO TABLET ANTIDOTES INCRELEX 5 PA; MO; LA acetylcysteine 3 MO intravenous kionex (with 4 MO sorbitol) MISCELLANEOUS AGENTS levocarnitine (with 4 MO acamprosate 4 MO sugar) anagrelide 3 MO levocarnitine oral 4 MO caffeine citrate oral 3 MO solution 100 mg/ml CARBAGLU 5 PA; MO; LA levocarnitine oral 4 MO tablet CHEMET 4 PA; MO midodrine 3 MO d10 %-0.45 % 4 sodium chloride nitisinone 5 MO d2.5 %-0.45 % 4 NORTHERA ORAL 5 PA; MO; QL sodium chloride CAPSULE 100 MG, (90 per 30 200 MG days) d5 % and 0.9 % 4 MO sodium chloride NORTHERA ORAL 5 PA; MO; QL CAPSULE 300 MG (180 per 30

d5 %-0.45 % sodium 4 MO days) chloride ORFADIN ORAL 5 MO; LA

deferasirox oral 5 PA; MO CAPSULE 20 MG tablet, dispersible ORFADIN ORAL 5 MO; LA

deferiprone 5 PA; MO SUSPENSION

dextrose 10 % and 4 pilocarpine hcl oral 4 MO 0.2 % nacl PROLASTIN-C 5 PA; LA

dextrose 10 % in 3 MO INTRAVENOUS

water (d10w) RECON SOLN

dextrose 5 % in 3 MO PROLASTIN-C 5 PA; MO; LA

water (d5w) INTRAVENOUS dextrose 5 %- 4 MO SOLUTION

lactated ringers RAVICTI 5 MO

dextrose 5%-0.2 % 4 REVCOVI 5 PA; MO; LA sod chloride riluzole 3 PA; MO dextrose 5%-0.3 % 4 sod.chloride You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 47 Drug Name Drug Requirements D rug Name Drug Requirements Tier /Limits Tier /Limits sevelamer carbonate 5 MO CHANTIX 3 MO oral powder in STARTING packet MONTH BOX sevelamer carbonate 4 MO; QL (540 NICOTROL 4 MO

oral tablet per 30 days) ICOTROL NSN 4 MO sodium chloride 0.9 4 MO % intravenous EAR, NOSE / THROAT

sodium chloride 3 MO MEDICATIONS irrigation MISCELLANEOUS AGENTS sodium polystyrene 4 MO azelastine 0.1% (137 2 MO; QL (60 (sorb free) mcg) spry per 30 days) sodium polystyrene 4 MO azelastine 0.15% 4 MO; QL (60 sulfonate oral na sal spray per 30 days) powder chlorhexidine 2 MO SOLIRIS 5 PA; MO gluconate mucous sps (with sorbitol) 3 MO membrane oral de nta 5000 plus3 MO sps (with sorbitol) 3 dentagel 3 MO rectal fluoride (sodium) 3 trientine 5 PA; MO; QL de ntal gel (240 per 30 ratropium bromide ipratropium bromide 2 MO; QL (30 days) nasal per 30 days) VELTASSA 3 MO oralone 4 MO XIAFLEX 5 PA; MO pa rinseroex oral 2 MO XURIDEN 5 PA; MO periogard 2 MO zoledronic acid- 3 PA; MO sf 3 MO mannitol-water intravenous sf 5000 plus 3 MO piggyback 5 mg/100 sodium fluoride 3 ml 50 00 plus SMOKING DETERRENTS triamcinolone 4 MO bupropion hcl 3 MO; QL (60 ac etonide dental (smoking deter) per 30 days) MISCELLANEOUS OTIC CHANTIX 3 MO PREPARATIONS CHANTIX 3 MO ac etic acid3 oticMO (ear)

CONTINUING ciprofloxacin hcl 3 MO

MONTH BOX otic (ear)

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 48 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits flac otic oil 4 hydrocortisone oral 3 MO fluocinolone 4 MO methylprednisolone 2 MO acetonide oil acetate hydrocortisone- 4 MO methylprednisolone 2 B/D PA; MO acetic acid oral tablet ofloxacin otic (ear) 3 MO methylprednisolone 2 MO oral tablets,dose

OTIC STEROID / ANTIBIOTIC pack CIPRODEX 3 MO methylprednisolone 4 MO ciprofloxacin- 3 MO sodium succ dexamethasone injection recon soln

neomycin- 3 MO 125 mg polymyxin-hc otic methylprednisolone 2 MO (ear) sodium succ injection recon soln ENDOCRINE/DIABETES 40 mg ADRENAL HORMONES methylprednisolone 4 MO cortisone 2 MO sodium succ intravenous recon

decadron oral tablet 3 soln 1,000 mg

DEPO-MEDROL 3 MO methylprednisolone 4 INJECTION sodium succ SUSPENSION 20 intravenous recon

MG/ML soln 500 mg

dexamethasone 2 MO prednisolone oral 2 MO intensol solution 15 mg/5 ml

dexamethasone oral 2 MO prednisolone sodium 2 MO

elixir phosphate oral dexamethasone oral 2 MO solution 15 mg/5 ml solution (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg dexamethasone oral 2 MO base/5 ml (6.7 mg/5 tablet ml) dexamethasone 4 MO prednisone intensol 4 B/D PA; MO sodium phos (pf) injection solution prednisone oral 2 MO solution dexamethasone 4 MO sodium phosphate prednisone oral 2 B/D PA; MO injection tablet fludrocortisone 2 MO prednisone oral 2 MO tablets,dose pack You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 49 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits SOLU-CORTEF 3 MO glimepiride oral 1 MO; QL (120 ACT-O-VIAL (PF) tablet 2 mg per 30 days) triamcinolone 2 MO glimepiride oral 1 MO; QL (60 acetonide injection tablet 4 mg per 30 days)

suspension 40 mg/ml glipizide oral tablet 1 MO; QL (120 ANTITHYROID AGENTS 10 mg per 30 days) methimazole oral 2 MO glipizide oral tablet 1 MO; QL (240 tablet 10 mg, 5 mg 5 mg per 30 days) propylthiouracil 3 MO glipizide oral tablet 2 MO; QL (60 extended release per 30 days) DIABETES THERAPY 24hr 10 mg acarbose oral tablet 2 MO; QL (90 glipizide oral tablet 2 MO; QL (240 100 mg per 30 days) extended release per 30 days) acarbose oral tablet 2 MO; QL (360 24hr 2.5 mg 25 mg per 30 days) glipizide oral tablet 2 MO; QL (120 acarbose oral tablet 2 MO; QL (180 extended release per 30 days) 50 mg per 30 days) 24hr 5 mg alcohol pads 2 MO glipizide-metformin 2 MO; QL (240 oral tablet 2.5-250 per 30 days) BAQSIMI 3 MO mg BYDUREON 3 PA; MO; QL glipizide-metformin 2 MO; QL (120 BCISE (4 per 28 days) oral tablet 2.5-500 per 30 days) BYDUREON 3 PA; MO; QL mg, 5-500 mg SUBCUTANEOUS (4 per 28 days) GLUCAGEN 3 MO PEN INJECTOR HYPOKIT BYETTA 4 PA; MO; QL GLUCAGON 3 SUBCUTANEOUS (2.4 per 30 (HCL) PEN INJECTOR 10 days) EMERGENCY KIT MCG/DOSE(250 MCG/ML) 2.4 ML GLUCAGON 3 MO EMERGENCY KIT BYETTA 4 PA; MO; QL (HUMAN) SUBCUTANEOUS (1.2 per 30 PEN INJECTOR 5 days) HUMALOG 3 MO; SI MCG/DOSE (250 JUNIOR KWIKPEN MCG/ML) 1.2 ML U-100 diazoxide 4 MO HUMALOG 3 MO; SI KWIKPEN GAUZE PADS 2 X 3 MO INSULIN 2 SUBCUTANEOUS glimepiride oral 1 MO; QL (240 INSULIN PEN 100 tablet 1 mg per 30 days) UNIT/ML You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 50 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits HUMALOG MIX 3 MO; SI INVOKAMET 3 MO; QL (120 50-50 INSULN U- ORAL TABLET 50- per 30 days) 100 500 MG HUMALOG MIX 3 MO; SI INVOKAMET XR 3 MO; QL (60 50-50 KWIKPEN ORAL TABLET, IR per 30 days) HUMALOG MIX 3 MO; SI - ER, BIPHASIC 75-25 KWIKPEN 24HR 150-1,000 MG, 150-500 MG, HUMALOG MIX 3 MO; SI 50-1,000 MG 75-25(U-

100)INSULN INVOKAMET XR 3 MO; QL (120 ORAL TABLET, IR per 30 days) HUMALOG U-100 3 MO; SI - ER, BIPHASIC INSULIN 24HR 50-500 MG HUMULIN 70/30 3 MO; SI INVOKANA 3 MO; QL (30 U-100 INSULIN per 30 days) HUMULIN 70/30 3 MO; SI JANUMET 3 MO; QL (60 U-100 KWIKPEN per 30 days) HUMULIN N NPH 3 MO; SI JANUMET XR 3 MO; QL (30 INSULIN ORAL TABLET, per 30 days) KWIKPEN ER MULTIPHASE HUMULIN N NPH 3 MO; SI 24 HR 100-1,000 U-100 INSULIN MG, 50-500 MG HUMULIN R 3 MO; SI JANUMET XR 3 MO; QL (60 REGULAR U-100 ORAL TABLET, per 30 days) INSULN ER MULTIPHASE 24 HR 50-1,000 MG HUMULIN R U-500 4 MO (CONC) INSULIN JANUVIA 3 MO; QL (30 per 30 days) HUMULIN R U-500 4 MO (CONC) KWIKPEN JARDIANCE 3 MO; QL (30 per 30 days) INSULIN PEN 3 MO NEEDLE LANTUS 3 MO; SI SOLOSTAR U-100 INSULIN 3 MO INSULIN SYRINGE (DISP) U-100 0.3 ML, 1 LANTUS U-100 3 MO; SI ML, 1/2 ML INSULIN INVOKAMET 3 MO; QL (60 LEVEMIR 4 ST; MO ORAL TABLET per 30 days) FLEXTOUCH U- 150-1,000 MG, 150- 100 INSULN 500 MG, 50-1,000 LEVEMIR U-100 4 ST; MO MG INSULIN

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 51 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits LYUMJEV 3 MO; SI repaglinide oral 2 MO; QL (960 KWIKPEN U-100 tablet 0.5 mg per 30 days)

INSULIN repaglinide oral 2 MO; QL (480 LYUMJEV U-100 3 MO; SI tablet 1 mg per 30 days)

INSULIN repaglinide oral 2 MO; QL (240 metformin oral 3 MO; QL (765 tablet 2 mg per 30 days)

solution per 30 days) SOLIQUA 100/33 3 MO; QL (15 metformin oral 1 MO; QL (75 per 30 days); tablet 1,000 mg per 30 days) SI metformin oral 1 MO; QL (150 SYMLINPEN 120 5 PA; MO; QL tablet 500 mg per 30 days) (10.8 per 30

metformin oral 1 MO; QL (90 days) tablet 850 mg per 30 days) SYMLINPEN 60 5 PA; MO; QL metformin oral 1 MO; QL (120 (6 per 30 days) tablet extended per 30 days) SYNJARDY 3 MO; QL (60 release 24 hr 500 mg per 30 days) metformin oral 1 MO; QL (75 SYNJARDY XR 3 MO; QL (60 tablet extended per 30 days) ORAL TABLET, IR per 30 days) release 24 hr 750 mg - ER, BIPHASIC NEEDLES, 3 MO 24HR 10-1,000 MG, INSULIN 12.5-1,000 MG, 5-

DISP.,SAFETY 1,000 MG

NOVOLOG 4 ST; MO SYNJARDY XR 3 MO; QL (30

FLEXPEN U-100 ORAL TABLET, IR per 30 days) INSULIN - ER, BIPHASIC 24HR 25-1,000 MG NOVOLOG MIX 4 ST; MO

70-30 U-100 TOUJEO MAX U- 3 MO; SI INSULN 300 SOLOSTAR

NOVOLOG MIX 4 ST; MO TOUJEO 3 MO; SI 70-30FLEXPEN U- SOLOSTAR U-300

100 INSULIN

NOVOLOG 4 ST; MO TRADJENTA 3 MO; QL (30

PENFILL U-100 per 30 days) INSULIN TRULICITY 3 PA; MO; QL NOVOLOG U-100 4 ST; MO (2 per 28 days) INSULIN ASPART MISCELLANEOUS HORMONES pioglitazone 2 MO; QL (30 ALDURAZYME 5 MO per 30 days) ANADROL-50 4 PA; MO cabergoline 4 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 52 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits calcitonin (salmon) 3 MO MIACALCIN 4 MO

calcitriol 2 MO INJECTION intravenous solution MYALEPT 5 PA; MO; LA

1 mcg/ml NAGLAZYME 5 MO; LA

calcitriol oral 2 MO NATPARA 5 PA; MO; LA;

capsule 0.25 mcg QL (2 per 28 calcitriol oral 3 MO days)

capsule 0.5 mcg oxandrolone oral 5 PA; MO; QL calcitriol oral 3 MO tablet 10 mg (60 per 30 solution days) CERDELGA 5 PA; MO oxandrolone oral 3 PA; MO; QL

CEREZYME 5 PA; MO tablet 2.5 mg (120 per 30

INTRAVENOUS days) RECON SOLN 400 PALYNZIQ 5 PA; MO; LA; UNIT SUBCUTANEOUS QL (15 per 30

cinacalcet oral 4 MO; QL (60 SYRINGE 10 days)

tablet 30 mg, 60 mg per 30 days) MG/0.5 ML

cinacalcet oral 4 MO; QL (120 PALYNZIQ 5 PA; MO; LA; tablet 90 mg per 30 days) SUBCUTANEOUS QL (4 per 30 SYRINGE 2.5 days) CRYSVITA 5 PA; MO; LA MG/0.5 ML danazol 4 MO PALYNZIQ 5 PA; MO; LA; desmopressin 3 MO SUBCUTANEOUS QL (60 per 30 injection SYRINGE 20 days) MG/ML desmopressin nasal 3 MO spray with pump paricalcitol 4 intravenous solution desmopressin nasal 3 MO 2 mcg/ml spray,non-aerosol paricalcitol 4 MO desmopressin oral 3 MO intravenous solution ELAPRASE 5 MO 5 mcg/ml FABRAZYME 5 MO paricalcitol oral 4 MO KANUMA 5 MO SAMSCA ORAL 5 PA; MO; QL TABLET 15 MG (30 per 30 KORLYM 5 PA; MO; QL days) (120 per 30 days) SAMSCA ORAL 5 PA; MO; QL TABLET 30 MG (60 per 30 KUVAN 5 PA; MO days) LUMIZYME 4 MO sapropterin 5 PA; MO MEPSEVII 5 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 53 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits SOMAVERT 5 PA; MO; QL zoledronic acid- 3 B/D PA; MO (30 per 30 mannitol-water days) intravenous

STRENSIQ 4 PA; MO; LA piggyback 4 mg/100 ml SYNAREL 4 MO ZOLEDRONIC AC- 3 B/D PA; MO testosterone 3 PA; MO MANNITOL- cypionate 0.9NACL intramuscular oil 100 mg/ml, 200 THYROID HORMONES mg/ml euthyrox 3 MO testosterone 3 PA levo-t 3 cypionate levothyroxine oral 1 MO intramuscular oil tablet 200 mg/ml (1 ml) levoxyl oral tablet 3 MO testosterone 4 PA; MO 100 mcg, 112 mcg, enanthate 125 mcg, 137 mcg, testosterone 3 PA; MO; QL 150 mcg, 175 mcg, transdermal gel in (150 per 30 200 mcg, 25 mcg, 50 metered-dose pump days) mcg, 75 mcg, 88 mcg 20.25 mg/1.25 gram liothyronine oral 2 MO (1.62 %) unithroid 3 MO testosterone 3 PA; MO; QL transdermal gel in (300 per 30 GASTROENTEROLOGY packet 1 % (25 days) mg/2.5gram) ANTIDIARRHEALS / ANTISPASMODICS testosterone 3 PA; MO; QL transdermal gel in (37.5 per 30 atropine injection 4 MO packet 1.62 % days) solution 0.4 mg/ml (20.25 mg/1.25 atropine injection 4 gram) syringe 0.05 mg/ml testosterone 3 PA; MO; QL atropine injection 2 MO transdermal gel in (150 per 30 syringe 0.1 mg/ml packet 1.62 % (40.5 days) mg/2.5 gram) dicyclomine oral 2 MO capsule tolvaptan oral tablet 5 PA; MO; QL 30 mg (60 per 30 dicyclomine oral 2 MO days) solution VIMIZIM 5 MO; LA dicyclomine oral 2 MO tablet zoledronic acid 3 B/D PA; MO intravenous solution diphenoxylate- 3 MO atropine You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 54 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits glycopyrrolate 4 MO dronabinol 4 B/D PA; MO; injection QL (60 per 30

glycopyrrolate oral 2 MO days) tablet 1 mg EMEND ORAL 4 B/D PA; MO

glycopyrrolate oral 4 SUSPENSION FOR

tablet 1.5 mg RECONSTITUTIO N glycopyrrolate oral 4 MO

tablet 2 mg ENTYVIO 5 PA; MO

loperamide oral 2 MO enulose 2 MO capsule GATTEX 30-VIAL 5 PA; MO opium tincture 3 MO GATTEX ONE- 5 PA; MO VIAL MISCELLANEOUS GASTROINTESTINAL AGENTS gavilyte-c 2 MO alosetron 5 MO gavilyte-g 2 MO AMITIZA 3 MO; QL (60 gavilyte-n 2 MO per 30 days) generlac 2 MO aprepitant 3 B/D PA; MO hydrocortisone 3 MO balsalazide 4 MO rectal budesonide oral 4 MO hydrocortisone 2 MO capsule,delayed,exte topical cream with nd.release perineal applicator budesonide oral 5 MO lactulose oral 2 MO tablet,delayed and solution 10 gram/15 ext.release ml CHENODAL 5 PA; MO; LA meclizine oral tablet 2 MO 12.5 mg, 25 mg CHOLBAM ORAL 5 PA; MO CAPSULE 250 MG mesalamine oral 4 MO tablet,delayed

CHOLBAM ORAL 5 PA; MO; QL release (dr/ec) 1.2

CAPSULE 50 MG (120 per 30 gram days) mesalamine rectal 4 MO

compro 4 MO enema

constulose 2 MO mesalamine with 4 MO CORTIFOAM 3 MO cleansing wipe CREON 3 MO metoclopramide hcl 2 MO injection solution cromolyn oral 3 MO metoclopramide hcl 2 CYSTADANE 5 MO injection syringe You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 55 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits metoclopramide hcl 2 MO procto-pak 2 MO

oral solution proctosol hc topical 2 MO

metoclopramide hcl 2 MO proctozone-hc 2 MO oral tablet RECTIV 4 MO OCALIVA 5 PA; MO; LA; QL (30 per 30 RELISTOR 5 PA; MO days) SUBCUTANEOUS SOLUTION ondansetron 2 B/D PA; MO RELISTOR 5 PA; MO

ondansetron hcl (pf) 3 MO SUBCUTANEOUS

injection solution SYRINGE

ondansetron hcl 3 MO REMICADE 5 PA; MO intravenous scopolamine base 4 MO; QL (10

ondansetron hcl oral 3 B/D PA; MO; per 30 days) solution QL (450 per 30 days) SUCRAID 5 MO ondansetron hcl oral 2 B/D PA sulfasalazine 2 MO tablet 24 mg trilyte with flavor 2 MO ondansetron hcl oral 2 B/D PA; MO packets tablet 4 mg, 8 mg ursodiol oral 3 MO palonosetron 4 MO capsule intravenous solution ursodiol oral tablet 4 MO 0.25 mg/5 ml VIOKACE 4 MO peg 3350- 2 MO electrolytes oral ULCER THERAPY recon soln 236- DEXILANT 4 MO; QL (30 22.74-6.74 -5.86 per 30 days) gram esomeprazole 4 MO; QL (30 peg-electrolyte 2 magnesium oral per 30 days) PENTASA 4 MO capsule,delayed release(dr/ec) 20 mg PLENVU 4 MO esomeprazole 4 MO

polyethylene glycol 3 MO magnesium oral

3350 oral powder capsule,delayed prochlorperazine 4 MO release(dr/ec) 40 mg prochlorperazine 2 MO esomeprazole 4 MO edisylate sodium intravenous recon soln 40 mg prochlorperazine 2 MO maleate oral famotidine (pf) 2 MO procto-med hc 2 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 56 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits famotidine (pf)-nacl 2 MO ACTIMMUNE 5 B/D PA; MO

(iso-os) ARCALYST 5 PA; MO

famotidine 2 MO BETASERON 5 PA; MO; QL

intravenous solution SUBCUTANEOUS (14 per 28 famotidine oral 4 MO KIT days)

suspension ILARIS (PF) 5 PA; MO; LA famotidine oral 2 MO SUBCUTANEOUS tablet 20 mg, 40 mg SOLUTION lansoprazole oral 3 MO; QL (30 INTRON A 5 B/D PA; MO capsule,delayed per 30 days) INJECTION

release(dr/ec) 15 mg MOZOBIL 5 B/D PA; MO

lansoprazole oral 3 MO NEULASTA 4 PA; MO capsule,delayed release(dr/ec) 30 mg NEULASTA 4 PA; MO ONPRO misoprostol 3 MO NEUPOGEN 5 PA; MO omeprazole oral 1 MO; QL (30 capsule,delayed per 30 days) NORDITROPIN 5 PA; MO release(dr/ec) 10 FLEXPRO mg, 20 mg PEGASYS 5 PA; MO; QL omeprazole oral 1 MO; QL (60 SUBCUTANEOUS (4 per 28 days) capsule,delayed per 30 days) SOLUTION release(dr/ec) 40 mg PEGASYS 5 PA; MO; QL pantoprazole oral 2 MO; QL (30 SUBCUTANEOUS (2 per 28 days) tablet,delayed per 30 days) SYRINGE release (dr/ec) 20 PEGINTRON 5 MO; QL (4 per mg SUBCUTANEOUS 28 days) pantoprazole oral 2 MO; QL (60 KIT 50 MCG/0.5 tablet,delayed per 30 days) ML release (dr/ec) 40 PROCRIT 3 PA; MO mg INJECTION PRILOSEC ORAL 4 MO SOLUTION 10,000 SUSP,DELAYED UNIT/ML, 2,000 RELEASE FOR UNIT/ML, 20,000 RECON UNIT/2 ML, 3,000 UNIT/ML, 4,000

sucralfate oral tablet 2 MO UNIT/ML IMMUNOLOGY, VACCINES / PROCRIT 5 PA; MO BIOTECHNOLOGY INJECTION SOLUTION 20,000 BIOTECHNOLOGY DRUGS UNIT/ML, 40,000 UNIT/ML You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 57 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits PROLEUKIN 4 B/D PA; MO HYPERHEP B S/D 3 INTRAMUSCULA VACCINES / MISCELLANEOUS R SOLUTION 220 IMMUNOLOGICALS UNIT/ML

ACTHIB (PF) 3 MO HYPERHEP B S/D 3 MO ADACEL(TDAP 3 MO INTRAMUSCULA ADOLESN/ADULT R SOLUTION 220 )(PF) UNIT/ML (5 ML) ATGAM 4 B/D PA HYPERHEP B S/D 3 INTRAMUSCULA BCG VACCINE, 3 MO R SYRINGE LIVE (PF) HYPERHEP B S-D 3 BEXSERO 3 MO NEONATAL BOOSTRIX TDAP 3 MO IMOVAX RABIES 4 MO BOTOX 4 PA; MO VACCINE (PF) DAPTACEL (DTAP 3 MO INFANRIX (DTAP) 3 MO PEDIATRIC) (PF) (PF) ENGERIX-B (PF) 3 B/D PA; MO IPOL 3 MO ENGERIX-B 3 B/D PA; MO IXIARO (PF) 4 MO PEDIATRIC (PF) KINRIX (PF) 3 INTRAMUSCULA INTRAMUSCULA R SYRINGE R SUSPENSION GAMASTAN 3 MO KINRIX (PF) 3 MO GAMASTAN S/D 3 INTRAMUSCULA GARDASIL 9 (PF) 4 MO R SYRINGE GRASTEK 3 PA; MO MENACTRA (PF) 3 MO INTRAMUSCULA HAVRIX (PF) 3 MO R SOLUTION INTRAMUSCULA R SUSPENSION MENVEO A-C-Y- 3 MO 1,440 ELISA W-135-DIP (PF) UNIT/ML M-M-R II (PF) 3 MO HAVRIX (PF) 3 MO PEDIARIX (PF) 3 MO INTRAMUSCULA PEDVAX HIB (PF) 3 MO R SYRINGE PENTACEL (PF) 3 MO HIBERIX (PF) 3 MO INTRAMUSCULA HIZENTRA 5 B/D PA; MO R KIT 15 LF UNIT- 20 MCG-5 LF/0.5 ML

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 58 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits PENTACEL (PF) 3 TWINRIX (PF) 3 MO INTRAMUSCULA INTRAMUSCULA R KIT 15LF- R SYRINGE

48MCG-62DU -10 TYPHIM VI 3

MCG/0.5ML INTRAMUSCULA PRIVIGEN 5 PA; MO R SOLUTION PROQUAD (PF) 3 MO TYPHIM VI 3 MO

QUADRACEL (PF) 3 MO INTRAMUSCULA R SYRINGE RABAVERT (PF) 3 MO VAQTA (PF) 3 MO RAGWITEK 3 MO VARIVAX (PF) 3 MO RECOMBIVAX HB 3 B/D PA; MO

(PF) VARIZIG 5 MO

INTRAMUSCULA INTRAMUSCULA

R SUSPENSION R SOLUTION

RECOMBIVAX HB 3 B/D PA; MO YF-VAX (PF) 3 MO (PF) ZOSTAVAX (PF) 4 MO INTRAMUSCULA R SYRINGE 10 MUSCULOSKELETAL / MCG/ML RHEUMATOLOGY RECOMBIVAX HB 3 B/D PA GOUT THERAPY (PF) allopurinol 1 MO INTRAMUSCULA R SYRINGE 5 colchicine oral 3 MO; QL (120 MCG/0.5 ML tablet per 30 days) ROTARIX 3 febuxostat 3 MO ROTATEQ 3 MO KRYSTEXXA 5 MO VACCINE probenecid 3 MO SHINGRIX (PF) 4 MO; QL (2 per probenecid- 3 MO 999 days) colchicine STAMARIL (PF) 3 OSTEOPOROSIS THERAPY TDVAX 3 MO alendronate oral 1 MO; QL (30 TENIVAC (PF) 3 MO tablet 10 mg, 5 mg per 30 days) TETANUS,DIPHTH 3 MO alendronate oral 1 MO; QL (4 per ERIA TOX tablet 35 mg, 70 mg 28 days) PED(PF) ibandronate oral 3 MO; QL (1 per TICE BCG 3 B/D PA; MO 30 days) TRUMENBA 3 MO

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 59 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits PROLIA 4 PA; MO; QL HUMIRA(CF) PEDI 5 PA; MO; QL (1 per 180 CROHNS (2 per 180 days) STARTER days) raloxifene 3 MO; QL (30 SUBCUTANEOUS

per 30 days) SYRINGE KIT 80 MG/0.8 ML-40 TERIPARATIDE 5 PA; MO; QL MG/0.4 ML (2.48 per 28

days) HUMIRA(CF) PEN 5 PA; MO; QL CROHNS-UC-HS (3 per 180 TYMLOS 5 PA; MO; QL days) (1.56 per 30

days) HUMIRA(CF) PEN 5 PA; MO; QL PSOR-UV-ADOL (3 per 180 OTHER RHEUMATOLOGICALS HS days) BENLYSTA 5 PA; MO HUMIRA(CF) PEN 5 PA; MO; QL

ENBREL 5 PA; MO; QL SUBCUTANEOUS (4 per 28 days) (8 per 28 days) PEN INJECTOR KIT 40 MG/0.4 ML ENBREL MINI 5 PA; MO; QL

(8 per 28 days) HUMIRA(CF) PEN 5 PA; MO; QL SUBCUTANEOUS (2 per 28 days) ENBREL 5 PA; MO; QL PEN INJECTOR SURECLICK (8 per 28 days) KIT 80 MG/0.8 ML HUMIRA PEN 5 PA; MO; QL HUMIRA(CF) 5 PA; MO; QL (4 per 28 days) SUBCUTANEOUS (2 per 28 days) HUMIRA PEN 5 PA; MO; QL SYRINGE KIT 10 CROHNS-UC-HS (6 per 180 MG/0.1 ML, 20 START days) MG/0.2 ML HUMIRA PEN 5 PA; MO; QL HUMIRA(CF) 5 PA; MO; QL PSOR-UVEITS- (4 per 180 SUBCUTANEOUS (4 per 28 days) ADOL HS days) SYRINGE KIT 40 MG/0.4 ML HUMIRA 5 PA; MO; QL SUBCUTANEOUS (4 per 28 days) leflunomide 3 MO; QL (30 SYRINGE KIT 40 per 30 days) MG/0.8 ML ORENCIA (WITH 5 PA; MO HUMIRA(CF) PEDI 5 PA; MO; QL MALTOSE) CROHNS (3 per 180 ORENCIA 5 PA; MO; QL STARTER days) CLICKJECT (4 per 28 days) SUBCUTANEOUS

SYRINGE KIT 80 ORENCIA 5 PA; MO; QL

MG/0.8 ML SUBCUTANEOUS (4 per 28 days) SYRINGE 125 MG/ML

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 60 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits ORENCIA 5 PA; MO; QL norethindrone 2 MO SUBCUTANEOUS (1.6 per 28 (contraceptive)

SYRINGE 50 days) norethindrone 3 MO

MG/0.4 ML acetate

ORENCIA 5 PA; MO; QL norethindrone ac-eth 3 PA; MO; SUBCUTANEOUS (2.8 per 28 estradiol oral tablet HRM

SYRINGE 87.5 days) 0.5-2.5 mg-mcg MG/0.7 ML norlyda 3 MO penicillamine 5 PA; MO PREMARIN ORAL 3 MO RINVOQ 5 PA; MO; QL (30 per 30 tulana 3 MO days) yuvafem 3 MO OBSTETRICS / GYNECOLOGY MISCELLANEOUS OB/GYN ESTROGENS / PROGESTINS clindamycin 3 MO phosphate vaginal dotti 3 PA; MO; HRM; QL (8 metronidazole 2 MO per 28 days) vaginal estradiol oral 4 PA; MO; MIRENA 3 MO; LA

HRM NEXPLANON 3 MO

estradiol 2 PA; MO; terconazole vaginal 3 MO transdermal patch HRM; QL (4 cream weekly per 28 days) terconazole vaginal 4 MO

estradiol vaginal 2 MO suppository cream tranexamic acid oral 3 MO estradiol vaginal 3 MO tablet vandazole 3 MO estradiol valerate 2 MO ORAL CONTRACEPTIVES / intramuscular oil 20 RELATED AGENTS

mg/ml, 40 mg/ml afirmelle 4 MO heather 3 MO alyacen 1/35 (28) 4 MO hydroxyprogesterone 5 MO aubra 4 MO caproate aubra eq 4 MO incassia 3 MO aurovela 1.5/30 (21) 4 MO jencycla 3 MO aurovela 1/20 (21) 4 MO medroxyprogesteron 3 MO e intramuscular aurovela 24 fe 4 MO medroxyprogesteron 2 MO aurovela fe 1.5/30 4 MO e oral (28) You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 61 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits aurovela fe 1-20 4 MO junel fe 1/20 (28) 4 MO

(28) junel fe 24 4 MO

bekyree (28) 4 MO kaitlib fe 4 MO

blisovi 24 fe 4 MO kalliga 4

blisovi fe 1.5/30 (28) 4 MO kelnor 1/35 (28) 4 MO

blisovi fe 1/20 (28) 4 MO kelnor 1-50 (28) 4 MO

camrese lo 4 MO l norgest/e.estradiol- 4 MO caziant (28) 4 MO e.estrad oral chateal eq (28) 4 MO tablets,dose pack,3 month 0.15 mg-20 drospirenone- 4 MO mcg/ 0.15 mg-25 e.estradiol-lm.fa mcg, 0.15 mg-30 oral tablet 3-0.03- mcg (84)/10 mcg (7) 0.451 mg (21) (7) larissia 4 MO drospirenone-ethinyl 4 MO

estradiol levonorgestrel- 4 MO ethinyl estrad oral emoquette 4 MO tablet 0.1-20 mg- estarylla 4 MO mcg, 90-20 mcg (28) ethynodiol diac-eth 4 MO levonorgestrel- 4 MO estradiol oral tablet ethinyl estrad oral 1-35 mg-mcg tablets,dose pack,3 month ethynodiol diac-eth 4 estradiol oral tablet levonorg-eth estrad 4 MO 1-50 mg-mcg triphasic fayosim 4 MO lillow (28) 4 MO femynor 4 MO low-ogestrel (28) 4 MO hailey 4 MO lo-zumandimine (28) 4 MO hailey 24 fe 4 MO melodetta 24 fe 4 MO iclevia 4 mibelas 24 fe 4 MO introvale 4 MO microgestin 1.5/30 4 MO (21) isibloom 4 MO microgestin 1/20 4 MO jasmiel (28) 4 MO (21) juleber 4 MO microgestin fe 1.5/30 4 MO junel 1.5/30 (21) 4 MO (28) junel 1/20 (21) 4 MO microgestin fe 1/20 4 MO (28) junel fe 1.5/30 (28) 4 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 62 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits mili 4 MO ANTIBIOTICS noreth-ethinyl 4 MO ak-poly-bac 2 MO estradiol-iron bacitracin 4 MO norethindrone ac-eth 3 MO ophthalmic (eye) estradiol oral tablet bacitracin- 2 MO 1-20 mg-mcg polymyxin b norethindrone- 4 MO ophthalmic (eye) e.estradiol-iron oral ciprofloxacin hcl 2 MO tablet,chewable ophthalmic (eye) norgestimate-ethinyl 4 MO erythromycin 2 MO estradiol ophthalmic (eye) ocella 4 MO gatifloxacin 2 MO previfem 4 MO gentak ophthalmic 2 MO rivelsa 4 MO (eye) ointment setlakin 4 MO gentamicin 2 MO simliya (28) 4 MO ophthalmic (eye) drops sprintec (28) 4 MO moxifloxacin 3 MO syeda 4 MO ophthalmic (eye) tarina 24 fe 4 MO NATACYN 4 MO tri-lo-mili 4 MO neomycin- 4 MO tri-lo-sprintec 4 MO bacitracin- polymyxin tri-mili 4 MO neomycin- 3 MO 4 MO tri-sprintec (28) polymyxin- tri-vylibra 4 MO gramicidin tri-vylibra lo 4 MO neo-polycin 4 MO tydemy 4 MO polycin 2 MO vienva 4 MO polymyxin b sulf- 2 MO

vylibra 4 MO trimethoprim

zarah 4 MO tobramycin 2 MO ophthalmic (eye) zumandimine (28) 4 MO ANTIVIRALS OXYTOCICS trifluridine 3 MO methylergonovine 5 PA; MO

oral ZIRGAN 4 MO BETA-BLOCKERS OPHTHALMOLOGY

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 63 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits betaxolol ophthalmic 4 MO sulfacetamide 4 MO (eye) sodium ophthalmic

carteolol 2 MO (eye) ointment levobunolol 2 MO NON-STEROIDAL ANTI- ophthalmic (eye) INFLAMMATORY AGENTS drops 0.5 % diclofenac sodium 2 MO timolol maleate 1 MO ophthalmic (eye) ophthalmic (eye) ketorolac 2 MO drops ophthalmic (eye) timolol maleate 2 MO ORAL DRUGS FOR GLAUCOMA ophthalmic (eye) drops, once daily acetazolamide 3 MO timolol maleate 3 MO acetazolamide 3 MO ophthalmic (eye) gel sodium forming solution methazolamide 4 MO MISCELLANEOUS OTHER GLAUCOMA DRUGS OPHTHALMOLOGICS AZOPT 4 MO azelastine 4 MO COMBIGAN 3 MO ophthalmic (eye) dorzolamide 2 MO cromolyn 2 MO ophthalmic (eye) dorzolamide-timolol 2 MO CYSTARAN 5 PA; MO dorzolamide-timolol 3 MO (pf) ophthalmic (eye) epinastine 4 MO dropperette EYLEA 5 PA; MO latanoprost 2 MO LUCENTIS 5 PA; MO LUMIGAN 3 MO OXERVATE 5 PA; MO OPHTHALMIC PHOSPHOLINE 4 MO (EYE) DROPS 0.01 IODIDE % pilocarpine hcl 3 MO travoprost 3 MO ophthalmic (eye) STEROID-ANTIBIOTIC drops 1 %, 2 %, 4 % COMBINATIONS RESTASIS 3 MO; QL (60 neomycin- 4 MO per 30 days) bacitracin-poly-hc RESTASIS 3 MO; QL (5.5 neomycin-polymyxin 2 MO MULTIDOSE per 30 days) b-dexameth sulfacetamide 2 MO sodium ophthalmic (eye) drops You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 64 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits neomycin- 4 MO diphenhydramine hcl 2 MO polymyxin-hc injection solution 50 ophthalmic (eye) mg/ml neo-polycin hc 4 MO diphenhydramine hcl 2 MO

tobramycin- 3 MO injection syringe dexamethasone EPINEPHRINE 3 MO; QL (2 per INJECTION AUTO- 30 days)

STEROIDS INJECTOR 0.15 dexamethasone 2 MO MG/0.15 ML, 0.3 sodium phosphate MG/0.3 ML ophthalmic (eye) epinephrine 3 MO; QL (2 per fluorometholone 4 MO injection auto- 30 days)

loteprednol 3 MO injector 0.15 mg/0.3

etabonate ml, 0.3 mg/0.3 ml

OZURDEX 5 MO hydroxyzine hcl oral 2 PA; MO; tablet HRM prednisolone acetate 3 MO levocetirizine oral 4 MO prednisolone sodium 4 MO solution phosphate

ophthalmic (eye) levocetirizine oral 2 MO; QL (30 tablet per 30 days) SYMPATHOMIMETICS promethazine oral 2 MO ALPHAGAN P 3 MO syrup OPHTHALMIC promethazine oral 2 PA; MO; (EYE) DROPS 0.1 tablet 25 mg HRM %

apraclonidine 4 MO PULMONARY AGENTS

brimonidine 4 MO acetylcysteine 2 B/D PA; MO ophthalmic (eye) ADEMPAS 5 PA; MO; LA; drops 0.15 % QL (90 per 30

brimonidine 2 MO days) ophthalmic (eye) ADVAIR DISKUS 3 MO; QL (60 drops 0.2 % per 30 days) RESPIRATORY AND ADVAIR HFA 3 MO; QL (12 per 30 days) ALLERGY albuterol sulfate 3 MO; QL (17

ANTIHISTAMINE / inhalation hfa per 30 days) ANTIALLERGENIC AGE NTS aerosol inhaler 90 cetirizine oral 2 MO mcg/actuation solution 1 mg/ml

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 65 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits albuterol sulfate 3 MO; QL (13.4 COMBIVENT 4 MO; QL (8 per inhalation hfa per 30 days) RESPIMAT 30 days)

aerosol inhaler 90 cromolyn inhalation 2 B/D PA; MO mcg/actuation (nda020503) DALIRESP 4 PA; MO; QL (30 per 30

albuterol sulfate 2 B/D PA; MO days) inhalation solution for nebulization ESBRIET ORAL 5 PA; MO; QL CAPSULE (270 per 30

albuterol sulfate oral 2 MO days) syrup ESBRIET ORAL 5 PA; MO; QL

albuterol sulfate oral 4 MO TABLET 267 MG (270 per 30

tablet days)

alyq 5 PA; MO; QL ESBRIET ORAL 5 PA; MO; QL (60 per 30 TABLET 801 MG (90 per 30

days) days)

ambrisentan 5 PA; MO; LA; FASENRA 5 PA; MO; QL QL (30 per 30 (1 per 28 days) days) FLOVENT DISKUS 3 MO; QL (60

ANORO ELLIPTA 3 MO; QL (60 INHALATION per 30 days)

per 30 days) BLISTER WITH ARNUITY 3 MO; QL (30 DEVICE 100 ELLIPTA per 30 days) MCG/ACTUATION ATROVENT HFA 4 MO; QL (25.8 , 50

per 30 days) MCG/ACTUATION

bosentan 4 PA; MO FLOVENT DISKUS 3 MO; QL (240 INHALATION per 30 days) BREO ELLIPTA 3 MO; QL (60 BLISTER WITH per 30 days) DEVICE 250 budesonide 4 B/D PA; MO; MCG/ACTUATION inhalation QL (120 per FLOVENT HFA 3 MO; QL (12 suspension for 30 days) AEROSOL per 30 days) nebulization 0.25 INHALER 110 mg/2 ml, 0.5 mg/2 ml MCG/ACTUATION budesonide 4 B/D PA; MO; FLOVENT HFA 3 MO; QL (24 inhalation QL (60 per 30 AEROSOL per 30 days) suspension for days) INHALER 220 nebulization 1 mg/2 MCG/ACTUATION ml FLOVENT HFA 3 MO; QL (10.6 CINRYZE 5 PA; MO; QL AEROSOL per 30 days) (20 per 30 INHALER 44 days) MCG/ACTUATION You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 66 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits flunisolide nasal 3 MO; QL (50 PERFOROMIST 3 B/D PA; MO; spray,non-aerosol per 30 days) QL (120 per 25 mcg (0.025 %) 30 days) fluticasone 2 MO; QL (16 PROAIR 3 MO; QL (2 per propionate nasal per 30 days) RESPICLICK 30 days) icatibant 5 PA; MO; QL PULMOZYME 5 B/D PA; MO; (270 per 30 QL (150 per days) 30 days) INCRUSE 3 MO; QL (30 SEREVENT 3 MO; QL (60 ELLIPTA per 30 days) DISKUS per 30 days) ipratropium bromide 2 B/D PA; MO sildenafil 5 PA; MO; QL inhalation (pulmonary arterial (224 per 30

ipratropium- 2 B/D PA; MO hypertension) oral days) albuterol suspension for reconstitution 10 KALYDECO ORAL 5 PA; MO; QL mg/ml GRANULES IN (56 per 28

PACKET days) sildenafil 3 PA; MO; QL (pulmonary arterial (90 per 30 KALYDECO ORAL 5 PA; MO; QL hypertension) oral days) TABLET (60 per 30 tablet 20 mg days) SYMDEKO 5 PA; MO; QL mometasone nasal 4 MO; QL (34 (56 per 28 per 30 days) days) montelukast oral 3 MO; QL (30 tadalafil (pulm. 5 PA; MO; QL granules in packet per 30 days) hypertension) (60 per 30 montelukast oral 2 MO; QL (30 days) tablet per 30 days) terbutaline oral 4 MO montelukast oral 2 MO; QL (30 terbutaline 5 MO tablet,chewable per 30 days) subcutaneous OFEV 5 PA; MO; QL theophylline oral 2 MO (60 per 30 tablet extended days) release 12 hr 300 OPSUMIT 5 PA; MO; LA mg, 450 mg ORKAMBI ORAL 5 PA; MO; QL theophylline oral 2 MO GRANULES IN (56 per 28 tablet extended PACKET days) release 24 hr ORKAMBI ORAL 5 PA; MO; QL TRELEGY 3 MO; QL (60 TABLET (112 per 28 ELLIPTA per 30 days) days) TRIKAFTA 5 PA; MO TYVASO 5 B/D PA; MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 67 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits TYVASO 5 B/D PA BENIGN PROSTATIC

INSTITUTIONAL HYPERPLASIA(BPH) THERAPY START KIT alfuzosin 2 MO; QL (30 TYVASO REFILL 5 B/D PA; MO per 30 days) KIT dutasteride 3 MO; QL (30 TYVASO 5 B/D PA; MO per 30 days) STARTER KIT finasteride oral 2 MO; QL (30 XOLAIR 5 PA; MO; LA; tablet 5 mg per 30 days) SUBCUTANEOUS QL (6 per 28

RECON SOLN days) tamsulosin 2 MO; QL (60 per 30 days) XOLAIR 5 PA; MO; LA; SUBCUTANEOUS QL (4 per 28 MISCELLANEOUS UROLOGICALS SYRINGE 150 days) bethanechol chloride 3 MO MG/ML CYSTAGON 4 MO; LA XOLAIR 5 PA; MO; LA;

SUBCUTANEOUS QL (1 per 28 ELMIRON 4 MO SYRINGE 75 days) K-PHOS NO 2 3 MO

MG/0.5 ML K-PHOS 3 MO zafirlukast 4 MO; QL (60 ORIGINAL

per 30 days) potassium citrate 4 MO UROLOGICALS RENACIDIN 3 MO ANTICHOLINERGICS / IRRIGATION SOLUTION 1980.6 ANTISPASMODICS MG-59.4 MG- MYRBETRIQ 4 MO; QL (30 980.4MG/30ML per 30 days) VITAMINS, HEMATINICS / oxybutynin chloride 2 MO oral syrup ELECTROLYTES oxybutynin chloride 2 MO ELECTROLYTES oral tablet calcium 3 MO oxybutynin chloride 3 MO; QL (30 acetate(phosphat oral tablet extended per 30 days) bind) release 24hr 10 mg, effer-k oral tablet, 3 MO 5 mg effervescent 25 meq oxybutynin chloride 3 MO; QL (60 klor-con 2 MO oral tablet extended per 30 days)

release 24hr 15 mg klor-con 10 3 MO

solifenacin 3 MO klor-con 8 3 MO

tolterodine 4 MO klor-con m10 2 MO klor-con m15 2 MO You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 68 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits klor-con m20 2 MO potassium chloride 4 klor-con/ef 3 MO in 0.9%nacl intravenous lactated ringers 4 MO parenteral solution intravenous 20 meq/l, 40 meq/l MAGNESIUM 4 potassium chloride 4 SULFATE IN D5W in 5 % dex INTRAVENOUS intravenous PIGGYBACK 1 parenteral solution GRAM/100 ML 20 meq/l, 30 meq/l, magnesium sulfate in 4 40 meq/l water intravenous potassium chloride 4 MO parenteral solution in lr-d5 intravenous magnesium sulfate in 4 parenteral solution water intravenous 20 meq/l piggyback 2 gram/50 potassium chloride 4 MO ml (4 %), 4 gram/50 in water intravenous ml (8 %) piggyback 10 magnesium sulfate in 4 MO meq/100 ml water intravenous potassium chloride 4 piggyback 4 in water intravenous gram/100 ml (4 %) piggyback 10 magnesium sulfate 4 MO meq/50 ml, 20 injection solution meq/100 ml, 20 meq/50 ml, 30 magnesium sulfate 4 meq/100 ml, 40 injection syringe meq/100 ml NORMOSOL-R 3 MO potassium chloride 4 MO potassium acetate 3 intravenous intravenous solution potassium chloride 2 MO 2 meq/ml oral capsule, potassium chlorid- 4 extended release d5-0.45%nacl potassium chloride 4 MO intravenous oral liquid parenteral solution 10 meq/l, 30 meq/l, potassium chloride 2 MO 40 meq/l oral packet potassium chlorid- 4 MO potassium chloride 2 MO d5-0.45%nacl oral tablet extended intravenous release parenteral solution 20 meq/l

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 69 Drug Name Drug Requirements Drug Name Drug Requirements Tier /Limits Tier /Limits potassium chloride 2 MO sodium chloride 4 MO oral tablet,er intravenous

particles/crystals sodium phosphate 3 MO potassium chloride- 4 0.45 % nacl MISCELLANEOUS NUTRITION PRODUCTS potassium chloride- 4 MO

d5-0.2%nacl AMINOSYN II 15 3 B/D PA

intravenous % parenteral solution AMINOSYN-PF 7 3 B/D PA 20 meq/l % (SULFITE-

potassium chloride- 4 FREE) d5-0.2%nacl electrolyte-48 in d5w 3 intravenous freamine iii 10 % 3 B/D PA parenteral solution 30 meq/l, 40 meq/l HEPATAMINE 8% 3 B/D PA potassium chloride- 4 intralipid 4 B/D PA d5-0.9%nacl intravenous emulsion 20 % potassium phosphate 3 m-/d-basic INTRALIPID 4 B/D PA intravenous solution INTRAVENOUS 3 mmol/ml EMULSION 30 % ringer's intravenous 4 NEPHRAMINE 5.4 3 B/D PA % sodium acetate 3 NORMOSOL-R PH 3 sodium bicarbonate 3 MO 7.4 intravenous solution 1 meq/ml (8.4 %) plenamine 4 B/D PA sodium bicarbonate 3 MO premasol 10 % 2 B/D PA; MO intravenous syringe travasol 10 % 4 B/D PA; MO 10 meq/10 ml (8.4 %), 7.5 % (0.9 TROPHAMINE 10 3 B/D PA; MO meq/ml) % sodium bicarbonate 3 VITAMINS / HEMATINICS intravenous syringe fluoride (sodium) 2 MO 8.4 % (1 meq/ml) oral tablet sodium chloride 0.45 4 MO fluoride (sodium) 2 MO % intravenous oral tablet,chewable parenteral solution 1 mg (2.2 mg sod. sodium chloride 3 % 4 MO fluoride) sodium chloride 5 % 4 MO prenatal vitamin 1 MO oral tablet

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 70 Index

A alfuzosin ...... 68 APTIVUS ...... 2 abacavir ...... 1 ALIMTA ...... 12 APTIVUS (WITH VITAMIN abacavir-lamivudine ...... 1 ALINIA ...... 7 E) ...... 2 abacavir-lamivudine- ALIQOPA ...... 12 ARCALYST ...... 57 zidovudine ...... 1 allopurinol ...... 59 ARIKAYCE ...... 7 ABELCET ...... 1 alosetron ...... 55 aripiprazole ...... 30 ABILIFY MAINTENA ...... 30 ALPHAGAN P ...... 65 ARNUITY ELLIPTA ...... 66 abiraterone ...... 12 alprazolam ...... 30 ARRANON ...... 12 ABRAXANE ...... 12 ALUNBRIG ...... 12 arsenic trioxide ...... 12 acamprosate ...... 47 alyacen 1/35 (28) ...... 61 ARSENIC TRIOXIDE ...... 12 acarbose ...... 50 alyq ...... 66 ARZERRA ...... 12 acebutolol ...... 36 amantadine hcl ...... 2 asenapine maleate ...... 30 acetaminophen-codeine ...... 27 AMBISOME ...... 1 atazanavir ...... 2 acetazolamide ...... 64 ambrisentan ...... 66 atenolol ...... 36 acetazolamide sodium ...... 64 amikacin ...... 7 atenolol-chlorthalidone ...... 36 acetic acid ...... 48 amiloride ...... 36 ATGAM ...... 58 acetylcysteine ...... 47, 65 amiloride-hydrochlorothiazide atomoxetine ...... 30 acitretin ...... 42 ...... 36 atorvastatin ...... 40 ACTHIB (PF) ...... 58 aminocaproic acid ...... 39 atovaquone ...... 7 ACTIMMUNE ...... 57 AMINOSYN II 15 % ...... 70 atovaquone-proguanil ...... 7 acyclovir ...... 1, 45 AMINOSYN-PF 7 % ATRIPLA ...... 2 acyclovir sodium ...... 2 (SULFITE-FREE) ...... 70 atropine ...... 54 ADACEL(TDAP amiodarone ...... 35 ATROVENT HFA ...... 66 ADOLESN/ADULT)(PF) 58 AMITIZA ...... 55 aubra ...... 61 ADASUVE ...... 30 amitriptyline ...... 30 aubra eq ...... 61 ADCETRIS ...... 12 amlodipine ...... 36 aurovela 1.5/30 (21) ...... 61 ADEMPAS ...... 65 amlodipine-benazepril ...... 36 aurovela 1/20 (21) ...... 61 adenosine ...... 35 amlodipine-valsartan ...... 36 aurovela 24 fe ...... 61 adriamycin ...... 12 ammonium lactate ...... 43 aurovela fe 1.5/30 (28) ...... 61 adrucil ...... 12 amoxapine ...... 30 aurovela fe 1-20 (28) ...... 62 ADVAIR DISKUS ...... 65 amoxicillin ...... 9 AVASTIN ...... 12 ADVAIR HFA ...... 65 amoxicillin-pot clavulanate ... 9, AYVAKIT ...... 12 AFINITOR ...... 12 10 azacitidine ...... 12 AFINITOR DISPERZ ...... 12 amphotericin b ...... 1 azathioprine ...... 12 afirmelle ...... 61 ampicillin ...... 10 azathioprine sodium ...... 12 AIMOVIG AUTOINJECTOR ampicillin sodium ...... 10 azelastine ...... 48, 64 ...... 25 ampicillin-sulbactam ...... 10 azithromycin ...... 6 ak-poly-bac ...... 63 ANADROL-50 ...... 52 AZOPT ...... 64 albendazole ...... 7 anagrelide ...... 47 aztreonam ...... 7 albuterol sulfate ...... 65, 66 anastrozole ...... 12 B alclometasone ...... 45 ANORO ELLIPTA ...... 66 bacitracin ...... 63 alcohol pads ...... 50 APOKYN ...... 24 bacitracin-polymyxin b ...... 63 ALDURAZYME ...... 52 apraclonidine ...... 65 baclofen ...... 26 ALECENSA ...... 12 aprepitant ...... 55 balsalazide ...... 55 alendronate ...... 59 APTIOM ...... 22 BALVERSA ...... 12

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 71 BANZEL ...... 22 BRUKINSA ...... 13 cefadroxil ...... 5 BAQSIMI ...... 50 budesonide ...... 55, 66 cefazolin ...... 5 BARACLUDE ...... 2 bumetanide ...... 36 cefazolin in dextrose (iso-os) .. 5 BAVENCIO ...... 12 buprenorphine hcl ...... 27 CEFAZOLIN IN DEXTROSE BCG VACCINE, LIVE (PF) 58 buprenorphine-naloxone ...... 29 (ISO-OS) ...... 5 bekyree (28)...... 62 bupropion hcl ...... 30 cefdinir ...... 5 BELEODAQ ...... 12 bupropion hcl (smoking deter) cefepime ...... 6 benazepril ...... 36 ...... 48 CEFEPIME IN DEXTROSE 5 benazepril-hydrochlorothiazide buspirone ...... 30 % ...... 5 ...... 36 busulfan ...... 13 cefepime in dextrose,iso-osm . 5 BENDEKA ...... 13 butorphanol ...... 29 cefixime ...... 6 BENLYSTA ...... 60 BYDUREON ...... 50 cefoxitin ...... 6 BENZNIDAZOLE ...... 7 BYDUREON BCISE ...... 50 cefoxitin in dextrose, iso-osm . 6 benztropine ...... 24 BYETTA ...... 50 ceftazidime ...... 6 beser ...... 45 BYSTOLIC ...... 36 CEFTAZIDIME IN D5W ...... 6 BESPONSA ...... 13 C ceftriaxone ...... 6 betamethasone dipropionate . 45 cabergoline ...... 52 CEFTRIAXONE ...... 6 betamethasone valerate ...... 45 CABLIVI ...... 39 ceftriaxone in dextrose,iso-os . 6 betamethasone, augmented ... 45 CABOMETYX ...... 13 cefuroxime axetil ...... 6 BETASERON ...... 57 caffeine citrate ...... 47 cefuroxime sodium ...... 6 betaxolol ...... 64 calcipotriene ...... 42 celecoxib ...... 29 bethanechol chloride ...... 68 calcitonin (salmon) ...... 53 CELONTIN ...... 22 bexarotene ...... 13 calcitriol ...... 53 cephalexin ...... 6 BEXSERO ...... 58 calcium acetate(phosphat bind) CEPROTIN (BLUE BAR) ... 39 bicalutamide ...... 13 ...... 68 CEPROTIN (GREEN BAR) 39 BICILLIN L-A ...... 10 CALQUENCE ...... 13 CERDELGA ...... 53 BIDIL ...... 36 camrese lo ...... 62 CEREZYME ...... 53 BIKTARVY ...... 2 candesartan ...... 36 cetirizine ...... 65 bisoprolol fumarate ...... 36 candesartan-hydrochlorothiazid CHANTIX ...... 48 bisoprolol-hydrochlorothiazide ...... 36 CHANTIX CONTINUING ...... 36 CAPASTAT ...... 7 MONTH BOX ...... 48 BLENREP ...... 13 CAPLYTA ...... 30 CHANTIX STARTING bleomycin ...... 13 CAPRELSA ...... 13 MONTH BOX ...... 48 BLINCYTO ...... 13 CARBAGLU ...... 47 chateal eq (28) ...... 62 blisovi 24 fe ...... 62 carbamazepine ...... 22 CHEMET ...... 47 blisovi fe 1.5/30 (28) ...... 62 carbidopa ...... 24 CHENODAL ...... 55 blisovi fe 1/20 (28) ...... 62 carbidopa-levodopa ...... 25 chlorhexidine gluconate ...... 48 BOOSTRIX TDAP ...... 58 carbidopa-levodopa- chloroquine phosphate ...... 7 BORTEZOMIB ...... 13 entacapone ...... 25 chlorpromazine ...... 30 bosentan ...... 66 carboplatin ...... 13 chlorthalidone ...... 36 BOSULIF ...... 13 carmustine ...... 13 CHOLBAM ...... 55 BOTOX ...... 58 carteolol ...... 64 cholestyramine (with sugar) . 40 BRAFTOVI ...... 13 cartia xt ...... 36 cholestyramine light ...... 40 BREO ELLIPTA ...... 66 carvedilol ...... 36 ciclopirox ...... 45 BRILINTA ...... 39 caspofungin ...... 1 cidofovir ...... 2 brimonidine ...... 65 CAYSTON ...... 7 cilostazol ...... 39 BRIVIACT ...... 22 caziant (28) ...... 62 CIMDUO ...... 2 bromocriptine ...... 24 cefaclor ...... 5 cinacalcet ...... 53

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 72 CINRYZE ...... 66 COTELLIC ...... 13 dentagel ...... 48 CIPRODEX ...... 49 CREON ...... 55 DEPO-MEDROL ...... 49 ciprofloxacin hcl ...... 10, 48, 63 CRESEMBA ...... 1 DESCOVY ...... 2 ciprofloxacin in 5 % dextrose CRIXIVAN ...... 2 desipramine ...... 31 ...... 10 cromolyn ...... 55, 64, 66 desmopressin ...... 53 ciprofloxacin-dexamethasone CRYSVITA ...... 53 desonide ...... 46 ...... 49 cyclobenzaprine ...... 26 desoximetasone ...... 46 cisplatin ...... 13 cyclophosphamide ...... 13 desvenlafaxine succinate ...... 31 citalopram ...... 30 cyclosporine ...... 13 dexamethasone ...... 49 cladribine ...... 13 cyclosporine modified ...... 13 dexamethasone intensol ...... 49 claravis ...... 44 CYRAMZA ...... 13 dexamethasone sodium phos clarithromycin ...... 6 CYSTADANE ...... 55 (pf) ...... 49 clindamycin hcl ...... 7 CYSTAGON ...... 68 dexamethasone sodium CLINDAMYCIN IN 0.9 % CYSTARAN ...... 64 phosphate ...... 49, 65 SOD CHLOR ...... 7 cytarabine ...... 13 DEXILANT ...... 56 clindamycin in 5 % dextrose .. 7 cytarabine (pf) ...... 14 dextroamphetamine ...... 31 clindamycin pediatric ...... 7 D dextroamphetamine- clindamycin phosphate .... 7, 44, d10 %-0.45 % sodium chloride amphetamine ...... 31 61 ...... 47 dextrose 10 % and 0.2 % nacl CLINDAMYCIN d2.5 %-0.45 % sodium ...... 47 PHOSPHATE ...... 44 chloride ...... 47 dextrose 10 % in water (d10w) clobazam...... 22 d5 % and 0.9 % sodium ...... 47 clobetasol ...... 45, 46 chloride ...... 47 dextrose 5 % in water (d5w) . 47 clobetasol-emollient ...... 46 d5 %-0.45 % sodium chloride dextrose 5 %-lactated ringers47 clofarabine ...... 13 ...... 47 dextrose 5%-0.2 % sod clomipramine ...... 30 dacarbazine ...... 14 chloride ...... 47 clonazepam ...... 22 dactinomycin ...... 14 dextrose 5%-0.3 % clonidine ...... 36 dalfampridine ...... 25 sod.chloride ...... 47 clonidine hcl ...... 36 DALIRESP ...... 66 DIACOMIT ...... 22 clopidogrel ...... 39 danazol ...... 53 diazepam ...... 22, 31 clorazepate dipotassium ...... 31 dantrolene ...... 26 diazepam intensol ...... 31 clotrimazole ...... 1, 45 dapsone ...... 7 diazoxide ...... 50 clotrimazole-betamethasone . 45 DAPTACEL (DTAP diclofenac potassium ...... 29 clozapine...... 31 PEDIATRIC) (PF) ...... 58 diclofenac sodium ...... 29, 64 COARTEM ...... 7 daptomycin ...... 7 dicloxacillin ...... 10 colchicine ...... 59 DAPTOMYCIN ...... 7 dicyclomine ...... 54 colesevelam ...... 40 DARZALEX ...... 14 didanosine ...... 2 colistin (colistimethate na) ..... 7 DARZALEX FASPRO ...... 14 diflunisal ...... 29 COMBIGAN ...... 64 daunorubicin ...... 14 digitek ...... 41 COMBIVENT RESPIMAT . 66 DAURISMO ...... 14 digox ...... 41 COMETRIQ ...... 13 decadron ...... 49 digoxin ...... 41 COMPLERA ...... 2 decitabine ...... 14 dihydroergotamine ...... 25 compro ...... 55 deferasirox ...... 47 DILANTIN 30 MG ...... 22 constulose ...... 55 deferiprone ...... 47 diltiazem hcl ...... 36, 37 COPIKTRA ...... 13 DELSTRIGO ...... 2 dilt-xr ...... 37 CORLANOR ...... 41 DEMSER ...... 36 dimethyl fumarate ...... 25 CORTIFOAM ...... 55 DENAVIR ...... 45 diphenhydramine hcl ...... 65 cortisone ...... 49 denta 5000 plus ...... 48 diphenoxylate-atropine ...... 54

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 73 dipyridamole ...... 39 efavirenz-lamivu-tenofov disop ergotamine-caffeine ...... 25 disulfiram ...... 47 ...... 2 ERIVEDGE ...... 14 divalproex ...... 22, 23 effer-k ...... 68 ERLEADA ...... 14 dobutamine ...... 41 ELAPRASE ...... 53 erlotinib ...... 14 dobutamine in d5w ...... 41 electrolyte-48 in d5w ...... 70 ertapenem ...... 7 docetaxel...... 14 ELIQUIS ...... 39 ERWINAZE ...... 14 dofetilide...... 35 ELIQUIS DVT-PE TREAT ery pads ...... 44 donepezil ...... 25, 26 30D START ...... 39 ERYTHROCIN ...... 6 dopamine ...... 42 ELLENCE ...... 14 erythrocin (as stearate) ...... 6 dopamine in 5 % dextrose ... 41, ELMIRON ...... 68 erythromycin ...... 7, 63 42 ELZONRIS ...... 14 erythromycin ethylsuccinate ... 7 DOPTELET (10 TAB PACK) EMCYT ...... 14 erythromycin with ethanol .... 44 ...... 39 EMEND ...... 55 erythromycin-benzoyl peroxide DOPTELET (15 TAB PACK) emoquette ...... 62 ...... 44 ...... 39 EMPLICITI ...... 14 ESBRIET ...... 66 DOPTELET (30 TAB PACK) EMSAM ...... 31 escitalopram oxalate ...... 31 ...... 39 emtricitabine ...... 2 esomeprazole magnesium ..... 56 dorzolamide ...... 64 emtricitabine-tenofovir (tdf) ... 2 esomeprazole sodium ...... 56 dorzolamide-timolol ...... 64 EMTRIVA ...... 2 estarylla ...... 62 dorzolamide-timolol (pf) ...... 64 EMVERM ...... 7 estradiol ...... 61 dotti ...... 61 enalapril maleate ...... 37 estradiol valerate ...... 61 DOVATO ...... 2 enalaprilat ...... 37 ethambutol ...... 7 doxazosin ...... 37 enalapril-hydrochlorothiazide ethosuximide ...... 23 doxepin ...... 31 ...... 37 ethynodiol diac-eth estradiol 62 doxorubicin...... 14 ENBREL ...... 60 etodolac ...... 29 doxorubicin, peg-liposomal .. 14 ENBREL MINI ...... 60 ETOPOPHOS ...... 14 doxy-100 ...... 11 ENBREL SURECLICK ...... 60 etoposide ...... 14 doxycycline hyclate ...... 11 endocet ...... 27 euthyrox ...... 54 doxycycline monohydrate .... 11 ENGERIX-B (PF) ...... 58 everolimus (antineoplastic) .. 14 DRIZALMA SPRINKLE ..... 31 ENGERIX-B PEDIATRIC everolimus dronabinol...... 55 (PF) ...... 58 (immunosuppressive) ...... 15 drospirenone-e.estradiol-lm.fa enoxaparin ...... 39 EVOMELA ...... 15 ...... 62 entacapone ...... 25 EVOTAZ ...... 2 drospirenone-ethinyl estradiol entecavir ...... 2 exemestane ...... 15 ...... 62 ENTRESTO ...... 42 EYLEA ...... 64 DROXIA ...... 14 ENTYVIO ...... 55 ezetimibe ...... 40 duloxetine ...... 31 enulose ...... 55 ezetimibe-simvastatin ...... 40 DUPIXENT PEN ...... 43 EPCLUSA ...... 2 F DUPIXENT SYRINGE ...... 43 EPIDIOLEX ...... 23 FABRAZYME ...... 53 duramorph (pf) ...... 27 epinastine ...... 64 famciclovir ...... 3 dutasteride ...... 68 epinephrine ...... 65 famotidine ...... 57 E EPINEPHRINE ...... 65 famotidine (pf) ...... 56 econazole ...... 45 epirubicin ...... 14 famotidine (pf)-nacl (iso-os) 57 EDURANT ...... 2 epitol ...... 23 FANAPT ...... 32 efavirenz ...... 2 EPIVIR HBV ...... 2 FARYDAK ...... 15 efavirenz-emtricitabin-tenofov eplerenone ...... 37 FASENRA ...... 66 2 epoprostenol (glycine) ...... 37 fayosim ...... 62 ERBITUX ...... 14 febuxostat ...... 59

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 74 felbamate ...... 23 fondaparinux ...... 39 GLUCAGON (HCL) felodipine ...... 37 fosamprenavir ...... 3 EMERGENCY KIT ...... 50 femynor ...... 62 fosinopril ...... 37 GLUCAGON EMERGENCY fenofibrate ...... 41 fosinopril-hydrochlorothiazide KIT (HUMAN) ...... 50 fenofibrate micronized ...... 40 ...... 37 glycopyrrolate ...... 55 fenofibrate nanocrystallized . 40 fosphenytoin ...... 23 glydo ...... 43 fentanyl ...... 27 freamine iii 10 % ...... 70 GRASTEK ...... 58 fentanyl citrate ...... 27 fulvestrant ...... 15 griseofulvin microsize ...... 1 fentanyl citrate (pf) ...... 27 furosemide ...... 37 griseofulvin ultramicrosize ..... 1 FENTANYL CITRATE (PF) FUZEON ...... 3 H ...... 27 FYCOMPA ...... 23 hailey ...... 62 FERRIPROX ...... 47 G hailey 24 fe ...... 62 FERRIPROX (2 TIMES A gabapentin ...... 23 HALAVEN ...... 15 DAY) ...... 47 galantamine ...... 26 halobetasol propionate ...... 46 FETZIMA ...... 32 GAMASTAN ...... 58 haloperidol ...... 32 finasteride ...... 68 GAMASTAN S/D ...... 58 haloperidol decanoate ...... 32 FINTEPLA ...... 23 ganciclovir sodium ...... 3 haloperidol lactate ...... 32 FIRDAPSE ...... 26 GARDASIL 9 (PF) ...... 58 HARVONI ...... 3 FIRMAGON KIT W gatifloxacin ...... 63 HAVRIX (PF) ...... 58 DILUENT SYRINGE ...... 15 GATTEX 30-VIAL ...... 55 heather ...... 61 flac otic oil ...... 49 GATTEX ONE-VIAL ...... 55 heparin (porcine) ...... 40 flecainide ...... 35 GAUZE PAD ...... 50 heparin (porcine) in 5 % dex 39 FLOVENT DISKUS ...... 66 gavilyte-c ...... 55 heparin (porcine) in nacl (pf) 40 FLOVENT HFA ...... 66 gavilyte-g ...... 55 heparin(porcine) in 0.45% nacl floxuridine ...... 15 gavilyte-n ...... 55 ...... 40 fluconazole ...... 1 GAVRETO ...... 15 HEPARIN(PORCINE) IN fluconazole in nacl (iso-osm) . 1 GAZYVA ...... 15 0.45% NACL ...... 40 flucytosine ...... 1 gemcitabine ...... 15 heparin, porcine (pf) ...... 40 fludarabine ...... 15 GEMCITABINE ...... 15 HEPARIN, PORCINE (PF) .. 40 fludrocortisone ...... 49 gemfibrozil ...... 41 HEPATAMINE 8% ...... 70 flunisolide ...... 67 generlac ...... 55 HERCEPTIN ...... 15 fluocinolone ...... 46 gengraf ...... 15 HERCEPTIN HYLECTA .... 15 fluocinolone acetonide oil .... 49 gentak ...... 63 HETLIOZ ...... 32 fluocinolone and shower cap 46 gentamicin ...... 8, 44, 63 HIBERIX (PF) ...... 58 fluocinonide ...... 46 gentamicin in nacl (iso-osm) . 7, HIZENTRA ...... 58 fluocinonide-e...... 46 8 HUMALOG JUNIOR fluocinonide-emollient ...... 46 GENTAMICIN IN NACL KWIKPEN U-100 ...... 50 fluoride (sodium) ...... 48, 70 (ISO-OSM) ...... 8 HUMALOG KWIKPEN fluorometholone ...... 65 gentamicin sulfate (ped) (pf) .. 8 INSULIN ...... 50 fluorouracil ...... 15, 43 GENVOYA ...... 3 HUMALOG MIX 50-50 fluoxetine ...... 32 GILOTRIF ...... 15 INSULN U-100 ...... 51 fluphenazine decanoate ...... 32 glatiramer ...... 26 HUMALOG MIX 50-50 fluphenazine hcl ...... 32 glatopa ...... 26 KWIKPEN ...... 51 flutamide ...... 15 glimepiride ...... 50 HUMALOG MIX 75-25 fluticasone propionate .... 46, 67 glipizide ...... 50 KWIKPEN ...... 51 fluvastatin ...... 41 glipizide-metformin ...... 50 HUMALOG MIX 75-25(U- fluvoxamine ...... 32 GLUCAGEN HYPOKIT ..... 50 100)INSULN ...... 51 FOLOTYN ...... 15

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 75 HUMALOG U-100 INSULIN I irbesartan ...... 37 ...... 51 ibandronate ...... 59 irbesartan-hydrochlorothiazide HUMIRA ...... 60 IBRANCE ...... 15 ...... 37 HUMIRA PEN ...... 60 ibu ...... 29 IRESSA ...... 16 HUMIRA PEN CROHNS-UC- ibuprofen ...... 29 irinotecan ...... 16 HS START ...... 60 icatibant ...... 67 ISENTRESS ...... 3 HUMIRA PEN PSOR- iclevia ...... 62 ISENTRESS HD ...... 3 UVEITS-ADOL HS ...... 60 ICLUSIG ...... 15, 16 isibloom ...... 62 HUMIRA(CF) ...... 60 icosapent ethyl ...... 41 isoniazid ...... 8 HUMIRA(CF) PEDI idarubicin ...... 16 isosorbide dinitrate ...... 42 CROHNS STARTER ...... 60 IDHIFA ...... 16 isosorbide mononitrate ...... 42 HUMIRA(CF) PEN ...... 60 ifosfamide ...... 16 isotretinoin ...... 44 HUMIRA(CF) PEN ILARIS (PF) ...... 57 ISTODAX ...... 16 CROHNS-UC-HS ...... 60 imatinib ...... 16 itraconazole ...... 1 HUMIRA(CF) PEN PSOR- IMBRUVICA ...... 16 ivermectin ...... 8 UV-ADOL HS ...... 60 IMFINZI ...... 16 IXEMPRA ...... 16 HUMULIN 70/30 U-100 imipenem-cilastatin ...... 8 IXIARO (PF) ...... 58 INSULIN ...... 51 imipramine hcl ...... 32 J HUMULIN 70/30 U-100 imiquimod ...... 43 JAKAFI ...... 16 KWIKPEN ...... 51 IMOVAX RABIES VACCINE jantoven ...... 40 HUMULIN N NPH INSULIN (PF) ...... 58 JANUMET ...... 51 KWIKPEN ...... 51 IMPAVIDO ...... 8 JANUMET XR ...... 51 HUMULIN N NPH U-100 incassia ...... 61 JANUVIA ...... 51 INSULIN ...... 51 INCRELEX ...... 47 JARDIANCE ...... 51 HUMULIN R REGULAR U- INCRUSE ELLIPTA ...... 67 jasmiel (28) ...... 62 100 INSULN ...... 51 indapamide ...... 37 jencycla ...... 61 HUMULIN R U-500 (CONC) INFANRIX (DTAP) (PF) ..... 58 JEVTANA ...... 16 INSULIN ...... 51 INFUGEM ...... 16 juleber ...... 62 HUMULIN R U-500 (CONC) INLYTA ...... 16 JULUCA ...... 3 KWIKPEN ...... 51 INQOVI ...... 16 junel 1.5/30 (21) ...... 62 hydralazine ...... 37 INREBIC ...... 16 junel 1/20 (21) ...... 62 hydrochlorothiazide ...... 37 INSULIN PEN NEEDLE ..... 51 junel fe 1.5/30 (28) ...... 62 hydrocodone-acetaminophen 27 INSULIN SYRINGE (DISP) junel fe 1/20 (28) ...... 62 hydrocodone-ibuprofen ...... 28 U-100 ...... 51 junel fe 24 ...... 62 hydrocortisone ...... 46, 49, 55 INTELENCE ...... 3 K hydrocortisone valerate ...... 46 intralipid ...... 70 KADCYLA ...... 16 hydrocortisone-acetic acid.... 49 INTRALIPID ...... 70 kaitlib fe ...... 62 hydromorphone ...... 28 INTRON A ...... 57 KALETRA ...... 3 hydromorphone (pf) ...... 28 introvale ...... 62 kalliga ...... 62 HYDROMORPHONE (PF) . 28 INVEGA SUSTENNA ...... 32 KALYDECO ...... 67 hydroxychloroquine ...... 8 INVEGA TRINZA ...... 33 KANUMA ...... 53 hydroxyprogesterone caproate INVIRASE ...... 3 kelnor 1/35 (28) ...... 62 ...... 61 INVOKAMET ...... 51 kelnor 1-50 (28) ...... 62 hydroxyurea ...... 15 INVOKAMET XR ...... 51 KEPIVANCE ...... 11 hydroxyzine hcl ...... 65 INVOKANA ...... 51 ketoconazole ...... 1, 45 HYPERHEP B S/D ...... 58 IPOL ...... 58 ketorolac ...... 64 HYPERHEP B S-D ipratropium bromide ...... 48, 67 KEYTRUDA ...... 16 NEONATAL ...... 58 ipratropium-albuterol ...... 67 KHAPZORY ...... 11

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 76 KINRIX (PF) ...... 58 levocarnitine ...... 47 LUPRON DEPOT ...... 17 kionex (with sorbitol) ...... 47 levocarnitine (with sugar) ..... 47 LUPRON DEPOT (3 KISQALI ...... 17 levocetirizine ...... 65 MONTH) ...... 17 KISQALI FEMARA CO- levofloxacin ...... 10, 11 LUPRON DEPOT (4 PACK ...... 16, 17 levofloxacin in d5w ...... 10 MONTH) ...... 17 klor-con ...... 68 levoleucovorin calcium ...... 11 LUPRON DEPOT (6 klor-con 10 ...... 68 levonorgestrel-ethinyl estrad 62 MONTH) ...... 17 klor-con 8 ...... 68 levonorg-eth estrad triphasic 62 LUPRON DEPOT-PED ...... 17 klor-con m10 ...... 68 levo-t ...... 54 LUPRON DEPOT-PED (3 klor-con m15 ...... 68 levothyroxine ...... 54 MONTH) ...... 17 klor-con m20 ...... 69 levoxyl ...... 54 LYNPARZA ...... 17 klor-con/ef ...... 69 LEXIVA ...... 3 LYSODREN ...... 17 KORLYM ...... 53 LIBTAYO ...... 17 LYUMJEV KWIKPEN U-100 K-PHOS NO 2 ...... 68 lidocaine ...... 43 INSULIN ...... 52 K-PHOS ORIGINAL ...... 68 lidocaine (pf) ...... 35, 43 LYUMJEV U-100 INSULIN KRYSTEXXA ...... 59 lidocaine hcl ...... 43 ...... 52 KUVAN ...... 53 lidocaine viscous ...... 43 M KYPROLIS ...... 17 lidocaine-prilocaine ...... 43 mafenide acetate ...... 44 L lillow (28) ...... 62 magnesium sulfate ...... 69 l norgest/e.estradiol-e.estrad . 62 lindane ...... 46 MAGNESIUM SULFATE IN labetalol ...... 37 linezolid ...... 8 D5W ...... 69 lactated ringers ...... 69 linezolid in dextrose 5% ...... 8 magnesium sulfate in water .. 69 lactulose ...... 55 linezolid-0.9% sodium chloride malathion ...... 46 lamivudine ...... 3 ...... 8 mannitol 20 % ...... 37 lamivudine-zidovudine ...... 3 LIORESAL ...... 26, 27 mannitol 25 % ...... 37 lamotrigine ...... 23 liothyronine ...... 54 maprotiline ...... 33 LANOXIN ...... 42 lisinopril ...... 37 MARPLAN ...... 33 lansoprazole ...... 57 lisinopril-hydrochlorothiazide MARQIBO ...... 17 LANTUS SOLOSTAR U-100 ...... 37 MATULANE ...... 17 INSULIN ...... 51 lithium carbonate ...... 33 meclizine ...... 55 LANTUS U-100 INSULIN .. 51 lithium citrate ...... 33 medroxyprogesterone ...... 61 lapatinib ...... 17 LONSURF ...... 17 mefloquine ...... 8 larissia...... 62 loperamide ...... 55 megestrol ...... 17, 18 latanoprost ...... 64 lopinavir-ritonavir ...... 3 MEKINIST ...... 18 LATUDA ...... 33 lorazepam ...... 33 MEKTOVI ...... 18 leflunomide ...... 60 lorazepam intensol ...... 33 melodetta 24 fe ...... 62 LEMTRADA ...... 26 LORBRENA ...... 17 meloxicam ...... 29 LENVIMA ...... 17 losartan ...... 37 melphalan ...... 18 letrozole ...... 17 losartan-hydrochlorothiazide 37 melphalan hcl ...... 18 leucovorin calcium ...... 11 loteprednol etabonate ...... 65 memantine ...... 26 LEUKERAN ...... 17 lovastatin ...... 41 MEMANTINE ...... 26 leuprolide ...... 17 low-ogestrel (28) ...... 62 MENACTRA (PF) ...... 58 LEVEMIR FLEXTOUCH U- loxapine succinate ...... 33 MENVEO A-C-Y-W-135-DIP 100 INSULN ...... 51 lo-zumandimine (28) ...... 62 (PF) ...... 58 LEVEMIR U-100 INSULIN 51 LUCENTIS ...... 64 MEPSEVII ...... 53 levetiracetam ...... 23 LUMIGAN ...... 64 mercaptopurine ...... 18 levetiracetam in nacl (iso-os) 23 LUMIZYME ...... 53 meropenem ...... 8 levobunolol ...... 64 LUMOXITI ...... 17

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 77 MEROPENEM-0.9% minoxidil ...... 38 neomycin-polymyxin b- SODIUM CHLORIDE ...... 8 MIRENA ...... 61 dexameth ...... 64 mesalamine ...... 55 mirtazapine ...... 33 neomycin-polymyxin- mesalamine with cleansing misoprostol ...... 57 gramicidin ...... 63 wipe ...... 55 mitomycin ...... 18 neomycin-polymyxin-hc . 49, 65 mesna ...... 11 mitoxantrone ...... 18 neo-polycin ...... 63 MESNEX ...... 11 M-M-R II (PF) ...... 58 neo-polycin hc ...... 65 metformin ...... 52 modafinil ...... 33 neostigmine methylsulfate .... 27 methadone ...... 28 molindone ...... 33 NEPHRAMINE 5.4 % ...... 70 methadone intensol ...... 28 mometasone ...... 46, 67 NERLYNX ...... 18 methadose ...... 28 MONJUVI ...... 18 NEULASTA ...... 57 methazolamide ...... 64 montelukast ...... 67 NEULASTA ONPRO ...... 57 methenamine hippurate ...... 11 morgidox ...... 11 NEUPOGEN ...... 57 methenamine mandelate ...... 11 morphine ...... 28, 29 NEUPRO ...... 25 methimazole ...... 50 MORPHINE ...... 28 nevirapine ...... 3 methotrexate sodium ...... 18 morphine (pf) ...... 28 NEXAVAR ...... 18 methotrexate sodium (pf) ..... 18 morphine concentrate ...... 28 NEXPLANON ...... 61 methoxsalen ...... 43 moxifloxacin ...... 63 niacin ...... 41 methyldopa ...... 37 MOZOBIL ...... 57 NICOTROL ...... 48 methylergonovine ...... 63 MULTAQ ...... 36 NICOTROL NS ...... 48 methylphenidate hcl ...... 33 mupirocin ...... 44 nifedipine ...... 38 methylprednisolone ...... 49 MYALEPT ...... 53 nilutamide ...... 18 methylprednisolone acetate .. 49 mycophenolate mofetil ...... 18 nimodipine ...... 38 methylprednisolone sodium mycophenolate mofetil (hcl) 18 NINLARO ...... 18 succ ...... 49 mycophenolate sodium ...... 18 NIPENT ...... 18 metoclopramide hcl ...... 55, 56 MYLOTARG ...... 18 nitisinone ...... 47 metolazone ...... 37 MYRBETRIQ ...... 68 nitro-bid ...... 42 metoprolol succinate ...... 38 N nitrofurantoin ...... 11 metoprolol ta-hydrochlorothiaz nafcillin ...... 10 nitrofurantoin macrocrystal .. 11 ...... 38 nafcillin in dextrose iso-osm 10 nitrofurantoin monohyd/m- metoprolol tartrate ...... 38 NAGLAZYME ...... 53 cryst ...... 11 metro i.v...... 8 naloxone ...... 29 nitroglycerin ...... 42 metronidazole ...... 8, 44, 61 naltrexone ...... 30 nitroglycerin in 5 % dextrose 42 metronidazole in nacl (iso-os) 8 NAMZARIC ...... 26 NORDITROPIN FLEXPRO 57 metyrosine ...... 38 naproxen ...... 30 noreth-ethinyl estradiol-iron . 63 mexiletine ...... 35 NARCAN ...... 30 norethindrone (contraceptive) MIACALCIN ...... 53 NATACYN ...... 63 ...... 61 mibelas 24 fe ...... 62 NATPARA ...... 53 norethindrone acetate ...... 61 micafungin ...... 1 NAYZILAM ...... 23 norethindrone ac-eth estradiol microgestin 1.5/30 (21) ...... 62 NEBUPENT ...... 8 ...... 61, 63 microgestin 1/20 (21) ...... 62 NEEDLES, INSULIN norethindrone-e.estradiol-iron microgestin fe 1.5/30 (28) .... 62 DISP.,SAFETY ...... 52 ...... 63 microgestin fe 1/20 (28) ...... 62 nefazodone ...... 33 norgestimate-ethinyl estradiol midodrine ...... 47 neomycin ...... 8 ...... 63 mili ...... 63 neomycin-bacitracin-poly-hc 64 norlyda ...... 61 milrinone ...... 42 neomycin-bacitracin- NORMOSOL-R ...... 69 milrinone in 5 % dextrose .... 42 polymyxin ...... 63 NORMOSOL-R PH 7.4 ...... 70 minocycline ...... 11 NORTHERA ...... 47

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 78 nortriptyline ...... 33 ORENCIA (WITH PENTASA ...... 56 NORVIR ...... 4 MALTOSE) ...... 60 pentoxifylline ...... 40 NOVOLOG FLEXPEN U-100 ORENCIA CLICKJECT ...... 60 PERFOROMIST ...... 67 INSULIN ...... 52 ORFADIN ...... 47 periogard ...... 48 NOVOLOG MIX 70-30 U-100 ORKAMBI ...... 67 PERJETA ...... 19 INSULN ...... 52 oseltamivir ...... 4 permethrin ...... 47 NOVOLOG MIX 70- osmitrol 15 % ...... 38 perphenazine ...... 34 30FLEXPEN U-100 ...... 52 osmitrol 20 % ...... 38 PERSERIS ...... 34 NOVOLOG PENFILL U-100 oxaliplatin ...... 18, 19 pfizerpen-g ...... 10 INSULIN ...... 52 oxandrolone ...... 53 phenelzine ...... 34 NOVOLOG U-100 INSULIN oxaprozin ...... 30 phenobarbital ...... 23 ASPART ...... 52 oxcarbazepine ...... 23 phenobarbital sodium ...... 23 NOXAFIL ...... 1 OXERVATE ...... 64 phentolamine ...... 38 NPLATE ...... 40 oxybutynin chloride ...... 68 phenytoin ...... 24 NUBEQA ...... 18 oxycodone ...... 29 phenytoin sodium ...... 24 NUEDEXTA ...... 26 oxycodone-acetaminophen ... 29 phenytoin sodium extended .. 24 NULOJIX ...... 18 oxycodone-aspirin ...... 29 PHESGO ...... 19 NUPLAZID ...... 34 oxymorphone ...... 29 PHOSPHOLINE IODIDE .... 64 nyamyc ...... 45 OZURDEX ...... 65 PIFELTRO ...... 4 nystatin ...... 1, 45 P pilocarpine hcl ...... 47, 64 nystatin-triamcinolone ...... 45 pacerone ...... 36 pimozide ...... 34 nystop ...... 45 paclitaxel ...... 19 pindolol ...... 38 O PADCEV ...... 19 pioglitazone ...... 52 OCALIVA ...... 56 paliperidone ...... 34 piperacillin-tazobactam ...... 10 ocella ...... 63 palonosetron ...... 56 PIPERACILLIN- OCREVUS ...... 26 PALYNZIQ ...... 53 TAZOBACTAM ...... 10 octreotide acetate ...... 18 PANRETIN ...... 43 PIQRAY ...... 19 ODEFSEY ...... 4 pantoprazole ...... 57 plenamine ...... 70 ODOMZO ...... 18 paricalcitol ...... 53 PLENVU ...... 56 OFEV ...... 67 paroex oral rinse ...... 48 podofilox ...... 43 ofloxacin ...... 49 paromomycin ...... 8 POLIVY ...... 19 olanzapine...... 34 paroxetine hcl ...... 34 polycin ...... 63 olmesartan ...... 38 PASER ...... 8 polyethylene glycol 3350 ..... 56 olmesartan- PAXIL ...... 34 polymyxin b sulf-trimethoprim hydrochlorothiazide ...... 38 PEDIARIX (PF) ...... 58 ...... 63 omeprazole ...... 57 PEDVAX HIB (PF) ...... 58 POMALYST ...... 19 ONCASPAR ...... 18 peg 3350-electrolytes ...... 56 PORTRAZZA ...... 19 ondansetron ...... 56 PEGASYS ...... 57 posaconazole ...... 1 ondansetron hcl ...... 56 peg-electrolyte ...... 56 potassium acetate ...... 69 ondansetron hcl (pf) ...... 56 PEGINTRON ...... 57 potassium chlorid-d5- ONIVYDE ...... 18 PEMAZYRE ...... 19 0.45%nacl ...... 69 ONUREG ...... 18 penicillamine ...... 61 potassium chloride ...... 69, 70 OPDIVO ...... 18 penicillin g potassium ...... 10 potassium chloride in 0.9%nacl opium tincture ...... 55 penicillin g procaine ...... 10 ...... 69 OPSUMIT ...... 67 penicillin g sodium ...... 10 potassium chloride in 5 % dex oralone ...... 48 penicillin v potassium ...... 10 ...... 69 ORENCIA ...... 60, 61 PENTACEL (PF) ...... 58, 59 potassium chloride in lr-d5 ... 69 pentamidine ...... 8 potassium chloride in water .. 69

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 79 potassium chloride-0.45 % nacl proctozone-hc ...... 56 REPATHA PUSHTRONEX 41 ...... 70 PROGRAF ...... 19 REPATHA SURECLICK .... 41 potassium chloride-d5- PROLASTIN-C ...... 47 RESTASIS ...... 64 0.2%nacl ...... 70 PROLEUKIN ...... 58 RESTASIS MULTIDOSE .... 64 potassium chloride-d5- PROLIA ...... 60 RETEVMO ...... 19 0.9%nacl ...... 70 PROMACTA ...... 40 RETROVIR ...... 4 potassium citrate ...... 68 promethazine ...... 65 REVCOVI ...... 47 potassium phosphate m-/d- propafenone ...... 36 REVLIMID ...... 19 basic ...... 70 propranolol ...... 38 revonto ...... 27 POTELIGEO ...... 19 propranolol-hydrochlorothiazid REXULTI ...... 34 PRADAXA ...... 40 ...... 38 REYATAZ ...... 4 pramipexole ...... 25 propylthiouracil ...... 50 ribavirin ...... 4 prasugrel ...... 40 PROQUAD (PF) ...... 59 rifabutin ...... 9 pravastatin ...... 41 protriptyline ...... 34 rifampin ...... 9 praziquantel ...... 8 PULMOZYME ...... 67 riluzole ...... 47 prazosin ...... 38 PURIXAN ...... 19 rimantadine ...... 4 prednicarbate ...... 46 pyrazinamide ...... 8 ringer's ...... 70 prednisolone ...... 49 pyridostigmine bromide ...... 27 RINVOQ ...... 61 prednisolone acetate ...... 65 pyrimethamine ...... 8 RISPERDAL CONSTA ...... 34 prednisolone sodium phosphate Q risperidone ...... 34 ...... 49, 65 QINLOCK ...... 19 ritonavir ...... 4 prednisone ...... 49 QUADRACEL (PF) ...... 59 RITUXAN ...... 19 prednisone intensol ...... 49 quetiapine ...... 34 RITUXAN HYCELA ...... 19 pregabalin ...... 24 quinapril ...... 38 rivastigmine ...... 26 PREMARIN ...... 61 quinapril-hydrochlorothiazide rivastigmine tartrate ...... 26 premasol 10 % ...... 70 ...... 38 rivelsa ...... 63 prenatal vitamin oral tablet ... 70 quinidine sulfate ...... 36 rizatriptan ...... 25 prevalite ...... 41 quinine sulfate ...... 9 ROMIDEPSIN ...... 19 previfem ...... 63 R ropinirole ...... 25 PREVYMIS ...... 4 RABAVERT (PF) ...... 59 rosadan ...... 44 PREZCOBIX ...... 4 RADICAVA ...... 26 rosuvastatin ...... 41 PREZISTA ...... 4 RAGWITEK ...... 59 ROTARIX ...... 59 PRIFTIN ...... 8 raloxifene ...... 60 ROTATEQ VACCINE ...... 59 PRILOSEC ...... 57 ramelteon ...... 34 roweepra ...... 24 PRIMAQUINE ...... 8 ramipril ...... 38 ROZLYTREK ...... 19 primidone ...... 24 ranolazine ...... 42 RUBRACA ...... 19 PRIVIGEN ...... 59 rasagiline ...... 25 rufinamide ...... 24 PROAIR RESPICLICK ...... 67 RAVICTI ...... 47 RUKOBIA ...... 4 probenecid ...... 59 RECOMBIVAX HB (PF) .... 59 RYDAPT ...... 19 probenecid-colchicine ...... 59 RECTIV ...... 56 RYTARY ...... 25 prochlorperazine ...... 56 regonol ...... 27 S prochlorperazine edisylate .... 56 REGRANEX ...... 44 salsalate ...... 30 prochlorperazine maleate oral RELENZA DISKHALER ...... 4 SAMSCA ...... 53 ...... 56 RELISTOR ...... 56 SANDIMMUNE ...... 19 PROCRIT ...... 57 REMICADE ...... 56 SANTYL ...... 44 procto-med hc ...... 56 RENACIDIN ...... 68 SAPHRIS ...... 34 procto-pak...... 56 repaglinide ...... 52 sapropterin ...... 53 proctosol hc 56 REPATHA ...... 41 SARCLISA ...... 19

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 80 scopolamine base...... 56 spironolacton-hydrochlorothiaz T SECUADO ...... 34 ...... 38 TABLOID ...... 20 selegiline hcl ...... 25 sprintec (28) ...... 63 TABRECTA ...... 20 selenium sulfide ...... 42 SPRITAM ...... 24 tacrolimus ...... 20, 44 SELZENTRY ...... 4 SPRYCEL ...... 20 tadalafil (pulm. hypertension) SEREVENT DISKUS ...... 67 sps (with sorbitol) ...... 48 ...... 67 sertraline ...... 34, 35 ssd ...... 44 TAFINLAR ...... 20 setlakin ...... 63 STAMARIL (PF) ...... 59 TAGRISSO ...... 20 sevelamer carbonate ...... 48 stavudine ...... 4 TALTZ AUTOINJECTOR .. 43 sf 48 STELARA ...... 42, 43 TALTZ AUTOINJECTOR (2 sf 5000 plus ...... 48 STIVARGA ...... 20 PACK) ...... 43 SHINGRIX (PF) ...... 59 STRENSIQ ...... 54 TALTZ AUTOINJECTOR (3 SIGNIFOR ...... 19 STREPTOMYCIN ...... 9 PACK) ...... 43 sildenafil (pulmonary arterial STRIBILD ...... 4 TALTZ SYRINGE ...... 43 hypertension) ...... 67 SUBOXONE ...... 30 TALZENNA ...... 20 silver sulfadiazine ...... 44 subvenite ...... 24 tamoxifen ...... 20 simliya (28) ...... 63 subvenite starter (blue) kit .... 24 tamsulosin ...... 68 SIMULECT ...... 19 subvenite starter (green) kit .. 24 TARGRETIN ...... 20 simvastatin ...... 41 subvenite starter (orange) kit 24 tarina 24 fe ...... 63 sirolimus ...... 19 SUCRAID ...... 56 TASIGNA ...... 20 SIRTURO ...... 9 sucralfate ...... 57 tazarotene ...... 44 SKYRIZI ...... 42 sulfacetamide sodium ...... 64 tazicef ...... 6 sodium acetate ...... 70 sulfacetamide sodium (acne) 44 TAZORAC ...... 44 sodium bicarbonate ...... 70 sulfadiazine ...... 11 TAZVERIK ...... 20 sodium chloride ...... 48, 70 sulfamethoxazole-trimethoprim TDVAX ...... 59 sodium chloride 0.45 % ...... 70 ...... 11 TECENTRIQ ...... 20 sodium chloride 0.9 % ...... 48 SULFAMYLON ...... 44 TECFIDERA ...... 26 sodium chloride 3 % ...... 70 sulfasalazine ...... 56 TEFLARO ...... 6 sodium chloride 5 % ...... 70 sulindac ...... 30 telmisartan ...... 38 sodium fluoride 5000 plus .... 48 sumatriptan ...... 25 TEMIXYS ...... 4 sodium phosphate ...... 70 sumatriptan succinate ...... 25 TEMODAR ...... 20 sodium polystyrene (sorb free) SUPRAX ...... 6 temsirolimus ...... 20 ...... 48 SUTENT ...... 20 TENIVAC (PF) ...... 59 sodium polystyrene sulfonate syeda ...... 63 tenofovir disoproxil fumarate . 4 ...... 48 SYLVANT ...... 20 terazosin ...... 38 solifenacin ...... 68 SYMDEKO ...... 67 terbinafine hcl ...... 1 SOLIQUA 100/33 ...... 52 SYMFI ...... 4 terbutaline ...... 67 SOLIRIS ...... 48 SYMFI LO ...... 4 terconazole ...... 61 SOLTAMOX ...... 19 SYMLINPEN 120 ...... 52 TERIPARATIDE ...... 60 SOLU-CORTEF ACT-O- SYMLINPEN 60 ...... 52 testosterone ...... 54 VIAL (PF) ...... 50 SYMPAZAN ...... 24 testosterone cypionate ...... 54 SOMATULINE DEPOT ...... 20 SYMTUZA ...... 4 testosterone enanthate ...... 54 SOMAVERT ...... 54 SYNAGIS ...... 4 TETANUS,DIPHTHERIA sorine ...... 36 SYNAREL ...... 54 TOX PED(PF) ...... 59 sotalol ...... 36 SYNERCID ...... 9 tetrabenazine ...... 26 sotalol af ...... 36 SYNJARDY ...... 52 tetracycline ...... 11 SOTYLIZE ...... 36 SYNJARDY XR ...... 52 THALOMID ...... 20 spironolactone ...... 38 SYNRIBO ...... 20 theophylline ...... 67

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 81 thioridazine ...... 35 trifluoperazine ...... 35 valproic acid (as sodium salt) thiotepa ...... 20 trifluridine ...... 63 ...... 24 thiothixene ...... 35 TRIKAFTA ...... 67 valrubicin ...... 21 tiagabine ...... 24 tri-lo-mili ...... 63 valsartan ...... 38 TIBSOVO ...... 20 tri-lo-sprintec ...... 63 valsartan-hydrochlorothiazide TICE BCG ...... 59 trilyte with flavor packets ..... 56 ...... 38 tigecycline ...... 9 trimethoprim ...... 11 VALSTAR ...... 21 timolol maleate ...... 38, 64 tri-mili ...... 63 VALTOCO ...... 24 TIVICAY ...... 4, 5 trimipramine ...... 35 vancomycin ...... 9 TIVICAY PD ...... 5 TRINTELLIX ...... 35 VANCOMYCIN ...... 9 tizanidine ...... 27 TRISENOX ...... 21 VANCOMYCIN IN 0.9 % tobramycin ...... 63 tri-sprintec (28) ...... 63 SODIUM CHL ...... 9 tobramycin in 0.225 % nacl .... 9 TRIUMEQ ...... 5 vandazole ...... 61 tobramycin sulfate ...... 9 tri-vylibra ...... 63 VANTAS ...... 21 tobramycin-dexamethasone .. 65 tri-vylibra lo ...... 63 VAQTA (PF) ...... 59 tolterodine...... 68 TRODELVY ...... 21 VARIVAX (PF) ...... 59 tolvaptan ...... 54 TROGARZO ...... 5 VARIZIG ...... 59 topiramate ...... 24 TROPHAMINE 10 % ...... 70 VASCEPA ...... 41 toposar ...... 20 TRULICITY ...... 52 VECTIBIX ...... 21 topotecan ...... 20 TRUMENBA ...... 59 VELCADE ...... 21 toremifene ...... 20 TRUVADA ...... 5 VELTASSA ...... 48 torsemide ...... 38 TUKYSA ...... 21 VEMLIDY ...... 5 TOUJEO MAX U-300 tulana ...... 61 VENCLEXTA ...... 21 SOLOSTAR ...... 52 TURALIO ...... 21 VENCLEXTA STARTING TOUJEO SOLOSTAR U-300 TWINRIX (PF) ...... 59 PACK ...... 21 INSULIN ...... 52 tydemy ...... 63 venlafaxine ...... 35 TRADJENTA ...... 52 TYKERB ...... 21 verapamil ...... 38, 39 tramadol ...... 30 TYMLOS ...... 60 VERSACLOZ ...... 35 TRAMADOL ...... 30 TYPHIM VI ...... 59 VERZENIO ...... 21 tranexamic acid ...... 61 TYSABRI ...... 26 vienva ...... 63 tranylcypromine ...... 35 TYVASO ...... 67 vigabatrin ...... 24 travasol 10 % ...... 70 TYVASO INSTITUTIONAL vigadrone ...... 24 travoprost ...... 64 START KIT ...... 68 VIIBRYD ...... 35 trazodone ...... 35 TYVASO REFILL KIT ...... 68 VIMIZIM ...... 54 TREANDA ...... 20 TYVASO STARTER KIT ... 68 VIMPAT ...... 24 TRECATOR ...... 9 U vinblastine ...... 21 TRELEGY ELLIPTA ...... 67 unithroid ...... 54 vincasar pfs ...... 21 TRELSTAR ...... 20 UNITUXIN ...... 21 vincristine ...... 21 treprostinil sodium ...... 38 UPTRAVI ...... 38 vinorelbine ...... 21 tretinoin (antineoplastic) ...... 20 ursodiol ...... 56 VIOKACE ...... 56 tretinoin topical ...... 44 UVADEX ...... 44 VIRACEPT ...... 5 triamcinolone acetonide 46, 48, V VIREAD ...... 5 50 valacyclovir ...... 5 VISTOGARD ...... 11 triamterene ...... 38 VALCHLOR ...... 44 VITRAKVI ...... 21 triamterene-hydrochlorothiazid valganciclovir ...... 5 VIVITROL ...... 30 ...... 38 valproate sodium ...... 24 VIZIMPRO ...... 21 triderm ...... 46 valproic acid ...... 24 voriconazole ...... 1 trientine...... 48 VOTRIENT ...... 21

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 82 VRAYLAR ...... 35 XPOVIO ...... 21 ZIRABEV ...... 22 vylibra...... 63 XTANDI ...... 21 ZIRGAN ...... 63 VYNDAMAX ...... 42 XURIDEN ...... 48 ZOLADEX ...... 22 VYXEOS ...... 21 XYREM ...... 35 zoledronic acid ...... 54 W Y zoledronic acid-mannitol-water warfarin ...... 40 YERVOY ...... 21 ...... 48, 54 X YF-VAX (PF) ...... 59 ZOLEDRONIC AC- XALKORI ...... 21 YONDELIS ...... 21 MANNITOL-0.9NACL .... 54 XATMEP ...... 21 yuvafem ...... 61 ZOLINZA ...... 22 XCOPRI ...... 24 Z zolpidem ...... 35 XCOPRI MAINTENANCE zafirlukast ...... 68 zonisamide ...... 24 PACK ...... 24 ZALTRAP ...... 21 ZORTRESS ...... 22 XCOPRI TITRATION PACK ZANOSAR ...... 21 ZOSTAVAX (PF) ...... 59 ...... 24 zarah ...... 63 ZTLIDO ...... 44 XERMELO ...... 21 ZEJULA ...... 22 zumandimine (28) ...... 63 XGEVA ...... 12 ZELBORAF ...... 22 ZYDELIG ...... 22 XIAFLEX ...... 48 ZEPZELCA ...... 22 ZYKADIA ...... 22 XIFAXAN ...... 9 zidovudine ...... 5 ZYPREXA RELPREVV ...... 35 XOLAIR ...... 68 ziprasidone hcl ...... 35 XOSPATA ...... 21 ziprasidone mesylate ...... 35

You can find information on what the symbols and abbreviations on this table mean by going to page v. This drug list was updated in March 2021. 83 This formulary was updated on 3/1/2021. For more recent information or other questions, please contact Mutual of Omaha Rx Customer Service at 1.855.864.6797 or, for TTY u sers, 1.800.716.3231, 24 hours a day, 7 days a week, or visit MutualofOmahaRx.com.

Express Scripts is the pharmacy benefit manager for Mutual of Omaha Rx and will be providing some services on behalf of Mutual of Omaha Rx.

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This drug list was updated in March 2021