2020 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

Please read: This document contains information about all of the drugs we cover in this plan.

Plan covered Cigna-HealthSpring Achieve Plus (HMO C-SNP)

This drug list was updated in December 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. HPMS Approved Formulary File Submission ID 20090, Version Number 19 INT_20_76977_C_Final_6o

Note to existing customers: This drug list 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 Cigna. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Achieve Plus (HMO SNP).

This document includes a list of the drugs (formulary) for our plans, which is current as of December 2020. For an updated drug list, 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 benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2021, and from time to time during the year.

What is the Cigna Comprehensive Drug List? you can also find information in the section entitled “How do A drug list is a list of covered drugs selected by Cigna in I request an exception to the Cigna Drug List?” consultation with a team of health care providers, which • Drugs removed from the market. If the Food and Drug represents the prescription therapies believed to be a necessary Administration (FDA) deems a drug on our drug list to be part of a quality treatment program. Cigna will generally unsafe or the drug’s manufacturer removes the drug from the cover the drugs listed in our drug list as long as the drug market, we will immediately remove the drug from our drug is medically necessary, the prescription is filled at a Cigna list and provide notice to customers who take the drug. network pharmacy, and other plan rules are followed. For more • Other changes. We may make other changes that affect information on how to fill your prescriptions, please review your customers currently taking a drug. For instance, we may Evidence of Coverage. add a that is not new to the market to replace Can the Drug List (formulary) change? a brand name drug currently on the drug list or add new Most changes in drug coverage happen on January 1, but we restrictions to the brand name drug or move it to a different may add or remove drugs on the drug list during the year, move cost-sharing tier.). Or we may make changes based on new them to different cost-sharing tiers, or add new restrictions. We clinical guidelines and/or studies. If we remove drugs from our must follow Medicare rules in making these changes. drug list, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost- Changes that can affect you this year. In the below cases, sharing tier, we must notify affected customers of the change you will be affected by coverage changes during the year: at least 30 days before the change becomes effective, or at • New generic drugs. We may immediately remove a brand the time the customer requests a refill of the drug, at which name drug on our drug list if we are replacing it with a new time the customer will receive a 30-day supply of the drug. generic drug that will appear on the same or lower cost- ––If we make these other changes, you or your prescriber sharing tier and with the same or fewer restrictions. Also, can ask us to make an exception and continue to cover the when adding the new generic drug, we may decide to keep brand name drug for you. The notice we provide you will the brand name drug on our drug list, but immediately move also include information on how to request an exception, it to a different cost-sharing tier or add new restrictions. If you and you can also find information in the section below are currently taking that brand name drug, we may not tell entitled “How do I request an exception to the Cigna’s you in advance before we make that change, but we will later Drug List?” provide you with information about the specific change(s) we have made. Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug on our 2020 drug ––If we make such a change, you or your prescriber can ask list that was covered at the beginning of the year, we will not us to make an exception and continue to cover the brand discontinue or reduce coverage of the drug during the 2020 name drug for you. The notice we provide you will also coverage year except as described above. This means these include information on how to request an exception, and drugs will remain available at the same cost-sharing and with

1 no new restrictions for those customers taking them for the • Quantity Limits: For certain drugs, Cigna limits the amount remainder of the coverage year. of the drug that Cigna will cover. For example, Cigna allows The enclosed drug list is current as of December 2020. To get for 1 tablet per day for candesartan 32mg. This applies to a updated information about the drugs covered by Cigna, please standard one-month supply (for total quantity of 30 per contact us. Our contact information appears on the front and 30 days) or three-month supply (for total quantity of 90 back cover pages. If there are significant changes made to the per 90 days). printed drug list within the covered year, you may be notified by • Step Therapy: In some cases, Cigna requires you to first try mail identifying the changes. Drug lists located on our website certain drugs to treat your medical condition before we will are reviewed and updated on a monthly basis. cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Cigna may not How do I use the Drug List? cover Drug B unless you try Drug A first. If Drug A does not There are two ways to find your drug within the drug list: work for you, Cigna will then cover Drug B. Medical Condition • Non-Extended Days Supply: For certain drugs, Cigna limits The drug list begins on page 7 The drugs in this drug list are the amount of the drug that Cigna will cover to only a 30-day grouped into categories depending on the type of medical supply or less, at one time. For example, customers who conditions that they are used to treat. For example, drugs have not had any recent fill of opioid pain medications within used to treat a heart condition are listed under the category, the past 120 days (referred to as “opioid naïve”) are limited “CARDIOVASCULAR, HYPERTENSION / LIPIDS”. If you know to a maximum of 7 days’ supply of opioid pain medication. what your drug is used for, look for the category name in the list Customers who have received a recent fill of an opioid pain that begins on page 7. Then look under the category name for medication (not opioid naïve) are limited to up to a month’s your drug. supply of that medication at one time. Other high cost drugs Covered Drug Index may be subject to a non-extended day supply restriction, If you are not sure what category to look under, you should look as well. for your drug in the Covered Drugs Index that begins on page You can find out if your drug has any additional requirements 58. The Covered Drugs Index provides an alphabetical list of all or limits by looking in the drug list that begins on page 7. You of the drugs included in this document. Both brand name drugs can also get more information about the restrictions applied to and generic drugs are listed in the Index. Look in the Index and specific covered drugs by visiting our website. We have posted find your drug. Next to your drug, you will see the page number online documents that explain our prior authorization and step where you can find coverage information. Turn to the page therapy restrictions. You may also ask us to send you a copy. listed in the Covered Drug Index and find the name of your drug Our contact information, along with the date we last updated the in the drug name column of the list. drug list, appears on the front and back cover pages. What are generic drugs? You can ask Cigna to make an exception to these restrictions Cigna covers both brand name drugs and generic drugs. A or limits or for a list of other, similar drugs that may treat generic drug is approved by the FDA as having the same active your health condition. See the section, “How do I request an ingredient as the brand name drug. Generally, generic drugs exception to the Cigna drug list?” on page 3 for information cost less than brand name drugs. about how to request an exception. Are there any restrictions on my coverage? Options for Maintenance Medications Some covered drugs may have additional requirements or limits Taking the medications prescribed by your doctor (or other on coverage. These requirements and limits may include: prescriber) is important to your health. We are committed to helping you control your chronic conditions • Prior Authorization: Cigna requires you or your doctor to by making it easy for you to receive your maintenance get prior authorization for certain drugs. This means that you medications. There are several ways we can work together will need to get approval from Cigna before you fill these to accomplish this goal: prescriptions. If you don’t get approval, Cigna may not cover the drug. • Talk with your doctor about whether a 90-day supply of your ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for

2 your overall health, and getting 90-day prescriptions of these amount of the drug that we will cover. If your drug has a medications can help ensure that you do not miss a dose. quantity limit, you can ask us to waive the limit and cover a • You can receive a 90-day supply at most retail pharmacies or greater amount. through one of our mail-order pharmacies. • You can ask us to provide a tiering exception for a higher • Talk to your pharmacist if you are experiencing any new cost-sharing drug to be covered at a lower cost-sharing tier challenges with your maintenance medications. under following circumstances: ––If the drug you’re taking is a brand name drug you can How can I use my prescription drug coverage to save ask us to cover your drug at the cost-sharing amount money on my medications? that applies to the lowest tier that contains brand name There may be opportunities for you to save money on your alternatives for treating your condition. medications using your Cigna coverage. ––If the drug you’re taking is a generic drug you can ask us • Ask your doctor (or other prescriber) if there are any lower- to cover your drug at the cost-sharing amount that applies cost generic alternatives available for any of your current to the lowest tier that contains either brand or generic medications. alternatives for treating your condition. • Some plans may offer a $0 copay for Tier 1 and 2 generic ––If the drug you’re taking is a biological product you can drugs filled at a preferred retail and/or mail-order pharmacies. ask us to cover your drug at the cost-sharing amount that Check the Drug Tier and Cost-share Tables on page 5 to see applies to the lowest tier that contains biological product if your plan offers these savings. alternatives for treating your condition. • Explore whether the ‘CMS Extra Help’ program may offer These exceptions would lower the amount you must pay for additional financial support for your medications. your drug. • If your medication is not covered in the Cigna drug list, talk Please note, if we grant your request to cover a drug that is with your doctor about alternative medications which are not in our drug list, you may not ask us to provide a higher covered in the drug list. level of coverage for the drug. Also, you may not ask us to What if my drug is not on the Drug List? provide a higher level of coverage for drugs that are in the Specialty tier. If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If Generally, Cigna will only approve your request for an exception you learn that Cigna does not cover your drug, you have if the alternative drugs included in our drug list, the lower cost- two options: sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to • You can ask Customer Service for a list of similar drugs that have adverse medical effects. are covered by Cigna. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that You should contact us to ask us for an initial coverage decision is covered by Cigna. for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction • You can ask Cigna to make an exception and cover your exception you should submit a statement from your drug. See the next section for information about how to prescriber or doctor supporting your request. Generally, request an exception. we must make our decision within 72 hours of getting your How do I request an exception to the Cigna Drug List? prescriber’s supporting statement. You can request an You can ask Cigna to make an exception to our coverage rules. expedited (fast) exception if you or your doctor believe that your There are several types of exceptions that you can ask us health could be seriously harmed by waiting up to 72 hours for to make. 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 • You can ask us to cover a drug even if it is not on our drug statement from your doctor or other prescriber. list. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to What do I do before I can talk to my doctor about changing provide the drug at a lower cost-sharing level. my drugs or requesting an exception? • You can ask us to waive coverage restrictions or limits on As a new or existing customer in our plan you may be taking your drug. For example, for certain drugs, Cigna limits the drugs that are not on our drug list. Or, you may be taking a drug 3 that is on our drug list but your ability to get it is limited. For The first column of the chart lists the drug name. Brand name example, you may need a prior authorization from us before drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic you can fill your prescription. You should talk to your doctor drugs are listed in lower-case italics (e.g., candesartan). to decide if you should switch to an appropriate drug that we The information in the Requirements/Limits column tells you if cover or request a drug list exception so that we will cover the Cigna has any special requirements for coverage of your drug. drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug up to a This plan offers additional prescription drug coverage in the 30-day supply, in certain cases during the first 90 days you are coverage gap. Please refer to your Evidence of Coverage to a customer of our plan. see this coverage and for more information. For each of your drugs that is not on our drug list or if your We provide quantity limits on certain drugs which are indicated ability to get your drugs is limited, we will cover a temporary with a QL in the Covered Drugs by Category list on page 7 30-day supply. If your prescription is written for fewer days, along with the amount dispensed per the days supplied. (For we’ll allow refills to provide up to a maximum 30-day supply of example: candesartan 32mg QL 30/30; this means the drug medication. After your first 30-day supply, we will not pay for candesartan 32mg is limited to 30 tablets per 30 days. For 90- these drugs without a drug list exception, even if you have been day supplies, this quantity limit would be expanded to 90 tablets a customer of the plan less than 90 days. per 90 days). If you are a resident of a long-term care facility and you need a What is a preferred network pharmacy? drug that is not on our drug list or if your ability to get your drugs If your plan has preferred network pharmacies, you will typically is limited, but you are past the first 90 days of membership in save money by using these pharmacies. Your prescription our plan, we will cover a 31-day emergency supply of that drug drug costs (like a copay or coinsurance) will typically be less while you pursue a drug list exception. at a preferred network pharmacy because it has a preferred In order to accommodate unexpected transitions of our agreement with your plan. If you need help finding a network customers that do not leave time for advanced planning, such pharmacy, please call Customer Service at 1-800-627-7534 as level-of-care changes due to discharge from a hospital to a (TTY 711), or you can visit www.CignaMedicare.com for the nursing facility or to a home, Cigna will allow a one-time 31-day most current Pharmacy Directory. supply (unless the prescription is written for fewer days). Cigna’s Drug List The comprehensive drug list that begins on page 7, provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 58.

For more information For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, 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.

4 Drug Tier and Cost-Share Table medications may be in Tier 3, Tier 4, Tier 5 or Tier 6. Keep in The following table represents the plan name, plan service mind that the name “Tier 3: Preferred Brand Drugs” is just a area, the drug tier number as it appears on the drug list, and the description of the majority of the drugs in the tier. It does not cost-share amount for that tier number. Tier 1 is for Preferred mean that there are only brand drugs in that tier. Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred For customers receiving Extra Help: Your Low Income Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Subsidy (LIS) copay level will be based on how the Food Specialty tier drugs. Tier 6 is for Cigna-HealthSpring Achieve and Drug Administration (FDA) classifies certain drugs. Due Plus (HMO SNP) plans only and is referred to as Select Diabetic to this, a generic drug may receive a preferred brand copay, Drugs. Please refer to the following chart. You may also refer to or a preferred brand drug may receive a generic drug copay. your Evidence of Coverage document for additional details. Please see your LIS Rider for additional information on these Cigna is not always able to keep all generic medications in the copay levels. Or call Customer Service for further clarification Preferred Generic and Generic drug tiers, and some generic regarding a specific drug.

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll. Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit www.CignaMedicare.com to search for a preferred retail or mail-order pharmacy near you.

Service Area: Arizona H0354-027 – Cigna-HealthSpring Achieve Plus (HMO C-SNP): Maricopa and Pinal (Apache Junction and Queen Creek: 85117, 85118, 85119, 85120, 85140, 85143, 85178, 85220), Arizona Preferred Retail Standard Retail Preferred Mail-Order Standard Mail-Order Cost-Sharing Cost-Sharing Cost-Sharing Cost-Sharing Drug Tier 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days Tier 1: Preferred Generic Drugs (GC) $0 / $0 / $0 $5 / $10 / $15 $0 / $0 / $0 $5 / $10 / $15 Tier 2: Generic Drugs (GC) $0 / $0 / $0 $13 / $26 / $39 $0 / $0 / $0 $13 / $26 / $39 Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $126 $47 / $94 / $141 Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $95 / $190 / $285 $100 / $200 / $300 Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days) Tier 6: Select Diabetic Drugs $9 / $18 / $18 $11 / $22 / $33 $9 / $18 / $18 $11 / $22 / $33

GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

5 My Medications In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711.

Page Number in My Medications Cost-Share through Cigna the Drug List

Drug List Key: B/D – This prescription drug has a Part B versus D NDS – Non-extended day supply medication. This drug administrative prior authorization requirement. This drug is only available as a 30-day supply or less. may be covered under Medicare Part B or D depending PA – This drug requires prior authorization on circumstances. QL – This drug has quantity limits ED – Excluded Drug ST – This drug has step therapy requirements GC – We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to Generally all medications in the drug list are available our Evidence of Coverage for more information about through mail-order, except when special circumstances this coverage. or situations prohibit mailing a particular medication to your home. HI (Home Infusion) – This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. - 8 p.m. local time. TTY users should call 711.

6 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS

ANTI - INFECTIVES abacavir oral tablet 4 QL (60/30) abacavir-lamivudine 3 QL (30/30) ANTIFUNGAL AGENTS abacavir-lamivudine-zidovudine 5 QL (60/30); NDS ABELCET 5 PA; NDS acyclovir oral capsule 2 AMBISOME 5 PA; NDS acyclovir oral suspension 200 4 amphotericin b 4 PA mg/5 ml caspofungin 5 PA; HI; NDS acyclovir oral tablet 2 clotrimazole mucous 2 acyclovir sodium intravenous 4 B/D PA membrane solution CRESEMBA ORAL 5 NDS adefovir 5 QL (30/30); NDS fluconazole 2 amantadine hcl 3 fluconazole in nacl (iso-osm) 4 HI APTIVUS 5 QL (120/30); NDS intravenous piggyback 200 mg/100 ml, 400 mg/200 ml APTIVUS (WITH VITAMIN E) 5 QL (285/28); NDS flucytosine 5 NDS atazanavir oral capsule 150 mg 4 QL (30/30) griseofulvin microsize 4 atazanavir oral capsule 200 mg 5 QL (60/30); NDS griseofulvin ultramicrosize 4 atazanavir oral capsule 300 mg 5 QL (30/30); NDS itraconazole oral capsule 4 PA; QL (120/30) ATRIPLA 5 QL (30/30); NDS itraconazole oral solution 5 PA; NDS BARACLUDE ORAL 4 QL (630/30) SOLUTION ketoconazole oral 2 BIKTARVY 5 QL (30/30); NDS micafungin 5 HI; NDS CIMDUO 5 QL (30/30); NDS MYCAMINE 5 HI; NDS COMPLERA 5 QL (30/30); NDS NOXAFIL ORAL SUSPENSION 5 PA; QL (600/30); NDS CRIXIVAN ORAL CAPSULE 4 QL (270/30) 200 MG NOXAFIL ORAL TABLET, 5 PA; QL (96/30); DELAYED RELEASE (DR/EC) NDS CRIXIVAN ORAL CAPSULE 4 QL (180/30) 400 MG nystatin oral suspension 2 DELSTRIGO 5 QL (30/30); NDS nystatin oral tablet 2 DESCOVY 5 QL (30/30); NDS POSACONAZOLE ORAL 5 PA; QL (96/30); TABLET,DELAYED RELEASE NDS didanosine oral 4 QL (30/30) (DR/EC) capsule,delayed release(dr/ec) 250 mg, 400 mg terbinafine hcl oral 2 DOVATO 5 QL (30/30); NDS voriconazole intravenous 5 PA; HI; NDS EDURANT 5 QL (30/30); NDS voriconazole oral suspension 5 PA; QL (300/30); for reconstitution NDS efavirenz oral capsule 200 mg 3 QL (120/30) voriconazole oral tablet 4 PA efavirenz oral capsule 50 mg 3 QL (180/30) ANTIVIRALS efavirenz oral tablet 5 QL (30/30); NDS abacavir oral solution 3 QL (960/30) efavirenz-lamivu-tenofov disop 5 QL (30/30); NDS emtricitabine 3 QL (30/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

7 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS EMTRIVA ORAL CAPSULE 3 QL (30/30) lamivudine oral tablet 100 mg, 3 QL (30/30) EMTRIVA ORAL SOLUTION 3 QL (680/28) 300 mg entecavir 4 QL (30/30) lamivudine oral tablet 150 mg 3 QL (60/30) EPCLUSA ORAL TABLET 200- 5 PA; NDS lamivudine-zidovudine 3 QL (60/30) 50 MG LEXIVA ORAL SUSPENSION 4 QL (1575/28) EPCLUSA ORAL TABLET 400- 5 PA; QL (28/28); lopinavir-ritonavir 3 QL (480/30) 100 MG NDS MAVYRET 5 PA; QL (84/28); EPIVIR HBV ORAL SOLUTION 4 NDS EVOTAZ 5 QL (30/30); NDS nevirapine oral suspension 3 QL (1200/30) famciclovir 3 QL (60/30) nevirapine oral tablet 3 QL (60/30) fosamprenavir 5 QL (120/30); NDS nevirapine oral tablet extended 3 QL (90/30) FUZEON SUBCUTANEOUS 5 QL (60/30); NDS release 24 hr 100 mg RECON SOLN nevirapine oral tablet extended 3 QL (30/30) GENVOYA 5 QL (30/30); NDS release 24 hr 400 mg HARVONI ORAL PELLETS IN 5 PA; QL (28/28); NORVIR ORAL POWDER IN 4 QL (360/30) PACKET 33.75-150 MG NDS PACKET HARVONI ORAL PELLETS IN 5 PA; QL (56/28); NORVIR ORAL SOLUTION 3 QL (480/30) PACKET 45-200 MG NDS NORVIR ORAL TABLET 4 QL (360/30) HARVONI ORAL TABLET 5 PA; QL (28/28); ODEFSEY 5 QL (30/30); NDS NDS oseltamivir 3 INTELENCE ORAL TABLET 5 QL (60/30); NDS PIFELTRO 5 QL (30/30); NDS 100 MG, 200 MG PREZCOBIX 5 QL (30/30); NDS INTELENCE ORAL TABLET 25 4 QL (120/30) MG PREZISTA ORAL 5 QL (400/30); NDS SUSPENSION INVIRASE ORAL TABLET 5 QL (120/30); NDS PREZISTA ORAL TABLET 150 4 QL (180/30) ISENTRESS HD 5 QL (60/30); NDS MG ISENTRESS ORAL POWDER 4 QL (60/30) PREZISTA ORAL TABLET 600 5 QL (60/30); NDS IN PACKET MG ISENTRESS ORAL TABLET 5 QL (120/30); NDS PREZISTA ORAL TABLET 75 3 QL (210/30) ISENTRESS ORAL 5 QL (180/30); NDS MG TABLET,CHEWABLE 100 MG PREZISTA ORAL TABLET 800 5 QL (30/30); NDS ISENTRESS ORAL 3 QL (180/30) MG TABLET,CHEWABLE 25 MG RETROVIR INTRAVENOUS 4 JULUCA 5 NDS REYATAZ ORAL POWDER IN 5 QL (180/30); NDS KALETRA ORAL TABLET 100- 3 QL (300/30) PACKET 25 MG ribavirin oral capsule 3 QL (168/28) KALETRA ORAL TABLET 200- 5 QL (120/30); NDS ribavirin oral tablet 200 mg 3 50 MG rimantadine 2 lamivudine oral solution 3 QL (900/30) ritonavir 3 QL (360/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

8 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS RUKOBIA 5 NDS zidovudine oral capsule 3 QL (180/30) SELZENTRY ORAL 5 QL (1610/26); NDS zidovudine oral syrup 3 QL (1680/28) SOLUTION zidovudine oral tablet 3 QL (60/30) SELZENTRY ORAL TABLET 5 QL (60/30); NDS 150 MG, 75 MG cefaclor oral capsule 2 SELZENTRY ORAL TABLET 4 QL (240/30) 25 MG cefaclor oral suspension for 3 reconstitution 125 mg/5 ml, 250 SELZENTRY ORAL TABLET 5 QL (120/30); NDS mg/5 ml, 375 mg/5 ml 300 MG cefaclor oral tablet extended 3 stavudine oral capsule 3 QL (60/30) release 12 hr STRIBILD 5 QL (30/30); NDS cefadroxil oral capsule 3 SYMFI 5 QL (30/30); NDS cefadroxil oral suspension for 3 SYMFI LO 5 QL (30/30); NDS reconstitution 250 mg/5 ml, 500 SYMTUZA 5 QL (30/30); NDS mg/5 ml SYNAGIS 5 PA; NDS cefadroxil oral tablet 3 tenofovir disoproxil fumarate 4 QL (30/30) cefazolin 4 HI TIVICAY ORAL TABLET 10 MG 4 QL (60/30) cefazolin in dextrose (iso-os) 4 HI intravenous piggyback 1 TIVICAY ORAL TABLET 25 5 QL (60/30); NDS gram/50 ml, 2 gram/50 ml MG, 50 MG CEFAZOLIN IN DEXTROSE 4 HI TIVICAY PD 5 QL (180/30); NDS (ISO-OS) INTRAVENOUS TRIUMEQ 5 QL (30/30); NDS PIGGYBACK 2 GRAM/100 ML TROGARZO 5 B/D PA; NDS cefdinir oral capsule 2 TRUVADA 5 QL (30/30); NDS cefdinir oral suspension for 3 TYBOST 3 QL (30/30) reconstitution valacyclovir oral tablet 1 gram 2 QL (120/30) CEFEPIME IN DEXTROSE 5% 4 HI valacyclovir oral tablet 500 mg 2 QL (60/30) cefepime in dextrose,iso-osm 4 HI valganciclovir 5 NDS cefepime injection 4 HI VEMLIDY 5 NDS cefixime oral capsule 4 QL (30/30) VIRACEPT ORAL TABLET 250 5 QL (270/30); NDS cefixime oral suspension for 4 MG reconstitution VIRACEPT ORAL TABLET 625 5 QL (120/30); NDS cefotetan 4 MG CEFOTETAN IN DEXTROSE, 4 VIREAD ORAL POWDER 5 QL (240/30); NDS ISO-OSM VIREAD ORAL TABLET 150 5 QL (30/30); NDS cefoxitin 4 HI MG, 200 MG, 250 MG cefoxitin in dextrose, iso-osm 4 HI VOSEVI 5 PA; QL (30/30); cefpodoxime 2 NDS cefprozil 2 XOFLUZA 4 ceftazidime 4 HI

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

9 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CEFTAZIDIME IN D5W 4 HI ery-tab oral tablet,delayed 3 in dextrose,iso-os 4 release (dr/ec) 250 mg ceftriaxone injection recon soln 4 ERY-TAB ORAL 3 1 gram, 10 gram, 2 gram, 250 TABLET,DELAYED RELEASE mg, 500 mg (DR/EC) 333 MG, 500 MG CEFTRIAXONE INJECTION 4 erythrocin (as stearate) oral 3 RECON SOLN 100 GRAM tablet 250 mg ceftriaxone intravenous 4 ERYTHROCIN INTRAVENOUS 4 RECON SOLN 500 MG cefuroxime axetil oral tablet 2 erythromycin ethylsuccinate 3 cefuroxime sodium injection 4 oral suspension for recon soln 750 mg reconstitution 200 mg/5 ml cefuroxime sodium intravenous 4 erythromycin ethylsuccinate 5 NDS cephalexin oral capsule 250 1 oral suspension for mg, 500 mg reconstitution 400 mg/5 ml cephalexin oral suspension for 2 erythromycin ethylsuccinate 3 reconstitution oral tablet SUPRAX ORAL SUSPENSION 4 erythromycin oral tablet 4 FOR RECONSTITUTION 500 erythromycin oral 3 MG/5 ML tablet,delayed release (dr/ec) tazicef 4 HI MISCELLANEOUS ANTIINFECTIVES TEFLARO 5 HI; NDS albendazole 5 NDS ERYTHROMYCINS / OTHER MACROLIDES ALINIA ORAL SUSPENSION 5 QL (180/30); NDS intravenous 4 HI FOR RECONSTITUTION azithromycin oral packet 3 ALINIA ORAL TABLET 5 QL (20/10); NDS azithromycin oral suspension 2 amikacin injection solution 4 HI for reconstitution 1,000 mg/4 ml, 500 mg/2 ml azithromycin oral tablet 250 2 ARIKAYCE 5 PA; NDS mg, 250 mg (6 pack), 500 mg, atovaquone 4 500 mg (3 pack) atovaquone-proguanil 2 azithromycin oral tablet 600 mg 2 QL (60/30) aztreonam injection recon soln 3 HI clarithromycin oral suspension 3 1 gram for reconstitution aztreonam injection recon soln 5 HI; NDS clarithromycin oral tablet 2 2 gram clarithromycin oral tablet 2 bacitracin intramuscular 4 extended release 24 hr CAPASTAT 4 DIFICID 5 PA; QL (20/10); NDS CAYSTON 5 PA; QL (84/56); NDS e.e.s. 400 oral tablet 3 sod succinate 4 ERYPED 400 5 NDS chloroquine phosphate 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

10 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS clindamycin hcl 2 linezolid in dextrose 5% 4 HI CLINDAMYCIN IN 0.9% SOD 4 HI linezolid oral suspension for 5 QL (1800/30); NDS CHLOR reconstitution clindamycin in 5% dextrose 4 HI linezolid oral tablet 3 QL (60/30) clindamycin pediatric 4 linezolid-0.9% sodium chloride 4 HI clindamycin phosphate injection 4 HI mefloquine 2 clindamycin phosphate 4 HI meropenem 4 HI intravenous solution 600 mg/4 MEROPENEM-0.9% SODIUM 4 HI ml CHLORIDE COARTEM 4 QL (24/30) metro i.v. 4 HI colistin (colistimethate na) 4 in nacl (iso-os) 4 HI CYCLOSERINE 2 metronidazole oral tablet 1 oral 3 NEBUPENT 3 B/D PA; QL (1/28) DAPTOMYCIN INTRAVENOUS 5 HI; NDS 2 RECON SOLN 350 MG ORBACTIV 5 QL (3/30); NDS daptomycin intravenous recon 5 HI; NDS soln 500 mg paromomycin 4 DARAPRIM 5 QL (90/30); NDS PASER 4 EMVERM 5 NDS PENTAM 3 ertapenem 4 HI pentamidine inhalation 3 B/D PA; QL (1/28) ethambutol 3 pentamidine injection 3 FIRVANQ 4 sulfate 4 in nacl (iso-osm) 4 praziquantel 4 intravenous piggyback 100 PRIFTIN 4 mg/100 ml, 60 mg/50 ml, 80 PRIMAQUINE 3 mg/100 ml, 80 mg/50 ml pyrazinamide 3 GENTAMICIN IN NACL 4 pyrimethamine 5 QL (90/30); NDS (ISO-OSM) INTRAVENOUS PIGGYBACK 100 MG/50 ML, quinine sulfate 4 PA; QL (42/7) 120 MG/100 ML 3 gentamicin injection solution 40 4 rifampin intravenous 4 mg/ml rifampin oral 2 gentamicin sulfate (ped) (pf) 4 RIFATER 4 hydroxychloroquine 2 SIRTURO ORAL TABLET 100 4 PA; QL (188/365) imipenem-cilastatin 4 HI MG isoniazid oral solution 3 SIRTURO ORAL TABLET 20 4 PA isoniazid oral tablet 2 MG oral 3 SIVEXTRO INTRAVENOUS 5 B/D PA; QL (6/28); NDS lincomycin 4

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

11 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SIVEXTRO ORAL 5 QL (6/28); NDS amoxicillin-pot clavulanate oral 2 streptomycin 4 suspension for reconstitution SYNERCID 5 HI; NDS amoxicillin-pot clavulanate oral 2 tablet tigecycline 5 HI; NDS amoxicillin-pot clavulanate oral 4 TOBI PODHALER 5 QL (1568/365); tablet extended release 12 hr INHALATION CAPSULE, W/ NDS INHALATION DEVICE amoxicillin-pot clavulanate oral 2 tablet,chewable tobramycin in 0.225% nacl 5 B/D PA; QL (280/28); NDS ampicillin oral capsule 500 mg 2 tobramycin sulfate 4 ampicillin sodium injection 4 HI recon soln 1 gram, 10 gram, 2 TRECATOR 3 gram VANCOMYCIN IN 0.9% 4 HI ampicillin sodium injection 4 SODIUM CHL INTRAVENOUS recon soln 125 mg, 250 mg, PIGGYBACK 500 mg VANCOMYCIN IN DEXTROSE 4 HI ampicillin sodium intravenous 4 HI 5% INTRAVENOUS PIGGYBACK ampicillin-sulbactam 4 HI VANCOMYCIN INJECTION 4 HI BICILLIN L-A 4 vancomycin intravenous recon 4 HI dicloxacillin 2 soln 1,000 mg, 10 gram, 250 nafcillin 4 HI mg, 5 gram, 500 mg, 750 mg nafcillin in dextrose iso-osm 4 HI VANCOMYCIN INTRAVENOUS 4 HI oxacillin injection 4 HI RECON SOLN 1.25 GRAM, 1.5 GRAM g potassium 4 HI vancomycin oral capsule 125 3 QL (40/10) penicillin v potassium oral 1 mg recon soln vancomycin oral capsule 250 3 QL (80/10) penicillin v potassium oral tablet 1 mg 250 mg vancomycin oral recon soln 2 penicillin v potassium oral tablet 2 500 mg VANCOMYCIN-WATER 4 INJECT (PEG) pfizerpen-g 4 HI XIFAXAN ORAL TABLET 550 5 PA; QL (90/30); PIPERACILLIN-TAZOBACTAM 4 HI MG NDS INTRAVENOUS RECON SOLN 13.5 GRAM piperacillin-tazobactam 4 HI amoxicillin oral capsule 1 intravenous recon soln 2.25 amoxicillin oral suspension for 1 gram, 3.375 gram, 4.5 gram, reconstitution 40.5 gram amoxicillin oral tablet 2 ZOSYN IN DEXTROSE (ISO- 4 HI amoxicillin oral tablet,chewable 2 OSM) 125 mg, 250 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

12 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS QUINOLONES DOXYCYCLINE 4 BAXDELA 4 QL (28/14) MONOHYDRATE ORAL CAPSULE,IR - DELAY 4 REL,BIPHASE ciprofloxacin hcl oral tablet 100 3 doxycycline monohydrate oral 2 mg suspension for reconstitution ciprofloxacin hcl oral tablet 250 2 doxycycline monohydrate oral 3 mg, 500 mg, 750 mg tablet ciprofloxacin in 5% dextrose 4 HI minocycline oral capsule 2 in d5w 4 HI minocycline oral tablet 2 levofloxacin intravenous 4 HI mondoxyne nl oral capsule 100 3 levofloxacin oral solution 4 mg, 75 mg levofloxacin oral tablet 2 morgidox 1 oral 4 NUZYRA INTRAVENOUS 4 QL (15/14) MOXIFLOXACIN-SOD. 4 NUZYRA ORAL 4 QL (30/14) ACE,SUL-WATER 2 moxifloxacin-sod.chloride(iso) 4 URINARY TRACT AGENTS SULFAS / RELATED AGENTS methenamine hippurate 2 3 MONUROL 4 - 4 4 intravenous nitrofurantoin macrocrystal 2 sulfamethoxazole-trimethoprim 4 oral suspension nitrofurantoin monohyd/m-cryst 2 sulfamethoxazole-trimethoprim 1 trimethoprim 2 oral tablet ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS sulfatrim 4 ADJUNCTIVE AGENTS leucovorin calcium injection 4 demeclocycline 3 leucovorin calcium oral 3 doxy-100 4 mesna 4 B/D PA doxycycline hyclate intravenous 4 MESNEX ORAL 5 NDS doxycycline hyclate oral 1 capsule XGEVA 5 PA; QL (1.7/28); NDS doxycycline hyclate oral tablet 1 100 mg ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS doxycycline hyclate oral tablet 2 abiraterone 5 PA; QL (120/30); 20 mg NDS doxycycline monohydrate oral 2 ABRAXANE 5 PA; NDS capsule 100 mg, 50 mg AFINITOR 5 PA; QL (28/28); NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

13 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS AFINITOR DISPERZ 5 PA; QL (56/28); BORTEZOMIB 5 PA; QL (14/21); NDS NDS ALECENSA 5 PA; QL (240/30); BOSULIF 5 PA; NDS NDS BRAFTOVI 5 PA; QL (180/30); ALIMTA 5 PA; NDS NDS ALIQOPA 5 PA; QL (3/28); NDS BRUKINSA 5 PA; NDS ALKERAN 4 busulfan 5 B/D PA; NDS ALUNBRIG ORAL TABLET 180 5 PA; QL (30/30); BUSULFEX 5 B/D PA; NDS MG, 90 MG NDS CABOMETYX ORAL TABLET 5 PA; QL (30/30); ALUNBRIG ORAL TABLET 30 5 PA; QL (180/30); 20 MG, 60 MG NDS MG NDS CABOMETYX ORAL TABLET 5 PA; QL (60/30); ALUNBRIG ORAL 5 PA; QL (60/365); 40 MG NDS TABLETS,DOSE PACK NDS CALQUENCE 5 PA; QL (60/30); anastrozole 2 NDS ARSENIC TRIOXIDE 4 B/D PA CAPRELSA ORAL TABLET 5 PA; QL (60/30); INTRAVENOUS SOLUTION 1 100 MG NDS MG/ML CAPRELSA ORAL TABLET 5 PA; QL (30/30); arsenic trioxide intravenous 4 B/D PA 300 MG NDS solution 2 mg/ml COMETRIQ ORAL CAPSULE 5 PA; QL (56/28); ASTAGRAF XL 4 PA 100 MG/DAY(80 MG X1-20 MG NDS AVASTIN 5 PA; NDS X1) AYVAKIT 5 PA; QL (30/30); COMETRIQ ORAL CAPSULE 5 PA; QL (112/28); NDS 140 MG/DAY(80 MG X1-20 MG NDS X3) AZASAN 3 PA COMETRIQ ORAL CAPSULE 5 PA; QL (84/28); azathioprine 2 PA 60 MG/DAY (20 MG X 3/DAY) NDS azathioprine sodium 4 PA COPIKTRA 5 PA; QL (60/30); BALVERSA ORAL TABLET 3 5 PA; QL (90/30); NDS MG NDS COSMEGEN 5 B/D PA; NDS BALVERSA ORAL TABLET 4 5 PA; QL (60/30); COTELLIC 5 PA; QL (63/28); MG NDS NDS BALVERSA ORAL TABLET 5 5 PA; QL (30/30); cyclophosphamide intravenous 5 B/D PA; NDS MG NDS recon soln BAVENCIO 5 PA; NDS CYCLOPHOSPHAMIDE 5 B/D PA; NDS BENDEKA 5 B/D PA; QL (8/21); INTRAVENOUS SOLUTION NDS cyclophosphamide oral capsule 3 B/D PA BESPONSA 5 PA; NDS cyclosporine intravenous 4 PA bexarotene 5 PA; NDS cyclosporine modified 4 PA 2 cyclosporine oral capsule 4 PA BLENREP 5 PA; NDS CYRAMZA 5 PA; NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

14 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS DARZALEX 5 PA; NDS everolimus 5 PA; QL (60/30); DARZALEX FASPRO 5 PA; NDS (immunosuppressive) oral NDS tablet 0.75 mg daunorubicin intravenous 4 B/D PA solution EVOMELA 5 PA; NDS DAURISMO ORAL TABLET 5 PA; QL (30/30); exemestane 2 QL (60/30) 100 MG NDS FARYDAK 5 PA; QL (6/21); NDS DAURISMO ORAL TABLET 25 5 PA; QL (60/30); FASLODEX 5 B/D PA; QL (30/30); MG NDS NDS DROXIA 3 FIRMAGON KIT W DILUENT 5 B/D PA; QL (4/365); ELIGARD 4 PA; QL (1/30) SYRINGE SUBCUTANEOUS NDS RECON SOLN 120 MG ELIGARD (3 MONTH) 4 PA; QL (1/90) FIRMAGON KIT W DILUENT 4 B/D PA; QL (1/28) ELIGARD (4 MONTH) 4 PA; QL (1/120) SYRINGE SUBCUTANEOUS ELIGARD (6 MONTH) 4 PA; QL (1/180) RECON SOLN 80 MG ELZONRIS 5 B/D PA; NDS fludarabine 4 B/D PA EMCYT 4 2 ENHERTU 5 PA; NDS FOLOTYN 5 B/D PA; NDS ENVARSUS XR ORAL TABLET 4 PA fulvestrant 5 B/D PA; QL (30/30); EXTENDED RELEASE 24 HR NDS 0.75 MG, 1 MG GAVRETO 5 PA; QL (120/30); ENVARSUS XR ORAL TABLET 5 PA; NDS NDS EXTENDED RELEASE 24 HR GAZYVA 5 PA; NDS 4 MG gemcitabine intravenous recon 4 B/D PA ERIVEDGE 5 PA; QL (28/28); soln NDS gemcitabine intravenous 4 B/D PA ERLEADA 5 PA; NDS solution 1 gram/26.3 ml (38 mg/ erlotinib oral tablet 100 mg, 150 5 PA; QL (30/30); ml), 2 gram/52.6 ml (38 mg/ml), mg NDS 200 mg/5.26 ml (38 mg/ml) erlotinib oral tablet 25 mg 5 PA; QL (60/30); GEMCITABINE 5 B/D PA; NDS NDS INTRAVENOUS SOLUTION etoposide intravenous 3 B/D PA 100 MG/ML everolimus (antineoplastic) 5 PA; QL (28/28); gengraf oral capsule 100 mg, 4 PA NDS 25 mg everolimus 4 PA; QL (60/30) gengraf oral solution 4 PA (immunosuppressive) oral GILOTRIF 5 PA; QL (30/30); tablet 0.25 mg NDS everolimus 5 PA; QL (120/30); GLEOSTINE ORAL CAPSULE 3 (immunosuppressive) oral NDS 10 MG, 40 MG tablet 0.5 mg GLEOSTINE ORAL CAPSULE 4 100 MG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

15 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS HALAVEN 5 PA; NDS KEYTRUDA INTRAVENOUS 5 PA; NDS HERCEPTIN HYLECTA 5 PA; NDS SOLUTION HERCEPTIN INTRAVENOUS 5 PA; NDS KISQALI 5 PA; QL (63/28); RECON SOLN 150 MG NDS hydroxyurea 2 KISQALI FEMARA CO-PACK 5 PA; QL (49/28); ORAL TABLET 200 MG/ NDS IBRANCE 5 PA; QL (21/28); DAY(200 MG X 1)-2.5 MG NDS KISQALI FEMARA CO-PACK 5 PA; QL (70/28); ICLUSIG ORAL TABLET 15 5 PA; QL (60/30); ORAL TABLET 400 MG/ NDS MG NDS DAY(200 MG X 2)-2.5 MG ICLUSIG ORAL TABLET 45 5 PA; QL (30/30); KISQALI FEMARA CO-PACK 5 PA; QL (91/28); MG NDS ORAL TABLET 600 MG/ NDS IDHIFA 5 PA; QL (30/30); DAY(200 MG X 3)-2.5 MG NDS KYPROLIS 5 B/D PA; NDS imatinib oral tablet 100 mg 5 PA; QL (180/30); LENVIMA ORAL CAPSULE 10 5 PA; QL (30/30); NDS MG/DAY (10 MG X 1), 4 MG NDS imatinib oral tablet 400 mg 5 PA; QL (60/30); LENVIMA ORAL CAPSULE 12 5 PA; QL (90/30); NDS MG/DAY (4 MG X 3), 18 MG/ NDS IMBRUVICA ORAL CAPSULE 5 PA; QL (120/30); DAY (10 MG X 1-4 MG X2), 24 140 MG NDS MG/DAY(10 MG X 2-4 MG X 1) IMBRUVICA ORAL CAPSULE 5 PA; QL (30/30); LENVIMA ORAL CAPSULE 14 5 PA; QL (60/30); 70 MG NDS MG/DAY(10 MG X 1-4 MG X NDS IMBRUVICA ORAL TABLET 5 PA; QL (30/30); 1), 20 MG/DAY (10 MG X 2), 8 NDS MG/DAY (4 MG X 2) IMFINZI 5 PA; NDS letrozole 2 INFUGEM 5 B/D PA; NDS LEUKERAN 4 INLYTA ORAL TABLET 1 MG 5 PA; QL (180/30); leuprolide subcutaneous kit 4 PA NDS LIBTAYO 5 PA; QL (7/21); NDS INLYTA ORAL TABLET 5 MG 5 PA; QL (120/30); LONSURF ORAL TABLET 5 PA; QL (100/28); NDS 15-6.14 MG NDS INQOVI 5 PA; QL (5/28); NDS LONSURF ORAL TABLET 5 PA; QL (80/28); INREBIC 5 PA; QL (120/30); 20-8.19 MG NDS NDS LORBRENA ORAL TABLET 5 PA; QL (30/30); IRESSA 5 PA; QL (30/30); 100 MG NDS NDS LORBRENA ORAL TABLET 25 5 PA; QL (90/30); irinotecan 4 B/D PA MG NDS ISTODAX 5 PA; NDS LUMOXITI 5 PA; NDS JAKAFI 5 PA; QL (60/30); LUPRON DEPOT 5 PA; QL (1/30); NDS NDS LUPRON DEPOT (3 MONTH) 5 PA; QL (1/84); NDS KADCYLA 5 PA; NDS LUPRON DEPOT (4 MONTH) 5 PA; QL (1/112); KANJINTI 5 PA; NDS NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

16 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS LUPRON DEPOT (6 MONTH) 5 PA; QL (1/168); MYLOTARG 5 PA; NDS NDS NERLYNX 5 PA; QL (180/30); LUPRON DEPOT-PED 5 PA; QL (1/30); NDS NDS LUPRON DEPOT-PED (3 5 PA; QL (1/84); NDS NEXAVAR 5 PA; QL (120/30); MONTH) INTRAMUSCULAR NDS SYRINGE KIT 11.25 MG 5 QL (60/30); NDS LUPRON DEPOT-PED (3 5 PA; QL (1/112); NINLARO 5 PA; QL (3/28); NDS MONTH) INTRAMUSCULAR NDS SYRINGE KIT 30 MG NUBEQA 5 PA; QL (120/30); NDS LYNPARZA ORAL TABLET 5 PA; QL (120/30); NDS NULOJIX 5 PA; QL (26/28); NDS LYSODREN 5 NDS octreotide acetate injection 4 PA MATULANE 5 NDS solution 1,000 mcg/ml, 100 megestrol oral suspension 400 3 PA mcg/ml, 200 mcg/ml, 500 mcg/ mg/10 ml (10 ml), 400 mg/10 ml ml (40 mg/ml) octreotide acetate injection 3 PA megestrol oral tablet 3 PA solution 50 mcg/ml MEKINIST ORAL TABLET 0.5 5 PA; QL (90/30); ODOMZO 5 PA; QL (30/30); MG NDS NDS MEKINIST ORAL TABLET 2 5 PA; QL (30/30); OGIVRI 5 PA; NDS MG NDS ONTRUZANT 5 PA; NDS MEKTOVI 5 PA; QL (180/30); OPDIVO 5 PA; QL (80/28); NDS NDS melphalan 2 B/D PA paclitaxel 4 B/D PA melphalan hcl 5 B/D PA; NDS PADCEV 5 PA; NDS mercaptopurine 2 PEMAZYRE 5 PA; QL (14/21); methotrexate sodium (pf) 4 NDS methotrexate sodium injection 4 PERJETA 5 PA; NDS methotrexate sodium oral 2 PHESGO 5 PA; NDS MONJUVI 5 PA; NDS PIQRAY ORAL TABLET 200 5 PA; QL (28/28); MVASI 5 PA; NDS MG/DAY (200 MG X 1) NDS mycophenolate mofetil (hcl) 4 PA PIQRAY ORAL TABLET 250 5 PA; QL (56/28); MG/DAY (200 MG X1-50 MG NDS mycophenolate mofetil oral 2 PA X1), 300 MG/DAY (150 MG X capsule 2) mycophenolate mofetil oral 5 PA; NDS POMALYST 5 PA; QL (21/28); suspension for reconstitution NDS mycophenolate mofetil oral 2 PA POTELIGEO 5 PA; NDS tablet PROGRAF INTRAVENOUS 4 PA mycophenolate sodium 2 PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

17 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS PROGRAF ORAL GRANULES 4 PA SOMATULINE DEPOT 5 PA; QL (0.2/28); IN PACKET SUBCUTANEOUS SYRINGE NDS PURIXAN 5 PA; QL (300/30); 60 MG/0.2 ML NDS SOMATULINE DEPOT 5 PA; QL (0.3/28); QINLOCK 5 PA; NDS SUBCUTANEOUS SYRINGE NDS 90 MG/0.3 ML RAPAMUNE ORAL SOLUTION 5 PA; NDS SPRYCEL 5 PA; QL (30/30); RETEVMO 5 PA; NDS NDS REVLIMID ORAL CAPSULE 10 5 PA; QL (28/28); STIVARGA 5 PA; QL (120/28); MG, 2.5 MG, 5 MG NDS NDS REVLIMID ORAL CAPSULE 15 5 PA; QL (21/28); SUTENT 5 PA; QL (28/28); MG, 20 MG, 25 MG NDS NDS RITUXAN 5 PA; NDS SYNRIBO 5 PA; QL (28/28); RITUXAN HYCELA 5 PA; NDS NDS ROMIDEPSIN INTRAVENOUS 5 PA; NDS TABLOID 4 SOLUTION TABRECTA 5 PA; NDS ROZLYTREK ORAL CAPSULE 5 PA; QL (150/30); tacrolimus oral 2 PA 100 MG NDS TAFINLAR 5 PA; QL (120/30); ROZLYTREK ORAL CAPSULE 5 PA; QL (90/30); NDS 200 MG NDS TAGRISSO 5 PA; QL (30/30); RUBRACA 5 PA; QL (120/30); NDS NDS TALZENNA 5 PA; QL (90/30); RUXIENCE 5 PA; NDS NDS RYDAPT 5 PA; QL (224/28); tamoxifen 2 NDS TARGRETIN TOPICAL 5 PA; QL (60/30); SANDIMMUNE ORAL 4 PA NDS SOLUTION TASIGNA ORAL CAPSULE 150 5 PA; QL (112/28); SANDOSTATIN LAR 5 PA; NDS MG, 200 MG NDS DEPOT INTRAMUSCULAR SUSPENSION,EXTENDED TASIGNA ORAL CAPSULE 50 5 PA; QL (420/30); REL RECON MG NDS SARCLISA 5 PA; NDS TAZVERIK 5 PA; NDS SIGNIFOR 5 PA; QL (60/30); TECENTRIQ INTRAVENOUS 5 PA; QL (20/21); NDS SOLUTION 1,200 MG/20 ML NDS (60 MG/ML) SIMULECT 5 B/D PA; NDS TECENTRIQ INTRAVENOUS 5 PA; QL (28/28); sirolimus oral solution 5 PA; NDS SOLUTION 840 MG/14 ML (60 NDS sirolimus oral tablet 4 PA MG/ML) SOLTAMOX 5 NDS temsirolimus 5 B/D PA; QL (4/28); SOMATULINE DEPOT 5 PA; QL (0.5/28); NDS SUBCUTANEOUS SYRINGE NDS THALOMID ORAL CAPSULE 5 PA; QL (28/28); 120 MG/0.5 ML 100 MG, 150 MG, 50 MG NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

18 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS THALOMID ORAL CAPSULE 5 PA; QL (56/28); VELCADE 5 PA; QL (14/21); 200 MG NDS NDS thiotepa 4 PA VENCLEXTA ORAL TABLET 3 PA; QL (60/30) TIBSOVO 5 PA; QL (60/30); 10 MG NDS VENCLEXTA ORAL TABLET 5 PA; QL (120/30); toposar 3 B/D PA 100 MG NDS topotecan intravenous recon 5 NDS VENCLEXTA ORAL TABLET 3 PA; QL (30/30) soln 50 MG toremifene 5 QL (30/30); NDS VENCLEXTA STARTING PACK 5 PA; QL (84/365); NDS TORISEL 5 B/D PA; QL (4/28); NDS VERZENIO 5 PA; QL (60/30); NDS TRAZIMERA 5 PA; NDS vincasar pfs intravenous 4 B/D PA TREANDA INTRAVENOUS 5 B/D PA; NDS solution 1 mg/ml RECON SOLN 100 MG vincristine 4 B/D PA TREANDA INTRAVENOUS 5 B/D PA; QL (8/21); RECON SOLN 25 MG NDS vinorelbine 4 B/D PA TRELSTAR INTRAMUSCULAR 5 PA; QL (1/84); NDS VITRAKVI ORAL CAPSULE 5 PA; QL (60/30); SUSPENSION FOR 100 MG NDS RECONSTITUTION 11.25 MG VITRAKVI ORAL CAPSULE 25 5 PA; QL (180/30); TRELSTAR INTRAMUSCULAR 5 PA; QL (1/168); MG NDS SUSPENSION FOR NDS VITRAKVI ORAL SOLUTION 5 PA; QL (300/30); RECONSTITUTION 22.5 MG NDS TRELSTAR INTRAMUSCULAR 5 PA; QL (1/28); NDS VIZIMPRO 5 PA; QL (30/30); SUSPENSION FOR NDS RECONSTITUTION 3.75 MG VOTRIENT 5 PA; QL (120/30); tretinoin (antineoplastic) 5 NDS NDS TRIPTODUR 5 PA; QL (1/168); VYXEOS 5 B/D PA; NDS NDS XALKORI 5 PA; QL (60/30); TRISENOX INTRAVENOUS 4 B/D PA NDS SOLUTION 2 MG/ML XATMEP 4 PA TRODELVY 5 PA; NDS XOSPATA 5 PA; QL (90/30); TRUXIMA 5 PA; NDS NDS TUKYSA ORAL TABLET 150 5 PA; QL (120/30); XPOVIO ORAL TABLET 100 5 PA; QL (20/28); MG NDS MG/WEEK (20 MG X 5) NDS TUKYSA ORAL TABLET 50 5 PA; QL (300/30); XPOVIO ORAL TABLET 40 5 PA; NDS MG NDS MG/WEEK (20 MG X 2), 60MG TYKERB 5 PA; QL (180/30); TWICE WEEK (120 MG/ NDS WEEK) UNITUXIN 5 PA; NDS XPOVIO ORAL TABLET 40MG 5 PA; QL (16/28); TWICE WEEK (80 MG/WEEK), NDS VECTIBIX 5 PA; NDS 80 MG/WEEK (20 MG X 4)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

19 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS XPOVIO ORAL TABLET 60 5 PA; QL (12/28); APTIOM ORAL TABLET 400 5 QL (90/30); NDS MG/WEEK (20 MG X 3) NDS MG XPOVIO ORAL TABLET 80MG 5 PA; QL (32/28); APTIOM ORAL TABLET 600 5 QL (60/30); NDS TWICE WEEK (160 MG/ NDS MG, 800 MG WEEK) BANZEL ORAL SUSPENSION 5 PA; QL (2400/30); XTANDI 5 PA; QL (120/30); NDS NDS BANZEL ORAL TABLET 5 PA; NDS YERVOY INTRAVENOUS 5 PA; QL (80/21); BRIVIACT ORAL SOLUTION 4 QL (600/30) SOLUTION 200 MG/40 ML (5 NDS MG/ML) BRIVIACT ORAL TABLET 4 QL (60/30) YERVOY INTRAVENOUS 5 PA; NDS oral capsule, er 2 SOLUTION 50 MG/10 ML (5 multiphase 12 hr MG/ML) carbamazepine oral suspension 2 YONDELIS 5 PA; NDS 100 mg/5 ml YONSA 5 PA; QL (120/30); carbamazepine oral tablet 2 NDS carbamazepine oral tablet 2 ZEJULA 5 PA; QL (90/30); extended release 12 hr NDS carbamazepine oral 2 ZELBORAF 5 PA; QL (240/30); tablet,chewable NDS CELONTIN ORAL CAPSULE 3 ZEPZELCA 5 PA; NDS 300 MG ZIRABEV 5 PA; NDS clobazam oral suspension 5 QL (480/30); NDS ZOLINZA 5 QL (120/30); NDS clobazam oral tablet 10 mg 4 QL (60/30) ZORTRESS ORAL TABLET 4 PA; QL (60/30) clobazam oral tablet 20 mg 5 QL (60/30); NDS 0.25 MG clonazepam oral tablet 0.5 mg, 2 QL (120/30) ZORTRESS ORAL TABLET 0.5 5 PA; QL (120/30); 1 mg MG NDS clonazepam oral tablet 2 mg 2 QL (300/30) ZORTRESS ORAL TABLET 5 PA; QL (60/30); clonazepam oral 2 QL (90/30) 0.75 MG, 1 MG NDS tablet,disintegrating 0.125 mg, ZYDELIG 5 PA; QL (60/30); 0.25 mg, 0.5 mg NDS clonazepam oral 2 QL (120/30) ZYKADIA ORAL TABLET 5 PA; QL (140/28); tablet,disintegrating 1 mg NDS clonazepam oral 2 QL (300/30) ZYTIGA ORAL TABLET 500 5 PA; QL (60/30); tablet,disintegrating 2 mg MG NDS DIASTAT 4 QL (5/30) DIASTAT ACUDIAL RECTAL 4 QL (40/30) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH KIT 12.5-15-17.5-20 MG ANTICONVULSANTS DIASTAT ACUDIAL RECTAL 4 QL (20/30) APTIOM ORAL TABLET 200 5 QL (180/30); NDS KIT 5-7.5-10 MG MG rectal kit 12.5-15- 4 QL (40/30) 17.5-20 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

20 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS diazepam rectal kit 2.5 mg 4 QL (5/30) LYRICA ORAL CAPSULE 100 4 QL (90/30) diazepam rectal kit 5-7.5-10 mg 4 QL (20/30) MG, 150 MG, 200 MG, 25 MG, 50 MG DILANTIN 30 MG 3 LYRICA ORAL CAPSULE 225 4 QL (60/30) divalproex 2 MG, 300 MG EPIDIOLEX 5 PA; NDS LYRICA ORAL CAPSULE 75 4 QL (120/30) epitol 2 MG ethosuximide 3 LYRICA ORAL SOLUTION 4 QL (900/30) felbamate oral suspension 5 NDS NAYZILAM 5 PA; QL (10/30); felbamate oral tablet 4 NDS FINTEPLA 5 PA; NDS oxcarbazepine 2 FYCOMPA ORAL 4 QL (720/30) PEGANONE 3 SUSPENSION oral elixir 3 QL (1500/30) FYCOMPA ORAL TABLET 10 4 QL (30/30) phenobarbital oral tablet 3 QL (120/30) MG, 12 MG, 8 MG oral suspension 2 FYCOMPA ORAL TABLET 2 4 QL (60/30) phenytoin oral tablet,chewable 2 MG, 4 MG, 6 MG phenytoin sodium extended 2 gabapentin oral capsule 100 2 QL (270/30) mg, 400 mg pregabalin oral capsule 100 3 QL (90/30) mg, 150 mg, 200 mg, 25 mg, gabapentin oral capsule 300 2 QL (360/30) 50 mg mg pregabalin oral capsule 225 3 QL (60/30) gabapentin oral solution 2 QL (2160/30) mg, 300 mg gabapentin oral tablet 600 mg 2 QL (180/30) pregabalin oral capsule 75 mg 3 QL (120/30) gabapentin oral tablet 800 mg 2 pregabalin oral solution 3 QL (900/30) lamotrigine oral tablet 2 primidone 2 lamotrigine oral tablet extended 2 roweepra 2 release 24hr roweepra xr 2 lamotrigine oral tablet, 2 chewable dispersible SPRITAM ORAL TABLET FOR 4 QL (60/30) SUSPENSION 1,000 MG, 250 lamotrigine oral 2 MG, 500 MG tablet,disintegrating SPRITAM ORAL TABLET FOR 4 QL (120/30) levetiracetam in nacl (iso-os) 4 SUSPENSION 750 MG levetiracetam intravenous 4 SYMPAZAN 5 PA; QL (60/30); levetiracetam oral 2 NDS LYRICA CR ORAL TABLET 3 QL (90/30) tiagabine 4 EXTENDED RELEASE 24 HR oral capsule, 2 165 MG, 82.5 MG sprinkle LYRICA CR ORAL TABLET 3 QL (60/30) topiramate oral tablet 2 EXTENDED RELEASE 24 HR 330 MG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

21 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS TROKENDI XR ORAL 4 QL (30/30) entacapone 4 QL (240/30) CAPSULE,EXTENDED NEUPRO 4 RELEASE 24HR 100 MG, 25 MG, 50 MG pramipexole oral tablet 2 TROKENDI XR ORAL 5 QL (60/30); NDS pramipexole oral tablet 4 QL (90/30) CAPSULE,EXTENDED extended release 24 hr 0.375 RELEASE 24HR 200 MG mg, 0.75 mg, 1.5 mg valproic acid 2 pramipexole oral tablet 4 QL (30/30) extended release 24 hr 2.25 valproic acid (as sodium salt) 2 mg, 3 mg, 3.75 mg, 4.5 mg oral solution rasagiline 3 VALTOCO 5 PA; QL (10/30); NDS ropinirole oral tablet 2 vigabatrin 5 PA; QL (180/30); RYTARY 4 ST NDS selegiline hcl 3 vigadrone 5 PA; QL (180/30); tolcapone 5 NDS NDS trihexyphenidyl 2 PA VIMPAT INTRAVENOUS 4 QL (1200/30) MIGRAINE / CLUSTER HEADACHE THERAPY VIMPAT ORAL SOLUTION 4 QL (1200/30) AIMOVIG AUTOINJECTOR 3 PA; QL (1/30) VIMPAT ORAL TABLET 100 4 QL (60/30) dihydroergotamine nasal 4 PA; QL (8/30) MG, 150 MG, 200 MG ergotamine-caffeine 3 QL (40/28) VIMPAT ORAL TABLET 50 MG 4 QL (120/30) migergot 5 QL (20/28); NDS XCOPRI 5 PA; NDS naratriptan 3 QL (18/28) XCOPRI MAINTENANCE 5 PA; NDS rizatriptan 3 QL (36/28) PACK sumatriptan 4 QL (18/28) XCOPRI TITRATION PACK 4 PA sumatriptan succinate oral 2 QL (18/28) zonisamide 2 sumatriptan succinate 4 QL (8/28) ANTIPARKINSONISM AGENTS subcutaneous cartridge APOKYN 5 PA; QL (60/30); sumatriptan succinate 4 QL (8/28) NDS subcutaneous pen injector benztropine injection 4 sumatriptan succinate 4 QL (8/28) benztropine oral 2 PA subcutaneous solution bromocriptine 4 sumatriptan succinate 4 QL (8/28) carbidopa 4 subcutaneous syringe 6 mg/0.5 carbidopa-levodopa oral tablet 2 ml carbidopa-levodopa oral tablet 3 MISCELLANEOUS NEUROLOGICAL THERAPY extended release AUSTEDO ORAL TABLET 12 5 PA; QL (120/30); carbidopa-levodopa oral 2 MG, 9 MG NDS tablet,disintegrating AUSTEDO ORAL TABLET 6 5 PA; QL (60/30); carbidopa-levodopa- 3 MG NDS entacapone

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

22 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS COPAXONE SUBCUTANEOUS 5 PA; QL (30/30); rivastigmine 4 QL (30/30) SYRINGE 20 MG/ML NDS rivastigmine tartrate 4 QL (60/30) COPAXONE SUBCUTANEOUS 5 PA; QL (12/28); TECFIDERA ORAL 5 PA; QL (14/30); SYRINGE 40 MG/ML NDS CAPSULE,DELAYED NDS dalfampridine 3 PA; QL (60/30) RELEASE(DR/EC) 120 MG dimethyl fumarate oral capsule, 5 PA; QL (14/30); TECFIDERA ORAL 5 PA; QL (120/365); delayed release(dr/ec) 120 mg NDS CAPSULE,DELAYED NDS dimethyl fumarate oral 5 PA; QL (120/365); RELEASE(DR/EC) 120 MG capsule,delayed release(dr/ec) NDS (14)- 240 MG (46) 120 mg (14)- 240 mg (46) TECFIDERA ORAL 5 PA; QL (60/30); dimethyl fumarate oral capsule, 5 PA; QL (60/30); CAPSULE,DELAYED NDS delayed release(dr/ec) 240 mg NDS RELEASE(DR/EC) 240 MG donepezil oral tablet 10 mg 2 QL (60/30) tetrabenazine oral tablet 12.5 5 PA; QL (90/30); mg NDS donepezil oral tablet 23 mg 4 QL (30/30) tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); donepezil oral tablet 5 mg 2 QL (30/30) NDS donepezil oral 2 QL (60/30) TYSABRI 5 PA; QL (15/28); tablet,disintegrating 10 mg NDS donepezil oral 2 QL (30/30) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY tablet,disintegrating 5 mg oral tablet 10 mg, 5 1 FIRDAPSE 5 PA; NDS mg galantamine oral capsule,ext 4 QL (30/30) baclofen oral tablet 20 mg 2 rel. pellets 24 hr cyclobenzaprine oral tablet 10 3 PA galantamine oral solution 4 QL (200/30) mg, 5 mg galantamine oral tablet 4 QL (60/30) dantrolene oral 3 GILENYA ORAL CAPSULE 0.5 5 PA; QL (30/30); methocarbamol oral 2 PA MG NDS pyridostigmine oral 5 NDS memantine oral 4 PA; QL (30/30) syrup capsule,sprinkle,er 24hr pyridostigmine bromide oral 3 memantine oral solution 2 PA; QL (300/30) tablet 60 mg memantine oral tablet 10 mg 2 PA; QL (60/30) pyridostigmine bromide oral 3 memantine oral tablet 5 mg 2 PA; QL (90/30) tablet extended release memantine oral tablets,dose 3 PA; QL (98/365) regonol 4 pack oral capsule 4 NAMZARIC ORAL CAP, 3 PA; QL (56/365) tizanidine oral tablet 2 SPRINKLE,ER 24HR DOSE PACK NARCOTIC NAMZARIC ORAL CAPSULE, 3 PA acetaminophen-codeine oral 2 QL (2700/30); NDS SPRINKLE,ER 24HR solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml, 300 NUEDEXTA 4 PA; QL (60/30) mg-30 mg /12.5 ml OCREVUS 5 PA; NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

23 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS acetaminophen-codeine oral 2 QL (360/30); NDS hydrocodone-acetaminophen 3 NDS tablet 300-15 mg, 300-30 mg oral solution 10-325 mg/15 acetaminophen-codeine oral 2 QL (180/30); NDS ml(15 ml) tablet 300-60 mg hydrocodone-acetaminophen 3 QL (2700/30); NDS ascomp with codeine 4 PA; QL (180/30) oral solution 7.5-325 mg/15 ml buprenorphine hcl injection 4 QL (150/30); NDS HYDROCODONE- 3 QL (180/30); NDS ACETAMINOPHEN ORAL buprenorphine hcl sublingual 4 PA; QL (90/30) TABLET 10-300 MG, 7.5-300 BUPRENORPHINE 4 QL (4/28); NDS MG TRANSDERMAL PATCH hydrocodone-acetaminophen 3 QL (180/30); NDS WEEKLY 10 MCG/HOUR, 15 oral tablet 10-325 mg, 7.5-325 MCG/HOUR, 20 MCG/HOUR, mg 5 MCG/HOUR hydrocodone-acetaminophen 3 QL (360/30); NDS buprenorphine transdermal 4 QL (4/28); NDS oral tablet 5-325 mg patch weekly 7.5 mcg/hour hydrocodone-ibuprofen oral 3 QL (150/30); NDS butalbital compound w/codeine 4 PA; QL (180/30) tablet 10-200 mg, 5-200 mg, butalbital-acetaminop-caf-cod 4 PA; QL (180/30) 7.5-200 mg butalbital-acetaminophen-caff 3 PA; QL (180/30) hydromorphone (pf) injection 4 NDS oral capsule solution 10 (mg/ml) (5 ml), 10 butalbital-acetaminophen-caff 3 PA; QL (180/30) mg/ml, 2 mg/ml oral tablet 50-325-40 mg hydromorphone injection 4 NDS butalbital-aspirin-caffeine oral 4 PA; QL (180/30) solution 2 mg/ml capsule hydromorphone injection 4 NDS duramorph (pf) 4 B/D PA; QL syringe 1 mg/ml, 2 mg/ml, 4 (180/30); NDS mg/ml endocet oral tablet 10-325 mg 3 QL (180/30); NDS hydromorphone oral liquid 3 QL (1200/30); NDS endocet oral tablet 2.5-325 mg, 3 QL (360/30); NDS hydromorphone oral tablet 2 3 QL (180/30); NDS 5-325 mg mg, 4 mg endocet oral tablet 7.5-325 mg 3 QL (240/30); NDS hydromorphone oral tablet 8 3 QL (120/30); NDS mg fentanyl 4 QL (10/30); NDS ibuprofen-oxycodone 3 QL (28/30); NDS fentanyl citrate (pf) injection 4 B/D PA; NDS solution INFUMORPH P/F 4 B/D PA; QL (200/30); NDS fentanyl citrate (pf) intravenous 4 B/D PA; NDS syringe 100 mcg/2 ml (50 mcg/ lorcet hd 3 QL (180/30); NDS ml) methadone injection solution 4 QL (150/30); NDS fentanyl citrate buccal lozenge 5 PA; QL (120/30); methadone intensol 3 QL (500/30); NDS on a handle 1,200 mcg, 1,600 NDS methadone oral concentrate 3 QL (500/30); NDS mcg, 800 mcg methadone oral solution 10 3 QL (450/30); NDS fentanyl citrate buccal lozenge 4 PA; QL (120/30); mg/5 ml on a handle 200 mcg, 400 mcg, NDS 600 mcg methadone oral solution 5 mg/5 3 QL (600/30); NDS ml

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

24 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS methadone oral tablet 10 mg 3 QL (120/30); NDS oral solution 10 mg/5 2 QL (700/30); NDS methadone oral tablet 5 mg 3 QL (180/30); NDS ml MITIGO (PF) 4 QL (200/30); NDS morphine oral solution 20 mg/5 2 QL (900/30); NDS ml (4 mg/ml) morphine (pf) injection solution 4 B/D PA; QL 0.5 mg/ml, 1 mg/ml (180/30); NDS MORPHINE ORAL TABLET 3 QL (120/30); NDS morphine concentrate oral 2 QL (240/30); NDS morphine oral tablet extended 3 QL (90/30); NDS solution release MORPHINE INJECTION 4 B/D PA; QL oxycodone oral concentrate 3 QL (120/30); NDS SOLUTION 10 MG/ML (240/30); NDS oxycodone oral solution 3 QL (1200/30); NDS MORPHINE INJECTION 4 B/D PA; NDS oxycodone oral tablet 3 QL (180/30); NDS SOLUTION 2 MG/ML oxycodone-acetaminophen oral 3 QL (180/30); NDS MORPHINE INJECTION 4 B/D PA; QL tablet 10-325 mg SOLUTION 4 MG/ML (480/30); NDS oxycodone-acetaminophen oral 3 NDS MORPHINE INJECTION 4 B/D PA; QL tablet 2.5-300 mg SOLUTION 5 MG/ML (700/30); NDS oxycodone-acetaminophen oral 3 QL (360/30); NDS morphine injection solution 8 4 B/D PA; QL tablet 2.5-325 mg, 5-325 mg mg/ml (250/30); NDS oxycodone-acetaminophen oral 3 QL (240/30); NDS morphine injection syringe 10 4 B/D PA; QL tablet 7.5-325 mg mg/ml (240/30); NDS oxycodone-aspirin 3 QL (180/30); NDS MORPHINE INJECTION 4 B/D PA; QL oxymorphone oral tablet 3 QL (90/30); NDS SYRINGE 2 MG/ML (1200/30); NDS extended release 12 hr morphine injection syringe 4 4 B/D PA; QL XTAMPZA ER 3 QL (60/30); NDS mg/ml (480/30); NDS zebutal oral capsule 50-325-40 3 PA; QL (180/30) morphine injection syringe 5 4 B/D PA; NDS mg mg/ml NON-NARCOTIC ANALGESICS morphine injection syringe 8 4 B/D PA; QL mg/ml (250/30); NDS buprenorphine- 4 QL (60/30) sublingual film 12-3 mg morphine intravenous solution 4 B/D PA; QL 10 mg/ml (240/30); NDS buprenorphine-naloxone 4 QL (90/30) sublingual film 2-0.5 mg, 4-1 MORPHINE INTRAVENOUS 4 B/D PA; QL mg, 8-2 mg SOLUTION 4 MG/ML (480/30); NDS buprenorphine-naloxone 2 QL (90/30) MORPHINE INTRAVENOUS 4 B/D PA; QL sublingual tablet SOLUTION 8 MG/ML (250/30); NDS butorphanol injection solution 1 4 QL (480/30); NDS MORPHINE INTRAVENOUS 4 B/D PA; QL mg/ml SYRINGE 10 MG/ML (240/30); NDS butorphanol injection solution 2 4 QL (240/30); NDS morphine intravenous syringe 4 B/D PA; QL mg/ml 2 mg/ml (1200/30); NDS butorphanol nasal 2 QL (5/30); NDS morphine intravenous syringe 4 B/D PA; QL 4 mg/ml (480/30); NDS celecoxib 2 QL (60/30) MORPHINE INTRAVENOUS 4 B/D PA; QL diclofenac potassium 2 SYRINGE 8 MG/ML (250/30); NDS diclofenac sodium oral 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

25 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS diclofenac sodium topical drops 4 QL (450/28) VIVITROL 5 PA; NDS diclofenac sodium topical gel 3 QL (1000/30) ZUBSOLV SUBLINGUAL 3 QL (30/30) 1% TABLET 0.7-0.18 MG, 11.4-2.9 diflunisal 2 MG ec-naproxen 2 ZUBSOLV SUBLINGUAL 3 QL (90/30) TABLET 1.4-0.36 MG, 2.9-0.71 etodolac 4 MG, 5.7-1.4 MG, 8.6-2.1 MG flurbiprofen oral tablet 100 mg 2 PSYCHOTHERAPEUTIC DRUGS ibu 1 ABILIFY MAINTENA 5 QL (1/28); NDS ibuprofen oral suspension 2 alprazolam oral tablet 0.25 mg, 2 QL (120/30) ibuprofen oral tablet 400 mg, 1 0.5 mg, 1 mg 600 mg, 800 mg alprazolam oral tablet 2 mg 2 QL (150/30) meloxicam oral tablet 1 alprazolam oral 3 QL (90/30) nabumetone 2 tablet,disintegrating 0.25 mg, nalbuphine injection solution 10 4 QL (180/30); NDS 0.5 mg, 1 mg mg/ml alprazolam oral 3 QL (150/30) nalbuphine injection solution 20 4 QL (90/30); NDS tablet,disintegrating 2 mg mg/ml amitriptyline 3 PA naloxone injection solution 2 amoxapine 3 naloxone injection syringe 1 2 aripiprazole oral solution 3 QL (900/30) mg/ml aripiprazole oral tablet 3 QL (30/30) 2 aripiprazole oral 5 QL (60/30); NDS naproxen oral suspension 3 tablet,disintegrating naproxen oral tablet 1 ARISTADA INITIO 5 QL (4.8/365); NDS naproxen oral tablet,delayed 2 ARISTADA INTRAMUSCULAR 5 QL (3.9/56); NDS release (dr/ec) SUSPENSION,EXTENDED naproxen sodium oral tablet 4 REL SYRING 1,064 MG/3.9 ML 275 mg, 550 mg ARISTADA INTRAMUSCULAR 5 QL (1.6/28); NDS NARCAN NASAL SPRAY,NON- 3 QL (4/30) SUSPENSION,EXTENDED AEROSOL 4 MG/ACTUATION REL SYRING 441 MG/1.6 ML oxaprozin 4 ARISTADA INTRAMUSCULAR 5 QL (2.4/28); NDS SUSPENSION,EXTENDED salsalate 2 REL SYRING 662 MG/2.4 ML SUBOXONE SUBLINGUAL 3 QL (60/30) ARISTADA INTRAMUSCULAR 5 QL (3.2/28); NDS FILM 12-3 MG SUSPENSION,EXTENDED SUBOXONE SUBLINGUAL 3 QL (90/30) REL SYRING 882 MG/3.2 ML FILM 2-0.5 MG, 4-1 MG, 8-2 armodafinil 4 PA; QL (30/30) MG atomoxetine oral capsule 10 4 QL (60/30) sulindac 2 mg, 18 mg, 25 mg, 40 mg tramadol oral tablet 50 mg 2 QL (240/30); NDS tramadol-acetaminophen 3 QL (240/30); NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

26 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS atomoxetine oral capsule 100 4 QL (30/30) clozapine oral tablet, 4 QL (180/30) mg, 60 mg, 80 mg disintegrating 150 mg BELSOMRA ORAL TABLET 10 3 QL (30/30) clozapine oral tablet, 5 QL (120/30); NDS MG, 15 MG, 20 MG disintegrating 200 mg BELSOMRA ORAL TABLET 5 3 QL (60/30) desipramine 3 MG desvenlafaxine succinate oral 4 QL (120/30) hcl oral tablet 100 3 QL (120/30) tablet extended release 24 hr mg 100 mg bupropion hcl oral tablet 75 mg 3 QL (180/30) desvenlafaxine succinate oral 4 QL (30/30) bupropion hcl oral tablet 3 QL (90/30) tablet extended release 24 hr extended release 24 hr 150 mg 25 mg, 50 mg bupropion hcl oral tablet 3 QL (30/30) dexmethylphenidate oral tablet 3 QL (60/30) extended release 24 hr 300 mg 10 mg, 2.5 mg bupropion hcl oral tablet 3 QL (60/30) dexmethylphenidate oral tablet 3 QL (120/30) sustained-release 12 hr 100 5 mg mg, 200 mg dextroamphetamine oral 4 QL (180/30) bupropion hcl oral tablet 3 QL (90/30) capsule, extended release 10 sustained-release 12 hr 150 mg mg buspirone 2 dextroamphetamine oral 4 QL (120/30) capsule, extended release 15 CAPLYTA 5 ST; QL (30/30); mg NDS dextroamphetamine oral 4 QL (60/30) chlorpromazine injection 4 capsule, extended release 5 chlorpromazine oral 2 mg citalopram oral solution 3 QL (600/30) dextroamphetamine oral 4 QL (1800/30) citalopram oral tablet 10 mg 1 QL (120/30) solution citalopram oral tablet 20 mg 1 QL (60/30) dextroamphetamine oral tablet 4 QL (180/30) citalopram oral tablet 40 mg 1 QL (90/30) dextroamphetamine- 4 QL (60/30) amphetamine oral clomipramine 3 PA capsule,extended release 24hr clonidine hcl oral tablet 4 QL (120/30) dextroamphetamine- 3 QL (180/30) extended release 12 hr amphetamine oral tablet 10 mg clorazepate dipotassium oral 3 QL (180/30) dextroamphetamine- 3 QL (60/30) tablet 15 mg, 3.75 mg amphetamine oral tablet 12.5 clorazepate dipotassium oral 3 QL (360/30) mg, 30 mg, 7.5 mg tablet 7.5 mg dextroamphetamine- 3 QL (120/30) clozapine oral tablet 3 amphetamine oral tablet 15 mg clozapine oral tablet, 4 QL (270/30) dextroamphetamine- 3 QL (90/30) disintegrating 100 mg amphetamine oral tablet 20 mg clozapine oral tablet, 4 dextroamphetamine- 3 QL (360/30) disintegrating 12.5 mg, 25 mg amphetamine oral tablet 5 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

27 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS diazepam injection syringe 2 oral tablet 10 mg, 20 2 diazepam oral solution 5 mg/5 2 QL (1200/30) mg ml (1 mg/ml) fluphenazine decanoate 4 diazepam oral tablet 2 QL (120/30) fluphenazine hcl injection 4 doxepin oral capsule 3 PA fluphenazine hcl oral 4 doxepin oral concentrate 3 PA concentrate doxepin oral tablet 3 QL (30/30) fluphenazine hcl oral elixir 4 DRIZALMA SPRINKLE ORAL 4 QL (180/30) fluphenazine hcl oral tablet 2 CAPSULE, DELAYED REL fluvoxamine oral tablet 2 SPRINKLE 20 MG GEODON INTRAMUSCULAR 4 QL (6/30) DRIZALMA SPRINKLE ORAL 4 QL (90/30) GUANIDINE 3 CAPSULE, DELAYED REL SPRINKLE 30 MG, 40 MG haloperidol decanoate 4 DRIZALMA SPRINKLE ORAL 4 QL (60/30) haloperidol lactate injection 4 CAPSULE, DELAYED REL haloperidol lactate oral 2 SPRINKLE 60 MG haloperidol oral tablet 0.5 mg, 1 1 duloxetine oral capsule,delayed 2 QL (180/30) mg, 2 mg, 5 mg release(dr/ec) 20 mg haloperidol oral tablet 10 mg, 2 duloxetine oral capsule,delayed 2 QL (90/30) 20 mg release(dr/ec) 30 mg HETLIOZ 5 PA; QL (30/30); duloxetine oral capsule,delayed 2 QL (60/30) NDS release(dr/ec) 60 mg imipramine hcl 3 PA EMSAM 5 QL (30/30); NDS INVEGA SUSTENNA 5 QL (0.75/28); NDS escitalopram oxalate oral 3 QL (600/30) INTRAMUSCULAR SYRINGE solution 117 MG/0.75 ML escitalopram oxalate oral tablet 2 INVEGA SUSTENNA 5 QL (1/28); NDS FANAPT ORAL TABLET 1 MG, 4 ST; QL (60/30) INTRAMUSCULAR SYRINGE 2 MG, 4 MG 156 MG/ML FANAPT ORAL TABLET 10 5 ST; QL (60/30); INVEGA SUSTENNA 5 QL (1.5/28); NDS MG, 12 MG, 6 MG, 8 MG NDS INTRAMUSCULAR SYRINGE 234 MG/1.5 ML FANAPT ORAL TABLETS, 4 ST; QL (16/365) DOSE PACK INVEGA SUSTENNA 4 QL (0.25/28) INTRAMUSCULAR SYRINGE FETZIMA ORAL CAPSULE, 4 ST; QL (56/365) 39 MG/0.25 ML EXT REL 24HR DOSE PACK INVEGA SUSTENNA 5 QL (0.5/28); NDS FETZIMA ORAL CAPSULE, 4 ST; QL (30/30) INTRAMUSCULAR SYRINGE EXTENDED RELEASE 24 HR 78 MG/0.5 ML fluoxetine oral capsule 2 INVEGA TRINZA 5 QL (0.88/90); NDS fluoxetine oral capsule,delayed 3 QL (4/28) INTRAMUSCULAR SYRINGE release(dr/ec) 273 MG/0.875 ML fluoxetine oral solution 2 QL (600/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

28 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS INVEGA TRINZA 5 QL (1.32/90); NDS nortriptyline 2 INTRAMUSCULAR SYRINGE NUPLAZID ORAL CAPSULE 5 PA; QL (30/30); 410 MG/1.315 ML NDS INVEGA TRINZA 5 QL (1.75/90); NDS NUPLAZID ORAL TABLET 10 5 PA; QL (30/30); INTRAMUSCULAR SYRINGE MG NDS 546 MG/1.75 ML olanzapine intramuscular 4 QL (30/30) INVEGA TRINZA 5 QL (2.63/90); NDS INTRAMUSCULAR SYRINGE olanzapine oral tablet 10 mg, 2 QL (120/30) 819 MG/2.625 ML 2.5 mg, 5 mg LATUDA ORAL TABLET 120 5 QL (30/30); NDS olanzapine oral tablet 15 mg, 2 QL (60/30) MG, 20 MG, 40 MG, 60 MG 20 mg LATUDA ORAL TABLET 80 MG 5 QL (60/30); NDS olanzapine oral tablet 7.5 mg 2 QL (30/30) lithium carbonate 2 olanzapine oral 3 QL (30/30) tablet,disintegrating lorazepam injection 4 olanzapine-fluoxetine 4 QL (30/30) lorazepam intensol 3 QL (150/30) oxazepam 2 QL (120/30) lorazepam oral concentrate 3 QL (150/30) paliperidone oral tablet 4 ST; QL (30/30) lorazepam oral tablet 0.5 mg, 2 QL (120/30) extended release 24hr 1.5 mg, 1 mg 3 mg, 9 mg lorazepam oral tablet 2 mg 2 QL (150/30) paliperidone oral tablet 4 ST; QL (60/30) loxapine succinate 2 extended release 24hr 6 mg maprotiline 4 paroxetine hcl oral tablet 10 mg 1 QL (60/30) MARPLAN 4 QL (180/30) paroxetine hcl oral tablet 20 mg 1 QL (90/30) methylphenidate hcl oral tablet 3 QL (90/30) paroxetine hcl oral tablet 30 2 QL (60/30) methylphenidate hcl oral tablet 3 QL (90/30) mg, 40 mg extended release paroxetine hcl oral tablet 3 QL (30/30) methylphenidate hcl oral tablet 3 QL (120/30) extended release 24 hr 12.5 mg extended release 24hr 18 mg, paroxetine hcl oral tablet 3 QL (60/30) 18 mg (bx rating) extended release 24 hr 25 mg, methylphenidate hcl oral tablet 3 QL (30/30) 37.5 mg extended release 24hr 27 mg, PAXIL ORAL SUSPENSION 4 ST; QL (900/30) 27 mg (bx rating), 54 mg, 54 perphenazine 4 mg (bx rating) perphenazine-amitriptyline 4 PA methylphenidate hcl oral tablet 3 QL (60/30) extended release 24hr 36 mg, PERSERIS 5 QL (1/30); NDS 36 mg (bx rating) phenelzine 3 mirtazapine oral tablet 2 pimozide 3 mirtazapine oral 2 QL (30/30) protriptyline 4 tablet,disintegrating quetiapine oral tablet 100 mg, 2 QL (90/30) molindone 2 200 mg, 25 mg, 50 mg nefazodone 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

29 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS quetiapine oral tablet 300 mg, 2 QL (60/30) trazodone 2 400 mg trifluoperazine 3 quetiapine oral tablet extended 3 QL (30/30) trimipramine 4 PA release 24 hr 150 mg, 200 mg TRINTELLIX 4 ST; QL (30/30) quetiapine oral tablet extended 3 QL (60/30) release 24 hr 300 mg, 400 mg, venlafaxine oral capsule, 2 QL (60/30) 50 mg extended release 24hr 150 mg, 37.5 mg ramelteon 3 venlafaxine oral capsule, 2 QL (90/30) REXULTI 5 QL (30/30); NDS extended release 24hr 75 mg RISPERDAL CONSTA 4 QL (2/28) venlafaxine oral tablet 2 INTRAMUSCULAR SUSPENSION,EXTENDED VERSACLOZ 4 QL (540/30) REL RECON 12.5 MG/2 ML, 25 VIIBRYD ORAL TABLET 4 ST; QL (30/30) MG/2 ML, 37.5 MG/2 ML VIIBRYD ORAL 4 ST; QL (60/365) RISPERDAL CONSTA 5 QL (2/28); NDS TABLETS,DOSE PACK 10 MG INTRAMUSCULAR (7)- 20 MG (23) SUSPENSION,EXTENDED VRAYLAR ORAL CAPSULE 5 ST; QL (30/30); REL RECON 50 MG/2 ML NDS risperidone oral solution 2 QL (240/30) VRAYLAR ORAL 4 ST; QL (14/365) risperidone oral tablet 2 CAPSULE,DOSE PACK risperidone oral tablet, 3 QL (60/30) XYREM 5 PA; QL (540/30); disintegrating 0.25 mg, 1 mg, 2 NDS mg, 3 mg oral capsule 10 mg 3 QL (60/30) risperidone oral tablet, 3 QL (120/30) zaleplon oral capsule 5 mg 3 QL (30/30) disintegrating 0.5 mg, 4 mg ziprasidone hcl 3 QL (60/30) SAPHRIS 4 QL (60/30) ziprasidone mesylate 4 QL (6/30) SECUADO 4 QL (30/30) oral tablet 3 QL (30/30) sertraline oral concentrate 2 QL (300/30) ZYPREXA RELPREVV 4 QL (2/28) sertraline oral tablet 100 mg, 2 QL (60/30) INTRAMUSCULAR 25 mg SUSPENSION FOR sertraline oral tablet 50 mg 2 QL (120/30) RECONSTITUTION 210 MG SILENOR 3 QL (30/30) ZYPREXA RELPREVV 5 QL (2/28); NDS temazepam oral capsule 15 2 QL (60/365) INTRAMUSCULAR mg, 30 mg SUSPENSION FOR RECONSTITUTION 300 MG temazepam oral capsule 22.5 3 QL (60/365) mg, 7.5 mg ZYPREXA RELPREVV 5 QL (1/28); NDS INTRAMUSCULAR thioridazine 3 SUSPENSION FOR thiothixene 4 RECONSTITUTION 405 MG tranylcypromine 4

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

30 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS

CARDIOVASCULAR, HYPERTENSION / LIPIDS bisoprolol fumarate 2 bisoprolol-hydrochlorothiazide 1 ANTIARRHYTHMIC AGENTS bumetanide injection 4 amiodarone intravenous 4 B/D PA bumetanide oral 2 solution BYSTOLIC 3 amiodarone oral 2 candesartan oral tablet 16 mg, 1 QL (60/30) dofetilide 3 4 mg, 8 mg flecainide 2 candesartan oral tablet 32 mg 1 QL (30/30) (pf) intravenous 4 candesartan-hydrochlorothiazid 1 syringe cartia xt 2 mexiletine 2 carvedilol 1 MULTAQ 3 QL (60/30) carvedilol phosphate 3 pacerone oral tablet 100 mg, 2 200 mg, 400 mg chlorothiazide oral tablet 500 2 mg propafenone oral 4 capsule,extended release 12 hr chlorothiazide sodium 4 propafenone oral tablet 2 chlorthalidone oral tablet 25 2 mg, 50 mg sulfate oral tablet 2 clonidine hcl oral tablet 0.1 mg, 1 sorine 2 0.2 mg sotalol af 2 clonidine hcl oral tablet 0.3 mg 2 sotalol oral 2 clonidine transdermal patch 3 QL (4/28) SOTYLIZE 4 weekly 0.1 mg/24 hr, 0.2 mg/24 ANTIHYPERTENSIVE THERAPY hr acebutolol 2 clonidine transdermal patch 3 QL (8/28) aliskiren 4 QL (30/30) weekly 0.3 mg/24 hr 2 DEMSER 5 PA; NDS amiloride-hydrochlorothiazide 2 diltiazem hcl intravenous 4 amlodipine 1 diltiazem hcl oral capsule,ext. 2 rel 24h degradable amlodipine-benazepril 1 diltiazem hcl oral capsule, 2 amlodipine-valsartan 1 extended release 12 hr amlodipine-valsartan-hcthiazid 1 diltiazem hcl oral capsule, 2 atenolol 1 extended release 24 hr 120 atenolol-chlorthalidone 1 mg, 180 mg, 240 mg, 300 mg, 420 mg benazepril 1 diltiazem hcl oral capsule, 2 benazepril-hydrochlorothiazide 1 extended release 24hr 120 mg, betaxolol oral 2 180 mg, 240 mg, 300 mg BIDIL 3 QL (180/30) diltiazem hcl oral tablet 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

31 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS diltiazem hcl oral tablet 2 metoprolol succinate 1 extended release 24 hr metoprolol ta-hydrochlorothiaz 2 dilt-xr 2 metoprolol tartrate oral 1 doxazosin 2 metyrosine 5 PA; NDS EDARBI 4 ST; QL (30/30) minoxidil oral 2 EDARBYCLOR 4 ST moexipril 1 enalapril maleate 1 nadolol 3 enalapril-hydrochlorothiazide 1 nadolol-bendroflumethiazide 3 ethacrynate sodium 4 oral tablet 80-5 mg felodipine 2 intravenous solution 4 fosinopril 1 QL (60/30) nicardipine oral 2 fosinopril-hydrochlorothiazide 1 QL (120/30) nifedipine oral tablet extended 2 QL (60/30) injection 2 release furosemide oral solution 10 mg/ 2 nifedipine oral tablet extended 2 QL (60/30) ml, 40 mg/5 ml (8 mg/ml) release 24hr furosemide oral tablet 1 nimodipine 4 hydralazine injection 4 nisoldipine 4 hydralazine oral 2 olmesartan 1 hydrochlorothiazide 1 olmesartan-hydrochlorothiazide 1 indapamide 1 perindopril erbumine 1 irbesartan oral tablet 150 mg 1 QL (60/30) phenoxybenzamine 5 NDS irbesartan oral tablet 300 mg, 1 QL (30/30) pindolol 1 75 mg prazosin 3 irbesartan-hydrochlorothiazide 1 QL (30/30) propranolol oral 3 isradipine 3 capsule,extended release 24 hr labetalol oral 2 propranolol oral solution 2 lisinopril 1 propranolol oral tablet 1 lisinopril-hydrochlorothiazide 1 propranolol-hydrochlorothiazid 2 losartan 1 QL (60/30) quinapril 1 losartan-hydrochlorothiazide 1 QL (30/30) quinapril-hydrochlorothiazide 1 oral tablet 100-12.5 mg, 100-25 ramipril 1 mg REMODULIN 5 B/D PA; NDS losartan-hydrochlorothiazide 1 QL (60/30) spironolactone 1 oral tablet 50-12.5 mg spironolacton-hydrochlorothiaz 2 matzim la 2 taztia xt oral capsule,extended 2 methyldopa 4 release 24 hr 120 mg, 180 mg, metolazone 2 240 mg, 300 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

32 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS TEKTURNA HCT 4 QL (30/30) aspirin-dipyridamole 4 QL (60/30) telmisartan oral tablet 20 mg, 1 QL (30/30) BRILINTA 3 QL (60/30) 40 mg cilostazol 2 telmisartan oral tablet 80 mg 1 QL (60/30) clopidogrel oral tablet 300 mg 2 QL (2/365) telmisartan-amlodipine 1 QL (30/30) clopidogrel oral tablet 75 mg 2 telmisartan-hydrochlorothiazid 1 QL (30/30) dipyridamole oral 3 PA oral tablet 40-12.5 mg, 80-25 mg ELIQUIS 3 telmisartan-hydrochlorothiazid 1 QL (60/30) ELIQUIS DVT-PE TREAT 30D 3 oral tablet 80-12.5 mg START terazosin 1 enoxaparin subcutaneous 3 solution tiadylt er 2 enoxaparin subcutaneous 3 timolol maleate oral 4 syringe 100 mg/ml, 30 mg/0.3 torsemide oral 2 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, trandolapril 1 80 mg/0.8 ml treprostinil sodium 5 B/D PA; NDS enoxaparin subcutaneous 4 syringe 120 mg/0.8 ml, 150 mg/ triamterene-hydrochlorothiazid 1 ml oral capsule 37.5-25 mg fondaparinux subcutaneous 5 NDS triamterene-hydrochlorothiazid 1 syringe 10 mg/0.8 ml, 5 mg/0.4 oral tablet ml, 7.5 mg/0.6 ml UPTRAVI 5 PA; NDS fondaparinux subcutaneous 4 valsartan oral tablet 160 mg, 40 1 QL (60/30) syringe 2.5 mg/0.5 ml mg, 80 mg heparin (porcine) in 5% dex 4 valsartan oral tablet 320 mg 1 QL (30/30) intravenous parenteral solution valsartan-hydrochlorothiazide 1 QL (30/30) 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), verapamil intravenous solution 4 25,000 unit/500 ml (50 unit/ml) verapamil oral capsule, 24 hr er 2 heparin (porcine) in nacl (pf) 4 pellet ct heparin (porcine) injection 3 verapamil oral capsule,ext rel. 2 solution pellets 24 hr 120 mg, 180 mg, 240 mg heparin(porcine) in 0.45% nacl 4 intravenous parenteral solution VERAPAMIL ORAL 3 25,000 unit/250 ml, 25,000 CAPSULE,EXT REL. PELLETS unit/500 ml 24 HR 360 MG heparin, porcine (pf) injection 4 verapamil oral tablet 1 syringe 5,000 unit/0.5 ml verapamil oral tablet extended 2 HEPARIN, PORCINE (PF) 4 release INJECTION SYRINGE 5,000 COAGULATION THERAPY UNIT/ML aminocaproic acid oral 4 jantoven 1

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

33 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS pentoxifylline 2 fenofibric acid (choline) oral 4 QL (60/30) phytonadione (vitamin k1) oral 2 ED; QL (3/30) capsule,delayed release(dr/ec) tablet 5 mg 45 mg PRADAXA 4 QL (60/30) gemfibrozil 2 prasugrel 4 QL (30/30) LIVALO 3 QL (30/30) PROMACTA ORAL POWDER 5 PA; QL (360/30); lovastatin 1 QL (60/30) IN PACKET 12.5 MG NDS oral tablet 500 mg 2 PROMACTA ORAL POWDER 5 PA; QL (180/30); niacin oral tablet extended 2 IN PACKET 25 MG NDS release 24 hr PROMACTA ORAL TABLET 5 PA; QL (30/30); niacor 2 NDS omega-3 acid ethyl esters 4 QL (120/30) warfarin 1 pravastatin oral tablet 10 mg, 1 QL (30/30) XARELTO 3 20 mg, 80 mg XARELTO DVT-PE TREAT 30D 3 pravastatin oral tablet 40 mg 1 QL (60/30) START prevalite 2 LIPID/ LOWERING AGENTS REPATHA 3 PA; QL (3/28) atorvastatin oral tablet 10 mg, 1 QL (30/30) REPATHA PUSHTRONEX 3 PA; QL (3.5/28) 20 mg, 80 mg REPATHA SURECLICK 3 PA; QL (3/28) atorvastatin oral tablet 40 mg 1 QL (60/30) rosuvastatin 1 QL (30/30) cholestyramine (with sugar) 2 simvastatin oral tablet 1 QL (30/30) cholestyramine light 2 VASCEPA ORAL CAPSULE 0.5 3 QL (240/30) colesevelam 3 GRAM colestipol 3 VASCEPA ORAL CAPSULE 1 3 QL (120/30) ezetimibe 2 QL (30/30) GRAM ezetimibe-simvastatin 4 QL (30/30) MISCELLANEOUS CARDIOVASCULAR AGENTS fenofibrate micronized oral 4 CORLANOR ORAL TABLET 4 PA; QL (60/30) capsule 130 mg, 43 mg digitek 2 fenofibrate micronized oral 3 digox 2 capsule 134 mg, 200 mg, 67 mg digoxin oral solution 50 mcg/ml 3 QL (150/30) (0.05 mg/ml) fenofibrate nanocrystallized oral 3 tablet 145 mg, 48 mg digoxin oral tablet 2 fenofibrate oral capsule 4 ENTRESTO 3 QL (60/30) fenofibrate oral tablet 160 mg, 2 ranolazine 4 QL (60/30) 54 mg NITRATES fenofibric acid (choline) oral 4 QL (30/30) isosorbide dinitrate oral tablet 3 capsule,delayed release(dr/ec) isosorbide mononitrate 2 135 mg minitran 2 nitroglycerin intravenous 4 B/D PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

34 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS nitroglycerin sublingual 2 lidocaine hcl injection solution 4 nitroglycerin transdermal patch 2 lidocaine hcl laryngotracheal 2 24 hour lidocaine hcl mucous 3 QL (60/30) nitroglycerin translingual 4 membrane jelly spray,non-aerosol lidocaine hcl mucous 3 QL (60/30) DERMATOLOGICALS/TOPICAL THERAPY membrane jelly in applicator lidocaine hcl mucous 2 ANTIPSORIATIC / ANTISEBORRHEIC membrane solution 4% (40 mg/ acitretin 4 PA ml) calcipotriene scalp 3 lidocaine topical adhesive 4 PA; QL (90/30) calcipotriene topical cream 4 QL (120/30) patch,medicated 5% calcipotriene topical ointment 4 QL (120/30) lidocaine topical ointment 4 QL (50/30) calcitriol topical 4 lidocaine viscous 1 selenium sulfide topical lotion 2 lidocaine-prilocaine topical 4 QL (30/30) cream SKYRIZI SUBCUTANEOUS 5 PA; QL (2/28); NDS SYRINGE KIT methoxsalen 4 STELARA SUBCUTANEOUS 5 PA; QL (0.5/28); PANRETIN 5 NDS SOLUTION NDS PICATO TOPICAL GEL 0.015% 4 QL (3/56) STELARA SUBCUTANEOUS 5 PA; QL (0.5/28); PICATO TOPICAL GEL 0.05% 4 QL (2/56) SYRINGE 45 MG/0.5 ML NDS pimecrolimus 4 QL (100/90) STELARA SUBCUTANEOUS 5 PA; QL (1/28); NDS podofilox 2 SYRINGE 90 MG/ML REGRANEX 5 PA; NDS MISCELLANEOUS DERMATOLOGICALS SANTYL 3 acyclovir topical cream 5 QL (5/30); NDS silver sulfadiazine 3 acyclovir topical ointment 4 QL (30/30) ssd 3 ammonium lactate 2 tacrolimus topical 3 QL (100/90) DENAVIR 5 QL (5/30); NDS TOLAK 4 DUPIXENT PEN 5 PA; NDS VALCHLOR 5 PA; QL (60/30); DUPIXENT SYRINGE 5 PA; NDS NDS fluorouracil topical cream 0.5% 5 NDS ZTLIDO 4 PA; QL (90/30) fluorouracil topical cream 5% 3 THERAPY FOR ACNE fluorouracil topical solution 2 amnesteem 4 glydo 3 QL (60/30) avita 4 PA imiquimod topical cream in 5 NDS claravis 4 metered-dose pump clindacin etz topical swab 2 imiquimod topical cream in 3 clindacin p 2 packet clindamycin phosphate topical 3 lidocaine (pf) injection solution 4 gel

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

35 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CLINDAMYCIN PHOSPHATE 3 ciclopirox topical shampoo 3 QL (120/28) TOPICAL GEL, ONCE DAILY ciclopirox topical solution 3 clindamycin phosphate topical 4 ciclopirox topical suspension 3 lotion clotrimazole topical cream 2 clindamycin phosphate topical 3 solution clotrimazole topical solution 2 QL (30/28) clindamycin phosphate topical 2 clotrimazole- 2 QL (45/28) swab topical cream ery pads 3 clotrimazole-betamethasone 2 QL (60/28) topical lotion erythromycin with ethanol 3 topical gel econazole 3 QL (85/28) erythromycin with ethanol 2 ketoconazole topical cream 2 QL (60/28) topical solution ketoconazole topical shampoo 2 QL (120/28) erythromycin-benzoyl peroxide 4 naftifine topical cream 3 QL (60/28) isotretinoin 4 NAFTIN TOPICAL GEL 3 metronidazole topical 3 nyamyc 2 myorisan 4 nystatin topical cream 2 QL (30/28) rosadan topical cream 3 nystatin topical ointment 2 QL (30/28) rosadan topical gel 3 nystatin topical powder 2 tazarotene 4 nystatin-triamcinolone 4 QL (60/28) TAZORAC TOPICAL CREAM 4 nystop 2 TAZORAC TOPICAL GEL 4 QL (100/30) TOPICAL tretinoin microspheres 4 PA ala-cort topical cream 1% 1 tretinoin topical cream 0.025%, 4 PA alclometasone 2 0.05%, 0.1% betamethasone dipropionate 3 tretinoin topical topical gel 3 PA betamethasone valerate topical 2 0.01% cream tretinoin topical topical gel 4 PA betamethasone valerate topical 3 0.025%, 0.05% foam zenatane 4 betamethasone valerate topical 2 TOPICAL ANTIBACTERIALS lotion gentamicin topical 3 betamethasone valerate topical 2 mupirocin 2 ointment mupirocin calcium 4 betamethasone, augmented 2 sodium (acne) 3 clobetasol scalp 2 QL (100/28) TOPICAL ANTIFUNGALS clobetasol topical cream 2 QL (120/28) ciclodan topical solution 3 clobetasol topical foam 4 QL (100/28) ciclopirox topical cream 3 QL (90/28) clobetasol topical gel 2 QL (120/28) clobetasol topical ointment 2 QL (120/28)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

36 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS clobetasol topical shampoo 4 QL (236/28) butyr-emollient 4 clobetasol-emollient topical 2 QL (120/28) hydrocortisone topical cream 1 cream 1%, 2.5% clobetasol-emollient topical 4 hydrocortisone topical lotion 2 foam 2.5% CLOCORTOLONE PIVALATE 4 hydrocortisone topical ointment 2 clodan 4 QL (236/28) 1%, 2.5% desonide topical cream 3 hydrocortisone valerate 3 desonide topical lotion 3 mometasone topical 2 desonide topical ointment 3 prednicarbate topical ointment 2 desoximetasone topical cream 4 triamcinolone acetonide topical 2 cream 0.025%, 0.5% desoximetasone topical gel 4 triamcinolone acetonide topical 1 desoximetasone topical 4 cream 0.1% ointment triamcinolone acetonide topical 2 fluocinolone and shower cap 3 lotion fluocinolone topical cream 2 triamcinolone acetonide topical 2 fluocinolone topical oil 3 ointment fluocinolone topical ointment 2 triderm topical cream 0.1% 1 fluocinolone topical solution 2 TOPICAL SCABICIDES / PEDICULICIDES fluocinonide topical cream 2 topical shampoo 3 0.05% malathion 4 fluocinonide topical cream 0.1% 4 permethrin topical cream 2 fluocinonide topical gel 2 QL (120/30) DIAGNOSTICS / MISCELLANEOUS AGENTS fluocinonide topical ointment 3 QL (120/30) fluocinonide topical solution 3 QL (120/30) IRRIGATING SOLUTIONS fluticasone propionate topical 2 lactated ringers irrigation 4 cream neomycin-polymyxin b gu 4 fluticasone propionate topical 2 PHYSIOLYTE 4 ointment PHYSIOSOL IRRIGATION 4 halobetasol propionate topical 3 ringer’s irrigation 4 cream tis-u-sol pentalyte 4 halobetasol propionate topical 3 ointment MISCELLANEOUS AGENTS hydrocortisone butyrate topical 4 acamprosate 2 cream anagrelide 2 hydrocortisone butyrate topical 3 ARALAST NP 5 B/D PA; NDS ointment AURYXIA 4 PA; QL (360/30) hydrocortisone butyrate topical 3 CARBAGLU 5 PA; NDS solution

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

37 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CARNITOR INTRAVENOUS 4 B/D PA LOKELMA 3 CHEMET 5 NDS midodrine 2 CLINIMIX 4.25%/D5W SULFIT 4 B/D PA nitisinone 5 NDS FREE NORTHERA ORAL CAPSULE 5 PA; QL (90/30); d10%-0.45% sodium chloride 4 B/D PA 100 MG NDS d2.5%-0.45% sodium chloride 4 B/D PA NORTHERA ORAL CAPSULE 5 PA; QL (180/30); d5% and 0.9% sodium chloride 4 200 MG, 300 MG NDS d5%-0.45% sodium chloride 4 ORFADIN 5 NDS deferasirox oral granules in 5 NDS pilocarpine hcl oral 3 packet PROLASTIN-C 5 B/D PA; NDS deferasirox oral tablet 5 NDS RENVELA ORAL POWDER IN 3 QL (180/30) dextrose 10% and 0.2% nacl 4 B/D PA PACKET DEXTROSE 10% IN WATER 4 B/D PA RENVELA ORAL TABLET 3 QL (540/30) (D10W) riluzole 3 dextrose 25% in water (d25w) 4 B/D PA SEVELAMER CARBONATE 4 QL (180/30) dextrose 30% in water (d30w) 4 B/D PA ORAL POWDER IN PACKET dextrose 40% in water (d40w) 4 B/D PA SEVELAMER CARBONATE 4 QL (540/30) ORAL TABLET DEXTROSE 5% IN WATER 4 (D5W) INTRAVENOUS sodium chloride 0.9% 4 PARENTERAL SOLUTION intravenous dextrose 5% in water (d5w) 4 sodium chloride irrigation 4 intravenous piggyback sodium phenylbutyrate 5 PA; NDS dextrose 5%-lactated ringers 4 B/D PA sodium polystyrene (sorb free) 3 dextrose 5%-0.2% sod chloride 4 sodium polystyrene sulfonate 3 dextrose 5%-0.3% sod.chloride 4 oral powder dextrose 50% in water (d50w) 4 B/D PA sps (with sorbitol) 3 dextrose 70% in water (d70w) 4 trientine 5 QL (240/30); NDS disulfiram 2 VELPHORO 4 QL (180/30) FERRIPROX 5 PA; NDS VELTASSA 3 FERRIPROX (2 TIMES A DAY) 5 PA; NDS water for irrigation, sterile 4 INCRELEX 4 PA XIAFLEX 5 PA; NDS JADENU 5 NDS ZEMAIRA 5 B/D PA; NDS JADENU SPRINKLE 5 NDS zoledronic acid-mannitol- 4 B/D PA; QL water intravenous piggyback 5 (100/365) kionex (with sorbitol) 3 mg/100 ml levocarnitine (with sugar) 2 SMOKING DETERRENTS levocarnitine oral solution 100 2 bupropion hcl (smoking deter) 3 QL (60/30) mg/ml CHANTIX 3 levocarnitine oral tablet 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

38 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CHANTIX CONTINUING 3 DEPO-MEDROL 4 MONTH BOX intensol 4 CHANTIX STARTING MONTH 3 dexamethasone oral elixir 2 BOX dexamethasone oral solution 2 NICOTROL 4 dexamethasone oral tablet 0.5 1 NICOTROL NS 4 QL (30/30) mg, 0.75 mg, 4 mg EAR, NOSE / THROAT MEDICATIONS dexamethasone oral tablet 1 2 mg, 1.5 mg, 2 mg, 6 mg MISCELLANEOUS AGENTS dexamethasone sodium phos 4 azelastine nasal 3 QL (30/25) (pf) injection solution gluconate 1 dexamethasone sodium 4 mucous membrane phosphate injection solution fluoride (sodium) dental paste 4 fludrocortisone 2 ipratropium bromide nasal 2 QL (30/30) hydrocortisone oral 3 spray,non-aerosol 0.03% MEDROL ORAL TABLET 2 MG 3 ipratropium bromide nasal 2 QL (45/30) methylprednisolone 2 spray,non-aerosol 42 mcg (0.06%) methylprednisolone acetate 4 oralone 3 methylprednisolone sodium 4 succ injection recon soln 125 paroex oral rinse 1 mg, 40 mg sodium fluoride-pot nitrate 4 methylprednisolone sodium 4 QL (8/30) triamcinolone acetonide dental 3 succ intravenous recon soln MISCELLANEOUS OTIC PREPARATIONS 1,000 mg otic (ear) 2 methylprednisolone sodium 4 QL (12/30) flac otic oil 4 succ intravenous recon soln 500 mg oil 4 oral solution 15 3 hydrocortisone-acetic acid 2 mg/5 ml OTIC STEROID / prednisolone sodium 3 CIPRO HC 3 phosphate oral solution 15 CIPRODEX 3 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml (5 mg/ml), 5 ciprofloxacin-dexamethasone 3 mg base/5 ml (6.7 mg/5 ml) CORTISPORIN-TC 4 prednisone intensol 4 neomycin-polymyxin-hc otic 3 prednisone oral solution 2 (ear) prednisone oral tablet 1 mg, 10 1 B/D PA ENDOCRINE/DIABETES mg, 2.5 mg, 20 mg, 5 mg ADRENAL HORMONES prednisone oral tablet 50 mg 2 B/D PA cortisone 4 prednisone oral tablets,dose 1 pack

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

39 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SOLU-CORTEF ACT-O-VIAL 4 glipizide-metformin oral tablet 1 QL (120/30) (PF) 2.5-500 mg, 5-500 mg triamcinolone acetonide 2 GLUCAGEN HYPOKIT 3 injection GLUCAGON (HCL) 3 ANTITHYROID AGENTS EMERGENCY KIT methimazole oral tablet 10 mg, 2 GLUCAGON EMERGENCY 3 5 mg KIT (HUMAN) propylthiouracil 3 GLYXAMBI 3 QL (30/30) DIABETES THERAPY GVOKE HYPOPEN 1-PACK 3 acarbose oral tablet 100 mg, 2 QL (90/30) GVOKE HYPOPEN 2-PACK 3 25 mg GVOKE PFS 1-PACK 3 acarbose oral tablet 50 mg 2 QL (180/30) SYRINGE PADS 2 GVOKE PFS 2-PACK 3 BAQSIMI 3 SYRINGE BD PEN NEEDLE 2 QL(200/30) HUMALOG JUNIOR KWIKPEN 6 U-100 BYDUREON BCISE 4 QL (4/28) HUMALOG KWIKPEN 6 BYDUREON 4 QL (4/28) INSULIN SUBCUTANEOUS PEN INJECTOR HUMALOG MIX 50-50 INSULN 6 U-100 CYCLOSET 4 QL (180/30) HUMALOG MIX 50-50 6 diazoxide 4 KWIKPEN FARXIGA ORAL TABLET 10 3 QL (30/30) HUMALOG MIX 75-25 6 MG KWIKPEN FARXIGA ORAL TABLET 5 MG 3 QL (60/30) HUMALOG MIX 75-25(U-100) 6 GAUZE PADS 2 X 2 2 INSULN glimepiride oral tablet 1 mg 1 QL (240/30) HUMALOG U-100 INSULIN 6 glimepiride oral tablet 2 mg 1 QL (120/30) HUMULIN 70/30 U-100 6 glimepiride oral tablet 4 mg 1 QL (60/30) INSULIN glipizide oral tablet 10 mg 1 QL (120/30) HUMULIN 70/30 U-100 6 KWIKPEN glipizide oral tablet 5 mg 1 QL (240/30) HUMULIN N NPH INSULIN 6 glipizide oral tablet extended 1 QL (60/30) KWIKPEN release 24hr 10 mg HUMULIN N NPH U-100 6 glipizide oral tablet extended 1 QL (240/30) INSULIN release 24hr 2.5 mg HUMULIN R REGULAR U-100 6 glipizide oral tablet extended 1 QL (120/30) INSULN release 24hr 5 mg HUMULIN R U-500 (CONC) 6 B/D PA glipizide-metformin oral tablet 1 QL (240/30) INSULIN 2.5-250 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

40 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS HUMULIN R U-500 (CONC) 6 metformin oral tablet extended 1 QL (120/30) KWIKPEN release 24 hr 500 mg (generic INSULIN PEN NEEDLE 2 QL (200/30) for glucophage xr) INSULIN SYRINGE (DISP) 2 QL (200/30) metformin oral tablet extended 1 QL (60/30) U-100 0.3 ML, 1 ML, 1/2 ML release 24 hr 750 mg (generic for glucophage xr) INVOKAMET 4 QL (60/30) metformin oral tablet extended 1 QL (60/30) INVOKAMET XR 4 QL (60/30) release (osm) 24 hr 1000mg, INVOKANA 4 QL (30/30) 500mg (generic for fortamet) JANUMET 3 QL (60/30) miglitol 4 QL (90/30) JANUMET XR ORAL TABLET, 3 QL (30/30) nateglinide oral tablet 120 mg 1 QL (90/30) ER MULTIPHASE 24 HR 100- nateglinide oral tablet 60 mg 1 QL (180/30) 1,000 MG NEEDLES, INSULIN 2 QL (200/30) JANUMET XR ORAL TABLET, 3 QL (60/30) DISP.,SAFETY ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG NOVOFINE PEN NEEDLE 2 QL(200/30) JANUVIA 3 QL (30/30) NOVOTWIST PEN NEEDLE 2 QL(200/30) JARDIANCE 3 QL (30/30) OMNIPOD 5 PACK 3 QL(30/30) JENTADUETO 3 QL (60/30) OMNIPOD DASH 5 PACK 3 QL(30/30) JENTADUETO XR ORAL 3 QL (60/30) OMNIPOD STARTER KIT 3 QL(1/365) TABLET, IR - ER, BIPHASIC OZEMPIC 3 QL (3/28) 24HR 2.5-1,000 MG pioglitazone oral tablet 15 mg 1 QL (90/30) JENTADUETO XR ORAL 3 QL (30/30) pioglitazone oral tablet 30 mg, 1 QL (30/30) TABLET, IR - ER, BIPHASIC 45 mg 24HR 5-1,000 MG pioglitazone-metformin 1 QL (90/30) LANTUS SOLOSTAR U-100 6 INSULIN PROGLYCEM 4 LANTUS U-100 INSULIN 6 repaglinide oral tablet 0.5 mg, 1 QL (120/30) 1 mg LEVEMIR FLEXTOUCH U-100 6 INSULN repaglinide oral tablet 2 mg 1 QL (240/30) LEVEMIR U-100 INSULIN 6 RIOMET 3 QL (750/30) LYUMJEV KWIKPEN U-100 6 RIOMET ER 3 QL (600/30) INSULIN SOLIQUA 100/33 3 QL (18/30) LYUMJEV KWIKPEN U-200 6 SYMLINPEN 120 5 PA; QL (10.8/28); INSULIN NDS LYUMJEV U-100 INSULIN 6 SYMLINPEN 60 5 PA; QL (6/30); NDS metformin oral solution 3 QL (750/30) SYNJARDY 3 QL (60/30) metformin oral tablet 1,000 mg 1 QL (75/30) SYNJARDY XR ORAL TABLET, 3 QL (60/30) metformin oral tablet 500 mg 1 QL (150/30) IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, metformin oral tablet 850 mg 1 QL (90/30) 5-1,000 MG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

41 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SYNJARDY XR ORAL TABLET, 3 QL (30/30) calcitriol oral 2 IR - ER, BIPHASIC 24HR CEREZYME INTRAVENOUS 5 B/D PA; NDS 25-1,000 MG RECON SOLN 400 UNIT TECHLITE PEN NEEDLE 2 QL(200/30) CHORIONIC 4 PA TOUJEO MAX U-300 6 GONADOTROPIN, HUMAN SOLOSTAR INTRAMUSCULAR TOUJEO SOLOSTAR U-300 6 cinacalcet oral tablet 30 mg, 60 4 QL (60/30) INSULIN mg TRADJENTA 3 QL (30/30) cinacalcet oral tablet 90 mg 4 QL (120/30) TRESIBA FLEXTOUCH U-100 6 danazol 4 TRESIBA FLEXTOUCH U-200 6 desmopressin injection 4 TRESIBA U-100 INSULIN 6 desmopressin nasal spray with 4 TRIJARDY XR ORAL TABLET, 3 QL (30/30) pump IR - ER, BIPHASIC 24HR 10-5- desmopressin nasal spray,non- 4 1,000 MG, 25-5-1,000 MG aerosol TRIJARDY XR ORAL TABLET, 3 QL (60/30) desmopressin oral 3 IR - ER, BIPHASIC 24HR 12.5- doxercalciferol intravenous 4 2.5-1,000 MG, 5-2.5-1,000 MG doxercalciferol oral capsule 0.5 4 QL (90/30) TRULICITY 3 QL (2/28) mcg V-GO 20 3 doxercalciferol oral capsule 1 4 QL (240/30) V-GO 30 3 mcg V-GO 40 3 doxercalciferol oral capsule 2.5 4 QL (120/30) VICTOZA 2-PAK 3 QL (9/30) mcg VICTOZA 3-PAK 3 QL (9/30) ELAPRASE 5 PA; NDS XIGDUO XR ORAL TABLET, 3 QL (30/30) FABRAZYME 5 B/D PA; NDS IR - ER, BIPHASIC 24HR KORLYM 5 PA; QL (120/30); 10-1,000 MG, 10-500 MG NDS XIGDUO XR ORAL TABLET, 3 QL (60/30) KUVAN 5 PA; NDS IR - ER, BIPHASIC 24HR 2.5- LUMIZYME 5 PA; NDS 1,000 MG, 5-1,000 MG, 5-500 MG MIACALCIN INJECTION 5 NDS XULTOPHY 100/3.6 3 QL (15/30) miglustat 5 QL (90/30); NDS MISCELLANEOUS HORMONES NAGLAZYME 5 PA; NDS ALDURAZYME 5 PA; NDS NATPARA 5 PA; QL (2/28); NDS ANADROL-50 5 PA; NDS oxandrolone oral tablet 10 mg 4 PA; QL (60/30) cabergoline 3 oxandrolone oral tablet 2.5 mg 3 PA; QL (120/30) calcitonin (salmon) 3 pamidronate 4 B/D PA calcitriol intravenous solution 1 4 paricalcitol oral capsule 1 mcg, 2 mcg/ml 2 mcg paricalcitol oral capsule 4 mcg 4

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

42 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SAMSCA ORAL TABLET 15 5 PA; QL (30/30); liothyronine oral 2 MG NDS SYNTHROID 3 SAMSCA ORAL TABLET 30 5 PA; QL (60/30); THYROLAR-1 3 MG NDS THYROLAR-1/2 3 sapropterin 5 PA; NDS THYROLAR-1/4 3 SENSIPAR ORAL TABLET 30 4 QL (60/30) MG, 60 MG THYROLAR-2 3 SENSIPAR ORAL TABLET 90 4 QL (120/30) THYROLAR-3 3 MG UNITHROID ORAL TABLET 3 SOMAVERT 5 PA; QL (30/30); 100 MCG, 112 MCG, 125 NDS MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, STIMATE 5 NDS 50 MCG, 75 MCG, 88 MCG SYNAREL 5 PA; NDS unithroid oral tablet 137 mcg 3 testosterone cypionate 3 intramuscular oil 100 mg/ml, GASTROENTEROLOGY 200 mg/ml (1 ml) ANTIDIARRHEALS / ANTISPASMODICS TESTOSTERONE CYPIONATE 3 atropine injection solution 0.4 4 INTRAMUSCULAR OIL 200 mg/ml MG/ML atropine injection syringe 0.05 4 testosterone enanthate 4 mg/ml, 0.1 mg/ml testosterone transdermal gel 4 PA; QL (300/30) dicyclomine oral capsule 1 testosterone transdermal gel in 4 PA; QL (300/30) dicyclomine oral solution 3 metered-dose pump 12.5 mg/ 1.25 gram (1%) dicyclomine oral tablet 1 testosterone transdermal gel 4 PA; QL (300/30) diphenoxylate-atropine oral 3 in packet 1% (25 mg/2.5gram), liquid 1% (50 mg/5 gram) diphenoxylate-atropine oral 2 tolvaptan oral tablet 30 mg 5 PA; QL (60/30); tablet NDS GLYCOPYRROLATE (PF) IN 4 zoledronic acid intravenous 4 B/D PA; QL (15/21) WATER INJECTION solution glycopyrrolate (pf) in water 4 THYROID HORMONES intravenous syringe 0.4 mg/2 ml (0.2 mg/ml) EUTHYROX 3 glycopyrrolate injection 4 LEVO-T 3 glycopyrrolate oral 2 levothyroxine oral 1 loperamide oral capsule 2 levoxyl oral tablet 100 mcg, 112 3 mcg, 175 mcg propantheline 4 LEVOXYL ORAL TABLET 125 3 MISCELLANEOUS GASTROINTESTINAL AGENTS MCG, 137 MCG, 150 MCG, alosetron oral tablet 0.5 mg 4 PA; QL (60/30) 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

43 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS alosetron oral tablet 1 mg 5 PA; QL (60/30); mesalamine oral 3 QL (120/30) NDS capsule,extended release 24hr AMITIZA 3 QL (60/30) mesalamine oral tablet,delayed 4 QL (120/30) aprepitant 4 B/D PA release (dr/ec) 1.2 gram APRISO 3 QL (120/30) mesalamine rectal enema 4 AVSOLA 5 PA; NDS mesalamine with cleansing 4 wipe balsalazide 4 metoclopramide hcl injection 4 budesonide oral 4 solution capsule,delayed,extend.release metoclopramide hcl oral 2 budesonide oral tablet,delayed 5 NDS solution and ext.release metoclopramide hcl oral tablet 2 compro 2 OCALIVA 5 PA; QL (30/30); constulose 2 NDS CREON 3 ondansetron 1 B/D PA cromolyn oral 3 ondansetron hcl (pf) 4 CYSTADANE 5 NDS ondansetron hcl intravenous 4 dronabinol 4 PA; QL (60/30) ondansetron hcl oral solution 3 B/D PA; QL EMEND ORAL SUSPENSION 4 B/D PA (450/30) FOR RECONSTITUTION ondansetron hcl oral tablet 1 B/D PA enulose 2 OSMOPREP 4 GATTEX 30-VIAL 5 PA; NDS palonosetron intravenous 5 B/D PA; NDS GATTEX ONE-VIAL 5 PA; NDS solution 0.25 mg/5 ml gavilyte-c 2 peg 3350-electrolytes oral 2 gavilyte-g 2 recon soln 236-22.74-6.74 -5.86 gram gavilyte-n 2 peg-electrolyte 2 generlac 2 PENTASA 3 granisetron (pf) intravenous 4 HI solution 1 mg/ml (1 ml) PLENVU 4 granisetron hcl intravenous 4 HI prochlorperazine 2 granisetron hcl oral 3 B/D PA; QL (30/30) prochlorperazine edisylate 4 hydrocortisone rectal 3 prochlorperazine maleate oral 2 hydrocortisone topical cream 1 procto-med hc 2 with perineal applicator procto-pak 2 lactulose oral solution 2 proctosol hc topical 2 LINZESS 3 QL (30/30) proctozone-hc 2 meclizine oral tablet 12.5 mg, 2 RECTIV 4 QL (30/30) 25 mg RELISTOR SUBCUTANEOUS 5 PA; NDS SOLUTION

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

44 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS RELISTOR SUBCUTANEOUS 5 PA; NDS pantoprazole oral 1 QL (60/30) SYRINGE tablet,delayed release (dr/ec) RENFLEXIS 5 PA; NDS ranitidine hcl oral syrup 2 SANCUSO 5 QL (4/28); NDS ranitidine hcl oral tablet 150 2 scopolamine base 4 QL (10/30) mg, 300 mg sulfasalazine 2 sucralfate oral suspension 4 SUPREP BOWEL PREP KIT 3 sucralfate oral tablet 2 trilyte with flavor packets 2 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY TRULANCE 4 BIOTECHNOLOGY DRUGS ursodiol 3 ACTIMMUNE 5 PA; NDS VIBERZI 4 PA; QL (60/30) ARANESP (IN 5 PA; QL (4/28); NDS VIOKACE ORAL TABLET 4 POLYSORBATE) INJECTION 10,440-39,150- 39,150 UNIT SOLUTION 100 MCG/ML, 200 VIOKACE ORAL TABLET 5 NDS MCG/ML, 300 MCG/ML, 60 20,880-78,300- 78,300 UNIT MCG/ML ZENPEP ORAL 3 ARANESP (IN 4 PA; QL (4/28) CAPSULE,DELAYED POLYSORBATE) INJECTION RELEASE(DR/EC) 10,000- SOLUTION 25 MCG/ML, 40 32,000 -42,000 UNIT, MCG/ML 15,000-47,000 -63,000 UNIT, ARANESP (IN 4 PA; QL (1.6/28) 20,000-63,000- 84,000 UNIT, POLYSORBATE) INJECTION 25,000-79,000- 105,000 UNIT, SYRINGE 10 MCG/0.4 ML, 40 3,000-10,000 -14,000-UNIT, MCG/0.4 ML 40,000-126,000- 168,000 UNIT, ARANESP (IN 5 PA; QL (2/28); NDS 5,000-17,000- 24,000 UNIT POLYSORBATE) INJECTION ULCER THERAPY SYRINGE 100 MCG/0.5 ML CARAFATE ORAL 4 ARANESP (IN 5 PA; QL (1.2/28); SUSPENSION POLYSORBATE) INJECTION NDS esomeprazole magnesium oral 3 QL (60/30) SYRINGE 150 MCG/0.3 ML capsule,delayed release(dr/ec) ARANESP (IN 5 PA; QL (1.6/28); famotidine oral suspension 4 POLYSORBATE) INJECTION NDS famotidine oral tablet 20 mg, 2 SYRINGE 200 MCG/0.4 ML 40 mg ARANESP (IN 4 PA; QL (1.68/28) lansoprazole oral 3 QL (60/30) POLYSORBATE) INJECTION capsule,delayed release(dr/ec) SYRINGE 25 MCG/0.42 ML misoprostol 3 ARANESP (IN 5 PA; QL (2.4/28); POLYSORBATE) INJECTION NDS nizatidine oral capsule 2 SYRINGE 300 MCG/0.6 ML omeprazole oral 2 QL (60/30) ARANESP (IN 5 PA; QL (1/21); NDS capsule,delayed release(dr/ec) POLYSORBATE) INJECTION SYRINGE 500 MCG/ML

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

45 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ARANESP (IN 4 PA; QL (1.2/28) REBIF TITRATION PACK 5 PA; QL (8.4/365); POLYSORBATE) INJECTION NDS SYRINGE 60 MCG/0.3 ML RETACRIT INJECTION 4 PA; QL (12/28) ARCALYST 5 PA; NDS SOLUTION 10,000 UNIT/ML, AVONEX INTRAMUSCULAR 5 PA; QL (1/28); NDS 2,000 UNIT/ML, 3,000 UNIT/ PEN INJECTOR KIT ML, 4,000 UNIT/ML AVONEX INTRAMUSCULAR 5 PA; QL (1/28); NDS RETACRIT INJECTION 5 PA; QL (6/28); NDS SYRINGE KIT SOLUTION 40,000 UNIT/ML BETASERON 5 PA; QL (14/28); SYLATRON SUBCUTANEOUS 5 PA; QL (4/28); NDS SUBCUTANEOUS KIT NDS KIT 200 MCG, 300 MCG GENOTROPIN 5 PA; NDS ZARXIO 5 PA; NDS GENOTROPIN MINIQUICK 4 PA ZIEXTENZO 5 PA; NDS SUBCUTANEOUS SYRINGE VACCINES / MISCELLANEOUS IMMUNOLOGICALS 0.2 MG/0.25 ML ACTHIB (PF) 3 GENOTROPIN MINIQUICK 5 PA; NDS ADACEL(TDAP ADOLESN/ 3 QL (0.5/365) SUBCUTANEOUS SYRINGE ADULT)(PF) 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 ATGAM 4 PA MG/0.25 ML, 1.2 MG/0.25 BCG VACCINE, LIVE (PF) 3 ML, 1.4 MG/0.25 ML, 1.6 BEXSERO 3 MG/0.25 ML, 1.8 MG/0.25 ML, BOOSTRIX TDAP 3 QL (0.5/365) 2 MG/0.25 ML BOTOX 4 PA INTRON A INJECTION RECON 5 NDS SOLN DAPTACEL (DTAP 3 PEDIATRIC) (PF) INTRON A INJECTION 5 NDS SOLUTION 10 MILLION UNIT/ ENGERIX-B (PF) 3 B/D PA; QL (8/365) ML INTRAMUSCULAR SYRINGE INTRON A INJECTION 4 ENGERIX-B PEDIATRIC (PF) 3 B/D PA; QL (3/365) SOLUTION 6 MILLION UNIT/ INTRAMUSCULAR SYRINGE ML fomepizole 5 NDS LEUKINE INJECTION RECON 5 PA; NDS GAMMAKED INJECTION 5 B/D PA; NDS SOLN SOLUTION 1 GRAM/10 ML MOZOBIL 5 QL (9.6/30); NDS (10%), 10 GRAM/100 ML (10%), 20 GRAM/200 ML REBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDS (10%), 5 GRAM/50 ML (10%) REBIF REBIDOSE 5 PA; QL (6/28); NDS GAMUNEX-C 5 B/D PA; NDS SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 GARDASIL 9 (PF) 3 QL (1.5/365) MCG/0.5 ML HAVRIX (PF) 3 REBIF REBIDOSE 5 PA; QL (8.4/365); INTRAMUSCULAR SUBCUTANEOUS PEN NDS SUSPENSION 1,440 ELISA INJECTOR 8.8MCG/0.2ML-22 UNIT/ML MCG/0.5ML (6)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

46 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS HAVRIX (PF) 3 TENIVAC (PF) 3 QL (0.5/28) INTRAMUSCULAR SYRINGE INTRAMUSCULAR SYRINGE HIBERIX (PF) 3 TETANUS,DIPHTHERIA TOX 3 HIZENTRA 5 B/D PA; NDS PED(PF) IMOVAX RABIES VACCINE 3 B/D PA TRUMENBA 3 (PF) TWINRIX (PF) 3 INFANRIX (DTAP) (PF) 3 INTRAMUSCULAR SYRINGE INTRAMUSCULAR TYPHIM VI 3 SUSPENSION VAQTA (PF) 3 IPOL 3 VARIVAX (PF) 3 QL (1/365) IXIARO (PF) 3 VARIZIG INTRAMUSCULAR 4 QL (12/30) KINRIX (PF) 3 SOLUTION MENACTRA (PF) 3 YF-VAX (PF) 3 INTRAMUSCULAR SOLUTION ZOSTAVAX (PF) 3 QL (1/999) MENVEO A-C-Y-W-135-DIP 3 (PF) MUSCULOSKELETAL / RHEUMATOLOGY M-M-R II (PF) 3 QL (2/365) GOUT THERAPY PEDIARIX (PF) 3 allopurinol 1 PEDVAX HIB (PF) 3 colchicine oral capsule 3 QL (60/30) PENTACEL (PF) 3 colchicine oral tablet 4 QL (120/30) INTRAMUSCULAR KIT FEBUXOSTAT 3 ST; QL (30/30) 15LF-48MCG-62DU -10 MCG/0.5ML MITIGARE 3 QL (60/30) PROQUAD (PF) 3 QL (2/365) probenecid 2 QUADRACEL (PF) 3 probenecid-colchicine 2 RABAVERT (PF) 3 B/D PA OSTEOPOROSIS THERAPY RECOMBIVAX HB (PF) 3 B/D PA; QL (3/365) alendronate oral tablet 10 mg, 1 QL (30/30) INTRAMUSCULAR 5 mg SUSPENSION 10 MCG/ML, 40 alendronate oral tablet 35 mg, 1 QL (4/28) MCG/ML 70 mg RECOMBIVAX HB (PF) 3 B/D PA BINOSTO 4 INTRAMUSCULAR FORTEO 5 PA; QL (2.4/28); SUSPENSION 5 MCG/0.5 ML NDS RECOMBIVAX HB (PF) 3 B/D PA; QL (3/365) ibandronate oral 1 QL (1/28) INTRAMUSCULAR SYRINGE PROLIA 4 QL (1/180) ROTARIX 3 raloxifene 2 QL (30/30) ROTATEQ VACCINE 3 risedronate oral tablet 150 mg 3 QL (1/30) SHINGRIX (PF) 3 QL (2/999) risedronate oral tablet 30 mg, 3 QL (30/30) STAMARIL (PF) 3 QL (1/999) 5 mg tdvax 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

47 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS risedronate oral tablet 35 mg, 3 QL (4/28) HUMIRA(CF) PEN PSOR-UV- 5 PA; QL (6/365); 35 mg (12 pack), 35 mg (4 ADOL HS NDS pack) HUMIRA(CF) PEN 5 PA; QL (4/28); NDS TYMLOS 5 PA; QL (1.56/30); SUBCUTANEOUS INJECTOR NDS KIT 40 MG/0.4 ML OTHER RHEUMATOLOGICALS HUMIRA(CF) 5 PA; QL (2/28); NDS BENLYSTA INTRAVENOUS 5 PA; QL (30/28); SUBCUTANEOUS SYRINGE RECON SOLN 120 MG NDS KIT 10 MG/0.1 ML, 20 MG/0.2 ML BENLYSTA INTRAVENOUS 5 PA; QL (9/28); NDS RECON SOLN 400 MG HUMIRA(CF) 5 PA; QL (4/28); NDS SUBCUTANEOUS SYRINGE DEPEN TITRATABS 5 NDS KIT 40 MG/0.4 ML ENBREL MINI 5 PA; QL (8/28); NDS leflunomide 2 ENBREL SUBCUTANEOUS 5 PA; QL (8/28); NDS ORENCIA 5 PA; QL (4/28); NDS RECON SOLN ORENCIA CLICKJECT 5 PA; QL (4/28); NDS ENBREL SUBCUTANEOUS 5 PA; QL (4/28); NDS SOLUTION penicillamine 5 NDS ENBREL SUBCUTANEOUS 5 PA; QL (4.08/28); RIDAURA 4 SYRINGE 25 MG/0.5 ML (0.5) NDS RINVOQ 5 PA; QL (30/30); ENBREL SUBCUTANEOUS 5 PA; QL (8/28); NDS NDS SYRINGE 50 MG/ML (1 ML) XELJANZ 5 PA; QL (60/30); ENBREL SURECLICK 5 PA; QL (8/28); NDS NDS HUMIRA PEN 5 PA; QL (4/28); NDS XELJANZ XR 5 PA; QL (30/30); NDS HUMIRA PEN CROHNS- 5 PA; QL (12/365); UC-HS START NDS OBSTETRICS / GYNECOLOGY HUMIRA PEN PSOR-UVEITS- 5 PA; QL (8/365); ESTROGENS / PROGESTINS ADOL HS NDS ALORA 3 PA; QL (8/28) HUMIRA SUBCUTANEOUS 5 PA; QL (2/28); NDS SYRINGE KIT 10 MG/0.2 ML, camila 2 20 MG/0.4 ML deblitane 2 HUMIRA SUBCUTANEOUS 5 PA; QL (4/28); NDS DELESTROGEN 4 SYRINGE KIT 40 MG/0.8 ML INTRAMUSCULAR OIL 10 MG/ HUMIRA(CF) PEDI CROHNS 5 PA; QL (6/365); ML STARTER SUBCUTANEOUS NDS DEPO-ESTRADIOL 4 SYRINGE KIT 80 MG/0.8 ML DEPO-PROVERA 4 QL (10/28) HUMIRA(CF) PEDI CROHNS 5 PA; QL (4/365); INTRAMUSCULAR STARTER SUBCUTANEOUS NDS SUSPENSION 400 MG/ML SYRINGE KIT 80 MG/0.8 dotti 2 PA; QL (8/28) ML-40 MG/0.4 ML DUAVEE 4 PA; QL (30/30) HUMIRA(CF) PEN CROHNS- 5 PA; QL (6/365); UC-HS NDS errin 2 estradiol oral 2 PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

48 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS estradiol transdermal patch 2 PA; QL (8/28) tranexamic acid oral 3 semiweekly vandazole 3 estradiol transdermal patch 2 PA; QL (4/28) ORAL CONTRACEPTIVES / RELATED AGENTS weekly afirmelle 2 estradiol vaginal cream 4 altavera (28) 2 estradiol vaginal tablet 4 QL (18/28) alyacen 1/35 (28) 2 estradiol valerate intramuscular 4 oil 20 mg/ml, 40 mg/ml alyacen 7/7/7 (28) 2 ESTRING 4 QL (1/90) amethia 2 fyavolv 3 PA amethia lo 2 heather 2 amethyst (28) 2 hydroxyprogesterone caproate 5 PA; NDS apri 2 incassia 2 aranelle (28) 2 jencycla 2 ashlyna 2 lyza 2 aubra 2 medroxyprogesterone 4 aubra eq 2 intramuscular suspension aurovela 1.5/30 (21) 2 medroxyprogesterone 2 aurovela 1/20 (21) 2 intramuscular syringe aurovela 24 fe 2 medroxyprogesterone oral 1 aurovela fe 1.5/30 (28) 2 MENEST ORAL TABLET 0.3 3 PA aurovela fe 1-20 (28) 2 MG, 0.625 MG, 1.25 MG aviane 2 MENOSTAR 3 PA; QL (4/28) ayuna 2 nora-be 2 azurette (28) 2 norethindrone (contraceptive) 2 balziva (28) 2 norethindrone acetate 2 bekyree (28) 2 norethindrone ac-eth estradiol 3 PA blisovi 24 fe 2 oral tablet 0.5-2.5 mg-mcg blisovi fe 1.5/30 (28) 2 PREMARIN INJECTION 4 blisovi fe 1/20 (28) 2 PREMARIN ORAL 3 briellyn 2 PREMARIN VAGINAL 3 camrese 2 progesterone micronized 2 camrese lo 2 sharobel 2 caziant (28) 2 yuvafem 4 QL (18/28) charlotte 24 fe 2 MISCELLANEOUS OB/GYN chateal (28) 2 clindamycin phosphate vaginal 3 chateal eq (28) 2 metronidazole vaginal 3 cryselle (28) 2 terconazole 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

49 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS cyclafem 1/35 (28) 2 kaitlib fe 2 cyclafem 7/7/7 (28) 2 kalliga 2 cyred 2 kariva (28) 2 cyred eq 2 kelnor 1/35 (28) 2 dasetta 1/35 (28) 2 kelnor 1-50 2 dasetta 7/7/7 (28) 2 kurvelo (28) 2 daysee 2 l norgest/e.estradiol-e.estrad 2 desog-e.estradiol/e.estradiol 2 larin 1.5/30 (21) 2 drospirenone-e.estradiol-lm.fa 2 larin 1/20 (21) 2 drospirenone-ethinyl estradiol 2 larin 24 fe 2 elinest 2 larin fe 1.5/30 (28) 2 ELLA 3 larin fe 1/20 (28) 2 emoquette 2 larissia 2 enpresse 2 layolis fe 2 enskyce 2 leena 28 2 estarylla 2 lessina 2 ethynodiol diac-eth estradiol 2 levonest (28) 2 falmina (28) 2 levonorgestrel-ethinyl estrad 2 fayosim 2 levonorg-eth estrad triphasic 2 femynor 2 levora-28 2 gianvi (28) 2 lillow (28) 2 hailey 2 lojaimiess 2 hailey 24 fe 2 loryna (28) 2 hailey fe 1.5/30 (28) 2 low-ogestrel (28) 2 hailey fe 1/20 (28) 2 lo-zumandimine (28) 2 introvale 2 lutera (28) 2 isibloom 2 marlissa (28) 2 jaimiess 2 melodetta 24 fe 2 jasmiel (28) 2 mibelas 24 fe 2 jolessa 2 microgestin 1.5/30 (21) 2 juleber 2 microgestin 1/20 (21) 2 junel 1.5/30 (21) 2 microgestin fe 1.5/30 (28) 2 junel 1/20 (21) 2 microgestin fe 1/20 (28) 2 junel fe 1.5/30 (28) 2 mili 2 junel fe 1/20 (28) 2 mono-linyah 2 junel fe 24 2 necon 0.5/35 (28) 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

50 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS nikki (28) 2 tri-legest fe 2 noreth-ethinyl estradiol-iron 2 tri-linyah 2 norethindrone ac-eth estradiol 2 tri-lo-estarylla 2 oral tablet 1-20 mg-mcg, 1.5-30 tri-lo-marzia 2 mg-mcg tri-lo-mili 2 norethindrone-e.estradiol-iron 2 oral tablet 1 mg-20 mcg (21)/75 tri-lo-sprintec 2 mg (7), 1.5 mg-30 mcg (21)/75 tri-mili 2 mg (7) tri-previfem (28) 2 norethindrone-e.estradiol-iron 2 tri-sprintec (28) 2 oral tablet,chewable trivora (28) 2 norgestimate-ethinyl estradiol 2 tri-vylibra 2 nortrel 0.5/35 (28) 2 tri-vylibra lo 2 nortrel 1/35 (21) 2 tydemy 2 nortrel 1/35 (28) 2 velivet triphasic regimen (28) 2 nortrel 7/7/7 (28) 2 vienva 2 ocella 2 viorele (28) 2 orsythia 2 volnea (28) 2 philith 2 vyfemla (28) 2 pimtrea (28) 2 vylibra 2 pirmella 2 wera (28) 2 portia 28 2 wymzya fe 2 previfem 2 zarah 2 reclipsen (28) 2 zovia 1/35e (28) 2 rivelsa 2 zumandimine (28) 2 setlakin 2 simliya (28) 2 OPHTHALMOLOGY simpesse 2 sprintec (28) 2 ak-poly-bac 2 sronyx 2 AZASITE 3 syeda 2 bacitracin ophthalmic (eye) 2 tarina 24 fe 2 bacitracin-polymyxin b 2 tarina fe 1/20 (28) 2 ophthalmic (eye) tarina fe 1-20 eq (28) 2 BESIVANCE 4 tilia fe 2 CILOXAN OPHTHALMIC 3 (EYE) OINTMENT tri femynor 2 ciprofloxacin hcl ophthalmic 2 tri-estarylla 2 (eye)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

51 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS erythromycin ophthalmic (eye) 2 CYSTARAN 5 PA; QL (60/28); gentak ophthalmic (eye) 2 NDS ointment epinastine 3 gentamicin ophthalmic (eye) 2 EYLEA 5 PA; NDS drops LACRISERT 4 moxifloxacin ophthalmic (eye) 3 olopatadine ophthalmic (eye) 3 drops PAZEO 3 NATACYN 3 PHOSPHOLINE IODIDE 4 neomycin-bacitracin-polymyxin 2 pilocarpine hcl ophthalmic (eye) 3 neomycin-polymyxin-gramicidin 2 drops 1%, 2%, 4% neo-polycin 2 RESTASIS 3 QL (60/30) ofloxacin ophthalmic (eye) 2 RESTASIS MULTIDOSE 3 QL (11/30) ofloxacin otic (ear) 2 sulfacetamide sodium 2 polycin 2 ophthalmic (eye) drops polymyxin b sulf-trimethoprim 2 sulfacetamide-prednisolone 2 tobramycin ophthalmic (eye) 2 XIIDRA 3 QL (60/30) TOBREX OPHTHALMIC (EYE) 4 NON-STEROIDAL ANTI-INFLAMMATORY AGENTS OINTMENT bromfenac 4 ANTIVIRALS diclofenac sodium ophthalmic 2 trifluridine 3 (eye) ZIRGAN 3 flurbiprofen sodium 2 BETA-BLOCKERS ketorolac ophthalmic (eye) 2 betaxolol ophthalmic (eye) 3 PROLENSA 3 carteolol 2 ORAL DRUGS FOR GLAUCOMA levobunolol ophthalmic (eye) 1 acetazolamide 3 drops 0.5% acetazolamide sodium 4 timolol maleate ophthalmic 1 methazolamide 4 (eye) drops OTHER GLAUCOMA DRUGS TIMOLOL MALEATE 4 OPHTHALMIC (EYE) GEL AZOPT 3 FORMING SOLUTION bimatoprost ophthalmic (eye) 2 QL (5/30) MISCELLANEOUS OPHTHALMOLOGICS COMBIGAN 3 atropine ophthalmic (eye) drops 3 dorzolamide 2 azelastine ophthalmic (eye) 2 dorzolamide-timolol 2 BLEPHAMIDE 3 latanoprost 2 BLEPHAMIDE S.O.P. 3 LUMIGAN OPHTHALMIC 3 cromolyn ophthalmic (eye) 2 (EYE) DROPS 0.01% RHOPRESSA 4 ST

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

52 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS

ROCKLATAN 4 ST RESPIRATORY AND ALLERGY SIMBRINZA 4 ANTIHISTAMINE / ANTIALLERGENIC AGENTS TRAVATAN Z 3 desloratadine oral tablet 2 travoprost 3 diphenhydramine hcl injection 4 ZIOPTAN (PF) 4 QL (30/30) solution 50 mg/ml STEROID-ANTIBIOTIC COMBINATIONS epinephrine injection auto- 2 QL (2/30) neomycin-bacitracin-poly-hc 3 injector neomycin-polymyxin 2 epinephrine injection solution 1 4 b-dexameth mg/ml neomycin-polymyxin-hc 2 EPIPEN 3 QL (2/30) ophthalmic (eye) EPIPEN 2-PAK 3 QL (2/30) neo-polycin hc 3 EPIPEN JR 3 QL (2/30) PRED-G 3 EPIPEN JR 2-PAK 3 QL (2/30) PRED-G S.O.P. 3 hydroxyzine hcl oral tablet 3 PA TOBRADEX OPHTHALMIC 3 levocetirizine oral solution 4 QL (300/30) (EYE) OINTMENT levocetirizine oral tablet 2 QL (120/30) tobramycin-dexamethasone 3 promethazine oral 2 PA ZYLET 3 promethazine rectal 4 STEROIDS suppository 12.5 mg, 25 mg dexamethasone sodium 2 promethegan rectal suppository 4 phosphate ophthalmic (eye) 25 mg, 50 mg DUREZOL 3 PULMONARY AGENTS fluorometholone 3 acetylcysteine 3 B/D PA INVELTYS 4 ADEMPAS 5 PA; QL (90/30); LOTEMAX 4 NDS LOTEMAX SM 4 ADVAIR DISKUS 3 QL (60/30) PRED MILD 3 ADVAIR HFA 3 QL (12/30) prednisolone acetate 3 albuterol sulfate inhalation 4 QL (17/30) prednisolone sodium 1 hfa aerosol inhaler 90 mcg/ phosphate ophthalmic (eye) actuation (generic for proair) SYMPATHOMIMETICS ALBUTEROL SULFATE 4 QL (13.4/30) ALPHAGAN P OPHTHALMIC 4 INHALATION HFA AEROSOL (EYE) DROPS 0.1% INHALER 90 MCG/ ACTUATION (GENERIC FOR apraclonidine 3 PROVENTIL) brimonidine ophthalmic (eye) 3 albuterol sulfate inhalation 4 QL (36/30) drops 0.15% hfa aerosol inhaler 90 mcg/ brimonidine ophthalmic (eye) 2 actuation (generic for ventolin) drops 0.2%

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

53 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS albuterol sulfate inhalation 2 B/D PA FLOVENT HFA AEROSOL 3 QL (24/30) solution for nebulization INHALER 220 MCG/ albuterol sulfate oral syrup 2 ACTUATION albuterol sulfate oral tablet 3 FLOVENT HFA AEROSOL 3 QL (10.6/30) INHALER 44 MCG/ albuterol sulfate oral tablet 2 ACTUATION extended release 12 hr flunisolide nasal spray,non- 3 QL (50/30) ambrisentan 5 PA; QL (30/30); aerosol 25 mcg (0.025%) NDS fluticasone propionate nasal 2 QL (16/30) ANORO ELLIPTA 3 QL (60/30) fluticasone propion-salmeterol 3 QL (60/30) ARNUITY ELLIPTA 3 QL (30/30) inhalation blister with device ATROVENT HFA 4 QL (25.8/30) icatibant 5 PA; QL (18/30); bosentan 5 PA; QL (60/30); NDS NDS INCRUSE ELLIPTA 3 QL (30/30) BREO ELLIPTA 3 QL (60/30) ipratropium bromide inhalation 2 B/D PA BROVANA 4 B/D PA ipratropium-albuterol 2 B/D PA budesonide inhalation 4 B/D PA KALYDECO 5 PA; QL (60/30); CINRYZE 5 PA; QL (20/30); NDS NDS levalbuterol hcl 4 B/D PA COMBIVENT RESPIMAT 3 QL (8/30) levalbuterol tartrate 3 QL (30/30) cromolyn inhalation 2 B/D PA; QL metaproterenol oral syrup 3 (240/30) mometasone nasal 3 QL (34/30) DALIRESP 4 PA; QL (30/30) montelukast oral granules in 3 QL (30/30) ESBRIET ORAL CAPSULE 5 PA; QL (270/30); packet NDS montelukast oral tablet 2 QL (30/30) ESBRIET ORAL TABLET 267 5 PA; QL (270/30); MG NDS montelukast oral 2 QL (30/30) tablet,chewable ESBRIET ORAL TABLET 801 5 PA; QL (90/30); MG NDS OFEV 5 PA; QL (60/30); NDS FLOVENT DISKUS 3 QL (60/30) INHALATION BLISTER OPSUMIT 5 PA; QL (30/30); WITH DEVICE 100 MCG/ NDS ACTUATION, 50 MCG/ ORKAMBI ORAL GRANULES 5 PA; QL (56/28); ACTUATION IN PACKET NDS FLOVENT DISKUS 3 QL (240/30) ORKAMBI ORAL TABLET 5 PA; QL (120/30); INHALATION BLISTER NDS WITH DEVICE 250 MCG/ PERFOROMIST 3 B/D PA; QL ACTUATION (120/30) FLOVENT HFA AEROSOL 3 QL (12/30) PROAIR HFA 3 QL (17/30) INHALER 110 MCG/ ACTUATION PROAIR RESPICLICK 3 QL (2/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

54 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS PULMICORT 4 B/D PA MYRBETRIQ ORAL TABLET 3 QL (30/30) PULMOZYME 5 B/D PA; QL EXTENDED RELEASE 24 HR (150/30); NDS 50 MG RUCONEST 5 PA; QL (8/30); NDS oxybutynin chloride oral syrup 1 QL (600/30) SEREVENT DISKUS 3 QL (60/30) oxybutynin chloride oral tablet 1 sildenafil (pulmonary arterial 3 PA; QL (90/30) oxybutynin chloride oral tablet 2 QL (60/30) hypertension) oral tablet extended release 24hr terbutaline 4 solifenacin 2 QL (30/30) THEO-24 4 tolterodine oral 3 QL (30/30) capsule,extended release 24hr theophylline oral tablet 3 extended release 12 hr 300 tolterodine oral tablet 3 mg, 450 mg TOVIAZ 3 QL (30/30) theophylline oral tablet 3 BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY extended release 24 hr alfuzosin 2 QL (30/30) TRACLEER ORAL TABLET 5 PA; NDS dutasteride 2 QL (30/30) FOR SUSPENSION dutasteride-tamsulosin 4 QL (30/30) TRELEGY ELLIPTA 3 QL (60/30) finasteride oral tablet 5 mg 2 QL (30/30) VENTAVIS 5 PA; QL (270/30); NDS tamsulosin 2 QL (60/30) VENTOLIN HFA 4 QL (36/30) MISCELLANEOUS UROLOGICALS wixela inhub 3 QL (60/30) bethanechol chloride 2 XHANCE 4 ST; QL (16/30) CYSTAGON 4 XOLAIR SUBCUTANEOUS 5 PA; QL (6/28); NDS ELMIRON 4 RECON SOLN K-PHOS ORIGINAL 4 XOLAIR SUBCUTANEOUS 5 PA; QL (5/28); NDS potassium citrate 4 SYRINGE RENACIDIN IRRIGATION 4 XOPENEX 4 B/D PA SOLUTION 1980.6 MG-59.4 XOPENEX CONCENTRATE 4 B/D PA MG-980.4MG/30ML YUPELRI 4 B/D PA VITAMINS, HEMATINICS / ELECTROLYTES zafirlukast 3 QL (60/30) ELECTROLYTES UROLOGICALS calcium acetate(phosphat bind) 2 ANTICHOLINERGICS / ANTISPASMODICS klor-con 2 darifenacin 4 KLOR-CON 10 3 flavoxate 2 KLOR-CON 8 3 MYRBETRIQ ORAL TABLET 3 QL (60/30) klor-con m10 1 EXTENDED RELEASE 24 HR klor-con m20 1 25 MG lactated ringers intravenous 4 B/D PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

55 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS MAGNESIUM SULFATE 4 B/D PA potassium chloride-d5- 4 B/D PA IN D5W INTRAVENOUS 0.3%nacl intravenous PIGGYBACK 1 GRAM/100 ML parenteral solution 20 meq/l magnesium sulfate in water 4 B/D PA POTASSIUM CHLORIDE-D5- 4 B/D PA magnesium sulfate injection 4 B/D PA 0.9%NACL NORMOSOL-R 4 B/D PA ringer’s intravenous 4 B/D PA PHOSLYRA 4 sodium bicarbonate 4 intravenous syringe 10 meq/10 POTASSIUM CHLORID-D5- 4 B/D PA ml (8.4%), 7.5% (0.9 meq/ml), 0.45%NACL INTRAVENOUS 8.4% (1 meq/ml) PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L sodium chloride 0.45% 4 intravenous parenteral solution potassium chlorid-d5- 4 B/D PA 0.45%nacl intravenous sodium chloride 3% 4 parenteral solution 30 meq/l sodium chloride 5% 4 potassium chloride in 0.9%nacl 4 B/D PA sodium chloride intravenous 4 intravenous parenteral solution TPN ELECTROLYTES 4 B/D PA 20 meq/l, 40 meq/l MISCELLANEOUS NUTRITION PRODUCTS potassium chloride in 5% dex 4 B/D PA intravenous parenteral solution AMINOSYN II 10% 4 B/D PA 20 meq/l, 30 meq/l, 40 meq/l AMINOSYN II 15% 4 B/D PA potassium chloride in lr-d5 4 B/D PA AMINOSYN-PF 7% (SULFITE- 4 B/D PA potassium chloride in water 4 B/D PA FREE) intravenous piggyback CLINIMIX 5%/D15W SULFITE 4 B/D PA potassium chloride intravenous 4 B/D PA FREE potassium chloride oral 2 CLINIMIX 4.25%/D10W SULF 4 B/D PA capsule, extended release FREE potassium chloride oral liquid 4 CLINIMIX 5%-D20W(SULFITE- 4 B/D PA FREE) potassium chloride oral packet 2 CLINIMIX E 4.25%/D10W SUL 4 B/D PA potassium chloride oral tablet 1 FREE extended release CLINISOL SF 15% 4 B/D PA potassium chloride oral 1 tablet,er particles/crystals electrolyte-48 in d5w 4 B/D PA potassium chloride-0.45% nacl 4 B/D PA FREAMINE HBC 6.9% 4 B/D PA POTASSIUM CHLORIDE-D5- 4 B/D PA freamine iii 10% 4 B/D PA 0.2%NACL INTRAVENOUS HEPATAMINE 8% 4 B/D PA PARENTERAL SOLUTION 20 INTRALIPID INTRAVENOUS 4 B/D PA MEQ/L EMULSION 20%, 30% potassium chloride-d5- 4 B/D PA KABIVEN 4 B/D PA 0.2%nacl intravenous NEPHRAMINE 5.4% 4 B/D PA parenteral solution 30 meq/l, 40 meq/l

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

56 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG NAME TIER LIMITS NORMOSOL-M IN 5% 4 B/D PA DEXTROSE NORMOSOL-R PH 7.4 4 B/D PA NUTRILIPID 4 B/D PA PERIKABIVEN 4 B/D PA PLENAMINE 4 B/D PA PREMASOL 10% 4 B/D PA PROCALAMINE 3% 4 B/D PA PROSOL 20% 4 B/D PA TRAVASOL 10% 4 B/D PA TROPHAMINE 10% 4 B/D PA VITAMINS / HEMATINICS fluoride (sodium) oral tablet 1 fluoride (sodium) oral 1 tablet,chewable 1 mg (2.2 mg sod. fluoride) prenatal vitamin oral tablet 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 6.

57 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE

A ADVAIR HFA...... 53 alosetron oral tablet 1 mg...... 44 AFINITOR ...... 13 ALPHAGAN P OPHTHALMIC abacavir-lamivudine ...... 7 AFINITOR DISPERZ...... 14 (EYE) DROPS 0.1%...... 53 abacavir-lamivudine-zidovudine. . . 7 afirmelle ...... 49 alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg...... 26 abacavir oral solution...... 7 AIMOVIG AUTOINJECTOR. . . . .22 alprazolam oral tablet 2 mg . . . . .26 abacavir oral tablet...... 7 ak-poly-bac ...... 51 ABELCET...... 7 alprazolam oral tablet, ala-cort topical cream 1%...... 36 disintegrating 0.25 mg, ABILIFY MAINTENA...... 26 albendazole...... 10 0.5 mg, 1 mg...... 26 abiraterone...... 13 albuterol sulfate inhalation hfa alprazolam oral tablet, ABRAXANE...... 13 aerosol inhaler 90 mcg/actuation disintegrating 2 mg...... 26 (generic for proair)...... 53 acamprosate...... 37 altavera (28) ...... 49 ALBUTEROL SULFATE acarbose oral tablet 50 mg. . . . . 40 ALUNBRIG ORAL TABLET 30 MG . 14 INHALATION HFA AEROSOL acarbose oral tablet 100 mg, 25 mg . 40 INHALER 90 MCG/ACTUATION ALUNBRIG ORAL TABLET acebutolol...... 31 (GENERIC FOR PROVENTIL). . . 53 180 MG, 90 MG...... 14 acetaminophen-codeine oral albuterol sulfate inhalation hfa ALUNBRIG ORAL TABLETS, solution 120 mg-12 mg /5 ml aerosol inhaler 90 mcg/actuation DOSE PACK...... 14 (5 ml), 120-12 mg/5 ml, (generic for ventolin)...... 53 alyacen 1/35 (28)...... 49 300 mg-30 mg /12.5 ml ...... 23 albuterol sulfate inhalation alyacen 7/7/7 (28)...... 49 acetaminophen-codeine oral solution for nebulization...... 54 amantadine hcl...... 7 tablet 300-15 mg, 300-30 mg. . . . 24 albuterol sulfate oral syrup. . . . . 54 AMBISOME...... 7 acetaminophen-codeine oral albuterol sulfate oral tablet. . . . . 54 tablet 300-60 mg ...... 24 ambrisentan...... 54 albuterol sulfate oral tablet acetazolamide...... 52 amethia...... 49 extended release 12 hr ...... 54 acetazolamide sodium...... 52 amethia lo...... 49 alclometasone...... 36 acetic acid otic (ear)...... 39 amethyst (28) ...... 49 ALCOHOL PADS...... 40 acetylcysteine...... 53 amikacin injection solution ALDURAZYME...... 42 1,000 mg/4 ml, 500 mg/2 ml. . . . .10 acitretin...... 35 ALECENSA...... 14 amiloride...... 31 ACTHIB (PF)...... 46 alendronate oral tablet 10 mg, 5 mg . 47 amiloride-hydrochlorothiazide . . . .31 ACTIMMUNE ...... 45 alendronate oral tablet aminocaproic acid oral...... 33 acyclovir oral capsule...... 7 35 mg, 70 mg ...... 47 AMINOSYN II 10%...... 56 acyclovir oral suspension alfuzosin...... 55 200 mg/5 ml...... 7 AMINOSYN II 15%...... 56 ALIMTA...... 14 acyclovir oral tablet...... 7 AMINOSYN-PF 7% ALINIA ORAL SUSPENSION (SULFITE-FREE)...... 56 acyclovir sodium FOR RECONSTITUTION...... 10 intravenous solution ...... 7 amiodarone intravenous solution . . 31 ALINIA ORAL TABLET...... 10 acyclovir topical cream...... 35 amiodarone oral...... 31 ALIQOPA...... 14 acyclovir topical ointment ...... 35 AMITIZA...... 44 aliskiren...... 31 ADACEL amitriptyline...... 26 ALKERAN ...... 14 (TDAP ADOLESN/ADULT)(PF). . . 46 amlodipine...... 31 allopurinol...... 47 adefovir...... 7 amlodipine-benazepril ...... 31 ALORA...... 48 ADEMPAS...... 53 amlodipine-valsartan...... 31 alosetron oral tablet 0.5 mg . . . . .43 ADVAIR DISKUS...... 53 amlodipine-valsartan-hcthiazid . . . 31 58 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE ammonium lactate...... 35 ARANESP (IN POLYSORBATE) ARISTADA INTRAMUSCULAR amnesteem...... 35 INJECTION SOLUTION SUSPENSION,EXTENDED REL 25 MCG/ML, 40 MCG/ML...... 45 SYRING 662 MG/2.4 ML...... 26 amoxapine...... 26 ARANESP (IN POLYSORBATE) ARISTADA INTRAMUSCULAR amoxicillin oral capsule ...... 12 INJECTION SOLUTION SUSPENSION,EXTENDED REL amoxicillin oral suspension 100 MCG/ML, 200 MCG/ML, SYRING 882 MG/3.2 ML...... 26 for reconstitution...... 12 300 MCG/ML, 60 MCG/ML. . . . . 45 armodafinil...... 26 amoxicillin oral tablet ...... 12 ARANESP (IN POLYSORBATE) ARNUITY ELLIPTA...... 54 INJECTION SYRINGE amoxicillin oral tablet, ARSENIC TRIOXIDE 10 MCG/0.4 ML, 40 MCG/0.4 ML. . 45 chewable 125 mg, 250 mg. . . . . 12 INTRAVENOUS SOLUTION amoxicillin-pot clavulanate oral ARANESP (IN POLYSORBATE) 1 MG/ML...... 14 INJECTION SYRINGE suspension for reconstitution. . . . 12 arsenic trioxide intravenous 25 MCG/0.42 ML...... 45 amoxicillin-pot clavulanate solution 2 mg/ml...... 14 oral tablet...... 12 ARANESP (IN POLYSORBATE) ascomp with codeine ...... 24 amoxicillin-pot clavulanate INJECTION SYRINGE ashlyna...... 49 oral tablet,chewable ...... 12 60 MCG/0.3 ML...... 46 aspirin-dipyridamole...... 33 amoxicillin-pot clavulanate oral ARANESP (IN POLYSORBATE) tablet extended release 12 hr. . . . 12 INJECTION SYRINGE ASTAGRAF XL...... 14 100 MCG/0.5 ML...... 45 amphotericin b ...... 7 atazanavir oral capsule 150 mg. . . .7 ARANESP (IN POLYSORBATE) atazanavir oral capsule 200 mg. . . .7 ampicillin oral capsule 500 mg. . . .12 INJECTION SYRINGE ampicillin sodium injection recon 150 MCG/0.3 ML...... 45 atazanavir oral capsule 300 mg. . . .7 soln 1 gram, 10 gram, 2 gram. . . .12 ARANESP (IN POLYSORBATE) atenolol...... 31 ampicillin sodium injection recon INJECTION SYRINGE atenolol-chlorthalidone...... 31 soln 125 mg, 250 mg, 500 mg. . . .12 200 MCG/0.4 ML...... 45 ATGAM...... 46 ampicillin sodium intravenous . . . .12 ARANESP (IN POLYSORBATE) atomoxetine oral capsule ampicillin-sulbactam...... 12 INJECTION SYRINGE 10 mg, 18 mg, 25 mg, 40 mg. . . . 26 300 MCG/0.6 ML...... 45 ANADROL-50...... 42 atomoxetine oral capsule ARANESP (IN POLYSORBATE) anagrelide ...... 37 100 mg, 60 mg, 80 mg...... 27 INJECTION SYRINGE atorvastatin oral tablet anastrozole ...... 14 500 MCG/ML...... 45 10 mg, 20 mg, 80 mg...... 34 ANORO ELLIPTA...... 54 ARCALYST...... 46 atorvastatin oral tablet 40 mg. . . . 34 APOKYN...... 22 ARIKAYCE...... 10 atovaquone...... 10 apraclonidine...... 53 aripiprazole oral solution...... 26 atovaquone-proguanil...... 10 aprepitant...... 44 aripiprazole oral tablet...... 26 ATRIPLA...... 7 apri...... 49 aripiprazole oral tablet, atropine injection solution 0.4 mg/ml. 43 APRISO ...... 44 disintegrating...... 26 atropine injection syringe APTIOM ORAL TABLET 200 MG. . 20 ARISTADA INITIO...... 26 0.05 mg/ml, 0.1 mg/ml...... 43 APTIOM ORAL TABLET 400 MG. . 20 ARISTADA INTRAMUSCULAR atropine ophthalmic (eye) drops. . .52 APTIOM ORAL TABLET SUSPENSION,EXTENDED REL ATROVENT HFA...... 54 600 MG, 800 MG...... 20 SYRING 1,064 MG/3.9 ML. . . . . 26 aubra...... 49 APTIVUS...... 7 ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL aubra eq...... 49 APTIVUS (WITH VITAMIN E)...... 7 SYRING 441 MG/1.6 ML...... 26 aurovela 1.5/30 (21)...... 49 ARALAST NP...... 37 aurovela 1/20 (21)...... 49 aranelle (28) ...... 49 59 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE aurovela 24 fe...... 49 bacitracin-polymyxin b betamethasone valerate aurovela fe 1.5/30 (28)...... 49 ophthalmic (eye)...... 51 topical ointment ...... 36 aurovela fe 1-20 (28) ...... 49 baclofen oral tablet 10 mg, 5 mg. . .23 BETASERON SUBCUTANEOUS KIT. 46 AURYXIA...... 37 baclofen oral tablet 20 mg...... 23 betaxolol ophthalmic (eye) . . . . . 52 AUSTEDO ORAL TABLET 6 MG. . 22 balsalazide...... 44 betaxolol oral...... 31 AUSTEDO ORAL TABLET BALVERSA ORAL TABLET 3 MG. . 14 bethanechol chloride...... 55 12 MG, 9 MG...... 22 BALVERSA ORAL TABLET 4 MG. . 14 bexarotene...... 14 AVASTIN...... 14 BALVERSA ORAL TABLET 5 MG. . 14 BEXSERO...... 46 aviane...... 49 balziva (28) ...... 49 bicalutamide ...... 14 avita...... 35 BANZEL ORAL SUSPENSION. . . 20 BICILLIN L-A...... 12 AVONEX INTRAMUSCULAR BANZEL ORAL TABLET...... 20 BIDIL...... 31 PEN INJECTOR KIT...... 46 BAQSIMI...... 40 BIKTARVY...... 7 AVONEX INTRAMUSCULAR BARACLUDE ORAL SOLUTION . . .7 bimatoprost ophthalmic (eye). . . . 52 SYRINGE KIT...... 46 BAVENCIO...... 14 BINOSTO...... 47 AVSOLA...... 44 BAXDELA...... 13 bisoprolol fumarate...... 31 ayuna...... 49 BCG VACCINE, LIVE (PF). . . . . 46 bisoprolol-hydrochlorothiazide. . . .31 AYVAKIT...... 14 BD PEN NEEDLE...... 40 BLENREP ...... 14 AZASAN...... 14 bekyree (28) ...... 49 BLEPHAMIDE...... 52 AZASITE...... 51 BELSOMRA ORAL TABLET 5 MG. .27 BLEPHAMIDE S.O.P...... 52 azathioprine...... 14 BELSOMRA ORAL TABLET blisovi 24 fe...... 49 azathioprine sodium...... 14 10 MG, 15 MG, 20 MG...... 27 blisovi fe 1.5/30 (28)...... 49 azelastine nasal...... 39 benazepril...... 31 blisovi fe 1/20 (28)...... 49 azelastine ophthalmic (eye). . . . .52 benazepril-hydrochlorothiazide. . . 31 BOOSTRIX TDAP...... 46 azithromycin intravenous...... 10 BENDEKA...... 14 BORTEZOMIB...... 14 azithromycin oral packet...... 10 BENLYSTA INTRAVENOUS bosentan...... 54 azithromycin oral suspension RECON SOLN 120 MG...... 48 BOSULIF...... 14 for reconstitution...... 10 BENLYSTA INTRAVENOUS BOTOX...... 46 azithromycin oral tablet RECON SOLN 400 MG...... 48 BRAFTOVI...... 14 250 mg, 250 mg (6 pack), benztropine injection...... 22 500 mg, 500 mg (3 pack)...... 10 BREO ELLIPTA ...... 54 benztropine oral...... 22 azithromycin oral tablet 600 mg. . . 10 briellyn...... 49 BESIVANCE ...... 51 AZOPT ...... 52 BRILINTA...... 33 BESPONSA...... 14 aztreonam injection brimonidine ophthalmic betamethasone, augmented. . . . .36 recon soln 1 gram...... 10 (eye) drops 0.2%...... 53 betamethasone dipropionate. . . . 36 aztreonam injection brimonidine ophthalmic recon soln 2 gram...... 10 betamethasone valerate (eye) drops 0.15%...... 53 topical cream...... 36 azurette (28)...... 49 BRIVIACT ORAL SOLUTION. . . . 20 betamethasone valerate BRIVIACT ORAL TABLET...... 20 topical foam...... 36 B betamethasone valerate bromfenac ...... 52 bacitracin intramuscular...... 10 topical lotion...... 36 bromocriptine ...... 22 bacitracin ophthalmic (eye). . . . . 51 BROVANA...... 54

60 Covered Drugs Index

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BRUKINSA ...... 14 butalbital compound w/codeine. . . 24 carbamazepine oral capsule, budesonide inhalation...... 54 butorphanol injection er multiphase 12 hr...... 20 budesonide oral capsule, solution 1 mg/ml...... 25 carbamazepine oral delayed,extend.release...... 44 butorphanol injection suspension 100 mg/5 ml...... 20 budesonide oral tablet, solution 2 mg/ml...... 25 carbamazepine oral tablet...... 20 delayed and ext.release...... 44 butorphanol nasal ...... 25 carbamazepine oral tablet, bumetanide injection...... 31 BYDUREON BCISE...... 40 chewable ...... 20 bumetanide oral...... 31 BYDUREON SUBCUTANEOUS carbamazepine oral tablet extended release 12 hr ...... 20 buprenorphine hcl injection. . . . . 24 PEN INJECTOR...... 40 carbidopa...... 22 buprenorphine hcl sublingual. . . . 24 BYSTOLIC...... 31 carbidopa-levodopa-entacapone. . .22 buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg. . . .25 C carbidopa-levodopa oral tablet . . . 22 buprenorphine-naloxone carbidopa-levodopa oral cabergoline ...... 42 sublingual film 12-3 mg ...... 25 tablet,disintegrating...... 22 CABOMETYX ORAL buprenorphine-naloxone carbidopa-levodopa oral TABLET 20 MG, 60 MG...... 14 sublingual tablet...... 25 tablet extended release...... 22 CABOMETYX ORAL buprenorphine transdermal CARNITOR INTRAVENOUS. . . . 38 TABLET 40 MG ...... 14 patch weekly 7.5 mcg/hour. . . . . 24 carteolol ...... 52 calcipotriene scalp...... 35 BUPRENORPHINE cartia xt...... 31 calcipotriene topical cream. . . . . 35 TRANSDERMAL PATCH WEEKLY carvedilol ...... 31 10 MCG/HOUR, 15 MCG/HOUR, calcipotriene topical ointment. . . . 35 carvedilol phosphate...... 31 20 MCG/HOUR, 5 MCG/HOUR. . . 24 calcitonin (salmon)...... 42 caspofungin...... 7 bupropion hcl oral tablet 75 mg. . . 27 calcitriol intravenous CAYSTON...... 10 bupropion hcl oral tablet 100 mg. . .27 solution 1 mcg/ml...... 42 caziant (28)...... 49 bupropion hcl oral tablet calcitriol oral...... 42 cefaclor oral capsule...... 9 extended release 24 hr 150 mg. . . 27 calcitriol topical...... 35 cefaclor oral suspension for bupropion hcl oral tablet calcium acetate(phosphat bind). . . 55 extended release 24 hr 300 mg. . . 27 reconstitution 125 mg/5 ml, CALQUENCE...... 14 bupropion hcl oral tablet sustained- 250 mg/5 ml, 375 mg/5 ml...... 9 camila...... 48 release 12 hr 100 mg, 200 mg. . . .27 cefaclor oral tablet bupropion hcl oral tablet sustained- camrese...... 49 extended release 12 hr ...... 9 release 12 hr 150 mg...... 27 camrese lo...... 49 cefadroxil oral capsule...... 9 bupropion hcl (smoking deter). . . .38 candesartan-hydrochlorothiazid . . .31 cefadroxil oral suspension for reconstitution 250 mg/5 ml, buspirone...... 27 candesartan oral tablet 16 mg, 4 mg, 8 mg...... 31 500 mg/5 ml...... 9 busulfan ...... 14 candesartan oral tablet 32 mg. . . .31 cefadroxil oral tablet...... 9 BUSULFEX...... 14 CAPASTAT...... 10 cefazolin...... 9 butalbital-acetaminop-caf-cod. . . .24 CAPLYTA...... 27 cefazolin in dextrose (iso-os) butalbital-acetaminophen-caff intravenous piggyback CAPRELSA ORAL TABLET 100 MG . 14 oral capsule...... 24 1 gram/50 ml, 2 gram/50 ml. . . . . 9 butalbital-acetaminophen-caff CAPRELSA ORAL TABLET 300 MG . 14 CEFAZOLIN IN DEXTROSE oral tablet 50-325-40 mg...... 24 CARAFATE ORAL SUSPENSION. .45 (ISO-OS) INTRAVENOUS butalbital-aspirin-caffeine CARBAGLU...... 37 PIGGYBACK 2 GRAM/100 ML. . . .9 oral capsule...... 24 cefdinir oral capsule ...... 9

61 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE cefdinir oral suspension chateal (28)...... 49 citalopram oral tablet 40 mg. . . . .27 for reconstitution...... 9 chateal eq (28)...... 49 claravis...... 35 CEFEPIME IN DEXTROSE 5%. . . .9 CHEMET ...... 38 clarithromycin oral suspension cefepime in dextrose,iso-osm . . . . 9 chloramphenicol sod succinate. . . 10 for reconstitution...... 10 cefepime injection...... 9 chlorhexidine gluconate clarithromycin oral tablet...... 10 cefixime oral capsule ...... 9 mucous membrane...... 39 clarithromycin oral tablet cefixime oral suspension chloroquine phosphate...... 10 extended release 24 hr ...... 10 for reconstitution...... 9 chlorothiazide oral tablet 500 mg . . 31 clindacin etz topical swab...... 35 cefotetan...... 9 chlorothiazide sodium...... 31 clindacin p ...... 35 CEFOTETAN IN chlorpromazine injection...... 27 clindamycin hcl...... 11 DEXTROSE, ISO-OSM...... 9 chlorpromazine oral...... 27 CLINDAMYCIN IN cefoxitin...... 9 0.9% SOD CHLOR...... 11 chlorthalidone oral tablet cefoxitin in dextrose, iso-osm. . . . .9 25 mg, 50 mg ...... 31 clindamycin in 5% dextrose . . . . .11 cefpodoxime...... 9 cholestyramine light ...... 34 clindamycin pediatric ...... 11 cefprozil ...... 9 cholestyramine (with sugar). . . . .34 clindamycin phosphate injection. . .11 ceftazidime...... 9 CHORIONIC GONADOTROPIN, clindamycin phosphate CEFTAZIDIME IN D5W...... 10 HUMAN INTRAMUSCULAR . . . . 42 intravenous solution 600 mg/4 ml. . 11 ceftriaxone in dextrose,iso-os . . . .10 ciclodan topical solution...... 36 clindamycin phosphate topical gel. .35 ceftriaxone injection recon soln ciclopirox topical cream...... 36 CLINDAMYCIN PHOSPHATE TOPICAL GEL, ONCE DAILY . . . .36 1 gram, 10 gram, 2 gram, ciclopirox topical shampoo. . . . . 36 250 mg, 500 mg...... 10 clindamycin phosphate ciclopirox topical solution...... 36 CEFTRIAXONE INJECTION topical lotion...... 36 ciclopirox topical suspension. . . . 36 RECON SOLN 100 GRAM. . . . . 10 clindamycin phosphate cilostazol...... 33 ceftriaxone intravenous...... 10 topical solution...... 36 CILOXAN OPHTHALMIC cefuroxime axetil oral tablet. . . . .10 clindamycin phosphate (EYE) OINTMENT...... 51 topical swab...... 36 cefuroxime sodium injection CIMDUO...... 7 recon soln 750 mg...... 10 clindamycin phosphate vaginal. . . 49 cinacalcet oral tablet 30 mg, 60 mg. .42 cefuroxime sodium intravenous. . . 10 CLINIMIX 4.25%/D5W cinacalcet oral tablet 90 mg. . . . .42 SULFIT FREE...... 38 celecoxib...... 25 CLINIMIX 4.25%/D10W CELONTIN ORAL CINRYZE...... 54 SULF FREE...... 56 CAPSULE 300 MG...... 20 CIPRODEX...... 39 CLINIMIX 5%/D15W cephalexin oral capsule ciprofloxacin...... 13 SULFITE FREE...... 56 250 mg, 500 mg...... 10 ciprofloxacin-dexamethasone . . . .39 CLINIMIX 5%-D20W cephalexin oral suspension ciprofloxacin hcl ophthalmic (eye). . 51 (SULFITE-FREE)...... 56 for reconstitution...... 10 ciprofloxacin hcl oral tablet 100 mg. 13 CLINIMIX E 4.25%/D10W CEREZYME INTRAVENOUS ciprofloxacin hcl oral tablet SUL FREE...... 56 RECON SOLN 400 UNIT ...... 42 250 mg, 500 mg, 750 mg...... 13 CLINISOL SF 15% ...... 56 CHANTIX...... 38 ciprofloxacin in 5% dextrose. . . . .13 clobazam oral suspension...... 20 CHANTIX CONTINUING CIPRO HC...... 39 MONTH BOX ...... 39 clobazam oral tablet 10 mg. . . . . 20 citalopram oral solution ...... 27 CHANTIX STARTING MONTH BOX . 39 clobazam oral tablet 20 mg. . . . . 20 citalopram oral tablet 10 mg. . . . .27 charlotte 24 fe...... 49 clobetasol-emollient topical cream. .37 citalopram oral tablet 20 mg. . . . .27

62 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE clobetasol-emollient topical foam. . 37 clozapine oral tablet ...... 27 cromolyn oral...... 44 clobetasol scalp...... 36 clozapine oral tablet, cryselle (28)...... 49 clobetasol topical cream ...... 36 disintegrating 12.5 mg, 25 mg. . . .27 cyclafem 1/35 (28)...... 50 clobetasol topical foam...... 36 clozapine oral tablet, cyclafem 7/7/7 (28)...... 50 disintegrating 100 mg...... 27 clobetasol topical gel ...... 36 cyclobenzaprine oral clozapine oral tablet, clobetasol topical ointment. . . . . 36 tablet 10 mg, 5 mg...... 23 disintegrating 150 mg...... 27 clobetasol topical shampoo . . . . .37 cyclophosphamide clozapine oral tablet, intravenous recon soln...... 14 CLOCORTOLONE PIVALATE. . . .37 disintegrating 200 mg...... 27 CYCLOPHOSPHAMIDE clodan...... 37 COARTEM...... 11 INTRAVENOUS SOLUTION . . . . 14 clomipramine...... 27 colchicine oral capsule...... 47 cyclophosphamide oral capsule . . .14 clonazepam oral tablet colchicine oral tablet...... 47 CYCLOSERINE...... 11 0.5 mg, 1 mg...... 20 colesevelam...... 34 CYCLOSET...... 40 clonazepam oral tablet 2 mg . . . . 20 colestipol...... 34 cyclosporine intravenous...... 14 clonazepam oral tablet, colistin (colistimethate na)...... 11 disintegrating 0.125 mg, cyclosporine modified...... 14 0.25 mg, 0.5 mg...... 20 COMBIGAN...... 52 cyclosporine oral capsule...... 14 clonazepam oral tablet, COMBIVENT RESPIMAT...... 54 CYRAMZA...... 14 disintegrating 1 mg...... 20 COMETRIQ ORAL CAPSULE cyred...... 50 60 MG/DAY (20 MG X 3/DAY). . . .14 clonazepam oral tablet, cyred eq...... 50 disintegrating 2 mg...... 20 COMETRIQ ORAL CAPSULE CYSTADANE ...... 44 clonidine hcl oral tablet 100 MG/DAY(80 MG X1-20 MG X1). 14 CYSTAGON...... 55 0.1 mg, 0.2 mg...... 31 COMETRIQ ORAL CAPSULE CYSTARAN...... 52 clonidine hcl oral tablet 0.3 mg . . . 31 140 MG/DAY(80 MG X1-20 MG X3). 14 clonidine hcl oral tablet COMPLERA ...... 7 extended release 12 hr ...... 27 compro ...... 44 D clonidine transdermal patch constulose...... 44 d2.5%-0.45% sodium chloride. . . .38 weekly 0.1 mg/24 hr, 0.2 mg/24 hr. .31 COPAXONE SUBCUTANEOUS d5%-0.45% sodium chloride. . . . .38 clonidine transdermal patch SYRINGE 20 MG/ML...... 23 d5% and 0.9% sodium chloride. . . 38 weekly 0.3 mg/24 hr...... 31 COPAXONE SUBCUTANEOUS d10%-0.45% sodium chloride . . . .38 clopidogrel oral tablet 75 mg . . . . 33 SYRINGE 40 MG/ML...... 23 dalfampridine...... 23 clopidogrel oral tablet 300 mg. . . .33 COPIKTRA ...... 14 DALIRESP...... 54 clorazepate dipotassium CORLANOR ORAL TABLET . . . . 34 danazol...... 42 oral tablet 7.5 mg...... 27 cortisone...... 39 dantrolene oral...... 23 clorazepate dipotassium CORTISPORIN-TC...... 39 oral tablet 15 mg, 3.75 mg . . . . . 27 dapsone oral...... 11 COSMEGEN...... 14 clotrimazole-betamethasone DAPTACEL COTELLIC...... 14 topical cream...... 36 (DTAP PEDIATRIC) (PF)...... 46 CREON...... 44 clotrimazole-betamethasone DAPTOMYCIN INTRAVENOUS topical lotion...... 36 CRESEMBA ORAL...... 7 RECON SOLN 350 MG...... 11 clotrimazole mucous membrane. . . 7 CRIXIVAN ORAL CAPSULE 200 MG. .7 daptomycin intravenous clotrimazole topical cream...... 36 CRIXIVAN ORAL CAPSULE 400 MG. .7 recon soln 500 mg...... 11 clotrimazole topical solution. . . . .36 cromolyn inhalation...... 54 DARAPRIM...... 11 cromolyn ophthalmic (eye). . . . . 52 darifenacin...... 55 63 Covered Drugs Index

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DARZALEX...... 15 desvenlafaxine succinate oral dextrose 5%-0.3% sod.chloride. . . 38 DARZALEX FASPRO...... 15 tablet extended release DEXTROSE 5% IN 24 hr 25 mg, 50 mg...... 27 dasetta 1/35 (28)...... 50 WATER (D5W) INTRAVENOUS desvenlafaxine succinate oral PARENTERAL SOLUTION. . . . . 38 dasetta 7/7/7 (28)...... 50 tablet extended release dextrose 5% in water (d5w) daunorubicin intravenous solution . .15 24 hr 100 mg...... 27 intravenous piggyback...... 38 DAURISMO ORAL TABLET 25 MG. .15 dexamethasone intensol...... 39 dextrose 5%-lactated ringers. . . . 38 DAURISMO ORAL dexamethasone oral elixir...... 39 dextrose 10% and 0.2% nacl. . . . 38 TABLET 100 MG...... 15 dexamethasone oral solution. . . . 39 DEXTROSE 10% daysee...... 50 dexamethasone oral tablet IN WATER (D10W)...... 38 deblitane...... 48 0.5 mg, 0.75 mg, 4 mg...... 39 dextrose 25% in water (d25w). . . .38 deferasirox oral granules dexamethasone oral tablet dextrose 30% in water (d30w). . . .38 in packet...... 38 1 mg, 1.5 mg, 2 mg, 6 mg...... 39 dextrose 40% in water (d40w). . . .38 deferasirox oral tablet...... 38 dexamethasone sodium dextrose 50% in water (d50w). . . .38 DELESTROGEN phos (pf) injection solution . . . . . 39 INTRAMUSCULAR OIL 10 MG/ML. 48 dexamethasone sodium dextrose 70% in water (d70w). . . .38 DELSTRIGO...... 7 phosphate injection solution. . . . .39 DIASTAT...... 20 demeclocycline...... 13 dexamethasone sodium DIASTAT ACUDIAL RECTAL KIT 5-7.5-10 MG...... 20 DEMSER...... 31 phosphate ophthalmic (eye). . . . .53 DIASTAT ACUDIAL RECTAL DENAVIR...... 35 dexmethylphenidate oral tablet 5 mg...... 27 KIT 12.5-15-17.5-20 MG...... 20 DEPEN TITRATABS...... 48 dexmethylphenidate diazepam injection syringe. . . . . 28 DEPO-ESTRADIOL ...... 48 oral tablet 10 mg, 2.5 mg...... 27 diazepam oral solution DEPO-MEDROL ...... 39 dextroamphetamine-amphetamine 5 mg/5 ml (1 mg/ml) ...... 28 DEPO-PROVERA oral capsule,extended release 24hr. .27 diazepam oral tablet...... 28 INTRAMUSCULAR dextroamphetamine-amphetamine diazepam rectal kit 2.5 mg . . . . . 21 SUSPENSION 400 MG/ML...... 48 oral tablet 5 mg...... 27 diazepam rectal kit 5-7.5-10 mg. . .21 DESCOVY...... 7 dextroamphetamine-amphetamine diazepam rectal kit desipramine...... 27 oral tablet 10 mg ...... 27 12.5-15-17.5-20 mg...... 20 desloratadine oral tablet ...... 53 dextroamphetamine-amphetamine diazoxide ...... 40 desmopressin injection...... 42 oral tablet 12.5 mg, 30 mg, 7.5 mg. .27 diclofenac potassium ...... 25 desmopressin nasal spray, dextroamphetamine-amphetamine diclofenac sodium ophthalmic (eye). .52 non-aerosol...... 42 oral tablet 15 mg ...... 27 diclofenac sodium oral...... 25 desmopressin nasal spray dextroamphetamine-amphetamine with pump...... 42 oral tablet 20 mg ...... 27 diclofenac sodium topical drops . . .26 desmopressin oral...... 42 dextroamphetamine oral capsule, diclofenac sodium topical gel 1%. . 26 extended release 5 mg...... 27 desog-e.estradiol/e.estradiol . . . . 50 dicloxacillin...... 12 dextroamphetamine oral capsule, desonide topical cream ...... 37 dicyclomine oral capsule...... 43 extended release 10 mg ...... 27 desonide topical lotion...... 37 dicyclomine oral solution...... 43 dextroamphetamine oral capsule, dicyclomine oral tablet...... 43 desonide topical ointment...... 37 extended release 15 mg ...... 27 didanosine oral capsule,delayed desoximetasone topical cream . . . 37 dextroamphetamine oral solution. . 27 release(dr/ec) 250 mg, 400 mg. . . .7 desoximetasone topical gel . . . . .37 dextroamphetamine oral tablet . . . 27 DIFICID...... 10 desoximetasone topical ointment. . 37 dextrose 5%-0.2% sod chloride. . . 38 diflunisal...... 26 64 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE digitek...... 34 donepezil oral tablet, drospirenone-ethinyl estradiol. . . .50 digox ...... 34 disintegrating 10 mg...... 23 DROXIA...... 15 digoxin oral solution dorzolamide...... 52 DUAVEE...... 48 50 mcg/ml (0.05 mg/ml)...... 34 dorzolamide-timolol...... 52 duloxetine oral capsule, digoxin oral tablet...... 34 dotti ...... 48 delayed release(dr/ec) 20 mg . . . .28 dihydroergotamine nasal...... 22 DOVATO...... 7 duloxetine oral capsule, DILANTIN 30 MG...... 21 doxazosin...... 32 delayed release(dr/ec) 30 mg . . . .28 diltiazem hcl intravenous...... 31 doxepin oral capsule...... 28 duloxetine oral capsule, delayed release(dr/ec) 60 mg . . . .28 diltiazem hcl oral capsule, doxepin oral concentrate...... 28 DUPIXENT PEN...... 35 extended release 12 hr ...... 31 doxepin oral tablet...... 28 DUPIXENT SYRINGE ...... 35 diltiazem hcl oral capsule, doxercalciferol intravenous. . . . . 42 extended release 24hr 120 mg, duramorph (pf)...... 24 doxercalciferol oral 180 mg, 240 mg, 300 mg...... 31 capsule 0.5 mcg...... 42 DUREZOL...... 53 diltiazem hcl oral capsule, dutasteride...... 55 extended release 24 hr 120 mg, doxercalciferol oral capsule 1 mcg. .42 dutasteride-tamsulosin...... 55 180 mg, 240 mg, 300 mg, 420 mg. .31 doxercalciferol oral diltiazem hcl oral capsule, capsule 2.5 mcg...... 42 ext.rel 24h degradable...... 31 doxy-100...... 13 E doxycycline hyclate intravenous. . .13 diltiazem hcl oral tablet...... 31 ec-naproxen...... 26 doxycycline hyclate oral capsule. . .13 diltiazem hcl oral tablet econazole...... 36 extended release 24 hr ...... 32 doxycycline hyclate EDARBI ...... 32 dilt-xr...... 32 oral tablet 20 mg ...... 13 EDARBYCLOR...... 32 dimethyl fumarate oral capsule, doxycycline hyclate EDURANT...... 7 delayed release(dr/ec) 120 mg. . . 23 oral tablet 100 mg...... 13 dimethyl fumarate oral capsule, doxycycline monohydrate e.e.s. 400 oral tablet...... 10 delayed release(dr/ec) 120 mg oral capsule 100 mg, 50 mg. . . . .13 efavirenz-lamivu-tenofov disop. . . .7 (14)- 240 mg (46)...... 23 DOXYCYCLINE MONOHYDRATE efavirenz oral capsule 50 mg. . . . .7 dimethyl fumarate oral capsule, ORAL CAPSULE,IR - DELAY efavirenz oral capsule 200 mg. . . . 7 REL,BIPHASE ...... 13 delayed release(dr/ec) 240 mg. . . 23 efavirenz oral tablet...... 7 doxycycline monohydrate oral diphenhydramine hcl injection ELAPRASE...... 42 solution 50 mg/ml...... 53 suspension for reconstitution. . . . 13 electrolyte-48 in d5w...... 56 diphenoxylate-atropine oral liquid. . 43 doxycycline monohydrate oral tablet...... 13 ELIGARD...... 15 diphenoxylate-atropine oral tablet. . 43 DRIZALMA SPRINKLE ORAL ELIGARD (3 MONTH)...... 15 dipyridamole oral...... 33 CAPSULE, DELAYED REL ELIGARD (4 MONTH)...... 15 disulfiram...... 38 SPRINKLE 20 MG...... 28 ELIGARD (6 MONTH)...... 15 divalproex...... 21 DRIZALMA SPRINKLE ORAL elinest...... 50 dofetilide...... 31 CAPSULE, DELAYED REL ELIQUIS...... 33 donepezil oral tablet 5 mg...... 23 SPRINKLE 30 MG, 40 MG. . . . . 28 ELIQUIS DVT-PE donepezil oral tablet 10 mg. . . . . 23 DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL TREAT 30D START...... 33 donepezil oral tablet 23 mg. . . . . 23 SPRINKLE 60 MG...... 28 ELLA...... 50 donepezil oral tablet, dronabinol ...... 44 ELMIRON...... 55 disintegrating 5 mg...... 23 drospirenone-e.estradiol-lm.fa. . . .50 ELZONRIS...... 15

65 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE

EMCYT...... 15 ENVARSUS XR ORAL erythromycin ethylsuccinate oral EMEND ORAL SUSPENSION TABLET EXTENDED RELEASE suspension for reconstitution FOR RECONSTITUTION...... 44 24 HR 0.75 MG, 1 MG...... 15 400 mg/5 ml...... 10 emoquette ...... 50 ENVARSUS XR ORAL erythromycin ethylsuccinate TABLET EXTENDED RELEASE oral tablet...... 10 EMSAM...... 28 24 HR 4 MG...... 15 erythromycin ophthalmic (eye). . . .52 emtricitabine...... 7 EPCLUSA ORAL erythromycin oral tablet...... 10 EMTRIVA ORAL CAPSULE. . . . . 8 TABLET 200-50 MG...... 8 erythromycin oral tablet, EMTRIVA ORAL SOLUTION. . . . .8 EPCLUSA ORAL delayed release (dr/ec) ...... 10 TABLET 400-100 MG...... 8 EMVERM...... 11 erythromycin with ethanol enalapril-hydrochlorothiazide. . . . 32 EPIDIOLEX...... 21 topical gel...... 36 enalapril maleate...... 32 epinastine...... 52 erythromycin with ethanol ENBREL MINI...... 48 epinephrine injection auto-injector. .53 topical solution...... 36 ENBREL SUBCUTANEOUS epinephrine injection ESBRIET ORAL CAPSULE. . . . .54 RECON SOLN...... 48 solution 1 mg/ml...... 53 ESBRIET ORAL TABLET 267 MG. .54 ENBREL SUBCUTANEOUS EPIPEN...... 53 ESBRIET ORAL TABLET 801 MG. .54 SOLUTION ...... 48 EPIPEN 2-PAK...... 53 escitalopram oxalate oral solution . .28 ENBREL SUBCUTANEOUS EPIPEN JR ...... 53 escitalopram oxalate oral tablet. . . 28 SYRINGE 25 MG/0.5 ML (0.5). . . .48 EPIPEN JR 2-PAK...... 53 esomeprazole magnesium oral ENBREL SUBCUTANEOUS epitol ...... 21 capsule,delayed release(dr/ec). . . 45 SYRINGE 50 MG/ML (1 ML) . . . . 48 EPIVIR HBV ORAL SOLUTION . . . 8 estarylla ...... 50 ENBREL SURECLICK...... 48 ergotamine-caffeine ...... 22 estradiol oral...... 48 endocet oral tablet 2.5-325 mg, 5-325 mg...... 24 ERIVEDGE ...... 15 estradiol transdermal patch semiweekly ...... 49 endocet oral tablet 7.5-325 mg. . . 24 ERLEADA ...... 15 estradiol transdermal patch weekly. 49 endocet oral tablet 10-325 mg. . . .24 erlotinib oral tablet 25 mg...... 15 estradiol vaginal cream ...... 49 ENGERIX-B PEDIATRIC (PF) erlotinib oral tablet 100 mg, 150 mg. .15 INTRAMUSCULAR SYRINGE. . . .46 errin...... 48 estradiol vaginal tablet...... 49 ENGERIX-B (PF) ertapenem...... 11 estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml...... 49 INTRAMUSCULAR SYRINGE. . . .46 ery pads...... 36 ESTRING...... 49 ENHERTU...... 15 ERYPED 400 ...... 10 ethacrynate sodium...... 32 enoxaparin subcutaneous solution. .33 ery-tab oral tablet,delayed enoxaparin subcutaneous syringe release (dr/ec) 250 mg...... 10 ethambutol...... 11 100 mg/ml, 30 mg/0.3 ml, 40 mg/ ERY-TAB ORAL TABLET, ethosuximide...... 21 0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml. 33 DELAYED RELEASE ethynodiol diac-eth estradiol. . . . .50 enoxaparin subcutaneous syringe (DR/EC) 333 MG, 500 MG. . . . . 10 etodolac ...... 26 120 mg/0.8 ml, 150 mg/ml...... 33 erythrocin (as stearate) etoposide intravenous ...... 15 enpresse...... 50 oral tablet 250 mg...... 10 EUTHYROX...... 43 enskyce...... 50 ERYTHROCIN INTRAVENOUS everolimus (antineoplastic). . . . . 15 entacapone...... 22 RECON SOLN 500 MG...... 10 everolimus (immunosuppressive) erythromycin-benzoyl peroxide. . . 36 entecavir...... 8 oral tablet 0.5 mg...... 15 ENTRESTO...... 34 erythromycin ethylsuccinate oral suspension for reconstitution everolimus (immunosuppressive) enulose...... 44 oral tablet 0.25 mg...... 15 200 mg/5 ml...... 10 66 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE everolimus (immunosuppressive) fenofibric acid (choline) oral FLOVENT HFA AEROSOL oral tablet 0.75 mg...... 15 capsule,delayed release INHALER 44 MCG/ACTUATION. . .54 EVOMELA...... 15 (dr/ec) 45 mg...... 34 FLOVENT HFA AEROSOL EVOTAZ...... 8 fenofibric acid (choline) oral INHALER 110 MCG/ACTUATION. . 54 capsule,delayed release exemestane...... 15 FLOVENT HFA AEROSOL (dr/ec) 135 mg ...... 34 INHALER 220 MCG/ACTUATION . .54 EYLEA...... 52 fentanyl...... 24 fluconazole...... 7 ezetimibe...... 34 fentanyl citrate buccal lozenge fluconazole in nacl (iso-osm) ezetimibe-simvastatin...... 34 on a handle 1,200 mcg, intravenous piggyback 1,600 mcg, 800 mcg...... 24 200 mg/100 ml, 400 mg/200 ml. . . .7 F fentanyl citrate buccal lozenge flucytosine ...... 7 on a handle 200 mcg, fludarabine...... 15 FABRAZYME ...... 42 400 mcg, 600 mcg...... 24 falmina (28)...... 50 fentanyl citrate (pf) fludrocortisone ...... 39 famciclovir ...... 8 injection solution...... 24 flunisolide nasal spray, non-aerosol 25 mcg (0.025%). . . .54 famotidine oral suspension. . . . . 45 fentanyl citrate (pf) fluocinolone acetonide oil...... 39 famotidine oral tablet intravenous syringe 20 mg, 40 mg ...... 45 100 mcg/2 ml (50 mcg/ml)...... 24 fluocinolone and shower cap. . . . 37 FANAPT ORAL TABLET FERRIPROX...... 38 fluocinolone topical cream...... 37 1 MG, 2 MG, 4 MG...... 28 FERRIPROX (2 TIMES A DAY). . . 38 fluocinolone topical oil ...... 37 FANAPT ORAL TABLET FETZIMA ORAL CAPSULE, fluocinolone topical ointment. . . . 37 10 MG, 12 MG, 6 MG, 8 MG . . . . 28 EXTENDED RELEASE 24 HR...... 28 fluocinolone topical solution. . . . .37 FANAPT ORAL TABLETS, FETZIMA ORAL CAPSULE, fluocinonide topical cream 0.1%. . .37 DOSE PACK...... 28 EXT REL 24HR DOSE PACK...... 28 fluocinonide topical cream 0.05%. . 37 FARXIGA ORAL TABLET 5 MG . . .40 finasteride oral tablet 5 mg. . . . . 55 fluocinonide topical gel...... 37 FARXIGA ORAL TABLET 10 MG. . 40 FINTEPLA...... 21 fluocinonide topical ointment. . . . 37 FARYDAK ...... 15 FIRDAPSE...... 23 fluocinonide topical solution. . . . .37 FASLODEX...... 15 FIRMAGON KIT W DILUENT fluoride (sodium) dental paste. . . .39 fayosim...... 50 SYRINGE SUBCUTANEOUS RECON SOLN 80 MG...... 15 fluoride (sodium) oral tablet . . . . .57 FEBUXOSTAT ...... 47 FIRMAGON KIT W DILUENT fluoride (sodium) oral tablet, felbamate oral suspension . . . . . 21 SYRINGE SUBCUTANEOUS chewable 1 mg felbamate oral tablet...... 21 RECON SOLN 120 MG...... 15 (2.2 mg sod. fluoride)...... 57 felodipine...... 32 FIRVANQ...... 11 fluorometholone...... 53 femynor...... 50 flac otic oil ...... 39 fluorouracil topical cream 0.5%. . . 35 fenofibrate micronized oral flavoxate...... 55 fluorouracil topical cream 5%. . . . 35 capsule 130 mg, 43 mg...... 34 flecainide ...... 31 fluorouracil topical solution. . . . . 35 fenofibrate micronized oral FLOVENT DISKUS INHALATION fluoxetine oral capsule...... 28 capsule 134 mg, 200 mg, 67 mg. . .34 BLISTER WITH DEVICE fluoxetine oral capsule, fenofibrate nanocrystallized 100 MCG/ACTUATION, delayed release(dr/ec)...... 28 oral tablet 145 mg, 48 mg...... 34 50 MCG/ACTUATION...... 54 fluoxetine oral solution...... 28 fenofibrate oral capsule...... 34 FLOVENT DISKUS INHALATION fluoxetine oral tablet 10 mg, 20 mg . 28 fenofibrate oral tablet BLISTER WITH DEVICE fluphenazine decanoate...... 28 160 mg, 54 mg...... 34 250 MCG/ACTUATION ...... 54 fluphenazine hcl injection ...... 28 67 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE fluphenazine hcl oral concentrate. . 28 G GENOTROPIN MINIQUICK fluphenazine hcl oral elixir...... 28 SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, fluphenazine hcl oral tablet. . . . . 28 gabapentin oral capsule 100 mg, 400 mg...... 21 0.8 MG/0.25 ML, 1 MG/0.25 ML, flurbiprofen oral tablet 100 mg. . . .26 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, gabapentin oral capsule 300 mg. . .21 flurbiprofen sodium...... 52 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, gabapentin oral solution...... 21 flutamide...... 15 2 MG/0.25 ML...... 46 gabapentin oral tablet 600 mg. . . .21 fluticasone propionate nasal. . . . .54 gentak ophthalmic (eye) ointment. . 52 gabapentin oral tablet 800 mg. . . .21 fluticasone propionate gentamicin injection topical cream...... 37 galantamine oral capsule, solution 40 mg/ml...... 11 ext rel. pellets 24 hr...... 23 fluticasone propionate GENTAMICIN IN NACL (ISO-OSM) topical ointment ...... 37 galantamine oral solution...... 23 INTRAVENOUS PIGGYBACK 100 MG/50 ML, 120 MG/100 ML. . .11 fluticasone propion-salmeterol galantamine oral tablet...... 23 inhalation blister with device. . . . .54 GAMMAKED INJECTION SOLUTION gentamicin in nacl (iso-osm) intravenous piggyback fluvoxamine oral tablet...... 28 1 GRAM/10 ML (10%), 10 GRAM/ 100 ML (10%), 20 GRAM/200 ML 100 mg/100 ml, 60 mg/50 ml, FOLOTYN ...... 15 (10%), 5 GRAM/50 ML (10%) . . . .46 80 mg/100 ml, 80 mg/50 ml . . . . .11 fomepizole...... 46 GAMUNEX-C ...... 46 gentamicin ophthalmic (eye) drops. .52 fondaparinux subcutaneous GARDASIL 9 (PF)...... 46 gentamicin sulfate (ped) (pf). . . . .11 syringe 2.5 mg/0.5 ml...... 33 GATTEX 30-VIAL...... 44 gentamicin topical...... 36 fondaparinux subcutaneous GENVOYA...... 8 syringe 10 mg/0.8 ml, GATTEX ONE-VIAL ...... 44 5 mg/0.4 ml, 7.5 mg/0.6 ml. . . . . 33 GAUZE PADS 2 X 2...... 40 GEODON INTRAMUSCULAR. . . .28 FORTEO...... 47 gavilyte-c ...... 44 gianvi (28) ...... 50 fosamprenavir...... 8 gavilyte-g...... 44 GILENYA ORAL CAPSULE 0.5 MG . 23 fosinopril...... 32 gavilyte-n...... 44 GILOTRIF...... 15 fosinopril-hydrochlorothiazide . . . .32 GAVRETO...... 15 GLEOSTINE ORAL CAPSULE 10 MG, 40 MG...... 15 FREAMINE HBC 6.9%...... 56 GAZYVA...... 15 GLEOSTINE ORAL freamine iii 10%...... 56 gemcitabine intravenous CAPSULE 100 MG...... 15 recon soln...... 15 fulvestrant...... 15 glimepiride oral tablet 1 mg. . . . . 40 furosemide injection ...... 32 gemcitabine intravenous solution 1 gram/26.3 ml (38 mg/ml), glimepiride oral tablet 2 mg. . . . . 40 furosemide oral solution 2 gram/52.6 ml (38 mg/ml), glimepiride oral tablet 4 mg. . . . . 40 10 mg/ml, 40 mg/5 ml (8 mg/ml). . .32 200 mg/5.26 ml (38 mg/ml). . . . . 15 glipizide-metformin oral furosemide oral tablet...... 32 GEMCITABINE INTRAVENOUS tablet 2.5-250 mg...... 40 FUZEON SUBCUTANEOUS SOLUTION 100 MG/ML...... 15 glipizide-metformin oral RECON SOLN...... 8 gemfibrozil...... 34 tablet 2.5-500 mg, 5-500 mg . . . . 40 fyavolv...... 49 generlac...... 44 glipizide oral tablet 5 mg...... 40 FYCOMPA ORAL SUSPENSION. . 21 gengraf oral capsule glipizide oral tablet 10 mg...... 40 FYCOMPA ORAL TABLET 100 mg, 25 mg...... 15 glipizide oral tablet extended 2 MG, 4 MG, 6 MG...... 21 gengraf oral solution...... 15 release 24hr 2.5 mg ...... 40 FYCOMPA ORAL TABLET GENOTROPIN...... 46 glipizide oral tablet extended 10 MG, 12 MG, 8 MG...... 21 GENOTROPIN MINIQUICK release 24hr 5 mg...... 40 SUBCUTANEOUS SYRINGE glipizide oral tablet extended 0.2 MG/0.25 ML...... 46 release 24hr 10 mg...... 40 68 Covered Drugs Index

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GLUCAGEN HYPOKIT ...... 40 haloperidol oral tablet HUMALOG MIX 75-25 GLUCAGON EMERGENCY 10 mg, 20 mg ...... 28 (U-100)INSULN...... 40 KIT (HUMAN)...... 40 HARVONI ORAL PELLETS HUMALOG U-100 INSULIN. . . . .40 GLUCAGON (HCL) IN PACKET 33.75-150 MG...... 8 HUMIRA(CF) PEDI CROHNS EMERGENCY KIT...... 40 HARVONI ORAL PELLETS STARTER SUBCUTANEOUS glycopyrrolate injection...... 43 IN PACKET 45-200 MG...... 8 SYRINGE KIT 80 MG/0.8 ML. . . . 48 glycopyrrolate oral...... 43 HARVONI ORAL TABLET...... 8 HUMIRA(CF) PEDI CROHNS HAVRIX (PF) INTRAMUSCULAR STARTER SUBCUTANEOUS GLYCOPYRROLATE (PF) SYRINGE KIT 80 MG/0.8 ML- IN WATER INJECTION...... 43 SUSPENSION 1,440 ELISA UNIT/ML...... 46 40 MG/0.4 ML...... 48 glycopyrrolate (pf) in water HUMIRA(CF) PEN intravenous syringe HAVRIX (PF) INTRAMUSCULAR CROHNS-UC-HS...... 48 0.4 mg/2 ml (0.2 mg/ml)...... 43 SYRINGE...... 47 HUMIRA(CF) PEN glydo ...... 35 heather...... 49 PSOR-UV-ADOL HS...... 48 GLYXAMBI...... 40 heparin(porcine) in 0.45% nacl intravenous parenteral solution HUMIRA(CF) PEN granisetron hcl intravenous. . . . . 44 25,000 unit/250 ml, SUBCUTANEOUS INJECTOR granisetron hcl oral...... 44 25,000 unit/500 ml...... 33 KIT 40 MG/0.4 ML...... 48 granisetron (pf) intravenous heparin (porcine) in 5% dex HUMIRA(CF) SUBCUTANEOUS solution 1 mg/ml (1 ml)...... 44 intravenous parenteral solution SYRINGE KIT 10 MG/0.1 ML, griseofulvin microsize...... 7 20,000 unit/500 ml (40 unit/ml), 20 MG/0.2 ML...... 48 griseofulvin ultramicrosize...... 7 25,000 unit/250 ml(100 unit/ml), HUMIRA(CF) SUBCUTANEOUS 25,000 unit/500 ml (50 unit/ml) . . . 33 SYRINGE KIT 40 MG/0.4 ML. . . . 48 GUANIDINE...... 28 heparin (porcine) injection solution. .33 HUMIRA PEN...... 48 GVOKE HYPOPEN 1-PACK . . . . 40 heparin (porcine) in nacl (pf). . . . .33 HUMIRA PEN CROHNS- GVOKE HYPOPEN 2-PACK . . . . 40 heparin, porcine (pf) injection UC-HS START...... 48 GVOKE PFS 1-PACK SYRINGE. . . . 40 syringe 5,000 unit/0.5 ml...... 33 HUMIRA PEN PSOR- GVOKE PFS 2-PACK SYRINGE. . . . 40 HEPARIN, PORCINE (PF) UVEITS-ADOL HS...... 48 INJECTION SYRINGE HUMIRA SUBCUTANEOUS H 5,000 UNIT/ML...... 33 SYRINGE KIT 10 MG/0.2 ML, HEPATAMINE 8%...... 56 20 MG/0.4 ML...... 48 hailey...... 50 HERCEPTIN HYLECTA...... 16 HUMIRA SUBCUTANEOUS hailey 24 fe ...... 50 SYRINGE KIT 40 MG/0.8 ML. . . . 48 HERCEPTIN INTRAVENOUS hailey fe 1.5/30 (28) ...... 50 RECON SOLN 150 MG...... 16 HUMULIN 70/30 U-100 INSULIN. . 40 hailey fe 1/20 (28)...... 50 HETLIOZ ...... 28 HUMULIN 70/30 U-100 KWIKPEN. .40 HALAVEN...... 16 HIBERIX (PF)...... 47 HUMULIN N NPH INSULIN KWIKPEN ...... 40 halobetasol propionate HIZENTRA...... 47 topical cream...... 37 HUMULIN N NPH U-100 INSULIN. .40 HUMALOG JUNIOR halobetasol propionate KWIKPEN U-100...... 40 HUMULIN R REGULAR topical ointment ...... 37 U-100 INSULN...... 40 HUMALOG KWIKPEN INSULIN. . .40 haloperidol decanoate...... 28 HUMULIN R U-500 HUMALOG MIX 50-50 (CONC) INSULIN...... 40 haloperidol lactate injection . . . . .28 INSULN U-100...... 40 HUMULIN R U-500 haloperidol lactate oral...... 28 HUMALOG MIX 50-50 KWIKPEN. . . 40 (CONC) KWIKPEN...... 41 haloperidol oral tablet HUMALOG MIX 75-25 KWIKPEN. . . 40 0.5 mg, 1 mg, 2 mg, 5 mg...... 28 hydralazine injection...... 32

69 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE hydralazine oral...... 32 hydromorphone (pf) injection INFUMORPH P/F...... 24 hydrochlorothiazide...... 32 solution 10 (mg/ml) (5 ml), INLYTA ORAL TABLET 1 MG. . . . 16 10 mg/ml, 2 mg/ml...... 24 hydrocodone-acetaminophen INLYTA ORAL TABLET 5 MG. . . . 16 hydroxychloroquine...... 11 oral solution 7.5-325 mg/15 ml . . . 24 INQOVI...... 16 hydroxyprogesterone caproate. . . 49 hydrocodone-acetaminophen oral INREBIC...... 16 solution 10-325 mg/15 ml(15 ml). . .24 hydroxyurea...... 16 INSULIN PEN NEEDLE...... 41 hydrocodone-acetaminophen hydroxyzine hcl oral tablet...... 53 INSULIN SYRINGE (DISP) oral tablet 5-325 mg ...... 24 U-100 0.3 ML, 1 ML, 1/2 ML. . . . .41 HYDROCODONE- I ACETAMINOPHEN ORAL INTELENCE ORAL TABLET 25 MG . 8 TABLET 10-300 MG, 7.5-300 MG. . 24 ibandronate oral...... 47 INTELENCE ORAL TABLET 100 MG, 200 MG...... 8 hydrocodone-acetaminophen oral IBRANCE...... 16 INTRALIPID INTRAVENOUS tablet 10-325 mg, 7.5-325 mg. . . .24 ibu...... 26 EMULSION 20%, 30%...... 56 hydrocodone-ibuprofen oral tablet ibuprofen oral suspension...... 26 10-200 mg, 5-200 mg, 7.5-200 mg. .24 INTRON A INJECTION ibuprofen oral tablet RECON SOLN...... 46 hydrocortisone-acetic acid . . . . . 39 400 mg, 600 mg, 800 mg...... 26 hydrocortisone butyrate INTRON A INJECTION ibuprofen-oxycodone ...... 24 SOLUTION 6 MILLION UNIT/ML. . 46 topical cream...... 37 icatibant ...... 54 hydrocortisone butyrate INTRON A INJECTION ICLUSIG ORAL TABLET 15 MG. . .16 SOLUTION 10 MILLION UNIT/ML. .46 topical ointment ...... 37 hydrocortisone butyrate ICLUSIG ORAL TABLET 45 MG. . .16 introvale ...... 50 topical solution...... 37 IDHIFA...... 16 INVEGA SUSTENNA INTRAMUSCULAR SYRINGE hydrocortisone butyr-emollient. . . .37 imatinib oral tablet 100 mg. . . . . 16 39 MG/0.25 ML...... 28 hydrocortisone oral...... 39 imatinib oral tablet 400 mg. . . . . 16 INVEGA SUSTENNA hydrocortisone rectal ...... 44 IMBRUVICA ORAL INTRAMUSCULAR SYRINGE CAPSULE 70 MG ...... 16 hydrocortisone topical cream 78 MG/0.5 ML...... 28 1%, 2.5%...... 37 IMBRUVICA ORAL INVEGA SUSTENNA hydrocortisone topical cream CAPSULE 140 MG...... 16 INTRAMUSCULAR SYRINGE with perineal applicator ...... 44 IMBRUVICA ORAL TABLET. . . . .16 117 MG/0.75 ML...... 28 hydrocortisone topical lotion 2.5%. .37 IMFINZI...... 16 INVEGA SUSTENNA hydrocortisone topical imipenem-cilastatin...... 11 INTRAMUSCULAR SYRINGE ointment 1%, 2.5% ...... 37 imipramine hcl...... 28 156 MG/ML...... 28 hydrocortisone valerate...... 37 imiquimod topical cream INVEGA SUSTENNA INTRAMUSCULAR SYRINGE hydromorphone injection in metered-dose pump...... 35 234 MG/1.5 ML...... 28 solution 2 mg/ml...... 24 imiquimod topical cream in packet. .35 INVEGA TRINZA INTRAMUSCULAR hydromorphone injection syringe IMOVAX RABIES VACCINE (PF). . 47 SYRINGE 273 MG/0.875 ML. . . . 28 1 mg/ml, 2 mg/ml, 4 mg/ml. . . . . 24 incassia...... 49 INVEGA TRINZA INTRAMUSCULAR hydromorphone oral liquid...... 24 INCRELEX...... 38 SYRINGE 410 MG/1.315 ML. . . . 29 hydromorphone oral tablet INCRUSE ELLIPTA...... 54 INVEGA TRINZA INTRAMUSCULAR 2 mg, 4 mg...... 24 indapamide ...... 32 SYRINGE 546 MG/1.75 ML. . . . .29 hydromorphone oral tablet 8 mg. . .24 INFANRIX (DTAP) (PF) INVEGA TRINZA INTRAMUSCULAR INTRAMUSCULAR SUSPENSION. .47 SYRINGE 819 MG/2.625 ML. . . . 29 INFUGEM...... 16 INVELTYS...... 53

70 Covered Drugs Index

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INVIRASE ORAL TABLET ...... 8 jaimiess...... 50 kariva (28) ...... 50 INVOKAMET...... 41 JAKAFI...... 16 kelnor 1/35 (28) ...... 50 INVOKAMET XR...... 41 jantoven ...... 33 kelnor 1-50...... 50 INVOKANA ...... 41 JANUMET ...... 41 ketoconazole oral...... 7 IPOL...... 47 JANUMET XR ORAL TABLET, ketoconazole topical cream . . . . .36 ipratropium-albuterol...... 54 ER MULTIPHASE 24 HR ketoconazole topical shampoo . . . 36 50-1,000 MG, 50-500 MG...... 41 ipratropium bromide inhalation . . . 54 ketorolac ophthalmic (eye). . . . . 52 JANUMET XR ORAL TABLET, ipratropium bromide nasal spray, ER MULTIPHASE 24 HR KEYTRUDA non-aerosol 0.03% ...... 39 INTRAVENOUS SOLUTION . . . . 16 100-1,000 MG...... 41 ipratropium bromide nasal spray, KINRIX (PF)...... 47 JANUVIA ...... 41 non-aerosol 42 mcg (0.06%). . . . 39 kionex (with sorbitol)...... 38 JARDIANCE...... 41 irbesartan-hydrochlorothiazide . . . 32 KISQALI...... 16 jasmiel (28) ...... 50 irbesartan oral tablet 150 mg. . . . 32 KISQALI FEMARA CO-PACK jencycla...... 49 irbesartan oral tablet ORAL TABLET 200 MG/DAY 300 mg, 75 mg...... 32 JENTADUETO ...... 41 (200 MG X 1)-2.5 MG...... 16 IRESSA...... 16 JENTADUETO XR ORAL KISQALI FEMARA CO-PACK TABLET, IR - ER, BIPHASIC irinotecan...... 16 ORAL TABLET 400 MG/DAY 24HR 2.5-1,000 MG...... 41 (200 MG X 2)-2.5 MG...... 16 ISENTRESS HD...... 8 JENTADUETO XR ORAL KISQALI FEMARA CO-PACK ISENTRESS ORAL POWDER TABLET, IR - ER, BIPHASIC ORAL TABLET 600 MG/DAY IN PACKET...... 8 24HR 5-1,000 MG...... 41 (200 MG X 3)-2.5 MG...... 16 ISENTRESS ORAL TABLET . . . . .8 jolessa...... 50 klor-con...... 55 ISENTRESS ORAL TABLET, juleber...... 50 KLOR-CON 8 ...... 55 CHEWABLE 25 MG ...... 8 JULUCA...... 8 KLOR-CON 10...... 55 ISENTRESS ORAL TABLET, junel 1.5/30 (21)...... 50 CHEWABLE 100 MG...... 8 klor-con m10...... 55 junel 1/20 (21)...... 50 isibloom...... 50 klor-con m20...... 55 junel fe 1.5/30 (28)...... 50 isoniazid oral solution...... 11 KORLYM...... 42 junel fe 1/20 (28) ...... 50 isoniazid oral tablet...... 11 K-PHOS ORIGINAL ...... 55 junel fe 24...... 50 isosorbide dinitrate oral tablet . . . .34 kurvelo (28)...... 50 KUVAN...... 42 isosorbide mononitrate...... 34 K isotretinoin...... 36 KYPROLIS...... 16 isradipine...... 32 KABIVEN...... 56 ISTODAX...... 16 KADCYLA ...... 16 L itraconazole oral capsule...... 7 kaitlib fe...... 50 labetalol oral...... 32 itraconazole oral solution...... 7 KALETRA ORAL LACRISERT ...... 52 TABLET 100-25 MG...... 8 ivermectin oral ...... 11 lactated ringers intravenous. . . . .55 KALETRA ORAL IXIARO (PF) ...... 47 lactated ringers irrigation...... 37 TABLET 200-50 MG...... 8 lactulose oral solution...... 44 kalliga ...... 50 J lamivudine oral solution...... 8 KALYDECO...... 54 lamivudine oral tablet JADENU...... 38 KANJINTI...... 16 100 mg, 300 mg...... 8 JADENU SPRINKLE...... 38 71 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE lamivudine oral tablet 150 mg . . . . 8 LEUKINE INJECTION lidocaine hcl mucous lamivudine-zidovudine...... 8 RECON SOLN...... 46 membrane jelly in applicator. . . . .35 lamotrigine oral tablet...... 21 leuprolide subcutaneous kit . . . . .16 lidocaine hcl mucous membrane solution 4% (40 mg/ml). .35 lamotrigine oral tablet, levalbuterol hcl...... 54 chewable dispersible ...... 21 levalbuterol tartrate...... 54 lidocaine (pf) injection solution. . . .35 lamotrigine oral tablet, LEVEMIR FLEXTOUCH lidocaine (pf) intravenous syringe. . 31 disintegrating...... 21 U-100 INSULN...... 41 lidocaine-prilocaine topical cream. . 35 lamotrigine oral tablet LEVEMIR U-100 INSULIN . . . . . 41 lidocaine topical adhesive extended release 24hr...... 21 levetiracetam in nacl (iso-os). . . . 21 patch,medicated 5%...... 35 lansoprazole oral capsule, levetiracetam intravenous...... 21 lidocaine topical ointment...... 35 delayed release(dr/ec)...... 45 levetiracetam oral ...... 21 lidocaine viscous...... 35 LANTUS SOLOSTAR levobunolol ophthalmic lillow (28) ...... 50 U-100 INSULIN...... 41 (eye) drops 0.5%...... 52 lincomycin ...... 11 LANTUS U-100 INSULIN ...... 41 levocarnitine oral lindane topical shampoo...... 37 larin 1.5/30 (21) ...... 50 solution 100 mg/ml ...... 38 linezolid-0.9% sodium chloride . . . 11 larin 1/20 (21)...... 50 levocarnitine oral tablet ...... 38 linezolid in dextrose 5%...... 11 larin 24 fe...... 50 levocarnitine (with sugar)...... 38 linezolid oral suspension larin fe 1.5/30 (28)...... 50 levocetirizine oral solution...... 53 for reconstitution...... 11 larin fe 1/20 (28)...... 50 levocetirizine oral tablet...... 53 linezolid oral tablet...... 11 larissia...... 50 levofloxacin in d5w ...... 13 LINZESS...... 44 latanoprost...... 52 levofloxacin intravenous ...... 13 liothyronine oral...... 43 LATUDA ORAL TABLET 80 MG. . .29 levofloxacin oral solution...... 13 lisinopril...... 32 LATUDA ORAL TABLET levofloxacin oral tablet...... 13 lisinopril-hydrochlorothiazide. . . . 32 120 MG, 20 MG, 40 MG, 60 MG. . .29 levonest (28)...... 50 lithium carbonate...... 29 layolis fe...... 50 levonorgestrel-ethinyl estrad . . . . 50 LIVALO...... 34 leena 28...... 50 levonorg-eth estrad triphasic. . . . 50 l norgest/e.estradiol-e.estrad. . . . 50 leflunomide ...... 48 levora-28...... 50 lojaimiess...... 50 LENVIMA ORAL CAPSULE LEVO-T...... 43 LOKELMA ...... 38 10 MG/DAY (10 MG X 1), 4 MG . . .16 LENVIMA ORAL CAPSULE levothyroxine oral...... 43 LONSURF ORAL 12 MG/DAY (4 MG X 3), 18 MG/DAY levoxyl oral tablet TABLET 15-6.14 MG...... 16 (10 MG X 1-4 MG X2), 24 MG/DAY 100 mcg, 112 mcg, 175 mcg . . . . 43 LONSURF ORAL (10 MG X 2-4 MG X 1)...... 16 LEVOXYL ORAL TABLET TABLET 20-8.19 MG...... 16 LENVIMA ORAL CAPSULE 125 MCG, 137 MCG, 150 MCG, loperamide oral capsule...... 43 14 MG/DAY(10 MG X 1-4 MG X 1), 200 MCG, 25 MCG, 50 MCG, lopinavir-ritonavir...... 8 75 MCG, 88 MCG...... 43 20 MG/DAY (10 MG X 2), lorazepam injection...... 29 8 MG/DAY (4 MG X 2)...... 16 LEXIVA ORAL SUSPENSION. . . . 8 lorazepam intensol ...... 29 lessina...... 50 LIBTAYO...... 16 lorazepam oral concentrate . . . . .29 letrozole ...... 16 lidocaine hcl injection solution. . . .35 lorazepam oral tablet 0.5 mg, 1 mg. .29 leucovorin calcium injection. . . . .13 lidocaine hcl laryngotracheal. . . . 35 lorazepam oral tablet 2 mg. . . . . 29 leucovorin calcium oral...... 13 lidocaine hcl mucous LORBRENA ORAL TABLET 25 MG . 16 LEUKERAN...... 16 membrane jelly...... 35 LORBRENA ORAL TABLET 100 MG. 16

72 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE lorcet hd...... 24 LYSODREN...... 17 memantine oral capsule, loryna (28)...... 50 LYUMJEV KWIKPEN sprinkle,er 24hr...... 23 losartan...... 32 U-100 INSULIN...... 41 memantine oral solution...... 23 losartan-hydrochlorothiazide LYUMJEV KWIKPEN memantine oral tablet 5 mg . . . . .23 oral tablet 50-12.5 mg...... 32 U-200 INSULIN...... 41 memantine oral tablet 10 mg. . . . 23 losartan-hydrochlorothiazide oral LYUMJEV U-100 INSULIN. . . . . 41 memantine oral tablets,dose pack. .23 tablet 100-12.5 mg, 100-25 mg. . . 32 lyza...... 49 MENACTRA (PF) LOTEMAX...... 53 INTRAMUSCULAR SOLUTION . . .47 LOTEMAX SM ...... 53 M MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG. . . . 49 lovastatin ...... 34 MAGNESIUM SULFATE low-ogestrel (28) ...... 50 IN D5W INTRAVENOUS MENOSTAR ...... 49 loxapine succinate...... 29 PIGGYBACK 1 GRAM/100 ML. . . 56 MENVEO A-C-Y-W-135-DIP (PF). . 47 lo-zumandimine (28)...... 50 magnesium sulfate injection. . . . .56 mercaptopurine...... 17 LUMIGAN OPHTHALMIC magnesium sulfate in water. . . . .56 meropenem...... 11 (EYE) DROPS 0.01%...... 52 malathion...... 37 MEROPENEM- 0.9% SODIUM CHLORIDE. . . . . 11 LUMIZYME ...... 42 maprotiline...... 29 mesalamine oral capsule, LUMOXITI ...... 16 marlissa (28)...... 50 extended release 24hr...... 44 LUPRON DEPOT ...... 16 MARPLAN...... 29 mesalamine oral tablet, LUPRON DEPOT (3 MONTH). . . .16 MATULANE...... 17 delayed release (dr/ec) 1.2 gram . . 44 LUPRON DEPOT (4 MONTH). . . .16 matzim la...... 32 mesalamine rectal enema...... 44 LUPRON DEPOT (6 MONTH). . . .17 MAVYRET...... 8 mesalamine with cleansing wipe. . .44 LUPRON DEPOT-PED ...... 17 meclizine oral tablet mesna...... 13 LUPRON DEPOT-PED 12.5 mg, 25 mg...... 44 MESNEX ORAL...... 13 (3 MONTH) INTRAMUSCULAR MEDROL ORAL TABLET 2 MG. . . 39 metaproterenol oral syrup...... 54 SYRINGE KIT 11.25 MG...... 17 medroxyprogesterone metformin oral solution...... 41 LUPRON DEPOT-PED intramuscular suspension...... 49 (3 MONTH) INTRAMUSCULAR medroxyprogesterone metformin oral tablet 1,000 mg. . . 41 SYRINGE KIT 30 MG...... 17 intramuscular syringe...... 49 metformin oral tablet 500 mg. . . . 41 lutera (28)...... 50 medroxyprogesterone oral . . . . . 49 metformin oral tablet 850 mg. . . . 41 LYNPARZA ORAL TABLET. . . . . 17 mefloquine...... 11 metformin oral tablet LYRICA CR ORAL TABLET megestrol oral suspension extended release 24 hr 500 mg EXTENDED RELEASE 400 mg/10 ml (10 ml), (generic for glucophage xr). . . . . 41 24 HR 165 MG, 82.5 MG...... 21 400 mg/10 ml (40 mg/ml)...... 17 metformin oral tablet LYRICA CR ORAL TABLET extended release 24 hr 750 mg megestrol oral tablet...... 17 EXTENDED RELEASE (generic for glucophage xr). . . . . 41 MEKINIST ORAL TABLET 0.5 MG. .17 24 HR 330 MG...... 21 metformin oral tablet extended LYRICA ORAL CAPSULE 75 MG. . 21 MEKINIST ORAL TABLET 2 MG. . .17 release (osm) 24 hr 1000mg, LYRICA ORAL CAPSULE MEKTOVI...... 17 500mg (generic for fortamet). . . . 41 100 MG, 150 MG, 200 MG, melodetta 24 fe...... 50 methadone injection solution. . . . 24 25 MG, 50 MG ...... 21 meloxicam oral tablet...... 26 methadone intensol...... 24 LYRICA ORAL CAPSULE melphalan...... 17 methadone oral concentrate. . . . .24 225 MG, 300 MG...... 21 melphalan hcl...... 17 methadone oral solution 5 mg/5 ml . 24 LYRICA ORAL SOLUTION. . . . . 21 73 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE methadone oral solution metro i.v...... 11 montelukast oral tablet,chewable. . 54 10 mg/5 ml...... 24 metronidazole in nacl (iso-os) . . . .11 MONUROL ...... 13 methadone oral tablet 5 mg. . . . .25 metronidazole oral tablet...... 11 morgidox...... 13 methadone oral tablet 10 mg. . . . 25 metronidazole topical...... 36 morphine concentrate oral solution . 25 methazolamide...... 52 metronidazole vaginal...... 49 MORPHINE INJECTION methenamine hippurate...... 13 metyrosine...... 32 SOLUTION 2 MG/ML...... 25 methimazole oral tablet mexiletine...... 31 MORPHINE INJECTION 10 mg, 5 mg...... 40 SOLUTION 4 MG/ML...... 25 MIACALCIN INJECTION...... 42 methocarbamol oral ...... 23 MORPHINE INJECTION mibelas 24 fe...... 50 methotrexate sodium injection. . . .17 SOLUTION 5 MG/ML...... 25 micafungin...... 7 methotrexate sodium oral...... 17 morphine injection solution 8 mg/ml. 25 microgestin 1.5/30 (21) ...... 50 methotrexate sodium (pf)...... 17 MORPHINE INJECTION microgestin 1/20 (21)...... 50 SOLUTION 10 MG/ML...... 25 methoxsalen...... 35 microgestin fe 1.5/30 (28)...... 50 MORPHINE INJECTION methyldopa ...... 32 microgestin fe 1/20 (28)...... 50 SYRINGE 2 MG/ML ...... 25 methylphenidate hcl oral tablet. . . 29 midodrine...... 38 morphine injection syringe 4 mg/ml. 25 methylphenidate hcl oral tablet migergot...... 22 morphine injection syringe 5 mg/ml. 25 extended release...... 29 morphine injection syringe 8 mg/ml. 25 methylphenidate hcl oral tablet miglitol...... 41 extended release 24hr 18 mg, miglustat...... 42 morphine injection syringe 10 mg/ml. 25 18 mg (bx rating)...... 29 mili...... 50 MORPHINE INTRAVENOUS methylphenidate hcl oral tablet minitran...... 34 SOLUTION 4 MG/ML...... 25 extended release 24hr 27 mg, minocycline oral capsule...... 13 MORPHINE INTRAVENOUS 27 mg (bx rating), 54 mg, SOLUTION 8 MG/ML...... 25 minocycline oral tablet...... 13 54 mg (bx rating)...... 29 morphine intravenous methylphenidate hcl oral tablet minoxidil oral...... 32 solution 10 mg/ml...... 25 extended release 24hr 36 mg, mirtazapine oral tablet...... 29 morphine intravenous 36 mg (bx rating)...... 29 mirtazapine oral tablet, syringe 2 mg/ml...... 25 methylprednisolone...... 39 disintegrating...... 29 morphine intravenous methylprednisolone acetate. . . . .39 misoprostol ...... 45 syringe 4 mg/ml...... 25 methylprednisolone sodium succ MITIGARE...... 47 MORPHINE INTRAVENOUS injection recon soln 125 mg, 40 mg. .39 MITIGO (PF)...... 25 SYRINGE 8 MG/ML ...... 25 methylprednisolone sodium succ M-M-R II (PF) ...... 47 MORPHINE INTRAVENOUS intravenous recon soln 1,000 mg. . 39 SYRINGE 10 MG/ML...... 25 moexipril...... 32 methylprednisolone sodium succ morphine oral solution 10 mg/5 ml. .25 molindone...... 29 intravenous recon soln 500 mg. . . 39 morphine oral solution mometasone nasal...... 54 metoclopramide hcl 20 mg/5 ml (4 mg/ml)...... 25 mometasone topical...... 37 injection solution...... 44 MORPHINE ORAL TABLET. . . . .25 mondoxyne nl oral capsule metoclopramide hcl oral solution. . .44 morphine oral tablet 100 mg, 75 mg...... 13 metoclopramide hcl oral tablet. . . .44 extended release...... 25 MONJUVI...... 17 metolazone ...... 32 morphine (pf) injection mono-linyah...... 50 metoprolol succinate...... 32 solution 0.5 mg/ml, 1 mg/ml. . . . .25 montelukast oral granules in packet. 54 metoprolol ta-hydrochlorothiaz . . . 32 moxifloxacin ophthalmic (eye) drops. 52 montelukast oral tablet...... 54 metoprolol tartrate oral...... 32 moxifloxacin oral ...... 13 74 Covered Drugs Index

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MOXIFLOXACIN-SOD. NAMZARIC ORAL CAP, nevirapine oral tablet extended ACE,SUL-WATER...... 13 SPRINKLE,ER 24HR DOSE PACK. 23 release 24 hr 400 mg...... 8 moxifloxacin-sod.chloride(iso). . . .13 NAMZARIC ORAL CAPSULE, NEXAVAR...... 17 MOZOBIL...... 46 SPRINKLE,ER 24HR...... 23 niacin oral tablet 500 mg...... 34 MULTAQ...... 31 naproxen oral suspension...... 26 niacin oral tablet extended mupirocin...... 36 naproxen oral tablet ...... 26 release 24 hr...... 34 mupirocin calcium...... 36 naproxen oral tablet, niacor...... 34 delayed release (dr/ec) ...... 26 MVASI...... 17 nicardipine intravenous solution. . .32 naproxen sodium oral MYCAMINE...... 7 nicardipine oral...... 32 tablet 275 mg, 550 mg...... 26 mycophenolate mofetil (hcl). . . . .17 NICOTROL ...... 39 naratriptan...... 22 NICOTROL NS...... 39 mycophenolate mofetil oral capsule. .17 NARCAN NASAL SPRAY,NON- nifedipine oral tablet mycophenolate mofetil oral AEROSOL 4 MG/ACTUATION . . . 26 suspension for reconstitution. . . . 17 extended release...... 32 NATACYN...... 52 mycophenolate mofetil oral tablet. . 17 nifedipine oral tablet nateglinide oral tablet 60 mg . . . . 41 extended release 24hr...... 32 mycophenolate sodium ...... 17 nateglinide oral tablet 120 mg. . . .41 nikki (28)...... 51 MYLOTARG...... 17 NATPARA...... 42 nilutamide...... 17 myorisan...... 36 NAYZILAM...... 21 nimodipine...... 32 MYRBETRIQ ORAL TABLET NEBUPENT...... 11 EXTENDED RELEASE NINLARO...... 17 24 HR 25 MG ...... 55 necon 0.5/35 (28)...... 50 nisoldipine ...... 32 MYRBETRIQ ORAL TABLET NEEDLES, INSULIN nitisinone ...... 38 DISP.,SAFETY...... 41 EXTENDED RELEASE nitrofurantoin...... 13 24 HR 50 MG ...... 55 nefazodone...... 29 nitrofurantoin macrocrystal. . . . . 13 neomycin...... 11 nitrofurantoin monohyd/m-cryst. . . 13 N neomycin-bacitracin-poly-hc. . . . .53 nitroglycerin intravenous...... 34 neomycin-bacitracin-polymyxin. . . 52 nabumetone...... 26 nitroglycerin sublingual...... 35 neomycin-polymyxin b-dexameth. . 53 nadolol...... 32 nitroglycerin transdermal nadolol-bendroflumethiazide neomycin-polymyxin b gu...... 37 patch 24 hour ...... 35 oral tablet 80-5 mg...... 32 neomycin-polymyxin-gramicidin . . .52 nitroglycerin translingual nafcillin ...... 12 neomycin-polymyxin-hc spray,non-aerosol ...... 35 ophthalmic (eye)...... 53 nafcillin in dextrose iso-osm. . . . .12 nizatidine oral capsule...... 45 neomycin-polymyxin-hc otic (ear). . 39 naftifine topical cream...... 36 nora-be...... 49 neo-polycin ...... 52 NAFTIN TOPICAL GEL...... 36 noreth-ethinyl estradiol-iron . . . . .51 neo-polycin hc...... 53 NAGLAZYME...... 42 norethindrone acetate...... 49 nalbuphine injection NEPHRAMINE 5.4%...... 56 norethindrone ac-eth estradiol solution 10 mg/ml...... 26 NERLYNX ...... 17 oral tablet 0.5-2.5 mg-mcg . . . . . 49 nalbuphine injection NEUPRO...... 22 norethindrone ac-eth estradiol solution 20 mg/ml...... 26 nevirapine oral suspension...... 8 oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg...... 51 naloxone injection solution. . . . . 26 nevirapine oral tablet ...... 8 norethindrone (contraceptive) . . . .49 naloxone injection syringe 1 mg/ml . 26 nevirapine oral tablet extended naltrexone ...... 26 release 24 hr 100 mg...... 8

75 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE norethindrone-e.estradiol-iron nystatin-triamcinolone...... 36 ONTRUZANT...... 17 oral tablet 1 mg-20 mcg (21)/75 mg nystop...... 36 OPDIVO...... 17 (7), 1.5 mg-30 mcg (21)/75 mg (7). .51 OPSUMIT...... 54 norethindrone-e.estradiol-iron oralone ...... 39 oral tablet,chewable ...... 51 O ORBACTIV ...... 11 norgestimate-ethinyl estradiol . . . .51 OCALIVA ...... 44 ORENCIA...... 48 NORMOSOL-M IN 5% DEXTROSE. 57 ocella...... 51 ORENCIA CLICKJECT ...... 48 NORMOSOL-R...... 56 OCREVUS...... 23 ORFADIN...... 38 NORMOSOL-R PH 7.4 ...... 57 octreotide acetate injection NORTHERA ORAL solution 1,000 mcg/ml, 100 mcg/ml, ORKAMBI ORAL GRANULES IN PACKET...... 54 CAPSULE 100 MG...... 38 200 mcg/ml, 500 mcg/ml...... 17 NORTHERA ORAL octreotide acetate injection ORKAMBI ORAL TABLET...... 54 CAPSULE 200 MG, 300 MG. . . . 38 solution 50 mcg/ml...... 17 orsythia...... 51 nortrel 0.5/35 (28) ...... 51 ODEFSEY...... 8 oseltamivir...... 8 nortrel 1/35 (21)...... 51 ODOMZO...... 17 OSMOPREP...... 44 nortrel 1/35 (28)...... 51 OFEV...... 54 oxacillin injection ...... 12 nortrel 7/7/7 (28)...... 51 ofloxacin ophthalmic (eye) . . . . . 52 oxandrolone oral tablet 2.5 mg . . . 42 nortriptyline ...... 29 ofloxacin otic (ear)...... 52 oxandrolone oral tablet 10 mg. . . .42 NORVIR ORAL POWDER OGIVRI...... 17 oxaprozin...... 26 IN PACKET...... 8 olanzapine-fluoxetine...... 29 oxazepam...... 29 NORVIR ORAL SOLUTION. . . . . 8 olanzapine intramuscular...... 29 oxcarbazepine ...... 21 NORVIR ORAL TABLET...... 8 olanzapine oral tablet 7.5 mg. . . . 29 oxybutynin chloride oral syrup. . . .55 NOVOFINE PEN NEEDLE. . . . . 41 olanzapine oral tablet oxybutynin chloride oral tablet. . . .55 NOVOTWIST PEN NEEDLE. . . . 41 10 mg, 2.5 mg, 5 mg...... 29 oxybutynin chloride oral tablet NOXAFIL ORAL SUSPENSION. . . 7 olanzapine oral tablet extended release 24hr...... 55 15 mg, 20 mg ...... 29 NOXAFIL ORAL TABLET, oxycodone-acetaminophen DELAYED RELEASE (DR/EC). . . .7 olanzapine oral tablet, oral tablet 2.5-300 mg...... 25 disintegrating...... 29 NUBEQA ...... 17 oxycodone-acetaminophen olmesartan...... 32 oral tablet 2.5-325 mg, 5-325 mg. . 25 NUEDEXTA...... 23 olmesartan-hydrochlorothiazide . . .32 oxycodone-acetaminophen NULOJIX ...... 17 olopatadine ophthalmic (eye). . . . 52 oral tablet 7.5-325 mg...... 25 NUPLAZID ORAL CAPSULE. . . . 29 omega-3 acid ethyl esters...... 34 oxycodone-acetaminophen NUPLAZID ORAL TABLET 10 MG. .29 omeprazole oral capsule, oral tablet 10-325 mg...... 25 NUTRILIPID...... 57 delayed release(dr/ec)...... 45 oxycodone-aspirin...... 25 NUZYRA INTRAVENOUS...... 13 OMNIPOD 5 PACK...... 41 oxycodone oral concentrate. . . . .25 NUZYRA ORAL...... 13 OMNIPOD DASH 5 PACK...... 41 oxycodone oral solution...... 25 nyamyc...... 36 OMNIPOD STARTER KIT...... 41 oxycodone oral tablet...... 25 nystatin oral suspension ...... 7 ondansetron...... 44 oxymorphone oral tablet nystatin oral tablet...... 7 extended release 12 hr ...... 25 ondansetron hcl intravenous . . . . 44 nystatin topical cream...... 36 OZEMPIC...... 41 ondansetron hcl oral solution. . . . 44 nystatin topical ointment ...... 36 ondansetron hcl oral tablet. . . . . 44 nystatin topical powder...... 36 ondansetron hcl (pf) ...... 44

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penicillin v potassium oral pilocarpine hcl ophthalmic P recon soln...... 12 (eye) drops 1%, 2%, 4%...... 52 pacerone oral tablet penicillin v potassium oral pilocarpine hcl oral...... 38 100 mg, 200 mg, 400 mg...... 31 tablet 250 mg ...... 12 pimecrolimus...... 35 paclitaxel...... 17 penicillin v potassium oral pimozide...... 29 tablet 500 mg ...... 12 PADCEV...... 17 pimtrea (28)...... 51 PENTACEL (PF) paliperidone oral tablet extended pindolol...... 32 release 24hr 1.5 mg, 3 mg, 9 mg . . 29 INTRAMUSCULAR KIT 15LF- 48MCG-62DU -10 MCG/0.5ML. . . 47 pioglitazone-metformin...... 41 paliperidone oral tablet extended pioglitazone oral tablet 15 mg . . . .41 release 24hr 6 mg...... 29 PENTAM...... 11 palonosetron intravenous pentamidine inhalation...... 11 pioglitazone oral tablet 30 mg, 45 mg ...... 41 solution 0.25 mg/5 ml...... 44 pentamidine injection...... 11 piperacillin-tazobactam intravenous pamidronate...... 42 PENTASA...... 44 recon soln 2.25 gram, 3.375 gram, PANRETIN...... 35 pentoxifylline...... 34 4.5 gram, 40.5 gram...... 12 pantoprazole oral tablet, PERFOROMIST...... 54 PIPERACILLIN-TAZOBACTAM delayed release (dr/ec) ...... 45 PERIKABIVEN...... 57 INTRAVENOUS RECON SOLN paricalcitol oral capsule perindopril erbumine...... 32 13.5 GRAM...... 12 1 mcg, 2 mcg...... 42 PERJETA...... 17 PIQRAY ORAL TABLET paricalcitol oral capsule 4 mcg. . . .42 200 MG/DAY (200 MG X 1) . . . . .17 permethrin topical cream...... 37 paroex oral rinse ...... 39 PIQRAY ORAL TABLET perphenazine ...... 29 paromomycin...... 11 250 MG/DAY (200 MG X1-50 MG X1), perphenazine-amitriptyline. . . . . 29 300 MG/DAY (150 MG X 2) . . . . .17 paroxetine hcl oral tablet 10 mg . . .29 PERSERIS...... 29 pirmella...... 51 paroxetine hcl oral tablet 20 mg . . .29 pfizerpen-g...... 12 PLENAMINE...... 57 paroxetine hcl oral tablet phenelzine...... 29 30 mg, 40 mg ...... 29 PLENVU...... 44 paroxetine hcl oral tablet phenobarbital oral elixir...... 21 podofilox...... 35 extended release 24 hr 12.5 mg. . .29 phenobarbital oral tablet ...... 21 polycin...... 52 paroxetine hcl oral tablet phenoxybenzamine...... 32 polymyxin b sulfate...... 11 extended release 24 hr phenytoin oral suspension . . . . . 21 polymyxin b sulf-trimethoprim . . . .52 25 mg, 37.5 mg...... 29 phenytoin oral tablet,chewable . . . 21 POMALYST...... 17 PASER ...... 11 phenytoin sodium extended. . . . .21 portia 28...... 51 PAXIL ORAL SUSPENSION . . . . 29 PHESGO...... 17 POSACONAZOLE ORAL PAZEO ...... 52 philith...... 51 TABLET,DELAYED PEDIARIX (PF)...... 47 ...... PHOSLYRA...... 56 RELEASE (DR/EC) 7 PEDVAX HIB (PF)...... 47 PHOSPHOLINE IODIDE...... 52 POTASSIUM CHLORID-D5- peg 3350-electrolytes oral recon 0.45%NACL INTRAVENOUS PHYSIOLYTE...... 37 soln 236-22.74-6.74 -5.86 gram. . .44 PARENTERAL SOLUTION PHYSIOSOL IRRIGATION. . . . . 37 10 MEQ/L, 20 MEQ/L, 40 MEQ/L. . 56 PEGANONE...... 21 phytonadione (vitamin k1) potassium chlorid-d5-0.45%nacl peg-electrolyte ...... 44 oral tablet 5 mg...... 34 intravenous parenteral solution PEMAZYRE...... 17 PICATO TOPICAL GEL 0.05% . . . 35 30 meq/l...... 56 penicillamine...... 48 PICATO TOPICAL GEL 0.015%. . .35 potassium chloride-0.45% nacl. . . 56 penicillin g potassium...... 12 PIFELTRO...... 8

77 Covered Drugs Index

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POTASSIUM CHLORIDE-D5- praziquantel...... 11 PRIMAQUINE...... 11 0.2%NACL INTRAVENOUS prazosin ...... 32 primidone...... 21 PARENTERAL SOLUTION PRED-G...... 53 PROAIR HFA ...... 54 20 MEQ/L...... 56 potassium chloride-d5-0.2%nacl PRED-G S.O.P...... 53 PROAIR RESPICLICK...... 54 intravenous parenteral solution PRED MILD...... 53 probenecid...... 47 30 meq/l, 40 meq/l...... 56 prednicarbate topical ointment. . . .37 probenecid-colchicine...... 47 potassium chloride-d5-0.3%nacl prednisolone acetate ...... 53 PROCALAMINE 3%...... 57 intravenous parenteral solution prednisolone oral solution prochlorperazine ...... 44 20 meq/l...... 56 15 mg/5 ml...... 39 prochlorperazine edisylate . . . . . 44 POTASSIUM CHLORIDE- prednisolone sodium phosphate prochlorperazine maleate oral. . . .44 D5-0.9%NACL ...... 56 ophthalmic (eye)...... 53 procto-med hc...... 44 potassium chloride in 0.9%nacl prednisolone sodium phosphate intravenous parenteral solution oral solution 15 mg/5 ml procto-pak ...... 44 20 meq/l, 40 meq/l...... 56 (3 mg/ml), 15 mg/5 ml (5 ml), proctosol hc topical...... 44 potassium chloride in 5% dex 25 mg/5 ml (5 mg/ml), proctozone-hc...... 44 intravenous parenteral solution 5 mg base/5 ml (6.7 mg/5 ml) . . . .39 progesterone micronized...... 49 20 meq/l, 30 meq/l, 40 meq/l. . . . 56 prednisone intensol...... 39 PROGLYCEM...... 41 potassium chloride in lr-d5 . . . . . 56 prednisone oral solution...... 39 PROGRAF INTRAVENOUS. . . . .17 potassium chloride intravenous. . . 56 prednisone oral tablet 1 mg, PROGRAF ORAL GRANULES potassium chloride in water 10 mg, 2.5 mg, 20 mg, 5 mg. . . . .39 IN PACKET...... 18 intravenous piggyback...... 56 prednisone oral tablet 50 mg. . . . 39 PROLASTIN-C...... 38 potassium chloride oral capsule, prednisone oral tablets,dose pack. .39 extended release...... 56 PROLENSA...... 52 pregabalin oral capsule 75 mg. . . .21 potassium chloride oral liquid. . . . 56 PROLIA...... 47 pregabalin oral capsule 100 mg, potassium chloride oral packet . . . 56 PROMACTA ORAL POWDER 150 mg, 200 mg, 25 mg, 50 mg. . . 21 IN PACKET 12.5 MG ...... 34 potassium chloride oral tablet, pregabalin oral capsule er particles/crystals...... 56 PROMACTA ORAL POWDER 225 mg, 300 mg...... 21 IN PACKET 25 MG...... 34 potassium chloride oral tablet pregabalin oral solution...... 21 extended release...... 56 PROMACTA ORAL TABLET. . . . .34 PREMARIN INJECTION...... 49 potassium citrate...... 55 promethazine oral...... 53 PREMARIN ORAL...... 49 POTELIGEO...... 17 promethazine rectal PREMARIN VAGINAL ...... 49 suppository 12.5 mg, 25 mg. . . . .53 PRADAXA...... 34 PREMASOL 10%...... 57 promethegan rectal pramipexole oral tablet...... 22 prenatal vitamin oral tablet. . . . . 57 suppository 25 mg, 50 mg...... 53 pramipexole oral tablet propafenone oral capsule, extended release 24 hr prevalite ...... 34 extended release 12 hr ...... 31 0.375 mg, 0.75 mg, 1.5 mg. . . . . 22 previfem...... 51 propafenone oral tablet ...... 31 pramipexole oral tablet PREZCOBIX...... 8 propantheline ...... 43 extended release 24 hr PREZISTA ORAL SUSPENSION. . .8 2.25 mg, 3 mg, 3.75 mg, 4.5 mg. . .22 propranolol-hydrochlorothiazid . . . 32 PREZISTA ORAL TABLET 75 MG. . 8 prasugrel...... 34 propranolol oral capsule, PREZISTA ORAL TABLET 150 MG. .8 pravastatin oral tablet extended release 24 hr ...... 32 PREZISTA ORAL TABLET 600 MG. .8 10 mg, 20 mg, 80 mg...... 34 propranolol oral solution ...... 32 PREZISTA ORAL TABLET 800 MG. .8 pravastatin oral tablet 40 mg. . . . 34 propranolol oral tablet...... 32 PRIFTIN...... 11 78 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE propylthiouracil...... 40 RAPAMUNE ORAL SOLUTION . . .18 RETACRIT INJECTION SOLUTION PROQUAD (PF)...... 47 rasagiline...... 22 10,000 UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML. . .46 PROSOL 20%...... 57 REBIF REBIDOSE RETACRIT INJECTION protriptyline ...... 29 SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) . 46 SOLUTION 40,000 UNIT/ML. . . . 46 PULMICORT...... 55 REBIF REBIDOSE RETEVMO...... 18 PULMOZYME...... 55 SUBCUTANEOUS PEN INJECTOR RETROVIR INTRAVENOUS . . . . .8 PURIXAN...... 18 22 MCG/0.5 ML, 44 MCG/0.5 ML. . 46 REVLIMID ORAL CAPSULE pyrazinamide...... 11 REBIF TITRATION PACK...... 46 10 MG, 2.5 MG, 5 MG...... 18 pyridostigmine bromide oral syrup. .23 REBIF (WITH ALBUMIN)...... 46 REVLIMID ORAL CAPSULE pyridostigmine bromide reclipsen (28) ...... 51 15 MG, 20 MG, 25 MG...... 18 oral tablet 60 mg ...... 23 RECOMBIVAX HB (PF) REXULTI...... 30 pyridostigmine bromide INTRAMUSCULAR SUSPENSION REYATAZ ORAL POWDER oral tablet extended release. . . . .23 5 MCG/0.5 ML ...... 47 IN PACKET...... 8 pyrimethamine ...... 11 RECOMBIVAX HB (PF) RHOPRESSA...... 52 INTRAMUSCULAR SUSPENSION ribavirin oral capsule...... 8 10 MCG/ML, 40 MCG/ML...... 47 Q ribavirin oral tablet 200 mg...... 8 RECOMBIVAX HB (PF) RIDAURA...... 48 QINLOCK...... 18 INTRAMUSCULAR SYRINGE. . . .47 rifabutin...... 11 QUADRACEL (PF) ...... 47 RECTIV...... 44 rifampin intravenous...... 11 quetiapine oral tablet regonol ...... 23 100 mg, 200 mg, 25 mg, 50 mg. . . 29 rifampin oral...... 11 REGRANEX ...... 35 quetiapine oral tablet RELISTOR SUBCUTANEOUS RIFATER...... 11 300 mg, 400 mg...... 30 SOLUTION ...... 44 riluzole...... 38 quetiapine oral tablet extended RELISTOR SUBCUTANEOUS rimantadine...... 8 release 24 hr 150 mg, 200 mg. . . .30 SYRINGE...... 45 ringer’s intravenous...... 56 quetiapine oral tablet extended REMODULIN...... 32 release 24 hr 300 mg, ringer’s irrigation...... 37 400 mg, 50 mg...... 30 RENACIDIN IRRIGATION RINVOQ...... 48 SOLUTION 1980.6 MG- quinapril ...... 32 RIOMET...... 41 59.4 MG-980.4MG/30ML...... 55 quinapril-hydrochlorothiazide. . . . 32 RIOMET ER...... 41 RENFLEXIS...... 45 risedronate oral tablet 30 mg, 5 mg. .47 quinidine sulfate oral tablet. . . . . 31 RENVELA ORAL POWDER quinine sulfate...... 11 IN PACKET...... 38 risedronate oral tablet 35 mg, 35 mg (12 pack), 35 mg (4 pack) . . 48 RENVELA ORAL TABLET...... 38 risedronate oral tablet 150 mg. . . .47 R repaglinide oral tablet 0.5 mg, 1 mg...... 41 RISPERDAL CONSTA RABAVERT (PF) ...... 47 INTRAMUSCULAR repaglinide oral tablet 2 mg . . . . .41 raloxifene...... 47 SUSPENSION,EXTENDED REPATHA...... 34 REL RECON 12.5 MG/2 ML, ramelteon...... 30 REPATHA PUSHTRONEX. . . . . 34 25 MG/2 ML, 37.5 MG/2 ML. . . . .30 ramipril ...... 32 REPATHA SURECLICK...... 34 RISPERDAL CONSTA ranitidine hcl oral syrup ...... 45 INTRAMUSCULAR RESTASIS...... 52 ranitidine hcl oral tablet SUSPENSION,EXTENDED 150 mg, 300 mg...... 45 RESTASIS MULTIDOSE...... 52 REL RECON 50 MG/2 ML...... 30 ranolazine...... 34 risperidone oral solution...... 30 79 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE risperidone oral tablet...... 30 SANDOSTATIN LAR sirolimus oral solution...... 18 risperidone oral tablet, DEPOT INTRAMUSCULAR sirolimus oral tablet...... 18 SUSPENSION,EXTENDED disintegrating 0.5 mg, 4 mg . . . . .30 SIRTURO ORAL TABLET 20 MG. . 11 REL RECON...... 18 risperidone oral tablet, SIRTURO ORAL TABLET 100 MG. .11 disintegrating 0.25 mg, SANTYL...... 35 SIVEXTRO INTRAVENOUS. . . . .11 1 mg, 2 mg, 3 mg...... 30 SAPHRIS...... 30 SIVEXTRO ORAL...... 12 ritonavir...... 8 sapropterin...... 43 SKYRIZI SUBCUTANEOUS RITUXAN...... 18 SARCLISA...... 18 SYRINGE KIT...... 35 RITUXAN HYCELA...... 18 scopolamine base...... 45 sodium bicarbonate intravenous rivastigmine...... 23 SECUADO...... 30 syringe 10 meq/10 ml (8.4%), 7.5% rivastigmine tartrate...... 23 selegiline hcl...... 22 (0.9 meq/ml), 8.4% (1 meq/ml) . . . 56 rivelsa...... 51 selenium sulfide topical lotion . . . .35 sodium chloride 0.9% intravenous. .38 rizatriptan...... 22 SELZENTRY ORAL SOLUTION. . . 9 sodium chloride 0.45% ROCKLATAN...... 53 SELZENTRY ORAL TABLET 25 MG. 9 intravenous parenteral solution. . . 56 ROMIDEPSIN INTRAVENOUS SELZENTRY ORAL TABLET sodium chloride 3%...... 56 SOLUTION ...... 18 150 MG, 75 MG...... 9 sodium chloride 5%...... 56 ropinirole oral tablet...... 22 SELZENTRY ORAL sodium chloride intravenous. . . . .56 rosadan topical cream...... 36 TABLET 300 MG...... 9 sodium chloride irrigation...... 38 rosadan topical gel ...... 36 SENSIPAR ORAL sodium fluoride-pot nitrate...... 39 TABLET 30 MG, 60 MG...... 43 rosuvastatin...... 34 sodium phenylbutyrate...... 38 SENSIPAR ORAL TABLET 90 MG. .43 ROTARIX...... 47 sodium polystyrene (sorb free) . . . 38 SEREVENT DISKUS...... 55 ROTATEQ VACCINE ...... 47 sodium polystyrene sulfonate sertraline oral concentrate...... 30 roweepra...... 21 oral powder...... 38 sertraline oral tablet 50 mg. . . . . 30 roweepra xr...... 21 solifenacin ...... 55 sertraline oral tablet 100 mg, 25 mg. .30 ROZLYTREK ORAL SOLIQUA 100/33...... 41 CAPSULE 100 MG...... 18 setlakin...... 51 SOLTAMOX...... 18 ROZLYTREK ORAL SEVELAMER CARBONATE SOLU-CORTEF ACT-O-VIAL (PF). .40 ORAL POWDER IN PACKET. . . . 38 CAPSULE 200 MG...... 18 SOMATULINE DEPOT RUBRACA...... 18 SEVELAMER CARBONATE SUBCUTANEOUS SYRINGE ORAL TABLET...... 38 RUCONEST ...... 55 60 MG/0.2 ML...... 18 sharobel...... 49 RUKOBIA...... 9 SOMATULINE DEPOT SHINGRIX (PF)...... 47 SUBCUTANEOUS SYRINGE RUXIENCE ...... 18 SIGNIFOR...... 18 90 MG/0.3 ML...... 18 RYDAPT...... 18 sildenafil (pulmonary arterial SOMATULINE DEPOT RYTARY...... 22 hypertension) oral tablet ...... 55 SUBCUTANEOUS SYRINGE 120 MG/0.5 ML...... 18 SILENOR...... 30 SOMAVERT...... 43 S silver sulfadiazine ...... 35 sorine...... 31 salsalate...... 26 SIMBRINZA...... 53 sotalol af...... 31 SAMSCA ORAL TABLET 15 MG. . .43 simliya (28) ...... 51 sotalol oral...... 31 SAMSCA ORAL TABLET 30 MG. . .43 simpesse ...... 51 SOTYLIZE...... 31 SANCUSO...... 45 SIMULECT...... 18 spironolactone ...... 32 SANDIMMUNE ORAL SOLUTION. .18 simvastatin oral tablet...... 34 80 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE spironolacton-hydrochlorothiaz. . . 32 sulindac...... 26 TAFINLAR...... 18 sprintec (28)...... 51 sumatriptan...... 22 TAGRISSO...... 18 SPRITAM ORAL TABLET sumatriptan succinate oral . . . . . 22 TALZENNA ...... 18 FOR SUSPENSION 1,000 MG, sumatriptan succinate tamoxifen...... 18 250 MG, 500 MG...... 21 subcutaneous cartridge...... 22 tamsulosin...... 55 SPRITAM ORAL TABLET sumatriptan succinate TARGRETIN TOPICAL ...... 18 FOR SUSPENSION 750 MG. . . . 21 subcutaneous pen injector . . . . . 22 tarina 24 fe...... 51 SPRYCEL ...... 18 sumatriptan succinate tarina fe 1/20 (28) ...... 51 sps (with sorbitol)...... 38 subcutaneous solution...... 22 tarina fe 1-20 eq (28) ...... 51 sronyx...... 51 sumatriptan succinate TASIGNA ORAL CAPSULE 50 MG. 18 ssd...... 35 subcutaneous syringe 6 mg/0.5 ml. .22 TASIGNA ORAL CAPSULE STAMARIL (PF)...... 47 SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML. .10 150 MG, 200 MG...... 18 stavudine oral capsule...... 9 SUPREP BOWEL PREP KIT. . . . 45 tazarotene ...... 36 STELARA SUBCUTANEOUS tazicef...... 10 SOLUTION ...... 35 SUTENT...... 18 STELARA SUBCUTANEOUS syeda...... 51 TAZORAC TOPICAL CREAM. . . .36 SYRINGE 45 MG/0.5 ML...... 35 SYLATRON SUBCUTANEOUS TAZORAC TOPICAL GEL...... 36 STELARA SUBCUTANEOUS KIT 200 MCG, 300 MCG...... 46 taztia xt oral capsule,extended SYRINGE 90 MG/ML...... 35 SYMFI...... 9 release 24 hr 120 mg, 180 mg, 240 mg, 300 mg...... 32 STIMATE ...... 43 SYMFI LO ...... 9 TAZVERIK...... 18 STIVARGA...... 18 SYMLINPEN 60...... 41 tdvax ...... 47 streptomycin...... 12 SYMLINPEN 120...... 41 TECENTRIQ INTRAVENOUS STRIBILD...... 9 SYMPAZAN...... 21 SOLUTION 1,200 MG/20 ML SUBOXONE SUBLINGUAL SYMTUZA...... 9 (60 MG/ML)...... 18 FILM 2-0.5 MG, 4-1 MG, 8-2 MG. . 26 SYNAGIS...... 9 TECENTRIQ INTRAVENOUS SUBOXONE SUBLINGUAL SYNAREL ...... 43 SOLUTION 840 MG/14 ML FILM 12-3 MG...... 26 SYNERCID ...... 12 (60 MG/ML)...... 18 sucralfate oral suspension . . . . . 45 SYNJARDY...... 41 TECFIDERA ORAL sucralfate oral tablet...... 45 CAPSULE,DELAYED RELEASE SYNJARDY XR ORAL TABLET, IR - (DR/EC) 120 MG...... 23 sulfacetamide-prednisolone. . . . .52 ER, BIPHASIC 24HR 10-1,000 MG, sulfacetamide sodium (acne). . . . 36 12.5-1,000 MG, 5-1,000 MG. . . . .41 TECFIDERA ORAL CAPSULE,DELAYED RELEASE sulfacetamide sodium SYNJARDY XR ORAL TABLET, IR - (DR/EC) 120 MG (14)- 240 MG (46). .23 ophthalmic (eye) drops...... 52 ER, BIPHASIC 24HR 25-1,000 MG. .42 TECFIDERA ORAL sulfadiazine...... 13 SYNRIBO...... 18 CAPSULE,DELAYED RELEASE sulfamethoxazole-trimethoprim SYNTHROID...... 43 (DR/EC) 240 MG...... 23 intravenous ...... 13 TECHLITE PEN NEEDLE...... 42 sulfamethoxazole-trimethoprim T TEFLARO...... 10 oral suspension ...... 13 TEKTURNA HCT...... 33 sulfamethoxazole-trimethoprim TABLOID ...... 18 oral tablet...... 13 TABRECTA ...... 18 telmisartan-amlodipine...... 33 sulfasalazine...... 45 tacrolimus oral ...... 18 telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg. . 33 sulfatrim ...... 13 tacrolimus topical...... 35

81 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE telmisartan-hydrochlorothiazid theophylline oral tablet tolterodine oral tablet ...... 55 oral tablet 80-12.5 mg...... 33 extended release 24 hr ...... 55 tolvaptan oral tablet 30 mg. . . . . 43 telmisartan oral tablet thioridazine ...... 30 topiramate oral capsule, sprinkle . . 21 20 mg, 40 mg ...... 33 thiotepa...... 19 topiramate oral tablet...... 21 telmisartan oral tablet 80 mg. . . . 33 thiothixene...... 30 toposar ...... 19 temazepam oral capsule THYROLAR-1...... 43 topotecan intravenous recon soln. . 19 15 mg, 30 mg ...... 30 THYROLAR-1/2...... 43 temazepam oral capsule toremifene ...... 19 THYROLAR-1/4...... 43 22.5 mg, 7.5 mg...... 30 TORISEL ...... 19 THYROLAR-2...... 43 temsirolimus ...... 18 torsemide oral...... 33 TENIVAC (PF) THYROLAR-3...... 43 TOUJEO MAX U-300 SOLOSTAR. .42 INTRAMUSCULAR SYRINGE. . . .47 tiadylt er ...... 33 TOUJEO SOLOSTAR tenofovir disoproxil fumarate . . . . .9 tiagabine...... 21 U-300 INSULIN...... 42 terazosin...... 33 TIBSOVO...... 19 TOVIAZ...... 55 terbinafine hcl oral...... 7 tigecycline ...... 12 TPN ELECTROLYTES...... 56 terbutaline ...... 55 tilia fe...... 51 TRACLEER ORAL TABLET FOR SUSPENSION...... 55 terconazole ...... 49 timolol maleate ophthalmic testosterone cypionate (eye) drops...... 52 TRADJENTA...... 42 intramuscular oil 100 mg/ml, TIMOLOL MALEATE OPHTHALMIC tramadol-acetaminophen...... 26 200 mg/ml (1 ml) ...... 43 (EYE) GEL FORMING SOLUTION. . 52 tramadol oral tablet 50 mg . . . . . 26 TESTOSTERONE timolol maleate oral...... 33 trandolapril...... 33 CYPIONATE INTRAMUSCULAR tis-u-sol pentalyte...... 37 tranexamic acid oral...... 49 OIL 200 MG/ML...... 43 TIVICAY ORAL TABLET 10 MG . . . 9 tranylcypromine...... 30 testosterone enanthate ...... 43 TIVICAY ORAL TABLET TRAVASOL 10% ...... 57 testosterone transdermal gel. . . . 43 25 MG, 50 MG ...... 9 TRAVATAN Z...... 53 testosterone transdermal gel TIVICAY PD...... 9 travoprost...... 53 in metered-dose pump tizanidine oral capsule...... 23 12.5 mg/ 1.25 gram (1%)...... 43 TRAZIMERA...... 19 tizanidine oral tablet ...... 23 testosterone transdermal gel trazodone...... 30 in packet 1% (25 mg/2.5gram), TOBI PODHALER INHALATION CAPSULE, TREANDA INTRAVENOUS 1% (50 mg/5 gram)...... 43 RECON SOLN 25 MG...... 19 W/INHALATION DEVICE ...... 12 TETANUS,DIPHTHERIA TOBRADEX OPHTHALMIC TREANDA INTRAVENOUS TOX PED(PF)...... 47 RECON SOLN 100 MG...... 19 (EYE) OINTMENT...... 53 tetrabenazine oral tablet 12.5 mg. . 23 TRECATOR...... 12 tobramycin-dexamethasone. . . . .53 tetrabenazine oral tablet 25 mg. . . 23 TRELEGY ELLIPTA ...... 55 tobramycin in 0.225% nacl. . . . . 12 tetracycline...... 13 TRELSTAR INTRAMUSCULAR tobramycin ophthalmic (eye) . . . . 52 THALOMID ORAL CAPSULE SUSPENSION FOR 100 MG, 150 MG, 50 MG...... 18 tobramycin sulfate...... 12 RECONSTITUTION 3.75 MG . . . .19 THALOMID ORAL TOBREX OPHTHALMIC TRELSTAR INTRAMUSCULAR CAPSULE 200 MG...... 19 (EYE) OINTMENT...... 52 SUSPENSION FOR THEO-24 ...... 55 TOLAK ...... 35 RECONSTITUTION 11.25 MG . . . 19 theophylline oral tablet extended tolcapone...... 22 TRELSTAR INTRAMUSCULAR release 12 hr 300 mg, 450 mg. . . .55 tolterodine oral capsule, SUSPENSION FOR extended release 24hr...... 55 RECONSTITUTION 22.5 MG . . . .19 82 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE treprostinil sodium...... 33 tri-lo-mili ...... 51 U TRESIBA FLEXTOUCH U-100. . . 42 tri-lo-sprintec...... 51 TRESIBA FLEXTOUCH U-200. . . 42 trilyte with flavor packets...... 45 UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, TRESIBA U-100 INSULIN...... 42 trimethoprim...... 13 150 MCG, 175 MCG, 200 MCG, tretinoin (antineoplastic)...... 19 tri-mili...... 51 25 MCG, 300 MCG, 50 MCG, tretinoin microspheres...... 36 trimipramine...... 30 75 MCG, 88 MCG...... 43 tretinoin topical cream TRINTELLIX...... 30 unithroid oral tablet 137 mcg. . . . 43 0.025%, 0.05%, 0.1%...... 36 tri-previfem (28)...... 51 UNITUXIN ...... 19 tretinoin topical topical gel 0.01%. . 36 TRIPTODUR...... 19 UPTRAVI ...... 33 tretinoin topical topical gel TRISENOX INTRAVENOUS ursodiol...... 45 0.025%, 0.05%...... 36 SOLUTION 2 MG/ML...... 19 triamcinolone acetonide dental. . . 39 tri-sprintec (28)...... 51 V triamcinolone acetonide injection. . 40 TRIUMEQ...... 9 valacyclovir oral tablet 1 gram. . . . 9 triamcinolone acetonide trivora (28)...... 51 topical cream 0.1%...... 37 valacyclovir oral tablet 500 mg . . . .9 tri-vylibra...... 51 triamcinolone acetonide VALCHLOR...... 35 tri-vylibra lo ...... 51 topical cream 0.025%, 0.5%. . . . .37 valganciclovir...... 9 TRODELVY...... 19 triamcinolone acetonide valproic acid...... 22 TROGARZO...... 9 topical lotion...... 37 valproic acid (as sodium salt) triamcinolone acetonide TROKENDI XR ORAL oral solution...... 22 topical ointment ...... 37 CAPSULE,EXTENDED RELEASE valsartan-hydrochlorothiazide . . . .33 24HR 100 MG, 25 MG, 50 MG . . . 22 triamterene-hydrochlorothiazid valsartan oral tablet oral capsule 37.5-25 mg ...... 33 TROKENDI XR ORAL 160 mg, 40 mg, 80 mg...... 33 triamterene-hydrochlorothiazid CAPSULE,EXTENDED RELEASE 24HR 200 MG...... 22 valsartan oral tablet 320 mg. . . . .33 oral tablet...... 33 TROPHAMINE 10%...... 57 VALTOCO...... 22 triderm topical cream 0.1%. . . . . 37 TRULANCE...... 45 VANCOMYCIN IN 0.9% SODIUM trientine...... 38 CHL INTRAVENOUS PIGGYBACK. 12 TRULICITY ...... 42 tri-estarylla...... 51 VANCOMYCIN IN DEXTROSE 5% TRUMENBA ...... 47 tri femynor ...... 51 INTRAVENOUS PIGGYBACK. . . .12 TRUVADA ...... 9 trifluoperazine...... 30 VANCOMYCIN INJECTION. . . . .12 TRUXIMA...... 19 trifluridine...... 52 vancomycin intravenous recon TUKYSA ORAL TABLET 50 MG. . .19 trihexyphenidyl...... 22 soln 1,000 mg, 10 gram, 250 mg, TRIJARDY XR ORAL TABLET, TUKYSA ORAL TABLET 150 MG. . 19 5 gram, 500 mg, 750 mg...... 12 IR - ER, BIPHASIC 24HR TWINRIX (PF) VANCOMYCIN INTRAVENOUS 10-5-1,000 MG, 25-5-1,000 MG. . .42 INTRAMUSCULAR SYRINGE. . . .47 RECON SOLN 1.25 GRAM, TRIJARDY XR ORAL TABLET, TYBOST...... 9 1.5 GRAM ...... 12 IR - ER, BIPHASIC 24HR 12.5- tydemy...... 51 vancomycin oral capsule 125 mg. . 12 . . . 2.5-1,000 MG, 5-2.5-1,000 MG 42 TYKERB...... 19 vancomycin oral capsule 250 mg. . 12 ...... tri-legest fe 51 TYMLOS...... 48 vancomycin oral recon soln . . . . .12 ...... tri-linyah 51 TYPHIM VI...... 47 VANCOMYCIN-WATER ...... INJECT (PEG) ...... 12 tri-lo-estarylla 51 TYSABRI...... 23 tri-lo-marzia...... 51 vandazole...... 49

83 Covered Drugs Index

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VAQTA (PF)...... 47 V-GO 30...... 42 VOSEVI ...... 9 VARIVAX (PF)...... 47 V-GO 40...... 42 VOTRIENT...... 19 VARIZIG VIBERZI...... 45 VRAYLAR ORAL CAPSULE. . . . .30 INTRAMUSCULAR SOLUTION . . .47 VICTOZA 2-PAK...... 42 VRAYLAR ORAL CAPSULE, VASCEPA ORAL VICTOZA 3-PAK...... 42 DOSE PACK...... 30 CAPSULE 0.5 GRAM...... 34 vienva...... 51 vyfemla (28)...... 51 VASCEPA ORAL vigabatrin...... 22 vylibra...... 51 CAPSULE 1 GRAM...... 34 vigadrone...... 22 VYXEOS...... 19 VECTIBIX...... 19 VIIBRYD ORAL TABLET...... 30 VELCADE ...... 19 VIIBRYD ORAL TABLETS,DOSE W velivet triphasic regimen (28). . . . 51 PACK 10 MG (7)- 20 MG (23). . . .30 VELPHORO...... 38 warfarin...... 34 VIMPAT INTRAVENOUS...... 22 VELTASSA...... 38 water for irrigation, sterile...... 38 VIMPAT ORAL SOLUTION. . . . . 22 VEMLIDY...... 9 wera (28) ...... 51 VIMPAT ORAL TABLET 50 MG. . . 22 VENCLEXTA ORAL wixela inhub...... 55 VIMPAT ORAL TABLET TABLET 10 MG ...... 19 wymzya fe ...... 51 100 MG, 150 MG, 200 MG. . . . . 22 VENCLEXTA ORAL vincasar pfs intravenous TABLET 50 MG ...... 19 solution 1 mg/ml...... 19 X VENCLEXTA ORAL vincristine...... 19 TABLET 100 MG...... 19 XALKORI...... 19 vinorelbine...... 19 VENCLEXTA STARTING PACK . . .19 XARELTO...... 34 venlafaxine oral capsule, VIOKACE ORAL TABLET XARELTO DVT-PE 10,440-39,150- 39,150 UNIT. . . . 45 extended release 24hr 75 mg . . . .30 TREAT 30D START...... 34 venlafaxine oral capsule, extended VIOKACE ORAL TABLET XATMEP...... 19 20,880-78,300- 78,300 UNIT. . . . 45 release 24hr 150 mg, 37.5 mg. . . .30 XCOPRI...... 22 viorele (28)...... 51 venlafaxine oral tablet...... 30 XCOPRI MAINTENANCE PACK. . .22 VIRACEPT ORAL TABLET 250 MG. .9 VENTAVIS...... 55 XCOPRI TITRATION PACK. . . . .22 VIRACEPT ORAL TABLET 625 MG. .9 VENTOLIN HFA...... 55 XELJANZ...... 48 VIREAD ORAL POWDER...... 9 verapamil intravenous solution . . . 33 XELJANZ XR ...... 48 VIREAD ORAL TABLET verapamil oral capsule, XGEVA...... 13 150 MG, 200 MG, 250 MG...... 9 24 hr er pellet ct...... 33 XHANCE...... 55 VITRAKVI ORAL verapamil oral capsule, XIAFLEX...... 38 ext rel. pellets 24 hr CAPSULE 25 MG ...... 19 XIFAXAN ORAL TABLET 550 MG. .12 120 mg, 180 mg, 240 mg...... 33 VITRAKVI ORAL VERAPAMIL ORAL CAPSULE, CAPSULE 100 MG...... 19 XIGDUO XR ORAL TABLET, EXT REL. PELLETS VITRAKVI ORAL SOLUTION. . . . 19 IR - ER, BIPHASIC 24HR 2.5- 1,000 MG, 5-1,000 MG, 5-500 MG. .42 24 HR 360 MG...... 33 VIVITROL...... 26 XIGDUO XR ORAL TABLET, verapamil oral tablet...... 33 VIZIMPRO...... 19 IR - ER, BIPHASIC 24HR verapamil oral tablet volnea (28)...... 51 10-1,000 MG, 10-500 MG...... 42 extended release...... 33 voriconazole intravenous...... 7 XIIDRA ...... 52 VERSACLOZ ...... 30 voriconazole oral suspension XOFLUZA...... 9 VERZENIO ...... 19 for reconstitution...... 7 V-GO 20...... 42 voriconazole oral tablet ...... 7 84 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE

XOLAIR SUBCUTANEOUS ZARXIO ...... 46 ZTLIDO...... 35 RECON SOLN...... 55 zebutal oral capsule ZUBSOLV SUBLINGUAL TABLET XOLAIR SUBCUTANEOUS 50-325-40 mg...... 25 0.7-0.18 MG, 11.4-2.9 MG . . . . . 26 SYRINGE...... 55 ZEJULA ...... 20 ZUBSOLV SUBLINGUAL TABLET XOPENEX...... 55 ZELBORAF...... 20 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG, 8.6-2.1 MG...... 26 XOPENEX CONCENTRATE. . . . 55 ZEMAIRA...... 38 zumandimine (28)...... 51 XOSPATA...... 19 zenatane...... 36 ZYDELIG...... 20 XPOVIO ORAL TABLET 40MG ZENPEP ORAL CAPSULE, TWICE WEEK (80 MG/WEEK), DELAYED RELEASE(DR/EC) ZYKADIA ORAL TABLET ...... 20 80 MG/WEEK (20 MG X 4). . . . . 19 10,000-32,000 -42,000 UNIT, ZYLET...... 53 XPOVIO ORAL TABLET 15,000-47,000 -63,000 UNIT, ZYPREXA RELPREVV 40 MG/WEEK (20 MG X 2), 60MG 20,000-63,000- 84,000 UNIT, INTRAMUSCULAR SUSPENSION TWICE WEEK (120 MG/WEEK). . .19 25,000-79,000- 105,000 UNIT, FOR RECONSTITUTION XPOVIO ORAL TABLET 3,000-10,000 -14,000-UNIT, 210 MG...... 30 40,000-126,000- 168,000 UNIT, 60 MG/WEEK (20 MG X 3). . . . . 20 ZYPREXA RELPREVV 5,000-17,000- 24,000 UNIT. . . . .45 XPOVIO ORAL TABLET 80MG INTRAMUSCULAR SUSPENSION TWICE WEEK (160 MG/WEEK). . .20 ZEPZELCA ...... 20 FOR RECONSTITUTION XPOVIO ORAL TABLET zidovudine oral capsule...... 9 300 MG...... 30 100 MG/WEEK (20 MG X 5). . . . .19 zidovudine oral syrup...... 9 ZYPREXA RELPREVV XTAMPZA ER...... 25 zidovudine oral tablet...... 9 INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION XTANDI...... 20 ZIEXTENZO ...... 46 405 MG...... 30 XULTOPHY 100/3.6 ...... 42 ZIOPTAN (PF)...... 53 ZYTIGA ORAL TABLET 500 MG. . .20 XYREM...... 30 ziprasidone hcl...... 30 ziprasidone mesylate...... 30 Y ZIRABEV...... 20 YERVOY INTRAVENOUS ZIRGAN ...... 52 SOLUTION 50 MG/10 ML zoledronic acid (5 MG/ML)...... 20 intravenous solution ...... 43 YERVOY INTRAVENOUS zoledronic acid-mannitol-water SOLUTION 200 MG/40 ML intravenous piggyback (5 MG/ML)...... 20 5 mg/100 ml...... 38 YF-VAX (PF)...... 47 ZOLINZA ...... 20 YONDELIS...... 20 zolpidem oral tablet...... 30 YONSA...... 20 zonisamide...... 22 YUPELRI...... 55 ZORTRESS ORAL TABLET 0.5 MG...... 20 yuvafem ...... 49 ZORTRESS ORAL TABLET 0.25 MG...... 20 Z ZORTRESS ORAL zafirlukast...... 55 TABLET 0.75 MG, 1 MG...... 20 zaleplon oral capsule 5 mg. . . . . 30 ZOSTAVAX (PF)...... 47 zaleplon oral capsule 10 mg. . . . .30 ZOSYN IN DEXTROSE (ISO-OSM). 12 zarah...... 51 zovia 1/35e (28)...... 51

85 Notice of Nondiscrimination: Discrimination is Against the Law

Cigna Medicare Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Cigna Medicare Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Cigna Medicare Services: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at 1-800-627-7534 (TTY 711), 8 a.m.–8 p.m., 7 days a week (hours apply Monday – Friday, February 15 – September 30).

If you believe that Cigna Medicare Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Cigna Medicare Services Attn: Medicare Grievance Department Attn: Customer Grievances PO Box 2888 Houston, TX 77252-2888 Phone: 1-800-668-3813 (TTY 711) Fax: 1-888-586-9946. You can file a grievance in writing by mail or fax. If you need help filing a grievance, Customer Service is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-627-7534 (TTY 711), 8 a.m.–8 p.m., 7 days a week (hours apply Monday – Friday, February 15 – September 30). ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-7534 (TTY 711), 8 a.m.–8 p.m , 7 días de la semana (horario se aplica de lunes - viernes, del 15 de febrero - 30 de septiembre). Cigna is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna depends on contract renewal. INT_17_49135 09302016

86 Notificación Contra la Discriminación: La Discriminación es Contra la Ley

Cigna Medicare Services cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Cigna Medicare Services no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. Cigna Medicare Services: • Proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes: o Intérpretes de lenguaje de señas capacitados. o Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos). • Proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes: o Intérpretes capacitados. o Información escrita en otros idiomas. Si necesita recibir estos servicios, comuníquese con Servicio al Cliente al 1-800-627-7534 (TTY 711), 8 a.m.– 8 p.m., 7 días de la semana (horario se aplica de lunes - viernes, del 15 de febrero - 30 de septiembre).

Si considera que Cigna Medicare Services no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a la siguiente persona: Cigna Medicare Services Attn: Medicare Grievance Department PO Box 29030 Phoenix, AZ 85038 Teléfono: 1-800-627-7534 (TTY 711) Fax: 1-866-567-2474.

Puede presentar el reclamo escrito por correo postal o fax. Si necesita ayuda para hacerlo, Servicio al Cliente está a su disposición para brindársela.

También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal (Oficina de Derechos Civiles portal de quejas), disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna Corporation. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad de Cigna Intellectual Property, Inc. ATTENTION: If you speak languages other than English, language assistance services, free of charge are available to you. Call 1-800-627-7534 (TTY 711), 8 a.m.–8 p.m., 7 days a week (hours apply Monday – Friday, February 15 – September 30). ATENCIÓN: si usted habla un idioma que no sea inglés, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-7534 (TTY 711), 8 a.m.–8 p.m , 7 días de la semana (horario se aplica de lunes - viernes, del 15 de febrero - 30 de septiembre). . Cigna-HealthSpring tiene contrato con Medicare para planes PDP, planes HMO y PPO en ciertos estados, y con ciertos programas estatales de Medicaid. La inscripción en Cigna-HealthSpring depende de la renovación de contrato. INT_17_49135S Alternate Format 09302016 87 0XOWLODQJXDJH,QWHUSUHWHU6HUYLFHV English – ATTENTION: If you speak English, language assistance services, free of charge are available to you. Call 1­800­627668­75343813 (TTY 711). Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1­800­­668627­­38137534 (TTY 711). Chinese – 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯炻ぐ⎗ẍ⃵屣䌚⼿婆妨㎜≑㚵⊁ˤ婳农暣 11­­800800­­668627­­38137534 (TTY 711)ˤ Vietnamese – CHÚ Ý: NӃu bҥn nói TiӃng ViӋt, có các dӏch vө hӛ trӧ ngôn ngӳ miӉn phí dành cho bҥn. Gӑi sӕ 11­­800800­­668627­­38137534 (TTY 711). French Creole – ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1­­800­­668627­­38137534 (TTY 711). Korean – 㨰㢌aG䚐ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤SG㛬㛨G㫴㠄G㉐⽸㏘⪰Gⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩⏼␘UG 11­­800800­­668627­­38137534 (TTY 711)ⶼ㡰⦐G㤸䞈䚨G㨰㐡㐐㝘U Polish – 8:$*$-HĪHOLPyZLV]SRSROVNXPRĪHV]VNRU]\VWDü]EH]SáDWQHMSRPRF\MĊ]\NRZHM =DG]ZRĔSRGQXPHU1­­800­­668627­­38137534 (TTY 711). French – ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1­­800­­668627­­38137534 (ATS 711). Arabic – 11­­800800­­668627­­38137534ϡϗέΑϝλΗ΍ .ϥΎΟϣϟΎΑϙϟέϓ΍ϭΗΗΔϳϭϐϠϟ΍ΓΩϋΎγϣϟ΍ΕΎϣΩΧϥΈϓˬΔϳΑέόϟ΍ΔϐϠϟ΍ΙΩΣΗΗΕϧϛ΍Ϋ· :ΔυϭΣϠϣ  711TTY  Russian – ȼɇɂɆȺɇɂȿ: ȿɫɥɢ ɜɵ ɝɨɜɨɪɢɬɟ ɧɚ ɪɭɫɫɤɨɦ ɹɡɵɤɟ, ɬɨ ɜɚɦ ɞɨɫɬɭɩɧɵ ɛɟɫɩɥɚɬɧɵɟ ɭɫɥɭɝɢ ɩɟɪɟɜɨɞɚ. Ɂɜɨɧɢɬɟ1­800­668627­38137534� ɬɟɥɟɬɚɣɩ  Tagalog – PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 11­­800800­­627668­­75343813� (TTY 711). Farsi/Persian – .ΩηΎΑ̶ϣϡϫ΍έϓΎϣη̵΍έΑϥΎ̴ϳ΍έΕέϭλΑ̶ϧΎΑίΕϼϳϬγΗˬΩϳϧ̶̯ϣϭ̴Ηϔ̶̳γέΎϓϥΎΑίϪΑέ̳΍ϪΟϭΗ .Ωϳέϳ̴ΑαΎϣΗ (711 :TTY) 1 ­ 1800­800­627­668­7534­3813 ΎΑ German – ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1­800­627668­75343813 (TTY 711). Portuguese – ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 11­­800800­­668627­­38137534 (TTY 711). Italian – ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 11­­800800­­668627­­38137534 (TTY 711). Japanese – ὀព஦㡯㸸᪥ᮏㄒࢆヰࡉࢀࡿሙྜࠊ↓ᩱࡢゝㄒᨭ᥼ࢆࡈ฼⏝࠸ࡓࡔࡅࡲࡍࠋ 11­800­800­668­627­3813­7534 (TTY 711)ࡲ࡛ࠊ࠾㟁ヰ࡟࡚ࡈ㐃⤡ࡃࡔࡉ࠸ࠋ Navajo – D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 1­800­627668­75343813 (TTY 711).

Gujarati – �યાન આપો: જો તમે �જરાતીુ બોલતા હો તો િન:��કુ ભાષા સહાય સેવાઓ તમારા માટ� �પલ�� છે. ફોન કરો 11­­800800­­627668­­75343813 (TTY 711). ΟϭΗ؟؏ϳΩΗϟϭΑϥΎΑίϭΩέ΍̟΁έ̳΍ف΁ϭΗ؏ϳ٫̟̯ف΋ϟفϳ٫ΏΎϳΗγΩ؏ϳϣΕϔϣΕΎϣΩΧϥϭΎόϣϥΎΑί؏لUrdu ؏ϳέ̯ϝΎ̯ 1-800-627-7534(TTY 711) H0354_17_49951 ACCEPTED 17_MLI_AZHMO 88

1-800-627-7534 (TTY 711) October 1 – March 31, 7 days a week, 8 a.m. – 8 p.m. local time. From April 1 – September 30, Monday – CignaMedicare.com Friday, 8 a.m. – 8 p.m. local time (a voicemail system is available on weekends and holidays).

This drug list was updated in December 2020. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit www.CignaMedicare.com. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. © 2019 Cigna 929082 o