Farmacopea De 2021 (Lista De Medicamentos Cubiertos)

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Farmacopea de 2021 (Lista de medicamentos cubiertos)

LEA LA SIGUIENTE INFORMACIÓN: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS ME- DICAMENTOS QUE CUBRIMOS EN ESTE PLAN. 00021082, V17

Esta farmacopea se actualizó el 09/01/2021. Para obtener información más reciente o si tiene otras preguntas, comuníquese con Servicios para Miembros de ConnectiCare al 1-800-224-2273, los usuarios de TTY deben llamar al 711, de 8.00 am a 8.00 pm, hora del este, los siete días de la semana, o visite connecticare.com/medicare. Última actualización 09/01/2021 H3528_200567_C Nota para los miembros existentes: Esta farmacopea se ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún se incluyan los medicamentos que usted toma.

Cuando esta lista de medicamentos (farmacopea) haga referencia a “nosotros”, “nos” o “nuestro”, significa ConnectiCare. Cuando se refiere a “plan” o “nuestro plan”, significa los planes Medicare Advantage de ConnectiCare. Nuestros planes Medicare Advantage incluyen los planes ConnectiCare Choice 1 (HMO), ConnectiCare Choice 2 (HMO), ConnectiCare Choice 3 (HMO), ConnectiCare Choice Part B Saver, ConnectiCare Flex 1 (HMO-POS), ConnectiCare Flex2 (HMO-POS), ConnectiCare Flex 3 (HMO-POS) y ConnectiCare Passage 1 (HMO).

Este documento incluye una lista de los medicamentos (farmacopea) para nuestro plan que se encuentra vigente desde el 09/01/2021 . Para obtener una actualización de la farmacopea, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización de la farmacopea, aparece en la portada y contraportada.

Generalmente, deberá utilizar farmacias de la red para hacer uso de su beneficio de medicamentos con receta. Los beneficios, la farmacopea, la red de farmacias o los copagos y el coseguro pueden cambiar a partir del 1.° de enero de 2022 y periódicamente durante el año.

Última actualización 09/01/2021 ii ¿Qué es la farmacopea de ConnectiCare?

Una farmacopea es una lista de medicamentos cubiertos seleccionados por nuestro plan tras consultar con un equipo de proveedores de atención médica, que representa las terapias con medicamentos con receta que se consideran una parte necesaria del programa de tratamiento de calidad. Generalmente, nuestro plan cubrirá los medicamentos mencionados en nuestra farmacopea siempre que el medicamento sea necesario por motivos médicos, el medicamento con receta se surta en una farmacia de la red del plan y se cumplan otras reglas del plan. Para obtener más información sobre cómo surtir sus medicamentos con receta, revise su Evidencia de Cobertura.

¿Puede modificarse la farmacopea (lista de medicamentos)? La mayoría de los cambios en la cobertura de medicamentos ocurren el 1.° de enero, pero nuestro plan puede agregar o quitar medicamentos de la lista de medicamentos durante el año, moverlos a diferentes niveles de costos compartidos o agregar nuevas restricciones. Debemos seguir las reglas de Medicare al hacer estos cambios.

Cambios que pueden afectarle este año: En los casos que figuran a continuación, usted se verá afectado por los cambios de cobertura durante el año:

• Nuevos medicamentos genéricos. Podemos eliminar inmediatamente un medicamento de marca de nuestra lista de medicamentos si lo reemplazamos por un nuevo medicamento genérico que estará en el mismo nivel de costos compartidos o en uno más bajo y que tenga las mismas restricciones o menos. Además, al agregar el nuevo medicamento genérico, podemos decidir mantener el medicamento de marca en nuestra lista de medicamentos, pero pasarlo inmediatamente a un nivel de costos compartidos diferente o agregar nuevas restricciones. Si actualmente está tomando ese medicamento de marca, es posible que no le comuniquemos por adelantado antes de realizar ese cambio, pero más adelante le proporcionaremos información acerca de los cambios específicos que hayamos realizado.

• Si realizamos dicho cambio, usted o el profesional autorizado para recetar pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. El aviso que le proporcionamos también incluirá información sobre cómo solicitar una excepción, y además, puede encontrar información en la sección de la página vi titulada “¿Cómo solicito una excepción a la farmacopea de ConnectiCare?”

• Medicamentos retirados del mercado. Si la Administración de Alimentos y Medicamentos (FDA) considera que un medicamento de nuestra farmacopea no es seguro o bien si el fabricante retira el medicamento del mercado, retiraremos de inmediato el medicamento de nuestra farmacopea y daremos aviso a los miembros que lo toman.

• Otros cambios. Es posible que hagamos otros cambios que afecten a los miembros que actualmente toman un medicamento. Por ejemplo, podemos agregar un medicamento genérico que no sea nuevo para el mercado para reemplazar un medicamento de marca actualmente incluido en la farmacopea o agregar nuevas restricciones al medicamento de marca o moverlo a un nivel de costo compartido diferente, o ambas opciones. O podemos hacer cambios basados en nuevas pautas clínicas. Si retiramos medicamentos de nuestra farmacopea, agregamos el requisito de autorización previa, límites de cantidad o restricciones de tratamiento escalonado sobre un medicamento o bien si movemos un medicamento a un nivel con costo compartido más alto, debemos notificar a los miembros afectados acerca del cambio al menos 30 días antes de que el cambio entre en vigencia o en el momento en que el miembro solicite resurtir el medicamento, cuando recibirá un suministro de 30 días del medicamento. Última actualización 09/01/2021 iii • Si realizamos estos otros cambios, usted o el profesional autorizado para recetar pueden solicitarnos que hagamos una excepción y sigamos cubriendo el medicamento de marca para usted. El aviso que le proporcionamos también incluirá información sobre cómo solicitar una excepción y, además, puede encontrar información en la página vi titulada “¿Cómo solicito una excepción a la farmacopea de ConnectiCare?”

Cambios que no le afectarán si actualmente está tomando el medicamento. Generalmente, si usted está tomando un medicamento de nuestra farmacopea 2021 que estaba cubierto al comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de cobertura 2021, excepto como se describe en la página iii. Esto significa que estos medicamentos permanecerán disponibles con el mismo costo compartido y sin nuevas restricciones para aquellos miembros que los tomen durante el resto del año de cobertura. Este año no recibirá una notificación directa sobre los cambios que no le afecten. Sin embargo, el 1.º de enero del próximo año, esos cambios le afectarían y es importante que controle la lista de medicamentos del nuevo año del beneficio para ver los cambios en los medicamentos.

La farmacopea adjunta se encuentra actualizada al 09/01/2021 . Para obtener información actualizada sobre los medicamentos cubiertos por nuestro plan, comuníquese con nosotros. Nuestra información de contacto aparece en la portada y contraportada.

Nota: En el caso de un cambio en la farmacopea de mitad de año que no requiera mantenimiento, el cambio se agrega a una lista completa de los cambios que se han hecho desde que se imprimió la farmacopea. La lista de cambios se incluye en el folleto de la farmacopea que se envía por correo postal a los nuevos miembros con su kit de bienvenida. Los miembros existentes pueden ver la actualización de la farmacopea visitando nuestro sitio web en www.connecticare.com/medicare. La farmacopea publicada en nuestro sitio web se actualiza de forma mensual.

Última actualización 09/01/2021 iv ¿Cómo debo usar la farmacopea?

Hay dos formas de encontrar un medicamento dentro de la farmacopea: Condición médica La farmacopea empieza en la página 1. Los medicamentos de esta farmacopea se agrupan en categorías según el tipo de condición médica que tratan. Por ejemplo, los medicamentos utilizados para tratar una afección cardíaca se enumeran bajo la categoría “Medicamentos cardiovasculares-antihipertensivos/para lípidos”. Si sabe para qué se usa su medicamento, busque el nombre de la categoría de la lista que comienza en la página 1. Luego, busque su medicamento en el nombre de la categoría.

Listado alfabético Si no está seguro de la categoría en la que debe buscar, busque su medicamento en el Índice que comienza en la página 95. El Índice proporciona una lista alfabética de todos los medicamentos incluidos en este documento. Tanto los medicamentos de marca como los medicamentos genéricos se enumeran en el Índice. Busque en el Índice para encontrar su medicamento. Junto a su medicamento, verá el número de página donde puede encontrar información sobre la cobertura. Busque la página que aparece en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos? Nuestro plan cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico está aprobado por la Administración de Alimentos y Medicamentos (FDA) porque tiene el mismo ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos son menos costosos que los medicamentos de marca.

¿Se aplican restricciones a mi cobertura? Es posible que algunos medicamentos cubiertos tengan requisitos o límites adicionales para la cobertura. Estos requisitos y límites pueden incluir:

• Autorización previa: Nuestro plan exige que usted o su médico obtenga una autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener una aprobación previa de nuestro plan antes de que pueda surtir sus medicamentos con receta. Si no obtiene la aprobación, es posible que nuestro plan no cubra el medicamento.

• Límites de cantidad: Para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubrirá. Por ejemplo, nuestro plan proporciona 30 comprimidos por receta de JANUVIA®. Esto puede ser adicional al suministro estándar de un mes o tres meses.

• Tratamiento escalonado: En algunos casos, nuestro plan le exige que primero pruebe ciertos medicamentos para tratar su condición médica antes de que cubramos cualquier otro medicamento para esa afección. Por ejemplo, si el Medicamento A y el Medicamento B sirven para tratar su condición médica, es posible que nuestro plan no cubra el Medicamento B a menos que pruebe primero el Medicamento A. Si el medicamento A no funciona para usted, nuestro plan cubrirá el medicamento B.

Para saber si su medicamento tiene requisitos o límites adicionales, búsquelo en la farmacopea que comienza en la página 1. También puede obtener más información sobre las restricciones aplicadas a medicamentos cubiertos específicos visitandonuestro sitio web. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y tratamiento escalonado. También

Última actualización 09/01/2021 v puede solicitarnos que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última actualización de la farmacopea, aparece en la portada y contraportada. Puede solicitarle a nuestro plan que haga una excepción a estas restricciones o límites o una lista de otros medicamentos similares que podrían tratar su afección de salud. Consulte la sección “Cómo solicito una excepción a la farmacopea de ConnectiCare”, en la página vi para obtener información sobre cómo solicitar una excepción. ¿Qué sucede si mi medicamento no aparece en la farmacopea? Si su medicamento no se incluye en esta farmacopea (lista de medicamentos cubiertos), primero debe comunicarse con Servicios para Miembros y preguntar si su medicamento está cubierto.

Si se entera de que nuestro plan no cubre su medicamento, usted tiene dos opciones:

• Puede solicitar a Servicios para Miembros una lista de medicamentos similares cubiertos por nuestro plan. Cuando reciba esta lista, muéstrela a su médico y pídale que le recete un medicamento similar que esté cubierto por nuestro plan.

Puede solicitar que hagamos una excepción y cubramos su medicamento. A continuación, encontrará información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción a la farmacopea de ConnectiCare? Puede solicitarle a nuestro plan que haga una excepción a las reglas de cobertura. Existen varios tipos de excepciones que puede solicitarnos.

• Puede solicitarnos que cubramos un medicamento incluso si no está en nuestra farmacopea. Si lo aprobamos, este medicamento se cubrirá a un nivel de costo compartido predeterminado y usted no podría pedirnos que le proporcionemos el medicamento a un nivel de costo compartido más bajo.

• Puede solicitarnos que cubramos un medicamento de la farmacopea a un nivel de costo compartido más bajo si este medicamento no se encuentra en el nivel de especialidad. Si lo aprobamos, esta sería la cantidad más baja que debe pagar por su medicamento.

• Puede solicitarnos que eximamos las restricciones o los límites de cobertura sobre su medicamento. Por ejemplo, para ciertos medicamentos, nuestro plan limita la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor.

Generalmente, nuestro plan solamente aprobará su solicitud de excepción si los medicamentos alternativos incluidos en la farmacopea del plan, un medicamento de costo compartido más bajo o las restricciones de utilización adicionales no fueran tan efectivas en el tratamiento de su afección o le provocaran efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción de la farmacopea o de restricción de utilización.Cuando solicite una excepción de la farmacopea o de restricción de utilización, debe enviar una declaración del profesional autorizado para recetar o médico que respalde su solicitud. Generalmente, debemos tomar una decisión dentro de las 72 horas posteriores a que recibamos la declaración de respaldo del profesional autorizado para recetar. Puede solicitar una excepción acelerada (rápida) si usted o su médico considera que su salud podría verse gravemente perjudicada si espera hasta 72 horas para conocer una decisión. Si se otorga la solicitud para acelerar el proceso, debemos brindarle una decisión a más tardar 24 horas después de recibir la declaración respaldatoria de su médico u otro profesional autorizado para recetar.

Última actualización 09/01/2021 vi ¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o solicitar una excepción?

Como miembro nuevo o existente de nuestro plan, es posible que tome medicamentos que no estén en nuestra farmacopea. O bien es posible que, aunque tome un medicamento que se encuentra en nuestra farmacopea, su capacidad para obtenerlo se vea limitada. Por ejemplo, es posible que necesite una autorización previa de nuestra parte antes de que pueda surtir su medicamento con receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento adecuado que cubramos o solicitar una excepción de la farmacopea para que cubramos el medicamento que toma. Mientras habla con su médico para determinar el curso de acción correcto para usted, podemos cubrir su medicamento en determinados casos durante los primeros 90 días de su membresía en nuestro plan.

Para cada uno de sus medicamentos que no están cubiertos en nuestra farmacopea o si su capacidad para obtener los medicamentos se encuentra limitada, cubriremos un suministro temporal de un mes. Si su medicamento con receta es para menos días, permitiremos que surta su receta para proporcionar un suministro de medicamento total de un mes como máximo. Después de su primer suministro de un mes, no deberá pagar estos medicamentos, incluso si ha sido miembro del plan durante menos de 90 días.

Si es residente de un centro de cuidados a largo plazo y necesita un medicamento que no esté en nuestra farmacopea o si su capacidad para obtenerlo es limitada pero ya pasaron los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días del medicamento mientras intenta obtener una excepción de la farmacopea.

Si es un miembro actual de nuestro plan y experimenta un cambio en el nivel de atención, como una admisión o alta hospitalaria de un centro de cuidados a largo plazo, le proporcionaremos un resurtido temporario por única vez de sus medicamentos, según sea necesario, para asistirle durante su transición al nuevo nivel de atención.

Cómo obtener más información

Para obtener más información sobre su cobertura de medicamentos con receta de ConnectiCare, revise su Evidencia de Cobertura y otros materiales del plan.

Si tiene preguntas sobre nuestro plan, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización de la farmacopea, aparece en la portada y contraportada.

Si tiene preguntas generales sobre la cobertura de medicamento con receta de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien visite http://www.medicare.gov.

Última actualización 09/01/2021 vii Farmacopea de ConnectiCare

La farmacopea que empieza en la página 1 proporciona información de cobertura sobre los medicamentos que cubre nuestro plan. Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 95.

La primera columna del cuadro indica el nombre del medicamento. Los medicamentos de marca se encuentran escritos con mayúsculas (p. ej., SYNTHROID) y los medicamentos genéricos se encuentran escritos en cursiva minúscula (p. ej., levothyroxine).

La información de la columna Requisitos/Límites le indica si nuestro plan tiene requisitos especiales de cobertura para su medicamento.

A continuación, encontrará una lista de abreviaturas que pueden aparecer en las páginas siguientes en la columna de Requisitos/Límites que le indican si existen requisitos especiales para la cobertura de su medicamento.

B/D PA Este medicamento con receta puede estar cubierto por Medicare Parte B o D según las circunstancias. Es posible que deba enviar información que describa el uso y ámbito de uso del medicamento para tomar una determinación.

LA Disponibilidad limitada. El medicamento con receta puede estar disponible solo en determinadas farmacias. Para obtener más información, llame a Servicios para Miembros.

MO Medicamento pedido por correo. Este medicamento con receta está disponible a través de nuestro servicio de pedidos por correo, además de poder obtenerse en nuestras farmacias de venta al detalle de la red. Considere usar el pedido por correo para sus medicamentos a largo plazo (de mantenimiento) (como medicamentos para la presión arterial alta). Las farmacias de venta al detalle de la red podrían ser más adecuadas para medicamentos con receta a corto plazo (como antibióticos).

PA Autorización previa. El plan exige que usted o su médico obtenga una autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener una aprobación antes de que pueda surtir sus medicamentos con receta. Si no obtiene la aprobación, es posible que no cubramos el medicamento.

QL Límite de cantidad. Para ciertos medicamentos, el plan limita la cantidad del medicamento que cubrirá.

ST Tratamiento escalonado. En algunos casos, el plan le exige que primero pruebe ciertos medicamentos para tratar su condición médica antes de que cubramos cualquier otro medicamento para esa afección. Por ejemplo, si el Medicamento A y el Medicamento B sirven para tratar su condición médica, es posible que no cubramos el Medicamento B a menos que pruebe primero el Medicamento A. Si el Medicamento A no funciona para usted, cubriremos el Medicamento B.

LDS Límite de suministro por día. Para ciertos medicamentos, el plan limita el suministro de días que cubriremos a un mes.

Última actualización 09/01/2021 viii Consulte los cuadros siguientes para conocer información sobre la forma en que los costos compartidos del plan se relacionan con los diferentes niveles indicados en esta farmacopea para el suministro de un mes/tres meses de un medicamento. Si usted es elegible para recibir “Ayuda Adicional” o un “Subsidio por bajos ingresos” (LIS), es posible que parte de la información en estos cuadros acerca del costo de los medicamentos con receta Parte D no se aplique a usted. Le enviaremos un inserto por separado denominado “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS), en el cual se le informa sobre su cobertura de medicamentos. Si no tiene este inserto, llame a Servicios para Miembros al número que aparece en la portada o contraportada y solicite la “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS). Cobertura de medicamentos con receta Parte D para los planes ConnectiCare Choice 1 (HMO) y ConnectiCare Flex 1 (HMO-POS)

Deducible $300 (excluye Nivel 1 y Nivel 2) Etapa de cobertura inicial Etapa de interrupción de Pedidos por Etapa de Nombre Minorista cobertura Nivel correo cobertura en caso del nivel (suministro para Minorista (suministro de catástrofe 30 días) (suministro para para 90 días) 30 días) Nivel 1 Medicamentos Costos compartidos Costos Costos compartidos El mayor del 5 % genéricos preferidos: compartidos preferidos: del costo, o copago preferidos copago de $2 estándares: copago de $2 de $3.70 Costos compartidos copago de $0 Costos compartidos estándares: estándares: copago de $9 copago de $9 Nivel 2 Medicamentos Costos compartidos Costos Costos compartidos El mayor del 5 % genéricos preferidos: copago compartidos preferidos: copago del costo, o copago de $10 estándares: de $10 de $3.70 Costos compartidos copago de $25 Costos compartidos estándares: copago estándares: copago de $20 de $20 Nivel 3 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % de marca preferidos: copago compartidos del precio del del costo, o copago preferidos de $42 estándares: medicamento de $9.20 Costos compartidos copago de estándares: copago $126 de $47 Nivel 4 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del no preferidos preferidos: copago compartidos del precio del 5 % del costo, o de $95 estándares: medicamento copago de $3.70 Costos compartidos copago de por medicamentos estándares: copago $285 de múltiples de $100 marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Nivel 5 Medicamentos Costos compartidos N/D 25 % de coseguro El mayor del de especialidad preferidos: del precio del 5 % del costo, o coseguro del 27 % medicamento copago de $3.70 Costos compartidos por medicamentos estándares: de múltiples coseguro del 27 % marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Tenga en cuenta lo siguiente: Si tiene un plan de salud grupal del empleador (EGHP), consulte su Resumen de Beneficios o comuníquese con Servicios para Miembros para conocer detalles de los beneficios y montos de los costos compartidos. Última actualización 09/01/2021 ix Consulte los cuadros siguientes para conocer información sobre la forma en que los costos compartidos del plan se relacionan con los diferentes niveles indicados en esta farmacopea para el suministro de un mes/tres meses de un medicamento. Si usted es elegible para recibir “Ayuda Adicional” o un “Subsidio por bajos ingresos” (LIS), es posible que parte de la información en estos cuadros acerca del costo de los medicamentos con receta Parte D no se aplique a usted. Le enviaremos un inserto por separado denominado “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS), en el cual se le informa sobre su cobertura de medicamentos. Si no tiene este inserto, llame a Servicios para Miembros al número que aparece en la portada o contraportada y solicite la “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS). Cobertura de medicamentos con receta Parte D para el plan ConnectiCare Choice 3 (HMO)

Deducible $445 (excluye Nivel 1, Nivel 2 y Nivel 3)

Etapa de cobertura inicial Etapa de interrupción de Etapa de Nombre Pedidos por cobertura Nivel Minorista cobertura en caso del nivel correo Minorista (suministro para de catástrofe (suministro (suministro para 30 días) para 90 días) 30 días) Nivel 1 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % genéricos preferidos: compartidos del precio del del costo, o copago preferidos copago de $2 estándares: medicamento de $3.70 Costos compartidos copago de $0 estándares: copago de $9 Nivel 2 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % genéricos preferidos: copago compartidos del precio del del costo, o copago de $10 estándares: medicamento de $3.70 Costos compartidos copago de $25 estándares: copago de $20 Nivel 3 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % de marca preferidos: copago compartidos del precio del del costo, o copago preferidos de $42 estándares: medicamento de $9.20 Costos compartidos copago de estándares: copago $126 de $47 Nivel 4 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del no preferidos preferidos: copago compartidos del precio del 5 % del costo, o de $95 estándares: medicamento copago de $3.70 Costos compartidos copago de por medicamentos estándares: copago $285 de múltiples de $100 marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Nivel 5 Medicamentos Costos compartidos N/D 25 % de coseguro El mayor del de especialidad preferidos: del precio del 5 % del costo, o coseguro del 25 % medicamento copago de $3.70 Costos compartidos por medicamentos estándares: de múltiples coseguro del 25 % marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Tenga en cuenta lo siguiente: Si tiene un plan de salud grupal del empleador (EGHP), consulte su Resumen de Beneficios o comuníquese con Servicios para Miembros para conocer detalles de los beneficios y montos de los costos compartidos. Última actualización 09/01/2021 x Consulte los cuadros siguientes para conocer información sobre la forma en que los costos compartidos del plan se relacionan con los diferentes niveles indicados en esta farmacopea para el suministro de un mes/tres meses de un medicamento. Si usted es elegible para recibir “Ayuda Adicional” o un “Subsidio por bajos ingresos” (LIS), es posible que parte de la información en estos cuadros acerca del costo de los medicamentos con receta Parte D no se aplique a usted. Le enviaremos un inserto por separado denominado “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS), en el cual se le informa sobre su cobertura de medicamentos. Si no tiene este inserto, llame a Servicios para Miembros al número que aparece en la portada o contraportada y solicite la “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS). Cobertura de medicamentos con receta Parte D para los planes ConnectiCare Flex 2 (HMO-POS) o ConnectiCare Flex 3 (HMO-POS)

Deducible $300 (excluye Nivel 1 y Nivel 2) Etapa de cobertura inicial Etapa de interrupción de Pedidos por Etapa de Nombre Minorista cobertura Nivel correo cobertura en caso del nivel (suministro para Minorista (suministro de catástrofe 30 días) (suministro para para 90 días) 30 días) Nivel 1 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % genéricos preferidos: compartidos del precio del del costo, o copago preferidos copago de $2 estándares: medicamento de $3.70 Costos compartidos copago de $0 estándares: copago de $9 Nivel 2 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % genéricos preferidos: copago compartidos del precio del del costo, o copago de $10 estándares: medicamento de $3.70 Costos compartidos copago de $25 estándares: copago de $20 Nivel 3 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % de marca preferidos: copago compartidos del precio del del costo, o copago preferidos de $42 estándares: medicamento de $9.20 Costos compartidos copago de estándares: copago $126 de $47 Nivel 4 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del no preferidos preferidos: copago compartidos del precio del 5 % del costo, o de $95 estándares: medicamento copago de $3.70 Costos compartidos copago de por medicamentos estándares: copago $285 de múltiples de $100 marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Nivel 5 Medicamentos Costos compartidos N/D 25 % de coseguro El mayor del de especialidad preferidos: del precio del 5 % del costo, o coseguro del 27 % medicamento copago de $3.70 Costos compartidos por medicamentos estándares: de múltiples coseguro del 27 % marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Tenga en cuenta lo siguiente: Si tiene un plan de salud grupal del empleador (EGHP), consulte su Resumen de Beneficios o comuníquese con Servicios para Miembros para conocer detalles de los beneficios y montos de los costos compartidos. Última actualización 09/01/2021 xi Consulte los cuadros siguientes para conocer información sobre la forma en que los costos compartidos del plan se relacionan con los diferentes niveles indicados en esta farmacopea para el suministro de un mes/tres meses de un medicamento. Si usted es elegible para recibir “Ayuda Adicional” o un “Subsidio por bajos ingresos” (LIS), es posible que parte de la información en estos cuadros acerca del costo de los medicamentos con receta Parte D no se aplique a usted. Le enviaremos un inserto por separado denominado “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS), en el cual se le informa sobre su cobertura de medicamentos. Si no tiene este inserto, llame a Servicios para Miembros al número que aparece en la portada o contraportada y solicite la “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS). Cobertura de medicamentos con receta Parte D para el plan ConnectiCare Passage 1 (HMO)

Deducible $275 (excluye Nivel 1 y Nivel 2)

Etapa de cobertura inicial Etapa de interrupción de Etapa de Nombre Pedidos por cobertura Nivel Minorista cobertura en caso del nivel correo Minorista (suministro para de catástrofe (suministro (suministro para 30 días) para 90 días) 30 días) Nivel 1 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % genéricos preferidos: compartidos del precio del del costo, o copago preferidos copago de $2 estándares: medicamento de $3.70 Costos compartidos copago de $0 estándares: copago de $9 Nivel 2 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % genéricos preferidos: copago compartidos del precio del del costo, o copago de $10 estándares: medicamento de $3.70 Costos compartidos copago de $25 estándares: copago de $20 Nivel 3 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del 5 % de marca preferidos: copago compartidos del precio del del costo, o copago preferidos de $42 estándares: medicamento de $9.20 Costos compartidos copago de estándares: copago $126 de $47 Nivel 4 Medicamentos Costos compartidos Costos 25 % de coseguro El mayor del no preferidos preferidos: copago compartidos del precio del 5 % del costo, o de $95 estándares: medicamento copago de $3.70 Costos compartidos copago de por medicamentos estándares: copago $285 de múltiples de $100 marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Nivel 5 Medicamentos Costos compartidos N/D 25 % de coseguro El mayor del de preferidos: del precio del 5 % del costo, o especialidad coseguro del 28 % medicamento copago de $3.70 Costos compartidos por medicamentos estándares: de múltiples coseguro del 28 % marcas genéricos/ preferidos; copago de $9.20 por todos los demás medicamentos Tenga en cuenta lo siguiente: Si tiene un plan de salud grupal del empleador (EGHP), consulte su Resumen de Beneficios o comuníquese con Servicios para Miembros para conocer detalles de los beneficios y montos de los costos compartidos. Última actualización 09/01/2021 xii Consulte los cuadros siguientes para conocer información sobre la forma en que los costos compartidos del plan se relacionan con los diferentes niveles indicados en esta farmacopea para el suministro de un mes/tres meses de un medicamento. Si usted es elegible para recibir “Ayuda Adicional” o un “Subsidio por bajos ingresos” (LIS), es posible que parte de la información en estos cuadros acerca del costo de los medicamentos con receta Parte D no se aplique a usted. Le enviaremos un inserto por separado denominado “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS), en el cual se le informa sobre su cobertura de medicamentos. Si no tiene este inserto, llame a Servicios para Miembros al número que aparece en la portada o contraportada y solicite la “Cláusula de la Evidencia de Cobertura para quienes reciben Ayuda Adicional para sus medicamentos con receta” (Cláusula LIS). Cobertura de medicamentos con receta Parte D para el plan ConnectiCare Choice Part B Saver (HMO)

Deducible $445 (excluye Nivel 1)

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ConnectiCare, Inc. es un plan HMO/HMO-POS con un contrato con Medicare. La inscripción en ConnectiCare depende de la renovación del contrato.

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Última actualización 09/01/2021 xv

Drug Name Drug Tier Requirements/Limits ANTI - INFECTIVES ANTIFUNGAL AGENTS ABELCET INTRAVENOUS SUSPENSION 4 B/D PA; MO AMBISOME INTRAVENOUS SUSPENSION 4 B/D PA; MO FOR RECONSTITUTION amphotericin b injection recon soln 2 B/D PA; MO caspofungin intravenous recon soln 5 B/D PA clotrimazole mucous membrane troche 2 MO fluconazole in nacl (iso-osm) intravenous 2 B/D PA; MO piggyback 200 mg/100 ml fluconazole in nacl (iso-osm) intravenous 2 B/D PA piggyback 400 mg/200 ml fluconazole oral suspension for reconstitution 2 MO fluconazole oral tablet 2 MO flucytosine oral capsule 2 MO griseofulvin microsize oral suspension 2 MO griseofulvin microsize oral tablet 2 MO griseofulvin ultramicrosize oral tablet 2 MO itraconazole oral capsule 2 MO; QL (120 per 30 days) ketoconazole oral tablet 2 MO NOXAFIL ORAL SUSPENSION 5 MO nystatin oral suspension 2 MO nystatin oral tablet 2 MO posaconazole oral tablet,delayed release (dr/ec) 5 PA; MO terbinafine hcl oral tablet 2 MO; QL (90 per 365 days) TOLSURA ORAL CAPSULE, SOLID 5 PA; MO; QL (120 per 30 days) DISPERSION voriconazole intravenous recon soln 2 B/D PA; MO voriconazole oral suspension for reconstitution 5 MO voriconazole oral tablet 200 mg 5 MO voriconazole oral tablet 50 mg 4 MO ANTIVIRALS abacavir oral solution 2 MO; QL (960 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 1

Drug Name Drug Tier Requirements/Limits abacavir oral tablet 2 MO; QL (60 per 30 days) abacavir-lamivudine oral tablet 4 MO; QL (30 per 30 days) abacavir-lamivudine-zidovudine oral tablet 5 MO; QL (60 per 30 days) acyclovir oral capsule 2 MO acyclovir oral suspension 200 mg/5 ml 2 MO acyclovir oral tablet 2 MO acyclovir sodium intravenous solution 2 B/D PA; MO adefovir oral tablet 5 MO amantadine hcl oral capsule 2 MO amantadine hcl oral solution 2 MO amantadine hcl oral tablet 2 MO APTIVUS ORAL CAPSULE 5 MO; QL (120 per 30 days) atazanavir oral capsule 150 mg, 200 mg 2 MO; QL (60 per 30 days) atazanavir oral capsule 300 mg 2 MO; QL (30 per 30 days) ATRIPLA ORAL TABLET 5 MO; QL (30 per 30 days) BARACLUDE ORAL SOLUTION 3 MO BIKTARVY ORAL TABLET 5 MO; QL (30 per 30 days) CABENUVA INTRAMUSCULAR 5 MO SUSPENSION,EXTENDED RELEASE cidofovir intravenous solution 2 B/D PA; MO CIMDUO ORAL TABLET 5 MO; QL (30 per 30 days) COMPLERA ORAL TABLET 5 MO; QL (30 per 30 days) DELSTRIGO ORAL TABLET 5 MO; QL (30 per 30 days) DESCOVY ORAL TABLET 5 MO; QL (30 per 30 days) didanosine oral capsule,delayed release(dr/ec) 2 MO; QL (30 per 30 days) 250 mg, 400 mg DOVATO ORAL TABLET 5 MO; QL (30 per 30 days) EDURANT ORAL TABLET 4 MO; QL (30 per 30 days) efavirenz oral capsule 200 mg 2 MO; QL (90 per 30 days) efavirenz oral capsule 50 mg 2 MO; QL (360 per 30 days) efavirenz oral tablet 2 MO; QL (30 per 30 days) efavirenz-emtricitabin-tenofov oral tablet 5 MO; QL (30 per 30 days) efavirenz-lamivu-tenofov disop oral tablet 5 MO; QL (30 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 2

Drug Name Drug Tier Requirements/Limits emtricitabine oral capsule 2 MO; QL (30 per 30 days) emtricitabine-tenofovir (tdf) oral tablet 5 MO; QL (30 per 30 days) EMTRIVA ORAL CAPSULE 3 MO; QL (30 per 30 days) EMTRIVA ORAL SOLUTION 3 MO; QL (680 per 28 days) entecavir oral tablet 4 MO; QL (30 per 30 days) EPCLUSA ORAL TABLET 200-50 MG 5 PA; MO; QL (30 per 30 days) EPCLUSA ORAL TABLET 400-100 MG 5 PA; MO; QL (28 per 28 days) EPIVIR HBV ORAL SOLUTION 4 MO etravirine oral tablet 4 MO; QL (60 per 30 days) EVOTAZ ORAL TABLET 5 MO; QL (30 per 30 days) famciclovir oral tablet 125 mg 2 MO famciclovir oral tablet 250 mg 2 MO; QL (60 per 30 days) famciclovir oral tablet 500 mg 2 MO; QL (21 per 7 days) fosamprenavir oral tablet 5 MO; QL (120 per 30 days) FUZEON SUBCUTANEOUS RECON SOLN 5 MO; QL (60 per 30 days) ganciclovir sodium intravenous recon soln 2 B/D PA; MO GENVOYA ORAL TABLET 5 MO; QL (30 per 30 days) HARVONI ORAL PELLETS IN PACKET 5 PA; MO; QL (28 per 28 days) HARVONI ORAL TABLET 45-200 MG 5 PA; MO; QL (30 per 30 days) HARVONI ORAL TABLET 90-400 MG 5 PA; MO; QL (28 per 28 days) INTELENCE ORAL TABLET 100 MG, 200 MG 5 MO; QL (60 per 30 days) INTELENCE ORAL TABLET 25 MG 3 MO; QL (120 per 30 days) INVIRASE ORAL TABLET 5 MO; QL (120 per 30 days) ISENTRESS HD ORAL TABLET 5 MO; QL (60 per 30 days) ISENTRESS ORAL POWDER IN PACKET 3 MO; QL (180 per 30 days) ISENTRESS ORAL TABLET 3 MO; QL (60 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 3 MO; QL (180 per 30 days) JULUCA ORAL TABLET 5 MO; QL (30 per 30 days) KALETRA ORAL TABLET 100-25 MG 3 MO; QL (300 per 30 days) KALETRA ORAL TABLET 200-50 MG 5 MO; QL (120 per 30 days) lamivudine oral solution 2 MO; QL (900 per 30 days) lamivudine oral tablet 100 mg, 300 mg 2 MO; QL (30 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 3

Drug Name Drug Tier Requirements/Limits lamivudine oral tablet 150 mg 2 MO; QL (60 per 30 days) lamivudine-zidovudine oral tablet 4 MO; QL (60 per 30 days) LEXIVA ORAL SUSPENSION 3 MO; QL (1575 per 28 days) lopinavir-ritonavir oral solution 5 MO; QL (480 per 30 days) lopinavir-ritonavir oral tablet 100-25 mg 2 MO; QL (300 per 30 days) lopinavir-ritonavir oral tablet 200-50 mg 2 MO; QL (120 per 30 days) nevirapine oral suspension 2 QL (1200 per 30 days) nevirapine oral tablet 2 MO; QL (60 per 30 days) nevirapine oral tablet extended release 24 hr 100 2 MO; QL (90 per 30 days) mg nevirapine oral tablet extended release 24 hr 400 2 MO; QL (30 per 30 days) mg NORVIR ORAL POWDER IN PACKET 3 MO; QL (360 per 30 days) NORVIR ORAL SOLUTION 3 MO; QL (480 per 30 days) ODEFSEY ORAL TABLET 5 MO; QL (30 per 30 days) oseltamivir oral capsule 30 mg 2 MO; QL (84 per 180 days) oseltamivir oral capsule 45 mg, 75 mg 2 MO; QL (42 per 180 days) oseltamivir oral suspension for reconstitution 2 MO PIFELTRO ORAL TABLET 5 MO; QL (30 per 30 days) PREVYMIS INTRAVENOUS SOLUTION 5 PA PREVYMIS ORAL TABLET 5 PA; MO PREZCOBIX ORAL TABLET 5 MO; QL (30 per 30 days) PREZISTA ORAL SUSPENSION 5 MO; QL (400 per 30 days) PREZISTA ORAL TABLET 150 MG 3 MO; QL (180 per 30 days) PREZISTA ORAL TABLET 600 MG 5 MO; QL (60 per 30 days) PREZISTA ORAL TABLET 75 MG 3 MO; QL (210 per 30 days) PREZISTA ORAL TABLET 800 MG 5 MO; QL (30 per 30 days) RELENZA DISKHALER INHALATION 4 MO; QL (60 per 180 days) BLISTER WITH DEVICE RETROVIR INTRAVENOUS SOLUTION 3 MO REYATAZ ORAL POWDER IN PACKET 3 MO; QL (180 per 30 days) ribavirin oral capsule 2 ribavirin oral tablet 200 mg 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 4

Drug Name Drug Tier Requirements/Limits rimantadine oral tablet 2 MO ritonavir oral tablet 2 MO; QL (360 per 30 days) RUKOBIA ORAL TABLET EXTENDED 5 MO; QL (60 per 30 days) RELEASE 12 HR SELZENTRY ORAL SOLUTION 3 MO; QL (1840 per 30 days) SELZENTRY ORAL TABLET 150 MG 5 MO; QL (60 per 30 days) SELZENTRY ORAL TABLET 25 MG 3 MO; QL (240 per 30 days) SELZENTRY ORAL TABLET 300 MG 5 MO; QL (120 per 30 days) SELZENTRY ORAL TABLET 75 MG 3 MO; QL (60 per 30 days) stavudine oral capsule 2 MO; QL (60 per 30 days) STRIBILD ORAL TABLET 5 MO; QL (30 per 30 days) SYMFI LO ORAL TABLET 5 MO; QL (30 per 30 days) SYMFI ORAL TABLET 5 MO; QL (30 per 30 days) SYMTUZA ORAL TABLET 5 MO; QL (30 per 30 days) SYNAGIS INTRAMUSCULAR SOLUTION 5 PA; MO TEMIXYS ORAL TABLET 5 MO; QL (30 per 30 days) tenofovir disoproxil fumarate oral tablet 2 MO; QL (30 per 30 days) TIVICAY ORAL TABLET 10 MG 4 MO; QL (60 per 30 days) TIVICAY ORAL TABLET 25 MG, 50 MG 5 MO; QL (60 per 30 days) TIVICAY PD ORAL TABLET FOR 5 MO; QL (180 per 30 days) SUSPENSION TRIUMEQ ORAL TABLET 5 MO; QL (30 per 30 days) TROGARZO INTRAVENOUS SOLUTION 5 PA; MO TRUVADA ORAL TABLET 5 MO; QL (30 per 30 days) TYBOST ORAL TABLET 3 MO; QL (30 per 30 days) valacyclovir oral tablet 2 MO valganciclovir oral recon soln 5 MO valganciclovir oral tablet 5 MO VIRACEPT ORAL TABLET 250 MG 3 MO; QL (270 per 30 days) VIRACEPT ORAL TABLET 625 MG 3 MO; QL (120 per 30 days) VIREAD ORAL POWDER 3 MO; QL (240 per 30 days) VIREAD ORAL TABLET 150 MG, 200 MG, 250 3 MO; QL (30 per 30 days) MG

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 5

Drug Name Drug Tier Requirements/Limits VOSEVI ORAL TABLET 5 PA; MO; QL (28 per 28 days) XOFLUZA ORAL TABLET 20 MG, 40 MG 4 MO; QL (2 per 180 days) zidovudine oral capsule 2 MO; QL (180 per 30 days) zidovudine oral syrup 2 MO; QL (1680 per 28 days) zidovudine oral tablet 2 MO; QL (60 per 30 days) CEPHALOSPORINS cefaclor oral capsule 2 MO cefaclor oral tablet extended release 12 hr 2 MO cefadroxil oral capsule 1 MO cefadroxil oral suspension for reconstitution 250 2 MO mg/5 ml, 500 mg/5 ml cefadroxil oral tablet 1 MO cefazolin in dextrose (iso-osm) intravenous 2 MO piggyback 1 gram/50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 500 mg 2 MO cefazolin injection recon soln 10 gram, 100 gram, 2 B/D PA 300 g cefazolin intravenous recon soln 2 cefdinir oral capsule 1 MO cefdinir oral suspension for reconstitution 1 MO cefepime in dextrose (iso-osm) intravenous 2 piggyback CEFEPIME IN DEXTROSE 5 % 2 MO INTRAVENOUS PIGGYBACK cefepime injection recon soln 2 MO cefixime oral capsule 4 MO cefixime oral suspension for reconstitution 2 MO CEFOTETAN IN DEXTROSE (ISO-OSM) 2 INTRAVENOUS PIGGYBACK cefotetan injection recon soln 2 cefoxitin in dextrose (iso-osm) intravenous 2 B/D PA piggyback cefoxitin intravenous recon soln 1 gram, 2 gram 2 B/D PA; MO cefoxitin intravenous recon soln 10 gram 2 B/D PA

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 6

Drug Name Drug Tier Requirements/Limits cefpodoxime oral suspension for reconstitution 2 MO cefpodoxime oral tablet 2 MO cefprozil oral suspension for reconstitution 2 MO cefprozil oral tablet 2 MO CEFTAZIDIME IN D5W INTRAVENOUS 2 PIGGYBACK ceftazidime injection recon soln 1 gram, 2 gram 2 MO ceftazidime injection recon soln 6 gram 2 ceftriaxone in dextrose (iso-osm) intravenous 2 MO piggyback ceftriaxone injection recon soln 1 gram, 2 gram, 2 B/D PA; MO 250 mg, 500 mg ceftriaxone injection recon soln 10 gram 2 CEFTRIAXONE INJECTION RECON SOLN 2 100 GRAM ceftriaxone intravenous recon soln 2 MO cefuroxime axetil oral tablet 2 MO cefuroxime sodium injection recon soln 750 mg 2 B/D PA; MO cefuroxime sodium intravenous recon soln 1.5 2 B/D PA; MO gram cefuroxime sodium intravenous recon soln 7.5 2 B/D PA gram cephalexin oral capsule 1 MO cephalexin oral suspension for reconstitution 1 MO cephalexin oral tablet 1 MO SUPRAX ORAL SUSPENSION FOR 4 RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE 4 MO TEFLARO INTRAVENOUS RECON SOLN 5 B/D PA; MO ERYTHROMYCINS / OTHER MACROLIDES azithromycin intravenous recon soln 2 B/D PA; MO azithromycin oral packet 2 MO azithromycin oral suspension for reconstitution 2 MO azithromycin oral tablet 250 mg (6 pack), 500 mg 2 (3 pack) Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 7

Drug Name Drug Tier Requirements/Limits azithromycin oral tablet 250 mg, 500 mg, 600 mg 2 MO clarithromycin oral suspension for reconstitution 2 MO clarithromycin oral tablet 2 MO clarithromycin oral tablet extended release 24 hr 2 MO erythrocin (as stearate) oral tablet 250 mg 2 MO ERYTHROCIN INTRAVENOUS RECON SOLN 3 B/D PA; MO 500 MG erythromycin ethylsuccinate oral suspension for 4 MO reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 4 erythromycin oral capsule,delayed release(dr/ec) 4 MO erythromycin oral tablet 4 MO MISCELLANEOUS ANTIINFECTIVES albendazole oral tablet 4 MO amikacin injection solution 1,000 mg/4 ml, 500 2 B/D PA; MO mg/2 ml ARIKAYCE INHALATION SUSPENSION FOR 5 PA; QL (236 per 28 days) NEBULIZATION atovaquone oral suspension 5 MO atovaquone-proguanil oral tablet 2 MO aztreonam injection recon soln 2 MO bacitracin intramuscular recon soln 2 MO CAYSTON INHALATION SOLUTION FOR 5 MO; LA; QL (84 per 28 days) NEBULIZATION chloramphenicol sod succinate intravenous recon 2 B/D PA soln chloroquine phosphate oral tablet 2 MO clindamycin hcl oral capsule 2 MO clindamycin pediatric oral recon soln 2 MO clindamycin phosphate injection solution 2 B/D PA; MO clindamycin phosphate intravenous solution 600 2 B/D PA; MO mg/4 ml COARTEM ORAL TABLET 4 MO colistin (colistimethate na) injection recon soln 4 B/D PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 8

Drug Name Drug Tier Requirements/Limits dapsone oral tablet 4 MO daptomycin intravenous recon soln 500 mg 5 MO ertapenem injection recon soln 4 MO ethambutol oral tablet 2 MO gentamicin in nacl (iso-osm) intravenous 2 MO piggyback 100 mg/100 ml, 60 mg/50 ml, 80 mg/50 ml GENTAMICIN IN NACL (ISO-OSM) 4 MO INTRAVENOUS PIGGYBACK 100 MG/50 ML GENTAMICIN IN NACL (ISO-OSM) 4 INTRAVENOUS PIGGYBACK 120 MG/100 ML gentamicin in nacl (iso-osm) intravenous 4 piggyback 80 mg/100 ml gentamicin injection solution 40 mg/ml 2 B/D PA; MO hydroxychloroquine oral tablet 1 MO imipenem-cilastatin intravenous recon soln 2 B/D PA; MO isoniazid injection solution 2 isoniazid oral solution 1 MO isoniazid oral tablet 1 MO ivermectin oral tablet 2 MO linezolid in dextrose 5% intravenous piggyback 5 PA linezolid oral suspension for reconstitution 4 PA; MO linezolid oral tablet 4 PA; MO linezolid-0.9% sodium chloride intravenous 5 PA parenteral solution mefloquine oral tablet 2 MO meropenem intravenous recon soln 2 MO MEROPENEM-0.9% SODIUM CHLORIDE 2 INTRAVENOUS PIGGYBACK metro i.v. intravenous piggyback 2 MO metronidazole in nacl (iso-osm) intravenous 2 MO piggyback metronidazole oral capsule 2 MO metronidazole oral tablet 2 MO neomycin oral tablet 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 9

Drug Name Drug Tier Requirements/Limits paromomycin oral capsule 2 MO PASER ORAL GRANULES DR FOR SUSP IN 4 MO PACKET pentamidine inhalation recon soln 4 B/D PA; MO pentamidine injection recon soln 4 B/D PA; MO polymyxin b sulfate injection recon soln 2 MO PRETOMANID ORAL TABLET 4 PA PRIFTIN ORAL TABLET 4 MO primaquine oral tablet 2 MO pyrazinamide oral tablet 2 MO pyrimethamine oral tablet 5 PA; MO quinine sulfate oral capsule 2 PA; MO rifabutin oral capsule 2 MO rifampin intravenous recon soln 2 B/D PA; MO rifampin oral capsule 2 MO SIRTURO ORAL TABLET 5 PA; LA STREPTOMYCIN INTRAMUSCULAR RECON 4 MO SOLN SYNERCID INTRAVENOUS RECON SOLN 4 B/D PA tigecycline intravenous recon soln 5 MO tinidazole oral tablet 2 MO TOBI PODHALER INHALATION CAPSULE, 5 MO; QL (224 per 28 days) W/INHALATION DEVICE tobramycin in 0.225 % nacl inhalation solution for 5 B/D PA; MO nebulization tobramycin sulfate injection recon soln 2 B/D PA tobramycin sulfate injection solution 2 B/D PA; MO TRECATOR ORAL TABLET 4 MO VANCOMYCIN IN 0.9 % SODIUM CHL 4 B/D PA INTRAVENOUS PIGGYBACK VANCOMYCIN IN DEXTROSE 5 % 4 B/D PA INTRAVENOUS PIGGYBACK VANCOMYCIN INJECTION RECON SOLN 2

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 10

Drug Name Drug Tier Requirements/Limits vancomycin intravenous recon soln 1,000 mg, 500 2 MO mg, 750 mg vancomycin intravenous recon soln 10 gram, 5 2 gram vancomycin oral capsule 125 mg 4 MO vancomycin oral capsule 250 mg 5 MO XIFAXAN ORAL TABLET 550 MG 5 MO PENICILLINS amoxicillin oral capsule 1 MO amoxicillin oral suspension for reconstitution 1 MO amoxicillin oral tablet 1 MO amoxicillin oral tablet,chewable 125 mg, 250 mg 1 MO amoxicillin-pot clavulanate oral suspension for 1 MO reconstitution amoxicillin-pot clavulanate oral tablet 1 MO amoxicillin-pot clavulanate oral tablet extended 1 MO release 12 hr amoxicillin-pot clavulanate oral tablet,chewable 1 MO ampicillin oral capsule 500 mg 2 MO ampicillin sodium injection recon soln 1 gram, 10 2 B/D PA; MO gram, 125 mg, 250 mg, 500 mg ampicillin sodium injection recon soln 2 gram 2 MO ampicillin sodium intravenous recon soln 2 B/D PA ampicillin-sulbactam injection recon soln 1.5 2 B/D PA; MO gram, 3 gram ampicillin-sulbactam injection recon soln 15 gram 2 B/D PA ampicillin-sulbactam intravenous recon soln 2 B/D PA BICILLIN C-R INTRAMUSCULAR SYRINGE 4 MO BICILLIN L-A INTRAMUSCULAR SYRINGE 4 MO dicloxacillin oral capsule 2 MO nafcillin in dextrose (iso-osm) intravenous 2 B/D PA piggyback nafcillin injection recon soln 1 gram, 2 gram 2 B/D PA; MO nafcillin injection recon soln 10 gram 5 B/D PA

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 11

Drug Name Drug Tier Requirements/Limits nafcillin intravenous recon soln 1 gram 2 B/D PA nafcillin intravenous recon soln 2 gram 2 B/D PA; MO oxacillin in dextrose (iso-osm) intravenous 2 piggyback 1 gram/50 ml oxacillin in dextrose (iso-osm) intravenous 4 MO piggyback 2 gram/50 ml oxacillin injection recon soln 1 gram 2 oxacillin injection recon soln 10 gram 5 oxacillin injection recon soln 2 gram 2 MO penicillin g potassium injection recon soln 20 2 B/D PA; MO million unit penicillin g potassium injection recon soln 5 2 MO million unit penicillin g procaine intramuscular syringe 1.2 2 MO million unit/2 ml penicillin g procaine intramuscular syringe 2 B/D PA; MO 600,000 unit/ml penicillin g sodium injection recon soln 2 B/D PA; MO penicillin v potassium oral recon soln 2 MO penicillin v potassium oral tablet 2 MO PIPERACILLIN-TAZOBACTAM 2 INTRAVENOUS RECON SOLN 13.5 GRAM piperacillin-tazobactam intravenous recon soln 2 MO 2.25 gram, 3.375 gram, 4.5 gram piperacillin-tazobactam intravenous recon soln 2 40.5 gram QUINOLONES ciprofloxacin hcl oral tablet 2 MO ciprofloxacin in 5 % dextrose intravenous 2 MO piggyback 200 mg/100 ml levofloxacin in d5w intravenous piggyback 250 2 mg/50 ml levofloxacin in d5w intravenous piggyback 500 2 MO mg/100 ml, 750 mg/150 ml levofloxacin intravenous solution 2 B/D PA; MO levofloxacin oral solution 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 12

Drug Name Drug Tier Requirements/Limits levofloxacin oral tablet 2 MO moxifloxacin oral tablet 2 MO MOXIFLOXACIN-SOD.ACE,SUL-WATER 4 B/D PA INTRAVENOUS PIGGYBACK moxifloxacin-sod.chloride(iso) intravenous 4 B/D PA; MO piggyback ofloxacin oral tablet 300 mg, 400 mg 2 MO SULFA'S / RELATED AGENTS sulfadiazine oral tablet 2 MO sulfamethoxazole-trimethoprim intravenous 2 B/D PA; MO solution sulfamethoxazole-trimethoprim oral suspension 1 MO sulfamethoxazole-trimethoprim oral tablet 1 MO TETRACYCLINES demeclocycline oral tablet 2 MO doxy-100 intravenous recon soln 2 MO doxycycline hyclate intravenous recon soln 2 doxycycline hyclate oral capsule 2 MO doxycycline hyclate oral tablet 100 mg, 20 mg 2 MO doxycycline hyclate oral tablet,delayed release 4 MO (dr/ec) 100 mg, 150 mg, 200 mg, 50 mg, 75 mg doxycycline monohydrate oral capsule 100 mg, 50 1 MO mg doxycycline monohydrate oral capsule 150 mg, 75 4 MO mg doxycycline monohydrate oral tablet 100 mg, 50 1 MO mg doxycycline monohydrate oral tablet 150 mg, 75 4 MO mg minocycline oral capsule 2 MO minocycline oral tablet 2 MO minocycline oral tablet extended release 24 hr 135 2 MO mg, 45 mg, 90 mg tetracycline oral capsule 2 MO URINARY TRACT AGENTS Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 13

Drug Name Drug Tier Requirements/Limits methenamine hippurate oral tablet 2 MO methenamine mandelate oral tablet 1 gram 2 MO nitrofurantoin macrocrystal oral capsule 2 MO nitrofurantoin monohyd/m-cryst oral capsule 2 MO trimethoprim oral tablet 2 MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS dexrazoxane hcl intravenous recon soln 2 B/D PA; MO ELITEK INTRAVENOUS RECON SOLN 5 B/D PA; MO leucovorin calcium injection recon soln 100 mg, 2 B/D PA; MO 200 mg, 350 mg, 50 mg leucovorin calcium injection recon soln 500 mg 2 B/D PA leucovorin calcium oral tablet 2 MO levoleucovorin calcium intravenous recon soln 50 4 B/D PA; MO mg levoleucovorin calcium intravenous solution 4 B/D PA mesna intravenous solution 2 B/D PA; MO MESNEX ORAL TABLET 5 MO XGEVA SUBCUTANEOUS SOLUTION 5 B/D PA; MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS abiraterone oral tablet 250 mg 5 MO; QL (120 per 30 days) abiraterone oral tablet 500 mg 5 MO; QL (60 per 30 days) ABRAXANE INTRAVENOUS SUSPENSION 4 B/D PA; MO FOR RECONSTITUTION adriamycin intravenous recon soln 10 mg 2 B/D PA; MO adriamycin intravenous solution 10 mg/5 ml 2 B/D PA; MO adriamycin intravenous solution 2 mg/ml, 20 2 B/D PA mg/10 ml, 50 mg/25 ml adrucil intravenous solution 2.5 gram/50 ml 2 B/D PA AFINITOR DISPERZ ORAL TABLET FOR 5 PA; MO; QL (150 per 30 days) SUSPENSION 2 MG AFINITOR DISPERZ ORAL TABLET FOR 5 PA; MO; QL (90 per 30 days) SUSPENSION 3 MG

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 14

Drug Name Drug Tier Requirements/Limits AFINITOR DISPERZ ORAL TABLET FOR 5 PA; MO; QL (60 per 30 days) SUSPENSION 5 MG AFINITOR ORAL TABLET 10 MG 5 PA; MO; QL (30 per 30 days) ALECENSA ORAL CAPSULE 5 PA; MO; QL (240 per 30 days) ALIMTA INTRAVENOUS RECON SOLN 5 B/D PA; MO ALIQOPA INTRAVENOUS RECON SOLN 5 PA ALUNBRIG ORAL TABLET 180 MG, 90 MG 5 PA; QL (30 per 30 days) ALUNBRIG ORAL TABLET 30 MG 5 PA; QL (180 per 30 days) ALUNBRIG ORAL TABLETS,DOSE PACK 5 PA; QL (30 per 30 days) anastrozole oral tablet 2 MO; QL (30 per 30 days) ASTAGRAF XL ORAL CAPSULE,EXTENDED 4 B/D PA; MO RELEASE 24HR AYVAKIT ORAL TABLET 5 PA; QL (30 per 30 days) azacitidine injection recon soln 5 MO AZASAN ORAL TABLET 3 B/D PA; MO azathioprine oral tablet 1 B/D PA; MO azathioprine sodium injection recon soln 2 BALVERSA ORAL TABLET 5 PA; LA BAVENCIO INTRAVENOUS SOLUTION 5 PA BELEODAQ INTRAVENOUS RECON SOLN 5 B/D PA BENDEKA INTRAVENOUS SOLUTION 5 PA; MO BESPONSA INTRAVENOUS RECON SOLN 5 PA; MO bexarotene oral capsule 5 PA; MO bicalutamide oral tablet 2 MO; QL (30 per 30 days) bleomycin injection recon soln 2 B/D PA; MO BOSULIF ORAL TABLET 100 MG 5 PA; MO; QL (90 per 30 days) BOSULIF ORAL TABLET 400 MG, 500 MG 5 PA; MO; QL (30 per 30 days) BRAFTOVI ORAL CAPSULE 75 MG 5 PA; MO; LA; QL (180 per 30 days) BRUKINSA ORAL CAPSULE 5 PA; LA; QL (120 per 30 days) CABOMETYX ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days) CALQUENCE ORAL CAPSULE 5 PA; LA; QL (60 per 30 days) CAPRELSA ORAL TABLET 100 MG 5 LA; QL (60 per 30 days) CAPRELSA ORAL TABLET 300 MG 5 LA; QL (30 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 15

Drug Name Drug Tier Requirements/Limits carboplatin intravenous solution 2 B/D PA; MO carmustine intravenous recon soln 3 B/D PA; MO cisplatin intravenous solution 2 B/D PA; MO cladribine intravenous solution 2 B/D PA; MO clofarabine intravenous solution 5 B/D PA COMETRIQ ORAL CAPSULE 5 PA; MO COPIKTRA ORAL CAPSULE 5 PA; LA; QL (60 per 30 days) COTELLIC ORAL TABLET 5 PA; MO; LA; QL (63 per 28 days) cyclophosphamide oral capsule 4 B/D PA; MO cyclosporine intravenous solution 2 cyclosporine modified oral capsule 2 B/D PA; MO cyclosporine modified oral solution 2 B/D PA cyclosporine oral capsule 2 B/D PA; MO CYRAMZA INTRAVENOUS SOLUTION 5 PA; MO cytarabine (pf) injection solution 100 mg/5 ml (20 2 B/D PA; MO mg/ml) cytarabine (pf) injection solution 20 mg/ml 2 B/D PA cytarabine injection solution 2 B/D PA; MO dacarbazine intravenous recon soln 2 B/D PA; MO DARZALEX INTRAVENOUS SOLUTION 5 PA; MO daunorubicin intravenous solution 2 B/D PA DAURISMO ORAL TABLET 100 MG 5 PA; MO; QL (30 per 30 days) DAURISMO ORAL TABLET 25 MG 5 PA; MO; QL (60 per 30 days) decitabine intravenous recon soln 5 MO doxorubicin intravenous recon soln 50 mg 2 B/D PA; MO doxorubicin intravenous solution 10 mg/5 ml, 20 2 B/D PA; MO mg/10 ml, 50 mg/25 ml doxorubicin intravenous solution 2 mg/ml 2 B/D PA doxorubicin, peg-liposomal intravenous 5 B/D PA; MO suspension DROXIA ORAL CAPSULE 3 MO ELIGARD (3 MONTH) SUBCUTANEOUS 3 PA; MO SYRINGE

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 16

Drug Name Drug Tier Requirements/Limits ELIGARD (4 MONTH) SUBCUTANEOUS 3 PA; MO SYRINGE ELIGARD (6 MONTH) SUBCUTANEOUS 3 PA; MO SYRINGE ELIGARD SUBCUTANEOUS SYRINGE 3 PA; MO EMCYT ORAL CAPSULE 3 MO EMPLICITI INTRAVENOUS RECON SOLN 5 PA; MO ENSPRYNG SUBCUTANEOUS SYRINGE 5 PA; MO ENVARSUS XR ORAL TABLET EXTENDED 4 B/D PA; MO RELEASE 24 HR epirubicin intravenous solution 4 B/D PA; MO ERIVEDGE ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) ERLEADA ORAL TABLET 5 MO; QL (120 per 30 days) erlotinib oral tablet 100 mg, 150 mg 5 PA; MO; QL (30 per 30 days) erlotinib oral tablet 25 mg 5 PA; MO; QL (90 per 30 days) etoposide intravenous solution 2 B/D PA; MO everolimus (antineoplastic) oral tablet 5 PA; MO; QL (30 per 30 days) everolimus (immunosuppressive) oral tablet 5 B/D PA; MO exemestane oral tablet 2 MO FARYDAK ORAL CAPSULE 10 MG 5 PA; MO; QL (12 per 21 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG 5 PA; MO; QL (6 per 21 days) FASLODEX INTRAMUSCULAR SYRINGE 5 B/D PA; MO fludarabine intravenous recon soln 4 B/D PA; MO fludarabine intravenous solution 4 B/D PA fluorouracil intravenous solution 2 B/D PA; MO flutamide oral capsule 2 MO FOTIVDA ORAL CAPSULE 5 PA; LA; QL (21 per 28 days) fulvestrant intramuscular syringe 5 B/D PA; MO GAVRETO ORAL CAPSULE 5 PA; MO; LA; QL (120 per 30 days) GAZYVA INTRAVENOUS SOLUTION 5 B/D PA; MO gemcitabine intravenous recon soln 1 gram, 200 5 B/D PA; MO mg gemcitabine intravenous recon soln 2 gram 5 B/D PA

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 17

Drug Name Drug Tier Requirements/Limits gemcitabine intravenous solution 1 gram/26.3 ml 5 B/D PA; MO (38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/5.26 ml (38 mg/ml) gengraf oral capsule 2 B/D PA; MO gengraf oral solution 2 B/D PA; MO GILOTRIF ORAL TABLET 5 PA; MO; QL (30 per 30 days) hydroxyurea oral capsule 2 MO IBRANCE ORAL CAPSULE 5 PA; MO; QL (21 per 28 days) IBRANCE ORAL TABLET 5 PA; MO; QL (21 per 28 days) ICLUSIG ORAL TABLET 10 MG, 30 MG, 45 5 PA; QL (30 per 30 days) MG ICLUSIG ORAL TABLET 15 MG 5 PA; QL (60 per 30 days) idarubicin intravenous solution 2 B/D PA; MO IDHIFA ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days) ifosfamide intravenous recon soln 2 B/D PA; MO ifosfamide intravenous solution 1 gram/20 ml 2 B/D PA; MO ifosfamide intravenous solution 3 gram/60 ml 2 B/D PA imatinib oral tablet 100 mg 5 PA; MO; QL (90 per 30 days) imatinib oral tablet 400 mg 5 PA; MO; QL (60 per 30 days) IMBRUVICA ORAL CAPSULE 5 PA; QL (30 per 30 days) IMBRUVICA ORAL TABLET 5 PA; QL (30 per 30 days) IMFINZI INTRAVENOUS SOLUTION 5 PA; MO INLYTA ORAL TABLET 1 MG 5 PA; MO; QL (180 per 30 days) INLYTA ORAL TABLET 5 MG 5 PA; MO; QL (120 per 30 days) INQOVI ORAL TABLET 5 PA; MO; QL (5 per 28 days) INREBIC ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) IRESSA ORAL TABLET 5 PA; MO; QL (30 per 30 days) irinotecan intravenous solution 100 mg/5 ml, 40 2 B/D PA; MO mg/2 ml irinotecan intravenous solution 500 mg/25 ml 2 B/D PA ISTODAX INTRAVENOUS RECON SOLN 5 B/D PA; MO JAKAFI ORAL TABLET 5 PA; MO; QL (60 per 30 days) KADCYLA INTRAVENOUS RECON SOLN 5 PA; MO KANJINTI INTRAVENOUS RECON SOLN 5 PA; MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 18

Drug Name Drug Tier Requirements/Limits KEYTRUDA INTRAVENOUS SOLUTION 5 PA KISQALI FEMARA CO-PACK ORAL TABLET 5 PA; MO; QL (49 per 30 days) 200 MG/DAY(200 MG X 1)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 5 PA; MO; QL (70 per 30 days) 400 MG/DAY(200 MG X 2)-2.5 MG KISQALI FEMARA CO-PACK ORAL TABLET 5 PA; MO; QL (91 per 30 days) 600 MG/DAY(200 MG X 3)-2.5 MG KISQALI ORAL TABLET 200 MG/DAY (200 5 PA; MO; QL (21 per 28 days) MG X 1) KISQALI ORAL TABLET 400 MG/DAY (200 5 PA; MO; QL (42 per 28 days) MG X 2) KISQALI ORAL TABLET 600 MG/DAY (200 5 PA; MO; QL (63 per 28 days) MG X 3) KOSELUGO ORAL CAPSULE 5 PA; LA KYPROLIS INTRAVENOUS RECON SOLN 5 PA lapatinib oral tablet 5 PA; MO; QL (180 per 30 days) LENVIMA ORAL CAPSULE 5 PA; MO letrozole oral tablet 2 MO; QL (30 per 30 days) LEUKERAN ORAL TABLET 3 MO leuprolide subcutaneous kit 2 PA; MO LONSURF ORAL TABLET 5 PA; MO LORBRENA ORAL TABLET 5 PA; MO LUPRON DEPOT (3 MONTH) 5 PA; MO INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (4 MONTH) 5 PA; MO INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT (6 MONTH) 5 PA; MO INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT INTRAMUSCULAR 3 PA; MO SYRINGE KIT 3.75 MG LUPRON DEPOT INTRAMUSCULAR 5 PA; MO SYRINGE KIT 7.5 MG LUPRON DEPOT-PED (3 MONTH) 5 PA; MO INTRAMUSCULAR SYRINGE KIT LUPRON DEPOT-PED INTRAMUSCULAR KIT 5 PA; MO LYNPARZA ORAL TABLET 5 PA; MO; QL (120 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 19

Drug Name Drug Tier Requirements/Limits LYSODREN ORAL TABLET 3 MATULANE ORAL CAPSULE 5 megestrol oral suspension 400 mg/10 ml (10 ml) 4 PA megestrol oral suspension 400 mg/10 ml (40 4 PA; MO mg/ml), 625 mg/5 ml (125 mg/ml) megestrol oral tablet 2 PA; MO MEKINIST ORAL TABLET 0.5 MG 5 PA; MO; QL (90 per 30 days) MEKINIST ORAL TABLET 2 MG 5 PA; MO; QL (30 per 30 days) MEKTOVI ORAL TABLET 5 PA; MO; LA; QL (180 per 30 days) melphalan hcl intravenous recon soln 2 B/D PA mercaptopurine oral tablet 2 MO methotrexate sodium (pf) injection recon soln 2 B/D PA methotrexate sodium (pf) injection solution 2 B/D PA; MO methotrexate sodium injection solution 2 B/D PA; MO methotrexate sodium oral tablet 1 B/D PA; MO mitomycin intravenous recon soln 2 B/D PA; MO mitoxantrone intravenous concentrate 2 B/D PA; MO MVASI INTRAVENOUS SOLUTION 5 PA; MO mycophenolate mofetil (hcl) intravenous recon 4 soln mycophenolate mofetil oral capsule 2 B/D PA; MO mycophenolate mofetil oral suspension for 2 B/D PA; MO reconstitution mycophenolate mofetil oral tablet 2 B/D PA; MO mycophenolate sodium oral tablet,delayed release 2 B/D PA; MO (dr/ec) MYLOTARG INTRAVENOUS RECON SOLN 5 PA; MO NERLYNX ORAL TABLET 5 PA; MO; LA; QL (180 per 30 days) NEXAVAR ORAL TABLET 5 PA; MO; LA; QL (120 per 30 days) nilutamide oral tablet 2 MO; QL (30 per 30 days) NINLARO ORAL CAPSULE 2.3 MG 5 PA; MO; QL (6 per 28 days) NINLARO ORAL CAPSULE 3 MG 5 PA; MO; QL (4 per 28 days) NINLARO ORAL CAPSULE 4 MG 5 PA; MO; QL (3 per 28 days) NUBEQA ORAL TABLET 5 PA; MO; LA; QL (120 per 30 days) Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 20

Drug Name Drug Tier Requirements/Limits NULOJIX INTRAVENOUS RECON SOLN 5 MO octreotide acetate injection solution 1,000 mcg/ml, 5 PA; MO 500 mcg/ml octreotide acetate injection solution 100 mcg/ml, 2 PA; MO 200 mcg/ml, 50 mcg/ml octreotide acetate injection syringe 100 mcg/ml (1 2 PA; MO ml), 50 mcg/ml (1 ml) octreotide acetate injection syringe 500 mcg/ml (1 5 PA; MO ml) ODOMZO ORAL CAPSULE 5 PA; MO; LA; QL (30 per 30 days) ONUREG ORAL TABLET 5 PA; MO; QL (14 per 28 days) OPDIVO INTRAVENOUS SOLUTION 100 5 PA; MO MG/10 ML, 40 MG/4 ML ORGOVYX ORAL TABLET 5 PA; LA oxaliplatin intravenous recon soln 100 mg 4 B/D PA; MO oxaliplatin intravenous recon soln 50 mg 4 B/D PA oxaliplatin intravenous solution 100 mg/20 ml, 50 4 B/D PA; MO mg/10 ml (5 mg/ml) oxaliplatin intravenous solution 200 mg/40 ml 4 B/D PA paclitaxel intravenous concentrate 2 B/D PA; MO PEMAZYRE ORAL TABLET 5 PA; LA; QL (14 per 21 days) PERJETA INTRAVENOUS SOLUTION 5 PA; MO PIQRAY ORAL TABLET 200 MG/DAY (200 5 PA; MO; QL (28 per 28 days) MG X 1) PIQRAY ORAL TABLET 250 MG/DAY (200 5 PA; MO; QL (56 per 28 days) MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) POMALYST ORAL CAPSULE 5 PA; MO; LA PORTRAZZA INTRAVENOUS SOLUTION 5 PA; MO POTELIGEO INTRAVENOUS SOLUTION 5 PA PROGRAF ORAL GRANULES IN PACKET 4 B/D PA; MO PURIXAN ORAL SUSPENSION 4 QINLOCK ORAL TABLET 5 PA; LA; QL (90 per 30 days) RETEVMO ORAL CAPSULE 40 MG 5 PA; MO; LA; QL (60 per 30 days) RETEVMO ORAL CAPSULE 80 MG 5 PA; MO; LA; QL (120 per 30 days) REVLIMID ORAL CAPSULE 5 PA; MO; LA; QL (28 per 28 days) Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 21

Drug Name Drug Tier Requirements/Limits ROZLYTREK ORAL CAPSULE 100 MG 5 PA; MO; QL (180 per 30 days) ROZLYTREK ORAL CAPSULE 200 MG 5 PA; MO; QL (90 per 30 days) RUBRACA ORAL TABLET 5 PA; MO; LA; QL (120 per 30 days) RUXIENCE INTRAVENOUS SOLUTION 5 PA; MO RYDAPT ORAL CAPSULE 5 PA; MO SANDIMMUNE ORAL SOLUTION 4 B/D PA; MO SIGNIFOR SUBCUTANEOUS SOLUTION 5 PA SIMULECT INTRAVENOUS RECON SOLN 10 3 MG SIMULECT INTRAVENOUS RECON SOLN 20 3 MO MG sirolimus oral solution 2 B/D PA; MO sirolimus oral tablet 2 B/D PA; MO SOLTAMOX ORAL SOLUTION 4 MO SOMATULINE DEPOT SUBCUTANEOUS 5 B/D PA; MO SYRINGE 120 MG/0.5 ML, 90 MG/0.3 ML SOMATULINE DEPOT SUBCUTANEOUS 5 MO SYRINGE 60 MG/0.2 ML SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 5 PA; MO; QL (30 per 30 days) MG, 80 MG SPRYCEL ORAL TABLET 20 MG 5 PA; MO; QL (90 per 30 days) SPRYCEL ORAL TABLET 70 MG 5 PA; MO; QL (60 per 30 days) STIVARGA ORAL TABLET 5 PA; MO; QL (84 per 28 days) SUTENT ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) SYNRIBO SUBCUTANEOUS RECON SOLN 5 B/D PA TABLOID ORAL TABLET 3 MO TABRECTA ORAL TABLET 5 PA; MO; QL (112 per 28 days) tacrolimus oral capsule 0.5 mg, 1 mg 2 B/D PA; MO tacrolimus oral capsule 5 mg 4 B/D PA; MO TAFINLAR ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) TAGRISSO ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days) TALZENNA ORAL CAPSULE 0.25 MG 5 PA; MO; QL (90 per 30 days) TALZENNA ORAL CAPSULE 1 MG 5 PA; MO; QL (30 per 30 days) tamoxifen oral tablet 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 22

Drug Name Drug Tier Requirements/Limits TARGRETIN TOPICAL GEL 5 PA; MO; QL (60 per 30 days) TASIGNA ORAL CAPSULE 150 MG, 200 MG 5 PA; MO; QL (112 per 28 days) TASIGNA ORAL CAPSULE 50 MG 5 PA; MO; QL (120 per 30 days) TAZVERIK ORAL TABLET 5 PA; LA; QL (240 per 30 days) TECENTRIQ INTRAVENOUS SOLUTION 5 PA; MO TEPMETKO ORAL TABLET 5 PA; LA; QL (60 per 30 days) THALOMID ORAL CAPSULE 100 MG, 50 MG 5 PA; MO; QL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG 5 PA; MO; QL (60 per 30 days) thiotepa injection recon soln 15 mg 5 PA; MO TIBSOVO ORAL TABLET 5 PA; QL (60 per 30 days) toposar intravenous solution 2 B/D PA; MO topotecan intravenous recon soln 5 B/D PA topotecan intravenous solution 4 mg/4 ml (1 5 B/D PA; MO mg/ml) toremifene oral tablet 5 MO; QL (30 per 30 days) TRAZIMERA INTRAVENOUS RECON SOLN 5 PA; MO TREANDA INTRAVENOUS RECON SOLN 5 B/D PA; MO TRELSTAR INTRAMUSCULAR SUSPENSION 5 B/D PA; MO FOR RECONSTITUTION tretinoin (antineoplastic) oral capsule 5 MO TUKYSA ORAL TABLET 5 PA; LA; QL (120 per 30 days) TURALIO ORAL CAPSULE 5 PA; LA; QL (120 per 30 days) TYKERB ORAL TABLET 5 PA; MO; LA; QL (180 per 30 days) UKONIQ ORAL TABLET 5 PA; QL (120 per 30 days) VELCADE INJECTION RECON SOLN 5 B/D PA; MO VENCLEXTA ORAL TABLET 10 MG 3 PA; LA; QL (60 per 30 days) VENCLEXTA ORAL TABLET 100 MG 5 PA; LA; QL (120 per 30 days) VENCLEXTA ORAL TABLET 50 MG 3 PA; LA; QL (30 per 30 days) VENCLEXTA STARTING PACK ORAL 5 PA; LA; QL (42 per 180 days) TABLETS,DOSE PACK VERZENIO ORAL TABLET 5 PA; MO; LA; QL (60 per 30 days) vinblastine intravenous solution 2 B/D PA; MO vincasar pfs intravenous solution 2 B/D PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 23

Drug Name Drug Tier Requirements/Limits vincristine intravenous solution 2 B/D PA; MO vinorelbine intravenous solution 2 B/D PA; MO VITRAKVI ORAL CAPSULE 100 MG 5 PA; MO; LA; QL (60 per 30 days) VITRAKVI ORAL CAPSULE 25 MG 5 PA; MO; LA; QL (180 per 30 days) VITRAKVI ORAL SOLUTION 5 PA; MO; LA; QL (300 per 30 days) VIZIMPRO ORAL TABLET 5 PA; MO; QL (30 per 30 days) VOTRIENT ORAL TABLET 5 PA; MO; QL (120 per 30 days) XALKORI ORAL CAPSULE 5 PA; MO; QL (60 per 30 days) XATMEP ORAL SOLUTION 4 PA; MO XERMELO ORAL TABLET 5 PA; QL (84 per 28 days) XOSPATA ORAL TABLET 5 PA; LA; QL (90 per 30 days) XPOVIO ORAL TABLET 5 PA; LA XTANDI ORAL CAPSULE 5 MO; QL (120 per 30 days) XTANDI ORAL TABLET 40 MG 5 MO; QL (120 per 30 days) XTANDI ORAL TABLET 80 MG 5 MO; QL (60 per 30 days) YERVOY INTRAVENOUS SOLUTION 5 PA; MO YONDELIS INTRAVENOUS RECON SOLN 5 PA YONSA ORAL TABLET 5 MO; QL (120 per 30 days) ZALTRAP INTRAVENOUS SOLUTION 5 PA; MO ZEJULA ORAL CAPSULE 5 PA; LA; QL (90 per 30 days) ZELBORAF ORAL TABLET 5 PA; MO; QL (240 per 30 days) ZIRABEV INTRAVENOUS SOLUTION 5 PA; MO ZOLINZA ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) ZORTRESS ORAL TABLET 1 MG 5 B/D PA; MO ZYDELIG ORAL TABLET 5 PA; MO; QL (60 per 30 days) ZYKADIA ORAL TABLET 5 PA; MO; QL (90 per 30 days) ZYTIGA ORAL TABLET 500 MG 5 MO; QL (60 per 30 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS APTIOM ORAL TABLET 5 PA; MO BANZEL ORAL SUSPENSION 5 PA; MO BANZEL ORAL TABLET 5 PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 24

Drug Name Drug Tier Requirements/Limits BRIVIACT INTRAVENOUS SOLUTION 4 PA BRIVIACT ORAL SOLUTION 5 PA; MO BRIVIACT ORAL TABLET 5 PA; MO carbamazepine oral capsule, er multiphase 12 hr 2 MO carbamazepine oral suspension 100 mg/5 ml 2 MO carbamazepine oral suspension 200 mg/10 ml 2 carbamazepine oral tablet 1 MO carbamazepine oral tablet extended release 12 hr 2 MO carbamazepine oral tablet,chewable 1 MO CELONTIN ORAL CAPSULE 300 MG 4 MO clobazam oral suspension 4 PA; MO clobazam oral tablet 4 PA; MO clonazepam oral tablet 2 MO clonazepam oral tablet,disintegrating 2 MO DIACOMIT ORAL CAPSULE 5 PA DIACOMIT ORAL POWDER IN PACKET 5 PA diazepam rectal kit 2.5 mg 4 MO DILANTIN 30 MG ORAL CAPSULE 4 MO divalproex oral capsule, delayed release sprinkle 2 divalproex oral tablet extended release 24 hr 2 MO divalproex oral tablet,delayed release (dr/ec) 2 MO EPIDIOLEX ORAL SOLUTION 5 PA; MO; LA epitol oral tablet 1 MO ethosuximide oral capsule 2 MO ethosuximide oral solution 2 MO felbamate oral suspension 2 MO felbamate oral tablet 2 MO FINTEPLA ORAL SOLUTION 5 PA; LA fosphenytoin injection solution 2 B/D PA; MO FYCOMPA ORAL SUSPENSION 5 PA; MO FYCOMPA ORAL TABLET 10 MG, 12 MG, 4 5 PA; MO MG, 6 MG, 8 MG FYCOMPA ORAL TABLET 2 MG 4 PA; MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 25

Drug Name Drug Tier Requirements/Limits gabapentin oral capsule 100 mg 2 MO; QL (180 per 30 days) gabapentin oral capsule 300 mg, 400 mg 2 MO; QL (270 per 30 days) gabapentin oral solution 250 mg/5 ml 2 MO; QL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 2 QL (2160 per 30 days) mg/6 ml (6 ml) gabapentin oral tablet 600 mg 2 MO; QL (180 per 30 days) gabapentin oral tablet 800 mg 2 MO; QL (120 per 30 days) lamotrigine oral tablet 2 MO lamotrigine oral tablet disintegrating, dose pk 25 2 MO mg(14)-50 mg (14)-100 mg (7) lamotrigine oral tablet extended release 24hr 2 MO lamotrigine oral tablet, chewable dispersible 2 MO lamotrigine oral tablet,disintegrating 2 MO lamotrigine oral tablets,dose pack 2 MO levetiracetam in nacl (iso-osm) intravenous 2 MO piggyback 1,000 mg/100 ml, 500 mg/100 ml levetiracetam in nacl (iso-osm) intravenous 2 piggyback 1,500 mg/100 ml levetiracetam intravenous solution 2 MO levetiracetam oral solution 100 mg/ml 2 MO levetiracetam oral solution 500 mg/5 ml (5 ml) 2 levetiracetam oral tablet 2 MO levetiracetam oral tablet extended release 24 hr 2 MO NAYZILAM NASAL SPRAY,NON-AEROSOL 5 PA; MO; QL (10 per 30 days) oxcarbazepine oral suspension 2 MO oxcarbazepine oral tablet 2 MO phenobarbital oral elixir 2 PA; MO phenobarbital oral tablet 100 mg, 15 mg, 30 mg, 2 PA 60 mg phenobarbital oral tablet 16.2 mg, 32.4 mg, 64.8 2 PA; MO mg, 97.2 mg phenytoin oral suspension 100 mg/4 ml 2 phenytoin oral suspension 125 mg/5 ml 2 MO phenytoin oral tablet,chewable 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 26

Drug Name Drug Tier Requirements/Limits phenytoin sodium extended release oral capsule 2 MO phenytoin sodium intravenous solution 2 B/D PA pregabalin oral capsule 100 mg, 150 mg, 200 mg, 2 MO; QL (90 per 30 days) 25 mg, 50 mg, 75 mg pregabalin oral capsule 225 mg, 300 mg 2 MO; QL (60 per 30 days) pregabalin oral solution 2 MO; QL (900 per 30 days) primidone oral tablet 2 MO roweepra oral tablet 4 MO rufinamide oral suspension 5 PA; MO rufinamide oral tablet 2 PA; MO SPRITAM ORAL TABLET FOR SUSPENSION 4 MO SYMPAZAN ORAL FILM 10 MG, 20 MG 5 PA; MO SYMPAZAN ORAL FILM 5 MG 4 PA; MO tiagabine oral tablet 4 MO topiramate oral capsule, sprinkle 2 PA; MO topiramate oral capsule,sprinkle,er 24hr 3 PA; MO topiramate oral tablet 2 PA; MO valproate sodium intravenous solution 2 B/D PA; MO valproic acid (as sodium salt) oral solution 250 2 MO mg/5 ml valproic acid (as sodium salt) oral solution 250 2 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) valproic acid oral capsule 2 MO VALTOCO NASAL SPRAY,NON-AEROSOL 5 PA; MO vigabatrin oral powder in packet 5 PA; MO; LA vigabatrin oral tablet 5 PA; MO; LA VIMPAT INTRAVENOUS SOLUTION 4 PA; MO VIMPAT ORAL SOLUTION 4 PA; MO VIMPAT ORAL TABLET 4 PA; MO XCOPRI MAINTENANCE PACK ORAL 5 PA; MO TABLET XCOPRI ORAL TABLET 5 PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 27

Drug Name Drug Tier Requirements/Limits XCOPRI TITRATION PACK ORAL 4 PA; MO TABLETS,DOSE PACK 12.5 MG (14)- 25 MG (14) XCOPRI TITRATION PACK ORAL 5 PA; MO TABLETS,DOSE PACK 150 MG (14)- 200 MG (14), 50 MG (14)- 100 MG (14) zonisamide oral capsule 2 PA; MO ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE 5 PA; MO; LA benztropine injection solution 2 B/D PA; MO benztropine oral tablet 2 MO bromocriptine oral capsule 2 MO bromocriptine oral tablet 2 MO carbidopa oral tablet 2 MO carbidopa-levodopa oral tablet 2 MO carbidopa-levodopa oral tablet extended release 2 MO carbidopa-levodopa oral tablet,disintegrating 2 MO carbidopa-levodopa-entacapone oral tablet 2 MO entacapone oral tablet 2 MO NEUPRO TRANSDERMAL PATCH 24 HOUR 4 MO pramipexole oral tablet 2 MO pramipexole oral tablet extended release 24 hr 2 MO rasagiline oral tablet 4 MO ropinirole oral tablet 2 MO ropinirole oral tablet extended release 24 hr 2 MO selegiline hcl oral capsule 2 MO selegiline hcl oral tablet 2 MO tolcapone oral tablet 2 trihexyphenidyl oral elixir 2 MO trihexyphenidyl oral tablet 2 MO MIGRAINE / CLUSTER HEADACHE THERAPY AIMOVIG AUTOINJECTOR SUBCUTANEOUS 3 PA; MO; QL (1 per 30 days) AUTO-INJECTOR

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 28

Drug Name Drug Tier Requirements/Limits AJOVY AUTOINJECTOR SUBCUTANEOUS 3 PA; MO; QL (1.5 per 30 days) AUTO-INJECTOR AJOVY SUBCUTANEOUS SYRINGE 3 PA; MO; QL (1.5 per 30 days) dihydroergotamine injection solution 2 dihydroergotamine nasal spray,non-aerosol 5 PA EMGALITY SUBCUTANEOUS PEN 3 PA; MO; QL (2 per 30 days) INJECTOR EMGALITY SUBCUTANEOUS SYRINGE 120 3 PA; MO; QL (2 per 30 days) MG/ML EMGALITY SUBCUTANEOUS SYRINGE 300 3 PA; MO; QL (3 per 30 days) MG/3 ML (100 MG/ML X 3) migergot rectal suppository 4 MO naratriptan oral tablet 2 MO; QL (18 per 28 days) NURTEC ODT ORAL 3 PA; QL (15 per 30 days) TABLET,DISINTEGRATING rizatriptan oral tablet 2 MO; QL (36 per 30 days) rizatriptan oral tablet,disintegrating 2 MO; QL (36 per 30 days) sumatriptan nasal spray,non-aerosol 20 2 MO; QL (12 per 30 days) mg/actuation sumatriptan nasal spray,non-aerosol 5 4 MO; QL (12 per 30 days) mg/actuation sumatriptan succinate oral tablet 2 MO; QL (9 per 30 days) sumatriptan succinate subcutaneous cartridge 2 MO; QL (10 per 30 days) sumatriptan succinate subcutaneous pen injector 2 MO; QL (10 per 30 days) sumatriptan succinate subcutaneous solution 2 MO; QL (10 per 30 days) UBRELVY ORAL TABLET 3 PA; QL (16 per 30 days) zolmitriptan oral tablet 2 MO; QL (12 per 30 days) zolmitriptan oral tablet,disintegrating 2 MO; QL (12 per 30 days) MISCELLANEOUS NEUROLOGICAL THERAPY AUBAGIO ORAL TABLET 5 MO dalfampridine oral tablet extended release 12 hr 5 PA; MO; QL (60 per 30 days) dimethyl fumarate oral capsule,delayed 5 MO release(dr/ec) donepezil oral tablet 2 MO; QL (30 per 30 days) donepezil oral tablet,disintegrating 2 MO; QL (30 per 30 days) Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 29

Drug Name Drug Tier Requirements/Limits EVRYSDI ORAL RECON SOLN 5 PA; MO; LA galantamine oral solution 2 MO galantamine oral tablet 2 MO GILENYA ORAL CAPSULE 0.5 MG 5 MO glatiramer subcutaneous syringe 5 glatopa subcutaneous syringe 5 MO INGREZZA INITIATION PACK ORAL 5 PA; LA; QL (28 per 180 days) CAPSULE,DOSE PACK INGREZZA ORAL CAPSULE 5 PA; LA; QL (30 per 30 days) KEVEYIS ORAL TABLET 5 PA MAVENCLAD (10 TABLET PACK) ORAL 5 MO TABLET MAVENCLAD (4 TABLET PACK) ORAL 5 MO TABLET MAVENCLAD (5 TABLET PACK) ORAL 5 MO TABLET MAVENCLAD (6 TABLET PACK) ORAL 5 MO TABLET MAVENCLAD (7 TABLET PACK) ORAL 5 MO TABLET MAVENCLAD (8 TABLET PACK) ORAL 5 MO TABLET MAVENCLAD (9 TABLET PACK) ORAL 5 MO TABLET MAYZENT ORAL TABLET 5 MO MAYZENT STARTER PACK ORAL 5 MO TABLETS,DOSE PACK memantine oral capsule,sprinkle,er 24hr 2 MO memantine oral solution 2 MO memantine oral tablet 2 MO MEMANTINE ORAL TABLETS,DOSE PACK 4 MO NUEDEXTA ORAL CAPSULE 4 PA; MO; QL (60 per 30 days) RADICAVA INTRAVENOUS SOLUTION 5 PA rivastigmine tartrate oral capsule 1.5 mg 2 MO; QL (240 per 30 days) rivastigmine tartrate oral capsule 3 mg 2 MO; QL (120 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 30

Drug Name Drug Tier Requirements/Limits rivastigmine tartrate oral capsule 4.5 mg, 6 mg 2 MO; QL (60 per 30 days) rivastigmine transdermal patch 24 hour 4 MO; QL (30 per 30 days) TECFIDERA ORAL CAPSULE,DELAYED 5 MO; LA RELEASE(DR/EC) TEGSEDI SUBCUTANEOUS SYRINGE 5 PA; MO tetrabenazine oral tablet 5 PA; MO TYSABRI INTRAVENOUS SOLUTION 5 PA; MO VUMERITY ORAL CAPSULE,DELAYED 5 MO RELEASE(DR/EC) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen oral tablet 10 mg, 20 mg 2 MO cyclobenzaprine oral tablet 10 mg, 5 mg 2 PA; MO dantrolene oral capsule 2 MO metaxalone oral tablet 2 PA; MO pyridostigmine bromide oral tablet 60 mg 2 MO pyridostigmine bromide oral tablet extended 2 MO release regonol injection solution 3 B/D PA tizanidine oral capsule 2 MO tizanidine oral tablet 2 MO NARCOTIC ANALGESICS acetaminophen-codeine oral tablet 300-15 mg, 2 MO; QL (360 per 30 days) 300-30 mg acetaminophen-codeine oral tablet 300-60 mg 2 MO; QL (180 per 30 days) buprenorphine hcl injection solution 2 B/D PA; MO buprenorphine hcl injection syringe 2 B/D PA buprenorphine hcl sublingual tablet 2 MO butalbital-acetaminop-caf-cod oral capsule 4 PA; MO; QL (360 per 30 days) butalbital-acetaminophen oral tablet 50-325 mg 4 PA; MO; QL (360 per 30 days) butalbital-acetaminophen-caff oral capsule 4 PA; MO; QL (360 per 30 days) butalbital-acetaminophen-caff oral tablet 4 PA; MO; QL (360 per 30 days) butalbital-aspirin-caffeine oral capsule 4 PA; MO; QL (180 per 30 days) butalbital-aspirin-caffeine oral tablet 4 PA; QL (180 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 31

Drug Name Drug Tier Requirements/Limits codeine sulfate oral tablet 2 MO; QL (180 per 30 days) endocet oral tablet 2 MO; QL (360 per 30 days) fentanyl citrate buccal lozenge on a handle 1,200 5 PA; MO; QL (39 per 30 days) mcg fentanyl citrate buccal lozenge on a handle 1,600 5 PA; MO; QL (29 per 30 days) mcg fentanyl citrate buccal lozenge on a handle 200 5 PA; MO; QL (120 per 30 days) mcg fentanyl citrate buccal lozenge on a handle 400 5 PA; MO; QL (116 per 30 days) mcg fentanyl citrate buccal lozenge on a handle 600 5 PA; MO; QL (77 per 30 days) mcg fentanyl citrate buccal lozenge on a handle 800 5 PA; MO; QL (58 per 30 days) mcg fentanyl transdermal patch 72 hour 100 mcg/hr, 2 PA; MO; QL (10 per 30 days) 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr hydrocodone-acetaminophen oral solution 10-325 2 QL (5550 per 30 days) mg/15 ml(15 ml) hydrocodone-acetaminophen oral solution 7.5-325 2 MO; QL (5550 per 30 days) mg/15 ml hydrocodone-acetaminophen oral tablet 10-300 2 MO; QL (360 per 30 days) mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg hydrocodone-ibuprofen oral tablet 2 MO; QL (50 per 30 days) hydromorphone (pf) injection solution 10 (mg/ml) 2 B/D PA; QL (120 per 30 days) (5 ml), 10 mg/ml hydromorphone injection solution 1 mg/ml 2 B/D PA; QL (300 per 30 days) hydromorphone injection solution 2 mg/ml 2 B/D PA; MO; QL (150 per 30 days) hydromorphone oral liquid 2 MO; QL (1500 per 30 days) hydromorphone oral tablet 2 MO; QL (180 per 30 days) methadone injection solution 2 B/D PA; QL (1200 per 30 days) methadone intensol oral concentrate 2 MO; QL (160 per 30 days) methadone oral concentrate 2 QL (160 per 30 days) methadone oral solution 10 mg/5 ml 2 PA; MO; QL (600 per 30 days) methadone oral solution 5 mg/5 ml 2 PA; MO; QL (1200 per 30 days) methadone oral tablet 10 mg 2 PA; MO; QL (120 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits methadone oral tablet 5 mg 2 PA; MO; QL (240 per 30 days) methadose oral concentrate 2 MO; QL (160 per 30 days) morphine (pf) injection solution 0.5 mg/ml 2 B/D PA; QL (4000 per 30 days) morphine (pf) injection solution 1 mg/ml 2 B/D PA; MO; QL (2000 per 30 days) morphine concentrate oral solution 2 MO; QL (300 per 30 days) MORPHINE INTRAVENOUS SYRINGE 10 4 B/D PA; QL (200 per 30 days) MG/ML MORPHINE INTRAVENOUS SYRINGE 8 4 B/D PA; QL (250 per 30 days) MG/ML morphine oral capsule, er multiphase 24 hr 120 2 PA; MO; QL (50 per 30 days) mg morphine oral capsule, er multiphase 24 hr 30 mg, 2 PA; MO; QL (60 per 30 days) 45 mg, 60 mg, 75 mg, 90 mg morphine oral capsule,extend.release pellets 10 2 PA; MO; QL (60 per 30 days) mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg morphine oral solution 2 MO; QL (900 per 30 days) morphine oral tablet 2 MO; QL (180 per 30 days) morphine oral tablet extended release 100 mg 2 PA; MO; QL (60 per 30 days) morphine oral tablet extended release 15 mg, 30 2 PA; MO; QL (90 per 30 days) mg, 60 mg morphine oral tablet extended release 200 mg 2 PA; MO; QL (30 per 30 days) oxycodone oral capsule 2 MO; QL (360 per 30 days) oxycodone oral concentrate 2 MO; QL (180 per 30 days) oxycodone oral solution 2 MO; QL (1200 per 30 days) oxycodone oral tablet 10 mg, 15 mg, 20 mg 2 MO; QL (180 per 30 days) oxycodone oral tablet 30 mg 2 MO; QL (134 per 30 days) oxycodone oral tablet 5 mg 2 MO; QL (360 per 30 days) oxycodone-acetaminophen oral tablet 10-325 mg, 2 MO; QL (360 per 30 days) 2.5-325 mg, 5-325 mg, 7.5-325 mg oxymorphone oral tablet 10 mg 2 MO; QL (200 per 30 days) oxymorphone oral tablet 5 mg 2 MO; QL (180 per 30 days) oxymorphone oral tablet extended release 12 hr 10 2 PA; MO; QL (90 per 30 days) mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 2 PA; MO; QL (67 per 30 days) mg

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 33

Drug Name Drug Tier Requirements/Limits oxymorphone oral tablet extended release 12 hr 40 2 PA; MO; QL (50 per 30 days) mg NON-NARCOTIC ANALGESICS buprenorphine-naloxone sublingual film 12-3 mg 4 MO; QL (60 per 30 days) buprenorphine-naloxone sublingual film 2-0.5 mg, 4 MO; QL (90 per 30 days) 4-1 mg, 8-2 mg buprenorphine-naloxone sublingual tablet 2 MO; QL (90 per 30 days) butorphanol injection solution 1 mg/ml 2 MO; QL (720 per 30 days) butorphanol injection solution 2 mg/ml 2 MO; QL (360 per 30 days) butorphanol nasal spray,non-aerosol 2 MO; QL (5 per 30 days) celecoxib oral capsule 2 MO DICLOFENAC EPOLAMINE TRANSDERMAL 4 PA PATCH 12 HOUR diclofenac potassium oral tablet 2 MO diclofenac sodium oral tablet extended release 24 2 MO hr diclofenac sodium oral tablet,delayed release 2 MO (dr/ec) diclofenac sodium topical drops 4 MO; QL (600 per 30 days) diclofenac sodium topical gel 1 % 4 MO; QL (1000 per 30 days) diclofenac-misoprostol oral tablet, ir, delayed 2 MO release, biphasic diflunisal oral tablet 2 MO ec-naproxen oral tablet,delayed release (dr/ec) 1 375 mg ec-naproxen oral tablet,delayed release (dr/ec) 1 MO 500 mg etodolac oral capsule 2 MO etodolac oral tablet 2 MO etodolac oral tablet extended release 24 hr 2 MO fenoprofen oral tablet 2 MO flurbiprofen oral tablet 100 mg 2 MO ibu oral tablet 1 MO ibuprofen oral suspension 2 MO ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 34

Drug Name Drug Tier Requirements/Limits indomethacin oral capsule 2 MO indomethacin oral capsule, extended release 2 MO ketoprofen oral capsule 50 mg, 75 mg 2 LUCEMYRA ORAL TABLET 5 PA; MO meloxicam oral tablet 1 MO nabumetone oral tablet 2 MO nalbuphine injection solution 10 mg/ml 2 B/D PA; MO; QL (200 per 30 days) nalbuphine injection solution 20 mg/ml 2 B/D PA; MO; QL (100 per 30 days) naloxone injection solution 1 MO naloxone injection syringe 1 MO naltrexone oral tablet 2 MO naproxen oral suspension 4 MO naproxen oral tablet 1 MO naproxen oral tablet,delayed release (dr/ec) 375 1 MO mg naproxen oral tablet,delayed release (dr/ec) 500 1 mg NARCAN NASAL SPRAY,NON-AEROSOL 4 MO oxaprozin oral tablet 2 MO PENNSAID TOPICAL SOLUTION IN 4 PA; MO METERED-DOSE PUMP piroxicam oral capsule 2 MO sulindac oral tablet 2 MO tolmetin oral capsule 2 MO tolmetin oral tablet 600 mg 2 MO tramadol oral tablet 50 mg 2 MO; QL (240 per 30 days) tramadol oral tablet extended release 24 hr 2 MO; QL (30 per 30 days) tramadol oral tablet, er multiphase 24 hr 2 MO; QL (30 per 30 days) tramadol-acetaminophen oral tablet 2 MO; QL (240 per 30 days) VIVITROL INTRAMUSCULAR SUSPENSION, 4 MO EXTENDED RELEASE RECON PSYCHOTHERAPEUTIC DRUGS ABILIFY MAINTENA INTRAMUSCULAR 5 MO SUSPENSION, EXTENDED RELEASE RECON Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits ABILIFY MAINTENA INTRAMUSCULAR 5 MO SUSPENSION, EXTENDED RELEASE SYRINGE alprazolam oral tablet 2 MO alprazolam oral tablet extended release 24 hr 2 PA; MO alprazolam oral tablet,disintegrating 2 MO amitriptyline oral tablet 2 PA; MO amoxapine oral tablet 2 MO aripiprazole oral solution 4 MO aripiprazole oral tablet 4 MO; QL (30 per 30 days) aripiprazole oral tablet,disintegrating 4 MO; QL (60 per 30 days) ARISTADA INITIO INTRAMUSCULAR 5 MO SUSPENSION,EXTENDED REL SYRING ARISTADA INTRAMUSCULAR SUSPENSION, 5 MO EXTENDED RELEASE SYRINGE armodafinil oral tablet 150 mg, 200 mg, 250 mg 4 PA; MO; QL (30 per 30 days) armodafinil oral tablet 50 mg 4 PA; MO; QL (90 per 30 days) asenapine maleate sublingual tablet 4 MO; QL (60 per 30 days) atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 2 MO; QL (60 per 30 days) mg atomoxetine oral capsule 100 mg, 60 mg, 80 mg 2 MO; QL (30 per 30 days) bupropion hcl oral tablet 2 MO bupropion hcl oral tablet extended release 24 hr 2 MO 150 mg, 300 mg bupropion hcl oral tablet sustained-release 12 hr 2 MO buspirone oral tablet 2 MO CAPLYTA ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) chlorpromazine injection solution 2 MO chlorpromazine oral tablet 2 MO citalopram oral solution 2 MO citalopram oral tablet 1 MO clomipramine oral capsule 2 PA; MO clonidine hcl oral tablet extended release 12 hr 2 MO; QL (120 per 30 days) clorazepate dipotassium oral tablet 2 PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 36

Drug Name Drug Tier Requirements/Limits clozapine oral tablet 2 clozapine oral tablet,disintegrating 100 mg, 12.5 2 mg, 25 mg clozapine oral tablet,disintegrating 150 mg, 200 4 mg desipramine oral tablet 2 MO desvenlafaxine succinate oral tablet extended 2 MO release 24 hr dexmethylphenidate oral capsule,er biphasic 50- 2 MO; QL (60 per 30 days) 50 10 mg, 15 mg, 20 mg, 5 mg dexmethylphenidate oral capsule,er biphasic 50- 2 MO; QL (30 per 30 days) 50 30 mg, 40 mg dexmethylphenidate oral tablet 10 mg 2 MO; QL (60 per 30 days) dexmethylphenidate oral tablet 2.5 mg, 5 mg 2 MO; QL (120 per 30 days) dextroamphetamine oral capsule, extended release 2 MO; QL (180 per 30 days) 10 mg, 5 mg dextroamphetamine oral capsule, extended release 2 MO; QL (120 per 30 days) 15 mg dextroamphetamine oral tablet 2 MO; QL (180 per 30 days) dextroamphetamine-amphetamine oral 4 MO; QL (30 per 30 days) capsule,extended release 24hr dextroamphetamine-amphetamine oral tablet 2 MO; QL (90 per 30 days) diazepam intensol oral concentrate 2 PA diazepam oral concentrate 2 PA; MO diazepam oral solution 5 mg/5 ml (1 mg/ml) 2 PA; MO diazepam oral tablet 2 PA; MO doxepin oral capsule 2 PA; MO doxepin oral concentrate 2 PA; MO DRIZALMA SPRINKLE ORAL CAPSULE, 4 PA; MO DELAYED REL SPRINKLE duloxetine oral capsule,delayed release(dr/ec) 2 MO EMSAM TRANSDERMAL PATCH 24 HOUR 4 PA; MO; QL (30 per 30 days) ergoloid oral tablet 2 MO escitalopram oxalate oral solution 2 MO escitalopram oxalate oral tablet 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits eszopiclone oral tablet 2 MO; QL (30 per 30 days) FANAPT ORAL TABLET 4 MO; QL (60 per 30 days) FANAPT ORAL TABLETS,DOSE PACK 4 MO; QL (8 per 28 days) FETZIMA ORAL CAPSULE, EXTENDED 4 MO; QL (30 per 30 days) RELEASE 24HR DOSE PACK FETZIMA ORAL CAPSULE,EXTENDED 4 MO; QL (30 per 30 days) RELEASE 24 HR fluoxetine (pmdd) oral tablet 2 fluoxetine oral capsule 2 MO fluoxetine oral capsule,delayed release(dr/ec) 2 MO fluoxetine oral solution 2 MO fluoxetine oral tablet 10 mg, 20 mg 2 MO fluoxetine oral tablet 60 mg 4 MO fluphenazine decanoate injection solution 2 MO fluphenazine hcl injection solution 2 MO fluphenazine hcl oral concentrate 2 MO fluphenazine hcl oral elixir 2 MO fluphenazine hcl oral tablet 2 MO fluvoxamine oral capsule,extended release 24hr 2 MO fluvoxamine oral tablet 2 MO GEODON INTRAMUSCULAR RECON SOLN 4 MO guanfacine oral tablet extended release 24 hr 2 MO; QL (30 per 30 days) haloperidol decanoate intramuscular solution 2 MO haloperidol lactate injection solution 2 MO haloperidol lactate oral concentrate 1 MO haloperidol oral tablet 2 MO HETLIOZ LQ ORAL SUSPENSION 5 PA; MO HETLIOZ ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) imipramine hcl oral tablet 2 PA; MO imipramine pamoate oral capsule 2 PA; MO INVEGA SUSTENNA INTRAMUSCULAR 5 MO SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits INVEGA SUSTENNA INTRAMUSCULAR 4 MO SYRINGE 39 MG/0.25 ML, 78 MG/0.5 ML LATUDA ORAL TABLET 4 MO lithium carbonate oral capsule 1 MO lithium carbonate oral tablet 1 MO lithium carbonate oral tablet extended release 1 MO lithium citrate oral solution 8 meq/5 ml 2 MO lorazepam intensol oral concentrate 2 PA lorazepam oral concentrate 2 PA; MO lorazepam oral tablet 2 PA; MO loxapine succinate oral capsule 2 MO maprotiline oral tablet 2 MO MARPLAN ORAL TABLET 4 MO methamphetamine oral tablet 2 PA; MO; QL (150 per 30 days) methylphenidate hcl oral capsule, er biphasic 30- 2 MO; QL (60 per 30 days) 70 10 mg, 20 mg, 30 mg methylphenidate hcl oral capsule, er biphasic 30- 2 MO; QL (30 per 30 days) 70 40 mg, 50 mg, 60 mg methylphenidate hcl oral capsule,er biphasic 50- 2 MO; QL (180 per 30 days) 50 10 mg methylphenidate hcl oral capsule,er biphasic 50- 2 MO; QL (90 per 30 days) 50 20 mg methylphenidate hcl oral capsule,er biphasic 50- 2 MO; QL (60 per 30 days) 50 30 mg methylphenidate hcl oral solution 2 MO methylphenidate hcl oral tablet 10 mg, 5 mg 2 MO; QL (180 per 30 days) methylphenidate hcl oral tablet 20 mg 2 MO; QL (90 per 30 days) methylphenidate hcl oral tablet extended release 2 MO; QL (90 per 30 days) methylphenidate hcl oral tablet extended release 2 MO; QL (120 per 30 days) 24hr 18 mg methylphenidate hcl oral tablet extended release 2 QL (120 per 30 days) 24hr 18 mg (bx rating) methylphenidate hcl oral tablet extended release 2 MO; QL (60 per 30 days) 24hr 36 mg

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits methylphenidate hcl oral tablet extended release 2 QL (60 per 30 days) 24hr 36 mg (bx rating) methylphenidate hcl oral tablet extended release 2 MO; QL (30 per 30 days) 24hr 54 mg methylphenidate hcl oral tablet extended release 2 QL (30 per 30 days) 24hr 54 mg (bx rating) mirtazapine oral tablet 2 MO mirtazapine oral tablet,disintegrating 30 mg, 45 2 MO mg modafinil oral tablet 100 mg 2 PA; MO; QL (30 per 30 days) modafinil oral tablet 200 mg 2 PA; MO; QL (60 per 30 days) molindone oral tablet 2 MO nefazodone oral tablet 2 MO nortriptyline oral capsule 2 MO nortriptyline oral solution 2 MO NUPLAZID ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) NUPLAZID ORAL TABLET 10 MG 5 PA; MO; QL (30 per 30 days) olanzapine intramuscular recon soln 2 MO olanzapine oral tablet 2 MO olanzapine oral tablet,disintegrating 2 MO olanzapine-fluoxetine oral capsule 2 MO oxazepam oral capsule 2 PA; MO paliperidone oral tablet extended release 24hr 1.5 4 MO; QL (30 per 30 days) mg, 3 mg paliperidone oral tablet extended release 24hr 6 4 MO; QL (60 per 30 days) mg paliperidone oral tablet extended release 24hr 9 5 MO; QL (30 per 30 days) mg paroxetine hcl oral tablet 1 MO paroxetine hcl oral tablet extended release 24 hr 2 MO paroxetine mesylate(menop.sym) oral capsule 2 MO PAXIL ORAL SUSPENSION 4 MO perphenazine oral tablet 2 MO perphenazine-amitriptyline oral tablet 2 PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits phenelzine oral tablet 2 MO pimozide oral tablet 2 MO protriptyline oral tablet 2 MO quetiapine oral tablet 2 MO quetiapine oral tablet extended release 24 hr 4 MO ramelteon oral tablet 4 MO; QL (30 per 30 days) REXULTI ORAL TABLET 5 MO RISPERDAL CONSTA INTRAMUSCULAR 3 MO SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML RISPERDAL CONSTA INTRAMUSCULAR 5 MO SUSPENSION,EXTENDED REL RECON 37.5 MG/2 ML, 50 MG/2 ML risperidone oral solution 2 MO risperidone oral tablet 2 MO risperidone oral tablet,disintegrating 2 MO SAPHRIS SUBLINGUAL TABLET 4 MO; QL (60 per 30 days) SECUADO TRANSDERMAL PATCH 24 HOUR 5 PA; MO; QL (30 per 30 days) sertraline oral concentrate 2 MO sertraline oral tablet 1 MO temazepam oral capsule 2 MO thioridazine oral tablet 2 MO thiothixene oral capsule 1 MO tranylcypromine oral tablet 2 MO trazodone oral tablet 2 MO trifluoperazine oral tablet 2 MO trimipramine oral capsule 2 PA; MO TRINTELLIX ORAL TABLET 4 MO venlafaxine oral capsule,extended release 24hr 2 MO venlafaxine oral tablet 2 MO venlafaxine oral tablet extended release 24hr 150 2 MO mg, 37.5 mg, 75 mg venlafaxine oral tablet extended release 24hr 225 4 MO mg

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits VERSACLOZ ORAL SUSPENSION 5 VIIBRYD ORAL TABLET 3 MO VIIBRYD ORAL TABLETS,DOSE PACK 10 3 MO; QL (30 per 30 days) MG (7)- 20 MG (23) VRAYLAR ORAL CAPSULE 1.5 MG 5 PA; MO; QL (120 per 30 days) VRAYLAR ORAL CAPSULE 3 MG 5 PA; MO; QL (60 per 30 days) VRAYLAR ORAL CAPSULE 4.5 MG 5 PA; MO; QL (40 per 30 days) VRAYLAR ORAL CAPSULE 6 MG 5 PA; MO; QL (30 per 30 days) VRAYLAR ORAL CAPSULE,DOSE PACK 4 PA; MO; QL (7 per 180 days) XYREM ORAL SOLUTION 5 PA; LA; QL (540 per 30 days) ziprasidone hcl oral capsule 2 MO ziprasidone mesylate intramuscular recon soln 4 zolpidem oral tablet 2 MO; QL (30 per 30 days) zolpidem oral tablet, extended release multiphase 2 MO; QL (30 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR 4 MO SUSPENSION FOR RECONSTITUTION CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone intravenous solution 2 B/D PA; MO amiodarone oral tablet 100 mg, 400 mg 2 amiodarone oral tablet 200 mg 2 MO dofetilide oral capsule 2 MO flecainide oral tablet 2 MO lidocaine (pf) intravenous solution 2 mexiletine oral capsule 2 MO MULTAQ ORAL TABLET 3 MO; QL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg 2 MO procainamide injection solution 2 propafenone oral capsule,extended release 12 hr 2 MO propafenone oral tablet 2 MO quinidine gluconate oral tablet extended release 2 MO quinidine sulfate oral tablet 2 MO sorine oral tablet 120 mg, 160 mg, 80 mg 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits sorine oral tablet 240 mg 2 sotalol af oral tablet 2 sotalol oral tablet 2 MO ANTIHYPERTENSIVE THERAPY acebutolol oral capsule 1 MO aliskiren oral tablet 4 MO amiloride oral tablet 2 MO amiloride-hydrochlorothiazide oral tablet 1 MO amlodipine oral tablet 1 MO amlodipine-benazepril oral capsule 1 MO amlodipine-olmesartan oral tablet 2 MO amlodipine-valsartan oral tablet 2 MO amlodipine-valsartan-hydrochlorothiazide oral 2 MO tablet atenolol oral tablet 1 MO atenolol-chlorthalidone oral tablet 1 MO benazepril oral tablet 1 MO; QL (60 per 30 days) benazepril-hydrochlorothiazide oral tablet 1 MO betaxolol oral tablet 2 MO bisoprolol fumarate oral tablet 2 MO bisoprolol-hydrochlorothiazide oral tablet 2 MO bumetanide injection solution 2 MO bumetanide oral tablet 2 MO BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 5 3 MO; QL (30 per 30 days) MG BYSTOLIC ORAL TABLET 20 MG 3 MO; QL (60 per 30 days) candesartan oral tablet 2 MO candesartan-hydrochlorothiazide oral tablet 2 MO captopril oral tablet 1 MO captopril-hydrochlorothiazide oral tablet 2 MO cartia xt oral capsule,extended release 24hr 2 MO carvedilol oral tablet 1 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits carvedilol phosphate oral capsule, er multiphase 4 ST 24 hr chlorothiazide sodium intravenous recon soln 2 MO chlorthalidone oral tablet 25 mg, 50 mg 2 MO clonidine hcl oral tablet 1 MO clonidine transdermal patch weekly 4 MO DEMSER ORAL CAPSULE 5 PA; MO diltiazem hcl intravenous recon soln 2 B/D PA diltiazem hcl intravenous solution 2 B/D PA diltiazem hcl oral capsule,ext.rel 24h degradable 2 MO diltiazem hcl oral capsule,extended release 12 hr 2 MO diltiazem hcl oral capsule,extended release 24 hr 2 MO diltiazem hcl oral capsule,extended release 24hr 2 120 mg, 180 mg, 240 mg, 300 mg diltiazem hcl oral capsule,extended release 24hr 2 MO 360 mg diltiazem hcl oral tablet 2 MO diltiazem hcl oral tablet extended release 24 hr 2 dilt-xr oral capsule, extended release 24h 2 MO degradable doxazosin oral tablet 1 mg, 2 mg, 4 mg 2 MO; QL (30 per 30 days) doxazosin oral tablet 8 mg 2 MO; QL (60 per 30 days) enalapril maleate oral tablet 1 MO enalapril-hydrochlorothiazide oral tablet 1 MO eplerenone oral tablet 2 MO felodipine oral tablet extended release 24 hr 1 MO fosinopril oral tablet 1 MO fosinopril-hydrochlorothiazide oral tablet 1 MO furosemide injection syringe 2 B/D PA; MO furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 1 MO mg/ml) furosemide oral tablet 1 MO hydralazine injection solution 2 B/D PA; MO hydralazine oral tablet 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 44

Drug Name Drug Tier Requirements/Limits hydrochlorothiazide oral capsule 1 MO hydrochlorothiazide oral tablet 1 MO indapamide oral tablet 1 MO irbesartan oral tablet 1 MO irbesartan-hydrochlorothiazide oral tablet 1 MO isradipine oral capsule 2 MO labetalol intravenous solution 2 B/D PA labetalol intravenous syringe 20 mg/4 ml (5 2 B/D PA mg/ml) labetalol oral tablet 2 MO lisinopril oral tablet 10 mg, 20 mg, 30 mg, 40 mg, 1 MO; QL (60 per 30 days) 5 mg lisinopril oral tablet 2.5 mg 1 MO lisinopril-hydrochlorothiazide oral tablet 1 MO losartan oral tablet 100 mg 1 MO; QL (45 per 30 days) losartan oral tablet 25 mg, 50 mg 1 MO; QL (60 per 30 days) losartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days) matzim la oral tablet extended release 24 hr 2 MO methyldopa-hydrochlorothiazide oral tablet 2 PA; MO metolazone oral tablet 2 MO metoprolol succinate oral tablet extended release 2 MO 24 hr metoprolol tartrate intravenous solution 1 B/D PA metoprolol tartrate oral tablet 1 MO metoprolol tartrate-hydrochlorothiazide oral 2 MO tablet metyrosine oral capsule 5 PA; MO minoxidil oral tablet 2 MO moexipril oral tablet 2 MO nadolol oral tablet 2 MO nadolol-bendroflumethiazide oral tablet 80-5 mg 2 MO nicardipine intravenous solution 2 nicardipine oral capsule 2 MO nifedipine oral tablet extended release 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 45

Drug Name Drug Tier Requirements/Limits nifedipine oral tablet extended release 24hr 2 MO nimodipine oral capsule 2 MO olmesartan oral tablet 1 MO; QL (30 per 30 days) olmesartan-amlodipine-hydrochlorothiazide oral 2 MO tablet olmesartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days) perindopril erbumine oral tablet 2 MO phenoxybenzamine oral capsule 5 PA; MO pindolol oral tablet 2 MO prazosin oral capsule 2 MO propranolol intravenous solution 2 B/D PA propranolol oral capsule,extended release 24 hr 2 MO propranolol oral solution 2 MO propranolol oral tablet 2 MO propranolol-hydrochlorothiazide oral tablet 2 MO quinapril oral tablet 1 MO quinapril-hydrochlorothiazide oral tablet 1 MO ramipril oral capsule 1 MO spironolactone oral tablet 2 MO spironolactone-hydrochlorothiazide oral tablet 2 MO taztia xt oral capsule,extended release 24 hr 2 MO TEKTURNA HCT ORAL TABLET 4 MO telmisartan oral tablet 2 MO telmisartan-hydrochlorothiazide oral tablet 2 MO terazosin oral capsule 1 mg, 2 mg, 5 mg 1 MO; QL (30 per 30 days) terazosin oral capsule 10 mg 1 MO; QL (60 per 30 days) tiadylt er oral capsule,extended release 24 hr 2 MO timolol maleate oral tablet 2 MO torsemide oral tablet 2 MO trandolapril oral tablet 2 MO trandolapril-verapamil oral tablet, ir - er, biphasic 2 MO 24hr treprostinil sodium injection solution 5 B/D PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits triamterene-hydrochlorothiazide oral capsule 2 MO 37.5-25 mg triamterene-hydrochlorothiazide oral tablet 2 MO UPTRAVI ORAL TABLET 5 PA; MO; LA; QL (60 per 30 days) UPTRAVI ORAL TABLETS,DOSE PACK 5 PA; MO; LA valsartan oral tablet 160 mg, 40 mg, 80 mg 1 MO; QL (60 per 30 days) valsartan oral tablet 320 mg 1 MO; QL (30 per 30 days) valsartan-hydrochlorothiazide oral tablet 1 MO; QL (30 per 30 days) verapamil intravenous solution 1 B/D PA verapamil intravenous syringe 2 B/D PA verapamil oral capsule, 24 hr er pellet ct 2 MO verapamil oral capsule, extended release pellets 2 MO 24 hr verapamil oral tablet 1 MO verapamil oral tablet extended release 2 MO COAGULATION THERAPY aspirin-dipyridamole oral capsule, er multiphase 4 MO 12 hr BRILINTA ORAL TABLET 3 MO cilostazol oral tablet 2 MO clopidogrel oral tablet 300 mg 2 MO; QL (1 per 30 days) clopidogrel oral tablet 75 mg 2 MO ELIQUIS DVT-PE TREAT 30D START ORAL 3 MO TABLETS,DOSE PACK ELIQUIS ORAL TABLET 3 MO enoxaparin subcutaneous solution 4 MO; QL (180 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 4 MO; QL (60 per 30 days) mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 4 MO; QL (48 per 30 days) 80 mg/0.8 ml enoxaparin subcutaneous syringe 30 mg/0.3 ml 4 MO; QL (18 per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml 4 MO; QL (24 per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml 4 MO; QL (36 per 30 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml 5 MO; QL (24 per 30 days)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits fondaparinux subcutaneous syringe 2.5 mg/0.5 ml 4 MO; QL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml 5 MO; QL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml 5 MO; QL (18 per 30 days) FRAGMIN SUBCUTANEOUS SOLUTION 4 MO; QL (30 per 30 days) FRAGMIN SUBCUTANEOUS SYRINGE 10,000 5 MO; QL (30 per 30 days) ANTI-XA UNIT/ML FRAGMIN SUBCUTANEOUS SYRINGE 12,500 5 MO; QL (15 per 30 days) ANTI-XA UNIT/0.5 ML FRAGMIN SUBCUTANEOUS SYRINGE 15,000 5 MO; QL (18 per 30 days) ANTI-XA UNIT/0.6 ML FRAGMIN SUBCUTANEOUS SYRINGE 18,000 5 MO; QL (21.6 per 30 days) ANTI-XA UNIT/0.72 ML FRAGMIN SUBCUTANEOUS SYRINGE 2,500 4 MO; QL (6 per 30 days) ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML FRAGMIN SUBCUTANEOUS SYRINGE 7,500 5 MO; QL (9 per 30 days) ANTI-XA UNIT/0.3 ML heparin (porcine) in 5 % dex intravenous 2 parenteral solution 20,000 unit/500 ml (40 unit/ml) heparin (porcine) in 5 % dex intravenous 2 MO parenteral solution 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in nacl (pf) intravenous 2 parenteral solution heparin (porcine) injection cartridge 2 MO heparin (porcine) injection solution 2 B/D PA; MO HEPARIN(PORCINE) IN 0.45% NACL 4 INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML heparin(porcine) in 0.45% nacl intravenous 2 MO parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml heparin, porcine (pf) injection solution 1,000 2 unit/ml heparin, porcine (pf) injection solution 5,000 2 MO unit/0.5 ml

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits heparin, porcine (pf) injection syringe 5,000 2 MO unit/0.5 ml jantoven oral tablet 3 MO MULPLETA ORAL TABLET 5 PA; MO; QL (7 per 14 days) pentoxifylline oral tablet extended release 2 MO PRADAXA ORAL CAPSULE 4 MO prasugrel oral tablet 2 MO PROMACTA ORAL POWDER IN PACKET 5 PA; MO; LA PROMACTA ORAL TABLET 5 PA; MO; LA warfarin oral tablet 1 MO XARELTO DVT-PE TREAT 30D START ORAL 3 MO TABLETS,DOSE PACK XARELTO ORAL TABLET 3 MO LIPID/CHOLESTEROL LOWERING AGENTS amlodipine-atorvastatin oral tablet 2 MO; QL (30 per 30 days) atorvastatin oral tablet 1 MO; QL (45 per 30 days) cholestyramine (with sugar) oral powder 2 MO cholestyramine (with sugar) oral powder in packet 2 MO cholestyramine light oral powder 2 cholestyramine light oral powder in packet 2 colesevelam oral powder in packet 2 MO colesevelam oral tablet 2 MO colestipol oral granules 2 MO colestipol oral packet 2 MO colestipol oral tablet 2 MO ezetimibe oral tablet 2 MO; QL (30 per 30 days) ezetimibe-simvastatin oral tablet 2 MO; QL (30 per 30 days) fenofibrate micronized oral capsule 2 MO fenofibrate nanocrystallized oral tablet 145 mg, 48 2 MO mg fenofibrate oral tablet 160 mg, 54 mg 2 MO fenofibric acid (choline) oral capsule,delayed 2 MO release(dr/ec)

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits fenofibric acid oral tablet 2 MO gemfibrozil oral tablet 1 MO icosapent ethyl oral capsule 4 MO; QL (120 per 30 days) JUXTAPID ORAL CAPSULE 5 PA; MO; LA lovastatin oral tablet 10 mg, 20 mg 1 MO; QL (45 per 30 days) lovastatin oral tablet 40 mg 1 MO; QL (60 per 30 days) niacin oral tablet extended release 24 hr 2 omega-3 acid ethyl esters oral capsule 2 MO PRALUENT SUBCUTANEOUS PEN 4 PA; QL (2 per 28 days) INJECTOR 150 MG/ML PRALUENT SUBCUTANEOUS PEN 4 PA; QL (4 per 28 days) INJECTOR 75 MG/ML pravastatin oral tablet 1 MO; QL (45 per 30 days) prevalite oral powder 2 MO prevalite oral powder in packet 2 MO REPATHA PUSHTRONEX SUBCUTANEOUS 4 PA; QL (3.5 per 28 days) WEARABLE INJECTOR REPATHA SUBCUTANEOUS SYRINGE 4 PA; QL (3 per 28 days) REPATHA SURECLICK SUBCUTANEOUS 4 PA; QL (3 per 28 days) PEN INJECTOR rosuvastatin oral tablet 1 MO; QL (30 per 30 days) simvastatin oral tablet 1 MO; QL (30 per 30 days) VASCEPA ORAL CAPSULE 0.5 GRAM 4 MO; QL (240 per 30 days) VASCEPA ORAL CAPSULE 1 GRAM 4 MO; QL (120 per 30 days) MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL SOLUTION 4 PA CORLANOR ORAL TABLET 4 PA; MO digitek oral tablet 125 mcg (0.125 mg) 1 MO digitek oral tablet 250 mcg (0.25 mg) 1 PA; MO digox oral tablet 125 mcg (0.125 mg) 1 MO digox oral tablet 250 mcg (0.25 mg) 1 PA; MO digoxin injection solution 2 digoxin oral solution 2 PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits digoxin oral tablet 125 mcg (0.125 mg) 1 MO digoxin oral tablet 250 mcg (0.25 mg) 1 PA; MO ENTRESTO ORAL TABLET 3 MO LANOXIN ORAL TABLET 125 MCG (0.125 4 MO MG), 62.5 MCG (0.0625 MG) LANOXIN ORAL TABLET 250 MCG (0.25 MG) 4 PA; MO ranolazine oral tablet extended release 12 hr 4 MO VECAMYL ORAL TABLET 4 VYNDAMAX ORAL CAPSULE 5 PA; MO; QL (30 per 30 days) VYNDAQEL ORAL CAPSULE 5 PA; MO; QL (120 per 30 days) NITRATES isosorbide dinitrate oral tablet 2 MO isosorbide mononitrate oral tablet 1 MO isosorbide mononitrate oral tablet extended 1 MO release 24 hr nitro-bid transdermal ointment 2 MO nitroglycerin intravenous solution 2 B/D PA nitroglycerin sublingual tablet 2 MO nitroglycerin transdermal patch 24 hour 2 MO nitroglycerin translingual spray,non-aerosol 2 MO DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule 10 mg, 25 mg 4 MO acitretin oral capsule 17.5 mg 5 MO calcipotriene scalp solution 2 MO; QL (60 per 30 days) calcipotriene topical cream 2 MO; QL (120 per 30 days) calcipotriene topical ointment 2 MO; QL (120 per 30 days) calcipotriene-betamethasone topical ointment 4 MO calcitriol topical ointment 2 COSENTYX (2 SYRINGES) SUBCUTANEOUS 5 PA; MO; QL (2 per 28 days) SYRINGE COSENTYX (2 PENS) SUBCUTANEOUS PEN 5 PA; MO; QL (2 per 28 days) INJECTOR

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Drug Name Drug Tier Requirements/Limits COSENTYX SUBCUTANEOUS PEN 5 PA; MO; QL (2 per 28 days) INJECTOR COSENTYX SUBCUTANEOUS SYRINGE 150 5 PA; MO; QL (2 per 28 days) MG/ML COSENTYX SUBCUTANEOUS SYRINGE 75 5 PA; MO; QL (2.5 per 28 days) MG/0.5 ML selenium sulfide topical lotion 2 MO SKYRIZI SUBCUTANEOUS PEN INJECTOR 5 PA; QL (2 per 30 days) SKYRIZI SUBCUTANEOUS SYRINGE 150 5 PA; QL (2 per 30 days) MG/ML SKYRIZI SUBCUTANEOUS SYRINGE KIT 5 PA; MO; QL (1 per 84 days) STELARA SUBCUTANEOUS SOLUTION 5 PA; MO; QL (1 per 84 days) STELARA SUBCUTANEOUS SYRINGE 45 5 PA; MO; QL (1 per 84 days) MG/0.5 ML STELARA SUBCUTANEOUS SYRINGE 90 5 PA; MO; QL (3 per 84 days) MG/ML MISCELLANEOUS DERMATOLOGICALS ammonium lactate topical cream 2 MO ammonium lactate topical lotion 2 MO diclofenac sodium topical gel 3 % 4 PA; MO; QL (100 per 30 days) DUPIXENT PEN SUBCUTANEOUS PEN 5 PA; MO INJECTOR 300 MG/2 ML DUPIXENT SUBCUTANEOUS SYRINGE 5 PA; MO fluorouracil topical cream 5 % 2 MO fluorouracil topical solution 2 MO imiquimod topical cream in packet 5 % 2 MO lidocaine (pf) injection solution 2 lidocaine hcl injection solution 2 lidocaine hcl laryngotracheal solution 2 MO lidocaine hcl mucous membrane jelly 2 MO lidocaine hcl mucous membrane jelly in applicator 2 MO lidocaine hcl mucous membrane solution 2 % 2 lidocaine hcl mucous membrane solution 4 % (40 2 MO mg/ml) lidocaine topical adhesive patch,medicated 5 % 2 PA; MO; QL (90 per 30 days) Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits lidocaine topical ointment 2 MO; QL (50 per 30 days) lidocaine viscous mucous membrane solution 2 MO lidocaine-prilocaine topical cream 2 MO; QL (30 per 30 days) methoxsalen oral capsule, liquid-filled, rapid 2 MO release PANRETIN TOPICAL GEL 5 PA; MO pimecrolimus topical cream 4 ST; MO podofilox topical solution 2 MO REGRANEX TOPICAL GEL 5 PA; MO; QL (30 per 30 days) SANTYL TOPICAL OINTMENT 4 MO silver sulfadiazine topical cream 2 MO ssd topical cream 2 MO tacrolimus topical ointment 4 MO VALCHLOR TOPICAL GEL 5 PA; MO THERAPY FOR ACNE adapalene topical cream 2 PA; MO adapalene topical gel 2 PA; MO adapalene topical gel with pump 2 PA; MO adapalene topical solution 2 PA amnesteem oral capsule 2 claravis oral capsule 4 clindamycin phosphate topical foam 2 clindamycin phosphate topical gel 2 MO CLINDAMYCIN PHOSPHATE TOPICAL GEL, 2 ONCE DAILY clindamycin phosphate topical lotion 2 MO clindamycin phosphate topical solution 2 MO clindamycin phosphate topical swab 2 MO clindamycin-benzoyl peroxide topical gel 2 MO clindamycin-benzoyl peroxide topical gel with 2 MO pump 1-5 % ery pads topical swab 2 MO erythromycin with ethanol topical gel 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits erythromycin with ethanol topical solution 2 MO erythromycin-benzoyl peroxide topical gel 2 MO metronidazole topical cream 2 MO metronidazole topical gel 2 MO metronidazole topical gel with pump 2 MO metronidazole topical lotion 2 MO tazarotene topical cream 4 MO tretinoin microspheres topical gel 2 PA; MO tretinoin microspheres topical gel with pump 2 PA; MO tretinoin topical cream 2 PA; MO tretinoin topical gel 0.01 %, 0.025 % 2 PA; MO TOPICAL ANTIBACTERIALS gentamicin topical cream 2 MO gentamicin topical ointment 2 MO mupirocin topical ointment 2 MO sulfacetamide sodium (acne) topical suspension 2 MO SULFAMYLON TOPICAL CREAM 4 MO TOPICAL ANTIFUNGALS ciclopirox topical cream 2 MO ciclopirox topical gel 2 MO ciclopirox topical shampoo 2 MO ciclopirox topical solution 2 MO ciclopirox topical suspension 2 MO clotrimazole topical cream 2 MO clotrimazole-betamethasone topical cream 2 MO clotrimazole-betamethasone topical lotion 2 MO econazole topical cream 2 MO ketoconazole topical cream 2 MO ketoconazole topical shampoo 2 MO nyamyc topical powder 2 MO nystatin topical cream 2 MO nystatin topical ointment 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits nystatin topical powder 2 nystatin-triamcinolone topical cream 2 MO nystatin-triamcinolone topical ointment 2 MO nystop topical powder 2 MO TOPICAL ANTIVIRALS acyclovir topical ointment 2 MO DENAVIR TOPICAL CREAM 5 MO; QL (5 per 30 days) TOPICAL CORTICOSTEROIDS ala-cort topical cream 1 % 2 MO ala-cort topical cream 2.5 % 2 alclometasone topical cream 2 MO alclometasone topical ointment 2 MO amcinonide topical cream 2 MO amcinonide topical lotion 2 MO amcinonide topical ointment 2 betamethasone dipropionate topical cream 2 MO betamethasone dipropionate topical lotion 2 MO betamethasone dipropionate topical ointment 2 MO betamethasone valerate topical cream 2 MO betamethasone valerate topical foam 2 MO betamethasone valerate topical lotion 2 MO betamethasone valerate topical ointment 2 MO betamethasone, augmented topical cream 2 MO betamethasone, augmented topical gel 2 MO betamethasone, augmented topical lotion 2 MO desoximetasone topical cream 4 MO desoximetasone topical gel 4 MO desoximetasone topical ointment 4 MO fluocinolone and shower cap scalp oil 2 MO fluocinolone topical oil 2 MO fluocinolone topical ointment 2 MO fluocinolone topical solution 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits fluticasone propionate topical cream 2 MO fluticasone propionate topical lotion 2 MO fluticasone propionate topical ointment 2 MO hydrocortisone butyrate topical cream 2 MO hydrocortisone butyrate topical ointment 2 MO hydrocortisone butyrate topical solution 2 MO hydrocortisone butyr-emollient topical cream 2 MO hydrocortisone topical cream 1 %, 2.5 % 2 MO hydrocortisone topical lotion 2.5 % 2 MO hydrocortisone topical ointment 2.5 % 2 MO hydrocortisone valerate topical cream 4 MO hydrocortisone valerate topical ointment 4 MO mometasone topical cream 2 MO mometasone topical ointment 2 MO mometasone topical solution 2 MO prednicarbate topical ointment 2 MO triamcinolone acetonide topical aerosol 2 MO triamcinolone acetonide topical cream 2 MO triamcinolone acetonide topical lotion 2 MO triamcinolone acetonide topical ointment 0.025 %, 2 MO 0.1 %, 0.5 % triderm topical cream 0.1 % 2 MO TOPICAL SCABICIDES / PEDICULICIDES lindane topical shampoo 2 MO malathion topical lotion 2 MO permethrin topical cream 2 MO DIAGNOSTICS / MISCELLANEOUS AGENTS IRRIGATING SOLUTIONS neomycin-polymyxin b gu irrigation solution 2 MO MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec) 2 MO anagrelide oral capsule 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits ARALAST NP INTRAVENOUS RECON SOLN 5 B/D PA; MO; LA AURYXIA ORAL TABLET 5 PA; MO cevimeline oral capsule 2 MO CHEMET ORAL CAPSULE 4 CLINIMIX 4.25%/D5W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 2.75%/D5W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION d10 %-0.45 % sodium chloride intravenous 2 parenteral solution d2.5 %-0.45 % sodium chloride intravenous 2 B/D PA parenteral solution d5 % and 0.9 % sodium chloride intravenous 2 B/D PA; MO parenteral solution d5 %-0.45 % sodium chloride intravenous 2 B/D PA; MO parenteral solution deferasirox oral tablet, dispersible 5 MO deferiprone oral tablet 5 PA; MO dextrose 10 % and 0.2 % nacl intravenous 2 B/D PA parenteral solution dextrose 10 % in water (d10w) intravenous 2 B/D PA parenteral solution dextrose 25 % in water (d25w) intravenous 2 B/D PA syringe dextrose 30 % in water (d30w) intravenous 2 B/D PA parenteral solution dextrose 5 % in water (d5w) intravenous 2 B/D PA; MO parenteral solution dextrose 5 % in water (d5w) intravenous 2 MO piggyback dextrose 5 %-lactated ringers intravenous 2 B/D PA; MO parenteral solution dextrose 5%-0.2 % sod chloride intravenous 2 B/D PA parenteral solution dextrose 5%-0.3 % sod.chloride intravenous 2 B/D PA parenteral solution

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits dextrose 50 % in water (d50w) intravenous 2 B/D PA; MO parenteral solution dextrose 50 % in water (d50w) intravenous 2 B/D PA; MO syringe dextrose 70 % in water (d70w) intravenous 2 B/D PA parenteral solution disulfiram oral tablet 2 MO droxidopa oral capsule 5 PA; MO ENDARI ORAL POWDER IN PACKET 5 PA; MO; LA; QL (180 per 30 days) EXSERVAN ORAL FILM 2 MO FERRIPROX (2 TIMES A DAY) ORAL 5 PA TABLET FERRIPROX ORAL TABLET 5 PA INCRELEX SUBCUTANEOUS SOLUTION 5 B/D PA; MO; LA lanthanum oral tablet,chewable 5 MO levocarnitine (with sugar) oral solution 2 B/D PA; MO levocarnitine oral solution 100 mg/ml 2 B/D PA; MO levocarnitine oral tablet 2 B/D PA; MO midodrine oral tablet 2 MO NORTHERA ORAL CAPSULE 5 PA; MO pilocarpine hcl oral tablet 2 MO RAVICTI ORAL LIQUID 5 PA; MO riluzole oral tablet 2 MO risedronate oral tablet 30 mg 2 MO sevelamer carbonate oral powder in packet 5 MO sevelamer carbonate oral tablet 2 MO sodium chloride 0.9 % intravenous parenteral 2 MO solution sodium chloride 0.9 % intravenous piggyback 2 MO sodium chloride irrigation solution 2 MO sodium polystyrene sulfonate oral powder 2 MO sps (with sorbitol) oral suspension 2 MO sps (with sorbitol) rectal enema 2 trientine oral capsule 5 PA; MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits zoledronic acid-mannitol-water intravenous 2 MO piggyback 5 mg/100 ml SMOKING DETERRENTS bupropion hcl (smoking deter) oral tablet extended 2 MO release 12 hr CHANTIX CONTINUING MONTH BOX ORAL 4 MO TABLET CHANTIX ORAL TABLET 4 MO CHANTIX STARTING MONTH BOX ORAL 4 MO TABLETS,DOSE PACK NICOTROL INHALATION CARTRIDGE 3 MO NICOTROL NS NASAL SPRAY,NON- 3 MO AEROSOL EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS azelastine nasal spray, aerosol 2 MO; QL (60 per 30 days) azelastine nasal spray,non-aerosol 2 MO; QL (60 per 30 days) chlorhexidine gluconate mucous membrane 2 MO mouthwash denta 5000 plus dental cream 2 MO dentagel dental gel 2 MO ipratropium bromide nasal spray,non-aerosol 21 2 MO; QL (60 per 30 days) mcg (0.03 %) ipratropium bromide nasal spray,non-aerosol 42 2 MO; QL (30 per 30 days) mcg (0.06 %) olopatadine nasal spray,non-aerosol 4 MO; QL (30.5 per 30 days) paroex oral rinse mucous membrane mouthwash 2 MO periogard mucous membrane mouthwash 2 MO sf 5000 plus dental cream 2 MO sf dental gel 2 MO triamcinolone acetonide dental paste 2 MO MISCELLANEOUS OTIC PREPARATIONS acetic acid otic (ear) solution 2 MO fluocinolone acetonide oil otic (ear) drops 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits hydrocortisone-acetic acid otic (ear) drops 2 MO ofloxacin otic (ear) drops 2 MO OTIC STEROID / ANTIBIOTIC CIPRODEX OTIC (EAR) DROPS,SUSPENSION 4 MO ciprofloxacin-dexamethasone otic (ear) 4 MO drops,suspension neomycin-polymyxin-hc otic (ear) 2 MO drops,suspension neomycin-polymyxin-hc otic (ear) solution 2 MO ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR INJECTION GEL 5 PA; MO dexamethasone intensol oral drops 2 MO dexamethasone oral elixir 2 MO dexamethasone oral solution 2 MO dexamethasone oral tablet 2 MO dexamethasone sodium phos (pf) injection solution 2 MO dexamethasone sodium phosphate injection 2 B/D PA; MO solution dexamethasone sodium phosphate injection 2 B/D PA; MO syringe fludrocortisone oral tablet 2 MO HEMADY ORAL TABLET 4 PA; MO hydrocortisone oral tablet 2 MO KENALOG INJECTION SUSPENSION 4 MO methylprednisolone acetate injection suspension 2 B/D PA; MO methylprednisolone oral tablet 2 MO methylprednisolone oral tablets,dose pack 2 MO methylprednisolone sodium succ injection recon 2 B/D PA; MO soln 125 mg, 40 mg methylprednisolone sodium succ intravenous 2 B/D PA; MO recon soln 1,000 mg millipred oral tablet 2 MO prednisolone oral solution 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits prednisolone sodium phosphate oral solution 10 2 MO mg/5 ml, 15 mg/5 ml (3 mg/ml), 20 mg/5 ml (4 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) prednisolone sodium phosphate oral solution 15 2 mg/5 ml (5 ml) prednisolone sodium phosphate oral 2 MO tablet,disintegrating prednisone intensol oral concentrate 2 MO prednisone oral solution 2 MO prednisone oral tablet 1 MO prednisone oral tablets,dose pack 1 MO SOLU-CORTEF ACT-O-VIAL (PF) INJECTION 3 B/D PA; MO RECON SOLN 1,000 MG/8 ML, 250 MG/2 ML, 500 MG/4 ML SOLU-CORTEF ACT-O-VIAL (PF) INJECTION 3 MO RECON SOLN 100 MG/2 ML triamcinolone acetonide injection suspension 40 2 MO mg/ml ANTITHYROID AGENTS methimazole oral tablet 10 mg, 5 mg 2 MO propylthiouracil oral tablet 2 MO DIABETES THERAPY acarbose oral tablet 2 MO alcohol pads topical pads, medicated 3 BASAGLAR KWIKPEN U-100 INSULIN 4 MO SUBCUTANEOUS PEN BYDUREON BCISE SUBCUTANEOUS AUTO- 3 MO; QL (4 per 28 days) INJECTOR BYETTA SUBCUTANEOUS PEN INJECTOR 3 MO; QL (2.4 per 30 days) 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 3 MO; QL (1.2 per 30 days) MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET ORAL TABLET 4 ST; MO diazoxide oral suspension 4 MO FARXIGA ORAL TABLET 3 MO; QL (30 per 30 days)

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Drug Name Drug Tier Requirements/Limits FIASP FLEXTOUCH U-100 INSULIN 3 MO SUBCUTANEOUS PEN FIASP PENFILL U-100 INSULIN 3 MO SUBCUTANEOUS CARTRIDGE FIASP U-100 INSULIN SUBCUTANEOUS 3 MO SOLUTION GAUZE PADS 2 X 2 3 glimepiride oral tablet 1 MO glipizide oral tablet 1 MO glipizide oral tablet extended release 24hr 1 MO glipizide-metformin oral tablet 2.5-250 mg, 2.5- 2 MO; QL (60 per 30 days) 500 mg glipizide-metformin oral tablet 5-500 mg 2 MO; QL (120 per 30 days) GLUCAGEN HYPOKIT INJECTION RECON 3 MO SOLN GLUCAGON (HCL) EMERGENCY KIT 3 INJECTION RECON SOLN glucagon emergency kit (human) injection recon 3 MO soln glyburide micronized oral tablet 2 ST; MO glyburide oral tablet 2 ST; MO glyburide-metformin oral tablet 2 ST; MO GVOKE HYPOPEN 1-PACK SUBCUTANEOUS 3 MO AUTO-INJECTOR GVOKE HYPOPEN 2-PACK SUBCUTANEOUS 3 MO AUTO-INJECTOR GVOKE PFS 1-PACK SUBCUTANEOUS 3 MO SYRINGE GVOKE PFS 2-PACK SUBCUTANEOUS 3 MO SYRINGE INSULIN PEN NEEDLE 3 MO INSULIN SYRINGE (DISP) U-100 SYRINGE 3 0.3 ML 29 GAUGE, 1/2 ML 28 GAUGE INSULIN SYRINGE (DISP) U-100 SYRINGE 1 3 MO ML 29 GAUGE X 1/2" JANUMET ORAL TABLET 3 MO; QL (60 per 30 days)

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Drug Name Drug Tier Requirements/Limits JANUMET XR ORAL TABLET, ER 3 MO; QL (60 per 30 days) MULTIPHASE 24 HR JANUVIA ORAL TABLET 3 MO; QL (30 per 30 days) JARDIANCE ORAL TABLET 3 MO KOMBIGLYZE XR ORAL TABLET, ER 3 MO; QL (30 per 30 days) MULTIPHASE 24 HR LANTUS SOLOSTAR U-100 INSULIN 3 MO SUBCUTANEOUS PEN LANTUS U-100 INSULIN SUBCUTANEOUS 3 MO SOLUTION LEVEMIR FLEXTOUCH U-100 INSULN 3 MO SUBCUTANEOUS INSULIN PEN LEVEMIR U-100 INSULIN SUBCUTANEOUS 3 MO SOLUTION metformin oral tablet 1 MO metformin oral tablet extended release 24 hr 500 1 MO; QL (120 per 30 days) mg metformin oral tablet extended release 24 hr 750 1 MO; QL (60 per 30 days) mg nateglinide oral tablet 2 MO NEEDLES, INSULIN DISP., SAFETY 3 MO NOVOFINE NEEDLE 3 MO NOVOLIN 70/30 U-100 INSULIN 3 MO SUBCUTANEOUS SUSPENSION NOVOLIN 70-30 FLEXPEN U-100 3 MO SUBCUTANEOUS INSULIN PEN NOVOLIN N FLEXPEN SUBCUTANEOUS 3 MO INSULIN PEN NOVOLIN N NPH U-100 INSULIN 3 MO SUBCUTANEOUS SUSPENSION NOVOLIN R FLEXPEN SUBCUTANEOUS 3 MO INSULIN PEN NOVOLIN R REGULAR U-100 INSULN 3 MO INJECTION SOLUTION NOVOLOG FLEXPEN U-100 INSULIN 3 MO SUBCUTANEOUS PEN

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits NOVOLOG MIX 70-30 U-100 INSULN 3 MO SUBCUTANEOUS SOLUTION NOVOLOG MIX 70-30FLEXPEN U-100 3 MO SUBCUTANEOUS INSULIN PEN NOVOLOG PENFILL U-100 INSULIN 3 MO SUBCUTANEOUS CARTRIDGE NOVOLOG U-100 INSULIN ASPART 3 MO SUBCUTANEOUS SOLUTION NOVOTWIST NEEDLE 3 MO ONGLYZA ORAL TABLET 3 MO; QL (30 per 30 days) OZEMPIC SUBCUTANEOUS PEN INJECTOR 3 MO; QL (1.5 per 28 days) 0.25 MG OR 0.5 MG(2 MG/1.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 3 QL (3 per 28 days) MG/DOSE (2 MG/1.5 ML) OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 3 MO; QL (3 per 28 days) MG/DOSE (4 MG/3 ML) pioglitazone oral tablet 2 MO pioglitazone-glimepiride oral tablet 2 MO; QL (30 per 30 days) pioglitazone-metformin oral tablet 2 MO; QL (90 per 30 days) repaglinide oral tablet 0.5 mg 1 MO; QL (930 per 30 days) repaglinide oral tablet 1 mg 1 MO; QL (480 per 30 days) repaglinide oral tablet 2 mg 1 MO; QL (240 per 30 days) RYBELSUS ORAL TABLET 3 MO; QL (30 per 30 days) SYMLINPEN 120 SUBCUTANEOUS PEN 4 MO INJECTOR SYMLINPEN 60 SUBCUTANEOUS PEN 4 MO INJECTOR SYNJARDY ORAL TABLET 3 MO; QL (60 per 30 days) SYNJARDY XR ORAL TABLET, IR - ER, 3 MO; QL (30 per 30 days) BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG SYNJARDY XR ORAL TABLET, IR - ER, 3 MO; QL (60 per 30 days) BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG TOUJEO MAX U-300 SOLOSTAR 3 MO SUBCUTANEOUS INSULIN PEN TOUJEO SOLOSTAR U-300 INSULIN 3 MO SUBCUTANEOUS PEN

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Drug Name Drug Tier Requirements/Limits TRESIBA FLEXTOUCH U-100 3 MO SUBCUTANEOUS INSULIN PEN TRESIBA FLEXTOUCH U-200 3 MO SUBCUTANEOUS INSULIN PEN TRESIBA U-100 INSULIN SUBCUTANEOUS 3 MO SOLUTION TRULICITY SUBCUTANEOUS PEN 3 MO; QL (4 per 28 days) INJECTOR 0.75 MG/0.5 ML TRULICITY SUBCUTANEOUS PEN 3 MO; QL (2 per 28 days) INJECTOR 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML VICTOZA 2-PAK SUBCUTANEOUS PEN 3 MO; QL (9 per 30 days) INJECTOR VICTOZA 3-PAK SUBCUTANEOUS PEN 3 MO; QL (9 per 30 days) INJECTOR XIGDUO XR ORAL TABLET, IR - ER, 3 MO; QL (30 per 30 days) BIPHASIC 24HR 10-1,000 MG, 10-500 MG, 5- 500 MG XIGDUO XR ORAL TABLET, IR - ER, 3 MO; QL (60 per 30 days) BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG MISCELLANEOUS HORMONES ALDURAZYME INTRAVENOUS SOLUTION 5 MO cabergoline oral tablet 2 MO; QL (20 per 30 days) calcitonin (salmon) injection solution 2 B/D PA; MO calcitonin (salmon) nasal spray,non-aerosol 2 MO calcitriol intravenous solution 1 mcg/ml 2 calcitriol oral capsule 2 B/D PA; MO calcitriol oral solution 2 B/D PA CEREZYME INTRAVENOUS RECON SOLN 5 MO 400 UNIT CHORIONIC GONADOTROPIN, HUMAN 4 PA; MO INTRAMUSCULAR RECON SOLN cinacalcet oral tablet 30 mg 4 B/D PA; MO; QL (60 per 30 days) cinacalcet oral tablet 60 mg 5 B/D PA; MO; QL (60 per 30 days) cinacalcet oral tablet 90 mg 5 B/D PA; MO; QL (120 per 30 days) danazol oral capsule 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits desmopressin injection solution 2 MO desmopressin nasal spray with pump 2 MO desmopressin nasal spray,non-aerosol 2 desmopressin oral tablet 2 MO ELAPRASE INTRAVENOUS SOLUTION 5 MO ELELYSO INTRAVENOUS RECON SOLN 5 MO FABRAZYME INTRAVENOUS RECON SOLN 5 PA; MO GALAFOLD ORAL CAPSULE 5 PA; MO; QL (15 per 30 days) JYNARQUE ORAL TABLET 5 PA; LA JYNARQUE ORAL TABLETS, SEQUENTIAL 5 PA; LA; QL (56 per 28 days) KORLYM ORAL TABLET 5 PA KUVAN ORAL TABLET,SOLUBLE 5 PA; MO methyltestosterone oral capsule 2 MO MIACALCIN INJECTION SOLUTION 3 B/D PA; MO miglustat oral capsule 5 PA; MO; LA NAGLAZYME INTRAVENOUS SOLUTION 5 MO NATPARA SUBCUTANEOUS CARTRIDGE 5 PA; MO; LA NOVAREL INTRAMUSCULAR RECON SOLN 4 PA; MO 10,000 UNIT ORILISSA ORAL TABLET 5 PA; MO oxandrolone oral tablet 10 mg 5 MO oxandrolone oral tablet 2.5 mg 2 MO pamidronate intravenous solution 2 B/D PA; MO PARICALCITOL HEMODIALYSIS PORT 3 B/D PA INJECTION SOLUTION paricalcitol intravenous solution 2 mcg/ml 3 B/D PA paricalcitol intravenous solution 5 mcg/ml 3 B/D PA; MO paricalcitol oral capsule 4 B/D PA; MO PREGNYL INTRAMUSCULAR RECON SOLN 4 PA; MO SAMSCA ORAL TABLET 15 MG 5 PA; MO; QL (30 per 30 days) SAMSCA ORAL TABLET 30 MG 5 PA; MO; QL (60 per 30 days) sapropterin oral tablet,soluble 5 PA; MO SOMAVERT SUBCUTANEOUS RECON SOLN 5 B/D PA; MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits SYNAREL NASAL SPRAY,NON-AEROSOL 5 MO testosterone cypionate intramuscular oil 100 2 MO mg/ml, 200 mg/ml testosterone cypionate intramuscular oil 200 2 mg/ml (1 ml) testosterone enanthate intramuscular oil 2 MO testosterone transdermal gel in metered-dose 2 MO pump 20.25 mg/1.25 gram (1.62 %) testosterone transdermal gel in packet 1.62 % 2 MO (20.25 mg/1.25 gram), 1.62 % (40.5 mg/2.5 gram) TOLVAPTAN ORAL TABLET 15 MG 5 PA; MO tolvaptan oral tablet 30 mg 5 PA; MO; QL (60 per 30 days) VPRIV INTRAVENOUS RECON SOLN 5 MO zoledronic acid intravenous solution 2 B/D PA; MO zoledronic acid-mannitol-water intravenous 5 B/D PA; MO piggyback 4 mg/100 ml THYROID HORMONES levothyroxine oral tablet 1 levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 4 MO 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg liothyronine intravenous solution 2 MO liothyronine oral tablet 2 MO SYNTHROID ORAL TABLET 4 MO unithroid oral tablet 1 MO GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine injection solution 0.4 mg/ml 2 atropine injection syringe 0.05 mg/ml, 0.1 mg/ml 2 dicyclomine oral capsule 2 MO dicyclomine oral solution 2 MO dicyclomine oral tablet 2 MO glycopyrrolate injection solution 2 MO glycopyrrolate oral tablet 1 mg, 2 mg 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits loperamide oral capsule 2 MO methscopolamine oral tablet 2 MO MISCELLANEOUS GASTROINTESTINAL AGENTS alosetron oral tablet 5 PA; MO; QL (60 per 30 days) aprepitant oral capsule 4 B/D PA; MO aprepitant oral capsule,dose pack 4 B/D PA; MO balsalazide oral capsule 2 MO budesonide oral capsule, delayed, extended 4 MO release budesonide oral tablet,delayed and ext.release 5 QL (30 per 30 days) CHOLBAM ORAL CAPSULE 5 PA compro rectal suppository 2 MO constulose oral solution 2 MO cromolyn oral concentrate 2 MO CYSTADANE ORAL POWDER 5 dronabinol oral capsule 4 B/D PA; MO EMEND ORAL SUSPENSION FOR 4 B/D PA RECONSTITUTION enulose oral solution 2 MO GATTEX 30-VIAL SUBCUTANEOUS KIT 5 PA; MO GATTEX ONE-VIAL SUBCUTANEOUS KIT 5 PA; MO gavilyte-c oral recon soln 2 MO gavilyte-g oral recon soln 2 MO gavilyte-n oral recon soln 2 MO generlac oral solution 2 MO granisetron (pf) intravenous solution 1 mg/ml (1 2 MO ml) granisetron hcl intravenous solution 2 MO granisetron hcl oral tablet 2 B/D PA; MO hydrocortisone rectal enema 2 MO hydrocortisone topical cream with perineal 2 MO applicator lactulose oral solution 10 gram/15 ml 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits lactulose oral solution 10 gram/15 ml (15 ml), 20 2 gram/30 ml LINZESS ORAL CAPSULE 3 MO; QL (30 per 30 days) meclizine oral tablet 12.5 mg, 25 mg 2 MO mesalamine oral capsule (with del rel tablets) 4 MO mesalamine oral capsule,extended release 24hr 2 mesalamine oral tablet,delayed release (dr/ec) 1.2 2 MO gram mesalamine rectal enema 2 MO mesalamine rectal suppository 4 MO mesalamine with cleansing wipe rectal enema kit 2 MO metoclopramide hcl injection solution 2 B/D PA; MO metoclopramide hcl injection syringe 2 B/D PA metoclopramide hcl oral solution 2 MO metoclopramide hcl oral tablet 1 MO MOVANTIK ORAL TABLET 3 MO MOVIPREP ORAL POWDER IN PACKET 3 MO ondansetron hcl (pf) injection solution 2 B/D PA; MO ondansetron hcl (pf) injection syringe 2 MO ondansetron hcl intravenous solution 2 MO ondansetron hcl oral solution 2 B/D PA; MO ondansetron hcl oral tablet 24 mg 2 B/D PA ondansetron hcl oral tablet 4 mg, 8 mg 2 B/D PA; MO ondansetron oral tablet,disintegrating 2 B/D PA; MO PANCREAZE ORAL CAPSULE,DELAYED 4 MO RELEASE(DR/EC) 10,500-35,500- 61,500 UNIT, 16,800-56,800- 98,400 UNIT, 2,600-8,800- 15,200 UNIT, 21,000-54,700- 83,900 UNIT, 37,000- 97,300- 149,900 UNIT, 4,200-14,200- 24,600 UNIT peg 3350-electrolytes oral recon soln 236-22.74- 1 MO 6.74 -5.86 gram peg-electrolyte oral recon soln 1 MO polyethylene glycol 3350 oral powder 2 MO prochlorperazine edisylate injection solution 2 MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits prochlorperazine maleate oral tablet 1 MO prochlorperazine rectal suppository 2 MO procto-pak topical cream with perineal applicator 2 MO proctosol hc topical cream with perineal 2 MO applicator proctozone-hc topical cream with perineal 2 MO applicator RECTIV RECTAL OINTMENT 4 MO; QL (30 per 30 days) RELISTOR SUBCUTANEOUS SOLUTION 5 MO RELISTOR SUBCUTANEOUS SYRINGE 5 MO REMICADE INTRAVENOUS RECON SOLN 5 PA; MO SANCUSO TRANSDERMAL PATCH WEEKLY 5 MO; QL (2 per 15 days) scopolamine base transdermal patch 3 day 4 MO; QL (10 per 30 days) sulfasalazine oral tablet 1 MO sulfasalazine oral tablet,delayed release (dr/ec) 2 MO trilyte with flavor packets oral recon soln 2 MO TRULANCE ORAL TABLET 3 MO; QL (30 per 30 days) ursodiol oral capsule 2 MO ursodiol oral tablet 2 MO VARUBI ORAL TABLET 4 B/D PA ZENPEP ORAL CAPSULE,DELAYED 3 MO RELEASE(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000- 168,000 UNIT, 5,000-17,000- 24,000 UNIT ULCER THERAPY amoxicillin-clarithromycin-lansoprazole oral 2 MO combo pack cimetidine hcl oral solution 2 MO cimetidine oral tablet 2 MO esomeprazole sodium intravenous recon soln 40 2 B/D PA; MO mg famotidine (pf) intravenous solution 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits famotidine (pf)-nacl (iso-osm) intravenous 2 B/D PA; MO piggyback famotidine intravenous solution 2 B/D PA; MO famotidine oral suspension 2 MO famotidine oral tablet 20 mg, 40 mg 1 MO lansoprazole oral capsule,delayed release(dr/ec) 2 MO misoprostol oral tablet 2 MO nizatidine oral capsule 2 nizatidine oral solution 2 MO omeprazole oral capsule,delayed release(dr/ec) 2 MO pantoprazole oral tablet,delayed release (dr/ec) 2 MO sucralfate oral suspension 2 MO sucralfate oral tablet 2 MO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE SUBCUTANEOUS SOLUTION 5 PA; MO ARCALYST SUBCUTANEOUS RECON SOLN 5 PA; MO AVONEX INTRAMUSCULAR PEN INJECTOR 5 MO KIT AVONEX INTRAMUSCULAR SYRINGE KIT 5 MO BETASERON SUBCUTANEOUS KIT 5 MO EGRIFTA SV SUBCUTANEOUS RECON SOLN 5 PA; MO EXTAVIA SUBCUTANEOUS KIT 5 MO EXTAVIA SUBCUTANEOUS RECON SOLN 5 GRANIX SUBCUTANEOUS SOLUTION 5 PA; MO GRANIX SUBCUTANEOUS SYRINGE 5 PA; MO INTRON A INJECTION RECON SOLN 10 5 B/D PA; MO MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML) INTRON A INJECTION RECON SOLN 18 4 B/D PA; MO MILLION UNIT (1 ML) INTRON A INJECTION SOLUTION 5 B/D PA; MO LEUKINE INJECTION RECON SOLN 5 PA; MO MOZOBIL SUBCUTANEOUS SOLUTION 5 B/D PA; MO Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits NORDITROPIN FLEXPRO SUBCUTANEOUS 5 PA; MO PEN INJECTOR PEGASYS SUBCUTANEOUS SOLUTION 5 MO; QL (4 per 28 days) PEGASYS SUBCUTANEOUS SYRINGE 5 MO; QL (2 per 28 days) PLEGRIDY INTRAMUSCULAR SYRINGE 5 MO PLEGRIDY SUBCUTANEOUS PEN INJECTOR 5 MO PLEGRIDY SUBCUTANEOUS SYRINGE 5 MO PROCRIT INJECTION SOLUTION 10,000 3 PA; MO; QL (24 per 30 days) UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 3 PA; MO UNIT/2 ML PROCRIT INJECTION SOLUTION 20,000 5 PA; MO; QL (24 per 30 days) UNIT/ML PROCRIT INJECTION SOLUTION 40,000 5 PA; MO; QL (6 per 30 days) UNIT/ML REBIF (WITH ALBUMIN) SUBCUTANEOUS 5 MO SYRINGE REBIF REBIDOSE SUBCUTANEOUS PEN 5 MO INJECTOR REBIF TITRATION PACK SUBCUTANEOUS 5 MO SYRINGE RETACRIT INJECTION SOLUTION 10,000 3 PA; MO; QL (24 per 30 days) UNIT/ML, 2,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML RETACRIT INJECTION SOLUTION 20,000 5 PA; MO; QL (24 per 30 days) UNIT/2 ML, 20,000 UNIT/ML RETACRIT INJECTION SOLUTION 40,000 5 PA; MO; QL (6 per 30 days) UNIT/ML ZARXIO INJECTION SYRINGE 5 PA; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) INTRAMUSCULAR RECON 3 MO SOLN ADACEL(TDAP ADOLESN/ADULT)(PF) 3 MO INTRAMUSCULAR SUSPENSION ADACEL(TDAP ADOLESN/ADULT)(PF) 3 MO INTRAMUSCULAR SYRINGE

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Drug Name Drug Tier Requirements/Limits BCG VACCINE, LIVE (PF) PERCUTANEOUS 4 B/D PA; MO SUSPENSION FOR RECONSTITUTION BEXSERO INTRAMUSCULAR SYRINGE 4 MO BOOSTRIX TDAP INTRAMUSCULAR 3 MO SUSPENSION BOOSTRIX TDAP INTRAMUSCULAR 3 MO SYRINGE DAPTACEL (DTAP PEDIATRIC) (PF) 3 MO INTRAMUSCULAR SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR 3 B/D PA; MO SUSPENSION ENGERIX-B (PF) INTRAMUSCULAR 3 B/D PA; MO SYRINGE ENGERIX-B PEDIATRIC (PF) 3 B/D PA; MO INTRAMUSCULAR SYRINGE fomepizole intravenous solution 2 B/D PA GAMMAGARD LIQUID INJECTION 5 PA; MO SOLUTION GAMMAGARD S-D (IGA < 1 MCG/ML) 5 B/D PA; MO INTRAVENOUS RECON SOLN GAMUNEX-C INJECTION SOLUTION 3 PA; MO GARDASIL 9 (PF) INTRAMUSCULAR 3 MO SUSPENSION GARDASIL 9 (PF) INTRAMUSCULAR 3 MO SYRINGE HAVRIX (PF) INTRAMUSCULAR 3 MO SUSPENSION 1,440 ELISA UNIT/ML HAVRIX (PF) INTRAMUSCULAR SYRINGE 3 MO HIBERIX (PF) INTRAMUSCULAR RECON 3 MO SOLN IMOVAX RABIES VACCINE (PF) 4 INTRAMUSCULAR RECON SOLN INFANRIX (DTAP) (PF) INTRAMUSCULAR 3 MO SYRINGE IPOL INJECTION SUSPENSION 3 IXIARO (PF) INTRAMUSCULAR SYRINGE 3

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits KINRIX (PF) INTRAMUSCULAR 3 SUSPENSION KINRIX (PF) INTRAMUSCULAR SYRINGE 3 MO MENACTRA (PF) INTRAMUSCULAR 3 MO SOLUTION MENQUADFI (PF) INTRAMUSCULAR 4 MO SOLUTION MENVEO A-C-Y-W-135-DIP (PF) 3 MO INTRAMUSCULAR KIT M-M-R II (PF) SUBCUTANEOUS RECON 3 MO SOLN PEDIARIX (PF) INTRAMUSCULAR SYRINGE 3 MO PEDVAX HIB (PF) INTRAMUSCULAR 3 SOLUTION PROQUAD (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION QUADRACEL (PF) INTRAMUSCULAR 3 SUSPENSION RABAVERT (PF) INTRAMUSCULAR 3 MO SUSPENSION FOR RECONSTITUTION RECOMBIVAX HB (PF) INTRAMUSCULAR 3 B/D PA; MO SUSPENSION RECOMBIVAX HB (PF) INTRAMUSCULAR 3 B/D PA; MO SYRINGE 10 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR 3 B/D PA SYRINGE 5 MCG/0.5 ML ROTARIX ORAL SUSPENSION FOR 4 RECONSTITUTION ROTATEQ VACCINE ORAL SOLUTION 3 MO SHINGRIX (PF) INTRAMUSCULAR 3 MO SUSPENSION FOR RECONSTITUTION STAMARIL (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION TDVAX INTRAMUSCULAR SUSPENSION 4 B/D PA; MO TENIVAC (PF) INTRAMUSCULAR 4 B/D PA; MO SUSPENSION TENIVAC (PF) INTRAMUSCULAR SYRINGE 4 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits TETANUS,DIPHTHERIA TOX PED(PF) 4 MO INTRAMUSCULAR SUSPENSION TRUMENBA INTRAMUSCULAR SYRINGE 3 MO TWINRIX (PF) INTRAMUSCULAR SYRINGE 3 MO TYPHIM VI INTRAMUSCULAR SOLUTION 3 TYPHIM VI INTRAMUSCULAR SYRINGE 3 MO VAQTA (PF) INTRAMUSCULAR 3 MO SUSPENSION VAQTA (PF) INTRAMUSCULAR SYRINGE 3 MO VARIVAX (PF) SUBCUTANEOUS 3 SUSPENSION FOR RECONSTITUTION VARIZIG INTRAMUSCULAR SOLUTION 4 MO YF-VAX (PF) SUBCUTANEOUS SUSPENSION 3 FOR RECONSTITUTION ZOSTAVAX (PF) SUBCUTANEOUS 3 QL (1 per 365 days) SUSPENSION FOR RECONSTITUTION MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet 1 MO allopurinol sodium intravenous recon soln 2 B/D PA febuxostat oral tablet 2 ST; MO MITIGARE ORAL CAPSULE 3 MO probenecid oral tablet 2 MO probenecid-colchicine oral tablet 2 MO OSTEOPOROSIS THERAPY alendronate oral solution 1 MO; QL (375 per 30 days) alendronate oral tablet 10 mg, 5 mg 1 MO; QL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg 1 MO; QL (5 per 30 days) FORTEO SUBCUTANEOUS PEN INJECTOR 20 5 MO; QL (2.4 per 28 days) MCG/DOSE (620MCG/2.48ML) ibandronate oral tablet 2 MO; QL (1 per 30 days) PROLIA SUBCUTANEOUS SYRINGE 4 PA; MO; QL (1 per 180 days) raloxifene oral tablet 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits risedronate oral tablet 150 mg, 35 mg, 35 mg (12 2 MO pack), 5 mg risedronate oral tablet 35 mg (4 pack) 2 risedronate oral tablet,delayed release (dr/ec) 2 MO TYMLOS SUBCUTANEOUS PEN INJECTOR 5 MO; QL (1.56 per 30 days) OTHER RHEUMATOLOGICALS BENLYSTA INTRAVENOUS RECON SOLN 4 B/D PA; MO 120 MG BENLYSTA INTRAVENOUS RECON SOLN 4 MO 400 MG BENLYSTA SUBCUTANEOUS AUTO- 5 PA; MO INJECTOR BENLYSTA SUBCUTANEOUS SYRINGE 5 PA; MO ENBREL MINI SUBCUTANEOUS 5 PA; MO; QL (8 per 28 days) CARTRIDGE ENBREL SUBCUTANEOUS RECON SOLN 5 PA; MO; QL (8 per 28 days) ENBREL SUBCUTANEOUS SOLUTION 5 PA; MO; QL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 5 PA; MO; QL (4 per 28 days) MG/0.5 ML (0.5) ENBREL SUBCUTANEOUS SYRINGE 50 5 PA; MO; QL (8 per 28 days) MG/ML (1 ML) ENBREL SURECLICK SUBCUTANEOUS PEN 5 PA; MO; QL (8 per 28 days) INJECTOR HUMIRA PEN CROHNS-UC-HS START 5 PA; MO; QL (6 per 180 days) SUBCUTANEOUS INJECTOR KIT HUMIRA PEN PSOR-UVEITS-ADOL HS 5 PA; MO; QL (4 per 180 days) SUBCUTANEOUS INJECTOR KIT HUMIRA PEN SUBCUTANEOUS INJECTOR 5 PA; MO; QL (2 per 28 days) KIT HUMIRA SUBCUTANEOUS SYRINGE KIT 40 5 PA; MO; QL (2 per 28 days) MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER 5 PA; MO; QL (3 per 180 days) SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML HUMIRA(CF) PEDI CROHNS STARTER 5 PA; MO; QL (2 per 180 days) SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-40 MG/0.4 ML

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits HUMIRA(CF) PEN CROHNS-UC-HS 5 PA; MO; QL (3 per 180 days) SUBCUTANEOUS INJECTOR KIT HUMIRA(CF) PEN PEDIATRIC UC 5 PA; MO; QL (3 per 180 days) SUBCUTANEOUS PEN INJECTOR KIT HUMIRA(CF) PEN PSOR-UV-ADOL HS 5 PA; MO; QL (3 per 180 days) SUBCUTANEOUS INJECTOR KIT HUMIRA(CF) SUBCUTANEOUS PEN 5 PA; MO; QL (2 per 28 days) INJECTOR KIT 40 MG/0.4 ML HUMIRA(CF) PEN SUBCUTANEOUS PEN 5 PA; MO; QL (3 per 180 days) INJECTOR KIT 80 MG/0.8 ML HUMIRA(CF) SUBCUTANEOUS SYRINGE 5 PA; MO; QL (2 per 28 days) KIT leflunomide oral tablet 2 MO; QL (30 per 30 days) ORENCIA CLICKJECT SUBCUTANEOUS 5 PA; MO; QL (4 per 28 days) AUTO-INJECTOR ORENCIA SUBCUTANEOUS SYRINGE 125 5 PA; MO; QL (4 per 28 days) MG/ML ORENCIA SUBCUTANEOUS SYRINGE 50 5 PA; MO; QL (1.6 per 28 days) MG/0.4 ML ORENCIA SUBCUTANEOUS SYRINGE 87.5 5 PA; MO; QL (2.8 per 28 days) MG/0.7 ML OTEZLA ORAL TABLET 5 PA; MO; QL (60 per 30 days) OTEZLA STARTER ORAL TABLETS,DOSE 5 PA; MO; QL (55 per 180 days) PACK 10 MG (4)-20 MG (4)-30 MG (47) penicillamine oral capsule 5 PA; MO penicillamine oral tablet 4 PA; MO RINVOQ ORAL TABLET EXTENDED 5 PA; MO; QL (30 per 30 days) RELEASE 24 HR XELJANZ ORAL SOLUTION 5 PA; MO XELJANZ ORAL TABLET 5 PA; MO; QL (60 per 30 days) XELJANZ XR ORAL TABLET EXTENDED 5 PA; MO; QL (30 per 30 days) RELEASE 24 HR OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS camila oral tablet 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits COMBIPATCH TRANSDERMAL PATCH 4 MO SEMIWEEKLY CRINONE VAGINAL GEL 4 PA; MO DEPO-SUBQ PROVERA 104 4 MO SUBCUTANEOUS SYRINGE errin oral tablet 2 MO estradiol oral tablet 2 PA; MO estradiol transdermal patch semiweekly 2 MO estradiol transdermal patch weekly 2 estradiol vaginal cream 2 MO estradiol valerate intramuscular oil 20 mg/ml, 40 2 MO mg/ml heather oral tablet 2 MO hydroxyprogesterone caproate intramuscular oil 4 PA jencycla oral tablet 2 MO jinteli oral tablet 4 MO lyza oral tablet 2 medroxyprogesterone intramuscular suspension 2 MO; QL (1 per 90 days) medroxyprogesterone intramuscular syringe 2 MO; QL (1 per 90 days) medroxyprogesterone oral tablet 2 MO norethindrone (contraceptive) oral tablet 2 norethindrone acetate oral tablet 2 MO PREMARIN INJECTION RECON SOLN 4 B/D PA PREMARIN VAGINAL CREAM 4 MO progesterone micronized oral capsule 2 MO MISCELLANEOUS OB/GYN CLEOCIN VAGINAL SUPPOSITORY 4 MO clindamycin phosphate vaginal cream 2 MO metronidazole vaginal gel 2 MO miconazole-3 vaginal suppository 2 MO ORIAHNN ORAL CAPSULE, SEQUENTIAL 5 PA; MO terconazole vaginal cream 2 MO terconazole vaginal suppository 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits tranexamic acid oral tablet 2 MO vandazole vaginal gel 2 MO ORAL CONTRACEPTIVES / RELATED AGENTS altavera (28) oral tablet 2 MO alyacen 1/35 (28) oral tablet 2 MO alyacen 7/7/7 (28) oral tablet 2 MO amethia oral tablets,dose pack,3 month 2 MO amethyst (28) oral tablet 2 MO apri oral tablet 2 MO aranelle (28) oral tablet 2 MO ashlyna oral tablets,dose pack,3 month 2 MO aubra eq oral tablet 2 MO aubra oral tablet 2 aviane oral tablet 2 MO azurette (28) oral tablet 2 MO balziva (28) oral tablet 2 MO blisovi 24 fe oral tablet 2 MO blisovi fe 1.5/30 (28) oral tablet 2 MO blisovi fe 1/20 (28) oral tablet 2 MO briellyn oral tablet 2 MO camrese lo oral tablets,dose pack,3 month 2 MO camrese oral tablets,dose pack,3 month 2 MO caziant (28) oral tablet 2 MO chateal (28) oral tablet 2 cryselle (28) oral tablet 2 MO cyclafem 1/35 (28) oral tablet 2 MO cyclafem 7/7/7 (28) oral tablet 2 MO dasetta 1/35 (28) oral tablet 2 MO dasetta 7/7/7 (28) oral tablet 2 MO daysee oral tablets,dose pack,3 month 2 MO desog-e.estradiol/e.estradiol oral tablet 2 drospirenone-e.estradiol-lm.fa oral tablet 3-0.02- 2 0.451 mg (24) (4) Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits drospirenone-ethinyl estradiol oral tablet 3-0.02 2 MO mg drospirenone-ethinyl estradiol oral tablet 3-0.03 2 mg elinest oral tablet 2 MO ELLA ORAL TABLET 3 emoquette oral tablet 2 MO enpresse oral tablet 2 MO enskyce oral tablet 2 MO estarylla oral tablet 2 MO falmina (28) oral tablet 2 MO introvale oral tablets,dose pack,3 month 2 MO jolessa oral tablets,dose pack,3 month 2 MO junel 1.5/30 (21) oral tablet 2 MO junel 1/20 (21) oral tablet 2 MO junel fe 1.5/30 (28) oral tablet 2 MO junel fe 1/20 (28) oral tablet 2 MO junel fe 24 oral tablet 2 MO kariva (28) oral tablet 2 MO kelnor 1/35 (28) oral tablet 2 MO kurvelo (28) oral tablet 2 MO l norgest/e.estradiol-e.estrad oral tablets,dose 2 pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7) l norgest/e.estradiol-e.estrad oral tablets,dose 2 MO pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg larissia oral tablet 2 MO layolis fe oral tablet,chewable 2 MO lessina oral tablet 2 MO levonest (28) oral tablet 2 MO levonorgestrel-ethinyl estrad oral tablet 0.1-20 2 MO mg-mcg levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 2 mg, 90-20 mcg (28)

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Drug Name Drug Tier Requirements/Limits levonorgestrel-ethinyl estrad oral tablets,dose 2 MO pack,3 month levonorg-eth estrad triphasic oral tablet 2 MO levora-28 oral tablet 2 MO loryna (28) oral tablet 2 MO low-ogestrel (28) oral tablet 2 MO lutera (28) oral tablet 2 MO marlissa (28) oral tablet 2 MO microgestin 1.5/30 (21) oral tablet 2 MO microgestin 1/20 (21) oral tablet 2 MO microgestin fe 1.5/30 (28) oral tablet 2 MO microgestin fe 1/20 (28) oral tablet 2 MO mono-linyah oral tablet 2 MO necon 0.5/35 (28) oral tablet 2 MO nikki (28) oral tablet 2 MO noreth-ethinyl estradiol-iron oral tablet,chewable 2 norgestimate-ethinyl estradiol oral tablet 2 0.18/0.215/0.25 mg-25 mcg norgestimate-ethinyl estradiol oral tablet 2 MO 0.18/0.215/0.25 mg-35 mcg (28) nortrel 0.5/35 (28) oral tablet 2 MO nortrel 1/35 (21) oral tablet 2 MO nortrel 1/35 (28) oral tablet 2 MO nortrel 7/7/7 (28) oral tablet 2 MO ocella oral tablet 2 MO orsythia oral tablet 2 MO philith oral tablet 2 MO pimtrea (28) oral tablet 2 MO pirmella oral tablet 2 MO portia 28 oral tablet 2 MO previfem oral tablet 2 MO reclipsen (28) oral tablet 2 MO sprintec (28) oral tablet 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits sronyx oral tablet 2 MO syeda oral tablet 2 MO tilia fe oral tablet 2 MO tri-estarylla oral tablet 2 MO tri-legest fe oral tablet 2 MO tri-linyah oral tablet 2 MO tri-previfem (28) oral tablet 2 MO tri-sprintec (28) oral tablet 2 MO trivora (28) oral tablet 2 MO TYBLUME ORAL TABLET,CHEWABLE 2 velivet triphasic regimen (28) oral tablet 2 MO viorele (28) oral tablet 2 MO wera (28) oral tablet 2 MO wymzya fe oral tablet,chewable 2 MO zarah oral tablet 2 MO zovia 1/35e (28) oral tablet 2 MO zovia 1-35 (28) oral tablet 2 OXYTOCICS methylergonovine oral tablet 2 OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac ophthalmic (eye) ointment 2 MO AZASITE OPHTHALMIC (EYE) DROPS 3 MO bacitracin ophthalmic (eye) ointment 2 MO bacitracin-polymyxin b ophthalmic (eye) ointment 2 MO BESIVANCE OPHTHALMIC (EYE) 3 MO DROPS,SUSPENSION ciprofloxacin hcl ophthalmic (eye) drops 2 MO erythromycin ophthalmic (eye) ointment 2 MO gatifloxacin ophthalmic (eye) drops 2 MO gentak ophthalmic (eye) ointment 1 MO gentamicin ophthalmic (eye) drops 1 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits levofloxacin ophthalmic (eye) drops 2 MO moxifloxacin ophthalmic (eye) drops 2 MO moxifloxacin ophthalmic (eye) drops, viscous 2 NATACYN OPHTHALMIC (EYE) 3 DROPS,SUSPENSION neomycin-bacitracin-polymyxin ophthalmic (eye) 2 MO ointment neomycin-polymyxin-gramicidin ophthalmic (eye) 2 MO drops neo-polycin ophthalmic (eye) ointment 2 MO ofloxacin ophthalmic (eye) drops 2 MO polycin ophthalmic (eye) ointment 2 MO polymyxin b sulf-trimethoprim ophthalmic (eye) 1 MO drops tobramycin ophthalmic (eye) drops 1 MO ANTIVIRALS trifluridine ophthalmic (eye) drops 2 MO ZIRGAN OPHTHALMIC (EYE) GEL 4 MO BETA-BLOCKERS betaxolol ophthalmic (eye) drops 2 MO BETIMOL OPHTHALMIC (EYE) DROPS 4 MO carteolol ophthalmic (eye) drops 1 MO levobunolol ophthalmic (eye) drops 0.5 % 1 MO timolol maleate ophthalmic (eye) drops (timoptic 1 MO generic) timolol maleate ophthalmic (eye) gel forming 2 MO solution (timoptic generic) MISCELLANEOUS OPHTHALMOLOGICS azelastine ophthalmic (eye) drops 2 MO BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) 3 MO OINTMENT cromolyn ophthalmic (eye) drops 2 MO CYSTARAN OPHTHALMIC (EYE) DROPS 4 epinastine ophthalmic (eye) drops 2 MO

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Drug Name Drug Tier Requirements/Limits olopatadine ophthalmic (eye) drops 0.1 % 4 MO olopatadine ophthalmic (eye) drops 0.2 % 2 MO OXERVATE OPHTHALMIC (EYE) DROPS 5 PA; MO; QL (112 per 365 days) pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 2 MO 4 % RESTASIS MULTIDOSE OPHTHALMIC (EYE) 3 MO; QL (1 per 30 days) DROPS RESTASIS OPHTHALMIC (EYE) 3 MO; QL (60 per 30 days) DROPPERETTE sulfacetamide sodium ophthalmic (eye) drops 1 MO sulfacetamide sodium ophthalmic (eye) ointment 2 MO sulfacetamide-prednisolone ophthalmic (eye) 2 MO drops NON-STEROIDAL ANTI-INFLAMMATORY AGENTS diclofenac sodium ophthalmic (eye) drops 2 MO flurbiprofen sodium ophthalmic (eye) drops 2 MO ILEVRO OPHTHALMIC (EYE) 4 MO DROPS,SUSPENSION ketorolac ophthalmic (eye) drops 2 MO PROLENSA OPHTHALMIC (EYE) DROPS 3 MO ORAL DRUGS FOR GLAUCOMA acetazolamide oral capsule, extended release 2 MO acetazolamide oral tablet 2 MO acetazolamide sodium injection recon soln 2 MO methazolamide oral tablet 2 MO OTHER GLAUCOMA DRUGS COMBIGAN OPHTHALMIC (EYE) DROPS 3 MO dorzolamide ophthalmic (eye) drops 2 MO dorzolamide-timolol ophthalmic (eye) drops 2 MO latanoprost ophthalmic (eye) drops 2 MO LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 3 MO; QL (2.5 per 30 days) % RHOPRESSA OPHTHALMIC (EYE) DROPS 3 MO ROCKLATAN OPHTHALMIC (EYE) DROPS 3 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits travoprost ophthalmic (eye) drops 2 MO; QL (2.5 per 30 days) STEROID-ANTIBIOTIC COMBINATIONS neomycin-bacitracin-poly-hc ophthalmic (eye) 2 MO ointment neomycin-polymyxin b-dexameth ophthalmic (eye) 1 MO drops,suspension neomycin-polymyxin b-dexameth ophthalmic (eye) 1 MO ointment neomycin-polymyxin-hc ophthalmic (eye) 2 MO drops,suspension neo-polycin hc ophthalmic (eye) ointment 2 MO tobramycin-dexamethasone ophthalmic (eye) 2 MO drops,suspension STEROIDS dexamethasone sodium phosphate ophthalmic 2 MO (eye) drops fluorometholone ophthalmic (eye) 2 MO drops,suspension prednisolone acetate ophthalmic (eye) 2 MO drops,suspension prednisolone sodium phosphate ophthalmic (eye) 2 MO drops SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC (EYE) DROPS 3 MO 0.1 % apraclonidine ophthalmic (eye) drops 2 MO brimonidine ophthalmic (eye) drops 0.15 % 4 brimonidine ophthalmic (eye) drops 0.2 % 2 MO RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS cetirizine oral solution 1 mg/ml 2 MO clemastine oral tablet 2.68 mg 2 PA; MO cyproheptadine oral syrup 2 PA; MO cyproheptadine oral tablet 2 PA; MO desloratadine oral tablet 2 MO

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits desloratadine oral tablet,disintegrating 2 MO diphenhydramine hcl injection solution 50 mg/ml 2 MO diphenhydramine hcl injection syringe 2 B/D PA; MO EPINEPHRINE INJECTION AUTO-INJECTOR 3 MO; QL (4 per 2 days) 0.15 MG/0.3 ML (MANUFACTURED BY MYLAN SPECIALTY) epinephrine injection auto-injector 0.3 mg/0.3 ml 3 MO; QL (4 per 2 days) (manufactured by mylan specialty) hydroxyzine hcl intramuscular solution 2 B/D PA; MO hydroxyzine hcl oral solution 4 MO hydroxyzine hcl oral tablet 4 MO levocetirizine oral solution 2 MO levocetirizine oral tablet 2 MO; QL (30 per 30 days) promethazine oral tablet 2 PA; MO PULMONARY AGENTS acetylcysteine solution 2 B/D PA; MO ADEMPAS ORAL TABLET 5 PA; MO; LA; QL (90 per 30 days) ADVAIR HFA AEROSOL INHALER 3 MO; QL (24 per 30 days) albuterol sulfate inhalation hfa aerosol inhaler 90 2 QL (17 per 30 days) mcg/actuation, 90 mcg/actuation (nda020503) albuterol sulfate inhalation solution for 2 B/D PA; MO; QL (360 per 30 days) nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) albuterol sulfate inhalation solution for 2 B/D PA; MO; QL (60 per 30 days) nebulization 2.5 mg/0.5 ml, 5 mg/ml albuterol sulfate oral syrup 2 MO albuterol sulfate oral tablet 2 MO albuterol sulfate oral tablet extended release 12 hr 2 MO alyq oral tablet 5 PA; QL (60 per 30 days) ambrisentan oral tablet 5 PA; MO; LA; QL (30 per 30 days) ANORO ELLIPTA INHALATION BLISTER 3 MO; QL (60 per 30 days) WITH DEVICE ARNUITY ELLIPTA INHALATION BLISTER 3 MO; QL (30 per 30 days) WITH DEVICE ASMANEX HFA AEROSOL INHALER 3 MO; QL (26 per 30 days)

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Drug Name Drug Tier Requirements/Limits ASMANEX TWISTHALER INHALATION 3 MO; QL (2 per 30 days) AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (120), 220 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (60) ASMANEX TWISTHALER INHALATION 3 QL (2 per 30 days) AEROSOL POWDR BREATH ACTIVATED 220 MCG/ ACTUATION (14) ATROVENT HFA AEROSOL INHALER 4 MO; QL (26 per 30 days) BEVESPI AEROSPHERE HFA AEROSOL 3 MO; QL (10.7 per 30 days) INHALER bosentan oral tablet 5 PA; MO; LA; QL (60 per 30 days) BREO ELLIPTA INHALATION BLISTER 3 MO; QL (60 per 30 days) WITH DEVICE budesonide inhalation suspension for nebulization 2 B/D PA; MO; QL (120 per 30 days) 0.25 mg/2 ml, 0.5 mg/2 ml budesonide inhalation suspension for nebulization 2 B/D PA; MO 1 mg/2 ml CINRYZE INTRAVENOUS RECON SOLN 5 PA; MO COMBIVENT RESPIMAT INHALATION MIST 4 MO; QL (8 per 30 days) cromolyn inhalation solution for nebulization 4 B/D PA; MO; QL (240 per 30 days) DALIRESP ORAL TABLET 4 MO DULERA INHALATION HFA AEROSOL 3 MO; QL (13 per 30 days) INHALER ESBRIET ORAL CAPSULE 5 PA; MO ESBRIET ORAL TABLET 5 PA; MO FLOVENT DISKUS INHALATION BLISTER 3 MO; QL (120 per 30 days) WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER 3 MO; QL (240 per 30 days) WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA AEROSOL INHALER 110 3 MO; QL (12 per 30 days) MCG/ACTUATION FLOVENT HFA AEROSOL INHALER 220 3 MO; QL (36 per 30 days) MCG/ACTUATION FLOVENT HFA AEROSOL INHALER 44 3 MO; QL (21 per 30 days) MCG/ACTUATION

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Drug Name Drug Tier Requirements/Limits flunisolide nasal spray,non-aerosol 2 MO; QL (50 per 30 days) fluticasone propionate nasal spray,suspension 2 MO; QL (16 per 30 days) fluticasone propion-salmeterol inhalation blister 2 QL (60 per 30 days) with device formoterol fumarate inhalation solution for 4 B/D PA; MO; QL (120 per 30 days) nebulization icatibant subcutaneous syringe 5 PA; MO INCRUSE ELLIPTA INHALATION BLISTER 3 MO; QL (30 per 30 days) WITH DEVICE ipratropium bromide inhalation solution 2 B/D PA; MO; QL (315 per 30 days) ipratropium-albuterol inhalation solution for 2 B/D PA; MO; QL (540 per 30 days) nebulization KALYDECO ORAL GRANULES IN PACKET 5 PA; MO; QL (60 per 30 days) KALYDECO ORAL TABLET 5 PA; MO; QL (60 per 30 days) levalbuterol hcl inhalation solution for 2 B/D PA; MO nebulization 0.31 mg/3 ml, 0.63 mg/3 ml levalbuterol hcl inhalation solution for 2 B/D PA; MO; QL (90 per 30 days) nebulization 1.25 mg/0.5 ml, 1.25 mg/3 ml metaproterenol oral syrup 2 MO mometasone nasal spray,non-aerosol 4 MO; QL (51 per 30 days) montelukast oral granules in packet 2 MO montelukast oral tablet 2 MO montelukast oral tablet,chewable 2 MO OFEV ORAL CAPSULE 5 PA; MO; QL (60 per 30 days) OPSUMIT ORAL TABLET 5 PA; MO; LA; QL (30 per 30 days) ORKAMBI ORAL GRANULES IN PACKET 5 PA; MO ORKAMBI ORAL TABLET 5 PA; MO ORLADEYO ORAL CAPSULE 5 PA; LA; QL (30 per 30 days) PERFOROMIST INHALATION SOLUTION 5 B/D PA; MO; QL (120 per 30 days) FOR NEBULIZATION PULMOZYME INHALATION SOLUTION 5 B/D PA; MO SEREVENT DISKUS INHALATION BLISTER 3 MO; QL (120 per 30 days) WITH DEVICE sildenafil (pulmonary arterial hypertension) oral 2 PA; MO; QL (90 per 30 days) tablet

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits SPIRIVA RESPIMAT INHALATION MIST 3 MO; QL (4 per 30 days) SPIRIVA WITH HANDIHALER INHALATION 3 MO; QL (30 per 30 days) CAPSULE, W/INHALATION DEVICE STIOLTO RESPIMAT INHALATION MIST 3 MO; QL (4 per 30 days) SYMBICORT HFA AEROSOL INHALER 3 MO; QL (20 per 30 days) SYMDEKO ORAL TABLETS, SEQUENTIAL 5 PA; MO; LA; QL (56 per 28 days) 100-150 MG (D)/ 150 MG (N) SYMDEKO ORAL TABLETS, SEQUENTIAL 5 PA; MO; QL (56 per 28 days) 50-75 MG (D)/ 75 MG (N) tadalafil (pulmonary arterial hypertension) oral 5 PA; QL (60 per 30 days) tablet 20 mg terbutaline oral tablet 2 MO terbutaline subcutaneous solution 2 MO theophylline oral elixir 2 theophylline oral solution 2 MO theophylline oral tablet extended release 12 hr 300 2 MO mg, 450 mg theophylline oral tablet extended release 24 hr 2 MO TRACLEER ORAL TABLET FOR 5 PA; MO; LA; QL (120 per 30 days) SUSPENSION TRELEGY ELLIPTA INHALATION BLISTER 3 MO; QL (60 per 30 days) WITH DEVICE TRIKAFTA ORAL TABLETS, SEQUENTIAL 5 PA; MO; QL (84 per 28 days) 100-50-75 MG(D) /150 MG (N) TRIKAFTA ORAL TABLETS, SEQUENTIAL 5 PA; MO; QL (60 per 30 days) 50-25-37.5 MG (D)/75 MG (N) VENTOLIN HFA AEROSOL INHALER 3 MO; QL (36 per 30 days) wixela inhub inhalation blister with device 4 QL (60 per 30 days) XOLAIR SUBCUTANEOUS RECON SOLN 5 PA; MO; LA; QL (6 per 28 days) XOLAIR SUBCUTANEOUS SYRINGE 150 5 PA; MO; LA; QL (4 per 28 days) MG/ML XOLAIR SUBCUTANEOUS SYRINGE 75 5 PA; MO; LA; QL (2 per 28 days) MG/0.5 ML zafirlukast oral tablet 2 MO UROLOGICALS

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Drug Name Drug Tier Requirements/Limits ANTICHOLINERGICS / ANTISPASMODICS flavoxate oral tablet 2 MO GELNIQUE TRANSDERMAL GEL IN PACKET 3 ST; MO; QL (30 per 30 days) MYRBETRIQ ORAL TABLET EXTENDED 3 MO RELEASE 24 HR oxybutynin chloride oral syrup 2 MO oxybutynin chloride oral tablet 2 MO oxybutynin chloride oral tablet extended release 2 MO; QL (60 per 30 days) 24hr 10 mg, 15 mg oxybutynin chloride oral tablet extended release 2 MO; QL (30 per 30 days) 24hr 5 mg solifenacin oral tablet 4 MO; QL (30 per 30 days) tolterodine oral capsule,extended release 24hr 4 MO; QL (30 per 30 days) tolterodine oral tablet 2 MO; QL (60 per 30 days) TOVIAZ ORAL TABLET EXTENDED 3 MO RELEASE 24 HR trospium oral capsule,extended release 24hr 2 MO; QL (30 per 30 days) trospium oral tablet 2 MO; QL (60 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY alfuzosin oral tablet extended release 24 hr 2 MO; QL (30 per 30 days) dutasteride oral capsule 2 MO; QL (30 per 30 days) dutasteride-tamsulosin oral capsule, er multiphase 2 MO; QL (30 per 30 days) 24 hr finasteride oral tablet 5 mg 2 MO tamsulosin oral capsule 2 MO MISCELLANEOUS UROLOGICALS bethanechol chloride oral tablet 2 MO CYSTAGON ORAL CAPSULE 4 LA ELMIRON ORAL CAPSULE 4 MO potassium citrate oral tablet extended release 2 MO tadalafil oral tablet 2.5 mg, 5 mg 4 PA; MO; QL (30 per 30 days) VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES

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Drug Name Drug Tier Requirements/Limits calcium acetate(phosphat bind) oral capsule 2 MO calcium acetate(phosphat bind) oral tablet 2 MO klor-con 10 oral tablet extended release 2 MO klor-con 8 oral tablet extended release 2 MO klor-con m15 oral tablet,er particles/crystals 2 MO klor-con m20 oral tablet,er particles/crystals 2 MO klor-con oral packet 2 MO k-tab oral tablet extended release 8 meq 2 MO lactated ringers intravenous parenteral solution 2 MO magnesium sulfate injection solution 2 B/D PA; MO magnesium sulfate injection syringe 2 B/D PA potassium chlorid-d5-0.45%nacl intravenous 2 B/D PA parenteral solution potassium chloride in 0.9%nacl intravenous 2 B/D PA parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous 2 B/D PA parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral 2 B/D PA solution 20 meq/l potassium chloride in water intravenous 2 piggyback potassium chloride intravenous solution 2 potassium chloride oral capsule, extended release 2 MO potassium chloride oral liquid 2 MO potassium chloride oral packet 2 potassium chloride oral tablet extended release 10 2 MO meq, 8 meq potassium chloride oral tablet extended release 20 2 meq potassium chloride oral tablet,er particles/crystals 2 MO 10 meq potassium chloride oral tablet,er particles/crystals 2 20 meq potassium chloride-0.45 % nacl intravenous 2 parenteral solution

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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Drug Name Drug Tier Requirements/Limits potassium chloride-d5-0.2%nacl intravenous 2 B/D PA parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride-d5-0.9%nacl intravenous 2 B/D PA parenteral solution ringer's intravenous parenteral solution 2 B/D PA sodium chloride 0.45 % intravenous parenteral 2 MO solution sodium chloride 3 % intravenous parenteral 2 solution sodium chloride 5 % intravenous parenteral 2 MO solution sodium chloride intravenous parenteral solution 2 MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN II 15 % INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION AMINOSYN-PF 7 % SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%/D15W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 4.25%/D10W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 5%-D20W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 6%-D5W (SULFITE-FREE) 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 8%-D10W(SULFITE-FREE) 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX 8%-D14W(SULFITE-FREE) 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D10W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 4.25%/D5W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D15W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 5%/D20W SULFITE FREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 92

Drug Name Drug Tier Requirements/Limits CLINIMIX E 8%-D10W SULFITEFREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION CLINIMIX E 8%-D14W SULFITEFREE 4 B/D PA INTRAVENOUS PARENTERAL SOLUTION DOJOLVI ORAL LIQUID 5 PA; MO; LA electrolyte-48 in d5w intravenous parenteral 2 B/D PA solution HEPATAMINE 8% INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION intralipid intravenous emulsion 20 % 4 B/D PA INTRALIPID INTRAVENOUS EMULSION 30 4 B/D PA % IONOSOL-MB IN D5W INTRAVENOUS 4 PARENTERAL SOLUTION ISOLYTE S PH 7.4 INTRAVENOUS 4 PARENTERAL SOLUTION ISOLYTE-P IN 5 % DEXTROSE 4 INTRAVENOUS PARENTERAL SOLUTION ISOLYTE-S INTRAVENOUS PARENTERAL 4 SOLUTION NORMOSOL-R PH 7.4 INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION PLASMA-LYTE 148 INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION PLASMA-LYTE A INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION plenamine intravenous parenteral solution 2 B/D PA premasol 10 % intravenous parenteral solution 4 B/D PA PROCALAMINE 3% INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION PROSOL 20 % INTRAVENOUS PARENTERAL 4 B/D PA SOLUTION travasol 10 % intravenous parenteral solution 4 B/D PA TROPHAMINE 10 % INTRAVENOUS 4 B/D PA PARENTERAL SOLUTION VITAMINS / HEMATINICS fluoride (sodium) oral tablet 2 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 93

Drug Name Drug Tier Requirements/Limits fluoride (sodium) oral tablet,chewable 1 mg (2.2 2 MO mg sod. fluoride) prenatal vitamin oral tablet 2

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 94

Index

A alfuzosin ...... 89 ampicillin-sulbactam ...... 11 abacavir ...... 1 ALIMTA ...... 14 anagrelide ...... 56 abacavir-lamivudine ...... 2 ALIQOPA ...... 14 anastrozole ...... 15 abacavir-lamivudine- aliskiren ...... 42 ANORO ELLIPTA ...... 85 zidovudine ...... 2 allopurinol ...... 74 APOKYN ...... 27 ABELCET ...... 1 allopurinol sodium ...... 74 apraclonidine ...... 84 ABILIFY MAINTENA ...... 35 alosetron ...... 67 aprepitant ...... 67 abiraterone ...... 14 ALPHAGAN P ...... 84 apri ...... 77 ABRAXANE ...... 14 alprazolam ...... 35 APTIOM ...... 24 acamprosate ...... 56 altavera (28) ...... 77 APTIVUS ...... 2 acarbose ...... 60 ALUNBRIG ...... 14, 15 ARALAST NP ...... 56 acebutolol ...... 42 alyacen 1/35 (28) ...... 77 aranelle (28) ...... 78 acetaminophen-codeine ...... 31 alyacen 7/7/7 (28) ...... 77 ARCALYST ...... 70 acetazolamide ...... 83 alyq ...... 85 ARIKAYCE ...... 8 acetazolamide sodium ...... 83 amantadine hcl ...... 2 aripiprazole ...... 35 acetic acid ...... 58 AMBISOME ...... 1 ARISTADA ...... 35 acetylcysteine ...... 85 ambrisentan ...... 85 ARISTADA INITIO ...... 35 acitretin ...... 50 amcinonide ...... 54 armodafinil ...... 35 ACTHAR ...... 59 amethia ...... 77 ARNUITY ELLIPTA ...... 85 ACTHIB (PF) ...... 71 amethyst (28) ...... 77 asenapine maleate ...... 35 ACTIMMUNE ...... 70 amikacin ...... 8 ashlyna ...... 78 acyclovir ...... 2, 54 amiloride ...... 42 ASMANEX HFA ...... 85 acyclovir sodium ...... 2 amiloride-hydrochlorothiazide ASMANEX TWISTHALER 85 ADACEL(TDAP ...... 42 aspirin-dipyridamole ...... 46 ADOLESN/ADULT)(PF) 71 AMINOSYN II 15 % ...... 90 ASTAGRAF XL ...... 15 adapalene ...... 52 AMINOSYN-PF 7 % atazanavir ...... 2 adefovir...... 2 SULFITE FREE ...... 90 atenolol ...... 42 ADEMPAS ...... 85 amiodarone ...... 41 atenolol-chlorthalidone ...... 42 adriamycin ...... 14 amitriptyline ...... 35 atomoxetine ...... 36 adrucil ...... 14 amlodipine ...... 42 atorvastatin ...... 48 ADVAIR HFA ...... 85 amlodipine-atorvastatin ...... 48 atovaquone ...... 8 AFINITOR ...... 14 amlodipine-benazepril ...... 42 atovaquone-proguanil ...... 8 AFINITOR DISPERZ ...... 14 amlodipine-olmesartan ...... 42 ATRIPLA ...... 2 AIMOVIG AUTOINJECTOR amlodipine-valsartan ...... 42 atropine ...... 66 ...... 28 amlodipine-valsartan- ATROVENT HFA ...... 85 AJOVY AUTOINJECTOR .. 28 hydrochlorothiazide ...... 42 AUBAGIO ...... 29 AJOVY SYRINGE ...... 28 ammonium lactate ...... 51 aubra ...... 78 ak-poly-bac ...... 81 amnesteem ...... 52 aubra eq ...... 78 ala-cort ...... 54 amoxapine ...... 35 AURYXIA ...... 56 albendazole ...... 8 amoxicil-clarithromy-lansopraz aviane ...... 78 albuterol sulfate ...... 85 ...... 69 AVONEX ...... 70 alclometasone ...... 54 amoxicillin ...... 11 AYVAKIT ...... 15 alcohol pads ...... 60 amoxicillin-pot clavulanate .. 11 azacitidine ...... 15 ALDURAZYME ...... 64 amphotericin b ...... 1 AZASAN ...... 15 ALECENSA ...... 14 ampicillin ...... 11 AZASITE ...... 81 alendronate ...... 74 ampicillin sodium ...... 11 azathioprine ...... 15 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 95 azathioprine sodium ...... 15 blisovi fe 1/20 (28) ...... 78 CAPRELSA ...... 15 azelastine ...... 58, 82 BOOSTRIX TDAP...... 71, 72 captopril ...... 43 azithromycin ...... 7 bosentan ...... 85 captopril-hydrochlorothiazide aztreonam ...... 8 BOSULIF ...... 15 ...... 43 azurette (28)...... 78 BRAFTOVI ...... 15 carbamazepine ...... 24 B BREO ELLIPTA ...... 85 carbidopa ...... 27 bacitracin ...... 8, 81 briellyn...... 78 carbidopa-levodopa ...... 27 bacitracin-polymyxin b ...... 81 BRILINTA ...... 46 carbidopa-levodopa- baclofen ...... 30 brimonidine ...... 84 entacapone ...... 28 balsalazide ...... 67 BRIVIACT ...... 24 carboplatin ...... 15 BALVERSA ...... 15 bromocriptine ...... 27 carmustine ...... 15 balziva (28) ...... 78 BRUKINSA...... 15 carteolol ...... 82 BANZEL ...... 24 budesonide ...... 67, 85, 86 cartia xt ...... 43 BARACLUDE ...... 2 bumetanide ...... 42, 43 carvedilol ...... 43 BASAGLAR KWIKPEN U- buprenorphine hcl ...... 31 carvedilol phosphate ...... 43 100 INSULIN ...... 60 buprenorphine-naloxone ...... 33 caspofungin ...... 1 BAVENCIO ...... 15 bupropion hcl ...... 36 CAYSTON ...... 8 BCG VACCINE, LIVE (PF) 71 bupropion hcl (smoking deter) caziant (28) ...... 78 BELEODAQ ...... 15 ...... 58 cefaclor ...... 6 benazepril ...... 42 buspirone ...... 36 cefadroxil ...... 6 benazepril-hydrochlorothiazide butalbital-acetaminop-caf-cod cefazolin ...... 6 ...... 42 ...... 31 cefazolin in dextrose (iso-osm) BENDEKA ...... 15 butalbital-acetaminophen ..... 31 ...... 6 BENLYSTA ...... 74, 75 butalbital-acetaminophen-caff cefdinir ...... 6 benztropine ...... 27 ...... 31 cefepime ...... 6 BESIVANCE ...... 81 butalbital-aspirin-caffeine .... 31 cefepime in dextrose (iso-osm) BESPONSA ...... 15 butorphanol ...... 33 ...... 6 betamethasone dipropionate . 54 BYDUREON BCISE ...... 60 CEFEPIME IN DEXTROSE 5 betamethasone valerate ...... 54 BYETTA ...... 60 % ...... 6 betamethasone, augmented... 54 BYSTOLIC ...... 43 cefixime ...... 6 BETASERON ...... 70 C cefotetan ...... 6 betaxolol ...... 42, 82 CABENUVA ...... 2 CEFOTETAN IN DEXTROSE bethanechol chloride ...... 89 cabergoline ...... 64 (ISO-OSM) ...... 6 BETIMOL ...... 82 CABOMETYX ...... 15 cefoxitin ...... 6 BEVESPI AEROSPHERE ... 85 calcipotriene ...... 50 cefoxitin in dextrose (iso-osm) bexarotene ...... 15 calcipotriene-betamethasone 51 ...... 6 BEXSERO ...... 71 calcitonin (salmon) ...... 64 cefpodoxime ...... 6 bicalutamide ...... 15 calcitriol ...... 51, 64 cefprozil ...... 6 BICILLIN C-R ...... 11 calcium acetate(phosphat bind) ceftazidime ...... 7 BICILLIN L-A ...... 11 ...... 89 CEFTAZIDIME IN D5W ...... 7 BIKTARVY ...... 2 CALQUENCE ...... 15 ceftriaxone ...... 7 bisoprolol fumarate ...... 42 camila ...... 76 CEFTRIAXONE ...... 7 bisoprolol-hydrochlorothiazide camrese ...... 78 ceftriaxone in dextrose (iso- ...... 42 camrese lo ...... 78 osm) ...... 7 bleomycin ...... 15 candesartan ...... 43 cefuroxime axetil ...... 7 BLEPHAMIDE S.O.P...... 82 candesartan- cefuroxime sodium ...... 7 blisovi 24 fe ...... 78 hydrochlorothiazide ...... 43 celecoxib ...... 33 blisovi fe 1.5/30 (28) ...... 78 CAPLYTA...... 36 CELONTIN ...... 24 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 96 cephalexin...... 7 clindamycin phosphate .... 8, 52, colestipol ...... 48 CEREZYME ...... 64 77 colistin (colistimethate na) ..... 8 cetirizine ...... 84 CLINDAMYCIN COMBIGAN ...... 83 cevimeline ...... 56 PHOSPHATE ...... 52 COMBIPATCH ...... 76 CHANTIX ...... 58 clindamycin-benzoyl peroxide COMBIVENT RESPIMAT .. 86 CHANTIX CONTINUING ...... 53 COMETRIQ ...... 15 MONTH BOX ...... 58 CLINIMIX 5%/D15W COMPLERA ...... 2 CHANTIX STARTING SULFITE FREE ...... 90 compro ...... 67 MONTH BOX ...... 58 CLINIMIX 4.25%/D10W constulose ...... 67 chateal (28) ...... 78 SULFITE FREE ...... 91 COPIKTRA ...... 15 CHEMET ...... 56 CLINIMIX 4.25%/D5W CORLANOR ...... 49 chloramphenicol sod succinate SULFITE FREE ...... 56 COSENTYX ...... 51 ...... 8 CLINIMIX 5%-D20W COSENTYX (2 SYRINGES) chlorhexidine gluconate ...... 58 SULFITE FREE ...... 91 ...... 51 chloroquine phosphate...... 8 CLINIMIX 6%-D5W COSENTYX PEN ...... 51 chlorothiazide sodium ...... 43 (SULFITE-FREE) ...... 91 COSENTYX PEN (2 PENS) 51 chlorpromazine ...... 36 CLINIMIX 8%- COTELLIC ...... 15 chlorthalidone ...... 43 D10W(SULFITE-FREE) . 91 CRINONE ...... 76 CHOLBAM ...... 67 CLINIMIX 8%- cromolyn ...... 67, 82, 86 cholestyramine (with sugar) . 48 D14W(SULFITE-FREE) . 91 cryselle (28) ...... 78 cholestyramine light ...... 48 CLINIMIX E 2.75%/D5W cyclafem 1/35 (28) ...... 78 CHORIONIC SULFITE FREE ...... 56 cyclafem 7/7/7 (28) ...... 78 GONADOTROPIN, CLINIMIX E 4.25%/D10W cyclobenzaprine ...... 30 HUMAN ...... 64 SULFITE FREE ...... 91 cyclophosphamide ...... 16 ciclopirox ...... 53 CLINIMIX E 4.25%/D5W CYCLOSET ...... 60 cidofovir ...... 2 SULFITE FREE ...... 91 cyclosporine ...... 16 cilostazol...... 46 CLINIMIX E 5%/D15W cyclosporine modified ...... 16 CIMDUO ...... 2 SULFITE FREE ...... 91 cyproheptadine ...... 84 cimetidine ...... 69 CLINIMIX E 5%/D20W CYRAMZA ...... 16 cimetidine hcl ...... 69 SULFITE FREE ...... 91 CYSTADANE ...... 67 cinacalcet ...... 64 CLINIMIX E 8%-D10W CYSTAGON ...... 89 CINRYZE ...... 86 SULFITEFREE ...... 91 CYSTARAN ...... 82 CIPRODEX ...... 59 CLINIMIX E 8%-D14W cytarabine ...... 16 ciprofloxacin hcl ...... 12, 81 SULFITEFREE ...... 91 cytarabine (pf) ...... 16 ciprofloxacin in 5 % dextrose clobazam ...... 24 D ...... 12 clofarabine ...... 15 d10 %-0.45 % sodium chloride ciprofloxacin-dexamethasone clomipramine ...... 36 ...... 56 ...... 59 clonazepam ...... 24, 25 d2.5 %-0.45 % sodium cisplatin ...... 15 clonidine ...... 43 chloride ...... 56 citalopram ...... 36 clonidine hcl ...... 36, 43 d5 % and 0.9 % sodium cladribine ...... 15 clopidogrel ...... 46 chloride ...... 56 claravis ...... 52 clorazepate dipotassium ...... 36 d5 %-0.45 % sodium chloride clarithromycin ...... 7 clotrimazole ...... 1, 53 ...... 56 clemastine ...... 84 clotrimazole-betamethasone . 53 dacarbazine ...... 16 CLEOCIN ...... 77 clozapine ...... 36 dalfampridine ...... 29 clindamycin hcl ...... 8 COARTEM ...... 8 DALIRESP ...... 86 clindamycin pediatric ...... 8 codeine sulfate ...... 31 danazol ...... 64 colesevelam ...... 48 dantrolene ...... 30 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 97 dapsone ...... 8 dextrose 5 %-lactated ringers56 dronabinol ...... 67 DAPTACEL (DTAP dextrose 5%-0.2 % sod drospirenone-e.estradiol-lm.fa PEDIATRIC) (PF) ...... 72 chloride ...... 56 ...... 78 daptomycin ...... 8 dextrose 5%-0.3 % drospirenone-ethinyl estradiol DARZALEX ...... 16 sod.chloride ...... 57 ...... 78 dasetta 1/35 (28) ...... 78 dextrose 50 % in water (d50w) DROXIA ...... 16 dasetta 7/7/7 (28) ...... 78 ...... 57 droxidopa ...... 57 daunorubicin ...... 16 dextrose 70 % in water (d70w) DULERA ...... 86 DAURISMO...... 16 ...... 57 duloxetine ...... 37 daysee ...... 78 DIACOMIT ...... 25 DUPIXENT PEN ...... 51 decitabine ...... 16 diazepam ...... 25, 37 DUPIXENT SYRINGE ...... 51 deferasirox ...... 56 diazepam intensol ...... 37 dutasteride ...... 89 deferiprone ...... 56 diazoxide ...... 60 dutasteride-tamsulosin ...... 89 DELSTRIGO ...... 2 DICLOFENAC EPOLAMINE E demeclocycline ...... 13 ...... 33 ec-naproxen ...... 34 DEMSER ...... 43 diclofenac potassium ...... 33 econazole ...... 53 DENAVIR ...... 54 diclofenac sodium.... 33, 34, 51, EDURANT ...... 2 denta 5000 plus...... 58 83 efavirenz ...... 2 dentagel ...... 58 diclofenac-misoprostol ...... 34 efavirenz-emtricitabin-tenofov DEPO-SUBQ PROVERA 104 dicloxacillin ...... 11 ...... 2 ...... 76 dicyclomine ...... 66 efavirenz-lamivu-tenofov disop DESCOVY ...... 2 didanosine ...... 2 ...... 2 desipramine ...... 36 diflunisal ...... 34 EGRIFTA SV ...... 70 desloratadine...... 84 digitek ...... 50 ELAPRASE ...... 65 desmopressin ...... 64, 65 digox ...... 50 electrolyte-48 in d5w ...... 91 desog-e.estradiol/e.estradiol . 78 digoxin ...... 50 ELELYSO ...... 65 desoximetasone ...... 54 dihydroergotamine...... 28 ELIGARD ...... 16 desvenlafaxine succinate ...... 36 DILANTIN 30 MG ...... 25 ELIGARD (3 MONTH) ...... 16 dexamethasone ...... 59 diltiazem hcl ...... 43 ELIGARD (4 MONTH) ...... 16 dexamethasone intensol...... 59 dilt-xr ...... 43 ELIGARD (6 MONTH) ...... 16 dexamethasone sodium phos dimethyl fumarate...... 29 elinest ...... 78 (pf) ...... 59 diphenhydramine hcl ...... 84 ELIQUIS ...... 47 dexamethasone sodium disulfiram...... 57 ELIQUIS DVT-PE TREAT phosphate ...... 59, 84 divalproex ...... 25 30D START ...... 46 dexmethylphenidate ...... 36 dofetilide ...... 41 ELITEK ...... 14 dexrazoxane hcl ...... 14 DOJOLVI ...... 91 ELLA ...... 78 dextroamphetamine ...... 36 donepezil ...... 29 ELMIRON ...... 89 dextroamphetamine- dorzolamide ...... 83 EMCYT ...... 16 amphetamine ...... 37 dorzolamide-timolol ...... 83 EMEND ...... 67 dextrose 10 % and 0.2 % nacl DOVATO ...... 2 EMGALITY PEN ...... 28 ...... 56 doxazosin ...... 43 EMGALITY SYRINGE ...... 28 dextrose 10 % in water (d10w) doxepin ...... 37 emoquette ...... 78 ...... 56 doxorubicin ...... 16 EMPLICITI ...... 16 dextrose 25 % in water (d25w) doxorubicin, peg-liposomal .. 16 EMSAM ...... 37 ...... 56 doxy-100 ...... 13 emtricitabine ...... 2 dextrose 30 % in water (d30w) doxycycline hyclate ...... 13 emtricitabine-tenofovir (tdf) ... 3 ...... 56 doxycycline monohydrate .... 13 EMTRIVA ...... 3 dextrose 5 % in water (d5w) 56 DRIZALMA SPRINKLE ..... 37 enalapril maleate ...... 43 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 98 enalapril-hydrochlorothiazide eszopiclone ...... 37 finasteride ...... 89 ...... 43 ethambutol ...... 8 FINTEPLA ...... 25 ENBREL ...... 75 ethosuximide ...... 25 flavoxate ...... 88 ENBREL MINI ...... 75 etodolac ...... 34 flecainide ...... 42 ENBREL SURECLICK ...... 75 etoposide ...... 17 FLOVENT DISKUS ...... 86 ENDARI ...... 57 etravirine ...... 3 FLOVENT HFA ...... 86 endocet ...... 31 everolimus (antineoplastic) .. 17 fluconazole ...... 1 ENGERIX-B (PF) ...... 72 everolimus fluconazole in nacl (iso-osm) . 1 ENGERIX-B PEDIATRIC (immunosuppressive) ...... 17 flucytosine ...... 1 (PF) ...... 72 EVOTAZ ...... 3 fludarabine ...... 17 enoxaparin ...... 47 EVRYSDI ...... 29 fludrocortisone ...... 59 enpresse ...... 78 exemestane ...... 17 flunisolide ...... 86 enskyce ...... 78 EXSERVAN ...... 57 fluocinolone ...... 55 ENSPRYNG ...... 16 EXTAVIA ...... 70 fluocinolone acetonide oil .... 58 entacapone ...... 28 ezetimibe ...... 49 fluocinolone and shower cap 54 entecavir ...... 3 ezetimibe-simvastatin ...... 49 fluoride (sodium) ...... 92 ENTRESTO ...... 50 F fluorometholone ...... 84 enulose ...... 67 FABRAZYME ...... 65 fluorouracil ...... 17, 51 ENVARSUS XR ...... 16 falmina (28) ...... 79 fluoxetine ...... 37 EPCLUSA ...... 3 famciclovir...... 3 fluoxetine (pmdd) ...... 37 EPIDIOLEX ...... 25 famotidine ...... 69 fluphenazine decanoate ...... 37 epinastine ...... 82 famotidine (pf) ...... 69 fluphenazine hcl ...... 37 epinephrine ...... 84 famotidine (pf)-nacl (iso-osm) flurbiprofen ...... 34 EPINEPHRINE ...... 84 ...... 69 flurbiprofen sodium ...... 83 epirubicin ...... 17 FANAPT ...... 37 flutamide ...... 17 epitol ...... 25 FARXIGA ...... 60 fluticasone propionate .... 55, 86 EPIVIR HBV...... 3 FARYDAK ...... 17 fluticasone propion-salmeterol eplerenone ...... 44 FASLODEX ...... 17 ...... 86 ergoloid...... 37 febuxostat ...... 74 fluvoxamine ...... 38 ERIVEDGE ...... 17 felbamate ...... 25 fomepizole ...... 72 ERLEADA ...... 17 felodipine ...... 44 fondaparinux ...... 47 erlotinib ...... 17 fenofibrate ...... 49 formoterol fumarate ...... 86 errin ...... 76 fenofibrate micronized ...... 49 FORTEO ...... 74 ertapenem ...... 8 fenofibrate nanocrystallized . 49 fosamprenavir ...... 3 ery pads ...... 53 fenofibric acid...... 49 fosinopril ...... 44 ERYTHROCIN ...... 8 fenofibric acid (choline) ...... 49 fosinopril-hydrochlorothiazide erythrocin (as stearate) ...... 8 fenoprofen ...... 34 ...... 44 erythromycin ...... 8, 81 fentanyl ...... 31 fosphenytoin ...... 25 erythromycin ethylsuccinate .. 8 fentanyl citrate ...... 31 FOTIVDA ...... 17 erythromycin with ethanol ... 53 FERRIPROX ...... 57 FRAGMIN ...... 47 erythromycin-benzoyl peroxide FERRIPROX (2 TIMES A fulvestrant ...... 17 ...... 53 DAY) ...... 57 furosemide ...... 44 ESBRIET ...... 86 FETZIMA ...... 37 FUZEON ...... 3 escitalopram oxalate ...... 37 FIASP FLEXTOUCH U-100 FYCOMPA ...... 25 esomeprazole sodium ...... 69 INSULIN ...... 61 G estarylla ...... 78 FIASP PENFILL U-100 gabapentin ...... 25 estradiol ...... 76, 77 INSULIN ...... 61 GALAFOLD ...... 65 estradiol valerate ...... 77 FIASP U-100 INSULIN ...... 61 galantamine ...... 29 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

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GAMMAGARD LIQUID .... 72 guanfacine ...... 38 hydrocodone-acetaminophen GAMMAGARD S-D (IGA < 1 GVOKE HYPOPEN 1-PACK ...... 31, 32 MCG/ML) ...... 72 ...... 61 hydrocodone-ibuprofen ...... 32 GAMUNEX-C ...... 72 GVOKE HYPOPEN 2-PACK hydrocortisone ...... 55, 59, 67 ganciclovir sodium ...... 3 ...... 61 hydrocortisone butyrate ...... 55 GARDASIL 9 (PF) ...... 72 GVOKE PFS 1-PACK hydrocortisone butyr-emollient gatifloxacin ...... 81 SYRINGE ...... 61 ...... 55 GATTEX 30-VIAL ...... 67 GVOKE PFS 2-PACK hydrocortisone valerate ...... 55 GATTEX ONE-VIAL ...... 67 SYRINGE ...... 61 hydrocortisone-acetic acid .... 59 GAUZE PAD ...... 61 H hydromorphone ...... 32 gavilyte-c ...... 67 haloperidol ...... 38 hydromorphone (pf) ...... 32 gavilyte-g ...... 67 haloperidol decanoate ...... 38 hydroxychloroquine ...... 9 gavilyte-n ...... 67 haloperidol lactate ...... 38 hydroxyprogesterone caproate GAVRETO ...... 17 HARVONI...... 3 ...... 77 GAZYVA ...... 17 HAVRIX (PF) ...... 72 hydroxyurea ...... 17 GELNIQUE ...... 88 heather ...... 77 hydroxyzine hcl ...... 84 gemcitabine ...... 17 HEMADY ...... 59 I gemfibrozil ...... 49 heparin (porcine) ...... 47 ibandronate ...... 74 generlac ...... 67 heparin (porcine) in 5 % dex 47 IBRANCE ...... 17 gengraf ...... 17 heparin (porcine) in nacl (pf) 47 ibu ...... 34 gentak ...... 81 heparin(porcine) in 0.45% nacl ibuprofen ...... 34 gentamicin ...... 9, 53, 81 ...... 48 icatibant ...... 86 gentamicin in nacl (iso-osm) .. 9 HEPARIN(PORCINE) IN ICLUSIG ...... 17, 18 GENTAMICIN IN NACL 0.45% NACL ...... 48 icosapent ethyl ...... 49 (ISO-OSM) ...... 9 heparin, porcine (pf) ...... 48 idarubicin ...... 18 GENVOYA ...... 3 HEPATAMINE 8% ...... 91 IDHIFA ...... 18 GEODON ...... 38 HETLIOZ ...... 38 ifosfamide ...... 18 GILENYA ...... 29 HETLIOZ LQ ...... 38 ILEVRO ...... 83 GILOTRIF ...... 17 HIBERIX (PF) ...... 72 imatinib ...... 18 glatiramer ...... 29 HUMIRA ...... 75 IMBRUVICA ...... 18 glatopa ...... 29 HUMIRA PEN ...... 75 IMFINZI ...... 18 glimepiride ...... 61 HUMIRA PEN CROHNS-UC- imipenem-cilastatin ...... 9 glipizide ...... 61 HS START ...... 75 imipramine hcl ...... 38 glipizide-metformin ...... 61 HUMIRA PEN PSOR- imipramine pamoate ...... 38 GLUCAGEN HYPOKIT ..... 61 UVEITS-ADOL HS ...... 75 imiquimod ...... 51 GLUCAGON (HCL) HUMIRA(CF) ...... 76 IMOVAX RABIES VACCINE EMERGENCY KIT ...... 61 HUMIRA(CF) PEDI (PF) ...... 72 glucagon emergency kit CROHNS STARTER ...... 75 INCRELEX ...... 57 (human) ...... 61 HUMIRA(CF) PEN ...... 75, 76 INCRUSE ELLIPTA ...... 86 glyburide...... 61 HUMIRA(CF) PEN indapamide ...... 44 glyburide micronized...... 61 CROHNS-UC-HS ...... 75 indomethacin ...... 34 glyburide-metformin ...... 61 HUMIRA(CF) PEN INFANRIX (DTAP) (PF) ..... 72 glycopyrrolate...... 66 PEDIATRIC UC...... 75 INGREZZA ...... 29 granisetron (pf) ...... 67 HUMIRA(CF) PEN PSOR- INGREZZA INITIATION granisetron hcl ...... 67 UV-ADOL HS ...... 75 PACK ...... 29 GRANIX ...... 70 hydralazine ...... 44 INLYTA ...... 18 griseofulvin microsize ...... 1 hydrochlorothiazide ...... 44 INQOVI ...... 18 griseofulvin ultramicrosize ..... 1 INREBIC ...... 18 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 100

INSULIN PEN NEEDLE ..... 61 junel fe 24 ...... 79 latanoprost ...... 83 INSULIN SYRINGE (DISP) JUXTAPID ...... 49 LATUDA ...... 38 U-100 ...... 61 JYNARQUE ...... 65 layolis fe ...... 79 INTELENCE ...... 3 K leflunomide ...... 76 intralipid ...... 91 KADCYLA ...... 18 LENVIMA ...... 19 INTRALIPID ...... 91 KALETRA ...... 3 lessina ...... 79 INTRON A ...... 70 KALYDECO ...... 86 letrozole ...... 19 introvale ...... 79 KANJINTI ...... 18 leucovorin calcium ...... 14 INVEGA SUSTENNA ...... 38 kariva (28) ...... 79 LEUKERAN ...... 19 INVIRASE ...... 3 kelnor 1/35 (28) ...... 79 LEUKINE ...... 70 IONOSOL-MB IN D5W ...... 91 KENALOG ...... 59 leuprolide ...... 19 IPOL ...... 72 ketoconazole ...... 1, 53, 54 levalbuterol hcl ...... 86, 87 ipratropium bromide ...... 58, 86 ketoprofen ...... 34 LEVEMIR FLEXTOUCH U- ipratropium-albuterol ...... 86 ketorolac ...... 83 100 INSULN ...... 62 irbesartan ...... 44 KEVEYIS ...... 29 LEVEMIR U-100 INSULIN 62 irbesartan-hydrochlorothiazide KEYTRUDA ...... 18 levetiracetam ...... 26 ...... 44 KINRIX (PF) ...... 72 levetiracetam in nacl (iso-osm) IRESSA ...... 18 KISQALI ...... 18, 19 ...... 26 irinotecan ...... 18 KISQALI FEMARA CO- levobunolol ...... 82 ISENTRESS ...... 3 PACK ...... 18 levocarnitine ...... 57 ISENTRESS HD ...... 3 klor-con ...... 89 levocarnitine (with sugar) ..... 57 ISOLYTE S PH 7.4 ...... 91 klor-con 10 ...... 89 levocetirizine ...... 84 ISOLYTE-P IN 5 % klor-con 8 ...... 89 levofloxacin ...... 12, 81 DEXTROSE ...... 91 klor-con m15 ...... 89 levofloxacin in d5w ...... 12 ISOLYTE-S ...... 91 klor-con m20 ...... 89 levoleucovorin calcium ...... 14 isoniazid ...... 9 KOMBIGLYZE XR ...... 62 levonest (28) ...... 79 isosorbide dinitrate ...... 50 KORLYM ...... 65 levonorgestrel-ethinyl estrad 79 isosorbide mononitrate ...... 50 KOSELUGO ...... 19 levonorg-eth estrad triphasic 79 isradipine ...... 44 k-tab ...... 89 levora-28 ...... 79 ISTODAX ...... 18 kurvelo (28) ...... 79 levothyroxine ...... 66 itraconazole ...... 1 KUVAN...... 65 levoxyl ...... 66 ivermectin ...... 9 KYPROLIS ...... 19 LEXIVA ...... 4 IXIARO (PF) ...... 72 L lidocaine ...... 52 J l norgest/e.estradiol-e.estrad . 79 lidocaine (pf) ...... 42, 51 JAKAFI ...... 18 labetalol ...... 44 lidocaine hcl ...... 51, 52 jantoven ...... 48 lactated ringers ...... 89 lidocaine viscous ...... 52 JANUMET ...... 61 lactulose ...... 67 lidocaine-prilocaine ...... 52 JANUMET XR ...... 62 lamivudine ...... 3 lindane ...... 55 JANUVIA ...... 62 lamivudine-zidovudine ...... 3 linezolid ...... 9 JARDIANCE ...... 62 lamotrigine...... 25 linezolid in dextrose 5% ...... 9 jencycla...... 77 LANOXIN ...... 50 linezolid-0.9% sodium chloride jinteli ...... 77 lansoprazole ...... 70 ...... 9 jolessa ...... 79 lanthanum ...... 57 LINZESS ...... 67 JULUCA ...... 3 LANTUS SOLOSTAR U-100 liothyronine ...... 66 junel 1.5/30 (21) ...... 79 INSULIN ...... 62 lisinopril ...... 44 junel 1/20 (21) ...... 79 LANTUS U-100 INSULIN .. 62 lisinopril-hydrochlorothiazide junel fe 1.5/30 (28) ...... 79 lapatinib ...... 19 ...... 44 junel fe 1/20 (28) ...... 79 larissia ...... 79 lithium carbonate ...... 38 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 101 lithium citrate ...... 38 MAVENCLAD (8 TABLET methylphenidate hcl ...... 38, 39 LONSURF ...... 19 PACK) ...... 30 methylprednisolone ...... 59 loperamide ...... 66 MAVENCLAD (9 TABLET methylprednisolone acetate .. 59 lopinavir-ritonavir ...... 4 PACK) ...... 30 methylprednisolone sodium lorazepam ...... 38 MAYZENT ...... 30 succ ...... 59 lorazepam intensol...... 38 MAYZENT STARTER PACK methyltestosterone ...... 65 LORBRENA ...... 19 ...... 30 metoclopramide hcl ...... 68 loryna (28) ...... 79 meclizine ...... 67 metolazone ...... 44 losartan ...... 44 medroxyprogesterone ...... 77 metoprolol succinate ...... 44 losartan-hydrochlorothiazide 44 mefloquine ...... 9 metoprolol tartrate ...... 44 lovastatin ...... 49 megestrol ...... 19 metoprolol tartrate- low-ogestrel (28) ...... 79 MEKINIST ...... 19 hydrochlorothiazide ...... 45 loxapine succinate ...... 38 MEKTOVI...... 19 metro i.v...... 9 LUCEMYRA ...... 34 meloxicam ...... 34 metronidazole ...... 9, 53, 77 LUMIGAN ...... 83 melphalan hcl ...... 19 metronidazole in nacl (iso- LUPRON DEPOT ...... 19 memantine ...... 30 osm) ...... 9 LUPRON DEPOT (3 MEMANTINE...... 30 metyrosine ...... 45 MONTH) ...... 19 MENACTRA (PF) ...... 72 mexiletine ...... 42 LUPRON DEPOT (4 MENQUADFI (PF) ...... 72 MIACALCIN ...... 65 MONTH) ...... 19 MENVEO A-C-Y-W-135-DIP miconazole-3 ...... 77 LUPRON DEPOT (6 (PF) ...... 73 microgestin 1.5/30 (21) ...... 79 MONTH) ...... 19 mercaptopurine ...... 20 microgestin 1/20 (21) ...... 79 LUPRON DEPOT-PED ...... 19 meropenem ...... 9 microgestin fe 1.5/30 (28) .... 79 LUPRON DEPOT-PED (3 MEROPENEM-0.9% microgestin fe 1/20 (28) ...... 80 MONTH) ...... 19 SODIUM CHLORIDE ...... 9 midodrine ...... 57 lutera (28) ...... 79 mesalamine ...... 68 migergot ...... 28 LYNPARZA...... 19 mesalamine with cleansing miglustat ...... 65 LYSODREN...... 19 wipe ...... 68 millipred ...... 59 lyza ...... 77 mesna ...... 14 minocycline ...... 13 M MESNEX...... 14 minoxidil ...... 45 magnesium sulfate ...... 89 metaproterenol ...... 87 mirtazapine ...... 39 malathion ...... 55 metaxalone...... 30 misoprostol ...... 70 maprotiline ...... 38 metformin ...... 62 MITIGARE ...... 74 marlissa (28) ...... 79 methadone ...... 32 mitomycin ...... 20 MARPLAN ...... 38 methadone intensol ...... 32 mitoxantrone ...... 20 MATULANE ...... 19 methadose ...... 32 M-M-R II (PF) ...... 73 matzim la ...... 44 methamphetamine ...... 38 modafinil ...... 39 MAVENCLAD (10 TABLET methazolamide ...... 83 moexipril ...... 45 PACK) ...... 29 methenamine hippurate ...... 13 molindone ...... 39 MAVENCLAD (4 TABLET methenamine mandelate ...... 13 mometasone ...... 55, 87 PACK) ...... 29 methimazole ...... 60 mono-linyah ...... 80 MAVENCLAD (5 TABLET methotrexate sodium ...... 20 montelukast ...... 87 PACK) ...... 29 methotrexate sodium (pf) ..... 20 morphine ...... 32, 33 MAVENCLAD (6 TABLET methoxsalen ...... 52 MORPHINE ...... 32 PACK) ...... 29 methscopolamine ...... 66 morphine (pf) ...... 32 MAVENCLAD (7 TABLET methyldopa- morphine concentrate ...... 32 PACK) ...... 30 hydrochlorothiazide ...... 44 MOVANTIK ...... 68 methylergonovine ...... 81 MOVIPREP ...... 68 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 102 moxifloxacin...... 12, 81 neo-polycin hc ...... 83 NOVOLOG FLEXPEN U-100 MOXIFLOXACIN- NERLYNX ...... 20 INSULIN ...... 62 SOD.ACE,SUL-WATER . 12 NEUPRO ...... 28 NOVOLOG MIX 70-30 U-100 moxifloxacin-sod.chloride(iso) nevirapine ...... 4 INSULN ...... 62 ...... 12 NEXAVAR ...... 20 NOVOLOG MIX 70- MOZOBIL ...... 70 niacin ...... 49 30FLEXPEN U-100 ...... 63 MULPLETA...... 48 nicardipine ...... 45 NOVOLOG PENFILL U-100 MULTAQ ...... 42 NICOTROL ...... 58 INSULIN ...... 63 mupirocin ...... 53 NICOTROL NS ...... 58 NOVOLOG U-100 INSULIN MVASI ...... 20 nifedipine ...... 45 ASPART ...... 63 mycophenolate mofetil ...... 20 nikki (28) ...... 80 NOVOTWIST ...... 63 mycophenolate mofetil (hcl) 20 nilutamide ...... 20 NOXAFIL ...... 1 mycophenolate sodium ...... 20 nimodipine ...... 45 NUBEQA ...... 20 MYLOTARG ...... 20 NINLARO ...... 20 NUEDEXTA ...... 30 MYRBETRIQ ...... 88 nitro-bid ...... 50 NULOJIX ...... 20 N nitrofurantoin macrocrystal .. 13 NUPLAZID ...... 39 nabumetone ...... 34 nitrofurantoin monohyd/m- NURTEC ODT ...... 28 nadolol ...... 45 cryst ...... 13 nyamyc ...... 54 nadolol-bendroflumethiazide 45 nitroglycerin ...... 50 nystatin ...... 1, 54 nafcillin...... 11 nizatidine ...... 70 nystatin-triamcinolone ...... 54 nafcillin in dextrose (iso-osm) NORDITROPIN FLEXPRO 70 nystop ...... 54 ...... 11 noreth-ethinyl estradiol-iron . 80 O NAGLAZYME...... 65 norethindrone (contraceptive) ocella ...... 80 nalbuphine ...... 34 ...... 77 octreotide acetate ...... 20 naloxone ...... 34 norethindrone acetate ...... 77 ODEFSEY ...... 4 naltrexone ...... 34 norgestimate-ethinyl estradiol ODOMZO ...... 20 naproxen ...... 34 ...... 80 OFEV ...... 87 naratriptan...... 28 NORMOSOL-R PH 7.4 ...... 92 ofloxacin ...... 12, 59, 81 NARCAN ...... 35 NORTHERA ...... 57 olanzapine ...... 39 NATACYN ...... 81 nortrel 0.5/35 (28)...... 80 olanzapine-fluoxetine ...... 39 nateglinide ...... 62 nortrel 1/35 (21)...... 80 olmesartan ...... 45 NATPARA ...... 65 nortrel 1/35 (28)...... 80 olmesartan-amlodipine- NAYZILAM ...... 26 nortrel 7/7/7 (28) ...... 80 hydrochlorothiazide ...... 45 necon 0.5/35 (28)...... 80 nortriptyline ...... 39 olmesartan- NEEDLES, INSULIN NORVIR ...... 4 hydrochlorothiazide ...... 45 DISP.,SAFETY ...... 62 NOVAREL ...... 65 olopatadine ...... 58, 82 nefazodone ...... 39 NOVOFINE...... 62 omega-3 acid ethyl esters ..... 49 neomycin ...... 9 NOVOLIN 70/30 U-100 omeprazole ...... 70 neomycin-bacitracin-poly-hc 83 INSULIN ...... 62 ondansetron ...... 68 neomycin-bacitracin- NOVOLIN 70-30 FLEXPEN ondansetron hcl ...... 68 polymyxin ...... 81 U-100 ...... 62 ondansetron hcl (pf) ...... 68 neomycin-polymyxin b gu ... 55 NOVOLIN N FLEXPEN ..... 62 ONGLYZA ...... 63 neomycin-polymyxin b- NOVOLIN N NPH U-100 ONUREG ...... 20 dexameth ...... 83 INSULIN ...... 62 OPDIVO ...... 21 neomycin-polymyxin- NOVOLIN R FLEXPEN...... 62 OPSUMIT ...... 87 gramicidin...... 81 NOVOLIN R REGULAR U- ORENCIA ...... 76 neomycin-polymyxin-hc 59, 83 100 INSULN ...... 62 ORENCIA CLICKJECT ...... 76 neo-polycin ...... 81 ORGOVYX ...... 21 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 103

ORIAHNN ...... 77 penicillin g sodium ...... 12 potassium chlorid-d5- ORILISSA ...... 65 penicillin v potassium ...... 12 0.45%nacl ...... 89 ORKAMBI ...... 87 PENNSAID ...... 35 potassium chloride ...... 90 ORLADEYO ...... 87 pentamidine ...... 9, 10 potassium chloride in 0.9%nacl orsythia ...... 80 pentoxifylline...... 48 ...... 89 oseltamivir ...... 4 PERFOROMIST ...... 87 potassium chloride in 5 % dex OTEZLA ...... 76 perindopril erbumine ...... 45 ...... 89 OTEZLA STARTER ...... 76 periogard ...... 58 potassium chloride in lr-d5 ... 90 oxacillin ...... 11, 12 PERJETA ...... 21 potassium chloride in water .. 90 oxacillin in dextrose(iso-osm) permethrin ...... 55 potassium chloride-0.45 % nacl ...... 11 perphenazine ...... 40 ...... 90 oxaliplatin ...... 21 perphenazine-amitriptyline ... 40 potassium chloride-d5- oxandrolone ...... 65 phenelzine ...... 40 0.2%nacl ...... 90 oxaprozin ...... 35 phenobarbital ...... 26 potassium chloride-d5- oxazepam ...... 40 phenoxybenzamine ...... 45 0.9%nacl ...... 90 oxcarbazepine ...... 26 phenytoin ...... 26 potassium citrate ...... 89 OXERVATE ...... 82 phenytoin sodium ...... 26 POTELIGEO ...... 21 oxybutynin chloride...... 88 phenytoin sodium extended .. 26 PRADAXA ...... 48 oxycodone ...... 33 philith...... 80 PRALUENT PEN ...... 49 oxycodone-acetaminophen ... 33 PIFELTRO ...... 4 pramipexole ...... 28 oxymorphone ...... 33 pilocarpine hcl ...... 57, 82 prasugrel ...... 48 OZEMPIC ...... 63 pimecrolimus ...... 52 pravastatin ...... 49 P pimozide ...... 40 prazosin ...... 45 pacerone ...... 42 pimtrea (28) ...... 80 prednicarbate ...... 55 paclitaxel ...... 21 pindolol ...... 45 prednisolone ...... 59 paliperidone ...... 40 pioglitazone ...... 63 prednisolone acetate ...... 84 pamidronate ...... 65 pioglitazone-glimepiride ...... 63 prednisolone sodium phosphate PANCREAZE ...... 68 pioglitazone-metformin ...... 63 ...... 60, 84 PANRETIN ...... 52 piperacillin-tazobactam ...... 12 prednisone ...... 60 pantoprazole ...... 70 PIPERACILLIN- prednisone intensol ...... 60 paricalcitol ...... 65 TAZOBACTAM ...... 12 pregabalin ...... 26 PARICALCITOL ...... 65 PIQRAY ...... 21 PREGNYL ...... 65 paroex oral rinse ...... 58 pirmella ...... 80 PREMARIN ...... 77 paromomycin ...... 9 piroxicam ...... 35 premasol 10 % ...... 92 paroxetine hcl ...... 40 PLASMA-LYTE 148 ...... 92 prenatal vitamin oral tablet ... 92 paroxetine PLASMA-LYTE A ...... 92 PRETOMANID ...... 10 mesylate(menop.sym) ...... 40 PLEGRIDY ...... 70, 71 prevalite ...... 49 PASER ...... 9 plenamine ...... 92 previfem ...... 80 PAXIL ...... 40 podofilox ...... 52 PREVYMIS ...... 4 PEDIARIX (PF) ...... 73 polycin ...... 81 PREZCOBIX ...... 4 PEDVAX HIB (PF) ...... 73 polyethylene glycol 3350 ..... 68 PREZISTA ...... 4 peg 3350-electrolytes ...... 68 polymyxin b sulfate ...... 10 PRIFTIN ...... 10 PEGASYS ...... 70 polymyxin b sulf-trimethoprim primaquine ...... 10 peg-electrolyte ...... 68 ...... 82 primidone ...... 26 PEMAZYRE ...... 21 POMALYST ...... 21 probenecid ...... 74 penicillamine ...... 76 portia 28 ...... 80 probenecid-colchicine ...... 74 penicillin g potassium...... 12 PORTRAZZA ...... 21 procainamide ...... 42 penicillin g procaine ...... 12 posaconazole ...... 1 PROCALAMINE 3% ...... 92 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 104 prochlorperazine ...... 68 REBIF TITRATION PACK . 71 RYDAPT ...... 21 prochlorperazine edisylate.... 68 reclipsen (28) ...... 80 S prochlorperazine maleate oral RECOMBIVAX HB (PF) .... 73 SAMSCA ...... 65 ...... 68 RECTIV...... 69 SANCUSO ...... 69 PROCRIT ...... 71 regonol ...... 30 SANDIMMUNE ...... 21 procto-pak...... 68 REGRANEX ...... 52 SANTYL ...... 52 proctosol hc ...... 69 RELENZA DISKHALER ...... 4 SAPHRIS ...... 40 proctozone-hc ...... 69 RELISTOR ...... 69 sapropterin ...... 65 progesterone micronized ...... 77 REMICADE ...... 69 scopolamine base ...... 69 PROGRAF ...... 21 repaglinide ...... 63 SECUADO ...... 40 PROLENSA ...... 83 REPATHA...... 49 selegiline hcl ...... 28 PROLIA ...... 74 REPATHA PUSHTRONEX 49 selenium sulfide ...... 51 PROMACTA ...... 48 REPATHA SURECLICK .... 49 SELZENTRY ...... 5 promethazine ...... 84 RESTASIS...... 82 SEREVENT DISKUS ...... 87 propafenone ...... 42 RESTASIS MULTIDOSE ... 82 sertraline ...... 40 propranolol ...... 45 RETACRIT ...... 71 sevelamer carbonate ...... 57 propranolol- RETEVMO ...... 21 sf 58 hydrochlorothiazide ...... 45 RETROVIR ...... 4 sf 5000 plus ...... 58 propylthiouracil ...... 60 REVLIMID ...... 21 SHINGRIX (PF) ...... 73 PROQUAD (PF) ...... 73 REXULTI ...... 40 SIGNIFOR ...... 21 PROSOL 20 % ...... 92 REYATAZ ...... 4 sildenafil (pulmonary arterial protriptyline ...... 40 RHOPRESSA ...... 83 hypertension) ...... 87 PULMOZYME ...... 87 ribavirin ...... 4 silver sulfadiazine ...... 52 PURIXAN ...... 21 rifabutin ...... 10 SIMULECT ...... 21 pyrazinamide ...... 10 rifampin ...... 10 simvastatin ...... 49 pyridostigmine bromide ...... 30 riluzole ...... 57 sirolimus ...... 22 pyrimethamine ...... 10 rimantadine ...... 4 SIRTURO ...... 10 Q ringer's ...... 90 SKYRIZI ...... 51 QINLOCK ...... 21 RINVOQ ...... 76 sodium chloride ...... 57, 90 QUADRACEL (PF) ...... 73 risedronate ...... 57, 74 sodium chloride 0.45 % ...... 90 quetiapine ...... 40 RISPERDAL CONSTA ...... 40 sodium chloride 0.9 % ...... 57 quinapril ...... 45 risperidone ...... 40 sodium chloride 3 % ...... 90 quinapril-hydrochlorothiazide ritonavir ...... 4 sodium chloride 5 % ...... 90 ...... 45 rivastigmine ...... 30 sodium polystyrene sulfonate quinidine gluconate ...... 42 rivastigmine tartrate ...... 30 ...... 57 quinidine sulfate ...... 42 rizatriptan...... 28 solifenacin ...... 88 quinine sulfate ...... 10 ROCKLATAN ...... 83 SOLTAMOX ...... 22 R ropinirole ...... 28 SOLU-CORTEF ACT-O- RABAVERT (PF) ...... 73 rosuvastatin ...... 49 VIAL (PF) ...... 60 RADICAVA ...... 30 ROTARIX ...... 73 SOMATULINE DEPOT ...... 22 raloxifene ...... 74 ROTATEQ VACCINE...... 73 SOMAVERT ...... 65 ramelteon ...... 40 roweepra ...... 26 sorine ...... 42 ramipril ...... 45 ROZLYTREK ...... 21 sotalol ...... 42 ranolazine ...... 50 RUBRACA ...... 21 sotalol af ...... 42 rasagiline ...... 28 rufinamide ...... 26 SPIRIVA RESPIMAT ...... 87 RAVICTI ...... 57 RUKOBIA ...... 5 SPIRIVA WITH REBIF (WITH ALBUMIN) . 71 RUXIENCE ...... 21 HANDIHALER ...... 87 REBIF REBIDOSE ...... 71 RYBELSUS...... 63 spironolactone ...... 45 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 105 spironolactone- tacrolimus ...... 22, 52 tilia fe ...... 80 hydrochlorothiazide ...... 45 tadalafil ...... 89 timolol maleate ...... 46, 82 sprintec (28)...... 80 tadalafil (pulm. hypertension) tinidazole ...... 10 SPRITAM ...... 26 ...... 87 TIVICAY ...... 5 SPRYCEL ...... 22 TAFINLAR ...... 22 TIVICAY PD ...... 5 sps (with sorbitol) ...... 57 TAGRISSO ...... 22 tizanidine ...... 31 sronyx ...... 80 TALZENNA ...... 22 TOBI PODHALER ...... 10 ssd ...... 52 tamoxifen ...... 22 tobramycin ...... 82 STAMARIL (PF) ...... 73 tamsulosin ...... 89 tobramycin in 0.225 % nacl .. 10 stavudine...... 5 TARGRETIN ...... 22 tobramycin sulfate ...... 10 STELARA ...... 51 TASIGNA ...... 22 tobramycin-dexamethasone .. 83 STIOLTO RESPIMAT ...... 87 tazarotene...... 53 tolcapone ...... 28 STIVARGA ...... 22 taztia xt ...... 45 tolmetin ...... 35 STREPTOMYCIN ...... 10 TAZVERIK ...... 22 TOLSURA ...... 1 STRIBILD ...... 5 TDVAX ...... 73 tolterodine ...... 88 sucralfate ...... 70 TECENTRIQ ...... 22 tolvaptan ...... 66 sulfacetamide sodium ...... 82 TECFIDERA ...... 30 TOLVAPTAN ...... 66 sulfacetamide sodium (acne) 53 TEFLARO ...... 7 topiramate ...... 27 sulfacetamide-prednisolone .. 82 TEGSEDI ...... 30 toposar ...... 22 sulfadiazine...... 13 TEKTURNA HCT ...... 45 topotecan ...... 23 sulfamethoxazole-trimethoprim telmisartan ...... 45 toremifene ...... 23 ...... 13 telmisartan- torsemide ...... 46 SULFAMYLON ...... 53 hydrochlorothiazide ...... 46 TOUJEO MAX U-300 sulfasalazine ...... 69 temazepam ...... 40 SOLOSTAR ...... 63 sulindac...... 35 TEMIXYS ...... 5 TOUJEO SOLOSTAR U-300 sumatriptan ...... 28, 29 TENIVAC (PF) ...... 73 INSULIN ...... 63 sumatriptan succinate ...... 29 tenofovir disoproxil fumarate . 5 TOVIAZ ...... 88 SUPRAX ...... 7 TEPMETKO ...... 22 TRACLEER ...... 88 SUTENT ...... 22 terazosin...... 46 tramadol ...... 35 syeda ...... 80 terbinafine hcl ...... 1 tramadol-acetaminophen ...... 35 SYMBICORT ...... 87 terbutaline ...... 87 trandolapril ...... 46 SYMDEKO ...... 87 terconazole...... 77 trandolapril-verapamil ...... 46 SYMFI ...... 5 testosterone ...... 66 tranexamic acid ...... 77 SYMFI LO ...... 5 testosterone cypionate .... 65, 66 tranylcypromine ...... 41 SYMLINPEN 120 ...... 63 testosterone enanthate ...... 66 travasol 10 % ...... 92 SYMLINPEN 60 ...... 63 TETANUS,DIPHTHERIA travoprost ...... 83 SYMPAZAN ...... 26 TOX PED(PF) ...... 73 TRAZIMERA ...... 23 SYMTUZA ...... 5 tetrabenazine ...... 30 trazodone ...... 41 SYNAGIS ...... 5 tetracycline ...... 13 TREANDA ...... 23 SYNAREL ...... 65 THALOMID ...... 22 TRECATOR ...... 10 SYNERCID ...... 10 theophylline ...... 87, 88 TRELEGY ELLIPTA ...... 88 SYNJARDY ...... 63 thioridazine ...... 40 TRELSTAR ...... 23 SYNJARDY XR ...... 63 thiotepa ...... 22 treprostinil sodium ...... 46 SYNRIBO ...... 22 thiothixene ...... 41 TRESIBA FLEXTOUCH U- SYNTHROID ...... 66 tiadylt er ...... 46 100 ...... 63 T tiagabine ...... 26 TRESIBA FLEXTOUCH U- TABLOID ...... 22 TIBSOVO ...... 22 200 ...... 64 TABRECTA ...... 22 tigecycline ...... 10 TRESIBA U-100 INSULIN . 64 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 106 tretinoin (antineoplastic) ...... 23 VALCHLOR ...... 52 VIZIMPRO ...... 23 tretinoin microspheres ...... 53 valganciclovir ...... 5 voriconazole ...... 1 tretinoin topical ...... 53 valproate sodium ...... 27 VOSEVI ...... 5 triamcinolone acetonide 55, 58, valproic acid ...... 27 VOTRIENT ...... 23 60 valproic acid (as sodium salt) VPRIV ...... 66 triamterene- ...... 27 VRAYLAR ...... 41 hydrochlorothiazide ...... 46 valsartan...... 46 VUMERITY ...... 30 triderm ...... 55 valsartan-hydrochlorothiazide VYNDAMAX ...... 50 trientine...... 58 ...... 46 VYNDAQEL ...... 50 tri-estarylla ...... 80 VALTOCO ...... 27 W trifluoperazine ...... 41 vancomycin ...... 10 warfarin ...... 48 trifluridine...... 82 VANCOMYCIN ...... 10 wera (28) ...... 81 trihexyphenidyl ...... 28 VANCOMYCIN IN 0.9 % wixela inhub ...... 88 TRIKAFTA ...... 88 SODIUM CHL ...... 10 wymzya fe ...... 81 tri-legest fe...... 80 VANCOMYCIN IN X tri-linyah ...... 80 DEXTROSE 5 % ...... 10 XALKORI ...... 23 trilyte with flavor packets ..... 69 vandazole ...... 77 XARELTO ...... 48 trimethoprim ...... 13 VAQTA (PF) ...... 74 XARELTO DVT-PE TREAT trimipramine ...... 41 VARIVAX (PF) ...... 74 30D START ...... 48 TRINTELLIX...... 41 VARIZIG...... 74 XATMEP ...... 23 tri-previfem (28) ...... 80 VARUBI ...... 69 XCOPRI ...... 27 tri-sprintec (28) ...... 80 VASCEPA ...... 49 XCOPRI MAINTENANCE TRIUMEQ ...... 5 VECAMYL ...... 50 PACK ...... 27 trivora (28)...... 80 VELCADE ...... 23 XCOPRI TITRATION PACK TROGARZO ...... 5 velivet triphasic regimen (28) ...... 27 TROPHAMINE 10 % ...... 92 ...... 80 XELJANZ ...... 76 trospium ...... 89 VENCLEXTA ...... 23 XELJANZ XR ...... 76 TRULANCE...... 69 VENCLEXTA STARTING XERMELO ...... 23 TRULICITY ...... 64 PACK ...... 23 XGEVA ...... 14 TRUMENBA ...... 73 venlafaxine ...... 41 XIFAXAN ...... 11 TRUVADA ...... 5 VENTOLIN HFA ...... 88 XIGDUO XR ...... 64 TUKYSA ...... 23 verapamil ...... 46 XOFLUZA ...... 5 TURALIO ...... 23 VERSACLOZ ...... 41 XOLAIR ...... 88 TWINRIX (PF) ...... 73 VERZENIO ...... 23 XOSPATA ...... 23 TYBLUME ...... 80 VICTOZA 2-PAK ...... 64 XPOVIO ...... 23 TYBOST ...... 5 VICTOZA 3-PAK ...... 64 XTANDI ...... 24 TYKERB ...... 23 vigabatrin ...... 27 XYREM ...... 41 TYMLOS ...... 74 VIIBRYD ...... 41 Y TYPHIM VI ...... 73 VIMPAT ...... 27 YERVOY ...... 24 TYSABRI ...... 30 vinblastine ...... 23 YF-VAX (PF) ...... 74 U vincasar pfs ...... 23 YONDELIS ...... 24 UBRELVY ...... 29 vincristine ...... 23 YONSA ...... 24 UKONIQ ...... 23 vinorelbine ...... 23 Z unithroid ...... 66 viorele (28) ...... 81 zafirlukast ...... 88 UPTRAVI ...... 46 VIRACEPT ...... 5 ZALTRAP ...... 24 ursodiol ...... 69 VIREAD ...... 5 zarah ...... 81 V VITRAKVI ...... 23 ZARXIO ...... 71 valacyclovir ...... 5 VIVITROL ...... 35 ZEJULA ...... 24 Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 107

ZELBORAF ...... 24 zoledronic acid-mannitol-water zovia 1/35e (28) ...... 81 ZENPEP ...... 69 ...... 58, 66 zovia 1-35 (28) ...... 81 zidovudine ...... 5, 6 ZOLINZA ...... 24 ZYDELIG ...... 24 ziprasidone hcl...... 41 zolmitriptan ...... 29 ZYKADIA ...... 24 ziprasidone mesylate ...... 41 zolpidem ...... 41 ZYPREXA RELPREVV ...... 41 ZIRABEV ...... 24 zonisamide ...... 27 ZYTIGA ...... 24 ZIRGAN ...... 82 ZORTRESS ...... 24 zoledronic acid ...... 66 ZOSTAVAX (PF) ...... 74

Brand-name drugs are CAPITALIZED. Generic drugs are lower-case italics. You can find information on what the symbols and abbreviations on this table mean by going to page viii.

This drug list was last updated on 08/20/2021. 108 175 Scott Swamp Road Farmington, CT 06032