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2021 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

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

Plans covered Cigna Preferred Medicare (HMO) Cigna Preferred Savings Medicare (HMO) Cigna True Choice Medicare (PPO) Cigna Alliance Medicare (HMO)

HPMS Approved Formulary File Submission ID 21121, Version 17 This formulary was updated on 09/01/2021. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m. local time, or visit CignaMedicare.com. The Formulary, pharmacy network, and/or provider network may change at any time. 21_F_07_EX_07_V09 September 2021 INT_21_87406_C_Final_2k

Note to existing customers: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,” it means Cigna Preferred Medicare (HMO), Cigna Preferred Savings Medicare (HMO), Cigna True Choice Medicare (PPO) and Cigna Alliance Medicare (HMO). This document includes a list of the drugs (formulary) for our plans, which is current as of September 2021. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2022, and from time to time during the year.

What is the Cigna Comprehensive Drug List? you can also find information in the section entitled “How do A drug list is a list of covered drugs selected by Cigna in I request an exception to the Cigna Drug List?” consultation with a team of health care providers, which • Drugs removed from the market. If the Food and Drug represents the prescription therapies believed to be a necessary Administration (FDA) deems a drug on our drug list to be part of a quality treatment program. Cigna will generally unsafe or the drug’s manufacturer removes the drug from the cover the drugs listed in our drug list as long as the drug market, we will immediately remove the drug from our drug is medically necessary, the prescription is filled at a Cigna list and provide notice to customers who take the drug. network pharmacy, and other plan rules are followed. For more • Other changes. We may make other changes that affect information on how to fill your prescriptions, please review your customers currently taking a drug. For instance, we may Evidence of Coverage. add a generic drug that is not new to the market to replace Can the Drug List (formulary) change? a brand name drug currently on the drug list; or add new Most changes in drug coverage happen on January 1, but we restrictions to the brand name drug or move it to a different may add or remove drugs on the drug list during the year, move cost-sharing tier or both. Or we may make changes based them to different cost-sharing tiers, or add new restrictions. We on new clinical guidelines and/or studies. If we remove drugs must follow Medicare rules in making these changes. from our drug list, add prior authorization, quantity limits, and/ or step therapy restrictions on a drug or move a drug to a Changes that can affect you this year. In the below cases, higher cost-sharing tier, we must notify affected customers you will be affected by coverage changes during the year: of the change at least 30 days before the change becomes • New generic drugs. We may immediately remove a brand effective, or at the time the customer requests a refill of the name drug on our drug list if we are replacing it with a new drug, at which time the customer will receive a 30-day supply generic drug that will appear on the same or lower cost- of the drug. sharing tier and with the same or fewer restrictions. Also, – If we make these other changes, you or your prescriber when adding the new generic drug, we may decide to keep can ask us to make an exception and continue to cover the the brand name drug on our drug list, but immediately move brand name drug for you. The notice we provide you will it to a different cost-sharing tier or add new restrictions. If you also include information on how to request an exception, are currently taking that brand name drug, we may not tell and you can also find information in the section below you in advance before we make that change, but we will later entitled “How do I request an exception to the Cigna provide you with information about the specific change(s) we Drug List?” have made. Changes that will not affect you if you are currently taking – If we make such a change, you or your prescriber can ask the drug. Generally, if you are taking a drug on our 2021 drug us to make an exception and continue to cover the brand list that was covered at the beginning of the year, we will not name drug for you. The notice we provide you will also discontinue or reduce coverage of the drug during the 2021 include information on how to request an exception, and coverage year except as described above. This means these

September 2021 1 drugs will remain available at the same cost-sharing and with will need to get approval from Cigna before you fill these no new restrictions for those customers taking them for the prescriptions. If you don’t get approval, Cigna may not cover remainder of the coverage year. You will not get direct notice the drug. this year about changes that do not affect you. However, on • Quantity Limits: For certain drugs, Cigna limits the amount January 1 of the next year, such changes would affect you, and of the drug that Cigna will cover. For example, Cigna allows it is important to check the drug list for the new benefit year for for 1 tablet per day for atorvastatin 40mg. This applies to a any changes to drugs. standard one-month supply (for total quantity of 30 per The enclosed drug list is current as of September 2021. To get 30 days) or three-month supply (for total quantity of 90 updated information about the drugs covered by Cigna, please per 90 days). contact us. Our contact information appears on the front and • Step Therapy: In some cases, Cigna requires you to first try back cover pages. If there are significant changes made to the certain drugs to treat your medical condition before we will printed drug list within the covered year, you may be notified by cover another drug for that condition. For example, if Drug A mail identifying the changes. Drug lists located on our website and Drug B both treat your medical condition, Cigna may not are reviewed and updated on a monthly basis. cover Drug B unless you try Drug A first. If Drug A does not How do I use the Drug List? work for you, Cigna will then cover Drug B. There are two ways to find your drug within the drug list: • Non-Extended Days Supply: For certain drugs, Cigna limits the amount of the drug that Cigna will cover to only a 30-day Medical Condition supply or less, at one time. For example, customers who The drug list begins on page 9. The drugs in this drug list are have not had any recent fill of opioid pain medications within grouped into categories depending on the type of medical the past 108 days (referred to as “opioid naïve”) are limited conditions that they are used to treat. For example, drugs to a maximum of 7 days’ supply of opioid pain medication. used to treat a heart condition are listed under the category, Customers who have received a recent fill of an opioid pain “CARDIOVASCULAR, HYPERTENSION / LIPIDS.” If you know medication (not opioid naïve) are limited to up to a month’s what your drug is used for, look for the category name in the list supply of that medication at one time. Other high cost drugs that begins on page 9. Then look under the category name for may be subject to a non-extended day supply restriction, your drug. as well. Covered Drug Index You can find out if your drug has any additional requirements If you are not sure what category to look under, you should look or limits by looking in the drug list that begins on page 9. You for your drug in the Covered Drugs Index that begins on page can also get more information about the restrictions applied to 57. The Covered Drugs Index provides an alphabetical list of all specific covered drugs by visiting our website. We have posted of the drugs included in this document. Both brand name drugs online documents that explain our prior authorization and step and generic drugs are listed in the Index. Look in the Index and therapy restrictions. You may also ask us to send you a copy. find your drug. Next to your drug, you will see the page number Our contact information, along with the date we last updated the where you can find coverage information. Turn to the page drug list, appears on the front and back cover pages. listed in the Covered Drug Index and find the name of your drug in the drug name column of the list. You can ask Cigna to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat What are generic drugs? your health condition. See the section, “How do I request an Cigna covers both brand name drugs and generic drugs. A exception to the Cigna drug list?” on page 3 for information generic drug is approved by the FDA as having the same active about how to request an exception. ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Options for Maintenance Medications Taking the medications prescribed by your doctor (or other Are there any restrictions on my coverage? prescriber) is important to your health. Some covered drugs may have additional requirements or limits We are committed to helping you control your chronic conditions on coverage. These requirements and limits may include: by making it easy for you to receive your maintenance • Prior Authorization: Cigna requires you or your doctor to medications. There are several ways we can work together get prior authorization for certain drugs. This means that you to accomplish this goal:

September 2021 2 • Talk with your doctor about whether a 90-day supply of your cost-sharing level, and you would not be able to ask us to ongoing, stable medications may be appropriate. Taking provide the drug at a lower cost-sharing level. these medications every day as prescribed is important for • You can ask us to waive coverage restrictions or limits on your overall health, and getting 90-day prescriptions of these your drug. For example, for certain drugs, Cigna limits the medications can help ensure that you do not miss a dose. amount of the drug that we will cover. If your drug has a • You can receive a 90-day supply at most retail pharmacies or quantity limit, you can ask us to waive the limit and cover a through one of our mail-order pharmacies. greater amount. • Talk to your pharmacist if you are experiencing any new • You can ask us to provide a tiering exception for a higher challenges with your maintenance medications. cost-sharing drug to be covered at a lower cost-sharing tier under following circumstances: How can I use my prescription drug coverage to save money on my medications? – If the drug you’re taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount There may be opportunities for you to save money on your that applies to the lowest tier that contains brand name medications using your Cigna coverage. alternatives for treating your condition. • Ask your doctor (or other prescriber) if there are any lower- – If the drug you’re taking is a generic drug you can ask us cost generic alternatives available for any of your current to cover your drug at the cost-sharing amount that applies medications. to the lowest tier that contains either brand or generic • Some plans may offer a $0 copay for Tier 1 and 2 generic alternatives for treating your condition. drugs filled at a preferred retail and/or mail-order pharmacies. – If the drug you’re taking is a biological product you can Check the Drug Tier and Cost-share Tables on page 5 to see ask us to cover your drug at the cost-sharing amount that if your plan offers these savings. applies to the lowest tier that contains biological product • Explore whether the ‘CMS Extra Help’ program may offer alternatives for treating your condition. additional financial support for your medications. These exceptions would lower the amount you must pay for • If your medication is not covered in the Cigna drug list, talk your drug. with your doctor about alternative medications which are Please note, if we grant your request to cover a drug that is covered in the drug list. not in our drug list, you may not ask us to provide a higher What if my drug is not on the Drug List? level of coverage for the drug. Also, you may not ask us to If your drug is not included in this drug list, you should first provide a higher level of coverage for drugs that are in the contact Customer Service and ask if your drug is covered. Specialty tier. If you learn that Cigna does not cover your drug, you have Generally, Cigna will only approve your request for an exception two options: if the alternative drugs included in our drug list, the lower cost- • You can ask Customer Service for a list of similar drugs that sharing drug or additional utilization restrictions would not be as are covered by Cigna. When you receive the list, show it to effective in treating your condition and/or would cause you to your doctor and ask him or her to prescribe a similar drug that have adverse medical effects. is covered by Cigna. You should contact us to ask us for an initial coverage decision • You can ask Cigna to make an exception and cover your for a drug list, tiering or utilization restriction exception. When drug. See the next section for information about how to you request a drug list, tiering or utilization restriction request an exception. exception you should submit a statement from your prescriber or doctor supporting your request. Generally, How do I request an exception to the Cigna Drug List? we must make our decision within 72 hours of getting your You can ask Cigna to make an exception to our coverage prescriber’s supporting statement. You can request an rules. There are several types of exceptions that you can ask expedited (fast) exception if you or your doctor believe that your us to make. health could be seriously harmed by waiting up to 72 hours for • You can ask us to cover a drug even if it is not on our drug a decision. If your request to expedite is granted, we must give list. If approved, this drug will be covered at a pre-determined you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

September 2021 3 What do I do before I can talk to my doctor about changing Cigna’s Drug List my drugs or requesting an exception? The comprehensive drug list that begins on page 9 provides As a new or existing customer in our plan you may be taking coverage information about all of the drugs covered by Cigna. If drugs that are not on our drug list. Or, you may be taking a drug you have trouble finding your drug in the list, turn to the Covered that is on our drug list but your ability to get it is limited. For Drug Index that begins on page 57. example, you may need a prior authorization from us before The first column of the chart lists the drug name. Brand name you can fill your prescription. You should talk to your doctor drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic to decide if you should switch to an appropriate drug that we drugs are listed in lower-case italics (e.g., atorvastatin). cover or request a drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the The information in the Requirements/Limits column tells you if right course of action for you, we may cover your drug up to a Cigna has any special requirements for coverage of your drug. 30-day supply, in certain cases during the first 90 days you are Some Cigna plans offer additional prescription drug coverage in a customer of our plan. the coverage gap. Please refer to your Evidence of Coverage to For each of your drugs that is not on our drug list or if your see if your plan has this coverage and for more information. ability to get your drugs is limited, we will cover a temporary We provide quantity limits on certain drugs which are indicated 30-day supply. If your prescription is written for fewer days, with a QL in the Covered Drugs by Category list on page 9 we’ll allow refills to provide up to a maximum 30-day supply of along with the amount dispensed per the days supplied. (For medication. After your first 30-day supply, we will not pay for example: atorvastatin 40mg QL 30/30; this means the drug these drugs without a drug list exception, even if you have been atorvastatin 40mg is limited to 30 tablets per 30 days. For a customer of the plan less than 90 days. 90-day supplies, this quantity limit would be expanded to If you are a resident of a long-term care facility and you need a 90 tablets per 90 days). drug that is not on our drug list or if your ability to get your drugs What is a preferred network pharmacy? is limited, but you are past the first 90 days of membership in If your plan has preferred network pharmacies, you will typically our plan, we will cover a 31-day emergency supply of that drug save money by using these pharmacies. Your prescription while you pursue a drug list exception. drug costs (like a copay or coinsurance) will typically be less In order to accommodate unexpected transitions of our at a preferred network pharmacy because it has a preferred customers that do not leave time for advanced planning, such agreement with your plan. If you need help finding a network as level-of-care changes due to discharge from a hospital to a pharmacy, please call Customer Service at 1-800-668-3813 nursing facility or to a home, Cigna will allow a one-time 31-day (TTY 711), or you can visit CignaMedicare.com for the most supply (unless the prescription is written for fewer days). current Pharmacy Directory.

For more information For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

September 2021 4 Drug Tier and Cost-Share Table the name “Tier 3: Preferred Brand Drugs” is just a description of The following table represents the plan name, plan service the majority of the drugs in the tier. It does not mean that there area, the drug tier number as it appears on the drug list, and the are only brand drugs in that tier. cost-share amount for that tier number. Tier 1 is for Preferred For customers receiving Extra Help: Your Low Income Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Subsidy (LIS) copay level will be based on how the Food Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for and Drug Administration (FDA) classifies certain drugs. Due Specialty tier drugs. Please refer to the following chart. You to this, a generic drug may receive a preferred brand copay, may also refer to your Evidence of Coverage document for or a preferred brand drug may receive a generic drug copay. additional details. Please see your LIS Rider for additional information on these Cigna is not always able to keep all generic medications in the copay levels. Or call Customer Service for further clarification Preferred Generic and Generic drug tiers, and some generic regarding a specific drug. medications may be in Tier 3, Tier 4 or Tier 5. Keep in mind that

To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll. If you qualified for Extra Help with your drug costs, your costs may be different from those described below. Please refer to your Evidence of Coverage (EOC) or call Customer Service to find out what your costs are. Cigna uses preferred network pharmacies. See your Pharmacy Directory or visit CignaMedicare.com to search for a preferred retail or mail-order pharmacy near you.

Service Area: Florida H5410-029 – Cigna Preferred Medicare (HMO): Hernando, Hillsborough, Manatee, Pasco and Pinellas, Florida Preferred Retail Standard Retail Preferred Mail-Order Standard Mail-Order Cost-Sharing Cost-Sharing Cost-Sharing Cost-Sharing Drug Tier 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days Tier 1: Preferred Generic Drugs (GC) $0 / $0 / $0 $10 / $20 / $30 $0 / $0 / $0 $10 / $20 / $30 Tier 2: Generic Drugs $0 / $0 / $0 $20 / $40 / $60 $0 / $0 / $0 $20 / $40 / $60 Tier 3: Preferred Brand Drugs $35 / $70 / $105 $47 / $94 / $141 $35 / $70 / $105 $47 / $94 / $141 Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $95 / $190 / $285 $100 / $200 / $300 Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. September 2021 5 Service Area: Florida H5410-030 – Cigna Preferred Savings Medicare (HMO): Hernando, Hillsborough, Manatee, Pasco and Pinellas, Florida Preferred Retail Standard Retail Preferred Mail-Order Standard Mail-Order Cost-Sharing Cost-Sharing Cost-Sharing Cost-Sharing Drug Tier 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days Tier 1: Preferred Generic Drugs (GC) $0 / $0 / $0 $7 / $14 / $21 $0 / $0 / $0 $7 / $14 / $21 Tier 2: Generic Drugs $4 / $8 / $8 $9 / $18 / $27 $4 / $8 / $0 $9 / $18 / $27 Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $126 $47 / $94 / $141 Tier 4: Non-Preferred Drugs $95 / $190 / $285 $100 / $200 / $300 $95 / $190 / $285 $100 / $200 / $300 Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

Service Area: Florida (Treasure Coast) H7849-014 – Cigna True Choice Medicare (PPO): Indian River, Martin and St. Lucie, Florida Preferred Retail Standard Retail Preferred Mail-Order Standard Mail-Order Cost-Sharing Cost-Sharing Cost-Sharing Cost-Sharing Drug Tier 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days Tier 1: Preferred Generic Drugs (GC) $0 / $0 / $0 $10 / $20 / $30 $0 / $0 / $0 $10 / $20 / $30 Tier 2: Generic Drugs (GC) $10 / $20 / $30 $20 / $40 / $60 $10 / $20 / $30 $20 / $40 / $60 Tier 3: Preferred Brand Drugs $45 / $90 / $135 $47 / $94 / $141 $45 / $90 / $135 $47 / $94 / $141 Tier 4: Non-Preferred Drugs $100 / $200 / $300 $100 / $200 / $300 $100 / $200 / $300 $100 / $200 / $300 Tier 5: Specialty Tier 30% (30 days) 30% (30 days) 30% (30 days) 30% (30 days)

Service Area: Tennessee H4513-042 – Cigna Alliance Medicare (HMO): Davidson, Sumner, Williamson and Wilson, Tennessee Preferred Retail Standard Retail Preferred Mail-Order Standard Mail-Order Cost-Sharing Cost-Sharing Cost-Sharing Cost-Sharing Drug Tier 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days Tier 1: Preferred Generic Drugs (GC) $3 / $6 / $6 $10 / $20 / $30 $3 / $6 / $0 $10 / $20 / $30 Tier 2: Generic Drugs (GC) $12 / $24 / $24 $20 / $40 / $60 $12 / $24 / $0 $20 / $40 / $60 Tier 3: Preferred Brand Drugs $42 / $84 / $126 $47 / $94 / $141 $42 / $84 / $126 $47 / $94 / $141 Tier 4: Non-Preferred Drugs 49% 49% 49% 49% Tier 5: Specialty Tier 33% (30 days) 33% (30 days) 33% (30 days) 33% (30 days)

GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage. September 2021 6 My Medications In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-668-3813, 7 days a week, 8 a.m. – 8 p.m. local time. TTY users can call 711.

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

Drug List Key: B/D – This prescription drug has a Part B versus D LA – Limited Availability. This prescription may be available administrative prior authorization requirement. This drug only at certain pharmacies. For more information consult may be covered under Medicare Part B or D depending your Pharmacy Directory or call Customer Service at on circumstances. 1-800-668-3813, 7 days a week, 8 a.m. – 8 p.m. local time. EX – Excluded Drug. This prescription drug is not normally TTY users can call 711. covered in a Medicare Prescription Drug Plan. The amount NDS – Non-extended day supply medication. This drug you pay when you fill a prescription for this drug does not is only available as a 30-day supply or less. count towards your total drug costs (that is, the amount you PA – This drug requires prior authorization pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your QL – This drug has quantity limits prescriptions, you will not get any extra help to pay for ST – This drug has step therapy requirements this drug. Generally all medications in the drug list are available GC – We provide additional coverage of the prescription through mail-order, except when special circumstances drugs in this tier in the coverage gap. Please refer to or situations prohibit mailing a particular medication to our Evidence of Coverage for more information about your home. this coverage.

September 2021 7 Drug List Table of Contents: The drugs in the drug list are grouped into categories depending on the type of medical conditions that they are used to treat. If you know what your drug is used for, look for the category name in the list below. Then look under the category name in the drug list for your drug. Page ANTI - INFECTIVES ...... 9 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ...... 15 AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...... 22 CARDIOVASCULAR, HYPERTENSION / LIPIDS ...... 31 DERMATOLOGICALS/TOPICAL THERAPY ...... 34 DIAGNOSTICS / MISCELLANEOUS AGENTS ...... 37 EAR, NOSE / THROAT MEDICATIONS ...... 39 ENDOCRINE/DIABETES...... 39 GASTROENTEROLOGY...... 43 IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...... 45 MUSCULOSKELETAL / RHEUMATOLOGY ...... 47 OBSTETRICS / GYNECOLOGY ...... 48 OPHTHALMOLOGY ...... 51 RESPIRATORY AND ALLERGY ...... 52 UROLOGICALS ...... 54 VITAMINS, HEMATINICS / ELECTROLYTES ...... 55

September 2021 8 Covered Drugs By Category

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

ANTI - INFECTIVES acyclovir oral tablet 2 acyclovir sodium intravenous 4 B/D PA ANTIFUNGAL AGENTS solution ABELCET 4 PA adefovir 5 NDS AMBISOME 5 PA; NDS hcl 3 amphotericin b 4 PA APTIVUS 5 QL (120/30); NDS caspofungin 5 PA; NDS atazanavir oral capsule 150 4 QL (30/30) clotrimazole mucous 2 mg, 300 mg membrane atazanavir oral capsule 200 mg 4 QL (60/30) CRESEMBA ORAL 5 NDS ATRIPLA 5 QL (30/30); NDS fluconazole 2 BARACLUDE ORAL 4 QL (630/30) fluconazole in nacl (iso-osm) 4 PA SOLUTION intravenous piggyback 200 BIKTARVY 5 NDS mg/100 ml, 400 mg/200 ml CABENUVA 5 NDS flucytosine 5 NDS CIMDUO 5 NDS griseofulvin microsize 4 COMPLERA 5 QL (30/30); NDS griseofulvin ultramicrosize 4 DELSTRIGO 5 NDS itraconazole oral capsule 4 QL (120/30) DESCOVY 5 QL (30/30); NDS itraconazole oral solution 5 NDS didanosine oral capsule, 4 QL (30/30) ketoconazole oral 2 delayed release(dr/ec) 250 mg, micafungin 5 NDS 400 mg nystatin oral 2 DOVATO 5 NDS posaconazole oral tablet, 5 QL (96/30); NDS EDURANT 5 QL (30/30); NDS delayed release (dr/ec) efavirenz oral capsule 200 mg 5 QL (120/30); NDS terbinafine hcl oral 2 efavirenz oral capsule 50 mg 3 QL (180/30) voriconazole intravenous 5 PA; NDS efavirenz oral tablet 5 QL (30/30); NDS voriconazole oral suspension 5 NDS efavirenz-emtricitabin-tenofov 5 QL (30/30); NDS for reconstitution efavirenz-lamivu-tenofov disop 5 QL (30/30); NDS voriconazole oral tablet 200 mg 5 NDS oral tablet 400-300-300 mg voriconazole oral tablet 50 mg 4 efavirenz-lamivu-tenofov disop 5 NDS ANTIVIRALS oral tablet 600-300-300 mg abacavir oral solution 3 QL (960/30) emtricitabine 3 QL (30/30) abacavir oral tablet 4 QL (60/30) emtricitabine-tenofovir (tdf) 5 QL (30/30); NDS abacavir-lamivudine 3 QL (30/30) EMTRIVA ORAL CAPSULE 4 QL (30/30) abacavir-lamivudine-zidovudine 5 QL (60/30); NDS EMTRIVA ORAL SOLUTION 4 QL (680/28) acyclovir oral capsule 2 entecavir 4 QL (30/30) acyclovir oral suspension 200 4 EPCLUSA 5 PA; QL (28/28); mg/5 ml NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 9 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS EPIVIR HBV ORAL SOLUTION 4 LEXIVA ORAL SUSPENSION 4 QL (1575/28) etravirine 5 QL (60/30); NDS lopinavir- oral solution 3 EVOTAZ 5 QL (30/30); NDS lopinavir-ritonavir oral tablet 4 QL (300/30) famciclovir 3 QL (60/30) 100-25 mg fosamprenavir 5 QL (120/30); NDS lopinavir-ritonavir oral tablet 4 QL (120/30) 200-50 mg FUZEON SUBCUTANEOUS 5 QL (60/30); NDS RECON SOLN MAVYRET 5 PA; QL (84/28); NDS GENVOYA 5 QL (30/30); NDS nevirapine oral suspension 4 QL (1200/30) HARVONI ORAL PELLETS IN 5 PA; QL (28/28); PACKET 33.75-150 MG NDS nevirapine oral tablet 3 QL (60/30) HARVONI ORAL PELLETS IN 5 PA; QL (56/28); nevirapine oral tablet extended 4 QL (90/30) PACKET 45-200 MG NDS release 24 hr 100 mg HARVONI ORAL TABLET 5 PA; QL (60/30); nevirapine oral tablet extended 4 QL (30/30) 45-200 MG NDS release 24 hr 400 mg HARVONI ORAL TABLET 5 PA; QL (28/28); NORVIR ORAL POWDER IN 4 90-400 MG NDS PACKET INTELENCE ORAL TABLET 5 QL (60/30); NDS NORVIR ORAL SOLUTION 3 QL (480/30) 100 MG, 200 MG ODEFSEY 5 QL (30/30); NDS INTELENCE ORAL TABLET 25 4 QL (120/30) 3 MG PIFELTRO 5 NDS INVIRASE ORAL TABLET 5 QL (120/30); NDS PREVYMIS ORAL 5 QL (30/30); NDS ISENTRESS HD 5 NDS PREZCOBIX 5 QL (30/30); NDS ISENTRESS ORAL POWDER 4 QL (60/30) PREZISTA ORAL 5 QL (400/30); NDS IN PACKET SUSPENSION ISENTRESS ORAL TABLET 5 QL (120/30); NDS PREZISTA ORAL TABLET 150 4 QL (240/30) ISENTRESS ORAL TABLET, 5 QL (180/30); NDS MG CHEWABLE 100 MG PREZISTA ORAL TABLET 600 5 QL (60/30); NDS ISENTRESS ORAL TABLET, 3 QL (180/30) MG CHEWABLE 25 MG PREZISTA ORAL TABLET 75 3 QL (480/30) JULUCA 5 NDS MG KALETRA ORAL TABLET 100- 4 QL (300/30) PREZISTA ORAL TABLET 800 5 QL (30/30); NDS 25 MG MG KALETRA ORAL TABLET 200- 5 QL (120/30); NDS RETROVIR INTRAVENOUS 4 50 MG REYATAZ ORAL POWDER IN 5 QL (240/30); NDS lamivudine oral solution 3 QL (900/30) PACKET lamivudine oral tablet 100 mg, 3 QL (30/30) oral capsule 3 300 mg ribavirin oral tablet 200 mg 3 lamivudine oral tablet 150 mg 3 QL (60/30) 2 lamivudine-zidovudine 3 QL (60/30) ritonavir 3 QL (360/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 10 Covered Drugs By Category

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

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 11 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS cefprozil 2 ery-tab oral tablet,delayed 3 ceftazidime 4 PA release (dr/ec) 250 mg CEFTAZIDIME IN D5W 4 PA ERY-TAB ORAL TABLET, 3 DELAYED RELEASE (DR/EC)

ceftriaxone in dextrose,iso-os 4 333 MG, 500 MG ceftriaxone injection recon soln 4 erythrocin (as stearate) oral 3 1 gram, 10 gram, 2 gram, 250 tablet 250 mg mg, 500 mg ERYTHROCIN INTRAVENOUS 4 PA CEFTRIAXONE INJECTION 4 RECON SOLN 500 MG RECON SOLN 100 GRAM erythromycin ethylsuccinate 3 ceftriaxone intravenous 4 oral suspension for cefuroxime axetil oral tablet 2 reconstitution 200 mg/5 ml cefuroxime sodium injection 4 PA erythromycin ethylsuccinate 5 NDS recon soln 750 mg oral suspension for cefuroxime sodium intravenous 4 PA reconstitution 400 mg/5 ml cephalexin oral capsule 250 1 erythromycin ethylsuccinate 3 mg, 500 mg oral tablet cephalexin oral suspension for 2 erythromycin oral tablet 4 reconstitution erythromycin oral tablet, 3 SUPRAX ORAL SUSPENSION 4 delayed release (dr/ec) FOR RECONSTITUTION 500 MISCELLANEOUS ANTIINFECTIVES MG/5 ML albendazole 5 NDS tazicef 4 PA amikacin injection solution 4 PA TEFLARO 5 PA; NDS 1,000 mg/4 ml, 500 mg/2 ml ERYTHROMYCINS / OTHER MACROLIDES ARIKAYCE 5 PA; LA; NDS azithromycin intravenous 4 PA atovaquone 5 NDS azithromycin oral packet 3 atovaquone-proguanil 2 azithromycin oral suspension 2 aztreonam injection recon soln 3 PA for reconstitution 1 gram azithromycin oral tablet 2 aztreonam injection recon soln 4 PA clarithromycin oral suspension 3 2 gram for reconstitution bacitracin intramuscular 4 clarithromycin oral tablet 2 CAYSTON 5 PA; LA; QL (84/28); clarithromycin oral tablet 2 NDS extended release 24 hr chloramphenicol sod succinate 4 DIFICID ORAL SUSPENSION 5 QL (136/10); NDS chloroquine phosphate 2 FOR RECONSTITUTION clindamycin hcl 2 DIFICID ORAL TABLET 5 QL (20/10); NDS CLINDAMYCIN IN 0.9% SOD 4 PA ERYPED 400 5 NDS CHLOR clindamycin in 5% dextrose 4 PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 12 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS clindamycin pediatric 4 linezolid oral suspension for 5 QL (1800/30); NDS clindamycin phosphate injection 4 PA reconstitution clindamycin phosphate 4 PA linezolid oral tablet 3 QL (60/30) intravenous solution 600 mg/4 linezolid-0.9% sodium chloride 4 PA ml mefloquine 2 COARTEM 4 QL (24/30) meropenem 4 colistin (colistimethate na) 5 PA; NDS MEROPENEM-0.9% SODIUM 4 2 CHLORIDE dapsone oral 3 metro i.v. 4 PA DAPTOMYCIN INTRAVENOUS 5 NDS metronidazole in nacl (iso-os) 4 PA RECON SOLN 350 MG metronidazole oral tablet 1 daptomycin intravenous recon 5 NDS 2 soln 500 mg nitazoxanide 5 QL (20/10); NDS EMVERM 5 NDS ORBACTIV 5 PA; QL (3/30); NDS ertapenem 4 paromomycin 4 ethambutol 3 PASER 4 FIRVANQ ORAL RECON 4 QL (300/10) SOLN 25 MG/ML PENTAM 3 FIRVANQ ORAL RECON 4 QL (450/10) inhalation 3 B/D PA; QL (1/28) SOLN 50 MG/ML pentamidine injection 3 gentamicin in nacl (iso-osm) 4 PA polymyxin b sulfate 4 PA intravenous piggyback 100 praziquantel 4 mg/100 ml, 60 mg/50 ml, 80 PRIFTIN 4 mg/100 ml, 80 mg/50 ml PRIMAQUINE 3 GENTAMICIN IN NACL 4 PA (ISO-OSM) INTRAVENOUS pyrazinamide 3 PIGGYBACK 100 MG/50 ML, pyrimethamine 5 PA; NDS 120 MG/100 ML quinine sulfate 4 PA; QL (42/7) gentamicin injection solution 40 4 PA rifabutin 3 mg/ml rifampin intravenous 4 gentamicin sulfate (ped) (pf) 4 PA rifampin oral 2 hydroxychloroquine 2 SIRTURO 4 PA; LA imipenem-cilastatin 4 SIVEXTRO INTRAVENOUS 5 PA; QL (6/28); NDS isoniazid oral solution 3 SIVEXTRO ORAL 5 QL (6/28); NDS isoniazid oral tablet 2 streptomycin 5 PA; NDS ivermectin oral 3 SYNERCID 5 PA; NDS lincomycin 4 PA tigecycline 5 PA; NDS linezolid in dextrose 5% 4 PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 13 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS TOBI PODHALER 5 QL (224/28); NDS amoxicillin-pot clavulanate oral 4 INHALATION CAPSULE, W/ tablet extended release 12 hr INHALATION DEVICE amoxicillin-pot clavulanate oral 2 tobramycin in 0.225% nacl 5 B/D PA; QL tablet,chewable (280/28); NDS ampicillin oral capsule 500 mg 2 tobramycin sulfate 4 PA ampicillin sodium 4 PA TRECATOR 3 ampicillin-sulbactam 4 PA VANCOMYCIN IN 0.9% 4 BICILLIN L-A 4 PA SODIUM CHL INTRAVENOUS PIGGYBACK dicloxacillin 2 VANCOMYCIN IN DEXTROSE 4 nafcillin 4 PA 5% INTRAVENOUS nafcillin in dextrose iso-osm 4 PA PIGGYBACK oxacillin injection 4 PA VANCOMYCIN INJECTION 4 penicillin g potassium 4 PA vancomycin intravenous recon 4 penicillin v potassium oral 1 soln 1,000 mg, 10 gram, 250 recon soln mg, 5 gram, 500 mg, 750 mg penicillin v potassium oral tablet 1 VANCOMYCIN INTRAVENOUS 4 250 mg RECON SOLN 1.25 GRAM, 1.5 penicillin v potassium oral tablet 2 GRAM 500 mg vancomycin oral capsule 125 3 PA; QL (40/10) pfizerpen-g 4 PA mg PIPERACILLIN-TAZOBACTAM 4 vancomycin oral capsule 250 3 PA; QL (80/10) INTRAVENOUS RECON SOLN mg 13.5 GRAM vancomycin oral recon soln 2 QL (450/10) piperacillin-tazobactam 4 VANCOMYCIN-WATER 4 intravenous recon soln 2.25 INJECT (PEG) gram, 3.375 gram, 4.5 gram, XIFAXAN ORAL TABLET 550 5 PA; QL (90/30); 40.5 gram MG NDS ZOSYN IN DEXTROSE (ISO- 4 PENICILLINS OSM) amoxicillin oral capsule 1 QUINOLONES amoxicillin oral suspension for 1 CIPRO ORAL SUSPENSION, 4 reconstitution MICROCAPSULE RECON amoxicillin oral tablet 2 ciprofloxacin hcl oral tablet 100 3 amoxicillin oral tablet,chewable 2 mg 125 mg, 250 mg ciprofloxacin hcl oral tablet 250 2 amoxicillin-pot clavulanate oral 2 mg, 500 mg, 750 mg suspension for reconstitution ciprofloxacin in 5% dextrose 4 PA amoxicillin-pot clavulanate oral 2 levofloxacin in d5w 4 PA tablet levofloxacin intravenous 4 PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 14 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS levofloxacin oral solution 4 NUZYRA INTRAVENOUS 5 PA; NDS levofloxacin oral tablet 2 NUZYRA ORAL 5 NDS moxifloxacin oral 4 tetracycline 2 MOXIFLOXACIN-SOD.ACE, 4 PA URINARY TRACT AGENTS SUL-WATER fosfomycin tromethamine 4 moxifloxacin-sod.chloride(iso) 4 PA methenamine hippurate 2 SULFAS / RELATED AGENTS MONUROL 4 sulfadiazine 3 nitrofurantoin 4 sulfamethoxazole-trimethoprim 4 PA nitrofurantoin macrocrystal 2 intravenous nitrofurantoin monohyd/m-cryst 2 sulfamethoxazole-trimethoprim 4 oral suspension trimethoprim 2 sulfamethoxazole-trimethoprim 1 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS oral tablet ADJUNCTIVE AGENTS TETRACYCLINES leucovorin calcium injection 4 demeclocycline 3 leucovorin calcium oral 3 doxy-100 4 PA mesna 4 B/D PA doxycycline hyclate intravenous 4 PA MESNEX ORAL 5 NDS doxycycline hyclate oral 1 capsule XGEVA 5 PA; QL (1.7/28); NDS doxycycline hyclate oral tablet 1 100 mg ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS doxycycline hyclate oral tablet 2 abiraterone oral tablet 250 mg 5 PA; QL (120/30); 20 mg NDS doxycycline monohydrate oral 2 abiraterone oral tablet 500 mg 5 PA; QL (60/30); capsule 100 mg, 50 mg NDS DOXYCYCLINE 4 ABRAXANE 5 PA; NDS MONOHYDRATE ORAL ADCETRIS 5 PA; NDS CAPSULE,IR - DELAY adriamycin intravenous recon 4 B/D PA REL,BIPHASE soln 10 mg doxycycline monohydrate oral 2 adriamycin intravenous solution 4 B/D PA suspension for reconstitution adrucil intravenous solution 2.5 4 B/D PA doxycycline monohydrate oral 3 gram/50 ml tablet AFINITOR DISPERZ ORAL 5 PA; QL (150/30); oral capsule 2 TABLET FOR SUSPENSION NDS minocycline oral tablet 2 2 MG mondoxyne nl oral capsule 100 3 AFINITOR DISPERZ ORAL 5 PA; QL (56/28); mg, 75 mg TABLET FOR SUSPENSION 3 NDS morgidox oral capsule 100 mg 1 MG, 5 MG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 15 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS AFINITOR ORAL TABLET 10 5 PA; QL (30/30); BORTEZOMIB 5 PA; NDS MG NDS BOSULIF ORAL TABLET 100 5 PA; QL (90/30); ALECENSA 5 PA; QL (240/30); MG NDS NDS BOSULIF ORAL TABLET 400 5 PA; QL (30/30); ALIMTA 5 PA; NDS MG, 500 MG NDS ALIQOPA 5 PA; NDS BRAFTOVI ORAL CAPSULE 5 PA; LA; QL ALUNBRIG ORAL TABLET 180 5 PA; QL (30/30); 75 MG (180/30); NDS MG, 90 MG NDS BRUKINSA 5 PA; LA; NDS ALUNBRIG ORAL TABLET 30 5 PA; QL (60/30); busulfan 5 B/D PA; NDS MG NDS CABOMETYX ORAL TABLET 5 PA; LA; QL (30/30); ALUNBRIG ORAL TABLETS, 5 PA; QL (30/30); 20 MG, 60 MG NDS DOSE PACK NDS CABOMETYX ORAL TABLET 5 PA; LA; QL (60/30); anastrozole 2 40 MG NDS ARRANON 4 B/D PA CALQUENCE 5 PA; LA; QL (60/30); arsenic trioxide 5 B/D PA; NDS NDS ARZERRA 5 B/D PA; NDS CAPRELSA ORAL TABLET 5 PA; LA; QL (60/30); 100 MG NDS ASTAGRAF XL ORAL 4 B/D PA CAPSULE,EXTENDED CAPRELSA ORAL TABLET 5 PA; LA; QL (30/30); RELEASE 24HR 0.5 MG, 1 MG 300 MG NDS ASTAGRAF XL ORAL 5 B/D PA; NDS carboplatin intravenous solution 4 B/D PA CAPSULE,EXTENDED carmustine 4 B/D PA RELEASE 24HR 5 MG cisplatin intravenous solution 4 B/D PA AYVAKIT 5 PA; LA; QL (30/30); cladribine 4 B/D PA NDS clofarabine 4 B/D PA azacitidine 5 B/D PA; NDS COMETRIQ ORAL CAPSULE 5 PA; QL (56/28); AZASAN 3 B/D PA 100 MG/DAY(80 MG X1-20 MG NDS azathioprine 2 B/D PA X1) azathioprine sodium 4 B/D PA COMETRIQ ORAL CAPSULE 5 PA; QL (112/28); BALVERSA 5 PA; LA; NDS 140 MG/DAY(80 MG X1-20 MG NDS X3) BAVENCIO 5 PA; NDS COMETRIQ ORAL CAPSULE 5 PA; QL (84/28); BELEODAQ 5 B/D PA; NDS 60 MG/DAY (20 MG X 3/DAY) NDS BENDEKA 5 B/D PA; NDS COPIKTRA 5 PA; LA; QL (60/30); BESPONSA 5 PA; NDS NDS bexarotene 5 PA; NDS COSMEGEN 5 B/D PA; NDS bicalutamide 2 COTELLIC 5 PA; LA; QL (63/28); BLENREP 5 PA; NDS NDS bleomycin 4 B/D PA cyclophosphamide intravenous 5 B/D PA; NDS recon soln BLINCYTO INTRAVENOUS 5 B/D PA; NDS KIT

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 16 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CYCLOPHOSPHAMIDE 5 B/D PA; NDS ENHERTU 5 PA; NDS INTRAVENOUS SOLUTION ENVARSUS XR 4 B/D PA cyclophosphamide oral 3 B/D PA epirubicin intravenous solution 4 B/D PA cyclosporine intravenous 4 B/D PA ERBITUX 5 B/D PA; NDS cyclosporine modified 4 B/D PA ERIVEDGE 5 PA; QL (30/30); cyclosporine oral capsule 4 B/D PA NDS CYRAMZA 5 PA; NDS ERLEADA 5 PA; QL (120/30); cytarabine 4 B/D PA NDS cytarabine (pf) 4 B/D PA erlotinib oral tablet 100 mg, 150 5 PA; QL (30/30); mg NDS dacarbazine 4 B/D PA erlotinib oral tablet 25 mg 5 PA; QL (60/30); dactinomycin 4 B/D PA NDS DANYELZA 5 PA; NDS ETOPOPHOS 4 B/D PA DARZALEX 5 PA; NDS etoposide intravenous 3 B/D PA DARZALEX FASPRO 5 PA; NDS everolimus (antineoplastic) 5 PA; QL (30/30); daunorubicin intravenous 4 B/D PA NDS solution everolimus 5 B/D PA; QL (60/30); DAURISMO ORAL TABLET 5 PA; QL (30/30); (immunosuppressive) oral NDS 100 MG NDS tablet 0.25 mg, 0.75 mg DAURISMO ORAL TABLET 25 5 PA; QL (60/30); everolimus 5 B/D PA; QL MG NDS (immunosuppressive) oral (120/30); NDS decitabine 5 B/D PA; NDS tablet 0.5 mg docetaxel intravenous solution 4 B/D PA EVOMELA 5 PA; NDS 160 mg/16 ml (10 mg/ml), 160 exemestane 2 mg/8 ml (20 mg/ml), 20 mg/2 ml FARYDAK 5 PA; QL (6/21); NDS (10 mg/ml), 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 FIRMAGON KIT W DILUENT 5 B/D PA; NDS ml (10 mg/ml) SYRINGE SUBCUTANEOUS RECON SOLN 120 MG doxorubicin 4 B/D PA FIRMAGON KIT W DILUENT 4 B/D PA

doxorubicin, peg-liposomal 5 B/D PA; NDS SYRINGE SUBCUTANEOUS DROXIA 3 RECON SOLN 80 MG ELIGARD 4 PA floxuridine 4 B/D PA ELIGARD (3 MONTH) 4 PA fludarabine 4 B/D PA ELIGARD (4 MONTH) 4 PA fluorouracil intravenous 4 B/D PA ELIGARD (6 MONTH) 4 PA flutamide 2 ELLENCE 4 B/D PA FOLOTYN 5 B/D PA; NDS ELZONRIS 5 B/D PA; NDS FOTIVDA 5 PA; LA; QL (21/28); EMCYT 5 NDS NDS EMPLICITI 4 PA fulvestrant 5 B/D PA; NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 17 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS GAVRETO 5 PA; LA; QL INLYTA ORAL TABLET 1 MG 5 PA; QL (180/30); (120/30); NDS NDS GAZYVA 5 PA; NDS INLYTA ORAL TABLET 5 MG 5 PA; QL (120/30); gemcitabine intravenous recon 4 B/D PA NDS soln INQOVI 5 PA; QL (5/28); NDS gemcitabine intravenous 4 B/D PA INREBIC 5 PA; LA; QL solution 1 gram/26.3 ml (38 mg/ (120/30); NDS ml), 2 gram/52.6 ml (38 mg/ml), IRESSA 5 PA; QL (30/30); 200 mg/5.26 ml (38 mg/ml) NDS GEMCITABINE 5 B/D PA; NDS irinotecan 4 B/D PA INTRAVENOUS SOLUTION 100 MG/ML IXEMPRA 5 B/D PA; NDS gengraf 4 B/D PA JAKAFI 5 PA; QL (60/30); NDS GILOTRIF 5 PA; QL (30/30); NDS JEMPERLI 5 PA; NDS HALAVEN 5 PA; NDS JEVTANA 4 B/D PA hydroxyurea 2 KADCYLA 5 PA; NDS IBRANCE 5 PA; QL (21/28); KANJINTI 5 PA; NDS NDS KEYTRUDA 5 PA; NDS ICLUSIG ORAL TABLET 10 5 PA; QL (30/30); KISQALI FEMARA CO-PACK 5 PA; QL (49/28); MG, 30 MG, 45 MG NDS ORAL TABLET 200 MG/ NDS ICLUSIG ORAL TABLET 15 5 PA; QL (60/30); DAY(200 MG X 1)-2.5 MG MG NDS KISQALI FEMARA CO-PACK 5 PA; QL (70/28); idarubicin 4 B/D PA ORAL TABLET 400 MG/ NDS DAY(200 MG X 2)-2.5 MG IDHIFA 5 PA; LA; QL (30/30); NDS KISQALI FEMARA CO-PACK 5 PA; QL (91/28); ORAL TABLET 600 MG/ NDS ifosfamide 4 B/D PA DAY(200 MG X 3)-2.5 MG imatinib oral tablet 100 mg 5 PA; QL (180/30); KISQALI ORAL TABLET 200 5 PA; QL (21/28); NDS MG/DAY (200 MG X 1) NDS imatinib oral tablet 400 mg 5 PA; QL (60/30); KISQALI ORAL TABLET 400 5 PA; QL (42/28); NDS MG/DAY (200 MG X 2) NDS IMBRUVICA ORAL CAPSULE 5 PA; QL (120/30); KISQALI ORAL TABLET 600 5 PA; QL (63/28); 140 MG NDS MG/DAY (200 MG X 3) NDS IMBRUVICA ORAL CAPSULE 5 PA; QL (30/30); KYPROLIS 5 B/D PA; NDS 70 MG NDS lapatinib 5 PA; QL (180/30); IMBRUVICA ORAL TABLET 5 PA; QL (30/30); NDS NDS LENVIMA ORAL CAPSULE 10 5 PA; QL (30/30); IMFINZI 5 PA; NDS MG/DAY (10 MG X 1), 4 MG NDS INFUGEM 5 B/D PA; NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 18 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS LENVIMA ORAL CAPSULE 12 5 PA; QL (90/30); MEKINIST ORAL TABLET 0.5 5 PA; QL (90/30); MG/DAY (4 MG X 3), 18 MG/ NDS MG NDS DAY (10 MG X 1-4 MG X2), 24 MEKINIST ORAL TABLET 2 5 PA; QL (30/30); MG/DAY(10 MG X 2-4 MG X 1) MG NDS LENVIMA ORAL CAPSULE 14 5 PA; QL (60/30); MEKTOVI 5 PA; LA; QL MG/DAY(10 MG X 1-4 MG X NDS (180/30); NDS 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY (4 MG X 2) melphalan 4 B/D PA letrozole 2 melphalan hcl 5 B/D PA; NDS LEUKERAN 4 mercaptopurine 2

leuprolide subcutaneous kit 5 PA; NDS methotrexate sodium (pf) 4 B/D PA LIBTAYO 5 PA; NDS methotrexate sodium injection 4 B/D PA LONSURF ORAL TABLET 5 PA; QL (100/28); methotrexate sodium oral 2 15-6.14 MG NDS mitomycin intravenous 4 B/D PA LONSURF ORAL TABLET 5 PA; QL (80/28); mitoxantrone 4 B/D PA 20-8.19 MG NDS MONJUVI 5 PA; NDS LORBRENA ORAL TABLET 5 PA; QL (30/30); MVASI 5 PA; NDS 100 MG NDS mycophenolate mofetil (hcl) 4 B/D PA LORBRENA ORAL TABLET 25 5 PA; QL (90/30); mycophenolate mofetil oral 2 B/D PA MG NDS capsule LUMAKRAS 5 PA; QL (240/30); mycophenolate mofetil oral 5 B/D PA; NDS NDS suspension for reconstitution LUMOXITI 5 PA; NDS mycophenolate mofetil oral 2 B/D PA LUPRON DEPOT 5 PA; NDS tablet LUPRON DEPOT (3 MONTH) 5 PA; NDS mycophenolate sodium 2 B/D PA LUPRON DEPOT (4 MONTH) 5 PA; NDS MYLOTARG 5 PA; NDS LUPRON DEPOT (6 MONTH) 5 PA; NDS NERLYNX 5 PA; LA; NDS LUPRON DEPOT-PED 5 PA; NDS NEXAVAR 5 PA; LA; QL LUPRON DEPOT-PED (3 5 PA; NDS (120/30); NDS MONTH) nilutamide 5 NDS LYNPARZA ORAL TABLET 5 PA; QL (120/30); NINLARO 5 PA; QL (3/28); NDS NDS NIPENT 4 B/D PA LYSODREN 5 NDS NUBEQA 5 PA; LA; QL MARQIBO 5 B/D PA; NDS (120/30); NDS MATULANE 5 NDS NULOJIX 5 PA; QL (26/28); megestrol oral suspension 400 3 PA NDS mg/10 ml (10 ml), 400 mg/10 octreotide acetate injection 5 PA; NDS ml (40 mg/ml) solution 1,000 mcg/ml, 500 megestrol oral tablet 3 PA mcg/ml

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 19 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS octreotide acetate injection 4 PA ROMIDEPSIN INTRAVENOUS 5 PA; NDS solution 100 mcg/ml, 200 mcg/ SOLUTION ml ROZLYTREK ORAL CAPSULE 5 PA; QL (150/30); octreotide acetate injection 3 PA 100 MG NDS solution 50 mcg/ml ROZLYTREK ORAL CAPSULE 5 PA; QL (90/30); ODOMZO 5 PA; LA; QL (30/30); 200 MG NDS NDS RUBRACA 5 PA; LA; QL OGIVRI 5 PA; NDS (120/30); NDS ONCASPAR 5 B/D PA; NDS RUXIENCE 5 PA; NDS ONIVYDE 5 PA; NDS RYBREVANT 5 PA; NDS ONUREG 5 PA; QL (14/28); RYDAPT 5 PA; QL (240/30); NDS NDS OPDIVO 5 PA; QL (80/28); SANDIMMUNE ORAL 4 B/D PA NDS SOLUTION ORGOVYX 5 PA; LA; QL (30/30); SANDOSTATIN LAR 5 PA; NDS NDS DEPOT INTRAMUSCULAR oxaliplatin 4 B/D PA SUSPENSION,EXTENDED REL RECON paclitaxel 4 B/D PA SARCLISA 5 PA; NDS PADCEV 5 PA; NDS SIGNIFOR 5 PA; NDS PEMAZYRE 5 PA; LA; QL (14/21); NDS SIMULECT 5 NDS PEPAXTO 5 PA; NDS sirolimus oral solution 5 B/D PA; NDS PERJETA 5 PA; NDS sirolimus oral tablet 4 B/D PA PHESGO 5 PA; NDS SOLTAMOX 5 NDS PIQRAY 5 PA; NDS SOMATULINE DEPOT 5 PA; NDS POLIVY 5 PA; NDS SPRYCEL ORAL TABLET 100 5 PA; QL (30/30); MG, 140 MG, 50 MG, 80 MG NDS POMALYST 5 PA; LA; QL (21/28); NDS SPRYCEL ORAL TABLET 20 5 PA; QL (60/30); MG, 70 MG NDS PORTRAZZA 4 B/D PA STIVARGA 5 PA; QL (84/28); POTELIGEO 5 PA; NDS NDS PROGRAF INTRAVENOUS 4 B/D PA SUTENT 5 PA; QL (30/30); PROGRAF ORAL GRANULES 4 B/D PA NDS IN PACKET SYNRIBO 5 PA; NDS PURIXAN 5 NDS TABLOID 4 QINLOCK 5 PA; LA; NDS TABRECTA 5 PA; NDS RETEVMO 5 PA; LA; NDS tacrolimus oral 2 B/D PA REVLIMID 5 PA; LA; QL (28/28); TAFINLAR 5 PA; QL (120/30); NDS NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 20 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS TAGRISSO 5 PA; LA; QL (30/30); TRUSELTIQ ORAL CAPSULE 5 PA; QL (21/28); NDS 100 MG/DAY (100 MG X 1) NDS TALZENNA ORAL CAPSULE 5 PA; QL (90/30); TRUSELTIQ ORAL CAPSULE 5 PA; QL (42/28); 0.25 MG NDS 125 MG/DAY(100 MG NDS TALZENNA ORAL CAPSULE 5 PA; QL (30/30); X1-25MG X1), 50 MG/DAY (25 1 MG NDS MG X 2) tamoxifen 2 TRUSELTIQ ORAL CAPSULE 5 PA; QL (63/28); 75 MG/DAY (25 MG X 3) NDS TARGRETIN TOPICAL 5 PA; NDS TRUXIMA 5 PA; NDS TASIGNA ORAL CAPSULE 150 5 PA; QL (112/28); MG, 200 MG NDS TUKYSA ORAL TABLET 150 5 PA; LA; QL MG (120/30); NDS TASIGNA ORAL CAPSULE 50 5 PA; QL (120/30); MG NDS TUKYSA ORAL TABLET 50 5 PA; LA; QL MG (300/30); NDS TAZVERIK 5 PA; LA; NDS TURALIO 5 PA; LA; NDS TECENTRIQ 5 PA; NDS TYKERB 5 PA; LA; QL TEMODAR INTRAVENOUS 5 B/D PA; NDS (180/30); NDS temsirolimus 5 B/D PA; NDS UKONIQ 5 PA; LA; QL TEPMETKO 5 PA; LA; QL (60/30); (120/30); NDS NDS UNITUXIN 5 PA; NDS THALOMID ORAL CAPSULE 5 PA; QL (28/28); valrubicin 4 B/D PA 100 MG, 150 MG, 50 MG NDS VECTIBIX 5 PA; NDS THALOMID ORAL CAPSULE 5 PA; QL (56/28); 200 MG NDS VELCADE 5 PA; NDS thiotepa 4 PA VENCLEXTA ORAL TABLET 4 PA; LA; QL (60/30) 10 MG TIBSOVO 5 PA; NDS VENCLEXTA ORAL TABLET 5 PA; LA; QL toposar 3 B/D PA 100 MG (120/30); NDS topotecan intravenous recon 5 B/D PA; NDS VENCLEXTA ORAL TABLET 5 PA; LA; QL (30/30); soln 50 MG NDS topotecan intravenous solution 4 B/D PA VENCLEXTA STARTING PACK 5 PA; LA; QL (42/30);

4 mg/4 ml (1 mg/ml) NDS toremifene 5 NDS VERZENIO 5 PA; LA; QL (60/30); TRAZIMERA 5 PA; NDS NDS TREANDA 5 B/D PA; NDS vinblastine 4 B/D PA TRELSTAR INTRAMUSCULAR 5 PA; NDS vincasar pfs 4 B/D PA SUSPENSION FOR vincristine 4 B/D PA RECONSTITUTION vinorelbine 4 B/D PA tretinoin (antineoplastic) 5 NDS VITRAKVI ORAL CAPSULE 5 PA; LA; QL (60/30); TRIPTODUR 5 PA; QL (1/168); 100 MG NDS NDS VITRAKVI ORAL CAPSULE 25 5 PA; LA; QL TRODELVY 5 PA; NDS MG (180/30); NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 21 Covered Drugs By Category

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

VITRAKVI ORAL SOLUTION 5 PA; LA; QL AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH (300/30); NDS VIZIMPRO 5 PA; QL (30/30); ANTICONVULSANTS NDS APTIOM ORAL TABLET 200 5 QL (180/30); NDS VOTRIENT 5 PA; QL (120/30); MG NDS APTIOM ORAL TABLET 400 5 QL (90/30); NDS VYXEOS 5 B/D PA; NDS MG XALKORI 5 PA; QL (60/30); APTIOM ORAL TABLET 600 5 QL (60/30); NDS NDS MG, 800 MG XATMEP 4 PA BANZEL 5 PA; NDS XOSPATA 5 PA; LA; NDS BRIVIACT INTRAVENOUS 5 NDS XPOVIO 5 PA; LA; NDS BRIVIACT ORAL SOLUTION 5 QL (600/30); NDS XTANDI ORAL CAPSULE 5 PA; QL (120/30); BRIVIACT ORAL TABLET 5 QL (60/30); NDS NDS carbamazepine oral capsule, er 2 XTANDI ORAL TABLET 40 MG 5 PA; QL (120/30); multiphase 12 hr NDS carbamazepine oral suspension 2 XTANDI ORAL TABLET 80 MG 5 PA; QL (60/30); 100 mg/5 ml, 200 mg/10 ml NDS carbamazepine oral tablet 2 YERVOY 5 PA; NDS carbamazepine oral tablet 2 YONDELIS 5 PA; NDS extended release 12 hr ZALTRAP 4 B/D PA carbamazepine oral tablet, 2 chewable ZANOSAR 4 B/D PA CELONTIN ORAL CAPSULE 3 ZEJULA 5 PA; LA; QL (90/30); 300 MG NDS clobazam oral suspension 4 PA; QL (480/30) ZELBORAF 5 PA; QL (240/30); NDS clobazam oral tablet 4 PA; QL (60/30) ZEPZELCA 5 PA; NDS clonazepam oral tablet 0.5 mg, 2 QL (90/30) 1 mg ZIRABEV 5 PA; NDS clonazepam oral tablet 2 mg 2 QL (300/30) ZOLADEX 4 B/D PA clonazepam oral tablet, 2 QL (90/30) ZOLINZA 5 PA; QL (120/30); disintegrating 0.125 mg, 0.25 NDS mg, 0.5 mg, 1 mg ZORTRESS ORAL TABLET 1 5 B/D PA; NDS clonazepam oral tablet, 2 QL (300/30) MG disintegrating 2 mg ZYDELIG 5 PA; QL (60/30); DIACOMIT ORAL CAPSULE 4 PA; LA; QL (360/30) NDS 250 MG ZYKADIA ORAL TABLET 5 PA; QL (90/30); DIACOMIT ORAL CAPSULE 4 PA; LA; QL (180/30) NDS 500 MG ZYNLONTA 5 PA; NDS DIACOMIT ORAL POWDER IN 4 PA; LA; QL (360/30) PACKET 250 MG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 22 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS DIACOMIT ORAL POWDER IN 4 PA; LA; QL (180/30) LYRICA CR ORAL TABLET 3 QL (30/30) PACKET 500 MG EXTENDED RELEASE 24 HR DIASTAT 4 165 MG, 82.5 MG DIASTAT ACUDIAL 4 LYRICA CR ORAL TABLET 3 QL (60/30) EXTENDED RELEASE 24 HR diazepam rectal 4 330 MG DILANTIN 30 MG 3 NAYZILAM 5 PA; QL (10/30); divalproex 2 NDS EPIDIOLEX 5 PA; LA; NDS oxcarbazepine 2 epitol 2 oral elixir 3 PA; QL (1500/30) ethosuximide 3 phenobarbital oral tablet 3 PA; QL (120/30) oral suspension 5 NDS phenobarbital sodium injection 3 felbamate oral tablet 4 solution FINTEPLA 5 PA; LA; NDS phenytoin oral suspension 2 fosphenytoin 3 phenytoin oral tablet,chewable 2 FYCOMPA ORAL 4 QL (720/30) phenytoin sodium extended 2 SUSPENSION phenytoin sodium intravenous 3 FYCOMPA ORAL TABLET 10 4 QL (30/30) solution MG, 12 MG, 8 MG pregabalin oral capsule 100 2 QL (90/30) FYCOMPA ORAL TABLET 2 4 QL (60/30) mg, 150 mg, 200 mg, 25 mg, MG, 4 MG, 6 MG 50 mg, 75 mg gabapentin oral capsule 100 2 QL (270/30) pregabalin oral capsule 225 2 QL (60/30) mg, 400 mg mg, 300 mg gabapentin oral capsule 300 2 QL (360/30) pregabalin oral solution 3 QL (900/30) mg pregabalin oral tablet extended 3 QL (30/30) gabapentin oral solution 4 QL (2160/30) release 24 hr 165 mg, 82.5 mg gabapentin oral tablet 600 mg 2 QL (180/30) pregabalin oral tablet extended 3 QL (60/30) release 24 hr 330 mg gabapentin oral tablet 800 mg 2 QL (120/30) primidone 2 lamotrigine oral tablet 2 roweepra 2 lamotrigine oral tablet extended 2 release 24hr rufinamide 5 PA; NDS lamotrigine oral tablet, 2 SPRITAM 4 chewable dispersible subvenite 3 lamotrigine oral tablet, 2 subvenite starter (blue) kit 3 disintegrating subvenite starter (green) kit 3

levetiracetam in nacl (iso-os) 4 subvenite starter (orange) kit 3 levetiracetam intravenous 3 SYMPAZAN 5 PA; QL (60/30); levetiracetam oral 2 NDS tiagabine 4

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 23 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS oral capsule, 2 PA -levodopa oral tablet, 2 sprinkle disintegrating topiramate oral tablet 2 PA carbidopa-levodopa- 3 TROKENDI XR ORAL 4 CAPSULE,EXTENDED entacapone 4 RELEASE 24HR 100 MG, 25 KYNMOBI SUBLINGUAL FILM 5 PA; QL (150/30); MG, 50 MG 10 MG, 15 MG, 20 MG, 25 MG, NDS TROKENDI XR ORAL 5 NDS 30 MG CAPSULE,EXTENDED NEUPRO 4 RELEASE 24HR 200 MG oral tablet 2 valproate sodium 3 pramipexole oral tablet 4 valproic acid 2 extended release 24 hr valproic acid (as sodium salt) 2 3 VALTOCO 5 PA; QL (10/30); oral tablet 2 NDS RYTARY 4 ST vigabatrin 5 PA; LA; QL (180/30); NDS hcl 3 vigadrone 5 PA; LA; QL 5 NDS (180/30); NDS 2 PA VIMPAT INTRAVENOUS 5 QL (1200/30); NDS MIGRAINE / CLUSTER HEADACHE THERAPY VIMPAT ORAL SOLUTION 5 QL (1200/30); NDS AIMOVIG AUTOINJECTOR 3 PA; QL (1/30) VIMPAT ORAL TABLET 100 5 QL (60/30); NDS nasal 5 PA; QL (8/28); NDS MG, 150 MG, 200 MG - 3 VIMPAT ORAL TABLET 50 MG 4 QL (120/30) migergot 5 NDS XCOPRI 5 PA; NDS naratriptan 3 QL (18/28) XCOPRI MAINTENANCE 5 PA; NDS rizatriptan 3 QL (36/28) PACK sumatriptan nasal spray,non- 4 QL (18/28) XCOPRI TITRATION PACK 4 PA aerosol 20 mg/actuation zonisamide 2 PA sumatriptan nasal spray,non- 4 QL (36/28) ANTIPARKINSONISM AGENTS aerosol 5 mg/actuation APOKYN 5 PA; LA; QL (60/30); sumatriptan succinate oral 2 QL (18/28) NDS sumatriptan succinate 4 QL (8/28) benztropine injection 4 subcutaneous cartridge benztropine oral 2 PA sumatriptan succinate 4 QL (8/28) 4 subcutaneous pen injector carbidopa 4 sumatriptan succinate 4 QL (8/28) subcutaneous solution carbidopa-levodopa oral tablet 2 MISCELLANEOUS NEUROLOGICAL THERAPY carbidopa-levodopa oral tablet 3 extended release AUSTEDO ORAL TABLET 12 5 PA; LA; QL MG, 9 MG (120/30); NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 24 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS AUSTEDO ORAL TABLET 6 5 PA; LA; QL (60/30); rivastigmine tartrate 4 QL (60/30) MG NDS TECFIDERA ORAL 5 PA; LA; QL (14/30); COPAXONE SUBCUTANEOUS 5 PA; QL (30/30); CAPSULE,DELAYED NDS SYRINGE 20 MG/ML NDS RELEASE(DR/EC) 120 MG COPAXONE SUBCUTANEOUS 5 PA; QL (12/28); TECFIDERA ORAL 5 PA; LA; QL SYRINGE 40 MG/ML NDS CAPSULE,DELAYED (120/180); NDS dalfampridine 3 PA; QL (60/30) RELEASE(DR/EC) 120 MG (14)- 240 MG (46) dimethyl fumarate oral capsule, 5 PA; QL (14/30); delayed release(dr/ec) 120 mg NDS TECFIDERA ORAL 5 PA; LA; QL (60/30); CAPSULE,DELAYED NDS dimethyl fumarate oral capsule, 5 PA; QL (120/180); RELEASE(DR/EC) 240 MG delayed release(dr/ec) 120 mg NDS (14)- 240 mg (46) tetrabenazine oral tablet 12.5 5 PA; QL (240/30); mg NDS dimethyl fumarate oral capsule, 5 PA; QL (60/30); delayed release(dr/ec) 240 mg NDS tetrabenazine oral tablet 25 mg 5 PA; QL (120/30); NDS donepezil oral tablet 10 mg 2 QL (60/30) TYSABRI 5 PA; NDS donepezil oral tablet 23 mg 4 MUSCLE RELAXANTS / ANTISPASMODIC THERAPY donepezil oral tablet 5 mg 2 QL (30/30) baclofen oral tablet 10 mg, 5 1 donepezil oral tablet, 2 QL (60/30) mg disintegrating 10 mg baclofen oral tablet 20 mg 2 donepezil oral tablet, 2 QL (30/30) disintegrating 5 mg cyclobenzaprine oral tablet 10 3 PA mg, 5 mg FIRDAPSE 5 PA; LA; NDS dantrolene oral 3 galantamine oral capsule,ext 4 QL (30/30) rel. pellets 24 hr methocarbamol oral 2 PA galantamine oral solution 4 QL (200/30) pyridostigmine bromide oral 5 NDS syrup galantamine oral tablet 4 QL (60/30) pyridostigmine bromide oral 3 GILENYA ORAL CAPSULE 0.5 5 PA; QL (30/30); tablet 60 mg MG NDS pyridostigmine bromide oral 3 oral capsule, 4 PA tablet extended release sprinkle,er 24hr regonol 4 memantine oral solution 2 PA; QL (300/30) tizanidine oral capsule 4 memantine oral tablet 10 mg 2 PA; QL (60/30) tizanidine oral tablet 2 memantine oral tablet 5 mg 2 PA; QL (90/30) NARCOTIC ANALGESICS memantine oral tablets,dose 3 PA; QL (98/28) pack acetaminophen-codeine oral 2 QL (4500/30); NDS solution 120 mg-12 mg /5 ml NAMZARIC 3 PA (5 ml), 120-12 mg/5 ml, 300 NUEDEXTA 5 PA; NDS mg-30 mg /12.5 ml OCREVUS 5 PA; NDS acetaminophen-codeine oral 2 QL (360/30); NDS rivastigmine 4 tablet 300-15 mg, 300-30 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 25 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS acetaminophen-codeine oral 2 QL (180/30); NDS oral solution 5 mg/5 4 QL (1200/30); NDS tablet 300-60 mg ml buprenorphine hcl injection 4 NDS methadone oral tablet 10 mg 3 QL (120/30); NDS buprenorphine hcl sublingual 4 PA methadone oral tablet 5 mg 3 QL (240/30); NDS BUPRENORPHINE 4 QL (4/28); NDS morphine (pf) injection solution 4 NDS TRANSDERMAL PATCH 0.5 mg/ml, 1 mg/ml WEEKLY 10 MCG/HOUR, 15 morphine concentrate oral 3 QL (900/30); NDS MCG/HOUR, 20 MCG/HOUR, solution 5 MCG/HOUR MORPHINE INJECTION 4 NDS buprenorphine transdermal 4 QL (4/28); NDS SOLUTION 10 MG/ML, 2 MG/ patch weekly 7.5 mcg/hour ML, 4 MG/ML, 5 MG/ML endocet 3 QL (360/30); NDS morphine injection solution 8 4 NDS fentanyl 4 QL (10/30); NDS mg/ml fentanyl citrate (pf) injection 4 NDS MORPHINE INJECTION 4 NDS solution SYRINGE 2 MG/ML fentanyl citrate (pf) injection 4 NDS morphine injection syringe 4 4 NDS syringe 50 mcg/ml mg/ml fentanyl citrate buccal lozenge 5 PA; QL (120/30); morphine intravenous solution 4 NDS on a handle NDS 10 mg/ml hydrocodone-acetaminophen 3 NDS MORPHINE INTRAVENOUS 4 NDS oral solution 10-325 mg/15 SOLUTION 4 MG/ML, 8 MG/ ml(15 ml) ML hydrocodone-acetaminophen 3 QL (5550/30); NDS MORPHINE INTRAVENOUS 4 NDS oral solution 7.5-325 mg/15 ml SYRINGE 10 MG/ML, 8 MG/ML HYDROCODONE- 3 QL (390/30); NDS morphine intravenous syringe 2 4 NDS ACETAMINOPHEN ORAL mg/ml, 4 mg/ml TABLET 10-300 MG, 7.5-300 morphine oral solution 3 QL (900/30); NDS MG MORPHINE ORAL TABLET 3 QL (180/30); NDS hydrocodone-acetaminophen 3 QL (360/30); NDS oral tablet 10-325 mg, 5-325 morphine oral tablet extended 3 QL (120/30); NDS mg, 7.5-325 mg release hydrocodone-ibuprofen 3 QL (50/30); NDS oxycodone oral concentrate 3 QL (180/30); NDS hydromorphone oral liquid 4 QL (2400/30); NDS oxycodone oral solution 3 QL (1200/30); NDS hydromorphone oral tablet 3 QL (180/30); NDS oxycodone oral tablet 10 mg, 3 QL (180/30); NDS 15 mg, 20 mg, 30 mg INFUMORPH P/F 5 B/D PA; NDS oxycodone oral tablet 5 mg 3 QL (360/30); NDS methadone injection solution 4 NDS oxycodone-acetaminophen oral 3 QL (360/30); NDS methadone intensol 4 QL (90/30); NDS tablet 10-325 mg, 2.5-325 mg, methadone oral concentrate 4 QL (90/30); NDS 5-325 mg, 7.5-325 mg methadone oral solution 10 4 QL (600/30); NDS oxymorphone oral tablet 3 QL (90/30); NDS mg/5 ml extended release 12 hr

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 26 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS XTAMPZA ER 3 QL (90/30); NDS naproxen sodium oral tablet 4 NON-NARCOTIC ANALGESICS 275 mg, 550 mg buprenorphine-naloxone 4 QL (60/30) NARCAN 3 sublingual film 12-3 mg oxaprozin 4 buprenorphine-naloxone 4 QL (360/30) salsalate 2 sublingual film 2-0.5 mg SUBOXONE SUBLINGUAL 3 QL (60/30) buprenorphine-naloxone 4 QL (90/30) FILM 12-3 MG sublingual film 4-1 mg, 8-2 mg SUBOXONE SUBLINGUAL 3 QL (360/30) buprenorphine-naloxone 2 QL (360/30) FILM 2-0.5 MG sublingual tablet 2-0.5 mg SUBOXONE SUBLINGUAL 3 QL (90/30) buprenorphine-naloxone 2 QL (90/30) FILM 4-1 MG, 8-2 MG sublingual tablet 8-2 mg sulindac 2 butorphanol nasal 3 QL (10/28); NDS oral tablet 50 mg 2 QL (240/30); NDS celecoxib 2 QL (60/30) tramadol-acetaminophen 3 QL (240/30); NDS diclofenac potassium 2 VIVITROL 5 NDS diclofenac sodium oral 2 ZUBSOLV SUBLINGUAL 3 QL (30/30) diclofenac sodium topical drops 4 QL (300/28) TABLET 0.7-0.18 MG, 1.4-0.36 diclofenac sodium topical gel 3 QL (1000/28) MG, 11.4-2.9 MG, 2.9-0.71 MG, 1% 5.7-1.4 MG diflunisal 2 ZUBSOLV SUBLINGUAL 3 QL (60/30) TABLET 8.6-2.1 MG ec-naproxen 2 PSYCHOTHERAPEUTIC DRUGS etodolac 4 ABILIFY MAINTENA 5 NDS flurbiprofen oral tablet 100 mg 2 ADASUVE 4 ibu 1 alprazolam oral tablet 0.25 mg, 2 QL (120/30) ibuprofen oral suspension 2 0.5 mg, 1 mg ibuprofen oral tablet 400 mg, 1 alprazolam oral tablet 2 mg 2 QL (150/30) 600 mg, 800 mg alprazolam oral tablet, 3 QL (90/30) meloxicam oral tablet 15 mg 1 disintegrating 0.25 mg, 0.5 mg, meloxicam oral tablet 7.5 mg 1 QL (60/30) 1 mg nabumetone 2 alprazolam oral tablet, 3 QL (150/30) naloxone injection solution 2 disintegrating 2 mg naloxone injection syringe 1 2 3 mg/ml 3 naltrexone 2 oral solution 3 naproxen oral suspension 3 aripiprazole oral tablet 2 QL (30/30) naproxen oral tablet 1 aripiprazole oral tablet, 5 QL (60/30); NDS naproxen oral tablet,delayed 2 disintegrating release (dr/ec) ARISTADA 5 NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 27 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ARISTADA INITIO 5 NDS dextroamphetamine oral 4 3 PA; QL (30/30) capsule, extended release maleate 4 QL (60/30) dextroamphetamine oral 4 QL (1800/30) solution oral capsule 10 4 QL (60/30) mg, 18 mg, 25 mg, 40 mg dextroamphetamine oral tablet 4 atomoxetine oral capsule 100 4 QL (30/30) dextroamphetamine- 4 QL (60/30) mg, 60 mg, 80 mg amphetamine oral capsule, extended release 24hr bupropion hcl oral tablet 100 3 QL (120/30) mg dextroamphetamine- 3 QL (180/30) amphetamine oral tablet 10 mg bupropion hcl oral tablet 75 mg 3 QL (180/30) dextroamphetamine- 3 QL (60/30) bupropion hcl oral tablet 3 QL (90/30) amphetamine oral tablet 12.5 extended release 24 hr 150 mg mg, 30 mg, 7.5 mg bupropion hcl oral tablet 3 QL (30/30) dextroamphetamine- 3 QL (120/30) extended release 24 hr 300 mg amphetamine oral tablet 15 mg bupropion hcl oral tablet 3 QL (60/30) dextroamphetamine- 3 QL (90/30)

sustained-release 12 hr amphetamine oral tablet 20 mg 2 dextroamphetamine- 3 QL (360/30) CAPLYTA 5 PA; QL (30/30); amphetamine oral tablet 5 mg NDS diazepam injection 2 injection 4 diazepam intensol 2 QL (240/30) chlorpromazine oral tablet 2 diazepam oral concentrate 2 QL (240/30) citalopram oral solution 3 diazepam oral solution 5 mg/5 2 QL (1200/30) citalopram oral tablet 1 ml (1 mg/ml) 3 diazepam oral tablet 2 QL (120/30) clonidine hcl oral tablet 4 oral capsule 3 extended release 12 hr doxepin oral concentrate 3 clorazepate dipotassium oral 3 QL (180/30) doxepin oral tablet 3 QL (30/30) tablet 15 mg DRIZALMA SPRINKLE ORAL 4 QL (60/30) clorazepate dipotassium oral 3 QL (90/30) CAPSULE, DELAYED REL

tablet 3.75 mg SPRINKLE 20 MG, 30 MG, 60 clorazepate dipotassium oral 3 QL (360/30) MG

tablet 7.5 mg DRIZALMA SPRINKLE ORAL 4 QL (90/30) oral tablet 3 CAPSULE, DELAYED REL clozapine oral tablet, 4 SPRINKLE 40 MG disintegrating duloxetine oral capsule,delayed 2 QL (60/30) 3 release(dr/ec) 20 mg, 30 mg, 60 mg desvenlafaxine succinate 4 QL (30/30) EMSAM 5 QL (30/30); NDS oral tablet 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 28 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS escitalopram oxalate oral 3 QL (600/30) oral tablet 10 mg, 2 solution 20 mg escitalopram oxalate oral tablet 2 HETLIOZ 5 PA; QL (30/30); FANAPT ORAL TABLET 1 MG 4 PA; QL (60/30) NDS FANAPT ORAL TABLET 10 5 PA; QL (60/30); hcl 3 MG, 12 MG, 2 MG, 4 MG, 6 NDS INVEGA SUSTENNA 5 NDS MG, 8 MG INTRAMUSCULAR SYRINGE FANAPT ORAL TABLETS, 4 PA; QL (8/28) 117 MG/0.75 ML, 156 MG/ML, DOSE PACK 234 MG/1.5 ML, 78 MG/0.5 ML FETZIMA ORAL CAPSULE, 4 ST; QL (28/28) INVEGA SUSTENNA 4 EXT REL 24HR DOSE PACK INTRAMUSCULAR SYRINGE 39 MG/0.25 ML FETZIMA ORAL CAPSULE, 4 ST; QL (30/30) EXTENDED RELEASE 24 HR INVEGA TRINZA 5 NDS fluoxetine (pmdd) oral tablet 10 3 QL (30/30) LATUDA ORAL TABLET 120 5 QL (30/30); NDS mg MG, 20 MG, 40 MG, 60 MG fluoxetine (pmdd) oral tablet 20 3 LATUDA ORAL TABLET 80 MG 5 QL (60/30); NDS mg lithium carbonate 2 fluoxetine oral capsule 10 mg 2 QL (30/30) lorazepam injection 4 fluoxetine oral capsule 20 mg 2 lorazepam intensol 3 QL (150/30) fluoxetine oral capsule 40 mg 2 QL (60/30) lorazepam oral concentrate 3 QL (150/30) fluoxetine oral capsule,delayed 3 QL (4/28) lorazepam oral tablet 0.5 mg, 2 QL (90/30) release(dr/ec) 1 mg fluoxetine oral solution 2 lorazepam oral tablet 2 mg 2 QL (150/30) fluoxetine oral tablet 10 mg 3 QL (30/30) succinate 2 fluoxetine oral tablet 20 mg 3 maprotiline 4 decanoate 4 MARPLAN 4 QL (180/30) fluphenazine hcl injection 4 hcl oral tablet 3 QL (90/30) fluphenazine hcl oral 4 methylphenidate hcl oral tablet 3 concentrate extended release fluphenazine hcl oral elixir 4 methylphenidate hcl oral tablet 3 fluphenazine hcl oral tablet 2 extended release 24hr 18 mg, 18 mg (bx rating), 27 mg, 27

fluvoxamine oral tablet 100 mg 2 QL (90/30) mg (bx rating), 36 mg, 36 mg fluvoxamine oral tablet 25 mg 2 QL (30/30) (bx rating), 54 mg, 54 mg (bx fluvoxamine oral tablet 50 mg 2 QL (60/30) rating) 4 mirtazapine oral tablet 2 haloperidol lactate injection 4 mirtazapine oral tablet, 2 QL (30/30) disintegrating haloperidol lactate oral 2 2 haloperidol oral tablet 0.5 mg, 1 1 mg, 2 mg, 5 mg 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 29 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS nortriptyline 2 RISPERDAL CONSTA 4 NUPLAZID ORAL CAPSULE 5 PA; QL (30/30); INTRAMUSCULAR NDS SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML NUPLAZID ORAL TABLET 10 5 PA; QL (30/30); MG NDS RISPERDAL CONSTA 5 NDS INTRAMUSCULAR intramuscular 4 QL (30/30) SUSPENSION,EXTENDED olanzapine oral tablet 2 REL RECON 25 MG/2 ML, 37.5 olanzapine oral tablet, 3 QL (30/30) MG/2 ML, 50 MG/2 ML disintegrating oral solution 2 olanzapine-fluoxetine 4 risperidone oral tablet 0.25 mg, 2 QL (60/30) oxazepam 2 QL (120/30) 0.5 mg, 1 mg, 2 mg, 3 mg oral tablet 4 PA; QL (30/30) risperidone oral tablet 4 mg 2 QL (120/30) extended release 24hr 1.5 mg, risperidone oral tablet, 3 QL (60/30) 3 mg, 9 mg disintegrating 0.25 mg, 0.5 mg, paliperidone oral tablet 4 PA; QL (60/30) 1 mg, 2 mg, 3 mg extended release 24hr 6 mg risperidone oral tablet, 3 QL (120/30) paroxetine hcl oral tablet 2 disintegrating 4 mg paroxetine hcl oral tablet 3 QL (60/30) SAPHRIS 5 QL (60/30); NDS extended release 24 hr SECUADO 4 QL (30/30) PAXIL ORAL SUSPENSION 4 ST; QL (900/30) sertraline oral concentrate 4 4 sertraline oral tablet 1 perphenazine-amitriptyline 4 temazepam 4 QL (60/365) PERSERIS 5 QL (1/30); NDS 3 phenelzine 3 thiothixene 4 3 tranylcypromine 4 protriptyline 4 trazodone 2 oral tablet 100 mg, 2 QL (90/30) 3 200 mg, 25 mg, 50 mg 4 quetiapine oral tablet 300 mg, 2 QL (60/30) TRINTELLIX 4 ST; QL (30/30) 400 mg venlafaxine oral capsule, 2 quetiapine oral tablet extended 3 QL (30/30) extended release 24hr release 24 hr 150 mg, 200 mg venlafaxine oral tablet 2 QL (90/30) quetiapine oral tablet extended 3 QL (60/30) release 24 hr 300 mg, 400 mg, VERSACLOZ 5 NDS 50 mg VIIBRYD ORAL TABLET 4 ST; QL (30/30) ramelteon 3 QL (30/30) VIIBRYD ORAL TABLETS, 4 ST; QL (30/30) REXULTI 5 QL (30/30); NDS DOSE PACK 10 MG (7)- 20 MG (23)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 30 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS VRAYLAR ORAL CAPSULE 5 PA; QL (30/30); amlodipine 1 NDS amlodipine-benazepril 1 VRAYLAR ORAL CAPSULE, 4 PA; QL (7/30) amlodipine-valsartan 1 DOSE PACK amlodipine-valsartan-hcthiazid 1 XYREM 5 PA; LA; QL (540/30); NDS atenolol 1

zaleplon oral capsule 10 mg 3 QL (60/30) atenolol-chlorthalidone 1 zaleplon oral capsule 5 mg 3 QL (30/30) benazepril 1

hcl 3 QL (60/30) benazepril- 1 ziprasidone mesylate 4 QL (6/30) betaxolol oral 2 zolpidem oral tablet 3 QL (30/30) BIDIL 3 ZYPREXA RELPREVV 5 PA; NDS bisoprolol fumarate 2 bisoprolol-hydrochlorothiazide 1 CARDIOVASCULAR, HYPERTENSION / LIPIDS injection 4 ANTIARRHYTHMIC AGENTS bumetanide oral 3 amiodarone intravenous 4 B/D PA BYSTOLIC 3 solution candesartan oral tablet 16 mg, 1 QL (60/30) amiodarone oral 2 4 mg, 8 mg dofetilide 3 candesartan oral tablet 32 mg 1 QL (30/30) flecainide 2 candesartan-hydrochlorothiazid 1 lidocaine (pf) intravenous 4 cartia xt 2 syringe carvedilol 1 mexiletine 2 carvedilol phosphate 3 pacerone oral tablet 100 mg, 2 chlorothiazide sodium 4 200 mg, 400 mg chlorthalidone oral tablet 25 2 propafenone oral capsule, 4 mg, 50 mg extended release 12 hr clonidine 4 QL (4/28) propafenone oral tablet 2 clonidine hcl oral tablet 0.1 mg, 1 quinidine sulfate oral tablet 2 0.2 mg sorine 2 clonidine hcl oral tablet 0.3 mg 2 sotalol af 2 DEMSER 5 PA; NDS sotalol oral 2 diltiazem hcl intravenous 4 SOTYLIZE 4 diltiazem hcl oral capsule,ext. 2 ANTIHYPERTENSIVE THERAPY rel 24h degradable acebutolol 2 diltiazem hcl oral capsule, 2 aliskiren 4 extended release 12 hr amiloride 2 amiloride-hydrochlorothiazide 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 31 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS diltiazem hcl oral capsule, 2 losartan-hydrochlorothiazide 1 QL (30/30) extended release 24 hr 120 oral tablet 100-12.5 mg, 100-25 mg, 180 mg, 240 mg, 300 mg, mg 420 mg losartan-hydrochlorothiazide 1 QL (60/30) diltiazem hcl oral capsule, 2 oral tablet 50-12.5 mg extended release 24hr 120 mg, matzim la 2 180 mg, 240 mg, 300 mg 4 diltiazem hcl oral tablet 2 metolazone 2 diltiazem hcl oral tablet 2 extended release 24 hr metoprolol succinate 1

dilt-xr 2 metoprolol ta-hydrochlorothiaz 2 doxazosin oral tablet 1 mg, 2 2 QL (30/30) metoprolol tartrate oral 1 mg, 4 mg metyrosine 5 PA; NDS doxazosin oral tablet 8 mg 2 QL (60/30) minoxidil oral 2 EDARBI 4 moexipril 1 EDARBYCLOR 4 nadolol 3 enalapril maleate 1 nadolol-bendroflumethiazide 3

enalapril-hydrochlorothiazide 1 oral tablet 80-5 mg ethacrynate sodium 4 nicardipine intravenous solution 4 felodipine 2 nicardipine oral 2 fosinopril 1 nifedipine oral tablet extended 2 release fosinopril-hydrochlorothiazide 1 nifedipine oral tablet extended 2 injection 4 release 24hr furosemide oral solution 10 mg/ 2 nimodipine 4 ml, 40 mg/5 ml (8 mg/ml) nisoldipine 4 furosemide oral tablet 1 olmesartan 1 hydralazine injection 4 olmesartan-hydrochlorothiazide 1 hydralazine oral 2 perindopril erbumine 1 hydrochlorothiazide 1 phenoxybenzamine 5 NDS indapamide 1 pindolol 1 irbesartan 1 QL (30/30) prazosin 3 irbesartan-hydrochlorothiazide 1 QL (30/30) propranolol oral capsule, 3 isradipine 3 extended release 24 hr labetalol oral 2 propranolol oral solution 2 lisinopril 1 propranolol oral tablet 1 lisinopril-hydrochlorothiazide 1 propranolol-hydrochlorothiazid 2 losartan 1 QL (60/30) quinapril 1 quinapril-hydrochlorothiazide 1

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 32 Covered Drugs By Category

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

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 33 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS PROMACTA ORAL POWDER 5 PA; LA; QL REPATHA 3 PA; QL (3/28) IN PACKET 25 MG (180/30); NDS REPATHA PUSHTRONEX 3 PA; QL (3.5/28) PROMACTA ORAL TABLET 5 PA; LA; QL (30/30); REPATHA SURECLICK 3 PA; QL (3/28) 12.5 MG, 25 MG, 50 MG NDS rosuvastatin 1 QL (30/30) PROMACTA ORAL TABLET 75 5 PA; LA; QL (60/30); MG NDS simvastatin oral tablet 1 QL (30/30) warfarin 1 VASCEPA 3 XARELTO 3 MISCELLANEOUS CARDIOVASCULAR AGENTS XARELTO DVT-PE TREAT 30D 3 CORLANOR ORAL TABLET 4 PA START digitek 2 LIPID/CHOLESTEROL LOWERING AGENTS digox 2 atorvastatin 1 QL (30/30) digoxin oral solution 3 cholestyramine (with sugar) 3 digoxin oral tablet 2 cholestyramine light 3 ENTRESTO 3 QL (60/30) colesevelam 3 LANOXIN ORAL TABLET 62.5 4 colestipol 3 MCG (0.0625 MG) ezetimibe 2 QL (30/30) ranolazine 4 QL (60/30) ezetimibe-simvastatin 4 QL (30/30) VYNDAMAX 5 PA; NDS fenofibrate micronized oral 3 VYNDAQEL 5 PA; NDS capsule 134 mg, 200 mg, 67 NITRATES mg isosorbide dinitrate oral tablet 3 fenofibrate nanocrystallized oral 3 isosorbide mononitrate 2 tablet 145 mg, 48 mg minitran 2 fenofibrate oral tablet 160 mg, 2 nitroglycerin intravenous 4 B/D PA 54 mg nitroglycerin sublingual 2 fenofibric acid (choline) 4 nitroglycerin transdermal patch 2 gemfibrozil 1 24 hour LIVALO 3 QL (30/30) nitroglycerin translingual 4 lovastatin oral tablet 10 mg 1 QL (30/30) lovastatin oral tablet 20 mg, 40 1 QL (60/30) DERMATOLOGICALS/TOPICAL THERAPY mg ANTIPSORIATIC / ANTISEBORRHEIC niacin oral tablet 500 mg 2 acitretin 4 PA niacin oral tablet extended 2 calcipotriene scalp 3 QL (120/30) release 24 hr calcipotriene topical cream 4 QL (120/30) niacor 2 calcipotriene topical ointment 4 QL (120/30) omega-3 acid ethyl esters 4 calcitriol topical 4 pravastatin 1 QL (30/30) selenium sulfide topical lotion 2 prevalite 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 34 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SKYRIZI SUBCUTANEOUS 5 PA; QL (1/28); NDS lidocaine hcl laryngotracheal 2 PEN INJECTOR lidocaine hcl mucous 3 QL (60/30) SKYRIZI SUBCUTANEOUS 5 PA; QL (1/28); NDS membrane jelly SYRINGE 150 MG/ML lidocaine hcl mucous 3 QL (60/30) SKYRIZI SUBCUTANEOUS 5 PA; QL (2/28); NDS membrane jelly in applicator SYRINGE KIT lidocaine hcl mucous 1 STELARA SUBCUTANEOUS 5 PA; QL (0.5/28); membrane solution 2% SOLUTION NDS lidocaine hcl mucous 2 STELARA SUBCUTANEOUS 5 PA; QL (0.5/28); membrane solution 4% (40 mg/ SYRINGE 45 MG/0.5 ML NDS ml) STELARA SUBCUTANEOUS 5 PA; QL (1/28); NDS lidocaine topical adhesive 4 PA; QL (90/30) SYRINGE 90 MG/ML patch,medicated 5% TALTZ SYRINGE 5 PA; QL (4/28); NDS lidocaine topical ointment 4 QL (50/30) MISCELLANEOUS DERMATOLOGICALS lidocaine viscous 1 ammonium lactate 3 lidocaine-prilocaine topical 4 QL (30/30) DUPIXENT PEN 5 PA; NDS cream SUBCUTANEOUS PEN methoxsalen 4 INJECTOR 200 MG/1.14 ML PANRETIN 5 NDS DUPIXENT PEN 5 PA; QL (8/28); NDS PICATO 5 NDS SUBCUTANEOUS PEN INJECTOR 300 MG/2 ML pimecrolimus 4 QL (100/30)

DUPIXENT SYRINGE 5 PA; QL (4.56/28); podofilox 2 SUBCUTANEOUS SYRINGE NDS REGRANEX 5 PA; NDS 200 MG/1.14 ML SANTYL 4 DUPIXENT SYRINGE 5 PA; QL (8/28); NDS silver sulfadiazine 3 SUBCUTANEOUS SYRINGE ssd 3 300 MG/2 ML tacrolimus topical 3 PA; QL (100/30) FLUOROURACIL TOPICAL 5 NDS CREAM 0.5% VALCHLOR 5 PA; NDS fluorouracil topical cream 5% 3 ZTLIDO 4 PA; QL (90/30) fluorouracil topical solution 2 THERAPY FOR ACNE glydo 3 QL (60/30) amnesteem 4 IMIQUIMOD TOPICAL CREAM 5 NDS avita 4 PA IN METERED-DOSE PUMP claravis 4 imiquimod topical cream in 5 NDS clindacin etz topical swab 2 QL (60/30) packet 3.75% clindacin p 2 QL (60/30) imiquimod topical cream in 3 clindamycin phosphate topical 3 QL (120/30) packet 5% gel lidocaine (pf) injection solution 4 CLINDAMYCIN PHOSPHATE 3 QL (120/30) lidocaine hcl injection solution 4 TOPICAL GEL, ONCE DAILY

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 35 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS clindamycin phosphate topical 4 QL (120/30) ciclopirox topical suspension 3 QL (60/28) lotion clotrimazole topical cream 2 QL (45/28) clindamycin phosphate topical 3 QL (120/30) clotrimazole topical solution 2 QL (30/28) solution clotrimazole-betamethasone 2 QL (45/28) clindamycin phosphate topical 2 QL (60/30) topical cream swab clotrimazole-betamethasone 2 QL (60/28) ery pads 3 topical lotion ERYTHROMYCIN WITH 4 econazole 3 QL (85/28) ETHANOL TOPICAL GEL ketoconazole topical cream 2 QL (60/28) erythromycin with ethanol 2 topical solution ketoconazole topical shampoo 2 QL (120/28)

erythromycin-benzoyl peroxide 4 naftifine 3 QL (60/28) isotretinoin oral capsule 10 mg, 4 NAFTIN TOPICAL GEL 3 QL (60/28) 20 mg, 30 mg, 40 mg nyamyc 2 metronidazole topical 3 nystatin topical cream 2 QL (30/28) myorisan 4 nystatin topical ointment 2 QL (30/28) rosadan topical cream 3 nystatin topical powder 2 rosadan topical gel 3 nystatin-triamcinolone 4 QL (60/28) tazarotene topical cream 4 PA nystop 2 TAZORAC 4 PA TOPICAL ANTIVIRALS tretinoin microspheres 4 PA acyclovir topical ointment 4 QL (30/30) tretinoin topical cream 0.025%, 4 PA DENAVIR 5 NDS 0.05%, 0.1% TOPICAL CORTICOSTEROIDS tretinoin topical topical gel 3 PA ala-cort topical cream 1% 1 0.01% alclometasone 2 tretinoin topical topical gel 4 PA betamethasone dipropionate 3 0.025%, 0.05% betamethasone valerate topical 2 zenatane 4 cream TOPICAL ANTIBACTERIALS betamethasone valerate topical 3 gentamicin topical 3 foam mupirocin 2 QL (44/30) betamethasone valerate topical 2 mupirocin calcium 4 QL (30/30) lotion sulfacetamide sodium (acne) 3 betamethasone valerate topical 2 TOPICAL ANTIFUNGALS ointment ciclodan topical solution 3 betamethasone, augmented 2 ciclopirox topical cream 3 QL (90/28) clobetasol scalp 2 QL (100/28) ciclopirox topical shampoo 3 QL (120/28) clobetasol topical cream 2 QL (120/28) ciclopirox topical solution 3 clobetasol topical foam 4 QL (100/28)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 36 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS clobetasol topical gel 2 QL (120/28) hydrocortisone butyrate topical 3 clobetasol topical ointment 2 QL (120/28) ointment clobetasol topical shampoo 4 QL (236/28) hydrocortisone butyrate topical 3 QL (120/30) solution clobetasol-emollient topical 2 QL (120/28) cream hydrocortisone butyr-emollient 4 QL (120/30) clobetasol-emollient topical 4 QL (100/28) hydrocortisone topical cream 1 foam 1%, 2.5% CLOCORTOLONE PIVALATE 4 hydrocortisone topical lotion 2 2.5% clodan 4 QL (236/28) hydrocortisone topical ointment 2 desonide topical cream 3 1%, 2.5% desonide topical lotion 3 hydrocortisone valerate 3 desonide topical ointment 3 mometasone topical 2 desoximetasone topical cream 4 prednicarbate topical ointment 2 desoximetasone topical gel 4 triamcinolone acetonide topical 2 desoximetasone topical 4 cream 0.025%, 0.5% ointment triamcinolone acetonide topical 1 fluocinolone and shower cap 3 cream 0.1% fluocinolone topical cream 2 triamcinolone acetonide topical 2 fluocinolone topical oil 3 lotion fluocinolone topical ointment 2 triamcinolone acetonide topical 2 ointment fluocinolone topical solution 2 triderm topical cream 0.1% 1 fluocinonide topical cream 2 0.05% tritocin 2 fluocinonide topical cream 0.1% 4 QL (120/30) TOPICAL SCABICIDES / PEDICULICIDES fluocinonide topical gel 2 QL (120/30) lindane topical shampoo 3 fluocinonide topical ointment 3 QL (120/30) malathion 4 fluocinonide topical solution 3 QL (120/30) permethrin 2 fluticasone propionate topical 2 DIAGNOSTICS / MISCELLANEOUS AGENTS cream fluticasone propionate topical 2 IRRIGATING SOLUTIONS ointment lactated ringers irrigation 4 halobetasol propionate topical 3 neomycin-polymyxin b gu 4 cream ringer's irrigation 4 halobetasol propionate topical 3 tis-u-sol pentalyte 4 ointment MISCELLANEOUS AGENTS hydrocortisone butyrate topical 4 QL (120/30) acamprosate 2 cream anagrelide 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 37 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ARALAST NP 5 LA; NDS levocarnitine (with sugar) 3 AURYXIA 5 PA; QL (360/30); levocarnitine oral solution 100 3 NDS mg/ml CARBAGLU 5 PA; LA; NDS levocarnitine oral tablet 3 CARNITOR INTRAVENOUS 5 B/D PA; NDS LOKELMA 3 CHEMET 4 PA midodrine 3 CLINIMIX 4.25%/D5W SULFIT 4 B/D PA nitisinone 5 NDS FREE NORTHERA ORAL CAPSULE 5 PA; QL (90/30); d10%-0.45% sodium chloride 4 100 MG NDS d2.5%-0.45% sodium chloride 4 NORTHERA ORAL CAPSULE 5 PA; QL (180/30); d5% and 0.9% sodium chloride 4 200 MG, 300 MG NDS d5%-0.45% sodium chloride 4 pilocarpine hcl oral 3 deferasirox oral granules in 5 PA; NDS PROLASTIN-C 5 PA; LA; NDS packet riluzole 3 deferasirox oral tablet 5 PA; NDS risedronate oral tablet 30 mg 3 QL (30/30) deferiprone 5 PA; NDS SEVELAMER CARBONATE 5 NDS dextrose 10% and 0.2% nacl 4 ORAL POWDER IN PACKET DEXTROSE 10% IN WATER 4 SEVELAMER CARBONATE 4 (D10W) ORAL TABLET dextrose 25% in water (d25w) 4 sodium chloride 0.9% 4 intravenous dextrose 30% in water (d30w) 4 sodium chloride irrigation 4 DEXTROSE 5% IN WATER 4 (D5W) INTRAVENOUS sodium phenylbutyrate 5 PA; NDS PARENTERAL SOLUTION sodium polystyrene sulfonate 3 dextrose 5% in water (d5w) 4 oral powder intravenous piggyback sps (with sorbitol) 3 dextrose 5%-lactated ringers 4 trientine 5 PA; QL (240/30); dextrose 5%-0.2% sod chloride 4 NDS dextrose 5%-0.3% sod.chloride 4 VELTASSA 3 dextrose 50% in water (d50w) 4 water for irrigation, sterile 4 dextrose 70% in water (d70w) 4 XIAFLEX 5 PA; NDS disulfiram 2 ZEMAIRA 5 LA; NDS oral capsule 100 mg 4 PA; QL (90/30) zoledronic acid-mannitol- 4 B/D PA water intravenous piggyback 5 droxidopa oral capsule 200 mg, 4 PA; QL (180/30) mg/100 ml 300 mg SMOKING DETERRENTS FERRIPROX 5 PA; NDS bupropion hcl (smoking deter) 3 QL (60/30) FERRIPROX (2 TIMES A DAY) 5 PA; NDS CHANTIX 4 INCRELEX 4 PA; LA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 38 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CHANTIX CONTINUING 4 dexamethasone oral elixir 2 MONTH BOX dexamethasone oral solution 2 CHANTIX STARTING MONTH 4 dexamethasone oral tablet 0.5 1 BOX mg, 0.75 mg, 4 mg NICOTROL 4 dexamethasone oral tablet 1 2 NICOTROL NS 4 mg, 1.5 mg, 2 mg, 6 mg 4 dexamethasone sodium phos 4 (pf) injection solution EAR, NOSE / THROAT MEDICATIONS dexamethasone sodium 4 MISCELLANEOUS AGENTS phosphate injection solution azelastine nasal 3 QL (60/30) fludrocortisone 2 chlorhexidine gluconate 1 hydrocortisone oral 3 mucous membrane MEDROL ORAL TABLET 2 MG 3 fluoride (sodium) dental paste 4 methylprednisolone 2 ipratropium bromide nasal 2 QL (30/30) methylprednisolone acetate 4 oralone 3 methylprednisolone sodium 4 paroex oral rinse 1 succ injection recon soln 125 sodium fluoride 5000 dry mouth 4 mg, 40 mg sodium fluoride-pot nitrate 4 methylprednisolone sodium 4 succ intravenous triamcinolone acetonide dental 3 prednisolone oral solution 3 MISCELLANEOUS OTIC PREPARATIONS prednisolone sodium 3 acetic acid otic (ear) 2 phosphate oral solution 15 flac otic oil 4 mg/5 ml (3 mg/ml), 15 mg/5 ml fluocinolone acetonide oil 4 (5 ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) hydrocortisone-acetic acid 2 prednisone intensol 4 ofloxacin otic (ear) 2 prednisone oral solution 2 OTIC STEROID / ANTIBIOTIC prednisone oral tablet 1 mg, 10 1 B/D PA CIPRO HC 3 mg, 2.5 mg, 20 mg, 5 mg CIPRODEX 3 prednisone oral tablet 50 mg 2 B/D PA ciprofloxacin-dexamethasone 3 prednisone oral tablets,dose 1 CORTISPORIN-TC 4 pack neomycin-polymyxin-hc otic 3 SOLU-CORTEF ACT-O-VIAL 4 (ear) (PF) ENDOCRINE/DIABETES triamcinolone acetonide 2 injection suspension 40 mg/ml ADRENAL HORMONES ANTITHYROID AGENTS DEPO-MEDROL 4 methimazole oral tablet 10 mg, 2 dexamethasone intensol 4 5 mg

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 39 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS propylthiouracil 3 GVOKE PFS 1-PACK 3 DIABETES THERAPY SYRINGE acarbose oral tablet 100 mg 2 QL (90/30) GVOKE PFS 2-PACK 3 SYRINGE acarbose oral tablet 25 mg 2 QL (360/30) HUMALOG JUNIOR KWIKPEN 3 acarbose oral tablet 50 mg 2 QL (180/30) U-100 PADS 2 HUMALOG KWIKPEN 3 BAQSIMI 3 INSULIN BD PEN NEEDLE 2 QL(200/30) HUMALOG MIX 50-50 INSULN 3 BYDUREON BCISE 4 QL (4/28) U-100 CYCLOSET 4 QL (180/30) HUMALOG MIX 50-50 3 KWIKPEN 4 HUMALOG MIX 75-25 3 FARXIGA ORAL TABLET 10 3 QL (30/30) KWIKPEN MG HUMALOG MIX 75-25(U-100) 3 FARXIGA ORAL TABLET 5 MG 3 QL (60/30) INSULN GAUZE PADS 2 X 2 2 HUMALOG U-100 INSULIN 3 glimepiride oral tablet 1 mg 1 QL (240/30) HUMULIN 70/30 U-100 3 glimepiride oral tablet 2 mg 1 QL (120/30) INSULIN glimepiride oral tablet 4 mg 1 QL (60/30) HUMULIN 70/30 U-100 3 glipizide oral tablet 10 mg 1 QL (120/30) KWIKPEN glipizide oral tablet 5 mg 1 QL (240/30) HUMULIN N NPH INSULIN 3 glipizide oral tablet extended 1 QL (60/30) KWIKPEN release 24hr 10 mg HUMULIN N NPH U-100 3 glipizide oral tablet extended 1 QL (240/30) INSULIN release 24hr 2.5 mg HUMULIN R REGULAR U-100 3 glipizide oral tablet extended 1 QL (120/30) INSULN release 24hr 5 mg HUMULIN R U-500 (CONC) 5 B/D PA; NDS glipizide-metformin oral tablet 1 QL (240/30) INSULIN 2.5-250 mg HUMULIN R U-500 (CONC) 5 NDS glipizide-metformin oral tablet 1 QL (120/30) KWIKPEN 2.5-500 mg, 5-500 mg INSULIN PEN NEEDLE 2 QL (200/30) GLUCAGEN HYPOKIT 3 INSULIN SYRINGE (DISP) 2 QL (200/30) GLUCAGON (HCL) 3 U-100 0.3 ML, 1 ML, 1/2 ML EMERGENCY KIT INVOKAMET 4 QL (60/30) GLUCAGON EMERGENCY 3 INVOKAMET XR 4 QL (60/30) KIT (HUMAN) INVOKANA 4 QL (30/30) GLYXAMBI 3 QL (30/30) JANUMET 3 QL (60/30) GVOKE HYPOPEN 1-PACK 3 GVOKE HYPOPEN 2-PACK 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 40 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS JANUMET XR ORAL TABLET, 3 QL (30/30) metformin oral tablet extended 1 QL (150/30) ER MULTIPHASE 24 HR 100- release 24hr 500 mg 1,000 MG miglitol oral tablet 100 mg 4 QL (90/30) JANUMET XR ORAL TABLET, 3 QL (60/30) miglitol oral tablet 25 mg 4 QL (360/30) ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG miglitol oral tablet 50 mg 4 QL (180/30) JANUVIA 3 QL (30/30) nateglinide oral tablet 120 mg 1 QL (90/30) JARDIANCE 3 QL (30/30) nateglinide oral tablet 60 mg 1 QL (180/30) JENTADUETO 3 QL (60/30) NEEDLES, INSULIN 2 QL (200/30) DISP.,SAFETY JENTADUETO XR ORAL 3 QL (60/30) TABLET, IR - ER, BIPHASIC NOVOFINE PEN NEEDLE 2 QL(200/30) 24HR 2.5-1,000 MG NOVOTWIST PEN NEEDLE 2 QL(200/30) JENTADUETO XR ORAL 3 QL (30/30) OMNIPOD 5 PACK 3 QL(30/30) TABLET, IR - ER, BIPHASIC OMNIPOD DASH 5 PACK 3 QL(30/30) 24HR 5-1,000 MG OMNIPOD STARTER KIT 3 QL(1/365) LANTUS SOLOSTAR U-100 3 OZEMPIC SUBCUTANEOUS 3 QL (1.5/28) INSULIN PEN INJECTOR 0.25 MG OR LANTUS U-100 INSULIN 3 0.5 MG(2 MG/1.5 ML) LEVEMIR FLEXTOUCH U-100 3 OZEMPIC SUBCUTANEOUS 3 QL (3/28) INSULN PEN INJECTOR 1 MG/DOSE LEVEMIR U-100 INSULIN 3 (2 MG/1.5 ML), 1 MG/DOSE (4 LYUMJEV KWIKPEN U-100 3 MG/3 ML) INSULIN pioglitazone 1 QL (30/30) LYUMJEV KWIKPEN U-200 3 pioglitazone-metformin 1 QL (90/30) INSULIN PROGLYCEM 5 NDS LYUMJEV U-100 INSULIN 3 repaglinide oral tablet 0.5 mg 1 QL (960/30) METFORMIN ORAL 3 QL (750/30) repaglinide oral tablet 1 mg 1 QL (480/30) SOLUTION repaglinide oral tablet 2 mg 1 QL (240/30) metformin oral tablet 1,000 mg 1 QL (75/30) RIOMET 3 QL (765/30) metformin oral tablet 500 mg 1 QL (150/30) RIOMET ER 3 QL (600/30) metformin oral tablet 850 mg 1 QL (90/30) RYBELSUS 3 QL (30/30) metformin oral tablet extended 1 QL (120/30) SOLIQUA 100/33 3 QL (15/30) release 24 hr 500 mg (generic for glucophage xr) SYMLINPEN 120 5 PA; QL (10.8/30); NDS metformin oral tablet extended 1 QL (60/30) release 24 hr 750 mg (generic SYMLINPEN 60 5 PA; QL (6/30); NDS for glucophage xr) SYNJARDY 3 QL (60/30) metformin oral tablet extended 1 QL (60/30) SYNJARDY XR ORAL TABLET, 3 QL (60/30) release 24hr 1,000 mg IR - ER, BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 41 Covered Drugs By Category

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

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 42 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS SOMAVERT 5 PA; QL (30/30); UNITHROID ORAL TABLET 3 NDS 100 MCG, 112 MCG, 125 SYNAREL 5 NDS MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, testosterone cypionate 3 50 MCG, 75 MCG, 88 MCG intramuscular oil 100 mg/ml, 200 mg/ml (1 ml) unithroid oral tablet 137 mcg 3 TESTOSTERONE CYPIONATE 3 GASTROENTEROLOGY INTRAMUSCULAR OIL 200 MG/ML ANTIDIARRHEALS / ANTISPASMODICS testosterone enanthate 4 atropine injection solution 0.4 4 mg/ml testosterone transdermal gel 4 PA; QL (300/30) atropine injection syringe 0.05 4 testosterone transdermal gel in 4 PA; QL (300/30) mg/ml, 0.1 mg/ml metered-dose pump 12.5 mg/ 1.25 gram (1%) dicyclomine oral capsule 1 testosterone transdermal gel 4 PA; QL (300/30) dicyclomine oral solution 3 in packet 1% (25 mg/2.5gram), dicyclomine oral tablet 1 1% (50 mg/5 gram) diphenoxylate-atropine oral 3 tolvaptan oral tablet 30 mg 5 PA; QL (60/30); liquid NDS diphenoxylate-atropine oral 2 zoledronic acid intravenous 4 B/D PA tablet solution GLYCOPYRROLATE (PF) IN 4 zoledronic acid-mannitol- 4 B/D PA WATER INJECTION water intravenous piggyback 4 glycopyrrolate (pf) in water 4 mg/100 ml intravenous syringe 0.4 mg/2 ZOLEDRONIC AC-MANNITOL- 4 B/D PA ml (0.2 mg/ml) 0.9NACL glycopyrrolate injection 4 THYROID HORMONES glycopyrrolate oral tablet 1 mg, 2 EUTHYROX 3 2 mg LEVO-T 3 oral capsule 2 levothyroxine oral tablet 1 MISCELLANEOUS GASTROINTESTINAL AGENTS levoxyl oral tablet 100 mcg, 112 3 alosetron 5 PA; NDS mcg, 175 mcg aprepitant 4 B/D PA LEVOXYL ORAL TABLET 125 3 AVSOLA 5 PA; NDS MCG, 137 MCG, 150 MCG, 200 MCG, 25 MCG, 50 MCG, balsalazide 4 75 MCG, 88 MCG budesonide oral capsule, 4 liothyronine oral 2 delayed,extend.release SYNTHROID 3 budesonide oral tablet,delayed 5 NDS and ext.release compro 2 constulose 3

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 43 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS CORTIFOAM 4 ondansetron hcl (pf) 4 CREON 3 ondansetron hcl intravenous 4 cromolyn oral 3 ondansetron hcl oral solution 3 B/D PA; QL CYSTADANE 5 NDS (450/30) dronabinol 4 B/D PA; QL (60/30) ondansetron hcl oral tablet 2 B/D PA EMEND ORAL SUSPENSION 4 B/D PA palonosetron intravenous 5 NDS FOR RECONSTITUTION solution 0.25 mg/5 ml enulose 3 peg 3350-electrolytes oral 2 recon soln 236-22.74-6.74 GATTEX 30-VIAL 5 PA; NDS -5.86 gram GATTEX ONE-VIAL 5 PA; NDS peg-electrolyte 2 gavilyte-c 2 PENTASA 5 NDS gavilyte-n 2 PLENVU 4 generlac 3 2 granisetron (pf) intravenous 4 B/D PA prochlorperazine edisylate 4 solution 1 mg/ml (1 ml) prochlorperazine maleate oral 2 granisetron hcl intravenous 4 procto-med hc 1 granisetron hcl oral 3 B/D PA; QL (60/30) procto-pak 2 hydrocortisone rectal 3 proctosol hc topical 1 hydrocortisone topical cream 1 with perineal applicator proctozone-hc 1 lactulose oral solution 2 RECTIV 4 LINZESS 3 QL (30/30) RELISTOR SUBCUTANEOUS 5 PA; NDS SOLUTION meclizine oral tablet 12.5 mg, 2 25 mg RELISTOR SUBCUTANEOUS 5 PA; NDS SYRINGE mesalamine oral capsule, 3 extended release 24hr RENFLEXIS 5 PA; NDS mesalamine oral tablet,delayed 4 SANCUSO 5 NDS release (dr/ec) 1.2 gram scopolamine base 4 QL (10/30) mesalamine rectal enema 4 sulfasalazine 2 mesalamine with cleansing 4 SUPREP BOWEL PREP KIT 3 wipe SUTAB 4 hcl oral 2 trilyte with flavor packets 2 solution ursodiol 3 metoclopramide hcl oral tablet 2 VIOKACE ORAL TABLET 4 MOVANTIK 4 QL (30/30) 10,440-39,150- 39,150 UNIT OCALIVA 5 PA; LA; QL (30/30); VIOKACE ORAL TABLET 5 NDS NDS 20,880-78,300- 78,300 UNIT ondansetron 2 B/D PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 44 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ZENPEP ORAL CAPSULE, 3 ARANESP (IN 4 PA DELAYED RELEASE(DR/EC) POLYSORBATE) INJECTION 10,000-32,000 -42,000 UNIT, SYRINGE 10 MCG/0.4 ML, 25 15,000-47,000 -63,000 UNIT, MCG/0.42 ML, 40 MCG/0.4 ML 20,000-63,000- 84,000 UNIT, ARANESP (IN 5 PA; NDS 25,000-79,000- 105,000 UNIT, POLYSORBATE) INJECTION 3,000-10,000 -14,000-UNIT, SYRINGE 100 MCG/0.5 ML, 40,000-126,000- 168,000 UNIT, 150 MCG/0.3 ML, 200 MCG/0.4 5,000-17,000- 24,000 UNIT ML, 300 MCG/0.6 ML, 500 ULCER THERAPY MCG/ML, 60 MCG/0.3 ML esomeprazole oral 3 ARCALYST 5 PA; NDS capsule,delayed release(dr/ec) AVONEX INTRAMUSCULAR 5 PA; QL (1/28); NDS famotidine oral suspension 4 PEN INJECTOR KIT famotidine oral tablet 20 mg, 2 AVONEX INTRAMUSCULAR 5 PA; QL (1/28); NDS 40 mg SYRINGE KIT lansoprazole oral capsule, 3 BETASERON 5 PA; QL (14/28); delayed release(dr/ec) SUBCUTANEOUS KIT NDS misoprostol 3 GENOTROPIN 5 PA; NDS nizatidine oral capsule 2 GENOTROPIN MINIQUICK 5 PA; NDS omeprazole oral capsule, 2 INTRON A INJECTION RECON 5 B/D PA; NDS delayed release(dr/ec) SOLN pantoprazole oral tablet, 1 INTRON A INJECTION 5 B/D PA; NDS delayed release (dr/ec) 20 mg SOLUTION 10 MILLION UNIT/ pantoprazole oral tablet, 1 QL (60/30) ML delayed release (dr/ec) 40 mg INTRON A INJECTION 4 B/D PA sucralfate oral suspension 4 SOLUTION 6 MILLION UNIT/ ML sucralfate oral tablet 2 LEUKINE INJECTION RECON 5 PA; NDS IMMUNOLOGY, VACCINES / BIOTECHNOLOGY SOLN BIOTECHNOLOGY DRUGS MOZOBIL 5 B/D PA; NDS ACTIMMUNE 5 PA; NDS NIVESTYM 5 PA; NDS ARANESP (IN 5 PA; NDS NYVEPRIA 5 PA; NDS POLYSORBATE) INJECTION REBIF (WITH ALBUMIN) 5 PA; QL (6/28); NDS SOLUTION 100 MCG/ML, 200 REBIF REBIDOSE 5 PA; QL (6/28); NDS MCG/ML, 300 MCG/ML, 60 SUBCUTANEOUS PEN MCG/ML INJECTOR 22 MCG/0.5 ML, 44 ARANESP (IN 4 PA MCG/0.5 ML POLYSORBATE) INJECTION REBIF REBIDOSE 5 PA; QL (4.2/180); SOLUTION 25 MCG/ML, 40 SUBCUTANEOUS PEN NDS MCG/ML INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 45 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS REBIF TITRATION PACK 5 PA; QL (4.2/180); IPOL 3 NDS IXIARO (PF) 3 RETACRIT 4 PA KINRIX (PF) 3 ZARXIO 5 PA; NDS MENACTRA (PF) 3 ZIEXTENZO 5 PA; NDS INTRAMUSCULAR SOLUTION VACCINES / MISCELLANEOUS IMMUNOLOGICALS MENQUADFI (PF) 3 ACTHIB (PF) 3 MENVEO A-C-Y-W-135-DIP 3 ADACEL(TDAP ADOLESN/ 3 (PF) ADULT)(PF) M-M-R II (PF) 3 ATGAM 4 B/D PA PEDIARIX (PF) 3 BCG VACCINE, LIVE (PF) 3 PEDVAX HIB (PF) 3 BEXSERO 3 PENTACEL (PF) 3 BOOSTRIX TDAP 3 INTRAMUSCULAR KIT 15LF-48MCG-62DU -10 BOTOX 4 PA MCG/0.5ML DAPTACEL (DTAP 3 PROQUAD (PF) 3 PEDIATRIC) (PF) QUADRACEL (PF) 3 ENGERIX-B (PF) 3 B/D PA INTRAMUSCULAR SYRINGE RABAVERT (PF) 3 ENGERIX-B PEDIATRIC (PF) 3 B/D PA RECOMBIVAX HB (PF) 3 B/D PA fomepizole 5 NDS ROTARIX 3 GAMMAKED INJECTION 5 B/D PA; NDS ROTATEQ VACCINE 3 SOLUTION 1 GRAM/10 ML SHINGRIX (PF) 3 QL (2/999) (10%), 10 GRAM/100 ML STAMARIL (PF) 3 (10%), 20 GRAM/200 ML (10%), 5 GRAM/50 ML (10%) TDVAX 3 GAMUNEX-C 5 B/D PA; NDS TENIVAC (PF) 3 INTRAMUSCULAR SYRINGE GARDASIL 9 (PF) 3 TETANUS,DIPHTHERIA TOX 3 HAVRIX (PF) 3 PED(PF) INTRAMUSCULAR SUSPENSION 1,440 ELISA TRUMENBA 3 UNIT/ML TWINRIX (PF) 3 HAVRIX (PF) 3 TYPHIM VI 3 INTRAMUSCULAR SYRINGE VAQTA (PF) 3 HIBERIX (PF) 3 VARIVAX (PF) 3 HIZENTRA 5 B/D PA; NDS VARIZIG 4 IMOVAX RABIES VACCINE 3 YF-VAX (PF) 3 (PF) ZOSTAVAX (PF) 3 INFANRIX (DTAP) (PF) 3 INTRAMUSCULAR SYRINGE

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 46 Covered Drugs By Category

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

MUSCULOSKELETAL / RHEUMATOLOGY HUMIRA PEN 5 PA; QL (4/28); NDS HUMIRA PEN CROHNS- 5 PA; QL (6/180); GOUT THERAPY UC-HS START NDS allopurinol 1 HUMIRA PEN PSOR-UVEITS- 5 PA; QL (4/180); colchicine oral tablet 4 QL (120/30) ADOL HS NDS FEBUXOSTAT 3 ST HUMIRA SUBCUTANEOUS 5 PA; QL (4/28); NDS MITIGARE 3 SYRINGE KIT 40 MG/0.8 ML probenecid 2 HUMIRA(CF) PEDI CROHNS 5 PA; QL (3/180); STARTER SUBCUTANEOUS NDS probenecid-colchicine 2 SYRINGE KIT 80 MG/0.8 ML OSTEOPOROSIS THERAPY HUMIRA(CF) PEDI CROHNS 5 PA; QL (2/180); alendronate oral tablet 10 mg, 1 QL (30/30) STARTER SUBCUTANEOUS NDS 5 mg SYRINGE KIT 80 MG/0.8 alendronate oral tablet 35 mg, 1 QL (4/28) ML-40 MG/0.4 ML 70 mg HUMIRA(CF) PEN CROHNS- 5 PA; QL (3/180); BINOSTO 4 QL (4/28) UC-HS NDS ibandronate oral 2 QL (1/30) HUMIRA(CF) PEN PEDIATRIC 5 PA; QL (4/180); UC NDS PROLIA 4 QL (1/180) HUMIRA(CF) PEN PSOR-UV- 5 PA; QL (3/180); raloxifene 2 QL (30/30) ADOL HS NDS risedronate oral tablet 150 mg 3 QL (1/30) HUMIRA(CF) PEN 5 PA; QL (4/28); NDS risedronate oral tablet 35 mg, 3 QL (4/28) SUBCUTANEOUS INJECTOR 35 mg (12 pack), 35 mg (4 KIT 40 MG/0.4 ML pack) HUMIRA(CF) PEN 5 PA; QL (3/28); NDS risedronate oral tablet 5 mg 3 QL (30/30) SUBCUTANEOUS PEN TERIPARATIDE 5 PA; QL (2.4/28); INJECTOR KIT 80 MG/0.8 ML NDS HUMIRA(CF) 5 PA; QL (2/28); NDS TYMLOS 5 PA; QL (1.56/30); SUBCUTANEOUS SYRINGE NDS KIT 10 MG/0.1 ML, 20 MG/0.2 OTHER RHEUMATOLOGICALS ML BENLYSTA 5 PA; NDS HUMIRA(CF) 5 PA; QL (4/28); NDS SUBCUTANEOUS SYRINGE DEPEN TITRATABS 5 NDS KIT 40 MG/0.4 ML ENBREL MINI 5 PA; QL (8/28); NDS leflunomide 2 QL (30/30) ENBREL SUBCUTANEOUS 5 PA; QL (16/28); ORENCIA CLICKJECT 5 PA; QL (4/28); NDS RECON SOLN NDS ORENCIA SUBCUTANEOUS 5 PA; QL (4/28); NDS ENBREL SUBCUTANEOUS 5 PA; QL (4/28); NDS SYRINGE 125 MG/ML SOLUTION ORENCIA SUBCUTANEOUS 5 PA; QL (1.6/28); ENBREL SUBCUTANEOUS 5 PA; QL (8/28); NDS SYRINGE 50 MG/0.4 ML NDS SYRINGE ORENCIA SUBCUTANEOUS 5 PA; QL (2.8/28); ENBREL SURECLICK 5 PA; QL (8/28); NDS SYRINGE 87.5 MG/0.7 ML NDS

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 47 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS penicillamine 5 NDS medroxyprogesterone 4 RIDAURA 5 NDS intramuscular suspension RINVOQ 5 PA; QL (30/30); medroxyprogesterone 2 NDS intramuscular syringe XELJANZ ORAL SOLUTION 5 PA; QL (300/30); medroxyprogesterone oral 1 NDS MENEST 3 XELJANZ ORAL TABLET 5 PA; QL (60/30); MENOSTAR 3 QL (4/28) NDS nora-be 2 XELJANZ XR 5 PA; QL (30/30); norethindrone (contraceptive) 2 NDS norethindrone acetate 2 OBSTETRICS / GYNECOLOGY norethindrone ac-eth estradiol 3 oral tablet 0.5-2.5 mg-mcg ESTROGENS / PROGESTINS PREMARIN INJECTION 4 ALORA 3 QL (8/28) PREMARIN ORAL 3 camila 2 PREMARIN VAGINAL 3 deblitane 2 progesterone micronized 2 DELESTROGEN 4 INTRAMUSCULAR OIL 10 MG/ sharobel 2 ML yuvafem 4 DEPO-ESTRADIOL 4 MISCELLANEOUS OB/GYN dotti 2 QL (8/28) clindamycin phosphate vaginal 3 DUAVEE 4 PA metronidazole vaginal 3 errin 2 terconazole 3 estradiol oral 2 tranexamic acid oral 3 estradiol transdermal patch 2 QL (8/28) vandazole 3 semiweekly ORAL CONTRACEPTIVES / RELATED AGENTS estradiol transdermal patch 2 QL (4/28) afirmelle 2 weekly altavera (28) 2 estradiol vaginal 4 alyacen 1/35 (28) 2 estradiol valerate intramuscular 4 oil 20 mg/ml, 40 mg/ml alyacen 7/7/7 (28) 2 ESTRING 4 amethia 2 fyavolv 3 amethyst (28) 2 heather 2 apri 2 hydroxyprogesterone caproate 5 NDS aranelle (28) 2 incassia 2 ashlyna 2 jencycla 2 aubra 2 lyza 2 aubra eq 2 aurovela 1.5/30 (21) 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 48 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS aurovela 1/20 (21) 2 estarylla 2 aurovela 24 fe 2 ethynodiol diac-eth estradiol 2 aurovela fe 1.5/30 (28) 2 falmina (28) 2 aurovela fe 1-20 (28) 2 fayosim 2 aviane 2 femynor 2 ayuna 2 gemmily 2 azurette (28) 2 hailey 2 balziva (28) 2 hailey 24 fe 2 blisovi 24 fe 2 hailey fe 1.5/30 (28) 2 blisovi fe 1.5/30 (28) 2 hailey fe 1/20 (28) 2 blisovi fe 1/20 (28) 2 iclevia 2 briellyn 2 introvale 2 camrese 2 isibloom 2 camrese lo 2 jaimiess 2 caziant (28) 2 jasmiel (28) 2 charlotte 24 fe 2 jolessa 2 chateal (28) 2 juleber 2 chateal eq (28) 2 junel 1.5/30 (21) 2 cryselle (28) 2 junel 1/20 (21) 2 cyclafem 1/35 (28) 2 junel fe 1.5/30 (28) 2 cyclafem 7/7/7 (28) 2 junel fe 1/20 (28) 2 cyred 2 junel fe 24 2 cyred eq 2 kaitlib fe 2 dasetta 1/35 (28) 2 kalliga 2 dasetta 7/7/7 (28) 2 kariva (28) 2 daysee 2 kelnor 1/35 (28) 2 desog-e.estradiol/e.estradiol 2 kelnor 1-50 (28) 2 desogestrel-ethinyl estradiol 2 kurvelo (28) 2 dolishale 2 l norgest/e.estradiol-e.estrad 2 drospirenone-e.estradiol-lm.fa 2 larin 1.5/30 (21) 2 drospirenone-ethinyl estradiol 2 larin 1/20 (21) 2 elinest 2 larin 24 fe 2 ELLA 3 larin fe 1.5/30 (28) 2 emoquette 2 larin fe 1/20 (28) 2 enpresse 2 larissia 2 enskyce 2 layolis fe 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 49 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS leena 28 2 nortrel 1/35 (28) 2 lessina 2 nortrel 7/7/7 (28) 2 levonest (28) 2 nylia 7/7/7 (28) 2 levonorgestrel-ethinyl estrad 2 nymyo 2 levonorg-eth estrad triphasic 2 ocella 2 levora-28 2 orsythia 2 lillow (28) 2 philith 2 lojaimiess 2 pimtrea (28) 2 loryna (28) 2 pirmella 2 low-ogestrel (28) 2 portia 28 2 lo-zumandimine (28) 2 previfem 2 lutera (28) 2 reclipsen (28) 2 marlissa (28) 2 rivelsa 2 merzee 2 setlakin 2 mibelas 24 fe 2 simliya (28) 2 microgestin 1.5/30 (21) 2 simpesse 2 microgestin 1/20 (21) 2 sprintec (28) 2 microgestin fe 1.5/30 (28) 2 sronyx 2 microgestin fe 1/20 (28) 2 syeda 2 mili 2 tarina 24 fe 2 mono-linyah 2 tarina fe 1/20 (28) 2 necon 0.5/35 (28) 2 tarina fe 1-20 eq (28) 2 nikki (28) 2 tilia fe 2 noreth-ethinyl estradiol-iron 2 tri femynor 2 norethindrone ac-eth estradiol 2 tri-estarylla 2 oral tablet 1-20 mg-mcg, 1.5-30 tri-legest fe 2 mg-mcg tri-linyah 2 norethindrone-e.estradiol-iron 2

oral capsule tri-lo-estarylla 2

norethindrone-e.estradiol-iron 2 tri-lo-marzia 2 oral tablet 1 mg-20 mcg (21)/75 tri-lo-mili 2 mg (7), 1.5 mg-30 mcg (21)/75 tri-lo-sprintec 2 mg (7) tri-mili 2 norethindrone-e.estradiol-iron 2 tri-nymyo 2 oral tablet,chewable tri-previfem (28) 2 norgestimate-ethinyl estradiol 2 tri-sprintec (28) 2 nortrel 0.5/35 (28) 2 trivora (28) 2 nortrel 1/35 (21) 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 50 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS tri-vylibra 2 neomycin-polymyxin-gramicidin 2 tri-vylibra lo 2 neo-polycin 2 TYBLUME 2 ofloxacin ophthalmic (eye) 2 tydemy 2 polycin 2 velivet triphasic regimen (28) 2 polymyxin b sulf-trimethoprim 2 vestura (28) 2 tobramycin ophthalmic (eye) 2 vienva 2 TOBREX OPHTHALMIC (EYE) 4 viorele (28) 2 OINTMENT volnea (28) 2 ANTIVIRALS vyfemla (28) 2 trifluridine 3 vylibra 2 ZIRGAN 3 wera (28) 2 BETA-BLOCKERS wymzya fe 2 carteolol 2 zarah 2 levobunolol ophthalmic (eye) 1 drops 0.5% zovia 1/35e (28) 2 timolol maleate ophthalmic 1

zovia 1-35 (28) 2 (eye) drops

zumandimine (28) 2 TIMOLOL MALEATE 4 OPHTHALMOLOGY OPHTHALMIC (EYE) GEL FORMING SOLUTION ANTIBIOTICS MISCELLANEOUS OPHTHALMOLOGICS ak-poly-bac 2 atropine ophthalmic (eye) drops 3 AZASITE 3 azelastine ophthalmic (eye) 2 bacitracin ophthalmic (eye) 2 BLEPHAMIDE 3 bacitracin-polymyxin b 2 BLEPHAMIDE S.O.P. 3 ophthalmic (eye) cromolyn ophthalmic (eye) 2 BESIVANCE 4 CYSTARAN 5 PA; NDS CILOXAN OPHTHALMIC 3 (EYE) OINTMENT epinastine 3 ciprofloxacin hcl ophthalmic 2 EYLEA 5 PA; NDS (eye) LACRISERT 4 erythromycin ophthalmic (eye) 2 olopatadine ophthalmic (eye) 3 gentak ophthalmic (eye) 2 OXERVATE 5 PA; QL (112/999); ointment NDS gentamicin ophthalmic (eye) 2 pilocarpine hcl ophthalmic (eye) 3 drops drops 1%, 2%, 4% moxifloxacin ophthalmic (eye) 3 RESTASIS 3 QL (60/30) NATACYN 3 RESTASIS MULTIDOSE 3 QL (60/30) neomycin-bacitracin-polymyxin 2

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 51 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS sulfacetamide sodium 2 PRED-G S.O.P. 3 ophthalmic (eye) drops tobramycin-dexamethasone 3 sulfacetamide-prednisolone 2 ZYLET 3 XIIDRA 3 QL (60/30) STEROIDS NON-STEROIDAL ANTI-INFLAMMATORY AGENTS dexamethasone sodium 2 bromfenac 4 phosphate ophthalmic (eye) diclofenac sodium ophthalmic 2 DUREZOL 3 (eye) fluorometholone 3 flurbiprofen sodium 2 INVELTYS 4 ketorolac ophthalmic (eye) 2 LOTEMAX 4 PROLENSA 3 LOTEMAX SM 4 ORAL DRUGS FOR GLAUCOMA prednisolone acetate 3 acetazolamide 3 prednisolone sodium 1 acetazolamide sodium 4 phosphate ophthalmic (eye) methazolamide 4 SYMPATHOMIMETICS OTHER GLAUCOMA DRUGS ALPHAGAN P OPHTHALMIC 3 AZOPT 4 (EYE) DROPS 0.1% bimatoprost ophthalmic (eye) 2 apraclonidine 3 brinzolamide 4 brimonidine ophthalmic (eye) 3 drops 0.15% COMBIGAN 3 brimonidine ophthalmic (eye) 2 dorzolamide 2 drops 0.2% dorzolamide-timolol 2 RESPIRATORY AND ALLERGY latanoprost 1 LUMIGAN OPHTHALMIC 3 ANTIHISTAMINE / ANTIALLERGENIC AGENTS (EYE) DROPS 0.01% desloratadine oral tablet 2 QL (30/30) RHOPRESSA 4 ST hcl injection 4 ROCKLATAN 4 ST solution 50 mg/ml SIMBRINZA 4 epinephrine injection auto- 3 QL (2/30) travoprost 3 injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml STEROID-ANTIBIOTIC COMBINATIONS epinephrine injection auto- 2 QL (2/30) neomycin-bacitracin-poly-hc 3 injector 0.15 mg/0.3 ml, 0.3 neomycin-polymyxin 2 mg/0.3 ml b-dexameth epinephrine injection solution 1 4 neomycin-polymyxin-hc 2 mg/ml ophthalmic (eye) hcl oral tablet 3 PA neo-polycin hc 3 levocetirizine oral solution 4 PRED-G 3 levocetirizine oral tablet 2 QL (30/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 52 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS oral 2 PA budesonide inhalation 4 B/D PA; QL promethazine rectal 4 suspension for nebulization (120/30) suppository 12.5 mg, 25 mg 0.25 mg/2 ml, 0.5 mg/2 ml promethegan rectal suppository 4 budesonide inhalation 4 B/D PA; QL (60/30) 25 mg, 50 mg suspension for nebulization 1 mg/2 ml PULMONARY AGENTS COMBIVENT RESPIMAT 3 QL (8/30) 3 B/D PA cromolyn inhalation 2 B/D PA ADEMPAS 5 PA; LA; QL (90/30); NDS DALIRESP 4 PA; QL (30/30) ADVAIR HFA 3 QL (12/30) ESBRIET ORAL CAPSULE 5 PA; QL (270/30); NDS albuterol sulfate inhalation 4 QL (17/30) hfa aerosol inhaler 90 mcg/ ESBRIET ORAL TABLET 267 5 PA; QL (270/30); actuation (generic for proair) MG NDS ALBUTEROL SULFATE 4 QL (13.4/30) ESBRIET ORAL TABLET 801 5 PA; QL (90/30); INHALATION HFA AEROSOL MG NDS INHALER 90 MCG/ FLOVENT DISKUS 3 QL (60/30) ACTUATION (GENERIC FOR INHALATION BLISTER PROVENTIL) WITH DEVICE 100 MCG/ albuterol sulfate inhalation 4 QL (36/30) ACTUATION, 50 MCG/ hfa aerosol inhaler 90 mcg/ ACTUATION actuation (generic for ventolin) FLOVENT DISKUS 3 QL (240/30) albuterol sulfate inhalation 2 B/D PA INHALATION BLISTER solution for nebulization WITH DEVICE 250 MCG/ ACTUATION albuterol sulfate oral syrup 2 FLOVENT HFA AEROSOL 3 QL (12/30) albuterol sulfate oral tablet 3 INHALER 110 MCG/ albuterol sulfate oral tablet 2 ACTUATION extended release 12 hr FLOVENT HFA AEROSOL 3 QL (24/30) alyq 5 PA; QL (60/30); INHALER 220 MCG/ NDS ACTUATION ambrisentan 5 PA; LA; QL (30/30); FLOVENT HFA AEROSOL 3 QL (10.6/30) NDS INHALER 44 MCG/ ANORO ELLIPTA 3 QL (60/30) ACTUATION arformoterol 4 B/D PA flunisolide 3 QL (50/30) ARNUITY ELLIPTA 3 QL (30/30) fluticasone propionate nasal 2 QL (16/30) ATROVENT HFA 4 QL (25.8/30) fluticasone propion-salmeterol 2 QL (60/30) inhalation blister with device bosentan 5 PA; LA; NDS HAEGARDA 5 PA; NDS BREO ELLIPTA 3 QL (60/30) icatibant 5 PA; QL (18/30); BROVANA 4 B/D PA NDS INCRUSE ELLIPTA 3 QL (30/30)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 53 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS ipratropium bromide inhalation 2 B/D PA THEO-24 4 ipratropium-albuterol 2 B/D PA oral tablet 3 KALYDECO ORAL GRANULES 5 PA; QL (56/28); extended release 12 hr 300 IN PACKET NDS mg, 450 mg KALYDECO ORAL TABLET 5 PA; QL (60/30); theophylline oral tablet 3 NDS extended release 24 hr levalbuterol hcl 4 B/D PA TRELEGY ELLIPTA 3 QL (60/30) metaproterenol oral syrup 3 TRIKAFTA 5 PA; NDS mometasone nasal 3 QL (34/30) VENTAVIS 5 PA; NDS montelukast oral granules in 3 QL (30/30) VENTOLIN HFA 3 QL (36/30) packet wixela inhub 2 QL (60/30) montelukast oral tablet 2 QL (30/30) XHANCE 4 ST; QL (32/30) montelukast oral tablet, 2 QL (30/30) XOLAIR SUBCUTANEOUS 5 PA; LA; QL (6/28); chewable RECON SOLN NDS OFEV 5 PA; QL (60/30); XOLAIR SUBCUTANEOUS 5 PA; LA; QL (4/28); NDS SYRINGE 150 MG/ML NDS OPSUMIT 5 PA; LA; NDS XOLAIR SUBCUTANEOUS 5 PA; LA; QL (1/28); ORKAMBI ORAL GRANULES 5 PA; QL (56/28); SYRINGE 75 MG/0.5 ML NDS IN PACKET NDS XOPENEX 4 B/D PA ORKAMBI ORAL TABLET 5 PA; QL (112/28); XOPENEX CONCENTRATE 4 B/D PA NDS YUPELRI 4 B/D PA; QL (90/30) PERFOROMIST 3 B/D PA; QL zafirlukast 3 QL (60/30) (120/30) PULMICORT INHALATION 4 B/D PA; QL UROLOGICALS SUSPENSION FOR (120/30) / ANTISPASMODICS NEBULIZATION 0.25 MG/2 ML, 0.5 MG/2 ML darifenacin 4 PULMICORT INHALATION 4 B/D PA; QL (60/30) flavoxate 2 SUSPENSION FOR MYRBETRIQ ORAL TABLET 3 NEBULIZATION 1 MG/2 ML EXTENDED RELEASE 24 HR PULMOZYME 5 B/D PA; QL oxybutynin chloride oral syrup 1 (150/30); NDS oxybutynin chloride oral tablet 1 SEREVENT DISKUS 3 QL (60/30) oxybutynin chloride oral tablet 2 QL (60/30) sildenafil (pulmonary arterial 3 PA; QL (90/30) extended release 24hr hypertension) oral tablet solifenacin 2 SYMDEKO 5 PA; QL (56/28); tolterodine 3 NDS TOVIAZ 3 QL (30/30) tadalafil (pulmonary arterial 5 PA; QL (60/30); BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY hypertension) oral tablet 20 mg NDS alfuzosin 2 terbutaline 4

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 54 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS dutasteride 2 potassium chlorid-d5- 4 dutasteride-tamsulosin 4 0.45%nacl intravenous parenteral solution 30 meq/l finasteride oral tablet 5 mg 2 QL (30/30) potassium chloride in 0.9%nacl 4 tamsulosin 2 QL (60/30) intravenous parenteral solution MISCELLANEOUS UROLOGICALS 20 meq/l, 40 meq/l bethanechol chloride 2 potassium chloride in 5% dex 4 CYSTAGON 4 LA intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l EDEX INTRACAVERNOSAL 1 EX; QL (6/30) KIT 10 MCG, 20 MCG, 40 MCG potassium chloride in lr-d5 4 intravenous parenteral solution ELMIRON 5 NDS 20 meq/l K-PHOS ORIGINAL 4 potassium chloride in water 4 MUSE INTRA-URETHRAL 1 EX; QL (6/30) intravenous piggyback SUPPOSITORY 1,000 MCG, potassium chloride intravenous 4 250 MCG, 500 MCG potassium chloride oral 2 potassium citrate 4 capsule, extended release RENACIDIN 4 potassium chloride oral liquid 4 SILDENAFIL ORAL TABLET 1 EX; QL (6/30) potassium chloride oral packet 2 100 MG, 25 MG, 50 MG potassium chloride oral tablet 1 VITAMINS, HEMATINICS / ELECTROLYTES extended release ELECTROLYTES potassium chloride oral tablet, 1 er particles/crystals 10 meq, 20 calcium acetate(phosphat bind) 2 meq klor-con 2 potassium chloride-0.45% nacl 4 KLOR-CON 10 3 POTASSIUM CHLORIDE-D5- 4 KLOR-CON 8 3 0.2%NACL INTRAVENOUS klor-con m10 1 PARENTERAL SOLUTION 20 klor-con m20 1 MEQ/L lactated ringers intravenous 4 potassium chloride-d5- 4 0.2%nacl intravenous MAGNESIUM SULFATE 4 parenteral solution 30 meq/l, 40 IN D5W INTRAVENOUS meq/l PIGGYBACK 1 GRAM/100 ML POTASSIUM CHLORIDE-D5- 4 magnesium sulfate in water 4 0.9%NACL magnesium sulfate injection 4 ringer's intravenous 4 POTASSIUM CHLORID-D5- 4 sodium bicarbonate 4 0.45%NACL INTRAVENOUS intravenous syringe 10 meq/10 PARENTERAL SOLUTION 10 ml (8.4%), 7.5% (0.9 meq/ml), MEQ/L, 20 MEQ/L, 40 MEQ/L 8.4% (1 meq/ml)

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 55 Covered Drugs By Category

DRUG REQUIREMENTS/ DRUG REQUIREMENTS/ DRUG NAME DRUG NAME TIER LIMITS TIER LIMITS sodium chloride 0.45% 4 TRAVASOL 10% 4 B/D PA intravenous parenteral solution TROPHAMINE 10% 4 B/D PA sodium chloride 3% 4 VITAMINS / HEMATINICS sodium chloride 5% 4 fluoride (sodium) oral tablet 1 sodium chloride intravenous 4 fluoride (sodium) oral tablet, 1 TPN ELECTROLYTES 4 B/D PA chewable 1 mg (2.2 mg sod. MISCELLANEOUS NUTRITION PRODUCTS fluoride) AMINOSYN II 15% 4 B/D PA PRENATAL VITAMIN ORAL 3 TABLET AMINOSYN-PF 7% (SULFITE- 4 B/D PA FREE) CLINIMIX 5%/D15W SULFITE 4 B/D PA FREE CLINIMIX 4.25%/D10W SULF 4 B/D PA FREE CLINIMIX 5%-D20W(SULFITE- 4 B/D PA FREE) CLINIMIX 6%-D5W (SULFITE- 4 B/D PA FREE) CLINIMIX 8%-D10W(SULFITE- 4 B/D PA FREE) CLINIMIX 8%-D14W(SULFITE- 4 B/D PA FREE) CLINIMIX E 4.25%/D10W SUL 4 B/D PA FREE CLINISOL SF 15% 4 B/D PA electrolyte-48 in d5w 4 freamine iii 10% 4 B/D PA HEPATAMINE 8% 4 B/D PA INTRALIPID INTRAVENOUS 4 B/D PA EMULSION 20%, 30% KABIVEN 4 B/D PA NORMOSOL-R PH 7.4 4 NUTRILIPID 4 B/D PA PERIKABIVEN 4 B/D PA PLENAMINE 4 B/D PA PREMASOL 10% 4 B/D PA PROCALAMINE 3% 4 B/D PA PROSOL 20% 4 B/D PA

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug You can find information on what the symbols and abbreviations on this table mean by going to page 7.

September 2021 56 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE

A adefovir ...... 9 ALIQOPA ...... 16 ADEMPAS ...... 53 aliskiren...... 31 abacavir-lamivudine ...... 9 adriamycin intravenous allopurinol...... 47 abacavir-lamivudine-zidovudine .....9 recon soln 10 mg ...... 15 ALORA ...... 48 abacavir oral solution ...... 9 adriamycin intravenous solution ....15 alosetron...... 43 abacavir oral tablet ...... 9 adrucil intravenous solution ALPHAGAN P OPHTHALMIC ABELCET...... 9 2.5 gram/50 ml ...... 15 (EYE) DROPS 0.1% ...... 52 ABILIFY MAINTENA...... 27 ADVAIR HFA ...... 53 alprazolam oral tablet abiraterone oral tablet 250 mg...... 15 AFINITOR DISPERZ ORAL TABLET 0.25 mg, 0.5 mg, 1 mg ...... 27 FOR SUSPENSION 2 MG ...... 15 abiraterone oral tablet 500 mg...... 15 alprazolam oral tablet 2 mg ...... 27 AFINITOR DISPERZ ORAL TABLET ABRAXANE...... 15 alprazolam oral tablet, FOR SUSPENSION 3 MG, 5 MG ...15 disintegrating 0.25 mg, acamprosate ...... 37 AFINITOR ORAL TABLET 10 MG ..16 0.5 mg, 1 mg ...... 27 acarbose oral tablet 25 mg ...... 40 afirmelle ...... 48 alprazolam oral tablet, acarbose oral tablet 50 mg ...... 40 AIMOVIG AUTOINJECTOR ...... 24 disintegrating 2 mg ...... 27 acarbose oral tablet 100 mg...... 40 ak-poly-bac ...... 51 altavera (28) ...... 48 acebutolol...... 31 ala-cort topical cream 1% ...... 36 ALUNBRIG ORAL TABLET 30 MG . 16 acetaminophen-codeine oral albendazole ...... 12 ALUNBRIG ORAL TABLET solution 120 mg-12 mg /5 ml 180 MG, 90 MG ...... 16 (5 ml), 120-12 mg/5 ml, albuterol sulfate inhalation hfa ALUNBRIG ORAL TABLETS, 300 mg-30 mg /12.5 ml ...... 25 aerosol inhaler 90 mcg/actuation (generic for proair)...... 53 DOSE PACK ...... 16 acetaminophen-codeine oral alyacen 1/35 (28) ...... 48 tablet 300-15 mg, 300-30 mg ...... 25 ALBUTEROL SULFATE INHALATION HFA AEROSOL alyacen 7/7/7 (28) ...... 48 acetaminophen-codeine oral INHALER 90 MCG/ACTUATION tablet 300-60 mg ...... 26 alyq...... 53 (GENERIC FOR PROVENTIL) .....53 acetazolamide...... 52 amantadine hcl ...... 9 albuterol sulfate inhalation hfa acetazolamide sodium ...... 52 aerosol inhaler 90 mcg/actuation AMBISOME ...... 9 acetic acid otic (ear) ...... 39 (generic for ventolin) ...... 53 ambrisentan...... 53 acetylcysteine ...... 53 albuterol sulfate inhalation amethia ...... 48 acitretin ...... 34 solution for nebulization ...... 53 amethyst (28) ...... 48 ACTHIB (PF) ...... 46 albuterol sulfate oral syrup ...... 53 amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml...... 12 ACTIMMUNE ...... 45 albuterol sulfate oral tablet ...... 53 amiloride ...... 31 acyclovir oral capsule ...... 9 albuterol sulfate oral tablet extended release 12 hr ...... 53 amiloride-hydrochlorothiazide ...... 31 acyclovir oral suspension 200 mg/5 ml...... 9 alclometasone...... 36 aminocaproic acid oral ...... 33 acyclovir oral tablet ...... 9 ALCOHOL PADS ...... 40 AMINOSYN II 15% ...... 56 acyclovir sodium ALDURAZYME...... 42 AMINOSYN-PF 7% intravenous solution ...... 9 ALECENSA ...... 16 (SULFITE-FREE)...... 56 acyclovir topical ointment ...... 36 alendronate oral tablet 10 mg, 5 mg . 47 amiodarone intravenous solution ...31 ADACEL alendronate oral tablet amiodarone oral ...... 31 (TDAP ADOLESN/ADULT)(PF) .....46 35 mg, 70 mg ...... 47 amitriptyline ...... 27 ADASUVE ...... 27 alfuzosin ...... 54 amlodipine ...... 31 ADCETRIS...... 15 ALIMTA ...... 16 amlodipine-benazepril ...... 31 September 2021 57 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE amlodipine-valsartan...... 31 ARANESP (IN POLYSORBATE) atomoxetine oral capsule amlodipine-valsartan-hcthiazid .....31 INJECTION SOLUTION 100 mg, 60 mg, 80 mg ...... 28 100 MCG/ML, 200 MCG/ML, ammonium lactate ...... 35 atorvastatin ...... 34 300 MCG/ML, 60 MCG/ML ...... 45 atovaquone ...... 12 amnesteem ...... 35 ARANESP (IN POLYSORBATE) amoxapine ...... 27 INJECTION SYRINGE atovaquone-proguanil...... 12 amoxicillin oral capsule ...... 14 10 MCG/0.4 ML, 25 MCG/ ATRIPLA...... 9 amoxicillin oral suspension 0.42 ML, 40 MCG/0.4 ML ...... 45 atropine injection for reconstitution...... 14 ARANESP (IN POLYSORBATE) solution 0.4 mg/ml ...... 43 amoxicillin oral tablet ...... 14 INJECTION SYRINGE atropine injection 100 MCG/0.5 ML, 150 MCG/0.3 ML, syringe 0.05 mg/ml, 0.1 mg/ml...... 43 amoxicillin oral tablet, 200 MCG/0.4 ML, 300 MCG/0.6 ML, atropine ophthalmic (eye) drops ....51 chewable 125 mg, 250 mg ...... 14 500 MCG/ML, 60 MCG/0.3 ML .....45 ATROVENT HFA ...... 53 amoxicillin-pot clavulanate oral ARCALYST ...... 45 suspension for reconstitution ...... 14 aubra ...... 48 arformoterol ...... 53 amoxicillin-pot clavulanate aubra eq ...... 48 ARIKAYCE ...... 12 oral tablet ...... 14 aurovela 1.5/30 (21) ...... 48 aripiprazole oral solution ...... 27 amoxicillin-pot clavulanate aurovela 1/20 (21) ...... 49 oral tablet,chewable ...... 14 aripiprazole oral tablet ...... 27 aurovela 24 fe ...... 49 amoxicillin-pot clavulanate oral aripiprazole oral tablet, aurovela fe 1.5/30 (28) ...... 49 tablet extended release 12 hr...... 14 disintegrating...... 27 aurovela fe 1-20 (28) ...... 49 amphotericin b ...... 9 ARISTADA ...... 27 AURYXIA ...... 38 ampicillin oral capsule 500 mg...... 14 ARISTADA INITIO ...... 28 AUSTEDO ORAL TABLET 6 MG ...25 ampicillin sodium ...... 14 armodafinil ...... 28 AUSTEDO ORAL TABLET ampicillin-sulbactam ...... 14 ARNUITY ELLIPTA ...... 53 12 MG, 9 MG...... 24 anagrelide ...... 37 ARRANON...... 16 aviane ...... 49 anastrozole ...... 16 arsenic trioxide ...... 16 avita ...... 35 ANORO ELLIPTA...... 53 ARZERRA ...... 16 AVONEX INTRAMUSCULAR APOKYN ...... 24 asenapine maleate ...... 28 PEN INJECTOR KIT...... 45 apraclonidine...... 52 ashlyna ...... 48 AVONEX INTRAMUSCULAR aprepitant ...... 43 aspirin-dipyridamole ...... 33 SYRINGE KIT ...... 45 apri ...... 48 ASTAGRAF XL ORAL AVSOLA ...... 43 APTIOM ORAL TABLET 200 MG ...22 CAPSULE, EXTENDED ayuna...... 49 RELEASE 24HR 0.5 MG, 1 MG ....16 APTIOM ORAL TABLET 400 MG ...22 AYVAKIT...... 16 ASTAGRAF XL ORAL CAPSULE, APTIOM ORAL TABLET EXTENDED RELEASE 24HR 5 MG . 16 azacitidine ...... 16 600 MG, 800 MG ...... 22 atazanavir oral capsule AZASAN ...... 16 APTIVUS ...... 9 150 mg, 300 mg ...... 9 AZASITE ...... 51 ARALAST NP ...... 38 atazanavir oral capsule 200 mg...... 9 azathioprine...... 16 aranelle (28) ...... 48 atenolol ...... 31 azathioprine sodium ...... 16 ARANESP (IN POLYSORBATE) atenolol-chlorthalidone ...... 31 azelastine nasal ...... 39 INJECTION SOLUTION azelastine ophthalmic (eye) ...... 51 25 MCG/ML, 40 MCG/ML ...... 45 ATGAM ...... 46 atomoxetine oral capsule azithromycin intravenous...... 12 10 mg, 18 mg, 25 mg, 40 mg ...... 28 azithromycin oral packet ...... 12

September 2021 58 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE azithromycin oral suspension betamethasone brimonidine ophthalmic for reconstitution...... 12 valerate topical lotion ...... 36 (eye) drops 0.15% ...... 52 azithromycin oral tablet ...... 12 betamethasone brinzolamide ...... 52 AZOPT ...... 52 valerate topical ointment ...... 36 BRIVIACT INTRAVENOUS...... 22 aztreonam injection BETASERON BRIVIACT ORAL SOLUTION...... 22 SUBCUTANEOUS KIT...... 45 recon soln 1 gram ...... 12 BRIVIACT ORAL TABLET...... 22 betaxolol oral...... 31 aztreonam injection bromfenac ...... 52 recon soln 2 gram ...... 12 bethanechol chloride...... 55 bromocriptine ...... 24 azurette (28) ...... 49 bexarotene...... 16 BROVANA ...... 53 BEXSERO ...... 46 BRUKINSA ...... 16 bicalutamide ...... 16 B budesonide inhalation suspension BICILLIN L-A ...... 14 bacitracin intramuscular...... 12 for nebulization 0.25 mg/2 ml, BIDIL ...... 31 0.5 mg/2 ml ...... 53 bacitracin ophthalmic (eye)...... 51 bacitracin-polymyxin b BIKTARVY ...... 9 budesonide inhalation suspension for nebulization 1 mg/2 ml ...... 53 ophthalmic (eye)...... 51 bimatoprost ophthalmic (eye)...... 52 budesonide oral capsule, baclofen oral tablet 10 mg, 5 mg ....25 BINOSTO ...... 47 delayed,extend.release ...... 43 baclofen oral tablet 20 mg...... 25 bisoprolol fumarate ...... 31 budesonide oral tablet, bisoprolol-hydrochlorothiazide ...... 31 balsalazide...... 43 delayed and ext.release...... 43 BLENREP ...... 16 BALVERSA ...... 16 bumetanide injection...... 31 bleomycin ...... 16 balziva (28) ...... 49 bumetanide oral ...... 31 BLEPHAMIDE...... 51 BANZEL ...... 22 buprenorphine hcl injection...... 26 BLEPHAMIDE S.O.P...... 51 BAQSIMI...... 40 buprenorphine hcl sublingual ...... 26 BARACLUDE ORAL SOLUTION ....9 BLINCYTO INTRAVENOUS KIT ....16 buprenorphine-naloxone BAVENCIO...... 16 blisovi 24 fe ...... 49 sublingual film 2-0.5 mg ...... 27 BCG VACCINE, LIVE (PF) ...... 46 blisovi fe 1.5/30 (28) ...... 49 buprenorphine-naloxone BD PEN NEEDLE ...... 40 blisovi fe 1/20 (28) ...... 49 sublingual film 4-1 mg, 8-2 mg...... 27 BELEODAQ...... 16 BOOSTRIX TDAP ...... 46 buprenorphine-naloxone sublingual film 12-3 mg ...... 27 benazepril...... 31 BORTEZOMIB ...... 16 buprenorphine-naloxone benazepril-hydrochlorothiazide .....31 bosentan...... 53 sublingual tablet 2-0.5 mg ...... 27 BOSULIF ORAL TABLET 100 MG ..16 BENDEKA ...... 16 buprenorphine-naloxone BENLYSTA...... 47 BOSULIF ORAL TABLET sublingual tablet 8-2 mg...... 27 400 MG, 500 MG ...... 16 benztropine injection...... 24 buprenorphine transdermal BOTOX ...... 46 benztropine oral ...... 24 patch weekly 7.5 mcg/hour ...... 26 BRAFTOVI ORAL BESIVANCE ...... 51 BUPRENORPHINE CAPSULE 75 MG ...... 16 BESPONSA...... 16 TRANSDERMAL PATCH WEEKLY BREO ELLIPTA ...... 53 10 MCG/HOUR, 15 MCG/HOUR, betamethasone, augmented...... 36 briellyn...... 49 20 MCG/HOUR, 5 MCG/HOUR.....26 betamethasone dipropionate ...... 36 BRILINTA ...... 33 bupropion hcl oral tablet 75 mg .....28 betamethasone brimonidine ophthalmic bupropion hcl oral tablet 100 mg ....28 valerate topical cream ...... 36 (eye) drops 0.2% ...... 52 bupropion hcl oral tablet betamethasone extended release 24 hr 150 mg.....28 valerate topical foam...... 36 September 2021 59 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE bupropion hcl oral tablet carbamazepine oral capsule, cefazolin injection recon soln extended release 24 hr 300 mg.....28 er multiphase 12 hr ...... 22 1 gram, 10 gram, 100 gram, bupropion hcl oral tablet carbamazepine oral suspension 300 g, 500 mg...... 11 sustained-release 12 hr ...... 28 100 mg/5 ml, 200 mg/10 ml ...... 22 cefazolin intravenous ...... 11 bupropion hcl (smoking deter) ...... 38 carbamazepine oral tablet ...... 22 cefdinir oral capsule ...... 11 buspirone ...... 28 carbamazepine oral tablet, cefdinir oral suspension busulfan ...... 16 chewable ...... 22 for reconstitution...... 11 butorphanol nasal ...... 27 carbamazepine oral tablet CEFEPIME IN DEXTROSE 5%.....11 extended release 12 hr ...... 22 BYDUREON BCISE ...... 40 cefepime in dextrose,iso-osm ...... 11 carbidopa ...... 24 BYSTOLIC ...... 31 cefepime injection ...... 11 carbidopa-levodopa-entacapone....24 CEFEPIME INTRAVENOUS ...... 11 C carbidopa-levodopa oral tablet .....24 cefixime...... 11 carbidopa-levodopa oral tablet, CEFOTETAN IN DEXTROSE, CABENUVA ...... 9 disintegrating...... 24 ISO-OSM ...... 11 cabergoline ...... 42 carbidopa-levodopa oral tablet cefotetan injection ...... 11 extended release ...... 24 CABOMETYX ORAL cefoxitin...... 11 TABLET 20 MG, 60 MG ...... 16 carboplatin intravenous solution ....16 cefoxitin in dextrose, iso-osm...... 11 CABOMETYX ORAL carmustine ...... 16 cefpodoxime ...... 11 TABLET 40 MG ...... 16 CARNITOR INTRAVENOUS ...... 38 cefprozil ...... 12 calcipotriene scalp...... 34 carteolol ...... 51 ceftazidime...... 12 calcipotriene topical cream ...... 34 cartia xt ...... 31 CEFTAZIDIME IN D5W ...... 12 calcipotriene topical ointment...... 34 carvedilol ...... 31 ceftriaxone in dextrose,iso-os ...... 12 calcitonin (salmon) injection ...... 42 carvedilol phosphate...... 31 ceftriaxone injection recon soln calcitonin (salmon) nasal...... 42 caspofungin ...... 9 1 gram, 10 gram, 2 gram, calcitriol intravenous CAYSTON ...... 12 250 mg, 500 mg ...... 12 solution 1 mcg/ml...... 42 caziant (28) ...... 49 CEFTRIAXONE INJECTION calcitriol oral...... 42 cefaclor oral capsule...... 11 RECON SOLN 100 GRAM ...... 12 calcitriol topical ...... 34 cefaclor oral suspension for ceftriaxone intravenous ...... 12 calcium acetate(phosphat bind).....55 reconstitution 125 mg/5 ml, cefuroxime axetil oral tablet ...... 12 CALQUENCE ...... 16 250 mg/5 ml, 375 mg/5 ml...... 11 cefuroxime sodium injection camila ...... 48 cefaclor oral tablet recon soln 750 mg ...... 12 camrese ...... 49 extended release 12 hr ...... 11 cefuroxime sodium intravenous .....12 camrese lo ...... 49 cefadroxil oral capsule ...... 11 celecoxib...... 27 candesartan-hydrochlorothiazid ....31 cefadroxil oral suspension for CELONTIN ORAL reconstitution 250 mg/5 ml, candesartan oral tablet CAPSULE 300 MG ...... 22 500 mg/5 ml...... 11 16 mg, 4 mg, 8 mg ...... 31 cephalexin oral capsule cefadroxil oral tablet ...... 11 candesartan oral tablet 32 mg ...... 31 250 mg, 500 mg ...... 12 cefazolin in dextrose (iso-os) CAPLYTA ...... 28 cephalexin oral suspension intravenous piggyback for reconstitution...... 12 CAPRELSA ORAL TABLET 100 MG . 16 1 gram/50 ml, 2 gram/50 ml ...... 11 CEREZYME INTRAVENOUS CAPRELSA ORAL TABLET 300 MG . 16 CEFAZOLIN IN DEXTROSE RECON SOLN 400 UNIT ...... 42 CARBAGLU...... 38 (ISO-OS) INTRAVENOUS CHANTIX ...... 38 PIGGYBACK 2 GRAM/100 ML .....11

September 2021 60 Covered Drugs Index

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CHANTIX CONTINUING cisplatin intravenous solution ...... 16 CLINIMIX 8%-D14W MONTH BOX ...... 39 citalopram oral solution ...... 28 (SULFITE-FREE)...... 56 CHANTIX STARTING citalopram oral tablet ...... 28 CLINIMIX E 4.25%/D10W MONTH BOX ...... 39 SUL FREE ...... 56 cladribine ...... 16 charlotte 24 fe ...... 49 CLINISOL SF 15% ...... 56 claravis ...... 35 chateal (28) ...... 49 clobazam oral suspension...... 22 clarithromycin oral suspension chateal eq (28) ...... 49 for reconstitution...... 12 clobazam oral tablet ...... 22 CHEMET ...... 38 clarithromycin oral tablet ...... 12 clobetasol-emollient topical cream ..37 chloramphenicol sod succinate .....12 clarithromycin oral tablet clobetasol-emollient topical foam ...37 chlorhexidine gluconate extended release 24 hr ...... 12 clobetasol scalp ...... 36 mucous membrane ...... 39 clindacin etz topical swab ...... 35 clobetasol topical cream ...... 36 chloroquine phosphate...... 12 clindacin p ...... 35 clobetasol topical foam...... 36 chlorothiazide sodium...... 31 clindamycin hcl ...... 12 clobetasol topical gel ...... 37 chlorpromazine injection ...... 28 CLINDAMYCIN IN clobetasol topical ointment ...... 37 chlorpromazine oral tablet...... 28 0.9% SOD CHLOR ...... 12 clobetasol topical shampoo ...... 37 chlorthalidone oral tablet clindamycin in 5% dextrose ...... 12 CLOCORTOLONE PIVALATE ...... 37 25 mg, 50 mg ...... 31 clindamycin pediatric ...... 13 clodan ...... 37 cholestyramine light ...... 34 clindamycin phosphate injection ....13 clofarabine ...... 16 cholestyramine (with sugar) ...... 34 clindamycin phosphate clomipramine ...... 28 CHORIONIC GONADOTROPIN, intravenous solution 600 mg/4 ml ...13 clonazepam oral tablet HUMAN INTRAMUSCULAR ...... 42 clindamycin phosphate topical gel ..35 0.5 mg, 1 mg ...... 22 ciclodan topical solution...... 36 CLINDAMYCIN PHOSPHATE clonazepam oral tablet 2 mg ...... 22 ciclopirox topical cream ...... 36 TOPICAL GEL, ONCE DAILY ...... 35 clonazepam oral tablet, ciclopirox topical shampoo ...... 36 clindamycin phosphate disintegrating 0.125 mg, ciclopirox topical solution...... 36 topical lotion...... 36 0.25 mg, 0.5 mg, 1 mg ...... 22 ciclopirox topical suspension ...... 36 clindamycin phosphate clonazepam oral tablet, topical solution ...... 36 cilostazol...... 33 disintegrating 2 mg ...... 22 clindamycin phosphate CILOXAN OPHTHALMIC clonidine ...... 31 topical swab...... 36 (EYE) OINTMENT ...... 51 clonidine hcl oral tablet clindamycin phosphate vaginal .....48 CIMDUO...... 9 0.1 mg, 0.2 mg ...... 31 CLINIMIX 4.25%/D5W cinacalcet oral tablet 30 mg, 60 mg . 42 clonidine hcl oral tablet 0.3 mg .....31 SULFIT FREE...... 38 cinacalcet oral tablet 90 mg ...... 42 clonidine hcl oral tablet CLINIMIX 4.25%/D10W extended release 12 hr ...... 28 CIPRODEX ...... 39 SULF FREE...... 56 clopidogrel oral tablet 75 mg ...... 33 ciprofloxacin-dexamethasone ...... 39 CLINIMIX 5%/D15W clopidogrel oral tablet 300 mg ...... 33 ciprofloxacin hcl ophthalmic (eye)...51 SULFITE FREE ...... 56 clorazepate dipotassium ciprofloxacin hcl oral tablet 100 mg . 14 CLINIMIX 5%-D20W oral tablet 3.75 mg...... 28 (SULFITE-FREE)...... 56 ciprofloxacin hcl oral tablet clorazepate dipotassium 250 mg, 500 mg, 750 mg ...... 14 CLINIMIX 6%-D5W oral tablet 7.5 mg ...... 28 ...... ciprofloxacin in 5% dextrose...... 14 (SULFITE-FREE) 56 CLINIMIX 8%-D10W clorazepate dipotassium CIPRO HC ...... 39 oral tablet 15 mg ...... 28 (SULFITE-FREE)...... 56 CIPRO ORAL SUSPENSION, MICROCAPSULE RECON ...... 14 September 2021 61 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE clotrimazole-betamethasone cyclafem 1/35 (28)...... 49 daptomycin intravenous topical cream...... 36 cyclafem 7/7/7 (28) ...... 49 recon soln 500 mg ...... 13 clotrimazole-betamethasone cyclobenzaprine oral darifenacin ...... 54 topical lotion...... 36 tablet 10 mg, 5 mg...... 25 DARZALEX ...... 17 clotrimazole mucous membrane .....9 cyclophosphamide DARZALEX FASPRO...... 17 clotrimazole topical cream...... 36 intravenous recon soln ...... 16 dasetta 1/35 (28) ...... 49 clotrimazole topical solution ...... 36 CYCLOPHOSPHAMIDE dasetta 7/7/7 (28) ...... 49 INTRAVENOUS SOLUTION ...... 17 clozapine oral tablet ...... 28 daunorubicin intravenous solution ..17 cyclophosphamide oral ...... 17 clozapine oral tablet, disintegrating . 28 DAURISMO ORAL TABLET 25 MG..17 CYCLOSERINE ...... 13 COARTEM...... 13 DAURISMO ORAL TABLET 100 MG . 17 CYCLOSET ...... 40 colchicine oral tablet ...... 47 daysee...... 49 cyclosporine intravenous...... 17 colesevelam...... 34 deblitane...... 48 cyclosporine modified...... 17 colestipol...... 34 decitabine...... 17 cyclosporine oral capsule ...... 17 colistin (colistimethate na)...... 13 deferasirox oral granules in packet..38 CYRAMZA ...... 17 COMBIGAN...... 52 deferasirox oral tablet...... 38 cyred ...... 49 COMBIVENT RESPIMAT ...... 53 deferiprone ...... 38 cyred eq ...... 49 COMETRIQ ORAL CAPSULE DELESTROGEN 60 MG/DAY (20 MG X 3/DAY) ...... 16 CYSTADANE ...... 44 INTRAMUSCULAR OIL 10 MG/ML . 48 COMETRIQ ORAL CAPSULE CYSTAGON...... 55 DELSTRIGO ...... 9 100 MG/DAY(80 MG X1-20 MG X1) ..16 CYSTARAN ...... 51 demeclocycline...... 15 COMETRIQ ORAL CAPSULE cytarabine...... 17 DEMSER ...... 31 140 MG/DAY(80 MG X1-20 MG X3) ..16 cytarabine (pf)...... 17 DENAVIR ...... 36 COMPLERA ...... 9 DEPEN TITRATABS ...... 47 compro ...... 43 D DEPO-ESTRADIOL ...... 48 constulose ...... 43 COPAXONE SUBCUTANEOUS d2.5%-0.45% sodium chloride ...... 38 DEPO-MEDROL ...... 39 SYRINGE 20 MG/ML ...... 25 d5%-0.45% sodium chloride...... 38 DESCOVY ...... 9 COPAXONE SUBCUTANEOUS d5% and 0.9% sodium chloride.....38 desipramine ...... 28 SYRINGE 40 MG/ML ...... 25 d10%-0.45% sodium chloride ...... 38 desloratadine oral tablet ...... 52 COPIKTRA ...... 16 dacarbazine...... 17 desmopressin injection...... 42 CORLANOR ORAL TABLET ...... 34 dactinomycin ...... 17 desmopressin nasal spray, non-aerosol ...... 42 CORTIFOAM...... 44 dalfampridine...... 25 desmopressin nasal spray CORTISPORIN-TC ...... 39 DALIRESP ...... 53 with pump...... 42 COSMEGEN ...... 16 danazol ...... 42 desmopressin oral ...... 42 COTELLIC ...... 16 dantrolene oral ...... 25 desog-e.estradiol/e.estradiol ...... 49 CREON...... 44 DANYELZA ...... 17 desogestrel-ethinyl estradiol...... 49 CRESEMBA ORAL ...... 9 dapsone oral ...... 13 desonide topical cream ...... 37 cromolyn inhalation ...... 53 DAPTACEL desonide topical lotion ...... 37 cromolyn ophthalmic (eye) ...... 51 (DTAP PEDIATRIC) (PF)...... 46 desonide topical ointment ...... 37 cromolyn oral...... 44 DAPTOMYCIN INTRAVENOUS desoximetasone topical cream .....37 cryselle (28)...... 49 RECON SOLN 350 MG ...... 13 desoximetasone topical gel ...... 37 September 2021 62 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE desoximetasone topical ointment ...37 DEXTROSE 10% digoxin oral solution ...... 34 desvenlafaxine succinate ...... 28 IN WATER (D10W) ...... 38 digoxin oral tablet...... 34 dexamethasone intensol ...... 39 dextrose 25% in water (d25w) ...... 38 dihydroergotamine nasal ...... 24 dexamethasone oral elixir ...... 39 dextrose 30% in water (d30w) ...... 38 DILANTIN 30 MG...... 23 dexamethasone oral solution ...... 39 dextrose 50% in water (d50w) ...... 38 diltiazem hcl intravenous ...... 31 dexamethasone oral tablet dextrose 70% in water (d70w) ...... 38 diltiazem hcl oral capsule, 0.5 mg, 0.75 mg, 4 mg ...... 39 DIACOMIT ORAL extended release 12 hr ...... 31 dexamethasone oral tablet CAPSULE 250 MG ...... 22 diltiazem hcl oral capsule, 1 mg, 1.5 mg, 2 mg, 6 mg ...... 39 DIACOMIT ORAL extended release 24hr 120 mg, dexamethasone sodium CAPSULE 500 MG ...... 22 180 mg, 240 mg, 300 mg ...... 32 phos (pf) injection solution ...... 39 DIACOMIT ORAL POWDER diltiazem hcl oral capsule, dexamethasone sodium IN PACKET 250 MG ...... 22 extended release 24 hr 120 mg, phosphate injection solution ...... 39 DIACOMIT ORAL POWDER 180 mg, 240 mg, 300 mg, 420 mg ..32 dexamethasone sodium IN PACKET 500 MG ...... 23 diltiazem hcl oral capsule, phosphate ophthalmic (eye) ...... 52 DIASTAT...... 23 ext.rel 24h degradable ...... 31 dexmethylphenidate oral tablet .....28 DIASTAT ACUDIAL ...... 23 diltiazem hcl oral tablet...... 32 dextroamphetamine- diazepam injection...... 28 diltiazem hcl oral tablet extended release 24 hr ...... 32 amphetamine oral capsule, diazepam intensol ...... 28 extended release 24hr ...... 28 dilt-xr ...... 32 diazepam oral concentrate ...... 28 dextroamphetamine- dimethyl fumarate oral capsule, diazepam oral solution amphetamine oral tablet 5 mg ...... 28 delayed release(dr/ec) 120 mg .....25 5 mg/5 ml (1 mg/ml) ...... 28 dextroamphetamine- dimethyl fumarate oral capsule, diazepam oral tablet ...... 28 amphetamine oral tablet 10 mg.....28 delayed release(dr/ec) 120 mg dextroamphetamine- diazepam rectal ...... 23 (14)- 240 mg (46) ...... 25 amphetamine oral tablet diazoxide ...... 40 dimethyl fumarate oral capsule, 12.5 mg, 30 mg, 7.5 mg...... 28 diclofenac potassium ...... 27 delayed release(dr/ec) 240 mg .....25 dextroamphetamine- diclofenac sodium diphenhydramine hcl injection amphetamine oral tablet 15 mg.....28 ophthalmic (eye) ...... 52 solution 50 mg/ml...... 52 dextroamphetamine- diclofenac sodium oral ...... 27 diphenoxylate-atropine oral liquid ...43 ..... amphetamine oral tablet 20 mg 28 diclofenac sodium topical drops ....27 diphenoxylate-atropine oral tablet...43 dextroamphetamine oral diclofenac sodium topical gel 1% ...27 dipyridamole oral ...... 33 capsule, extended release ...... 28 dicloxacillin...... 14 disulfiram ...... 38 dextroamphetamine oral solution ...28 dicyclomine oral capsule ...... 43 divalproex...... 23 dextroamphetamine oral tablet .....28 dicyclomine oral solution ...... 43 docetaxel intravenous solution dextrose 5%-0.2% sod chloride.....38 dicyclomine oral tablet ...... 43 160 mg/16 ml (10 mg/ml), 160 mg/ dextrose 5%-0.3% sod.chloride.....38 8 ml (20 mg/ml), 20 mg/2 ml didanosine oral capsule, delayed (10 mg/ml), 20 mg/ml (1 ml), DEXTROSE 5% IN release(dr/ec) 250 mg, 400 mg ...... 9 WATER (D5W) INTRAVENOUS 80 mg/4 ml (20 mg/ml), PARENTERAL SOLUTION...... 38 DIFICID ORAL SUSPENSION 80 mg/8 ml (10 mg/ml) ...... 17 FOR RECONSTITUTION ...... 12 dextrose 5% in water (d5w) dofetilide ...... 31 intravenous piggyback ...... 38 DIFICID ORAL TABLET...... 12 dolishale ...... 49 dextrose 5%-lactated ringers ...... 38 diflunisal ...... 27 donepezil oral tablet 5 mg ...... 25 dextrose 10% and 0.2% nacl ...... 38 digitek ...... 34 donepezil oral tablet 10 mg...... 25 digox ...... 34 donepezil oral tablet 23 mg...... 25 September 2021 63 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE donepezil oral tablet, droxidopa oral capsule 100 mg .....38 ELIGARD (6 MONTH) ...... 17 disintegrating 5 mg ...... 25 droxidopa oral capsule elinest ...... 49 donepezil oral tablet, 200 mg, 300 mg ...... 38 ELIQUIS ...... 33 disintegrating 10 mg ...... 25 DUAVEE ...... 48 ELIQUIS DVT-PE dorzolamide ...... 52 duloxetine oral capsule, TREAT 30D START...... 33 dorzolamide-timolol ...... 52 delayed release(dr/ec) ELLA ...... 49 20 mg, 30 mg, 60 mg ...... 28 dotti ...... 48 ELLENCE...... 17 DUPIXENT PEN SUBCUTANEOUS DOVATO ...... 9 ELMIRON ...... 55 PEN INJECTOR 200 MG/1.14 ML ..35 doxazosin oral tablet ELZONRIS...... 17 1 mg, 2 mg, 4 mg...... 32 DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG/2 ML .....35 EMCYT ...... 17 doxazosin oral tablet 8 mg ...... 32 DUPIXENT SYRINGE EMEND ORAL SUSPENSION doxepin oral capsule...... 28 SUBCUTANEOUS SYRINGE FOR RECONSTITUTION ...... 44 doxepin oral concentrate ...... 28 200 MG/1.14 ML ...... 35 emoquette ...... 49 doxepin oral tablet ...... 28 DUPIXENT SYRINGE EMPLICITI ...... 17 doxercalciferol...... 42 SUBCUTANEOUS SYRINGE EMSAM...... 28 300 MG/2 ML ...... 35 doxorubicin ...... 17 emtricitabine ...... 9 DUREZOL ...... 52 doxorubicin, peg-liposomal ...... 17 emtricitabine-tenofovir (tdf) ...... 9 dutasteride ...... 55 doxy-100...... 15 EMTRIVA ORAL CAPSULE ...... 9 dutasteride-tamsulosin ...... 55 doxycycline hyclate intravenous ....15 EMTRIVA ORAL SOLUTION ...... 9 doxycycline hyclate oral capsule....15 E EMVERM ...... 13 doxycycline hyclate enalapril-hydrochlorothiazide ...... 32 oral tablet 20 mg ...... 15 ec-naproxen...... 27 enalapril maleate ...... 32 doxycycline hyclate econazole...... 36 ENBREL MINI ...... 47 oral tablet 100 mg ...... 15 EDARBI ...... 32 doxycycline monohydrate ENBREL SUBCUTANEOUS RECON SOLN ...... 47 oral capsule 100 mg, 50 mg ...... 15 EDARBYCLOR...... 32 DOXYCYCLINE MONOHYDRATE EDEX INTRACAVERNOSAL KIT ENBREL SUBCUTANEOUS ORAL CAPSULE,IR - DELAY 10 MCG, 20 MCG, 40 MCG ...... 55 SOLUTION ...... 47 REL,BIPHASE ...... 15 EDURANT ...... 9 ENBREL SUBCUTANEOUS doxycycline monohydrate oral efavirenz-emtricitabin-tenofov ...... 9 SYRINGE ...... 47 suspension for reconstitution ...... 15 efavirenz-lamivu-tenofov disop ENBREL SURECLICK ...... 47 doxycycline monohydrate oral tablet 400-300-300 mg...... 9 endocet ...... 26 oral tablet ...... 15 efavirenz-lamivu-tenofov disop ENGERIX-B PEDIATRIC (PF) ...... 46 DRIZALMA SPRINKLE ORAL oral tablet 600-300-300 mg...... 9 ENGERIX-B (PF) CAPSULE, DELAYED REL efavirenz oral capsule 50 mg ...... 9 INTRAMUSCULAR SYRINGE...... 46 SPRINKLE 20 MG, 30 MG, 60 MG . 28 efavirenz oral capsule 200 mg ...... 9 ENHERTU ...... 17 DRIZALMA SPRINKLE ORAL efavirenz oral tablet...... 9 enoxaparin ...... 33 CAPSULE, DELAYED REL SPRINKLE 40 MG...... 28 ELAPRASE ...... 42 enpresse...... 49 dronabinol ...... 44 electrolyte-48 in d5w...... 56 enskyce...... 49 drospirenone-e.estradiol-lm.fa ...... 49 ELIGARD ...... 17 entacapone ...... 24 drospirenone-ethinyl estradiol ...... 49 ELIGARD (3 MONTH) ...... 17 entecavir...... 9 DROXIA ...... 17 ELIGARD (4 MONTH) ...... 17 ENTRESTO ...... 34 September 2021 64 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE enulose ...... 44 erythromycin oral tablet ...... 12 ezetimibe-simvastatin...... 34 ENVARSUS XR ...... 17 erythromycin oral tablet, EPCLUSA ...... 9 delayed release (dr/ec) ...... 12 F EPIDIOLEX ...... 23 ERYTHROMYCIN WITH ETHANOL TOPICAL GEL ...... 36 FABRAZYME ...... 42 epinastine...... 51 erythromycin with ethanol falmina (28) ...... 49 epinephrine injection auto-injector topical solution ...... 36 famciclovir ...... 10 0.15 mg/0.3 ml, 0.3 mg/0.3 ml ...... 52 ESBRIET ORAL CAPSULE ...... 53 famotidine oral suspension ...... 45 epinephrine injection auto-injector 0.15 mg/0.15 ml, 0.3 mg/0.3 ml.....52 ESBRIET ORAL TABLET 267 MG ..53 famotidine oral tablet 20 mg, 40 mg..45 epinephrine injection ESBRIET ORAL TABLET 801 MG ..53 FANAPT ORAL TABLET 1 MG .....29 solution 1 mg/ml ...... 52 escitalopram oxalate oral solution ..29 FANAPT ORAL TABLET 10 MG, epirubicin intravenous solution .....17 escitalopram oxalate oral tablet.....29 12 MG, 2 MG, 4 MG, 6 MG, 8 MG ..29 epitol ...... 23 esomeprazole magnesium oral FANAPT ORAL TABLETS, DOSE PACK ...... 29 EPIVIR HBV ORAL SOLUTION ....10 capsule,delayed release(dr/ec) .....45 FARXIGA ORAL TABLET 5 MG ....40 ERBITUX ...... 17 estarylla ...... 49 FARXIGA ORAL TABLET 10 MG ...40 ergotamine-caffeine ...... 24 estradiol oral ...... 48 FARYDAK ...... 17 ERIVEDGE ...... 17 estradiol transdermal patch semiweekly ...... 48 fayosim ...... 49 ERLEADA ...... 17 estradiol transdermal patch weekly . 48 FEBUXOSTAT ...... 47 erlotinib oral tablet 25 mg ...... 17 estradiol vaginal ...... 48 felbamate oral suspension ...... 23 erlotinib oral tablet 100 mg, 150 mg..17 estradiol valerate intramuscular felbamate oral tablet ...... 23 errin ...... 48 oil 20 mg/ml, 40 mg/ml ...... 48 felodipine ...... 32 ertapenem ...... 13 ESTRING ...... 48 femynor ...... 49 ery pads ...... 36 ethacrynate sodium...... 32 fenofibrate micronized oral ERYPED 400 ...... 12 ethambutol ...... 13 capsule 134 mg, 200 mg, 67 mg ....34 ery-tab oral tablet,delayed ethosuximide ...... 23 fenofibrate nanocrystallized release (dr/ec) 250 mg ...... 12 ethynodiol diac-eth estradiol...... 49 oral tablet 145 mg, 48 mg ...... 34 ERY-TAB ORAL TABLET, fenofibrate oral tablet DELAYED RELEASE etodolac ...... 27 160 mg, 54 mg ...... 34 (DR/EC) 333 MG, 500 MG ...... 12 ETOPOPHOS ...... 17 fenofibric acid (choline) ...... 34 erythrocin (as stearate) etoposide intravenous ...... 17 fentanyl ...... 26 oral tablet 250 mg ...... 12 etravirine...... 10 fentanyl citrate buccal ERYTHROCIN INTRAVENOUS EUTHYROX...... 43 RECON SOLN 500 MG ...... 12 lozenge on a handle ...... 26 everolimus (antineoplastic) ...... 17 erythromycin-benzoyl peroxide .....36 fentanyl citrate (pf) everolimus (immunosuppressive) injection solution...... 26 erythromycin ethylsuccinate oral oral tablet 0.5 mg ...... 17 suspension for reconstitution fentanyl citrate (pf) everolimus (immunosuppressive) 200 mg/5 ml...... 12 injection syringe 50 mcg/ml ...... 26 oral tablet 0.25 mg, 0.75 mg...... 17 erythromycin ethylsuccinate oral FERRIPROX ...... 38 EVOMELA ...... 17 suspension for reconstitution FERRIPROX (2 TIMES A DAY) .....38 400 mg/5 ml...... 12 EVOTAZ ...... 10 FETZIMA ORAL CAPSULE, erythromycin ethylsuccinate exemestane...... 17 EXTENDED RELEASE 24 HR...... 29 oral tablet ...... 12 EYLEA...... 51 FETZIMA ORAL CAPSULE, erythromycin ophthalmic (eye)...... 51 ezetimibe ...... 34 EXT REL 24HR DOSE PACK...... 29 September 2021 65 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE finasteride oral tablet 5 mg ...... 55 fluocinolone topical solution ...... 37 fluticasone propion-salmeterol FINTEPLA ...... 23 fluocinonide topical cream 0.1% ....37 inhalation blister with device...... 53 FIRDAPSE ...... 25 fluocinonide topical cream 0.05% ...37 fluvoxamine oral tablet 25 mg ...... 29 FIRMAGON KIT W DILUENT fluocinonide topical gel...... 37 fluvoxamine oral tablet 50 mg ...... 29 SYRINGE SUBCUTANEOUS fluocinonide topical ointment ...... 37 fluvoxamine oral tablet 100 mg .....29 RECON SOLN 80 MG ...... 17 fluocinonide topical solution ...... 37 FOLOTYN ...... 17 FIRMAGON KIT W DILUENT fomepizole ...... 46 SYRINGE SUBCUTANEOUS fluoride (sodium) dental paste ...... 39 fondaparinux subcutaneous RECON SOLN 120 MG ...... 17 fluoride (sodium) oral tablet ...... 56 syringe 2.5 mg/0.5 ml ...... 33 FIRVANQ ORAL RECON fluoride (sodium) oral tablet, fondaparinux subcutaneous SOLN 25 MG/ML ...... 13 chewable 1 mg (2.2 mg sod. fluoride) ...... 56 syringe 10 mg/0.8 ml, FIRVANQ ORAL RECON 5 mg/0.4 ml, 7.5 mg/0.6 ml ...... 33 SOLN 50 MG/ML ...... 13 fluorometholone ...... 52 fosamprenavir ...... 10 flac otic oil ...... 39 fluorouracil intravenous ...... 17 fosfomycin tromethamine ...... 15 flavoxate ...... 54 FLUOROURACIL TOPICAL CREAM 0.5% ...... 35 fosinopril ...... 32 flecainide ...... 31 fosinopril-hydrochlorothiazide ...... 32 FLOVENT DISKUS INHALATION fluorouracil topical cream 5% ...... 35 BLISTER WITH DEVICE fluorouracil topical solution ...... 35 fosphenytoin ...... 23 100 MCG/ACTUATION, fluoxetine oral capsule 10 mg ...... 29 FOTIVDA ...... 17 50 MCG/ACTUATION...... 53 fluoxetine oral capsule 20 mg ...... 29 freamine iii 10% ...... 56 FLOVENT DISKUS INHALATION fluoxetine oral capsule 40 mg ...... 29 fulvestrant...... 17 BLISTER WITH DEVICE furosemide injection ...... 32 250 MCG/ACTUATION ...... 53 fluoxetine oral capsule, delayed release(dr/ec) ...... 29 furosemide oral solution FLOVENT HFA AEROSOL 10 mg/ml, 40 mg/5 ml (8 mg/ml) ....32 INHALER 44 MCG/ACTUATION....53 fluoxetine oral solution ...... 29 furosemide oral tablet...... 32 FLOVENT HFA AEROSOL fluoxetine oral tablet 10 mg...... 29 INHALER 110 MCG/ACTUATION...53 fluoxetine oral tablet 20 mg...... 29 FUZEON SUBCUTANEOUS RECON SOLN ...... 10 FLOVENT HFA AEROSOL fluoxetine (pmdd) oral tablet 10 mg . 29 fyavolv ...... 48 INHALER 220 MCG/ACTUATION ..53 fluoxetine (pmdd) oral tablet 20 mg . 29 FYCOMPA ORAL SUSPENSION ...23 floxuridine...... 17 fluphenazine decanoate...... 29 FYCOMPA ORAL TABLET fluconazole...... 9 fluphenazine hcl injection ...... 29 2 MG, 4 MG, 6 MG ...... 23 fluconazole in nacl (iso-osm) fluphenazine hcl oral concentrate ...29 intravenous piggyback FYCOMPA ORAL TABLET fluphenazine hcl oral elixir...... 29 200 mg/100 ml, 400 mg/200 ml...... 9 10 MG, 12 MG, 8 MG ...... 23 fluphenazine hcl oral tablet ...... 29 flucytosine ...... 9 flurbiprofen oral tablet 100 mg ...... 27 fludarabine ...... 17 G flurbiprofen sodium ...... 52 fludrocortisone ...... 39 gabapentin oral capsule flutamide...... 17 flunisolide ...... 53 100 mg, 400 mg ...... 23 fluticasone propionate nasal...... 53 fluocinolone acetonide oil ...... 39 gabapentin oral capsule 300 mg ....23 fluticasone propionate fluocinolone and shower cap ...... 37 gabapentin oral solution...... 23 topical cream...... 37 fluocinolone topical cream...... 37 gabapentin oral tablet 600 mg ...... 23 fluticasone propionate fluocinolone topical oil ...... 37 topical ointment ...... 37 gabapentin oral tablet 800 mg ...... 23 fluocinolone topical ointment ...... 37 galantamine oral capsule, ext rel. pellets 24 hr...... 25 September 2021 66 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE galantamine oral solution...... 25 GILENYA ORAL CAPSULE 0.5 MG . 25 H galantamine oral tablet...... 25 GILOTRIF...... 18 GAMMAKED INJECTION glimepiride oral tablet 1 mg...... 40 HAEGARDA ...... 53 SOLUTION 1 GRAM/10 ML glimepiride oral tablet 2 mg...... 40 hailey ...... 49 (10%), 10 GRAM/100 ML hailey 24 fe ...... 49 (10%), 20 GRAM/200 ML glimepiride oral tablet 4 mg...... 40 hailey fe 1.5/30 (28) ...... 49 (10%), 5 GRAM/50 ML (10%) ...... 46 glipizide-metformin oral tablet 2.5-250 mg ...... 40 hailey fe 1/20 (28) ...... 49 GAMUNEX-C ...... 46 glipizide-metformin oral HALAVEN...... 18 GARDASIL 9 (PF) ...... 46 tablet 2.5-500 mg, 5-500 mg ...... 40 halobetasol propionate GATTEX 30-VIAL...... 44 glipizide oral tablet 5 mg ...... 40 topical cream...... 37 GATTEX ONE-VIAL ...... 44 glipizide oral tablet 10 mg ...... 40 halobetasol propionate GAUZE PADS 2 X 2 ...... 40 glipizide oral tablet extended topical ointment ...... 37 gavilyte-c ...... 44 release 24hr 2.5 mg ...... 40 haloperidol decanoate ...... 29 gavilyte-n ...... 44 glipizide oral tablet extended haloperidol lactate injection ...... 29 GAVRETO ...... 18 release 24hr 5 mg ...... 40 haloperidol lactate oral ...... 29 GAZYVA ...... 18 glipizide oral tablet extended haloperidol oral tablet gemcitabine intravenous recon soln . 18 release 24hr 10 mg ...... 40 0.5 mg, 1 mg, 2 mg, 5 mg ...... 29 gemcitabine intravenous solution GLUCAGEN HYPOKIT ...... 40 haloperidol oral tablet 1 gram/26.3 ml (38 mg/ml), GLUCAGON EMERGENCY 10 mg, 20 mg ...... 29 2 gram/52.6 ml (38 mg/ml), KIT (HUMAN) ...... 40 HARVONI ORAL PELLETS 200 mg/5.26 ml (38 mg/ml)...... 18 GLUCAGON (HCL) IN PACKET 33.75-150 MG ...... 10 GEMCITABINE INTRAVENOUS EMERGENCY KIT...... 40 HARVONI ORAL PELLETS SOLUTION 100 MG/ML...... 18 glycopyrrolate injection...... 43 IN PACKET 45-200 MG ...... 10 gemfibrozil ...... 34 glycopyrrolate oral tablet HARVONI ORAL gemmily ...... 49 1 mg, 2 mg ...... 43 TABLET 45-200 MG ...... 10 generlac ...... 44 GLYCOPYRROLATE (PF) HARVONI ORAL gengraf ...... 18 IN WATER INJECTION ...... 43 TABLET 90-400 MG ...... 10 GENOTROPIN ...... 45 glycopyrrolate (pf) in water HAVRIX (PF) INTRAMUSCULAR intravenous syringe SUSPENSION GENOTROPIN MINIQUICK ...... 45 0.4 mg/2 ml (0.2 mg/ml)...... 43 1,440 ELISA UNIT/ML ...... 46 gentak ophthalmic (eye) ointment...51 glydo ...... 35 HAVRIX (PF) INTRAMUSCULAR gentamicin injection GLYXAMBI...... 40 SYRINGE ...... 46 solution 40 mg/ml...... 13 granisetron hcl intravenous...... 44 heather ...... 48 GENTAMICIN IN NACL (ISO-OSM) granisetron hcl oral ...... 44 heparin(porcine) in 0.45% nacl INTRAVENOUS PIGGYBACK intravenous parenteral solution 100 MG/50 ML, 120 MG/100 ML....13 granisetron (pf) intravenous 25,000 unit/250 ml, solution 1 mg/ml (1 ml)...... 44 gentamicin in nacl (iso-osm) 25,000 unit/500 ml...... 33 intravenous piggyback griseofulvin microsize ...... 9 heparin (porcine) in 5% dex 100 mg/100 ml, 60 mg/50 ml, griseofulvin ultramicrosize...... 9 intravenous parenteral solution 80 mg/100 ml, 80 mg/50 ml ...... 13 GVOKE HYPOPEN 1-PACK ...... 40 20,000 unit/500 ml (40 unit/ml), gentamicin ophthalmic (eye) drops..51 25,000 unit/250 ml(100 unit/ml), GVOKE HYPOPEN 2-PACK ...... 40 gentamicin sulfate (ped) (pf)...... 13 25,000 unit/500 ml (50 unit/ml) .....33 GVOKE PFS 1-PACK SYRINGE. . . . 40 gentamicin topical ...... 36 heparin (porcine) injection solution ..33 GVOKE PFS 2-PACK SYRINGE. . . . 40 GENVOYA ...... 10 heparin (porcine) in nacl (pf)...... 33 September 2021 67 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE heparin, porcine (pf) injection HUMIRA PEN CROHNS- hydrocortisone topical cream syringe 5,000 unit/0.5 ml ...... 33 UC-HS START ...... 47 with perineal applicator ...... 44 HEPARIN, PORCINE (PF) HUMIRA PEN PSOR- hydrocortisone topical lotion 2.5% ..37 INJECTION SYRINGE UVEITS-ADOL HS...... 47 hydrocortisone topical 5,000 UNIT/ML ...... 33 HUMIRA SUBCUTANEOUS ointment 1%, 2.5% ...... 37 HEPATAMINE 8% ...... 56 SYRINGE KIT 40 MG/0.8 ML...... 47 hydrocortisone valerate ...... 37 HETLIOZ ...... 29 HUMULIN 70/30 U-100 INSULIN ...40 hydromorphone oral liquid...... 26 HIBERIX (PF) ...... 46 HUMULIN 70/30 U-100 KWIKPEN..40 hydromorphone oral tablet ...... 26 HIZENTRA...... 46 HUMULIN N NPH hydroxychloroquine ...... 13 INSULIN KWIKPEN ...... 40 HUMALOG JUNIOR hydroxyprogesterone caproate .....48 KWIKPEN U-100 ...... 40 HUMULIN N NPH U-100 INSULIN..40 hydroxyurea...... 18 HUMALOG KWIKPEN INSULIN ....40 HUMULIN R REGULAR hydroxyzine hcl oral tablet...... 52 HUMALOG MIX 50-50 U-100 INSULN ...... 40 INSULN U-100 ...... 40 HUMULIN R U-500 HUMALOG MIX 50-50 KWIKPEN. . . 40 (CONC) INSULIN...... 40 I HUMALOG MIX 75-25 KWIKPEN. . . 40 HUMULIN R U-500 ibandronate oral ...... 47 (CONC) KWIKPEN ...... 40 HUMALOG MIX 75-25 IBRANCE ...... 18 hydralazine injection ...... 32 (U-100)INSULN ...... 40 ibu...... 27 hydralazine oral ...... 32 HUMALOG U-100 INSULIN ...... 40 ibuprofen oral suspension ...... 27 hydrochlorothiazide ...... 32 HUMIRA(CF) PEDI CROHNS ibuprofen oral tablet STARTER SUBCUTANEOUS hydrocodone-acetaminophen 400 mg, 600 mg, 800 mg ...... 27 SYRINGE KIT 80 MG/0.8 ML...... 47 oral solution 7.5-325 mg/15 ml .....26 icatibant ...... 53 HUMIRA(CF) PEDI CROHNS hydrocodone-acetaminophen oral iclevia...... 49 STARTER SUBCUTANEOUS solution 10-325 mg/15 ml(15 ml)....26 SYRINGE KIT 80 MG/0.8 ML- HYDROCODONE- ICLUSIG ORAL TABLET 40 MG/0.4 ML ...... 47 ACETAMINOPHEN ORAL 10 MG, 30 MG, 45 MG ...... 18 HUMIRA(CF) PEN TABLET 10-300 MG, 7.5-300 MG...26 ICLUSIG ORAL TABLET 15 MG ....18 CROHNS-UC-HS...... 47 hydrocodone-acetaminophen idarubicin ...... 18 HUMIRA(CF) PEN oral tablet 10-325 mg, IDHIFA...... 18 ...... PEDIATRIC UC 47 5-325 mg, 7.5-325 mg 26 ifosfamide...... 18 HUMIRA(CF) PEN hydrocodone-ibuprofen ...... 26 imatinib oral tablet 100 mg ...... 18 PSOR-UV-ADOL HS...... 47 hydrocortisone-acetic acid ...... 39 imatinib oral tablet 400 mg ...... 18 HUMIRA(CF) PEN hydrocortisone butyrate IMBRUVICA ORAL SUBCUTANEOUS INJECTOR topical cream...... 37 KIT 40 MG/0.4 ML ...... 47 CAPSULE 70 MG ...... 18 hydrocortisone butyrate IMBRUVICA ORAL HUMIRA(CF) PEN topical ointment ...... 37 SUBCUTANEOUS PEN CAPSULE 140 MG ...... 18 hydrocortisone butyrate INJECTOR KIT 80 MG/0.8 ML...... 47 IMBRUVICA ORAL TABLET...... 18 topical solution ...... 37 HUMIRA(CF) SUBCUTANEOUS IMFINZI...... 18 hydrocortisone butyr-emollient...... 37 SYRINGE KIT 10 MG/0.1 ML, imipenem-cilastatin ...... 13 20 MG/0.2 ML ...... 47 hydrocortisone oral ...... 39 imipramine hcl...... 29 HUMIRA(CF) SUBCUTANEOUS hydrocortisone rectal ...... 44 IMIQUIMOD TOPICAL CREAM SYRINGE KIT 40 MG/0.4 ML...... 47 hydrocortisone topical IN METERED-DOSE PUMP...... 35 HUMIRA PEN ...... 47 cream 1%, 2.5%...... 37

September 2021 68 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE imiquimod topical cream INVOKAMET XR ...... 40 JANUMET XR ORAL TABLET, in packet 3.75% ...... 35 INVOKANA ...... 40 ER MULTIPHASE 24 HR 100-1,000 MG ...... 41 imiquimod topical cream IPOL...... 46 in packet 5% ...... 35 JANUVIA ...... 41 ipratropium-albuterol...... 54 IMOVAX RABIES VACCINE (PF) ...46 JARDIANCE ...... 41 ipratropium bromide inhalation .....54 incassia...... 48 jasmiel (28) ...... 49 ipratropium bromide nasal...... 39 INCRELEX ...... 38 JEMPERLI ...... 18 irbesartan ...... 32 INCRUSE ELLIPTA...... 53 jencycla...... 48 irbesartan-hydrochlorothiazide .....32 indapamide ...... 32 JENTADUETO ...... 41 IRESSA...... 18 INFANRIX (DTAP) (PF) JENTADUETO XR ORAL irinotecan ...... 18 INTRAMUSCULAR SYRINGE...... 46 TABLET, IR - ER, BIPHASIC ISENTRESS HD...... 10 INFUGEM...... 18 24HR 2.5-1,000 MG ...... 41 ISENTRESS ORAL INFUMORPH P/F...... 26 JENTADUETO XR ORAL POWDER IN PACKET ...... 10 TABLET, IR - ER, BIPHASIC INLYTA ORAL TABLET 1 MG...... 18 ISENTRESS ORAL TABLET ...... 10 24HR 5-1,000 MG ...... 41 INLYTA ORAL TABLET 5 MG...... 18 ISENTRESS ORAL TABLET, JEVTANA ...... 18 INQOVI ...... 18 CHEWABLE 25 MG ...... 10 jolessa ...... 49 INREBIC...... 18 ISENTRESS ORAL TABLET, juleber ...... 49 INSULIN PEN NEEDLE...... 40 CHEWABLE 100 MG ...... 10 JULUCA ...... 10 INSULIN SYRINGE (DISP) isibloom...... 49 junel 1.5/30 (21) ...... 49 U-100 0.3 ML, 1 ML, 1/2 ML...... 40 isoniazid oral solution ...... 13 junel 1/20 (21) ...... 49 INTELENCE ORAL TABLET 25 MG . 10 isoniazid oral tablet ...... 13 junel fe 1.5/30 (28)...... 49 INTELENCE ORAL TABLET isosorbide dinitrate oral tablet ...... 34 100 MG, 200 MG ...... 10 junel fe 1/20 (28) ...... 49 isosorbide mononitrate ...... 34 INTRALIPID INTRAVENOUS junel fe 24...... 49 isotretinoin oral capsule EMULSION 20%, 30% ...... 56 10 mg, 20 mg, 30 mg, 40 mg ...... 36 INTRON A INJECTION K isradipine ...... 32 RECON SOLN ...... 45 KABIVEN ...... 56 INTRON A INJECTION itraconazole oral capsule...... 9 SOLUTION 6 MILLION UNIT/ML ...45 itraconazole oral solution...... 9 KADCYLA ...... 18 INTRON A INJECTION ivermectin oral ...... 13 kaitlib fe...... 49 SOLUTION 10 MILLION UNIT/ML ..45 IXEMPRA ...... 18 KALETRA ORAL introvale ...... 49 IXIARO (PF) ...... 46 TABLET 100-25 MG ...... 10 INVEGA SUSTENNA KALETRA ORAL INTRAMUSCULAR SYRINGE J TABLET 200-50 MG ...... 10 39 MG/0.25 ML...... 29 kalliga ...... 49 INVEGA SUSTENNA jaimiess...... 49 KALYDECO ORAL INTRAMUSCULAR SYRINGE JAKAFI ...... 18 GRANULES IN PACKET ...... 54 117 MG/0.75 ML, 156 MG/ML, jantoven ...... 33 KALYDECO ORAL TABLET ...... 54 234 MG/1.5 ML, 78 MG/0.5 ML.....29 JANUMET ...... 40 KANJINTI ...... 18 INVEGA TRINZA ...... 29 JANUMET XR ORAL TABLET, kariva (28) ...... 49 INVELTYS ...... 52 ER MULTIPHASE 24 HR kelnor 1/35 (28) ...... 49 INVIRASE ORAL TABLET ...... 10 50-1,000 MG, 50-500 MG ...... 41 kelnor 1-50 (28) ...... 49 INVOKAMET ...... 40 September 2021 69 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE ketoconazole oral...... 9 lamivudine oral tablet letrozole ...... 19 ketoconazole topical cream ...... 36 100 mg, 300 mg ...... 10 leucovorin calcium injection ...... 15 ketoconazole topical shampoo .....36 lamivudine oral tablet 150 mg ...... 10 leucovorin calcium oral...... 15 ketorolac ophthalmic (eye) ...... 52 lamivudine-zidovudine ...... 10 LEUKERAN ...... 19 KEYTRUDA...... 18 lamotrigine oral tablet ...... 23 LEUKINE INJECTION KINRIX (PF)...... 46 lamotrigine oral tablet, RECON SOLN ...... 45 chewable dispersible ...... 23 KISQALI FEMARA CO-PACK leuprolide subcutaneous kit ...... 19 ORAL TABLET 200 MG/DAY lamotrigine oral tablet, levalbuterol hcl ...... 54 disintegrating...... 23 (200 MG X 1)-2.5 MG...... 18 LEVEMIR FLEXTOUCH KISQALI FEMARA CO-PACK lamotrigine oral tablet U-100 INSULN ...... 41 extended release 24hr ...... 23 ORAL TABLET 400 MG/DAY LEVEMIR U-100 INSULIN ...... 41 (200 MG X 2)-2.5 MG...... 18 LANOXIN ORAL TABLET levetiracetam in nacl (iso-os) ...... 23 KISQALI FEMARA CO-PACK 62.5 MCG (0.0625 MG) ...... 34 ORAL TABLET 600 MG/DAY lansoprazole oral capsule, levetiracetam intravenous ...... 23 (200 MG X 3)-2.5 MG...... 18 delayed release(dr/ec) ...... 45 levetiracetam oral ...... 23 KISQALI ORAL TABLET LANTUS SOLOSTAR levobunolol ophthalmic 200 MG/DAY (200 MG X 1) ...... 18 U-100 INSULIN...... 41 (eye) drops 0.5% ...... 51 KISQALI ORAL TABLET LANTUS U-100 INSULIN ...... 41 levocarnitine oral solution 100 mg/ml ...... 38 400 MG/DAY (200 MG X 2) ...... 18 lapatinib ...... 18 levocarnitine oral tablet ...... 38 KISQALI ORAL TABLET larin 1.5/30 (21) ...... 49 600 MG/DAY (200 MG X 3) ...... 18 levocarnitine (with sugar)...... 38 larin 1/20 (21) ...... 49 klor-con ...... 55 levocetirizine oral solution ...... 52 larin 24 fe ...... 49 KLOR-CON 8 ...... 55 levocetirizine oral tablet ...... 52 larin fe 1.5/30 (28) ...... 49 KLOR-CON 10 ...... 55 levofloxacin in d5w ...... 14 larin fe 1/20 (28) ...... 49 klor-con m10 ...... 55 levofloxacin intravenous ...... 14 larissia ...... 49 klor-con m20 ...... 55 levofloxacin oral solution ...... 15 latanoprost ...... 52 KORLYM...... 42 levofloxacin oral tablet ...... 15 LATUDA ORAL TABLET 80 MG ....29 K-PHOS ORIGINAL ...... 55 LATUDA ORAL TABLET levonest (28) ...... 50 kurvelo (28) ...... 49 120 MG, 20 MG, 40 MG, 60 MG ....29 levonorgestrel-ethinyl estrad ...... 50 KUVAN ...... 42 layolis fe ...... 49 levonorg-eth estrad triphasic ...... 50 KYNMOBI SUBLINGUAL leena 28 ...... 50 levora-28...... 50 FILM 10 MG, 15 MG, leflunomide ...... 47 LEVO-T...... 43 20 MG, 25 MG, 30 MG ...... 24 LENVIMA ORAL CAPSULE levothyroxine oral tablet...... 43 KYPROLIS...... 18 10 MG/DAY (10 MG X 1), 4 MG ....18 levoxyl oral tablet LENVIMA ORAL CAPSULE 100 mcg, 112 mcg, 175 mcg ...... 43 L 12 MG/DAY (4 MG X 3), 18 MG/DAY LEVOXYL ORAL TABLET (10 MG X 1-4 MG X2), 24 MG/DAY labetalol oral ...... 32 125 MCG, 137 MCG, 150 MCG, (10 MG X 2-4 MG X 1) ...... 19 200 MCG, 25 MCG, 50 MCG, LACRISERT ...... 51 LENVIMA ORAL CAPSULE 75 MCG, 88 MCG ...... 43 lactated ringers intravenous ...... 55 14 MG/DAY(10 MG X 1-4 MG X 1), LEXIVA ORAL SUSPENSION ...... 10 lactated ringers irrigation ...... 37 20 MG/DAY (10 MG X 2), LIBTAYO...... 19 8 MG/DAY (4 MG X 2) ...... 19 lactulose oral solution...... 44 lidocaine hcl injection solution ...... 35 lessina ...... 50 lamivudine oral solution ...... 10 lidocaine hcl laryngotracheal ...... 35 September 2021 70 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE lidocaine hcl mucous lorazepam injection ...... 29 LYUMJEV KWIKPEN membrane jelly ...... 35 lorazepam intensol ...... 29 U-200 INSULIN...... 41 lidocaine hcl mucous lorazepam oral concentrate ...... 29 LYUMJEV U-100 INSULIN ...... 41 membrane jelly in applicator ...... 35 lorazepam oral tablet 0.5 mg, 1 mg . 29 lyza...... 48 lidocaine hcl mucous lorazepam oral tablet 2 mg ...... 29 membrane solution 2% ...... 35 M lidocaine hcl mucous membrane LORBRENA ORAL TABLET 25 MG . 19 solution 4% (40 mg/ml) ...... 35 LORBRENA ORAL TABLET 100 MG . 19 MAGNESIUM SULFATE IN D5W lidocaine (pf) injection solution...... 35 loryna (28) ...... 50 INTRAVENOUS PIGGYBACK 1 GRAM/100 ML ...... 55 lidocaine (pf) intravenous syringe ...31 losartan ...... 32 magnesium sulfate injection ...... 55 lidocaine-prilocaine topical cream...35 losartan-hydrochlorothiazide magnesium sulfate in water ...... 55 lidocaine topical adhesive oral tablet 50-12.5 mg ...... 32 patch,medicated 5% ...... 35 losartan-hydrochlorothiazide oral malathion ...... 37 tablet 100-12.5 mg, 100-25 mg .....32 lidocaine topical ointment ...... 35 maprotiline ...... 29 LOTEMAX ...... 52 lidocaine viscous ...... 35 marlissa (28) ...... 50 LOTEMAX SM ...... 52 lillow (28) ...... 50 MARPLAN ...... 29 lovastatin oral tablet 10 mg...... 34 lincomycin ...... 13 MARQIBO ...... 19 lovastatin oral tablet 20 mg, 40 mg..34 lindane topical shampoo ...... 37 MATULANE ...... 19 low-ogestrel (28) ...... 50 linezolid-0.9% sodium chloride .....13 matzim la ...... 32 loxapine succinate...... 29 linezolid in dextrose 5% ...... 13 MAVYRET ...... 10 linezolid oral suspension lo-zumandimine (28) ...... 50 meclizine oral tablet for reconstitution...... 13 LUMAKRAS...... 19 12.5 mg, 25 mg...... 44 linezolid oral tablet...... 13 LUMIGAN OPHTHALMIC MEDROL ORAL TABLET 2 MG.....39 (EYE) DROPS 0.01%...... 52 LINZESS ...... 44 medroxyprogesterone LUMIZYME ...... 42 intramuscular suspension ...... 48 liothyronine oral ...... 43 LUMOXITI ...... 19 medroxyprogesterone lisinopril...... 32 LUPRON DEPOT ...... 19 intramuscular syringe ...... 48 lisinopril-hydrochlorothiazide ...... 32 LUPRON DEPOT (3 MONTH)...... 19 medroxyprogesterone oral ...... 48 lithium carbonate ...... 29 LUPRON DEPOT (4 MONTH)...... 19 mefloquine ...... 13 LIVALO ...... 34 LUPRON DEPOT (6 MONTH)...... 19 megestrol oral suspension l norgest/e.estradiol-e.estrad ...... 49 400 mg/10 ml (10 ml), LUPRON DEPOT-PED ...... 19 lojaimiess ...... 50 400 mg/10 ml (40 mg/ml)...... 19 LUPRON DEPOT-PED (3 MONTH). 19 LOKELMA ...... 38 megestrol oral tablet ...... 19 LONSURF ORAL lutera (28)...... 50 MEKINIST ORAL TABLET 0.5 MG..19 TABLET 15-6.14 MG ...... 19 LYNPARZA ORAL TABLET...... 19 MEKINIST ORAL TABLET 2 MG....19 LONSURF ORAL LYRICA CR ORAL TABLET MEKTOVI ...... 19 TABLET 20-8.19 MG ...... 19 EXTENDED RELEASE 24 HR 165 MG, 82.5 MG...... 23 meloxicam oral tablet 7.5 mg ...... 27 loperamide oral capsule...... 43 LYRICA CR ORAL TABLET meloxicam oral tablet 15 mg...... 27 lopinavir-ritonavir oral solution ...... 10 EXTENDED RELEASE melphalan...... 19 lopinavir-ritonavir 24 HR 330 MG ...... 23 melphalan hcl ...... 19 oral tablet 100-25 mg ...... 10 LYSODREN ...... 19 memantine oral capsule, lopinavir-ritonavir LYUMJEV KWIKPEN sprinkle,er 24hr...... 25 oral tablet 200-50 mg ...... 10 U-100 INSULIN...... 41 September 2021 71 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE memantine oral solution...... 25 methadone oral solution 10 mg/5 ml . 26 micafungin ...... 9 memantine oral tablet 5 mg ...... 25 methadone oral tablet 5 mg ...... 26 microgestin 1.5/30 (21) ...... 50 memantine oral tablet 10 mg ...... 25 methadone oral tablet 10 mg ...... 26 microgestin 1/20 (21) ...... 50 memantine oral tablets,dose pack ..25 methazolamide ...... 52 microgestin fe 1.5/30 (28) ...... 50 MENACTRA (PF) methenamine hippurate ...... 15 microgestin fe 1/20 (28) ...... 50 INTRAMUSCULAR SOLUTION ....46 methimazole oral tablet midodrine ...... 38 MENEST...... 48 10 mg, 5 mg...... 39 migergot ...... 24 MENOSTAR ...... 48 methocarbamol oral ...... 25 miglitol oral tablet 25 mg ...... 41 MENQUADFI (PF) ...... 46 methotrexate sodium injection ...... 19 miglitol oral tablet 50 mg ...... 41 MENVEO A-C-Y-W-135-DIP (PF) ...46 methotrexate sodium oral ...... 19 miglitol oral tablet 100 mg ...... 41 mercaptopurine ...... 19 methotrexate sodium (pf)...... 19 miglustat ...... 42 meropenem ...... 13 methoxsalen ...... 35 mili ...... 50 MEROPENEM-0.9% methyldopa ...... 32 minitran ...... 34 SODIUM CHLORIDE ...... 13 methylphenidate hcl oral tablet .....29 minocycline oral capsule ...... 15 merzee ...... 50 methylphenidate hcl oral tablet minocycline oral tablet ...... 15 mesalamine oral capsule, extended release ...... 29 minoxidil oral ...... 32 extended release 24hr ...... 44 methylphenidate hcl oral tablet mesalamine oral tablet, extended release 24hr 18 mg, mirtazapine oral tablet ...... 29 delayed release (dr/ec) 1.2 gram ...44 18 mg (bx rating), 27 mg, 27 mg mirtazapine oral tablet, disintegrating...... 29 mesalamine rectal enema ...... 44 (bx rating), 36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating) ...... 29 misoprostol ...... 45 mesalamine with cleansing wipe....44 methylprednisolone ...... 39 MITIGARE ...... 47 mesna ...... 15 methylprednisolone acetate ...... 39 mitomycin intravenous ...... 19 MESNEX ORAL ...... 15 methylprednisolone sodium succ mitoxantrone ...... 19 metaproterenol oral syrup ...... 54 injection recon soln 125 mg, 40 mg ..39 M-M-R II (PF) ...... 46 METFORMIN ORAL SOLUTION ...41 methylprednisolone sodium moexipril ...... 32 metformin oral tablet 1,000 mg .....41 succ intravenous ...... 39 molindone...... 29 metformin oral tablet 500 mg ...... 41 metoclopramide hcl oral solution....44 mometasone nasal ...... 54 metformin oral tablet 850 mg ...... 41 metoclopramide hcl oral tablet...... 44 mometasone topical ...... 37 metformin oral tablet extended metolazone ...... 32 release 24hr 1,000 mg ...... 41 mondoxyne nl oral metoprolol succinate...... 32 metformin oral tablet extended capsule 100 mg, 75 mg ...... 15 metoprolol ta-hydrochlorothiaz .....32 release 24hr 500 mg...... 41 MONJUVI ...... 19 metoprolol tartrate oral ...... 32 metformin oral tablet mono-linyah ...... 50 extended release 24 hr 500 mg metro i.v...... 13 montelukast oral granules (generic for glucophage xr)...... 41 metronidazole in nacl (iso-os) ...... 13 in packet ...... 54 metformin oral tablet metronidazole oral tablet ...... 13 montelukast oral tablet ...... 54 extended release 24 hr 750 mg metronidazole topical ...... 36 montelukast oral tablet, chewable ..54 (generic for glucophage xr)...... 41 metronidazole vaginal...... 48 MONUROL ...... 15 methadone injection solution ...... 26 metyrosine ...... 32 morgidox oral capsule 100 mg...... 15 methadone intensol...... 26 mexiletine ...... 31 morphine concentrate oral solution . 26 methadone oral concentrate...... 26 MIACALCIN INJECTION...... 42 morphine injection solution 8 mg/ml..26 methadone oral solution 5 mg/5 ml . 26 mibelas 24 fe...... 50 September 2021 72 Covered Drugs Index

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MORPHINE INJECTION N neo-polycin hc...... 52 SOLUTION 10 MG/ML, NERLYNX ...... 19 2 MG/ML, 4 MG/ML, 5 MG/ML .....26 nabumetone...... 27 NEUPRO ...... 24 MORPHINE INJECTION nadolol...... 32 nevirapine oral suspension ...... 10 SYRINGE 2 MG/ML ...... 26 nadolol-bendroflumethiazide nevirapine oral tablet ...... 10 morphine injection syringe 4 mg/ml ..26 oral tablet 80-5 mg ...... 32 MORPHINE INTRAVENOUS nevirapine oral tablet extended nafcillin ...... 14 release 24 hr 100 mg ...... 10 SOLUTION 4 MG/ML, 8 MG/ML ....26 nafcillin in dextrose iso-osm ...... 14 morphine intravenous nevirapine oral tablet extended naftifine ...... 36 release 24 hr 400 mg ...... 10 solution 10 mg/ml...... 26 NAFTIN TOPICAL GEL ...... 36 ...... morphine intravenous NEXAVAR 19 syringe 2 mg/ml, 4 mg/ml ...... 26 NAGLAZYME ...... 42 niacin oral tablet 500 mg ...... 34 MORPHINE INTRAVENOUS naloxone injection solution ...... 27 niacin oral tablet SYRINGE 10 MG/ML, 8 MG/ML ....26 naloxone injection syringe 1 mg/ml . 27 extended release 24 hr ...... 34 morphine oral solution ...... 26 naltrexone ...... 27 niacor...... 34 MORPHINE ORAL TABLET ...... 26 NAMZARIC ...... 25 nicardipine intravenous solution ....32 morphine oral tablet naproxen oral suspension ...... 27 nicardipine oral ...... 32 extended release ...... 26 naproxen oral tablet ...... 27 NICOTROL ...... 39 morphine (pf) injection naproxen oral tablet, NICOTROL NS ...... 39 solution 0.5 mg/ml, 1 mg/ml ...... 26 delayed release (dr/ec) ...... 27 nifedipine oral tablet MOVANTIK ...... 44 naproxen sodium oral extended release ...... 32 moxifloxacin ophthalmic (eye) ...... 51 tablet 275 mg, 550 mg ...... 27 nifedipine oral tablet moxifloxacin oral ...... 15 naratriptan ...... 24 extended release 24hr ...... 32 MOXIFLOXACIN-SOD. NARCAN ...... 27 nikki (28) ...... 50 ACE, SUL-WATER ...... 15 NATACYN...... 51 nilutamide...... 19 moxifloxacin-sod.chloride(iso) ...... 15 nateglinide oral tablet 60 mg ...... 41 nimodipine ...... 32 MOZOBIL ...... 45 nateglinide oral tablet 120 mg ...... 41 NINLARO ...... 19 mupirocin ...... 36 NATPARA...... 42 NIPENT...... 19 mupirocin calcium ...... 36 NAYZILAM ...... 23 nisoldipine ...... 32 MUSE INTRA-URETHRAL necon 0.5/35 (28) ...... 50 nitazoxanide ...... 13 SUPPOSITORY 1,000 MCG, nitisinone ...... 38 250 MCG, 500 MCG ...... 55 NEEDLES, INSULIN DISP.,SAFETY . 41 nitrofurantoin ...... 15 MVASI ...... 19 nefazodone ...... 29 nitrofurantoin macrocrystal ...... 15 mycophenolate mofetil (hcl) ...... 19 neomycin ...... 13 nitrofurantoin monohyd/m-cryst.....15 mycophenolate mofetil oral capsule..19 neomycin-bacitracin-poly-hc...... 52 nitroglycerin intravenous ...... 34 mycophenolate mofetil oral neomycin-bacitracin-polymyxin .....51 suspension for reconstitution ...... 19 neomycin-polymyxin b-dexameth ...52 nitroglycerin sublingual...... 34 mycophenolate mofetil oral tablet ...19 neomycin-polymyxin b gu ...... 37 nitroglycerin transdermal patch 24 hour ...... 34 mycophenolate sodium ...... 19 neomycin-polymyxin-gramicidin ....51 nitroglycerin translingual ...... 34 MYLOTARG...... 19 neomycin-polymyxin-hc NIVESTYM ...... 45 myorisan ...... 36 ophthalmic (eye)...... 52 nizatidine oral capsule ...... 45 MYRBETRIQ ORAL TABLET neomycin-polymyxin-hc otic (ear) ...39 EXTENDED RELEASE 24 HR...... 54 neo-polycin ...... 51 nora-be ...... 48 September 2021 73 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE noreth-ethinyl estradiol-iron ...... 50 nystatin oral ...... 9 ondansetron hcl oral solution ...... 44 norethindrone acetate...... 48 nystatin topical cream...... 36 ondansetron hcl oral tablet ...... 44 norethindrone ac-eth estradiol nystatin topical ointment ...... 36 ondansetron hcl (pf) ...... 44 oral tablet 0.5-2.5 mg-mcg ...... 48 nystatin topical powder...... 36 ONIVYDE ...... 20 norethindrone ac-eth estradiol nystatin-triamcinolone...... 36 ONUREG ...... 20 oral tablet 1-20 mg-mcg, nystop ...... 36 OPDIVO ...... 20 1.5-30 mg-mcg ...... 50 NYVEPRIA...... 45 OPSUMIT ...... 54 norethindrone (contraceptive) ...... 48 norethindrone-e.estradiol-iron oralone ...... 39 oral capsule ...... 50 O ORBACTIV ...... 13 ORENCIA CLICKJECT ...... 47 norethindrone-e.estradiol-iron OCALIVA ...... 44 oral tablet 1 mg-20 mcg (21)/75 mg ORENCIA SUBCUTANEOUS ocella ...... 50 (7), 1.5 mg-30 mcg (21)/75 mg (7) ..50 SYRINGE 50 MG/0.4 ML...... 47 OCREVUS ...... 25 norethindrone-e.estradiol-iron ORENCIA SUBCUTANEOUS oral tablet,chewable ...... 50 octreotide acetate injection solution SYRINGE 87.5 MG/0.7 ML...... 47 1,000 mcg/ml, 500 mcg/ml ...... 19 norgestimate-ethinyl estradiol ...... 50 ORENCIA SUBCUTANEOUS octreotide acetate injection NORMOSOL-R PH 7.4 ...... 56 SYRINGE 125 MG/ML ...... 47 solution 50 mcg/ml...... 20 NORTHERA ORAL ORGOVYX...... 20 octreotide acetate injection s CAPSULE 100 MG ...... 38 ORKAMBI ORAL olution 100 mcg/ml, 200 mcg/ml ....20 NORTHERA ORAL GRANULES IN PACKET ...... 54 ODEFSEY ...... 10 CAPSULE 200 MG, 300 MG ...... 38 ORKAMBI ORAL TABLET...... 54 ODOMZO ...... 20 nortrel 0.5/35 (28) ...... 50 orsythia ...... 50 OFEV...... 54 nortrel 1/35 (21) ...... 50 oseltamivir ...... 10 ofloxacin ophthalmic (eye) ...... 51 nortrel 1/35 (28) ...... 50 oxacillin injection ...... 14 ofloxacin otic (ear) ...... 39 nortrel 7/7/7 (28)...... 50 oxaliplatin ...... 20 OGIVRI ...... 20 nortriptyline ...... 30 oxandrolone oral tablet 2.5 mg .....42 olanzapine-fluoxetine ...... 30 NORVIR ORAL POWDER oxandrolone oral tablet 10 mg ...... 42 olanzapine intramuscular...... 30 IN PACKET ...... 10 oxaprozin ...... 27 olanzapine oral tablet ...... 30 NORVIR ORAL SOLUTION ...... 10 oxazepam...... 30 olanzapine oral tablet, NOVOFINE PEN NEEDLE ...... 41 oxcarbazepine ...... 23 disintegrating...... 30 NOVOTWIST PEN NEEDLE ...... 41 OXERVATE ...... 51 olmesartan ...... 32 NUBEQA ...... 19 oxybutynin chloride oral syrup ...... 54 olmesartan-hydrochlorothiazide ....32 NUEDEXTA ...... 25 oxybutynin chloride oral tablet ...... 54 olopatadine ophthalmic (eye) ...... 51 NULOJIX ...... 19 oxybutynin chloride oral tablet omega-3 acid ethyl esters ...... 34 NUPLAZID ORAL CAPSULE...... 30 extended release 24hr ...... 54 omeprazole oral capsule, NUPLAZID ORAL TABLET 10 MG ..30 oxycodone-acetaminophen oral delayed release(dr/ec) ...... 45 NUTRILIPID...... 56 tablet 10-325 mg, 2.5-325 mg, OMNIPOD 5 PACK ...... 41 5-325 mg, 7.5-325 mg ...... 26 NUZYRA INTRAVENOUS...... 15 OMNIPOD DASH 5 PACK...... 41 oxycodone oral concentrate ...... 26 NUZYRA ORAL ...... 15 OMNIPOD STARTER KIT...... 41 oxycodone oral solution ...... 26 nyamyc ...... 36 ONCASPAR...... 20 oxycodone oral tablet 5 mg...... 26 nylia 7/7/7 (28) ...... 50 ondansetron...... 44 oxycodone oral tablet nymyo ...... 50 ondansetron hcl intravenous ...... 44 10 mg, 15 mg, 20 mg, 30 mg ...... 26 September 2021 74 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE oxymorphone oral tablet penicillin v potassium pimecrolimus ...... 35 extended release 12 hr ...... 26 oral recon soln ...... 14 pimozide ...... 30 OZEMPIC SUBCUTANEOUS penicillin v potassium pimtrea (28) ...... 50 PEN INJECTOR 0.25 MG oral tablet 250 mg ...... 14 pindolol ...... 32 OR 0.5 MG(2 MG/1.5 ML)...... 41 penicillin v potassium pioglitazone ...... 41 OZEMPIC SUBCUTANEOUS oral tablet 500 mg ...... 14 PEN INJECTOR 1 MG/DOSE PENTACEL (PF) pioglitazone-metformin...... 41 (2 MG/1.5 ML), 1 MG/DOSE INTRAMUSCULAR KIT 15LF- piperacillin-tazobactam (4 MG/3 ML) ...... 41 48MCG-62DU -10 MCG/0.5ML .....46 intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram ...14 PENTAM...... 13 PIPERACILLIN-TAZOBACTAM P pentamidine inhalation ...... 13 INTRAVENOUS RECON SOLN pacerone oral tablet pentamidine injection ...... 13 13.5 GRAM ...... 14 ...... 100 mg, 200 mg, 400 mg 31 PENTASA...... 44 PIQRAY...... 20 ...... paclitaxel 20 pentoxifylline ...... 33 pirmella ...... 50 PADCEV ...... 20 PEPAXTO...... 20 PLENAMINE ...... 56 paliperidone oral tablet extended PERFOROMIST...... 54 PLENVU ...... 44 release 24hr 1.5 mg, 3 mg, 9 mg ...30 PERIKABIVEN ...... 56 podofilox ...... 35 paliperidone oral tablet perindopril erbumine ...... 32 extended release 24hr 6 mg...... 30 POLIVY...... 20 PERJETA ...... 20 palonosetron intravenous polycin ...... 51 solution 0.25 mg/5 ml ...... 44 permethrin ...... 37 polymyxin b sulfate ...... 13 pamidronate intravenous solution ...42 perphenazine ...... 30 polymyxin b sulf-trimethoprim ...... 51 PANRETIN...... 35 perphenazine-amitriptyline ...... 30 POMALYST ...... 20 pantoprazole oral tablet, PERSERIS...... 30 portia 28 ...... 50 delayed release (dr/ec) 20 mg ...... 45 pfizerpen-g ...... 14 PORTRAZZA ...... 20 pantoprazole oral tablet, phenelzine ...... 30 posaconazole oral tablet, delayed release (dr/ec) 40 mg ...... 45 phenobarbital oral elixir ...... 23 delayed release (dr/ec) ...... 9 paricalcitol oral ...... 42 phenobarbital oral tablet ...... 23 POTASSIUM CHLORID-D5- paroex oral rinse ...... 39 phenobarbital sodium 0.45%NACL INTRAVENOUS paromomycin...... 13 injection solution...... 23 PARENTERAL SOLUTION 10 MEQ/L, 20 MEQ/L, 40 MEQ/L ...55 paroxetine hcl oral tablet ...... 30 phenoxybenzamine ...... 32 potassium chlorid-d5-0.45%nacl paroxetine hcl oral tablet phenytoin oral suspension ...... 23 intravenous parenteral solution extended release 24 hr ...... 30 phenytoin oral tablet,chewable .....23 30 meq/l ...... 55 ...... PASER 13 phenytoin sodium extended ...... 23 potassium chloride-0.45% nacl .....55 PAXIL ORAL SUSPENSION ...... 30 phenytoin sodium POTASSIUM CHLORIDE-D5- PEDIARIX (PF)...... 46 intravenous solution ...... 23 0.2%NACL INTRAVENOUS PEDVAX HIB (PF) ...... 46 PHESGO ...... 20 PARENTERAL SOLUTION 20 MEQ/L ...... 55 peg 3350-electrolytes oral recon philith ...... 50 soln 236-22.74-6.74 -5.86 gram ....44 PICATO...... 35 potassium chloride-d5-0.2%nacl intravenous parenteral solution peg-electrolyte ...... 44 PIFELTRO ...... 10 30 meq/l, 40 meq/l ...... 55 PEMAZYRE...... 20 pilocarpine hcl ophthalmic POTASSIUM CHLORIDE- penicillamine ...... 48 (eye) drops 1%, 2%, 4% ...... 51 D5-0.9%NACL ...... 55 penicillin g potassium ...... 14 pilocarpine hcl oral...... 38 September 2021 75 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE potassium chloride in 0.9%nacl prednisone oral solution...... 39 proctosol hc topical ...... 44 intravenous parenteral solution prednisone oral tablet 1 mg, proctozone-hc ...... 44 20 meq/l, 40 meq/l ...... 55 10 mg, 2.5 mg, 20 mg, 5 mg...... 39 progesterone micronized...... 48 potassium chloride in 5% dex prednisone oral tablet 50 mg ...... 39 intravenous parenteral solution PROGLYCEM ...... 41 prednisone oral tablets,dose pack ..39 20 meq/l, 30 meq/l, 40 meq/l ...... 55 PROGRAF INTRAVENOUS ...... 20 potassium chloride in lr-d5 pregabalin oral capsule PROGRAF ORAL intravenous parenteral 100 mg, 150 mg, 200 mg, GRANULES IN PACKET ...... 20 25 mg, 50 mg, 75 mg ...... 23 solution 20 meq/l ...... 55 PROLASTIN-C ...... 38 pregabalin oral capsule potassium chloride intravenous.....55 PROLENSA...... 52 225 mg, 300 mg ...... 23 potassium chloride in water PROLIA...... 47 pregabalin oral solution ...... 23 intravenous piggyback ...... 55 pregabalin oral tablet extended PROMACTA ORAL POWDER potassium chloride oral IN PACKET 12.5 MG ...... 33 release 24 hr 165 mg, 82.5 mg .....23 capsule, extended release ...... 55 pregabalin oral tablet PROMACTA ORAL POWDER potassium chloride oral liquid...... 55 IN PACKET 25 MG ...... 34 extended release 24 hr 330 mg.....23 potassium chloride oral packet .....55 PROMACTA ORAL TABLET PREMARIN INJECTION ...... 48 potassium chloride oral tablet, er 12.5 MG, 25 MG, 50 MG ...... 34 PREMARIN ORAL...... 48 particles/crystals 10 meq, 20 meq ..55 PROMACTA ORAL TABLET 75 MG . 34 PREMARIN VAGINAL ...... 48 potassium chloride oral promethazine oral ...... 53 PREMASOL 10%...... 56 tablet extended release ...... 55 promethazine rectal potassium citrate ...... 55 PRENATAL VITAMIN suppository 12.5 mg, 25 mg ...... 53 ORAL TABLET ...... 56 POTELIGEO ...... 20 promethegan rectal prevalite ...... 34 PRADAXA ...... 33 suppository 25 mg, 50 mg ...... 53 previfem ...... 50 pramipexole oral tablet ...... 24 propafenone oral capsule, pramipexole oral tablet PREVYMIS ORAL ...... 10 extended release 12 hr ...... 31 extended release 24 hr ...... 24 PREZCOBIX ...... 10 propafenone oral tablet ...... 31 PRASUGREL ...... 33 PREZISTA ORAL SUSPENSION ...10 propranolol-hydrochlorothiazid .....32 pravastatin ...... 34 PREZISTA ORAL TABLET 75 MG ..10 propranolol oral capsule, extended release 24 hr ...... 32 praziquantel...... 13 PREZISTA ORAL TABLET 150 MG . 10 propranolol oral solution ...... 32 prazosin ...... 32 PREZISTA ORAL TABLET 600 MG . 10 propranolol oral tablet...... 32 PRED-G ...... 52 PREZISTA ORAL TABLET 800 MG . 10 propylthiouracil ...... 40 PRED-G S.O.P...... 52 PRIFTIN ...... 13 PROQUAD (PF) ...... 46 prednicarbate topical ointment...... 37 PRIMAQUINE ...... 13 PROSOL 20%...... 56 prednisolone acetate ...... 52 primidone ...... 23 protriptyline ...... 30 prednisolone oral solution ...... 39 probenecid ...... 47 prednisolone sodium phosphate probenecid-colchicine...... 47 PULMICORT INHALATION SUSPENSION FOR ophthalmic (eye)...... 52 PROCALAMINE 3% ...... 56 NEBULIZATION 0.25 MG/ prednisolone sodium phosphate prochlorperazine ...... 44 2 ML, 0.5 MG/2 ML ...... 54 oral solution 15 mg/5 ml prochlorperazine edisylate ...... 44 (3 mg/ml), 15 mg/5 ml (5 ml), PULMICORT INHALATION 25 mg/5 ml (5 mg/ml), prochlorperazine maleate oral ...... 44 SUSPENSION FOR NEBULIZATION 1 MG/2 ML...... 54 5 mg base/5 ml (6.7 mg/5 ml) ...... 39 procto-med hc...... 44 PULMOZYME ...... 54 prednisone intensol ...... 39 procto-pak ...... 44 PURIXAN ...... 20 September 2021 76 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE pyrazinamide...... 13 RECTIV...... 44 risedronate oral tablet 35 mg, pyridostigmine bromide oral syrup ..25 regonol ...... 25 35 mg (12 pack), 35 mg (4 pack) ...47 pyridostigmine bromide REGRANEX ...... 35 risedronate oral tablet 150 mg ...... 47 oral tablet 60 mg ...... 25 RELISTOR SUBCUTANEOUS RISPERDAL CONSTA pyridostigmine bromide SOLUTION ...... 44 INTRAMUSCULAR SUSPENSION,EXTENDED oral tablet extended release ...... 25 RELISTOR SUBCUTANEOUS REL RECON 12.5 MG/2 ML...... 30 pyrimethamine ...... 13 SYRINGE ...... 44 RISPERDAL CONSTA RENACIDIN...... 55 INTRAMUSCULAR Q RENFLEXIS...... 44 SUSPENSION,EXTENDED repaglinide oral tablet 0.5 mg ...... 41 REL RECON 25 MG/2 ML, QINLOCK ...... 20 ...... repaglinide oral tablet 1 mg ...... 41 37.5 MG/2 ML, 50 MG/2 ML 30 QUADRACEL (PF) ...... 46 ...... repaglinide oral tablet 2 mg ...... 41 risperidone oral solution 30 quetiapine oral tablet risperidone oral tablet 0.25 mg, 100 mg, 200 mg, 25 mg, 50 mg.....30 REPATHA...... 34 0.5 mg, 1 mg, 2 mg, 3 mg ...... 30 quetiapine oral tablet 3 REPATHA PUSHTRONEX ...... 34 risperidone oral tablet 4 mg ...... 30 00 mg, 400 mg ...... 30 REPATHA SURECLICK ...... 34 risperidone oral tablet, quetiapine oral tablet extended RESTASIS ...... 51 disintegrating 0.25 mg, release 24 hr 150 mg, 200 mg...... 30 RESTASIS MULTIDOSE ...... 51 0.5 mg, 1 mg, 2 mg, 3 mg ...... 30 quetiapine oral tablet extended RETACRIT ...... 46 risperidone oral tablet, release 24 hr 300 mg, disintegrating 4 mg ...... 30 400 mg, 50 mg ...... 30 RETEVMO ...... 20 ritonavir ...... 10 quinapril ...... 32 RETROVIR INTRAVENOUS ...... 10 rivastigmine ...... 25 quinapril-hydrochlorothiazide ...... 32 REVLIMID ...... 20 rivastigmine tartrate...... 25 quinidine sulfate oral tablet ...... 31 REXULTI...... 30 rivelsa ...... 50 quinine sulfate...... 13 REYATAZ ORAL POWDER IN PACKET ...... 10 rizatriptan ...... 24 R RHOPRESSA ...... 52 ROCKLATAN...... 52 ribavirin oral capsule ...... 10 ROMIDEPSIN RABAVERT (PF) ...... 46 ribavirin oral tablet 200 mg ...... 10 INTRAVENOUS SOLUTION ...... 20 raloxifene ...... 47 RIDAURA ...... 48 ropinirole oral tablet...... 24 ramelteon ...... 30 rifabutin ...... 13 rosadan topical cream ...... 36 ramipril ...... 33 rifampin intravenous ...... 13 rosadan topical gel ...... 36 ranolazine...... 34 rifampin oral...... 13 rosuvastatin ...... 34 rasagiline ...... 24 riluzole...... 38 ROTARIX ...... 46 REBIF REBIDOSE rimantadine ...... 10 ROTATEQ VACCINE ...... 46 SUBCUTANEOUS PEN INJECTOR ringer's intravenous...... 55 roweepra...... 23 8.8MCG/0.2ML-22 MCG/0.5ML (6) . 45 ringer's irrigation ...... 37 ROZLYTREK ORAL REBIF REBIDOSE CAPSULE 100 MG ...... 20 SUBCUTANEOUS PEN INJECTOR RINVOQ ...... 48 ROZLYTREK ORAL 22 MCG/0.5 ML, 44 MCG/0.5 ML ...45 RIOMET ...... 41 CAPSULE 200 MG ...... 20 REBIF TITRATION PACK ...... 46 RIOMET ER...... 41 RUBRACA ...... 20 REBIF (WITH ALBUMIN)...... 45 risedronate oral tablet 5 mg ...... 47 rufinamide ...... 23 reclipsen (28) ...... 50 risedronate oral tablet 30 mg ...... 38 RUKOBIA ...... 11 RECOMBIVAX HB (PF) ...... 46 September 2021 77 Covered Drugs Index

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RUXIENCE ...... 20 SILDENAFIL ORAL TABLET sorine...... 31 RYBELSUS ...... 41 100 MG, 25 MG, 50 MG ...... 55 sotalol af ...... 31 RYBREVANT...... 20 sildenafil (pulmonary arterial sotalol oral ...... 31 hypertension) oral tablet ...... 54 RYDAPT...... 20 SOTYLIZE ...... 31 silver sulfadiazine ...... 35 RYTARY ...... 24 spironolactone ...... 33 SIMBRINZA...... 52 spironolacton-hydrochlorothiaz .....33 simliya (28) ...... 50 S sprintec (28) ...... 50 simpesse ...... 50 SPRITAM ...... 23 salsalate ...... 27 SIMULECT...... 20 SPRYCEL ORAL TABLET SAMSCA ORAL TABLET 15 MG....42 simvastatin oral tablet...... 34 20 MG, 70 MG ...... 20 SAMSCA ORAL TABLET 30 MG....42 sirolimus oral solution...... 20 SPRYCEL ORAL TABLET SANCUSO ...... 44 sirolimus oral tablet ...... 20 100 MG, 140 MG, 50 MG, 80 MG...20 SANDIMMUNE ORAL SOLUTION..20 SIRTURO ...... 13 sps (with sorbitol)...... 38 SANDOSTATIN LAR DEPOT SIVEXTRO INTRAVENOUS...... 13 sronyx ...... 50 INTRAMUSCULAR SUSPENSION, SIVEXTRO ORAL ...... 13 ssd ...... 35 EXTENDED REL RECON...... 20 SKYRIZI SUBCUTANEOUS STAMARIL (PF) ...... 46 SANTYL ...... 35 PEN INJECTOR...... 35 stavudine oral capsule ...... 11 SAPHRIS ...... 30 SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS sapropterin ...... 42 SYRINGE 150 MG/ML ...... 35 SOLUTION ...... 35 SARCLISA ...... 20 SKYRIZI SUBCUTANEOUS STELARA SUBCUTANEOUS scopolamine base ...... 44 SYRINGE KIT ...... 35 SYRINGE 45 MG/0.5 ML...... 35 SECUADO ...... 30 sodium bicarbonate intravenous STELARA SUBCUTANEOUS selegiline hcl ...... 24 syringe 10 meq/10 ml (8.4%), 7.5% SYRINGE 90 MG/ML ...... 35 (0.9 meq/ml), 8.4% (1 meq/ml) .....55 selenium sulfide topical lotion ...... 34 STIVARGA...... 20 sodium chloride 0.9% intravenous ..38 SELZENTRY ORAL SOLUTION ....11 streptomycin ...... 13 sodium chloride 0.45% SELZENTRY ORAL STRIBILD ...... 11 intravenous parenteral solution .....56 TABLET 25 MG ...... 11 SUBOXONE SUBLINGUAL sodium chloride 3% ...... 56 SELZENTRY ORAL FILM 2-0.5 MG ...... 27 sodium chloride 5% ...... 56 TABLET 150 MG, 75 MG...... 11 SUBOXONE SUBLINGUAL SELZENTRY ORAL sodium chloride intravenous...... 56 FILM 4-1 MG, 8-2 MG ...... 27 TABLET 300 MG ...... 11 sodium chloride irrigation...... 38 SUBOXONE SUBLINGUAL SEREVENT DISKUS ...... 54 sodium fluoride 5000 dry mouth ....39 FILM 12-3 MG...... 27 sertraline oral concentrate...... 30 sodium fluoride-pot nitrate...... 39 subvenite ...... 23 sertraline oral tablet...... 30 sodium phenylbutyrate ...... 38 subvenite starter (blue) kit...... 23 setlakin ...... 50 sodium polystyrene subvenite starter (green) kit ...... 23 SEVELAMER CARBONATE sulfonate oral powder ...... 38 subvenite starter (orange) kit ...... 23 ORAL POWDER IN PACKET ...... 38 solifenacin ...... 54 sucralfate oral suspension ...... 45 SEVELAMER CARBONATE SOLIQUA 100/33 ...... 41 sucralfate oral tablet ...... 45 ORAL TABLET ...... 38 SOLTAMOX ...... 20 sulfacetamide-prednisolone ...... 52 sharobel ...... 48 SOLU-CORTEF ACT-O-VIAL (PF) ..39 sulfacetamide sodium (acne) ...... 36 SHINGRIX (PF) ...... 46 SOMATULINE DEPOT...... 20 sulfacetamide sodium SIGNIFOR ...... 20 SOMAVERT...... 43 ophthalmic (eye) drops...... 52 September 2021 78 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE sulfadiazine ...... 15 SYNTHROID ...... 43 TECHLITE PEN NEEDLE ...... 42 sulfamethoxazole-trimethoprim TEFLARO...... 12 intravenous ...... 15 T TEKTURNA HCT ...... 33 sulfamethoxazole-trimethoprim telmisartan ...... 33 oral suspension ...... 15 TABLOID ...... 20 telmisartan-amlodipine ...... 33 sulfamethoxazole-trimethoprim TABRECTA ...... 20 telmisartan-hydrochlorothiazid...... 33 oral tablet ...... 15 tacrolimus oral ...... 20 temazepam ...... 30 sulfasalazine ...... 44 tacrolimus topical ...... 35 TEMIXYS ...... 11 sulindac...... 27 tadalafil (pulmonary arterial sumatriptan nasal spray, hypertension) oral tablet 20 mg.....54 TEMODAR INTRAVENOUS...... 21 non-aerosol 5 mg/actuation ...... 24 TAFINLAR ...... 20 temsirolimus ...... 21 sumatriptan nasal spray, TAGRISSO...... 21 TENIVAC (PF) INTRAMUSCULAR SYRINGE...... 46 non-aerosol 20 mg/actuation ...... 24 TALTZ SYRINGE ...... 35 sumatriptan succinate oral ...... 24 TALZENNA ORAL tenofovir disoproxil fumarate ...... 11 sumatriptan succinate CAPSULE 0.25 MG...... 21 TEPMETKO...... 21 subcutaneous cartridge ...... 24 TALZENNA ORAL CAPSULE 1 MG . 21 terazosin oral capsule 1 mg, 2 mg, 5 mg...... 33 sumatriptan succinate tamoxifen ...... 21 subcutaneous pen injector ...... 24 terazosin oral capsule 10 mg ...... 33 tamsulosin ...... 55 sumatriptan succinate terbinafine hcl oral ...... 9 TARGRETIN TOPICAL ...... 21 subcutaneous solution ...... 24 terbutaline ...... 54 tarina 24 fe...... 50 SUPRAX ORAL SUSPENSION terconazole ...... 48 FOR RECONSTITUTION tarina fe 1/20 (28) ...... 50 TERIPARATIDE ...... 47 500 MG/5 ML ...... 12 tarina fe 1-20 eq (28) ...... 50 testosterone cypionate SUPREP BOWEL PREP KIT ...... 44 TASIGNA ORAL CAPSULE 50 MG . 21 intramuscular oil SUTAB ...... 44 TASIGNA ORAL CAPSULE 100 mg/ml, 200 mg/ml (1 ml) ...... 43 150 MG, 200 MG ...... 21 SUTENT ...... 20 TESTOSTERONE syeda...... 50 tazarotene topical cream ...... 36 CYPIONATE INTRAMUSCULAR SYMDEKO...... 54 tazicef ...... 12 OIL 200 MG/ML ...... 43 SYMFI ...... 11 TAZORAC ...... 36 testosterone enanthate ...... 43 SYMFI LO ...... 11 taztia xt oral capsule, testosterone transdermal gel ...... 43 extended release 24 hr SYMLINPEN 60 ...... 41 testosterone transdermal gel 120 mg, 180 mg, 240 mg, 300 mg ..33 in metered-dose pump SYMLINPEN 120 ...... 41 TAZVERIK ...... 21 12.5 mg/ 1.25 gram (1%)...... 43 SYMPAZAN ...... 23 TDVAX ...... 46 testosterone transdermal gel SYMTUZA ...... 11 TECENTRIQ ...... 21 in packet 1% (25 mg/2.5gram), SYNAREL ...... 43 1% (50 mg/5 gram) ...... 43 TECFIDERA ORAL CAPSULE, SYNERCID ...... 13 DELAYED RELEASE TETANUS,DIPHTHERIA SYNJARDY ...... 41 (DR/EC) 120 MG ...... 25 TOX PED(PF) ...... 46 SYNJARDY XR ORAL TABLET, IR - TECFIDERA ORAL CAPSULE, tetrabenazine oral tablet 12.5 mg ...25 ER, BIPHASIC 24HR 10-1,000 MG, DELAYED RELEASE(DR/EC) tetrabenazine oral tablet 25 mg.....25 12.5-1,000 MG, 5-1,000 MG...... 41 120 MG (14)- 240 MG (46) ...... 25 tetracycline...... 15 SYNJARDY XR ORAL TABLET, IR - TECFIDERA ORAL CAPSULE, THALOMID ORAL CAPSULE ER, BIPHASIC 24HR 25-1,000 MG ..42 DELAYED RELEASE 100 MG, 150 MG, 50 MG ...... 21 SYNRIBO ...... 20 (DR/EC) 240 MG ...... 25 September 2021 79 Covered Drugs Index

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THALOMID ORAL toposar ...... 21 triamcinolone acetonide CAPSULE 200 MG ...... 21 topotecan intravenous recon soln...21 topical cream 0.025%, 0.5%...... 37 THEO-24 ...... 54 topotecan intravenous triamcinolone acetonide theophylline oral tablet extended solution 4 mg/4 ml (1 mg/ml) ...... 21 topical lotion...... 37 release 12 hr 300 mg, 450 mg...... 54 toremifene ...... 21 triamcinolone acetonide topical ointment ...... 37 theophylline oral tablet torsemide oral ...... 33 extended release 24 hr ...... 54 triamterene-hydrochlorothiazid TOUJEO MAX U-300 SOLOSTAR ..42 thioridazine ...... 30 oral capsule 37.5-25 mg ...... 33 TOUJEO SOLOSTAR triamterene-hydrochlorothiazid thiotepa ...... 21 U-300 INSULIN...... 42 oral tablet ...... 33 thiothixene ...... 30 TOVIAZ...... 54 triderm topical cream 0.1% ...... 37 tiadylt er ...... 33 TPN ELECTROLYTES...... 56 trientine ...... 38 tiagabine...... 23 TRADJENTA ...... 42 tri-estarylla ...... 50 TIBSOVO ...... 21 tramadol-acetaminophen...... 27 tri femynor ...... 50 tigecycline ...... 13 tramadol oral tablet 50 mg ...... 27 trifluoperazine ...... 30 tilia fe ...... 50 trandolapril ...... 33 trifluridine ...... 51 timolol maleate ophthalmic tranexamic acid oral ...... 48 (eye) drops...... 51 trihexyphenidyl ...... 24 tranylcypromine ...... 30 TIMOLOL MALEATE TRIJARDY XR ORAL TABLET, OPHTHALMIC (EYE) TRAVASOL 10% ...... 56 IR - ER, BIPHASIC 24HR GEL FORMING SOLUTION ...... 51 travoprost ...... 52 10-5-1,000 MG, 25-5-1,000 MG ....42 timolol maleate oral ...... 33 TRAZIMERA ...... 21 TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5- tis-u-sol pentalyte...... 37 trazodone ...... 30 2.5-1,000 MG, 5-2.5-1,000 MG .....42 TIVICAY ORAL TABLET 10 MG ....11 TREANDA ...... 21 TRIKAFTA ...... 54 TIVICAY ORAL TABLET TRECATOR ...... 14 tri-legest fe ...... 50 25 MG, 50 MG ...... 11 TRELEGY ELLIPTA ...... 54 tri-linyah ...... 50 TIVICAY PD...... 11 TRELSTAR INTRAMUSCULAR tri-lo-estarylla...... 50 tizanidine oral capsule ...... 25 SUSPENSION FOR RECONSTITUTION ...... 21 tri-lo-marzia ...... 50 tizanidine oral tablet ...... 25 tri-lo-mili ...... 50 TOBI PODHALER TRESIBA FLEXTOUCH U-100 .....42 INHALATION CAPSULE, TRESIBA FLEXTOUCH U-200 .....42 tri-lo-sprintec ...... 50 W/INHALATION DEVICE ...... 14 TRESIBA U-100 INSULIN ...... 42 trilyte with flavor packets ...... 44 tobramycin-dexamethasone ...... 52 tretinoin (antineoplastic)...... 21 trimethoprim...... 15 tobramycin in 0.225% nacl ...... 14 tretinoin microspheres ...... 36 tri-mili...... 50 tobramycin ophthalmic (eye) ...... 51 tretinoin topical cream trimipramine...... 30 tobramycin sulfate ...... 14 0.025%, 0.05%, 0.1%...... 36 TRINTELLIX ...... 30 TOBREX OPHTHALMIC tretinoin topical topical gel 0.01% ...36 tri-nymyo...... 50 (EYE) OINTMENT ...... 51 tretinoin topical topical gel tri-previfem (28) ...... 50 0.025%, 0.05% ...... 36 tolcapone ...... 24 TRIPTODUR ...... 21 triamcinolone acetonide dental .....39 tolterodine ...... 54 tri-sprintec (28) ...... 50 triamcinolone acetonide tolvaptan oral tablet 30 mg ...... 43 tritocin ...... 37 injection suspension 40 mg/ml...... 39 topiramate oral capsule, sprinkle ...24 TRIUMEQ...... 11 triamcinolone acetonide topiramate oral tablet ...... 24 topical cream 0.1% ...... 37 trivora (28) ...... 50 September 2021 80 Covered Drugs Index

DRUG PAGE DRUG PAGE DRUG PAGE tri-vylibra...... 51 UNITUXIN ...... 21 VECTIBIX...... 21 tri-vylibra lo ...... 51 UPTRAVI ...... 33 VELCADE ...... 21 TRODELVY ...... 21 ursodiol ...... 44 velivet triphasic regimen (28) ...... 51 TROGARZO ...... 11 VELTASSA...... 38 TROKENDI XR ORAL CAPSULE, V VEMLIDY ...... 11 EXTENDED RELEASE 24HR VENCLEXTA ORAL valacyclovir oral tablet 1 gram ...... 11 100 MG, 25 MG, 50 MG ...... 24 TABLET 10 MG ...... 21 valacyclovir oral tablet 500 mg .....11 TROKENDI XR ORAL CAPSULE, VENCLEXTA ORAL EXTENDED RELEASE 24HR VALCHLOR ...... 35 TABLET 50 MG ...... 21 200 MG ...... 24 valganciclovir...... 11 VENCLEXTA ORAL TROPHAMINE 10% ...... 56 valproate sodium ...... 24 TABLET 100 MG ...... 21 TRULICITY ...... 42 valproic acid...... 24 VENCLEXTA STARTING PACK ....21 TRUMENBA ...... 46 valproic acid (as sodium salt)...... 24 venlafaxine oral capsule, TRUSELTIQ ORAL CAPSULE valrubicin ...... 21 extended release 24hr ...... 30 75 MG/DAY (25 MG X 3) ...... 21 valsartan-hydrochlorothiazide ...... 33 venlafaxine oral tablet...... 30 TRUSELTIQ ORAL CAPSULE valsartan oral tablet VENTAVIS ...... 54 100 MG/DAY (100 MG X 1) ...... 21 160 mg, 40 mg, 80 mg ...... 33 VENTOLIN HFA ...... 54 TRUSELTIQ ORAL CAPSULE 125 MG/DAY(100 MG X1-25MG X1), valsartan oral tablet 320 mg ...... 33 verapamil intravenous solution .....33 50 MG/DAY (25 MG X 2) ...... 21 VALTOCO...... 24 verapamil oral capsule, 24 hr er pellet ct ...... 33 TRUVADA ...... 11 VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS verapamil oral capsule, TRUXIMA ...... 21 PIGGYBACK ...... 14 ext rel. pellets 24 hr TUKYSA ORAL TABLET 50 MG ....21 VANCOMYCIN IN DEXTROSE 120 mg, 180 mg, 240 mg ...... 33 TUKYSA ORAL TABLET 150 MG ...21 5% INTRAVENOUS PIGGYBACK ..14 VERAPAMIL ORAL CAPSULE, TURALIO ...... 21 VANCOMYCIN INJECTION ...... 14 EXT REL. PELLETS 24 HR 360 MG ...... 33 TWINRIX (PF)...... 46 vancomycin intravenous recon TYBLUME ...... 51 soln 1,000 mg, 10 gram, 250 mg, verapamil oral tablet ...... 33 TYBOST ...... 11 5 gram, 500 mg, 750 mg ...... 14 verapamil oral tablet extended release ...... 33 tydemy...... 51 VANCOMYCIN INTRAVENOUS RECON VERSACLOZ ...... 30 TYKERB ...... 21 SOLN 1.25 GRAM, 1.5 GRAM...... 14 VERZENIO ...... 21 TYMLOS...... 47 vancomycin oral capsule 125 mg ...14 vestura (28) ...... 51 TYPHIM VI...... 46 vancomycin oral capsule 250 mg ...14 V-GO 20 ...... 42 TYSABRI ...... 25 vancomycin oral recon soln ...... 14 V-GO 30 ...... 42 VANCOMYCIN-WATER V-GO 40 ...... 42 U INJECT (PEG) ...... 14 VICTOZA 2-PAK...... 42 vandazole...... 48 UKONIQ ...... 21 VICTOZA 3-PAK...... 42 VAQTA (PF) ...... 46 UNITHROID ORAL TABLET vienva ...... 51 100 MCG, 112 MCG, 125 MCG, VARENICLINE ...... 39 vigabatrin ...... 24 150 MCG, 175 MCG, 200 MCG, VARIVAX (PF)...... 46 25 MCG, 300 MCG, 50 MCG, vigadrone ...... 24 VARIZIG ...... 46 75 MCG, 88 MCG ...... 43 VIIBRYD ORAL TABLET ...... 30 VASCEPA...... 34 unithroid oral tablet 137 mcg ...... 43

September 2021 81 Covered Drugs Index

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VIIBRYD ORAL TABLETS, DOSE vylibra ...... 51 XOLAIR SUBCUTANEOUS PACK 10 MG (7)- 20 MG (23) ...... 30 VYNDAMAX ...... 34 SYRINGE 150 MG/ML ...... 54 VIMPAT INTRAVENOUS ...... 24 VYNDAQEL...... 34 XOPENEX ...... 54 VIMPAT ORAL SOLUTION ...... 24 VYXEOS...... 22 XOPENEX CONCENTRATE ...... 54 VIMPAT ORAL TABLET 50 MG .....24 XOSPATA ...... 22 VIMPAT ORAL TABLET W XPOVIO ...... 22 100 MG, 150 MG, 200 MG ...... 24 XTAMPZA ER ...... 27 warfarin ...... 34 vinblastine ...... 21 XTANDI ORAL CAPSULE...... 22 water for irrigation, sterile ...... 38 vincasar pfs ...... 21 XTANDI ORAL TABLET 40 MG.....22 wera (28) ...... 51 vincristine ...... 21 XTANDI ORAL TABLET 80 MG.....22 wixela inhub...... 54 vinorelbine ...... 21 XULTOPHY 100/3.6 ...... 42 wymzya fe ...... 51 VIOKACE ORAL TABLET XYREM ...... 31 10,440-39,150- 39,150 UNIT ...... 44 VIOKACE ORAL TABLET X 20,880-78,300- 78,300 UNIT ...... 44 Y XALKORI ...... 22 viorele (28)...... 51 YERVOY ...... 22 XARELTO...... 34 VIRACEPT ORAL YF-VAX (PF) ...... 46 XARELTO DVT-PE TABLET 250 MG ...... 11 YONDELIS...... 22 TREAT 30D START...... 34 VIRACEPT ORAL YUPELRI ...... 54 TABLET 625 MG ...... 11 XATMEP ...... 22 yuvafem ...... 48 VIREAD ORAL POWDER...... 11 XCOPRI ...... 24 VIREAD ORAL TABLET XCOPRI MAINTENANCE PACK....24 150 MG, 200 MG, 250 MG ...... 11 XCOPRI TITRATION PACK ...... 24 Z VITRAKVI ORAL XELJANZ ORAL SOLUTION ...... 48 zafirlukast ...... 54 CAPSULE 25 MG ...... 21 XELJANZ ORAL TABLET ...... 48 zaleplon oral capsule 5 mg ...... 31 VITRAKVI ORAL XELJANZ XR ...... 48 zaleplon oral capsule 10 mg...... 31 CAPSULE 100 MG ...... 21 XGEVA ...... 15 ZALTRAP ...... 22 VITRAKVI ORAL SOLUTION...... 22 XHANCE...... 54 ZANOSAR ...... 22 VIVITROL...... 27 XIAFLEX...... 38 zarah ...... 51 VIZIMPRO ...... 22 XIFAXAN ORAL TABLET 550 MG ..14 ZARXIO ...... 46 volnea (28) ...... 51 XIGDUO XR ORAL TABLET, ZEJULA ...... 22 voriconazole intravenous...... 9 IR - ER, BIPHASIC 24HR ZELBORAF ...... 22 voriconazole oral suspension 2.5-1,000 MG, 5-1,000 MG, ZEMAIRA ...... 38 for reconstitution...... 9 5-500 MG ...... 42 zenatane...... 36 voriconazole oral tablet 50 mg ...... 9 XIGDUO XR ORAL TABLET, ZENPEP ORAL CAPSULE, voriconazole oral tablet 200 mg...... 9 IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG ...... 42 DELAYED RELEASE(DR/EC) VOSEVI ...... 11 10,000-32,000 -42,000 UNIT, XIIDRA ...... 52 VOTRIENT...... 22 15,000-47,000 -63,000 UNIT, XOFLUZA...... 11 VRAYLAR ORAL CAPSULE...... 31 20,000-63,000- 84,000 UNIT, XOLAIR SUBCUTANEOUS 25,000-79,000- 105,000 UNIT, VRAYLAR ORAL CAPSULE, RECON SOLN ...... 54 3,000-10,000 -14,000-UNIT, DOSE PACK ...... 31 XOLAIR SUBCUTANEOUS 40,000-126,000- 168,000 UNIT, vyfemla (28)...... 51 SYRINGE 75 MG/0.5 ML...... 54 5,000-17,000- 24,000 UNIT ...... 45 September 2021 82 Covered Drugs Index

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ZEPZELCA ...... 22 zidovudine oral capsule ...... 11 zidovudine oral syrup ...... 11 zidovudine oral tablet ...... 11 ZIEXTENZO ...... 46 ziprasidone hcl ...... 31 ziprasidone mesylate ...... 31 ZIRABEV ...... 22 ZIRGAN ...... 51 ZOLADEX ...... 22 zoledronic acid intravenous solution ...... 43 zoledronic acid-mannitol-water intravenous piggyback 4 mg/100 ml...... 43 zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml...... 38 ZOLEDRONIC AC- MANNITOL-0.9NACL ...... 43 ZOLINZA ...... 22 zolpidem oral tablet ...... 31 zonisamide...... 24 ZORTRESS ORAL TABLET 1 MG ..22 ZOSTAVAX (PF) ...... 46 ZOSYN IN DEXTROSE (ISO-OSM) ...... 14 zovia 1-35 (28) ...... 51 zovia 1/35e (28) ...... 51 ZTLIDO ...... 35 ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG, 1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG...... 27 ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG ...... 27 zumandimine (28) ...... 51 ZYDELIG ...... 22 ZYKADIA ORAL TABLET ...... 22 ZYLET...... 52 ZYNLONTA ...... 22 ZYPREXA RELPREVV ...... 31

September 2021 83 Notes

84 Notes

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