Oregon Essential Rx Drug List
The Essential Rx Drug List includes a list of drugs covered by Health Net. This drug list is for Oregon. The drug list is updated often and may change. To get the most up-to-date information, you may view the latest drug list on our website at www.healthnet.com/ordruglistpdf or call us at the toll-free telephone number on your Health Net ID card.
OR Essential Drug List Updated: July 1, 2021 Welcome to Health Net
What is the Essential Rx Drug List? The Essential Rx Drug List or formulary is a list of covered drugs used to treat common diseases or health problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide which drugs should be included. The committee reviews new drugs and new information about existing drugs and chooses drugs based on: • Safety; • Effectiveness; • Side effects; and • Value (If two drugs are equally effective, the less costly drug will be preferred)
How much will I pay for my drugs? To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan documents.
Abbreviation Copayment/Coinsurance Description 1 Tier 1 copayment or Generic drugs coinsurance 2 Tier 2 copayment or Preferred brand drugs coinsurance 3 Tier 3 copayment or Non-preferred brand drugs coinsurance SP Specialty copayment or Specialty drugs. This category includes self- coinsurance injectable and some oral high cost drugs. You may be required to get these drugs from a Specialty pharmacy. AC Anticancer drug copayment Oral anticancer drugs. You may be required to or coinsurance get these drugs from a Specialty pharmacy. GP Generic Preferred This includes most brand name drugs with a generic equivalent. Depending on your plan, these drugs are either not covered (non- formulary), covered at Tier 3 or covered at a copayment plus the difference in cost between the brand and generic drug. Refer to your Summary of Benefits or other plan documents.
How do I use the drug list? Look for your drug in the index at the end of this booklet. The index lists all of the drugs on the drug list. Both brand name drugs and generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug.
ii What if my drug is not on the drug list? If your drug is not on the drug list, call us at the telephone number on your Health Net ID card and ask if your drug is covered. If your drug is not covered, you can ask your doctor to prescribe a similar drug that is covered. Your doctor can ask us to make an exception if he or she feels you need the drug that is not covered. If we approve an exception request for a drug not on the drug list, the non-preferred brand tier (Tier 3) copayment will apply.
What are generic drugs? A generic drug contains the same active ingredient and works the same way as the brand name drug. Generic drugs are safe and effective, and generally cost less.
Generic drugs are available on the drug list at Tier 1. Brand name drugs with a generic equivalent are either non-formulary or non-preferred, depending on your plan benefits. If your doctor determines that you need a brand name drug instead of its generic equivalent, your doctor can submit a prior authorization request for a formulary exception with documentation of medical necessity.
Are there any limits on my drug coverage? Some drugs have limits on coverage. The table below provides a description of abbreviations that may appear in the Limits column on the drug list: Abbreviation Definition Description AL Age Limit These drugs may require prior authorization if your age does not fall within manufacturer, FDA or clinical recommendations. PA Prior Authorization These drugs require prior authorization for coverage, effectiveness or safety reasons. This means that your doctor must request approval from Health Net before the drug will be covered. PV Preventive Benefit If your plan has a preventive benefit, these drugs are covered at no cost. QL Quantity Limit These drugs have a limit on the amount that will be covered. Your doctor must request approval from Health Net for a higher quantity of the drug. RX/OTC Prescription & Certain drugs are available both in a prescription Over-the-Counter form and in an OTC form. Only prescription (OTC) drugs are covered by your plan with the exception of some insulins, insulin supplies and some covered preventive drugs. ST Step Therapy You must first try another specific drug(s) before these drugs will be covered.
How can I get an exception to the rules for drug coverage? Your doctor can ask for an exception to our rules for drug coverage. • Your doctor can ask us to cover your drug even if it is not on the drug list. • Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a quantity limit of 1 tablet per day, your doctor can ask us to cover more. To request an exception, your doctor can fax a prior authorization form along with a written statement supporting the request to us at 1-800-255-9198.
iii Are injectable drugs covered? Injectable drugs are not covered, except for those listed on the drug list. Some injectable drugs are considered “specialty drugs” and, in most cases, must be obtained from one of Health Net’s approved Specialty Pharmacies.
Are compounded prescriptions covered? Compounded prescriptions require prior authorization for coverage. If prior authorization is granted, your Tier 3 copayment or coinsurance applies.
Can I go to any pharmacy? To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a pharmacy near you, visit our website at www.healthnet.com or call us at the telephone number on your Health Net ID card.
If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill Health Net online, so you may have to pay the full cost of your drug. If you do pay out-of-pocket for your drug, you may be able to send us your pharmacy receipt and ask for reimbursement of our share of the cost. Please refer to your plan documents for more information.
Some injectable and high cost drugs (including anticancer drugs) may be considered “specialty drugs”. These drugs must be obtained from one of Health Net’s approved Specialty pharmacies.
Can I use a mail order pharmacy? You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs. Maintenance drugs are those needed for a long term condition.
To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day supply of each drug. Mail order forms are available on our website at www.healthnet.com or you may call us at the telephone number on your Health Net ID card to request a form.
How often can I refill my prescription? • For prescriptions written for 10-days or less, you may refill after 50 percent of the supply has been used as directed. • For prescriptions written for more than 10-days, you may refill after 74 percent of the supply has been used as directed.
If your physician has increased your dose, your pharmacy must be notified of the change. If this change will result in an early refill request, your pharmacy can contact Health Net for an override.
How can I save money on my prescription drugs? You can save time and money with these simple steps: • Ask your doctor about generic drugs that may work for you. • Fill prescriptions at Health Net participating pharmacies. • Be sure your doctor prescribes drugs on the drug list • Fill your maintenance drugs through our mail order pharmacy program.
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Nondiscrimination Notice Health Net Health Plan of Oregon, Inc. (Health Net) complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently
because of race, color, national origin, age, disability, or sex. Health Net: • Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). • Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net’s Customer Contact Center at 1-888-802-7001 (TTY: 711). If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Nondiscrimination Notice FLY029224ER00 (1/20)
OR WA Commercial Notice of Language Assistance
Health Net Health Plan of Oregon, Inc. is a subsidiary of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved. OR WA Commercial Notice of Language Assistance FLY029225ER00 (1/20) Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ADHD/ANTI-NARCOLEPSY/ANTI- DEXEDRINE CP24 OBESITY/ANOREXIANTS - Drugs to Treat (dextroamphetamine GP ADHD, Sleep and Eating Disorders sulfate) Amphetamines dextroamphetamine 1 (Dextroamphetamine sulfate cp24 Sulfate) PROCENTRA 1 dextroamphetamine 1 SOLN sulfate soln (Dextroamphetamine Sulfate) ZENZEDI TABS 10 1 dextroamphetamine 1 MG, 2.5 MG, 5 MG, 7.5 MG sulfate tabs ADDERALL TABS PA methamphetamine hcl 1 (amphetamine- GP tabs dextroamphetamine) VYVANSE CAPS QL(1 ea daily) ADDERALL XR CP24 QL(1 ea daily) (lisdexamfetamine 2 (amphetamine- GP dimesylate) dextroamphetamine) VYVANSE CHEW QL(1 ea daily) amphetamine- QL(1 ea daily) (lisdexamfetamine 2 dextroamphetamine dimesylate) cp24 1.25 mg-1.25 mg- Analeptics 1.25 mg-1.25 mg, 2.5 mg-2.5 mg-2.5 mg-2.5 caffeine citrate soln 1 mg, 3.75 mg-3.75 mg- 1 Attention-Deficit/Hyperactivity Disorder (ADHD) 3.75 mg-3.75 mg, 5 atomoxetine hcl caps QL(2 ea daily) mg-5 mg-5 mg-5 mg, 10 mg, 18 mg, 25 mg, 1 6.25 mg-6.25 mg-6.25 40 mg mg-6.25 mg, 7.5 mg- QL(1 ea daily) 7.5 mg-7.5 mg-7.5 mg atomoxetine hcl caps 1 100 mg, 60 mg, 80 mg amphetamine- QL(4 ea daily) dextroamphetamine clonidine hcl (adhd) 1 tabs 1.25 mg-1.25 mg- tb12 QL(1 ea daily) 1.25 mg-1.25 mg, guanfacine hcl (adhd) 1 1.875 mg-1.875 mg- tb24 1.875 mg-1.875 mg, INTUNIV TB24 QL(1 ea daily) GP ) 2.5 mg-2.5 mg-2.5 mg- 1 (guanfacine hcl (adhd) 2.5 mg, 3.125 mg- KAPVAY TB12 ( QL(4 ea daily) clonidine GP 3.125 mg-3.125 mg- hcl (adhd)) 3.125 mg, 3.75 mg- STRATTERA CAPS 100 QL(1 ea daily) 3.75 mg-3.75 mg-3.75 MG, 60 MG, 80 MG GP mg, 5 mg-5 mg-5 mg-5 (atomoxetine hcl) mg, 7.5 mg-7.5 mg-7.5 STRATTERA CAPS 18 MG QL(2 ea daily) GP mg-7.5 mg (atomoxetine hcl) DESOXYN TABS PA GP Stimulants - Misc. (methamphetamine hcl)
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
1 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits armodafinil tabs 1 PA methylphenidate hcl tabs 10 mg, 20 mg, 5 1 CONCERTA TBCR 27 MG QL(1 ea daily) GP mg (methylphenidate hcl) methylphenidate hcl QL(1 ea daily) DAYTRANA PTCH QL(1 ea daily) 3 tb24 18 mg, 27 mg, 54 1 (methylphenidate) mg dexmethylphenidate hcl QL(1 ea daily) QL(2 ea daily) methylphenidate hcl 1 cp24 10 mg, 15 mg, 20 1 tb24 36 mg mg, 30 mg, 40 mg, 5 mg methylphenidate hcl QL(1 ea daily) tbcr 18 mg, 20 mg, 27 1 dexmethylphenidate hcl 1 mg, 54 mg cp24 25 mg, 35 mg QL(2 ea daily) methylphenidate hcl 1 dexmethylphenidate hcl QL(2 ea daily) tbcr 36 mg tabs 10 mg, 2.5 mg, 5 1 METHYLPHENIDATE QL(1 ea daily) mg HYDROCHLORIDE ER FOCALIN TABS QL(2 ea daily) TBCR (methylphenidate 3 (dexmethylphenidate GP hcl) hcl) 1 ST; QL(1 ea FOCALIN XR CP24 10 QL(1 ea daily) modafinil tabs daily) MG, 20 MG, 30 MG, 40 NUVIGIL TABS PA MG, 5 MG GP GP (armodafinil) (dexmethylphenidate PROVIGIL TABS ST; QL(1 ea hcl) GP (modafinil) daily) FOCALIN XR CP24 35 MG (dexmethylphenidate GP QUILLIVANT XR SRER PA; QL(12 ml 3 daily) hcl) (methylphenidate hcl) METHYLIN SOLN RELEXXII TBCR QL(1 ea daily) GP 3 (methylphenidate hcl) (methylphenidate hcl) RITALIN LA CP24 QL(1 ea daily) methylphenidate hcl GP (methylphenidate hcl) chew 10 mg, 2.5 mg, 5 1 RITALIN TABS mg GP (methylphenidate hcl) methylphenidate hcl QL(1 ea daily) cp24 10 mg, 20 mg, 30 1 ALLERGENIC EXTRACTS/BIOLOGICALS MISC mg, 40 mg Allergenic Extracts methylphenidate hcl GRASTEK SUBL (timothy PA cpcr 10 mg, 40 mg, 50 1 grass pollen allergen 3 mg, 60 mg extract) methylphenidate hcl QL(2 ea daily) 1 ODACTRA SUBL (dust PA cpcr 20 mg, 30 mg mite mixed allergen 3 methylphenidate hcl extract) soln 10 mg/5ml, 5 1 mg/5ml
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 2 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ORALAIR ADULT SAMPLE PA PA tobramycin nebu 300 SP KIT SUBL (grass mixed mg/4ml pollens allergen 3 tobramycin nebu 300 SP extract) mg/5ml ORALAIR ADULT PA PA STARTER PACK SUBL tobramycin sulfate soln SP (grass mixed pollens 3 ANALGESICS - ANTI-INFLAMMATORY - Drugs allergen extract) to Treat Pain, Swelling, Muscle and Joint ORALAIR SUBL (grass PA Conditions mixed pollens allergen 3 Anti-TNF-alpha - Monoclonal Antibodies extract) HUMIRA PEDIATRIC PA RAGWITEK SUBL (short PA CROHNS DISEASE 3 ragweed pollen 3 STARTER PACK PSKT allergen extract) (adalimumab) HUMIRA PEN PNKT PA Biologicals Misc 3 ( ) ADAGEN SOLN PA adalimumab SP (pegademase bovine) HUMIRA PEN-CD/UC/HS PA STARTER PNKT 3 AMINOGLYCOSIDES - Drugs to Treat Bacterial (adalimumab) Infections HUMIRA PEN-PEDIATRIC PA Aminoglycosides UC STARTER PACK 3 amikacin sulfate soln SP PA PNKT (adalimumab) HUMIRA PEN-PS/UV PA ARIKAYCE SUSP PA STARTER PNKT 3 (amikacin sulfate SP (adalimumab) liposome) HUMIRA PSKT PA BETHKIS NEBU PA 3 SP (adalimumab) (tobramycin) SIMPONI ARIA SOLN PA SP PA ( ) gentamicin in saline SP golimumab soln SIMPONI SOAJ PA SP gentamicin sulfate soln SP PA (golimumab) SIMPONI SOSY PA KITABIS PAK NEBU SP SP (golimumab) (tobramycin) Antirheumatic - Enzyme Inhibitors neomycin sulfate tabs 1 RINVOQ TB24 PA SP paromomycin sulfate (upadacitinib) 1 XELJANZ TABS 10 MG, 5 PA caps SP streptomycin sulfate PA MG (tofacitinib citrate) SP XELJANZ XR TB24 PA solr SP (tofacitinib citrate) TOBI NEBU (tobramycin) SP Antirheumatic Antimetabolites TOBI PODHALER CAPS PA SP (tobramycin) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
3 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METHOTREXATE TABS ARTHROTEC 50 TBEC (methotrexate sodium 2 (diclofenac w/ GP (antirheumatic)) misoprostol) OTREXUP SOAJ PA ARTHROTEC 75 TBEC (methotrexate SP (diclofenac w/ GP (antirheumatic)) misoprostol) RASUVO SOAJ PA CELEBREX CAPS 100 ST; QL(2 ea GP (methotrexate SP MG, 50 MG (celecoxib) daily) (antirheumatic)) ST; QL(2 ea CELEBREX CAPS 400 MG Gold Compounds GP daily); AL(At (celecoxib) least 60 yrs RIDAURA CAPS 2 old) (auranofin) ST; QL(2 ea celecoxib caps 100 mg, 1 Interleukin-1 Blockers 200 mg, 50 mg daily) ARCALYST SOLR PA SP ST; QL(2 ea (rilonacept) celecoxib caps 400 mg 1 daily); AL(At Interleukin-1 Receptor Antagonist (IL-1Ra) least 60 yrs old) KINERET SOSY PA SP DAYPRO TABS (anakinra) GP (oxaprozin) Interleukin-6 Receptor Inhibitors DICLOFENAC CAPS ST; QL(3 ea ACTEMRA SOLN PA 3 daily) SP (diclofenac) (tocilizumab) diclofenac potassium ACTEMRA SOSY PA 1 SP tabs (tocilizumab) KEVZARA SOAJ 150 PA; SP diclofenac sodium tb24 1 MG/1.14ML, 200 SP 1 MG/1.14ML (sarilumab) diclofenac sodium tbec KEVZARA SOSY 150 PA diclofenac w/ 1 MG/1.14ML, 200 SP misoprostol tbec MG/1.14ML (sarilumab) DUEXIS TABS PA 3 Nonsteroidal Anti-inflammatory Agents (NSAIDs) (ibuprofen-famotidine) (Diclofenac Potassium) EC-NAPROSYN TBEC 1 GP CATAFLAM TABS (naproxen) (Ibuprofen) IBU TABS 1 etodolac caps 200 mg, 1 300 mg (Nabumetone) RELAFEN 1 QL(4 ea daily) TABS 500 MG etodolac tabs 400 mg, 1 500 mg (Nabumetone) RELAFEN 1 QL(3 ea daily) TABS 750 MG QL(2 ea daily) etodolac tb24 400 mg, 1 (Naproxen) EC- 1 500 mg, 600 mg NAPROXEN TBEC FELDENE CAPS GP (piroxicam)
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 4 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FENOPROFEN CALCIUM MOBIC TABS 15 MG QL(1 ea daily) GP CAPS 200 MG 3 (meloxicam) (fenoprofen calcium) MOBIC TABS 7.5 MG QL(2 ea daily) GP fenoprofen calcium 1 (meloxicam) caps 200 mg, 400 mg QL(4 ea daily) nabumetone tabs 500 1 fenoprofen calcium 1 mg tabs 600 mg nabumetone tabs 750 QL(3 ea daily) FENORTHO CAPS 1 3 mg (fenoprofen calcium) NALFON CAPS 400 MG 3 flurbiprofen tabs 1 (fenoprofen calcium) NALFON TABS 600 MG GP ibuprofen tabs 1 (fenoprofen calcium) INDOCIN SUPP RE 50 MG NAPRELAN TB24 3 GP (indomethacin) (naproxen sodium) INDOCIN SUSP OR 25 NAPROSYN SUSP 2 GP MG/5ML (indomethacin) (naproxen) ST; QL(3 ea NAPROSYN TABS indomethacin caps 20 1 GP mg daily) (naproxen) naproxen sodium tabs 1 indomethacin caps 25 1 mg, 50 mg naproxen sodium tb24 1 indomethacin cpcr 75 1 mg naproxen susp 1 ketoprofen caps 1 naproxen tabs 1 ketoprofen cp24 1 naproxen tbec 1 KETOROLAC QL(1 ea daily,5 TROMETHAMINE SOLN day(s) limit) naproxen- PA NA 15.75 MG/SPRAY 3 esomeprazole 1 (ketorolac magnesium tbec tromethamine) oxaprozin tabs 1 ketorolac tromethamine Limit 20 per 1 month;QL(0.67 piroxicam caps 1 tabs or 10 mg ea daily) SPRIX SOLN (ketorolac QL(1 ea daily,5 LODINE TABS (etodolac) GP 3 tromethamine) day(s) limit) meclofenamate sodium 1 sulindac tabs 1 caps TIVORBEX CAPS ST; QL(3 ea 1 3 mefenamic acid caps (indomethacin) daily) QL(1 ea daily) meloxicam tabs 15 mg 1 tolmetin sodium caps 1 QL(2 ea daily) meloxicam tabs 7.5 mg 1 tolmetin sodium tabs 1
You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
5 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIMOVO TBEC PA Analgesic Combinations (naproxen- (Acetaminophen- esomeprazole GP Salicylamide- 1 magnesium) Phenyltoloxamine) ZIPSOR CAPS ST DURAXIN CAPS 3 (diclofenac potassium) (Butalbital-Acetaminophen) 1 BUPAP, TENCON TABS ZORVOLEX CAPS 18 MG, ST; QL(3 ea 3 35 MG (diclofenac) daily) (Butalbital-Acetaminophen- 1 Caffeine) BAC TABS Phosphodiesterase 4 (PDE4) Inhibitors (Butalbital-Acetaminophen- OTEZLA TABS PA Caffeine) ESGIC, 3 1 (apremilast) PHRENILIN FORTE, OTEZLA TBPK PA ZEBUTAL CAPS 3 (apremilast) (Butalbital-Acetaminophen- Caffeine) VANATOL LQ, 1 Pyrimidine Synthesis Inhibitors VANATOL S, VTOL LQ ARAVA TABS 10 MG QL(2 ea daily) SOLN GP (leflunomide) butalbital- ARAVA TABS 20 MG QL(1 ea daily) acetaminophen tabs GP 1 (leflunomide) 300 mg-50 mg, 325 mg-50 mg leflunomide tabs 10 mg 1 QL(2 ea daily) butalbital- leflunomide tabs 20 mg 1 QL(1 ea daily) acetaminophen- 1 caffeine caps Selective Costimulation Modulators butalbital- ORENCIA CLICKJECT PA SP acetaminophen- 1 SOAJ (abatacept) caffeine tabs ORENCIA SOLR PA SP butalbital-aspirin- (abatacept) 1 caffeine caps ORENCIA SOSY PA SP BUTALBITAL/ASPIRIN/CA (abatacept) FFEINE TABS Soluble Tumor Necrosis Factor Receptor Agents (butalbital-aspirin- 2 ENBREL MINI SOCT PA caffeine) 3 (etanercept) ESGIC TABS (butalbital- ENBREL SOLN PA GP 3 acetaminophen- (etanercept) caffeine) ENBREL SOLR PA 3 FIORICET CAPS (etanercept) (butalbital- GP ENBREL SOSY PA acetaminophen- 3 (etanercept) caffeine) ENBREL SURECLICK PA FIORINAL CAPS 3 SOAJ (etanercept) (butalbital-aspirin- GP ANALGESICS - NonNarcotic - Drugs to Treat caffeine) Pain, Muscle and Joint Conditions Salicylates You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 6 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ADULT ASPIRIN PV STRENGTH, SM ASPIRIN REGIMEN, ASPIR-LOW, ENTERIC COATED, ST ASPIRIN 81, ASPIRIN JOSEPH ASPIRIN, TGT ADULT LOW DOSE, ASPIRIN, TGT ASPIRIN ASPIRIN ADULT LOW LOW DOSE, TGT STRENGTH, ASPIRIN EC ENTERIC-COATED LOW DOSE, ASPIRIN ASPIRIN TBEC ENTERIC COATED (Aspirin) ASPIRIN 81 LOW PV ADULT LOW STRENGTH, DOSE, ASPIRIN ADULT ASPIRIN LOW DOSE, LOW STRENGTH, BAYER ASPIRIN, BAYER ASPIRIN CHILDRENS, ASPIRIN EC LOW DOSE, ASPIRIN LOW DOSE, BAYER ASPIRIN ASPIRIN LOW REGIMEN, BAYER LOW STRENGTH, BAYER DOSE, CVS ASPIRIN, CHEWABLE LOW DOSE, CVS ASPIRIN ADULT CHILDRENS ASPIRIN, LOW STRENGTH, CVS CHILDRENS ASPIRIN ASPIRIN EC, CVS LOW STRENGTH, CVS ASPIRIN LOW DOSE, CVS ASPIRIN ADULT LOW ASPIRIN LOW DOSE, EQ ASPIRIN LOW STRENGTH, ECOTRIN DOSE, EQL ASPIRIN LOW LOW STRENGTH, DOSE, GNP ADULT ECPIRIN, EQ ASPIRIN ASPIRIN LOW ADULT LOW DOSE, EQ STRENGTH, ASPIRIN EC, EQL GOODSENSE ASPIRIN, ASPIRIN EC, EQL PV GOODSENSE ASPIRIN PV ASPIRIN LOW DOSE, ADULT LOW STRENGTH, GNP ASPIRIN, GNP HM ASPIRIN, PX ASPIRIN, ASPIRIN LOW DOSE, QC ASPIRIN LOW DOSE, GOODSENSE ASPIRIN, QC CHEWABLE ASPIRIN GOODSENSE ASPIRIN LOW DOSE, QC LOW DOSE, H-E-B CHILDRENS ASPIRIN, RA ASPIRIN, HM ASPIRIN, ASPIRIN ADULT LOW HM ASPIRIN EC, HM DOSE, RA ASPIRIN ASPIRIN EC LOW DOSE, ADULT LOW STRENGTH, KLS ASPIRIN EC, KLS RA ASPIRIN CHILDRENS, ASPIRIN LOW DOSE, KP SB CHILDRENS ASPIRIN, ASPIRIN, MEIJER SM ASPIRIN ADULT LOW ASPIRIN EC, MINIPRIN STRENGTH, SM ASPIRIN LOW DOSE, PX ENTERIC LOW DOSE, SM ASPIRIN, QC ASPIRIN, CHILDRENS ASPIRIN, ST QC ASPIRIN LOW DOSE, JOSEPH LOW DOSE QC ENTERIC ASPIRIN, ASPIRIN, TGT ASPIRIN, RA ASPIRIN EC, RA TGT CHILDRENS ASPIRIN EC ADULT LOW ASPIRIN CHEW STRENGTH, SB ASPIRIN, SB ASPIRIN ADULT LOW STRENGTH, SB ASPIRIN EC, SB LOW DOSE ASA EC, SM ASPIRIN ADULT LOW STRENGTH, SM ASPIRIN EC LOW You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
7 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Aspirin) ASPIRIN ADULT, PV (Methadone Hcl) 1 BAYER ADVANCED METHADOSE TBSO ASPIRIN REGULAR (Morphine Sulfate) SP PA STRENGTH, BAYER DURAMORPH SOLN ASPIRIN, CVS ASPIRIN, ABSTRAL SUBL PA EQ ASPIRIN, EQL 3 ASPIRIN, GNP ASPIRIN, (fentanyl citrate) GOODSENSE ASPIRIN, ACTIQ LPOP ( PA fentanyl GP HM ADULT ASPIRIN, HM PV citrate) ASPIRIN, MEDIQUE ASPIRIN, NORWICH codeine sulfate tabs 1 ASPIRIN, PX ASPIRIN, QC CONZIP CP24 ( ASPIRIN, RA ASPIRIN, RA tramadol 3 PAIN RELIEF ASPIRIN, SB hcl) ASPIRIN, SM ADULT DILAUDID LIQD OR 1 ASPIRIN, SM ASPIRIN, MG/ML (hydromorphone GP TGT ASPIRIN TABS hcl) ASCRIPTIN TABS PV DILAUDID TABS OR 2 (aspirin buffered (al PV MG, 4 MG, 8 MG GP hydrox-mg hydrox-ca (hydromorphone hcl) carb)) DOLOPHINE TABS QL(12 ea daily) GP aspirin chew PV PV (methadone hcl) PV DURAGESIC PT72 Limit 15 per aspirin tabs PV GP month;QL(0.5 (fentanyl) ea daily) PV PV aspirin tbec EMBEDA CPCR PA 3 diflunisal tabs 1 (morphine-naltrexone) fentanyl citrate lpop bu PA ECOTRIN REGULAR PV 1200 mcg, 1600 mcg, STRENGTH TBEC GP 1 (aspirin) 200 mcg, 400 mcg, 600 mcg, 800 mcg PV ECOTRIN TBEC (aspirin) GP fentanyl citrate tabs bu PA; QL(3 ea 100 mcg, 200 mcg, 400 daily) salsalate tabs 1 1 mcg, 600 mcg, 800 ST JOSEPH ADULT PV mcg ANALGESICLOW DOSE GP fentanyl pt72 100 Limit 15 per BITE SIZE CHEW month;QL(0.5 (aspirin) mcg/hr, 12 mcg/hr, 25 1 mcg/hr, 50 mcg/hr, 75 ea daily) ST JOSEPH ADULT PV GP mcg/hr CHEW (aspirin) FENTORA TABS PA; QL(3 ea 3 ANALGESICS - OPIOID - Drugs to Treat Pain, (fentanyl citrate) daily) Muscle and Joint Conditions hydromorphone hcl liqd 1 Opioid Agonists 1 mg/ml (Methadone Hcl) METHADONE HCL 1 hydromorphone hcl 1 INTENSOL CONC tabs 2 mg, 4 mg, 8 mg You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 8 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydromorphone hcl QL(4 ea daily) morphine sulfate soln 1 tb24 12 mg, 16 mg, 8 or 10 mg/5ml, 100 1 mg mg/5ml, 20 mg/5ml, 20 KADIAN CP24 10 MG, 40 QL(1 ea daily) mg/ml MG, 50 MG (morphine GP morphine sulfate supp sulfate) re 10 mg, 20 mg, 30 1 KADIAN CP24 100 MG, 20 QL(2 ea daily) mg, 5 mg MG, 30 MG, 60 MG, 80 MG GP morphine sulfate tabs 1 (morphine sulfate) or 15 mg, 30 mg KADIAN CP24 200 MG QL(1 ea daily) 3 morphine sulfate tbcr or QL(3 ea daily) (morphine sulfate) 100 mg, 15 mg, 200 1 LAZANDA SOLN 100 PA mg, 30 mg, 60 mg MCG/ACT, 400 MCG/ACT 3 MS CONTIN TBCR QL(3 ea daily) (fentanyl citrate) GP (morphine sulfate) meperidine hcl soln 1 NUCYNTA ER TB12 QL(2 ea daily) 2 (tapentadol hcl) meperidine hcl tabs 1 NUCYNTA TABS 2 methadone hcl conc or 1 (tapentadol hcl) 10 mg/ml OPANA TABS GP PA (oxymorphone hcl) methadone hcl soln ij SP 10 mg/ml OXAYDO TABS 5 MG 2 METHADONE HCL SOLN PA (oxycodone hcl) IJ 10 MG/ML (methadone SP OXAYDO TABS 7.5 MG QL(4 ea daily) 3 hcl) (oxycodone hcl) methadone hcl soln or 1 oxycodone hcl caps 5 1 10 mg/5ml, 5 mg/5ml mg methadone hcl tabs or QL(12 ea daily) 1 oxycodone hcl conc 1 10 mg, 5 mg 100 mg/5ml methadone hcl tbso or 1 oxycodone hcl tabs 10 40 mg mg, 15 mg, 20 mg, 30 1 QL(1 ea daily) mg, 5 mg morphine sulfate beads 1 cp24 oxymorphone hcl tabs 1 morphine sulfate cp24 QL(1 ea daily) 10 mg, 5 mg or 10 mg, 40 mg, 50 1 oxymorphone hcl tb12 QL(2 ea daily) mg 10 mg, 15 mg, 20 mg, 1 morphine sulfate cp24 QL(2 ea daily) 30 mg, 40 mg, 5 mg, or 100 mg, 20 mg, 30 1 7.5 mg mg, 60 mg, 80 mg QDOLO SOLN ( tramadol 3 PA hcl) morphine sulfate soln ij SP 0.5 mg/ml, 1 mg/ml ROXICODONE TABS GP (oxycodone hcl)
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9 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ROXYBOND TABA 5 MG QL(4 ea daily) FIORINAL/CODEINE #3 3 (oxycodone hcl) CAPS (butalbital-aspirin- GP caffeine w/cod) SUBSYS LIQD (fentanyl) 3 PA hydrocodone- 1 tramadol hcl cp24 100 acetaminophen soln mg, 150 mg, 200 mg, 1 hydrocodone- 1 300 mg acetaminophen tabs tramadol hcl tabs 100 1 hydrocodone-ibuprofen 1 mg tabs QL(8 ea daily) tramadol hcl tabs 50 1 LORTAB ELIX mg (hydrocodone- 3 tramadol hcl tb24 100 1 acetaminophen) mg, 200 mg, 300 mg NALOCET TABS ULTRAM TABS ( QL(8 ea daily) ( 3 tramadol GP oxycodone w/ hcl) acetaminophen) Opioid Combinations NORCO TABS (Butalbital-Aspirin-Caffeine (hydrocodone- GP W/Cod) 1 acetaminophen) ASCOMP/CODEINE CAPS oxycodone w/ 1 (Hydrocodone- acetaminophen tabs Acetaminophen) LORCET, 1 LORCET HD, LORCET oxycodone-aspirin tabs 1 PLUS TABS QL(4 ea daily) oxycodone-ibuprofen 1 (Hydrocodone-Ibuprofen) 1 IBUDONE TABS tabs (Oxycodone W/ OXYCODONE/ACETAMIN OPHEN TABS Acetaminophen) 1 3 ENDOCET TABS (oxycodone w/ acetaminophen) acetaminophen w/ 1 codeine soln PERCOCET TABS (oxycodone w/ GP acetaminophen w/ 1 codeine tabs acetaminophen) PRIMLEV TABS butalbital- (oxycodone w/ 3 acetaminophen- 1 acetaminophen) caffeine w/ codeine PROLATE TABS 10 MG- caps 300 MG, 300 MG-5 MG, 300 MG-7.5 MG butalbital-aspirin- 1 3 caffeine w/cod caps (oxycodone w/ FIORICET/CODEINE acetaminophen) CAPS (butalbital- GP tramadol- 1 acetaminophen- acetaminophen tabs caffeine w/ codeine)
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Updated 07/01/2021 10 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TYLENOL/CODEINE #3 Limit 7.5mls TABS (acetaminophen GP butorphanol tartrate 1 per w/ codeine) soln month;QL(0.25 ml daily) TYLENOL/CODEINE #4 BUTRANS PTWK Limit 4 per TABS (acetaminophen GP GP month;QL(0.15 w/ codeine) (buprenorphine) ea daily) ULTRACET TABS pentazocine w/ 1 (tramadol- GP naloxone tabs ) acetaminophen SUBOXONE FILM 0.5 MG- QL(4 ea daily) Opioid Partial Agonists 2 MG (buprenorphine GP BELBUCA FILM QL(2 ea daily) hcl-naloxone hcl 3 (buprenorphine hcl) dihydrate) BUNAVAIL FILM PA required for SUBOXONE FILM 1 MG-4 QL(3 ea daily) ( 3 more than 30 MG, 12 MG-3 MG, 2 MG-8 buprenorphine hcl- day supply per GP naloxone hcl dihydrate) MG (buprenorphine hcl- year; naloxone hcl dihydrate) BUPRENEX SOLN PA SP PA required for (buprenorphine hcl) ZUBSOLV SUBL (buprenorphine hcl- 3 more than 30 PA day supply per buprenorphine hcl soln SP naloxone hcl dihydrate) ij 0.3 mg/ml year; QL(4 ea daily) ANDROGENS-ANABOLIC - Drugs to Regulate buprenorphine hcl subl 1 sl 2 mg Hormones buprenorphine hcl subl QL(3 ea daily) Anabolic Steroids 1 ANADROL-50 TABS sl 8 mg 3 buprenorphine hcl- QL(4 ea daily) (oxymetholone) naloxone hcl dihydrate 1 oxandrolone tabs 1 film 0.5 mg-2 mg buprenorphine hcl- QL(3 ea daily) Androgens ANDRODERM PT24 ST; QL(1 ea naloxone hcl dihydrate 1 3 daily) film 1 mg-4 mg, 12 mg- (testosterone) 3 mg, 2 mg-8 mg ANDROGEL GEL 20.25 QL(10 gm MG/1.25GM, 40.5 GP daily) buprenorphine hcl- QL(4 ea daily) MG/2.5GM (testosterone) 1 naloxone hcl dihydrate ANDROGEL GEL 25 QL(10 gm subl 0.5 mg-2 mg MG/2.5GM, 50 MG/5GM 2 daily) buprenorphine hcl- QL(3 ea daily) (testosterone) naloxone hcl dihydrate 1 ANDROGEL PUMP GEL QL(10 gm GP subl 2 mg-8 mg (testosterone) daily) buprenorphine ptwk td Limit 4 per month;QL(0.15 danazol caps 1 10 mcg/hr, 15 mcg/hr, 1 20 mcg/hr, 5 mcg/hr, ea daily) 7.5 mcg/hr
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11 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPO-TESTOSTERONE CORTIFOAM FOAM SOLN 100 MG/ML ( SP hydrocortisone acetate 2 (testosterone (intrarectal)) cypionate) hydrocortisone 1 DEPO-TESTOSTERONE (intrarectal) enem SOLN 200 MG/ML UCERIS FOAM RE 2 PA (testosterone GP MG/ACT (budesonide 3 cypionate) (intrarectal)) FORTESTA GEL QL(4 gm daily) GP (testosterone) Rectal Combinations METHITEST TABS ANALPRAM-HC CREA 1 2 (methyltestosterone) %-1 % (hydrocortisone GP acetate w/ pramoxine) methyltestosterone 1 caps ANALPRAM-HC LOTN 1 %-2.5 % (hydrocortisone 3 STRIANT MISC QL(2 ea daily) 3 acetate w/ pramoxine) (testosterone) TESTIM GEL PA; QL(10 gm hydrocortisone acetate 1 3 w/ pramoxine crea (testosterone) daily) lidocaine- testosterone cypionate SP soln im 100 mg/ml hydrocortisone acetate 1 (rectal) kit testosterone cypionate 1 PROCORT CREA soln im 200 mg/ml (hydrocortisone acetate 3 testosterone enanthate SP w/ pramoxine) soln im PROCTOFOAM HC FOAM testosterone gel td 1 %, QL(10 gm (hydrocortisone acetate 2 1.62 %, 20.25 daily) w/ pramoxine) 1 mg/1.25gm, 25 Rectal Steroids mg/2.5gm, 40.5 mg/2.5gm, 50 mg/5gm (Hydrocortisone (Rectal)) PROCTO-MED HC, 1 QL(4 gm daily) PROCTOSOL HC, testosterone gel td 10 1 mg/act PROCTOZONE-HC CREA testosterone soln td 30 QL(6 ml daily) (Hydrocortisone Acetate 1 (Rectal)) ANUCORT-HC, 1 mg/act HEMMOREX-HC SUPP ANORECTAL AND RELATED PRODUCTS - (Hydrocortisone Acetate Rectal Drugs to Treat Pain, Swelling and Itching (Rectal)) ANUSOL-HC 1 Intrarectal Steroids SUPP RE 25 MG (Hydrocortisone ANUSOL-HC CREA EX 2.5 (Intrarectal)) COLOCORT 1 % (hydrocortisone GP ENEM (rectal)) CORTENEMA ENEM hydrocortisone (rectal) 1 (hydrocortisone GP crea (intrarectal))
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Updated 07/01/2021 12 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits hydrocortisone acetate 1 metronidazole caps 1 (rectal) supp PA PROCTOCORT SUPP metronidazole in nacl SP (hydrocortisone acetate GP soln (rectal)) metronidazole tabs 1 Vasodilating Agents NEBUPENT SOLR RECTIV OINT (pentamidine GP (nitroglycerin (intra- 3 isethionate) anal)) pentamidine isethionate 1 ANTHELMINTICS - Drugs to Treat Worm solr Infections PRIMSOL SOLN 3 Anthelmintics (trimethoprim hcl) albendazole tabs 1 tinidazole tabs 1 ALBENZA TABS GP trimethoprim tabs 1 (albendazole) AL(At least 2 XIFAXAN TABS 200 MG PA; QL(9 ea BENZNIDAZOLE TABS 3 per fill retail,9 3 yrs old - Up to (rifaximin) (benznidazole) 12 yrs old) ea per fill mail) BILTRICIDE TABS XIFAXAN TABS 550 MG PA; QL(2 ea GP 3 (praziquantel) (rifaximin) daily) EMVERM CHEW QL(6 ea per fill Anti-infective Misc. - Combinations 3 retail,6 ea per (mebendazole) (Methenamine-Hyosc- fill mail) Methylene Blue-Sod Phos- 1 Phenyl Sal) ivermectin tabs PHOSPHASAL, URELLE, 1 URETRON D/S, URIN D/S, praziquantel tabs 1 URO-458, UTIRA-C, STROMECTOL TABS VILEVEV MB TABS GP (ivermectin) (Methenamine-Hyosc- Methylene Blue-Sod Phos- ANTI-INFECTIVE AGENTS - MISC. - Drugs to Phenyl Sal) URIBEL, URO- 1 Treat Bacterial Infections MP, USTELL, VILAMIT MB Anti-infective Agents - Misc. CAPS PA (Sulfamethoxazole- (Bacitracin) BACIIM SOLR SP Trimethoprim) SULFATRIM 1 PEDIATRIC SUSP SP PA bacitracin solr BACTRIM DS TABS FLAGYL CAPS ( GP GP sulfamethoxazole- (metronidazole) trimethoprim) FLAGYL TABS BACTRIM TABS GP (metronidazole) (sulfamethoxazole- GP IMPAVIDO CAPS trimethoprim) SP (miltefosine)
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13 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VANCOCIN CAPS PA sulfamethoxazole- 1 GP trimethoprim susp (vancomycin hcl) VANCOCIN HCL CAPS PA sulfamethoxazole- 1 GP trimethoprim tabs (vancomycin hcl) PA Antiprotozoal Agents vancomycin hcl caps or 1 ALINIA SUSR 100 125 mg, 250 mg 3 MG/5ML (nitazoxanide) Leprostatics ALINIA TABS 500 MG GP dapsone tabs 1 (nitazoxanide) Lincosamides atovaquone susp 1 CLEOCIN CAPS OR 150 MEPRON SUSP MG, 300 MG, 75 MG GP GP (atovaquone) (clindamycin hcl) 1 CLEOCIN PEDIATRIC nitazoxanide tabs GRANULES SOLR GP Carbapenems (clindamycin palmitate hydrochloride) SP PA doripenem solr CLEOCIN PHOSPHATE PA SOLN IJ 900 MG/6ML ertapenem sodium solr SP PA (clindamycin SP imipenem-cilastatin solr SP PA phosphate) CLEOCIN PHOSPHATE PA INVANZ SOLR PA SP SOLN IV 600 MG/4ML (ertapenem sodium) (clindamycin SP meropenem solr SP PA phosphate) MERREM SOLR PA clindamycin hcl caps 1 SP (meropenem) clindamycin palmitate PRIMAXIN IV SOLR PA 1 SP hydrochloride solr (imipenem-cilastatin) PA clindamycin phosphate SP Chloramphenicols in d5w soln chloramphenicol PA PA SP clindamycin phosphate SP sodium succinate solr soln Cyclic Lipopeptides LINCOCIN SOLN PA SP CUBICIN RF SOLR PA (lincomycin hcl) SP (daptomycin) lincomycin hcl soln SP PA CUBICIN SOLR PA SP (daptomycin) Oxazolidinones PA daptomycin solr SP linezolid susr 100 1 mg/5ml Glycopeptides FIRVANQ SOLR PA 3 (vancomycin hcl) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 14 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(20 ea per ANTIANGINAL AGENTS - Drugs to Treat Chest 1 90 days Pain linezolid tabs 600 mg retail,20 ea per 90 days mail) Antianginals-Other SIVEXTRO TABS QL(6 ea per 90 RANEXA TB12 1000 MG 2 GP (tedizolid phosphate) days retail) (ranolazine) ZYVOX SUSR 100 RANEXA TB12 500 MG QL(4 ea daily) GP GP MG/5ML (linezolid) (ranolazine) QL(20 ea per ranolazine tb12 1000 ZYVOX TABS 600 MG 1 GP 90 days mg (linezolid) retail,20 ea per QL(4 ea daily) 90 days mail) ranolazine tb12 500 mg 1 Polymyxins Nitrates PA polymyxin b sulfate solr SP (Nitroglycerin) MINITRAN 1 QL(1 ea daily) PT24 Urinary Anti-infectives (Nitroglycerin) NITRO- 1 fosfomycin TIME CPCR 1 DILATRATE SR CPCR tromethamine pack 3 FURADANTIN SUSP (isosorbide dinitrate) GP GONITRO PACK PA (nitrofurantoin) 3 HIPREX TABS (nitroglycerin) (methenamine GP ISORDIL TITRADOSE hippurate) TABS (isosorbide GP MACROBID CAPS dinitrate) (nitrofurantoin monohyd GP isosorbide dinitrate tabs macro) 10 mg, 20 mg, 30 mg, 1 MACRODANTIN CAPS 40 mg, 5 mg (nitrofurantoin GP isosorbide dinitrate tbcr 1 macrocrystal) 40 mg methenamine hippurate 1 isosorbide mononitrate 1 tabs tabs methenamine isosorbide mononitrate 1 mandelate tabs 0.5 gm, 1 tb24 1 gm NITRO-BID OINT 2 MONUROL PACK (nitroglycerin) (fosfomycin GP NITRO-DUR PT24 0.1 QL(1 ea daily) tromethamine) MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR GP nitrofurantoin 1 macrocrystal caps (nitroglycerin) nitrofurantoin monohyd NITRO-DUR PT24 0.3 QL(1 ea daily) 1 MG/HR, 0.8 MG/HR 2 macro caps (nitroglycerin) nitrofurantoin susp 1
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15 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nitroglycerin cpcr or 2.5 1 alprazolam tabs 1 mg, 9 mg nitroglycerin pt24 td 0.1 QL(1 ea daily) alprazolam tb24 1 mg/hr, 0.2 mg/hr, 0.4 1 mg/hr, 0.6 mg/hr alprazolam tbdp 1 ATIVAN TABS nitroglycerin soln tl 0.4 1 GP mg/spray (lorazepam) chlordiazepoxide hcl nitroglycerin subl sl 0.3 1 1 mg, 0.4 mg, 0.6 mg caps NITROLINGUAL clorazepate 1 PUMPSPRAY SOLN GP dipotassium tabs (nitroglycerin) diazepam conc 5 mg/ml 1 NITROMIST AERS 3 (nitroglycerin) diazepam soln 5 1 NITROSTAT SUBL mg/5ml GP (nitroglycerin) diazepam tabs 10 mg, 1 2 mg, 5 mg ANTIANXIETY AGENTS - Drugs to Treat Anxiety lorazepam conc 1 Antianxiety Agents - Misc. buspirone hcl tabs 1 lorazepam tabs 1 PA oxazepam caps 10 mg, hydroxyzine hcl soln im SP 1 25 mg/ml, 50 mg/ml 15 mg, 30 mg TRANXENE T TABS hydroxyzine hcl syrp or 1 10 mg/5ml (clorazepate GP dipotassium) hydroxyzine hcl tabs or 1 VALIUM TABS 10 mg, 25 mg, 50 mg GP (diazepam) hydroxyzine pamoate 1 XANAX TABS caps GP (alprazolam) meprobamate tabs 1 XANAX XR TB24 GP VISTARIL CAPS (alprazolam) GP (hydroxyzine pamoate) ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms Benzodiazepines Antiarrhythmics Type I-A (Alprazolam) 1 ALPRAZOLAM XR TB24 disopyramide 1 (Diazepam) DIAZEPAM 1 phosphate caps INTENSOL CONC NORPACE CAPS (Lorazepam) LORAZEPAM 1 (disopyramide GP INTENSOL CONC phosphate) ALPRAZOLAM INTENSOL 3 CONC (alprazolam)
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Updated 07/01/2021 16 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NORPACE CR CP12 100 Antiasthmatic - Monoclonal Antibodies MG (disopyramide 2 FASENRA PEN SOAJ PA SP phosphate) (benralizumab) NORPACE CR CP12 150 NUCALA SOAJ PA SP MG (disopyramide 3 (mepolizumab) phosphate) NUCALA SOSY PA SP procainamide hcl soln SP PA (mepolizumab) XOLAIR SOLR PA SP quinidine gluconate 1 tbcr (omalizumab) XOLAIR SOSY PA SP quinidine sulfate tabs 1 (omalizumab) Antiarrhythmics Type I-B Bronchodilators - Anticholinergics ATROVENT HFA AERS Limit 2 inhalers mexiletine hcl caps 150 1 mg, 200 mg, 250 mg ( 2 per ipratropium bromide month;QL(0.86 Antiarrhythmics Type I-C hfa) gm daily) flecainide acetate tabs 1 INCRUSE ELLIPTA AEPB Limit 1 inhaler 2 per month;QL(1 (umeclidinium bromide) propafenone hcl cp12 ea daily) 225 mg, 325 mg, 425 1 ipratropium bromide 1 mg soln QL(6 ea daily) SPIRIVA HANDIHALER QL(1 ea daily) propafenone hcl tabs 1 150 mg CAPS (tiotropium 2 QL(3 ea daily) bromide monohydrate) propafenone hcl tabs 1 225 mg, 300 mg SPIRIVA RESPIMAT Limit 1 inhaler per RYTHMOL SR CP12 AERS (tiotropium 2 GP month;QL(0.14 (propafenone hcl) bromide monohydrate) gm daily) Antiarrhythmics Type III Leukotriene Modulators (Amiodarone Hcl) ACCOLATE TABS 1 GP PACERONE TABS (zafirlukast) amiodarone hcl tabs 1 QL(1 ea daily) montelukast sodium 1 chew dofetilide caps 1 montelukast sodium QL(1 ea daily) MULTAQ TABS 1 2 pack (dronedarone hcl) montelukast sodium QL(1 ea daily) TIKOSYN CAPS 1 GP tabs (dofetilide) SINGULAIR CHEW QL(1 ea daily) GP ANTIASTHMATIC AND BRONCHODILATOR (montelukast sodium) AGENTS - Drugs to Treat Lung Conditions SINGULAIR PACK QL(1 ea daily) GP Anti-Inflammatory Agents (montelukast sodium) cromolyn sodium nebu 1 zafirlukast tabs 1
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17 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits zileuton tb12 1 ST PULMICORT FLEXHALER Limit 2 inhalers AEPB 90 MCG/ACT per 2 month;QL(0.27 ZYFLO TABS (zileuton) 3 ST (budesonide (inhalation)) ea daily) Selective Phosphodiesterase 4 (PDE4) Inhibitors PULMICORT SUSP 0.5 QL(4 ml daily) DALIRESP TABS QL(1 ea daily) 3 MG/2ML (budesonide GP (roflumilast) (inhalation)) Steroid Inhalants PULMICORT SUSP 1 QL(2 ml daily) ARNUITY ELLIPTA AEPB QL(1 ea daily) MG/2ML (budesonide GP (fluticasone furoate 2 (inhalation)) (inhalation)) QVAR REDIHALER AERB Limit 1 inhaler QL(8 ml daily) 40 MCG/ACT per budesonide (inhalation) 1 2 month;QL(0.36 susp 0.25 mg/2ml (beclomethasone dipropionate hfa) gm daily) budesonide (inhalation) QL(4 ml daily) 1 QVAR REDIHALER AERB Limit 2 Inhalers susp 0.5 mg/2ml 80 MCG/ACT per QL(2 ml daily) 2 month;QL(0.72 budesonide (inhalation) 1 (beclomethasone susp 1 mg/2ml dipropionate hfa) gm daily) FLOVENT DISKUS AEPB QL(20 ea daily) Sympathomimetics 100 MCG/BLIST 2 (Fluticasone-Salmeterol) 1 QL(2 ea daily) (fluticasone propionate WIXELA INHUB AEPB (inhalation)) ADVAIR DISKUS AEPB QL(2 ea daily) GP FLOVENT DISKUS AEPB QL(8 ea daily) (fluticasone-salmeterol) 250 MCG/BLIST 2 Limit 1 inhaler (fluticasone propionate ADVAIR HFA AERO 2 per (inhalation)) (fluticasone-salmeterol) month;QL(0.4 FLOVENT DISKUS AEPB QL(40 ea daily) gm daily) 50 MCG/BLIST Limit 2 inhalers (fluticasone propionate 2 albuterol sulfate aers in 1 per (inhalation)) 108 mcg/act month;QL(0.57 FLOVENT HFA AERO 110 Limit 2 inhalers gm daily) MCG/ACT, 220 MCG/ACT per QL(1.2 gm albuterol sulfate aers in 1 (fluticasone propionate 2 month;QL(0.8 108 mcg/act daily) gm daily) hfa) QL(0.45 gm albuterol sulfate aers in 1 FLOVENT HFA AERO 44 Limit 1 inhaler 108 mcg/act daily) MCG/ACT ( 2 per fluticasone month;QL(0.36 albuterol sulfate nebu propionate hfa) gm daily) in 0.083 %, 0.5 %, 0.63 1 PULMICORT FLEXHALER Limit 2 inhalers mg/3ml, 1.25 mg/3ml, AEPB 180 MCG/ACT per 2.5 mg/0.5ml 2 (budesonide month;QL(0.07 ALBUTEROL SULFATE (inhalation)) ea daily) NEBU IN 0.5 % (albuterol 2 sulfate) albuterol sulfate syrp or 1 2 mg/5ml You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 18 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits albuterol sulfate tabs or Limit 2 inhalers 1 PROAIR RESPICLICK 2 mg, 4 mg 3 per AEPB ( ) month;QL(0.07 QL(2 ea daily) albuterol sulfate albuterol sulfate tb12 or 1 ea daily) 4 mg, 8 mg Limit 2 inhalers ANORO ELLIPTA AEPB QL(2 ea daily) PROVENTIL HFA AERS 1 per (umeclidinium- 2 (albuterol sulfate) month;QL(0.45 vilanterol) gm daily) ARCAPTA NEOHALER QL(1 ea daily) SEREVENT DISKUS QL(2 ea daily) CAPS (indacaterol 3 AEPB (salmeterol 2 maleate) xinafoate) BREO ELLIPTA AEPB QL(2 ea daily) STIOLTO RESPIMAT Limit 1 inhaler (fluticasone furoate- 2 AERS ( 2 per tiotropium month;QL(0.14 vilanterol) bromide-olodaterol hcl) gm daily) budesonide-formoterol Limit 1 inhaler Limit 1 inhaler 1 per STRIVERDI RESPIMAT per fumarate dihydrate month;QL(0.34 2 aero AERS (olodaterol hcl) month;QL(0.14 gm daily) gm daily) COMBIVENT RESPIMAT Limit 1 inhaler SYMBICORT AERO QL(0.34 gm AERS ( 3 per daily) ipratropium- month;QL(0.2 (budesonide-formoterol GP albuterol) gm daily) fumarate dihydrate) fluticasone-salmeterol QL(2 ea daily) terbutaline sulfate tabs 1 aepb 100 mcg/act-50 TRELEGY ELLIPTA AEPB QL(2 ea daily) mcg/act, 100 100 MCG/INH-25 mcg/dose-50 MCG/INH-62.5 MCG/INH 2 mcg/dose, 250 1 (fluticasone- mcg/act-50 mcg/act, umeclidinium-vilanterol) 250 mcg/dose-50 TRELEGY ELLIPTA AEPB 1 inhaler per mcg/dose, 50 200 MCG/INH-25 month;QL(2 ea mcg/dose-500 MCG/INH-62.5 MCG/INH 2 daily) mcg/dose (fluticasone- umeclidinium-vilanterol) ipratropium-albuterol 1 soln Limit 2 inhalers VENTOLIN HFA AERS 1 per levalbuterol hcl nebu 1 (albuterol sulfate) month;QL(0.54 gm daily) levalbuterol tartrate Limit 2 inhalers 1 per month;QL(1 Limit 2 inhalers aero VENTOLIN HFA AERS gm daily) 1 per (albuterol sulfate) month;QL(1.2 metaproterenol sulfate 1 gm daily) tabs XOPENEX Limit 2 inhalers CONCENTRATE NEBU GP PROAIR HFA AERS 1 per (levalbuterol hcl) (albuterol sulfate) month;QL(0.57 gm daily)
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19 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 2 inhalers QL(3 ml per 10 XOPENEX HFA AERO enoxaparin sodium SP 1 per month;QL(1 soln ij 300 mg/3ml days retail) (levalbuterol tartrate) gm daily) enoxaparin sodium QL(20 ml per XOPENEX NEBU GP soln sc 100 mg/ml, 150 SP 10 days retail) (levalbuterol hcl) mg/ml Xanthines enoxaparin sodium QL(16 ml per aminophylline soln SP PA soln sc 120 mg/0.8ml, SP 10 days retail) ELIXOPHYLLIN ELIX 80 mg/0.8ml 3 (theophylline) enoxaparin sodium QL(6 ml per 10 SP days retail) THEO-24 CP24 soln sc 30 mg/0.3ml 2 QL(8 ml per 10 (theophylline) enoxaparin sodium SP soln sc 40 mg/0.4ml days retail) theophylline soln 1 QL(12 ml per enoxaparin sodium SP theophylline tb12 1 soln sc 60 mg/0.6ml 10 days retail) PA; fondaparinux sodium SP theophylline tb24 1 soln FRAGMIN SOLN 10000 QL(20 ml per ANTICOAGULANTS - Blood Thinners UNIT/ML (dalteparin SP 365 days retail) Coumarin Anticoagulants sodium) (Warfarin Sodium) 1 FRAGMIN SOLN 12500 QL(10 ml per JANTOVEN TABS UNIT/0.5ML (dalteparin SP 365 days retail) COUMADIN TABS ) GP sodium (warfarin sodium) FRAGMIN SOLN 15000 QL(12 ml per warfarin sodium tabs 1 UNIT/0.6ML (dalteparin SP 365 days retail) sodium) Direct Factor Xa Inhibitors FRAGMIN SOLN 18000 QL(14 ml per BEVYXXA CAPS QL(42 ea per 365 days retail) 3 UNT/0.72ML (dalteparin SP (betrixaban maleate) 42 days retail) sodium) ELIQUIS STARTER PACK 2 FRAGMIN SOLN 2500 QL(4 ml per TBPK (apixaban) UNIT/0.2ML, 5000 365 days retail) SP ELIQUIS TABS UNIT/0.2ML (dalteparin 2 (apixaban) sodium) XARELTO STARTER FRAGMIN SOLN 7500 QL(6 ml per PACK TBPK 2 UNIT/0.3ML (dalteparin SP 365 days retail) (rivaroxaban) sodium) XARELTO TABS 10 MG, FRAGMIN SOLN 95000 PA 15 MG, 20 MG 2 UNIT/3.8ML (dalteparin SP (rivaroxaban) sodium) Heparins And Heparinoid-Like Agents heparin (porcine) in ARIXTRA SOLN PA; sodium chloride soln SP SP (fondaparinux sodium) 0.9 %-1000 unit/500ml, 0.9 %-2000 unit/l
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Updated 07/01/2021 20 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits heparin sod (porcine) in SP clobazam susp 1 d5w soln clobazam tabs 1 heparin sodium SP (porcine) soln clonazepam tabs 1 HEPARIN SODIUM/NACL 0.45% SOLN (heparin SP clonazepam tbdp 1 (porcine) in sodium chloride) DIASTAT ACUDIAL GEL Limit 4 per HEPARIN (diazepam 3 month;QL(0.14 SODIUM/SODIUM (anticonvulsant)) ea daily) CHLORIDE 0.9% SOLN SP DIASTAT PEDIATRIC GEL Limit 4 per (heparin (porcine) in (diazepam 3 month;QL(0.14 sodium chloride) (anticonvulsant)) ea daily) HEPARIN Limit 4 per SODIUM/SODIUM diazepam (anticonvulsant) gel 10 3 month;QL(0.14 CHLORIDE SOLN SP ea daily) (heparin (porcine) in mg sodium chloride) diazepam Limit 4 per LOVENOX SOLN IJ 300 QL(3 ml per 10 (anticonvulsant) gel 2.5 1 month;QL(0.14 MG/3ML (enoxaparin SP days retail) mg, 20 mg ea daily) sodium) KLONOPIN TABS GP LOVENOX SOLN SC 100 QL(20 ml per (clonazepam) MG/ML, 150 MG/ML SP 10 days retail) NAYZILAM SOLN PA; QL(10 ea (enoxaparin sodium) (midazolam SP per 30 days LOVENOX SOLN SC 120 QL(16 ml per (anticonvulsant)) retail) MG/0.8ML, 80 MG/0.8ML SP 10 days retail) (enoxaparin sodium) ONFI SUSP (clobazam) GP LOVENOX SOLN SC 30 QL(6 ml per 10 ONFI TABS (clobazam) GP MG/0.3ML (enoxaparin SP days retail) sodium) VALTOCO LIQD PA; QL(10 ea LOVENOX SOLN SC 40 QL(8 ml per 10 (diazepam SP per 30 days retail) MG/0.4ML (enoxaparin SP days retail) (anticonvulsant)) sodium) VALTOCO LQPK PA; QL(10 ea LOVENOX SOLN SC 60 QL(12 ml per (diazepam SP per 30 days retail) MG/0.6ML (enoxaparin SP 10 days retail) (anticonvulsant)) sodium) Anticonvulsants - Misc. (Carbamazepine) EPITOL 1 ANTICONVULSANTS - Drugs to Treat Seizures TABS AMPA Glutamate Receptor Antagonists (Lamotrigine) SUBVENITE FYCOMPA SUSP STARTER KIT/BLUE, 3 (perampanel) SUBVENITE STARTER 1 KIT/GREEN, SUBVENITE FYCOMPA TABS 3 STARTER KIT/ORANGE (perampanel) KIT Anticonvulsants - Benzodiazepines You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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21 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Lamotrigine) SUBVENITE KEPPRA SOLN IV 500 PA 1 SP TABS MG/5ML (levetiracetam) (Levetiracetam) KEPPRA SOLN OR 100 1 3 ROWEEPRA TABS MG/ML (levetiracetam) (Levetiracetam) 1 KEPPRA TABS OR 1000 ROWEEPRA XR TB24 MG, 250 MG, 500 MG, 750 3 APTIOM TABS 200 MG, QL(2 ea daily) MG (levetiracetam) 400 MG, 600 MG 3 KEPPRA XR TB24 (eslicarbazepine 3 (levetiracetam) acetate) LAMICTAL CHEWABLE APTIOM TABS 800 MG QL(1 ea daily) DISPERSIBLE CHEW 3 (eslicarbazepine 3 (lamotrigine) acetate) LAMICTAL ODT KIT PA BANZEL SUSP 3 GP (lamotrigine) (rufinamide) LAMICTAL ODT KIT PA BANZEL TABS GP GP (lamotrigine) (rufinamide) LAMICTAL ODT TBDP 100 PA carbamazepine chew 1 MG, 200 MG, 25 MG, 50 3 MG (lamotrigine) carbamazepine cp12 1 LAMICTAL STARTER/NOT TAKING carbamazepine susp 1 CARBAMAZEPINE KIT GP (lamotrigine) 1 carbamazepine tabs LAMICTAL STARTER/TAKING 1 carbamazepine tb12 CARBAMAZEPINE/NOT GP CARBATROL CP12 TAKING VALPROATE KIT 3 (carbamazepine) (lamotrigine) DIACOMIT CAPS 250 MG PA; QL(12 ea LAMICTAL SP (stiripentol) daily) STARTER/TAKING VALPROATE KIT GP DIACOMIT CAPS 500 MG PA; QL(6 ea SP (lamotrigine) (stiripentol) daily) LAMICTAL TABS DIACOMIT PACK 250 MG PA; QL(12 ea 3 SP (lamotrigine) (stiripentol) daily) LAMICTAL XR KIT PA DIACOMIT PACK 500 MG PA; QL(6 ea 3 SP (lamotrigine) (stiripentol) daily) LAMICTAL XR TB24 100 PA; QL(1 ea EPIDIOLEX SOLN PA SP MG, 200 MG, 25 MG, 50 3 daily) (cannabidiol) MG (lamotrigine) 1 LAMICTAL XR TB24 250 PA gabapentin caps 3 MG (lamotrigine) gabapentin soln 1 LAMICTAL XR TB24 300 3 MG (lamotrigine) gabapentin tabs 1
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Updated 07/01/2021 22 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEURONTIN TABS lamotrigine chew 25 1 3 mg, 5 mg (gabapentin) lamotrigine kit 1 PA oxcarbazepine susp 1 lamotrigine kit 25 mg, 1 oxcarbazepine tabs 1 OXTELLAR XR TB24 lamotrigine tabs 100 3 mg, 150 mg, 200 mg, 1 (oxcarbazepine) 25 mg pregabalin caps 100 PA; QL(3 ea lamotrigine tb24 100 PA; QL(1 ea mg, 200 mg, 25 mg, 50 1 daily) mg, 200 mg, 25 mg, 50 1 daily) mg, 75 mg mg PA; QL(2 ea pregabalin caps 150 1 PA mg, 225 mg, 300 mg daily) lamotrigine tb24 250 1 mg PA pregabalin soln 20 1 mg/ml lamotrigine tb24 300 1 mg primidone tabs 1 lamotrigine tbdp 100 PA QUDEXY XR CS24 PA mg, 200 mg, 25 mg, 50 1 3 (topiramate) mg PA rufinamide susp 1 levetiracetam soln iv SP 500 mg/5ml rufinamide tabs 1 levetiracetam soln or 1 TEGRETOL SUSP 100 mg/ml, 500 mg/5ml 3 (carbamazepine) levetiracetam tabs or TEGRETOL TABS 1000 mg, 250 mg, 500 1 3 mg, 750 mg (carbamazepine) TEGRETOL-XR TB12 100 GP levetiracetam tb24 or 1 500 mg, 750 mg MG (carbamazepine) TEGRETOL-XR TB12 200 LYRICA CAPS 100 MG, PA; QL(3 ea MG, 400 MG 200 MG, 25 MG, 50 MG, daily) 3 3 (carbamazepine) 75 MG (pregabalin) TOPAMAX SPRINKLE LYRICA CAPS 150 MG, PA; QL(2 ea 3 CPSP ( ) 225 MG, 300 MG 3 daily) topiramate TOPAMAX TABS (pregabalin) 3 LYRICA SOLN 20 MG/ML PA (topiramate) 3 (pregabalin) topiramate cpsp 15 mg, 1 MYSOLINE TABS 25 mg 3 (primidone) topiramate cs24 100 PA NEURONTIN CAPS mg, 150 mg, 200 mg, 1 3 (gabapentin) 25 mg, 50 mg NEURONTIN SOLN 3 (gabapentin)
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23 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits topiramate tabs 100 (Phenytoin) PHENYTOIN 1 mg, 200 mg, 25 mg, 50 1 INFATABS CHEW CEREBYX SOLN PA mg SP TRILEPTAL SUSP (fosphenytoin sodium) 3 (oxcarbazepine) DILANTIN CAPS 100 MG TRILEPTAL TABS (phenytoin sodium 3 3 (oxcarbazepine) extended) TROKENDI XR CP24 PA DILANTIN CAPS 30 MG 3 (topiramate) (phenytoin sodium 2 VIMPAT SOLN extended) 2 DILANTIN INFATABS (lacosamide) 3 VIMPAT TABS CHEW (phenytoin) 2 DILANTIN-125 SUSP (lacosamide) 3 ZONEGRAN CAPS (phenytoin) 3 PA (zonisamide) fosphenytoin sodium SP soln 1 zonisamide caps PEGANONE TABS 3 Carbamates (ethotoin) PHENYTEK CAPS felbamate susp 1 (phenytoin sodium 3 felbamate tabs 1 extended) FELBATOL SUSP phenytoin chew 1 3 (felbamate) phenytoin sodium FELBATOL TABS 1 3 extended caps (felbamate) phenytoin sodium soln SP PA GABA Modulators (Vigabatrin) VIGADRONE 1 phenytoin susp 1 PACK GABITRIL TABS Succinimides 3 CELONTIN CAPS (tiagabine hcl) 2 SABRIL PACK (methsuximide) GP (vigabatrin) ethosuximide caps 1 SABRIL TABS GP (vigabatrin) ethosuximide soln 1 ZARONTIN CAPS tiagabine hcl tabs 1 3 (ethosuximide) vigabatrin pack 1 ZARONTIN SOLN 3 (ethosuximide) vigabatrin tabs 1 Valproic Acid Hydantoins DEPAKENE CAPS 250 MG 3 (valproic acid)
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Updated 07/01/2021 24 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits DEPAKOTE ER TB24 WELLBUTRIN SR TB12 3 GP (divalproex sodium) (bupropion hcl) DEPAKOTE SPRINKLES WELLBUTRIN XL TB24 QL(1 ea daily) GP CSDR (divalproex 3 (bupropion hcl) sodium) Monoamine Oxidase Inhibitors (MAOIs) DEPAKOTE TBEC EMSAM PT24 QL(1 ea daily) 3 3 (divalproex sodium) (selegiline) 1 MARPLAN TABS divalproex sodium csdr 3 (isocarboxazid) divalproex sodium tb24 1 NARDIL TABS GP (phenelzine sulfate) divalproex sodium tbec 1 PARNATE TABS valproic acid caps or 1 (tranylcypromine GP sulfate) ANTIDEPRESSANTS - Drugs to Treat Depression phenelzine sulfate tabs 1 Alpha-2 Receptor Antagonists (Tetracyclics) tranylcypromine sulfate 1 mirtazapine tabs 1 tabs Selective Serotonin Reuptake Inhibitors (SSRIs) mirtazapine tbdp 1 CELEXA TABS 10 MG QL(4 ea daily) REMERON SOLTAB TBDP (citalopram GP GP (mirtazapine) hydrobromide) REMERON TABS CELEXA TABS 20 MG QL(2 ea daily) GP (mirtazapine) (citalopram GP hydrobromide) Antidepressants - Misc. CELEXA TABS 40 MG QL(1 ea daily) APLENZIN TB24 ST; QL(1 ea (citalopram GP (bupropion 3 daily) hydrobromide) hydrobromide) citalopram QL(20 ml daily) bupropion hcl tabs 100 1 hydrobromide soln 10 1 mg, 75 mg mg/5ml bupropion hcl tb12 100 1 citalopram QL(4 ea daily) mg, 150 mg, 200 mg hydrobromide tabs 10 1 QL(1 ea daily) bupropion hcl tb24 150 1 mg mg, 300 mg citalopram QL(2 ea daily) ST; QL(1 ea bupropion hcl tb24 450 1 hydrobromide tabs 20 1 mg daily) mg FORFIVO XL TB24 ST; QL(1 ea citalopram QL(1 ea daily) 3 daily) (bupropion hcl) hydrobromide tabs 40 1 maprotiline hcl tabs 1 mg escitalopram oxalate 1 soln You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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25 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits escitalopram oxalate 1 Serotonin Modulators tabs nefazodone hcl tabs 1 fluoxetine hcl caps 10 1 mg, 20 mg, 40 mg trazodone hcl tabs 1 fluoxetine hcl cpdr 90 TRINTELLIX TABS ST; QL(1 ea 1 3 mg (vortioxetine hbr) daily) fluoxetine hcl soln 20 VIIBRYD STARTER PACK ST 1 3 mg/5ml KIT (vilazodone hcl) fluoxetine hcl tabs 10 VIIBRYD TABS ST 1 3 mg, 20 mg (vilazodone hcl) fluoxetine hcl tabs 60 ST; QL(1 ea Serotonin-Norepinephrine Reuptake Inhibitors 1 daily) mg CYMBALTA CPEP QL(2 ea daily) GP FLUOXETINE ST; QL(1 ea (duloxetine hcl) HYDROCHLORIDE TABS 3 daily) DESVENLAFAXINE ER ST; QL(1 ea 3 (fluoxetine hcl) TB24 (desvenlafaxine) daily) fluvoxamine maleate 1 desvenlafaxine 1 cp24 succinate tb24 fluvoxamine maleate 1 1 ST; QL(1 ea tabs desvenlafaxine tb24 daily) LEXAPRO TABS QL(2 ea daily) GP duloxetine hcl cpep 20 1 (escitalopram oxalate) mg, 30 mg, 60 mg paroxetine hcl tabs 1 EFFEXOR XR CP24 37.5 QL(1 ea daily) MG, 75 MG (venlafaxine GP paroxetine hcl tb24 1 hcl) PAXIL CR TB24 FETZIMA CP24 120 MG, ST; QL(1 ea GP (paroxetine hcl) 40 MG, 80 MG 3 daily) (levomilnacipran hcl) PAXIL TABS 10 MG, 30 MG, 40 MG (paroxetine GP FETZIMA CP24 20 MG ST; QL(2 ea 3 daily) hcl) (levomilnacipran hcl) PEXEVA TABS FETZIMA TITRATION ST 3 PACK C4PK (paroxetine mesylate) 3 (levomilnacipran hcl) PROZAC CAPS GP KHEDEZLA TB24 ST; QL(1 ea (fluoxetine hcl) 3 (desvenlafaxine) daily) sertraline hcl conc 1 QL(2 ea daily) venlafaxine hcl cp24 1 150 mg sertraline hcl tabs 1 venlafaxine hcl cp24 QL(1 ea daily) ZOLOFT CONC 1 GP 37.5 mg, 75 mg (sertraline hcl) venlafaxine hcl tabs ZOLOFT TABS ( sertraline GP 100 mg, 25 mg, 37.5 1 hcl) mg, 50 mg, 75 mg
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Updated 07/01/2021 26 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits venlafaxine hcl tb24 miglitol tabs 1 150 mg, 225 mg, 37.5 1 PRECOSE TABS mg, 75 mg GP (acarbose) Tricyclic Agents Antidiabetic - Amylin Analogs amitriptyline hcl tabs 1 SYMLINPEN 120 SOPN PA SP (pramlintide acetate) amoxapine tabs 1 SYMLINPEN 60 SOPN PA ANAFRANIL CAPS SP GP (pramlintide acetate) (clomipramine hcl) Antidiabetic Combinations clomipramine hcl caps 1 ACTOPLUS MET TABS (pioglitazone hcl- GP desipramine hcl tabs 1 metformin hcl) doxepin hcl caps 1 DUETACT TABS (pioglitazone hcl- GP doxepin hcl conc 1 glimepiride) glipizide-metformin hcl 1 imipramine hcl tabs 1 tabs imipramine pamoate 1 glyburide-metformin 1 caps tabs NORPRAMIN TABS GLYXAMBI TABS GP (desipramine hcl) (empagliflozin- 2 nortriptyline hcl caps 10 linagliptin) mg, 25 mg, 50 mg, 75 1 JANUMET TABS mg (sitagliptin-metformin 2 PAMELOR CAPS hcl) GP (nortriptyline hcl) JANUMET XR TB24 (sitagliptin-metformin 2 1 protriptyline hcl tabs hcl) SURMONTIL CAPS GP pioglitazone hcl- 1 (trimipramine maleate) glimepiride tabs TOFRANIL TABS GP pioglitazone hcl- 1 (imipramine hcl) metformin hcl tabs trimipramine maleate 1 repaglinide-metformin 1 caps hcl tabs ANTIDIABETICS - Drugs to Regulate Blood SOLIQUA 100/33 SOPN PA Sugar (insulin glargine- SP Alpha-Glucosidase Inhibitors lixisenatide) acarbose tabs 1 SYNJARDY TABS (empagliflozin- 2 GLYSET TABS (miglitol) GP metformin hcl)
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27 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SYNJARDY XR TB24 GLUCAGON EMERGENCY KIT FOR (empagliflozin- 2 2 metformin hcl) LOW BLOOD SUGAR TRIJARDY XR TB24 SOLR (glucagon hcl) (empagliflozin- 2 GLUCAGON linagliptin-metformin) EMERGENCY KIT KIT GP (glucagon (rdna)) XIGDUO XR TB24 GVOKE PFS SOSY QL(0.02 ml (dapagliflozin- 2 2 daily) metformin hcl) (glucagon) XULTOPHY 100/3.6 SOPN PA KORLYM TABS PA ( (insulin degludec- SP mifepristone SP liraglutide) (hyperglycemia)) PROGLYCEM SUSP GP Biguanides (diazoxide) GLUMETZA TB24 PA SP (metformin hcl) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TABS metformin hcl soln 500 2 1 (sitagliptin phosphate) mg/5ml metformin hcl tabs Dopamine Receptor Agonists - Antidiabetic 1000 mg, 500 mg, 850 1 CYCLOSET TABS mg (bromocriptine 3 mesylate (diabetes)) PA metformin hcl tb24 SP 1000 mg, 500 mg Incretin Mimetic Agents (GLP-1 Receptor OZEMPIC SOPN PA metformin hcl tb24 500 1 SP mg, 750 mg (semaglutide) TRULICITY SOPN PA METFORMIN SP HYDROCHLORIDE SOLN 1 (dulaglutide) VICTOZA SOPN PA (metformin hcl) SP RIOMET SOLN (liraglutide) 3 (metformin hcl) Insulin Sensitizing Agents ACTOS TABS Diabetic Other GP BAQSIMI ONE PACK QL(0.069 ea (pioglitazone hcl) 2 daily) AVANDIA TABS POWD (glucagon) 2 BAQSIMI TWO PACK QL(0.069 ea (rosiglitazone maleate) 2 POWD (glucagon) daily) pioglitazone hcl tabs 1 diazoxide susp 1 Insulin GLUCAGEN HYPOKIT HUMALOG JUNIOR Limit 45mls per SOLR (glucagon hcl 2 KWIKPEN SOPN (insulin 2 month;QL(1.5 (rdna)) lispro) ml daily) glucagon (rdna) kit 1 HUMALOG KWIKPEN Limit 45mls per SOPN 100 UNIT/ML 2 month;QL(1.5 (insulin lispro) ml daily)
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OR Essential Drug List
Updated 07/01/2021 28 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HUMALOG KWIKPEN Limit 4mls per HUMULIN R U-500 Limit 2 vials per SOPN 100 UNIT/ML month;QL(1.5 month;QL(1.5 2 (CONCENTRATED) 2 (insulin lispro) ml daily) SOLN (insulin regular ml daily) HUMALOG KWIKPEN Limit 24mls per (human)) SOPN 200 UNIT/ML 2 month;QL(0.8 HUMULIN R U-500 Limit 2 vials per (insulin lispro) ml daily) KWIKPEN SOPN (insulin 2 month;QL(1.5 ml daily) HUMALOG MIX 50/50 Limit 45mls per regular (human)) KWIKPEN SUPN (insulin month;QL(1.5 INSULIN LISPRO Limit 45mls per lispro protamine & 2 ml daily) PROTAMINE/INSULIN month;QL(1.5 lispro) LISPRO KWIKPEN SUPN 2 ml daily) ( HUMALOG MIX 50/50 Limit 4 vials per insulin lispro protamine & lispro) SUSP (insulin lispro 2 month;QL(1.5 protamine & lispro) ml daily) LANTUS SOLN (insulin Limit 45mls per 2 month;QL(1.5 HUMALOG MIX 75/25 Limit 45mls per glargine) ml daily) KWIKPEN SUPN (insulin month;QL(1.5 2 ml daily) LANTUS SOLOSTAR Limit 45mls per lispro protamine & 2 month;QL(1.5 lispro) SOPN (insulin glargine) ml daily) HUMALOG MIX 75/25 Limit 45mls per LEVEMIR FLEXTOUCH Limit 45mls per month;QL(1.5 2 month;QL(1.5 SUSP (insulin lispro 2 SOPN (insulin detemir) protamine & lispro) ml daily) ml daily) Limit 45mls per LEVEMIR SOLN (insulin Limit 45mls per HUMALOG SOCT 2 month;QL(1.5 2 month;QL(1.5 detemir) (insulin lispro) ml daily) ml daily) Limit 45mls per Limit 3 boxes HUMALOG SOLN (insulin TOUJEO MAX SOLOSTAR 2 month;QL(1.5 2 per lispro) ml daily) SOPN (insulin glargine) month;QL(0.6 ml daily) HUMULIN 70/30 KWIKPEN Limit 45mls per month;QL(1.5 Limit 3 boxes SUPN (insulin nph TOUJEO SOLOSTAR 2 ml daily) 2 per isophane & reg SOPN (insulin glargine) month;QL(0.6 (human)) ml daily) HUMULIN 70/30 SUSP Limit 45mls per Limit 3 boxes month;QL(1.5 TRESIBA FLEXTOUCH (insulin nph isophane & 2 SOPN 100 UNIT/ML 2 per ml daily) month;QL(1.5 reg (human)) (insulin degludec) HUMULIN N KWIKPEN Limit 45mls per ml daily) SUPN (insulin nph 2 month;QL(1.5 TRESIBA FLEXTOUCH Limit 3 boxes ml daily) SOPN 200 UNIT/ML 2 per (human) (isophane)) month;QL(0.9 HUMULIN N SUSP Limit 45mls per (insulin degludec) ml daily) month;QL(1.5 (insulin nph (human) 2 TRESIBA SOLN (insulin (isophane)) ml daily) 2 degludec) HUMULIN R SOLN Limit 45mls per (insulin regular 2 month;QL(1.5 Meglitinide Analogues (human)) ml daily) nateglinide tabs 1
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OR Essential Drug List
29 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRANDIN TABS (Loperamide Hcl) ANTI- RX/OTC GP (repaglinide) DIARRHEAL, CVS ANTI- DIARRHEAL, EQ ANTI- repaglinide tabs 1 DIARRHEAL, GNP ANTI- DIARRHEAL, HM ANTI- STARLIX TABS GP DIARRHEAL, HM 1 (nateglinide) LOPERAMIDE HCL, QC Sodium-Glucose Co-Transporter 2 (SGLT2) ANTI-DIARRHEAL, RA ANTI-DIARRHEAL, SM FARXIGA TABS ANTI-DIARRHEAL, TGT (dapagliflozin 2 LOPERAMIDE HCL CAPS propanediol) diphenoxylate w/ JARDIANCE TABS 1 2 atropine liqd (empagliflozin) diphenoxylate w/ 1 Sulfonylureas atropine tabs (Glipizide) GLIPIZIDE XL IMODIUM A-D CAPS RX/OTC 1 GP TB24 (loperamide hcl) AMARYL TABS GP LOMOTIL TABS (glimepiride) (diphenoxylate w/ GP glimepiride tabs 1 atropine) RX/OTC glipizide tabs 1 loperamide hcl caps 1 MOTOFEN TABS 2 glipizide tb24 1 (difenoxin w/ atropine) GLUCOTROL TABS GP opium tincture tinc 1 (glipizide) GLUCOTROL XL TB24 paregoric tinc 1 GP (glipizide) ANTIDOTES AND SPECIFIC ANTAGONISTS glyburide micronized 1 tabs Antidotes - Chelating Agents CHEMET CAPS glyburide tabs 1 3 (succimer) GLYNASE TABS GP PA (glyburide micronized) deferasirox pack SP tolbutamide tabs 1 deferasirox tabs SP PA ANTIDIARRHEAL/PROBIOTIC AGENTS - Drugs deferasirox tbso SP PA to Treat Diarrhea Antidiarrheal - Chloride Channel Antagonists deferiprone tabs SP PA MYTESI TBEC PA; QL(2 ea EXJADE TBSO PA 3 daily) SP (crofelemer) (deferasirox) Antiperistaltic Agents FERRIPROX SOLN 100 PA SP MG/ML (deferiprone)
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OR Essential Drug List
Updated 07/01/2021 30 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FERRIPROX TABS 1000 PA QL(2 ea daily) SP granisetron hcl tabs 1 MG (deferiprone) FERRIPROX TABS 500 PA PA; Limit 50mls SP ondansetron hcl soln 4 1 per MG (deferiprone) mg/5ml month;QL(1.67 FERRIPROX TWICE-A- PA SP ml daily) DAY TABS (deferiprone) ondansetron hcl tabs 4 QL(20 ea per JADENU SPRINKLE PACK PA 1 fill retail,60 ea SP mg, 8 mg (deferasirox) per fill mail) JADENU TABS PA QL(20 ea per SP (deferasirox) ondansetron tbdp 1 fill retail,60 ea per fill mail) Antidotes and Specific Antagonists SP PA RADIOGARDASE CAPS palonosetron hcl soln (prussian blue insoluble PALONOSETRON PA (ferric 3 HYDROCHLORIDE SOLN SP hexacyanoferrate ii)) (palonosetron hcl) SANCUSO PTCH PA VISTOGARD PACK 3 (uridine triacetate SP (granisetron) (emergency treatment)) ZOFRAN TABS QL(20 ea per GP fill retail,60 ea Opioid Antagonists (ondansetron hcl) per fill mail) PA required for QL(20 ea per EVZIO SOAJ ( ZUPLENZ FILM naloxone SP more than 30 3 fill retail,60 ea hcl) day supply per (ondansetron) per fill mail) year; PA required for Antiemetics - Anticholinergic (Meclizine Hcl) CVS RX/OTC naloxone hcl soaj 2 SP more than 30 mg/0.4ml day supply per MOTION SICKNESS II, year; CVS MOTION SICKNESS LESSDROWSY naloxone hcl sosy 2 SP FORMULA, DRAMAMINE mg/2ml LESS DROWSY, EQL naltrexone hcl tabs 1 MOTION SICKNESS RELIEF, GNP MOTION 1 Limit 2 boxes SICKNESS RELIEF, HM NARCAN LIQD MOTION RELIEF, HM 3 per month;QL(4 (naloxone hcl) ea per 30 days MOTION SICKNESS retail) RELIEF, SM MOTION SICKNESS, TRAVEL- ANTIEMETICS - Drugs to Treat Nausea and EASE, WAL-DRAM II Vomiting TABS 5-HT3 Receptor Antagonists meclizine hcl tabs 1 RX/OTC ALOXI SOLN PA SP (palonosetron hcl) MECLIZINE HYDROCHLORIDE TABS 3 ANZEMET TABS PA; Limit 2 per 3 month;QL(0.07 (meclizine hcl) (dolasetron mesylate) ea daily) scopolamine pt72 1
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OR Essential Drug List
31 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIGAN CAPS EMEND TRIPACK CAPS QL(3 ea per fill GP retail,9 ea per (trimethobenzamide GP (aprepitant) hcl) fill mail) VARUBI TBPK (rolapitant QL(4 ea per fill trimethobenzamide hcl 1 3 retail) caps hcl) Antiemetics - Miscellaneous ANTIFUNGALS - Drugs to Treat Fungal Infections AKYNZEO CAPS QL(2 ea per 28 Antifungal - Glucan Synthesis Inhibitors (netupitant- 3 days retail) CANCIDAS SOLR PA palonosetron) SP (caspofungin acetate) BONJESTA TBCR QL(2 ea daily) PA (doxylamine- 3 caspofungin acetate SP pyridoxine) solr 50 mg, 70 mg CESAMET CAPS PA; QL(2 ea CASPOFUNGIN ACETATE PA 3 SOLR 50 MG, 70 MG SP ( ) daily) nabilone (caspofungin acetate) DICLEGIS TBEC QL(4 ea daily) ERAXIS SOLR PA ( SP doxylamine- GP (anidulafungin) pyridoxine) micafungin sodium solr PA doxylamine-pyridoxine QL(4 ea daily) SP 1 100 mg, 50 mg tbec MYCAMINE SOLR PA SP dronabinol caps 1 (micafungin sodium) MARINOL CAPS Antifungals GP (dronabinol) ABELCET SUSP PA SP Substance P/Neurokinin 1 (NK1) Receptor (amphotericin b lipid) QL(3 ea per fill AMBISOME SUSR PA aprepitant caps 1 retail,9 ea per (amphotericin b SP fill mail) liposome) QL(1 ea per fill PA aprepitant caps 125 1 amphotericin b solr SP mg, 80 mg retail,3 ea per fill mail) ANCOBON CAPS GP QL(2 ea per fill (flucytosine) aprepitant caps 40 mg 1 retail,6 ea per fill mail) flucytosine caps 1 QL(3 ea per fill griseofulvin microsize aprepitant misc 1 retail,9 ea per 1 fill mail) susp griseofulvin microsize EMEND CAPS 125 MG, 80 QL(1 ea per fill 1 GP retail,3 ea per tabs MG (aprepitant) fill mail) griseofulvin 1 EMEND CAPS 40 MG QL(2 ea per fill ultramicrosize tabs GP retail,6 ea per (aprepitant) fill mail) nystatin tabs 1
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OR Essential Drug List
Updated 07/01/2021 32 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(90 ea per ANTIHISTAMINES - Drugs to Treat Allergies terbinafine hcl tabs 1 365 days retail,90 ea per Antihistamines - Alkylamines 365 days mail) (Dexchlorpheniramine 1 Imidazole-Related Antifungals Maleate) RYCLORA SOLN CRESEMBA CAPS dexchlorpheniramine 1 (isavuconazonium 3 maleate soln sulfate) Antihistamines - Ethanolamines DIFLUCAN SUSR GP (fluconazole) DIFLUCAN TABS GP (fluconazole) fluconazole susr 1 fluconazole tabs 1 itraconazole caps 1 PA itraconazole soln 1 PA ketoconazole tabs 1 NOXAFIL SUSP 40 MG/ML 3 (posaconazole) NOXAFIL TBEC 100 MG GP (posaconazole) posaconazole tbec 1 SPORANOX CAPS PA GP (itraconazole) SPORANOX PULSEPAK PA GP CAPS (itraconazole) SPORANOX SOLN PA GP (itraconazole) TOLSURA CAPS PA SP (itraconazole) VFEND SUSR GP (voriconazole) VFEND TABS GP (voriconazole) voriconazole susr or 40 1 mg/ml voriconazole tabs or 1 200 mg, 50 mg
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33 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Diphenhydramine Hcl) (Diphenhydramine Hcl) ALLERGY CHILDRENS, ALLERGY RELIEF AURODRYL ALLERGY CHILDRENS, CVS CHILDRENS, CVS ALLERGY RELIEF ALLERGY RELIEF, CVS CHILDRENS, EQ 1 ALLERGY RELIEF ALLERGY RELIEF ADULTMAXIMUM CHILDRENS, RA STRENGTH, CVS ALLERGY RELIEF CHILDRENS ALLERGY, CHILDRENS LIQD 12.5 CVS CHILDRENS MG/5ML ALLERGY RELIEF, DYE- (Diphenhydramine Hcl) FREE ALLERGY RELIEF BANOPHEN, KP CHILDRENS, EQL DIPHENHYDRAMINE 1 CHILDRENS ALLERGY, HCL, PHARBEDRYL GERI-DRYL, GNP CAPS ALLERGY ANTIHISTAMINE, GNP (Diphenhydramine Hcl) DI- 1 ALLERGY PHEN, DIPHEN ELIX ANTIHISTAMINECHILDRE BENADRYL ALLERGY NS, GNP CHILDRENS CHILDRENS LIQD GP ALLERGY, H-E-B (diphenhydramine hcl) CHILDRENS ALLERGY, carbinoxamine maleate HM ALLERGY RELIEF 1 CHILDRENS, LIQUID soln 4 mg/5ml ALLERGY RELIEF, M- 1 carbinoxamine maleate 1 DRYL, NARAMIN, tabs 4 mg PEDIACARE CHILDRENS CLEMASTINE FUMARATE ALLERGY, PX ALLERGY, SYRP 0.67 MG/5ML QC ALLERGY 2 CHILDRENS, RA (clemastine fumarate) ALLERGY, RA ALLERGY clemastine fumarate 1 MEDICATION tabs 2.68 mg CHILDRENS, RA DIPHEDRYL ALLERGY, diphenhydramine hcl 1 SB ALLERGY MEDICINE, caps or 50 mg SILADRYL ALLERGY, SM diphenhydramine hcl 1 ALLERGY RELIEF, SM elix or 12.5 mg/5ml ALLERGY RELIEF CHILDRENS, TGT diphenhydramine hcl ALLERGY RELIEF liqd or 12.5 mg/5ml, 25 1 CHILDRENS, TGT mg/10ml ALLERGY RELIEF PA CHILDRENS DYE FREE, diphenhydramine hcl SP TOTAL ALLERGY soln ij 50 mg/ml MEDICINE, WAL-DRYL Antihistamines - Non-Sedating ALLERGY, WAL-DRYL ALLERGY CHILDRENS, WAL-DRYL ALLERGY DYE-FREECHILDRENS LIQD
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OR Essential Drug List
Updated 07/01/2021 34 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cetirizine Hcl) ALL DAY RX/OTC (Cetirizine Hcl) EQ RX/OTC ALLERGY CHILDRENS, ALLERGY RELIEF SOLN 1 ALL-DAY ALLERGY OR 1 MG/ML CHILDRENS, CETIRIZINE (Cetirizine Hcl) QC RX/OTC HCL ALLERGY ALLERGY RELIEF 1 CHILDRENS, CETIRIZINE CHILDRENS SYRP HCL CHILDRENS, CETIRIZINE HCL (Cetirizine Hcl) RA RX/OTC CHILDRENSALLERGY, ALLERGY RELIEF 1 CETIRIZINE CHILDRENS SYRP 5 HYDROCHLORIDECHILD MG/5ML RENS ALLERGY, EQL ALL cetirizine hcl soln 1 RX/OTC DAY ALLERGY CLARINEX TABS PA; QL(1 ea CHILDRENS, GNP ALL GP DAY ALLERGY (desloratadine) daily) CHILDRENS, desloratadine tabs 5 PA; QL(1 ea GOODSENSE ALL DAY 1 daily) ALLERGYCHILDRENS, mg HM ALL DAY ALLERGY 1 desloratadine tbdp 2.5 1 CHILDRENS, HM mg, 5 mg CETIRIZINE HCL CHILDRENS, KLS ALLER- ZYRTEC CHILDRENS RX/OTC TEC CHILDRENS, PX ALLERGY SOLN GP CHILDRENS ALLERGY, (cetirizine hcl) QC CHILDRENS Antihistamines - Phenothiazines ALLERGY, SB CETIRIZINE HCL (Promethazine Hcl) CHILDRENS, SM ALL DAY PHENADOZ, 1 ALLERGY CHILDRENS, PROMETHEGAN SUPP PHENERGAN SOLN PA TGT ALL DAY ALLERGY SP RELIEF CHILDRENS, (promethazine hcl) WAL-ZYR, WAL-ZYR ALL promethazine hcl soln ij PA DAY ALLERGY SP CHILDRENS, WAL-ZYR 25 mg/ml, 50 mg/ml ALL DAY promethazine hcl soln 1 ALLERGYCHILDRENS, or 6.25 mg/5ml WAL-ZYR CHILDRENS SOLN promethazine hcl supp 1 (Cetirizine Hcl) ALLERGY RX/OTC re 12.5 mg, 25 mg, 50 RELIEF CHILDRENS, RA mg ALLERGY RELIEF 1 promethazine hcl syrp 1 CHILDRENS SOLN 1 or 6.25 mg/5ml MG/ML, 5 MG/5ML promethazine hcl tabs (Cetirizine Hcl) CVS RX/OTC ALLERGY RELIEF or 12.5 mg, 25 mg, 50 1 mg CHILDRENS, EQ 1 ALLERGY RELIEF Antihistamines - Piperidines CHILDRENS SOLN 5 MG/5ML cyproheptadine hcl syrp 1 cyproheptadine hcl tabs 1
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OR Essential Drug List
35 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANTIHYPERLIPIDEMICS - Drugs to Treat High colestipol hcl gran 1 Cholesterol Antihyperlipidemics - Combinations colestipol hcl pack 1 QL(1 ea daily) ezetimibe-simvastatin 1 colestipol hcl tabs 1 tabs VYTORIN TABS QL(1 ea daily) QUESTRAN LIGHT POWD GP GP (ezetimibe-simvastatin) (cholestyramine light) QUESTRAN PACK Antihyperlipidemics - Misc. GP (cholestyramine) ST icosapent ethyl caps 1 QUESTRAN POWD GP LOVAZA CAPS (omega- (cholestyramine) GP WELCHOL PACK 3-acid ethyl esters) GP omega-3-acid ethyl (colesevelam hcl) 1 WELCHOL TABS esters caps GP (colesevelam hcl) VASCEPA CAPS ST 3 (icosapent ethyl) Fibric Acid Derivatives ANTARA CAPS Bile Acid Sequestrants 3 (fenofibrate micronized) (Cholestyramine Light) 1 PREVALITE PACK choline fenofibrate cpdr 1 (Cholestyramine Light) 1 PREVALITE POWD fenofibrate caps 150 1 mg, 50 mg cholestyramine light 1 pack fenofibrate micronized 1 caps cholestyramine light 1 powd fenofibrate tabs 145 mg, 160 mg, 48 mg, 54 1 cholestyramine pack 1 mg FENOFIBRATE TABS 160 cholestyramine powd 1 3 MG (fenofibrate) 1 FENOFIBRIC ACID TABS colesevelam hcl pack 3 105 MG (fenofibric acid) colesevelam hcl tabs 1 FIBRICOR TABS 3 COLESTID FLAVORED (fenofibric acid) GP GRAN (colestipol hcl) gemfibrozil tabs 1 COLESTID FLAVORED GP LIPOFEN CAPS PACK (colestipol hcl) 3 (fenofibrate) COLESTID GRAN GP LOPID TABS (colestipol hcl) GP (gemfibrozil) COLESTID PACK GP TRICOR TABS (colestipol hcl) GP (fenofibrate) COLESTID TABS GP (colestipol hcl) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 36 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRIGLIDE TABS 3 Microsomal Triglyceride Transfer Protein (MTP) (fenofibrate) JUXTAPID CAPS PA SP TRILIPIX CPDR ( choline GP (lomitapide mesylate) fenofibrate) Nicotinic Acid Derivatives HMG CoA Reductase Inhibitors niacin ALTOPREV TB24 3 (antihyperlipidemic) 1 (lovastatin) tbcr atorvastatin calcium QL(1 ea daily) NIASPAN TBCR ( 1 niacin GP tabs (antihyperlipidemic)) fluvastatin sodium caps 1 QL(1 ea daily) Proprotein Convertase Subtilisin/Kexin Type 9 PRALUENT SOAJ PA QL(1 ea daily) SP fluvastatin sodium tb24 1 (alirocumab) LESCOL XL TB24 QL(1 ea daily) REPATHA PUSHTRONEX PA GP (fluvastatin sodium) SYSTEM SOCT SP LIVALO TABS ST; QL(1 ea (evolocumab) 3 daily) REPATHA SOSY PA (pitavastatin calcium) SP (evolocumab) 1 $0 copay, age lovastatin tabs 40 to 76;PV REPATHA SURECLICK PA SP PRAVACHOL TABS 20 QL(1 ea daily) SOAJ (evolocumab) MG, 80 MG (pravastatin GP ANTIHYPERTENSIVES - Drugs to Treat High sodium) Blood Pressure PRAVACHOL TABS 40 QL(2 ea daily) ACE Inhibitors MG (pravastatin GP ACCUPRIL TABS GP sodium) (quinapril hcl) pravastatin sodium QL(1 ea daily) ALTACE CAPS 1.25 MG, 5 QL(1 ea daily) GP tabs 10 mg, 20 mg, 80 1 MG (ramipril) mg ALTACE CAPS 10 MG QL(2 ea daily) QL(2 ea daily) GP pravastatin sodium 1 (ramipril) tabs 40 mg benazepril hcl tabs 1 QL(1 ea daily) rosuvastatin calcium 1 tabs captopril tabs 1 QL(1 ea daily) simvastatin tabs 10 mg, QL(2 ea daily) 20 mg, 40 mg, 5 mg, 1 enalapril maleate tabs 1 80 mg EPANED SOLN QL(5 ml daily) 3 ZOCOR TABS QL(1 ea daily) ( ) GP enalapril maleate (simvastatin) fosinopril sodium tabs 1 Intestinal Cholesterol Absorption Inhibitors 1 ezetimibe tabs 1 lisinopril tabs LOTENSIN TABS GP ZETIA TABS (ezetimibe) GP (benazepril hcl)
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OR Essential Drug List
37 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EDARBI TABS moexipril hcl tabs 1 3 (azilsartan medoxomil) perindopril erbumine 1 eprosartan mesylate 1 tabs tabs PRINIVIL TABS (lisinopril) GP irbesartan tabs 1 Limited to 1 QBRELIS SOLN losartan potassium tabs 1 3 bottle per (lisinopril) month.;QL(5 ml MICARDIS TABS daily) GP (telmisartan) quinapril hcl tabs 1 olmesartan medoxomil 1 QL(1 ea daily) tabs ramipril caps 1.25 mg, 1 2.5 mg, 5 mg telmisartan tabs 1 ramipril caps 10 mg 1 QL(2 ea daily) valsartan tabs 1 1 trandolapril tabs Antiadrenergic Antihypertensives VASOTEC TABS QL(2 ea daily) CARDURA TABS GP GP (enalapril maleate) (doxazosin mesylate) CATAPRES TABS ZESTRIL TABS (lisinopril) GP GP (clonidine hcl) Agents for Pheochromocytoma CATAPRES-TTS-1 PTWK DEMSER CAPS GP GP (clonidine) (metyrosine) CATAPRES-TTS-2 PTWK GP DIBENZYLINE CAPS (clonidine) (phenoxybenzamine GP CATAPRES-TTS-3 PTWK GP hcl) (clonidine) metyrosine caps 1 clonidine hcl tabs 1 phenoxybenzamine hcl 1 caps clonidine ptwk 1 Angiotensin II Receptor Antagonists doxazosin mesylate 1 ATACAND TABS tabs GP (candesartan cilexetil) guanfacine hcl tabs 1 AVAPRO TABS GP (irbesartan) methyldopa tabs 1 candesartan cilexetil MINIPRESS CAPS 1 GP tabs (prazosin hcl) COZAAR TABS ( losartan GP prazosin hcl caps 1 potassium) DIOVAN TABS terazosin hcl caps 1 GP (valsartan) Antihypertensive Combinations
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OR Essential Drug List
Updated 07/01/2021 38 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACCURETIC TABS DIOVAN HCT TABS (quinapril- GP (valsartan- GP hydrochlorothiazide) hydrochlorothiazide) DUTOPROL TB24 amlodipine besylate- 1 benazepril hcl caps (metoprolol & 3 amlodipine besylate- hydrochlorothiazide) olmesartan medoxomil 1 EDARBYCLOR TABS tabs (azilsartan medoxomil- 3 chlorthalidone) amlodipine besylate- 1 valsartan tabs enalapril maleate & amlodipine-valsartan- hydrochlorothiazide 1 hydrochlorothiazide 1 tabs tabs EXFORGE HCT TABS ( ATACAND HCT TABS amlodipine-valsartan- 2 ) (candesartan cilexetil- GP hydrochlorothiazide hydrochlorothiazide) EXFORGE TABS (amlodipine besylate- GP atenolol & 1 valsartan) chlorthalidone tabs AVALIDE TABS fosinopril sodium & 1 (irbesartan- GP hydrochlorothiazide hydrochlorothiazide) tabs HYZAAR TABS ( AZOR TABS (amlodipine losartan GP besylate-olmesartan GP potassium & ) medoxomil) hydrochlorothiazide benazepril & irbesartan- 1 hydrochlorothiazide 1 hydrochlorothiazide tabs tabs BENICAR HCT TABS lisinopril & (olmesartan hydrochlorothiazide 1 medoxomil- GP tabs hydrochlorothiazide) LOPRESSOR HCT TABS bisoprolol & (metoprolol & GP hydrochlorothiazide 1 hydrochlorothiazide) tabs losartan potassium & BYVALSON TABS hydrochlorothiazide 1 3 (nebivolol-valsartan) tabs candesartan cilexetil- LOTENSIN HCT TABS hydrochlorothiazide 1 (benazepril & GP tabs hydrochlorothiazide) captopril & LOTREL CAPS (amlodipine besylate- GP hydrochlorothiazide 1 benazepril hcl) tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
39 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits methyldopa & TENORETIC 50 TABS hydrochlorothiazide 1 (atenolol & GP tabs chlorthalidone) metoprolol & trandolapril-verapamil 1 hydrochlorothiazide 1 hcl tbcr tabs TRIBENZOR TABS (olmesartan METOPROLOL GP SUCCINATE medoxomil-amlodipine- ER/HYDROCHLOROTHIA 3 hydrochlorothiazide) ZIDE TB24 (metoprolol TWYNSTA TABS & hydrochlorothiazide) (telmisartan- GP MICARDIS HCT TABS amlodipine) (telmisartan- GP valsartan- hydrochlorothiazide) hydrochlorothiazide 1 olmesartan medoxomil- tabs amlodipine- 1 VASERETIC TABS hydrochlorothiazide (enalapril maleate & GP tabs hydrochlorothiazide) olmesartan medoxomil- ZESTORETIC TABS hydrochlorothiazide 1 (lisinopril & GP tabs hydrochlorothiazide) propranolol & ZIAC TABS ( bisoprolol & GP hydrochlorothiazide 1 hydrochlorothiazide) tabs Antihypertensives - Misc. quinapril- VECAMYL TABS PA SP hydrochlorothiazide 1 (mecamylamine hcl) tabs TARKA TBCR Direct Renin Inhibitors (trandolapril-verapamil GP aliskiren fumarate tabs 1 ) hcl TEKTURNA TABS 3 TEKTURNA HCT TABS (aliskiren fumarate) (aliskiren- 3 hydrochlorothiazide) Selective Aldosterone Receptor Antagonists eplerenone tabs 1 telmisartan-amlodipine 1 tabs INSPRA TABS GP telmisartan- (eplerenone) 1 hydrochlorothiazide Vasodilators tabs PA hydralazine hcl soln ij SP TENORETIC 100 TABS 20 mg/ml (atenolol & GP chlorthalidone) hydralazine hcl tabs or 10 mg, 100 mg, 25 mg, 1 50 mg You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 40 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits minoxidil tabs 1 FIRDAPSE TABS PA (amifampridine SP ANTIMALARIALS - Drugs to Treat Malaria phosphate) (Parasitic Infections) GUANIDINE HCL TABS 2 Antimalarial Combinations (guanidine hcl) MESTINON SOLN 60 PA atovaquone-proguanil 1 hcl tabs MG/5ML (pyridostigmine GP COARTEM TABS Limit 24 per bromide) (artemether- 2 month;QL(0.8 MESTINON TABS 60 MG lumefantrine) ea daily) (pyridostigmine GP MALARONE TABS bromide) (atovaquone-proguanil GP MESTINON TIMESPAN hcl) TBCR (pyridostigmine GP ) Antimalarials bromide pyridostigmine bromide PA chloroquine phosphate 1 1 tabs soln 60 mg/5ml DARAPRIM TABS PA pyridostigmine bromide 3 1 (pyrimethamine) tabs 60 mg KRINTAFEL TABS QL(2 ea per 30 pyridostigmine bromide 2 1 (tafenoquine succinate) days retail) tbcr 180 mg RUZURGI TABS PA; QL(10 ea 1 QL(6 ea per fill SP mefloquine hcl tabs retail) (amifampridine) daily) PLAQUENIL TABS ANTIMYCOBACTERIAL AGENTS - Drugs to (hydroxychloroquine 1 Treat Tuberculosis (Bacterial Infections) sulfate) Anti TB Combinations primaquine phosphate RIFAMATE CAPS 1 2 tabs (isoniazid & rifampin) PRIMAQUINE RIFATER TABS PHOSPHATE TABS GP (isoniazid-rifampin w/ 3 (primaquine phosphate) pyrazinamide) PA pyrimethamine tabs 1 Antimycobacterial Agents CAPASTAT SULFATE PA QUALAQUIN CAPS PA; QL(42 ea GP per 7 days SOLR (capreomycin SP (quinine sulfate) retail) sulfate) PA; QL(42 ea quinine sulfate caps 1 per 7 days cycloserine caps 1 retail) ethambutol hcl tabs 1 ANTIMYASTHENIC/CHOLINERGIC AGENTS PA isoniazid soln ij 100 SP Antimyasthenic/Cholinergic Agents mg/ml isoniazid syrp or 50 1 mg/5ml
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OR Essential Drug List
41 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CYCLOPHOSPHAMIDE isoniazid tabs or 100 1 mg, 300 mg TABS 25 MG AC MYAMBUTOL TABS (cyclophosphamide) GP GLEOSTINE CAPS PA (ethambutol hcl) AC MYCOBUTIN CAPS (lomustine) GP LEUKERAN TABS (rifabutin) AC PASER PACK (chlorambucil) 3 (aminosalicylic acid) melphalan hcl solr AC PA PRIFTIN TABS 3 (rifapentine) melphalan tabs AC MYLERAN TABS pyrazinamide tabs 1 AC (busulfan) rifabutin caps 1 TEMODAR CAPS AC RIFADIN CAPS OR 150 (temozolomide) GP MG, 300 MG (rifampin) temozolomide caps AC RIFADIN SOLR IV 600 MG PA ZANOSAR SOLR PA SP AC (rifampin) (streptozocin) rifampin caps or 150 1 mg, 300 mg Antimetabolites (Fluorouracil) ADRUCIL AC PA rifampin solr iv 600 mg SP PA SOLN SIRTURO TABS 100 MG ALIMTA SOLR SP AC (bedaquiline fumarate) (pemetrexed disodium) SIRTURO TABS 20 MG ARRANON SOLN PA 3 AC (bedaquiline fumarate) (nelarabine) TRECATOR TABS azacitidine susr AC PA 2 (ethionamide) capecitabine tabs AC ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer cladribine soln AC PA Alkylating Agents PA ALKERAN SOLR IV 50 MG PA clofarabine soln AC AC (melphalan hcl) CLOLAR SOLN PA ALKERAN TABS OR 2 MG AC AC (clofarabine) (melphalan) cytarabine soln AC PA busulfan soln AC PA DACOGEN SOLR PA BUSULFEX SOLN PA AC AC (decitabine) (busulfan) decitabine solr AC PA cyclophosphamide AC caps 25 mg, 50 mg floxuridine solr AC PA
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OR Essential Drug List
Updated 07/01/2021 42 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA fludarabine phosphate AC Antineoplastic - Angiogenesis Inhibitors soln INLYTA TABS (axitinib) AC PA PA fludarabine phosphate AC solr LENVIMA 10 MG DAILY PA PA DOSE CPPK (lenvatinib AC fluorouracil soln AC mesylate) gemcitabine hcl soln AC PA LENVIMA 12MG DAILY PA DOSE CPPK (lenvatinib AC gemcitabine hcl solr AC PA mesylate) LENVIMA 14 MG DAILY PA GEMCITABINE PA HYDROCHLORIDE SOLN DOSE CPPK (lenvatinib AC 1 GM/10ML, 2 GM/20ML, AC mesylate) 200 MG/2ML LENVIMA 18 MG DAILY PA (gemcitabine hcl) DOSE CPPK (lenvatinib AC GEMCITABINE PA mesylate) HYDROCHLORIDE SOLN AC LENVIMA 20 MG DAILY PA 1.5 GM/15ML DOSE CPPK (lenvatinib AC (gemcitabine hcl) mesylate) GEMCITABINE SOLN PA AC LENVIMA 24 MG DAILY PA (gemcitabine hcl) DOSE CPPK (lenvatinib AC mercaptopurine tabs AC mesylate) LENVIMA 4 MG DAILY PA methotrexate sodium DOSE CPPK (lenvatinib AC soln ij 1 gm/40ml, 250 SP mesylate) mg/10ml, 50 mg/2ml LENVIMA 8 MG DAILY PA methotrexate sodium SP DOSE CPPK (lenvatinib AC solr ij 1 gm mesylate) methotrexate sodium 1 Antineoplastic - Anti-HER2 Agents tabs or 2.5 mg TUKYSA TABS PA ONUREG TABS PA AC AC (tucatinib) (azacitidine) PURIXAN SUSP PA; AL(Up to Antineoplastic - Antibodies AC ARZERRA CONC PA (mercaptopurine) 13 yrs old ) AC TABLOID TABS (ofatumumab) AC CAMPATH SOLN PA (thioguanine) AC ) TREXALL TABS (alemtuzumab 3 RITUXAN SOLN PA (methotrexate sodium) AC VIDAZA SUSR PA (rituximab) AC YERVOY SOLN PA (azacitidine) AC XATMEP SOLN PA (ipilimumab) AC (methotrexate) Antineoplastic - BCL-2 Inhibitors XELODA TABS AC (capecitabine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
43 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VENCLEXTA STARTING PA DEPO-PROVERA SUSP PA PACK TBPK AC (medroxyprogesterone (venetoclax) acetate SP VENCLEXTA TABS PA (antineoplastic)) AC (venetoclax) ELIGARD KIT ( PA leuprolide AC Antineoplastic - EGFR Inhibitors acetate (3 month)) ERBITUX SOLN PA ELIGARD KIT ( PA AC leuprolide AC (cetuximab) acetate (4 month)) PA ELIGARD KIT ( PA erlotinib hcl tabs AC leuprolide AC acetate (6 month)) GILOTRIF TABS (afatinib PA AC ELIGARD KIT (leuprolide PA dimaleate) AC acetate) PA IRESSA TABS (gefitinib) AC EMCYT CAPS TAGRISSO TABS PA (estramustine AC AC (osimertinib mesylate) phosphate sodium) TARCEVA TABS PA ERLEADA TABS PA AC AC (erlotinib hcl) (apalutamide) VIZIMPRO TABS PA AC AC exemestane tabs (dacomitinib) FARESTON TABS AC Antineoplastic - Hedgehog Pathway Inhibitors (toremifene citrate) DAURISMO TABS PA FEMARA TABS AC AC (glasdegib maleate) (letrozole) ERIVEDGE CAPS FIRMAGON SOLR PA AC AC (vismodegib) (degarelix acetate) ODOMZO CAPS PA AC AC (sonidegib phosphate) flutamide caps Antineoplastic - Hormonal and Related Agents letrozole tabs AC PA abiraterone acetate AC PA tabs leuprolide acetate kit AC AC LEUPROLIDE PA anastrozole tabs ACETATE/BUPIVACAINE ARIMIDEX TABS HYDROCHLORIDE SOLN AC AC (anastrozole) (leuprolide acetate- AROMASIN TABS bupivacaine hcl) AC (exemestane) LUPRON DEPOT (1- PA MONTH) KIT 3.75 MG SP bicalutamide tabs AC (leuprolide acetate) CASODEX TABS PA AC LUPRON DEPOT (1- (bicalutamide) MONTH) KIT 7.5 MG AC (leuprolide acetate)
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Updated 07/01/2021 44 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LUPRON DEPOT (3- PA Antineoplastic - Immunomodulators MONTH) KIT 11.25 MG POMALYST CAPS PA SP AC (leuprolide acetate (3 (pomalidomide) month)) LUPRON DEPOT (3- PA Antineoplastic - PDGFR-alpha Inhibitors AYVAKIT TABS PA; QL(1 ea MONTH) KIT 22.5 MG AC AC (leuprolide acetate (3 (avapritinib) daily) month)) Antineoplastic - XPO1 Inhibitors LUPRON DEPOT (4- PA XPOVIO 100 MG ONCE PA MONTH) KIT (leuprolide AC WEEKLY TBPK AC acetate (4 month)) (selinexor) LUPRON DEPOT (6- PA XPOVIO 40 MG ONCE PA MONTH) KIT (leuprolide AC WEEKLY TBPK AC acetate (6 month)) (selinexor) LYSODREN TABS AC XPOVIO 40 MG TWICE PA (mitotane) WEEKLY TBPK AC (selinexor) megestrol acetate susp 1 40 mg/ml, 400 mg/10ml XPOVIO 60 MG ONCE PA WEEKLY TBPK AC megestrol acetate tabs AC 20 mg, 40 mg (selinexor) XPOVIO 60 MG TWICE PA NILANDRON TABS AC WEEKLY TBPK AC (nilutamide) (selinexor) nilutamide tabs AC XPOVIO 80 MG ONCE PA WEEKLY TBPK AC NUBEQA TABS PA AC (selinexor) (darolutamide) XPOVIO 80 MG TWICE PA SOLTAMOX SOLN AC WEEKLY TBPK AC (tamoxifen citrate) (selinexor) AC PV XPOVIO TBPK PA tamoxifen citrate tabs AC (selinexor) toremifene citrate tabs AC Antineoplastic Antibiotics TRELSTAR MIXJECT PA mitoxantrone hcl conc SP PA SUSR (triptorelin AC pamoate) Antineoplastic Combinations XTANDI CAPS PA AC KISQALI FEMARA 200 PA (enzalutamide) DOSE TBPK (ribociclib AC XTANDI TABS PA succinate-letrozole) AC (enzalutamide) KISQALI FEMARA 400 PA YONSA TABS PA DOSE TBPK (ribociclib AC AC (abiraterone acetate) succinate-letrozole) ZYTIGA TABS PA KISQALI FEMARA 600 PA AC (abiraterone acetate) DOSE TBPK (ribociclib AC succinate-letrozole) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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45 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LONSURF TABS PA FOTIVDA CAPS PA AC AC (trifluridine-tipiracil) (tivozanib hcl) RITUXAN HYCELA SOLN PA GLEEVEC TABS ( PA imatinib AC (rituximab- AC mesylate) hyaluronidase human) IBRANCE CAPS PA AC Antineoplastic Enzyme Inhibitors (palbociclib) AFINITOR DISPERZ TBSO PA; QL(1 ea IBRANCE TABS PA AC AC (everolimus) daily) (palbociclib) AFINITOR TABS 10 MG PA; QL(1 ea ICLUSIG TABS 10 MG, 30 PA AC AC (everolimus) daily) MG (ponatinib hcl) AFINITOR TABS 2.5 MG, 5 PA; QL(1 ea ICLUSIG TABS 15 MG, 45 AC AC MG, 7.5 MG (everolimus) daily) MG (ponatinib hcl) ALECENSA CAPS PA IDHIFA TABS PA AC AC (alectinib hcl) (enasidenib mesylate) ALUNBRIG TABS PA PA AC imatinib mesylate tabs AC (brigatinib) ALUNBRIG TBPK PA IMBRUVICA CAPS PA AC AC (brigatinib) (ibrutinib) BALVERSA TABS PA IMBRUVICA TABS PA AC AC (erdafitinib) (ibrutinib) BOSULIF TABS PA INREBIC CAPS PA AC AC (bosutinib) (fedratinib hcl) PA BRAFTOVI CAPS PA ISTODAX (OVERFILL) AC AC SOLR (romidepsin) (encorafenib) PA BRUKINSA CAPS PA JAKAFI TABS (ruxolitinib AC AC (zanubrutinib) phosphate) CABOMETYX TABS PA KISQALI TBPK (ribociclib PA AC AC (cabozantinib s-malate) succinate) CALQUENCE CAPS PA KOSELUGO CAPS PA AC SP (acalabrutinib) (selumetinib sulfate) CAPRELSA TABS PA AC lapatinib ditosylate tabs AC (vandetanib) LORBRENA TABS PA COMETRIQ KIT AC AC (lorlatinib) (cabozantinib s-malate) LUMAKRAS TABS PA COPIKTRA CAPS PA AC AC (sotorasib) (duvelisib) LYNPARZA TABS PA COTELLIC TABS PA AC AC (olaparib) (cobimetinib fumarate) MEKINIST TABS PA AC PA; QL(1 ea ( AC everolimus tabs daily) trametinib dimethyl sulfoxide) FARYDAK CAPS PA AC (panobinostat lactate)
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Updated 07/01/2021 46 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MEKTOVI TABS PA TAZVERIK TABS PA AC AC (binimetinib) (tazemetostat hbr) NERLYNX TABS PA PA AC temsirolimus soln AC (neratinib maleate) NEXAVAR TABS PA TIBSOVO TABS PA AC AC (sorafenib tosylate) (ivosidenib) NINLARO CAPS PA TORISEL SOLN PA AC AC (ixazomib citrate) (temsirolimus) PEMAZYRE TABS PA; QL(1 ea TRUSELTIQ CPPK PA AC AC (pemigatinib) daily) (infigratinib phosphate) PIQRAY 200MG DAILY PA TURALIO CAPS PA AC AC DOSE TBPK (alpelisib) (pexidartinib hcl) PIQRAY 250MG DAILY PA TYKERB TABS (lapatinib PA AC AC DOSE TBPK (alpelisib) ditosylate) PIQRAY 300MG DAILY PA VELCADE SOLR PA AC AC DOSE TBPK (alpelisib) (bortezomib) QINLOCK TABS PA VERZENIO TABS PA AC AC (ripretinib) (abemaciclib) RETEVMO CAPS PA VITRAKVI CAPS PA AC AC (selpercatinib) (larotrectinib sulfate) ROMIDEPSIN SOLR PA VITRAKVI SOLN PA AC AC (romidepsin) (larotrectinib sulfate) ROZLYTREK CAPS PA VOTRIENT TABS PA AC AC (entrectinib) (pazopanib hcl) RUBRACA TABS PA XALKORI CAPS PA AC AC (rucaparib camsylate) (crizotinib) RYDAPT CAPS PA XOSPATA TABS PA AC AC (midostaurin) (gilteritinib fumarate) SPRYCEL TABS PA ZEJULA CAPS (niraparib PA AC AC (dasatinib) tosylate) STIVARGA TABS PA; SP ZELBORAF TABS PA AC AC (regorafenib) (vemurafenib) SUTENT CAPS ( PA ZOLINZA CAPS PA sunitinib AC AC malate) (vorinostat) TABRECTA TABS PA ZYDELIG TABS PA AC AC (capmatinib hcl) (idelalisib) TAFINLAR CAPS PA ZYKADIA CAPS PA AC AC (dabrafenib mesylate) (ceritinib) TALZENNA CAPS PA ZYKADIA TABS PA AC AC (talazoparib tosylate) (ceritinib) TASIGNA CAPS ( PA Antineoplastics Misc. nilotinib AC hcl) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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47 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ACTIMMUNE SOLN PA ETOPOPHOS SOLR PA SP AC (interferon gamma-1b) (etoposide phosphate) ALFERON N SOLN PA AC etoposide caps or 50 AC (interferon alfa-n3) mg bexarotene caps AC PA etoposide soln iv 1 PA gm/50ml, 100 mg/5ml, AC HYDREA CAPS AC 500 mg/25ml (hydroxyurea) Topoisomerase I Inhibitors hydroxyurea caps AC HYCAMTIN CAPS OR 0.25 PA INTRON A SOLN PA MG, 1 MG (topotecan AC AC (interferon alfa-2b) hcl) INTRON A SOLR PA HYCAMTIN SOLR IV 4 MG PA AC AC (interferon alfa-2b) (topotecan hcl) MATULANE CAPS topotecan hcl soln 4 PA AC AC (procarbazine hcl) mg/4ml SYLATRON KIT PA TOPOTECAN HCL SOLN PA (peginterferon alfa-2b AC 4 MG/4ML (topotecan AC (antineoplastic)) hcl) TARGRETIN CAPS OR 75 PA TOPOTECAN HCL SOLN PA AC MG (bexarotene) 4 MG/4ML (topotecan AC hcl) tretinoin AC (chemotherapy) caps topotecan hcl solr 4 mg AC PA UVADEX SOLN PA (methoxsalen SP ANTIPARKINSON AND RELATED THERAPY (photopheresis)) AGENTS - Drugs to Treat Parkinson's Disease Chemotherapy Adjuncts Antiparkinson Adjunctive Therapy KEPIVANCE SOLR PA carbidopa tabs 1 SP (palifermin) LODOSYN TABS GP Chemotherapy Rescue/Antidote/Protective Agents (carbidopa) PA leucovorin calcium soln AC Antiparkinson Anticholinergics ij 500 mg/50ml benztropine mesylate PA PA SP leucovorin calcium solr AC soln ij 1 mg/ml ij 100 mg, 350 mg benztropine mesylate leucovorin calcium tabs tabs or 0.5 mg, 1 mg, 2 1 or 10 mg, 15 mg, 25 AC mg mg, 5 mg COGENTIN SOLN PA SP MESNEX TABS (mesna) AC (benztropine mesylate) Mitotic Inhibitors trihexyphenidyl hcl soln 1 (Etoposide) TOPOSAR AC PA 1 SOLN trihexyphenidyl hcl tabs
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Updated 07/01/2021 48 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antiparkinson COMT Inhibitors NEUPRO PT24 4 QL(1 ea daily) COMTAN TABS MG/24HR, 6 MG/24HR 3 GP ) (entacapone) (rotigotine OSMOLEX ER T4PK PA 3 entacapone tabs 1 (amantadine hcl) TASMAR TABS OSMOLEX ER TB24 PA GP 3 (tolcapone) (amantadine hcl) PARLODEL CAPS tolcapone tabs 1 (bromocriptine GP Antiparkinson Dopaminergics mesylate) amantadine hcl caps 1 PARLODEL TABS (bromocriptine GP amantadine hcl syrp 1 mesylate) pramipexole 1 amantadine hcl tabs 1 dihydrochloride tabs pramipexole bromocriptine mesylate 1 1 caps dihydrochloride tb24 REQUIP XL TB24 bromocriptine mesylate 1 tabs (ropinirole GP hydrochloride) carbidopa-levodopa 1 tabs ropinirole hydrochloride 1 tabs carbidopa-levodopa 1 tbcr ropinirole hydrochloride 1 carbidopa-levodopa tb24 1 RYTARY CPCR PA tbdp 3 carbidopa-levodopa- (carbidopa-levodopa) 1 SINEMET CR TBCR entacapone tabs GP (carbidopa-levodopa) DUOPA SUSP SP SINEMET TABS (carbidopa-levodopa) GP (carbidopa-levodopa) GOCOVRI CP24 PA 3 (amantadine hcl) STALEVO 100 TABS (carbidopa-levodopa- GP MIRAPEX ER TB24 entacapone) (pramipexole GP dihydrochloride) STALEVO 125 TABS (carbidopa-levodopa- GP MIRAPEX TABS entacapone) (pramipexole GP dihydrochloride) STALEVO 150 TABS (carbidopa-levodopa- GP NEUPRO PT24 1 ) MG/24HR, 3 MG/24HR, 8 3 entacapone MG/24HR (rotigotine) STALEVO 200 TABS NEUPRO PT24 2 QL(3 ea daily) (carbidopa-levodopa- GP 3 MG/24HR (rotigotine) entacapone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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49 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STALEVO 50 TABS NUPLAZID CAPS PA; QL(1 ea SP (carbidopa-levodopa- GP (pimavanserin tartrate) daily) entacapone) NUPLAZID TABS PA; QL(1 ea SP STALEVO 75 TABS (pimavanserin tartrate) daily) (carbidopa-levodopa- GP VRAYLAR CAPS PA 3 entacapone) (cariprazine hcl) VRAYLAR CPPK PA Antiparkinson Monoamine Oxidase Inhibitors 3 AZILECT TABS (cariprazine hcl) GP (rasagiline mesylate) ziprasidone hcl caps 1 rasagiline mesylate 1 PA tabs ziprasidone mesylate SP solr 1 selegiline hcl caps Benzisoxazoles FANAPT TABS PA selegiline hcl tabs 1 3 (iloperidone) ZELAPAR TBDP 3 FANAPT TITRATION PA (selegiline hcl) PACK TABS 3 ANTIPSYCHOTICS/ANTIMANIC AGENTS - (iloperidone) Drugs to Treat Mood Disorders INVEGA SUSTENNA PA Antimanic Agents SUSY (paliperidone SP palmitate) lithium carbonate caps 1 INVEGA TB24 GP lithium carbonate tabs 1 (paliperidone) INVEGA TRINZA SUSY PA SP lithium carbonate tbcr 1 (paliperidone palmitate) LITHIUM SOLN (lithium) 3 paliperidone tb24 1 LITHOBID TBCR ( PERSERIS PRSY PA lithium 3 SP carbonate) (risperidone) RISPERDAL CONSTA PA Antipsychotics - Misc. SRER (risperidone SP CAPLYTA CAPS PA; QL(1 ea 3 microspheres) (lumateperone tosylate) daily) RISPERDAL SOLN EQUETRO CP12 GP (risperidone) (carbamazepine 3 RISPERDAL TABS (antipsychotic)) GP (risperidone) GEODON CAPS OR 20 MG, 40 MG, 60 MG, 80 MG GP risperidone soln 1 (ziprasidone hcl) GEODON SOLR IM 20 MG PA risperidone tabs 1 SP (ziprasidone mesylate) risperidone tbdp 1 LATUDA TABS PA 3 (lurasidone hcl) Butyrophenones
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Updated 07/01/2021 50 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SECUADO PT24 PA; QL(1 ea haloperidol lactate conc 1 3 (asenapine) daily) haloperidol tabs 1 SEROQUEL TABS GP (quetiapine fumarate) Dibenzapines SEROQUEL XR TB24 PA PA GP asenapine maleate 1 (quetiapine fumarate) subl VERSACLOZ SUSP QL(18 ml daily) 3 clozapine tabs 100 mg, 1 (clozapine) 200 mg, 25 mg, 50 mg ZYPREXA SOLR IM 10 PA SP clozapine tbdp 100 mg, MG (olanzapine) 12.5 mg, 150 mg, 200 1 ZYPREXA TABS OR 10 mg, 25 mg MG, 15 MG, 2.5 MG, 20 GP CLOZARIL TABS MG, 5 MG, 7.5 MG GP (clozapine) (olanzapine) FAZACLO TBDP 100 MG, ZYPREXA ZYDIS TBDP GP GP 25 MG (clozapine) (olanzapine) FAZACLO TBDP 12.5 MG, Dihydroindolones 150 MG, 200 MG 3 1 (clozapine) molindone hcl tabs Phenothiazines loxapine succinate 1 caps (Prochlorperazine) 1 PA COMPRO SUPP olanzapine solr im 10 SP mg chlorpromazine hcl tabs 1 olanzapine tabs or 10 fluphenazine hcl conc 5 1 mg, 15 mg, 2.5 mg, 20 1 mg/ml mg, 5 mg, 7.5 mg fluphenazine hcl elix 1 olanzapine tbdp or 10 2.5 mg/5ml mg, 15 mg, 20 mg, 5 1 mg fluphenazine hcl tabs 1 mg, 10 mg, 2.5 mg, 5 1 quetiapine fumarate mg tabs 100 mg, 200 mg, 1 25 mg, 300 mg, 400 perphenazine tabs 1 mg, 50 mg prochlorperazine 1 quetiapine fumarate PA maleate tabs tb24 150 mg, 200 mg, 1 300 mg, 400 mg, 50 prochlorperazine supp 1 mg thioridazine hcl tabs 1 SAPHRIS SUBL 10 MG, PA 2.5 MG, 5 MG (asenapine GP trifluoperazine hcl tabs 1 maleate) SAPHRIS SUBL 5 MG PA Quinolinone Derivatives 3 (asenapine maleate)
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51 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ABILIFY TABS BIKTARVY TABS GP (aripiprazole) (bictegravir- emtricitabine-tenofovir 2 aripiprazole soln 1 1 mg/ml alafenamide fumarate) COMBIVIR TABS aripiprazole tabs 10 GP mg, 15 mg, 2 mg, 20 1 (lamivudine-zidovudine) mg, 30 mg, 5 mg COMPLERA TABS ST PA (emtricitabine- aripiprazole tbdp 10 1 2 mg, 15 mg rilpivirine-tenofovir disoproxil fumarate) REXULTI TABS PA 3 CRIXIVAN CAPS (brexpiprazole) 2 (indinavir sulfate) Thioxanthenes DELSTRIGO TABS ST thiothixene caps 1 (doravirine-lamivudine- tenofovir disoproxil 3 ANTISEPTICS & DISINFECTANTS fumarate) Antiseptics & Disinfectants DESCOVY TABS PA (emtricitabine-tenofovir 2 formaldehyde soln 1 alafenamide fumarate) ANTIVIRALS - Drugs to Treat Viral Infections didanosine cpdr 1 Antiretrovirals DOVATO TABS (dolutegravir sodium- 2 abacavir sulfate soln 1 lamivudine) EDURANT TABS abacavir sulfate tabs 1 2 (rilpivirine hcl) abacavir sulfate- 1 lamivudine tabs efavirenz caps 1 abacavir sulfate- efavirenz tabs 1 lamivudine-zidovudine 1 tabs efavirenz-emtricitabine- tenofovir disoproxil 1 APTIVUS CAPS 2 fumarate tabs (tipranavir) APTIVUS SOLN emtricitabine caps 1 2 (tipranavir) emtricitabine-tenofovir atazanavir sulfate caps 1 disoproxil fumarate 1 tabs ATRIPLA TABS EMTRIVA CAPS 200 MG (efavirenz- GP emtricitabine-tenofovir GP (emtricitabine) EMTRIVA SOLN 10 disoproxil fumarate) 2 MG/ML (emtricitabine) EPIVIR SOLN GP (lamivudine) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 52 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits EPIVIR TABS LEXIVA SUSP 50 MG/ML GP (lamivudine) (fosamprenavir 2 EPZICOM TABS calcium) (abacavir sulfate- GP LEXIVA TABS 700 MG lamivudine) (fosamprenavir GP EVOTAZ TABS calcium) (atazanavir sulfate- 2 lopinavir-ritonavir soln 1 cobicistat) nevirapine susp 1 fosamprenavir calcium 1 tabs 1 FUZEON SOLR PA nevirapine tabs SP (enfuvirtide) nevirapine tb24 1 GENVOYA TABS NORVIR SOLN 80 MG/ML (elvitegravir-cobicistat- 2 emtricitabine-tenofovir 2 (ritonavir) NORVIR TABS 100 MG alafenamide) GP INTELENCE TABS (ritonavir) 2 PIFELTRO TABS (etravirine) 2 INVIRASE TABS (doravirine) 2 PREZCOBIX TABS (saquinavir mesylate) 2 ISENTRESS CHEW (darunavir-cobicistat) 2 PREZISTA SUSP (raltegravir potassium) 2 ISENTRESS HD TABS (darunavir ethanolate) 2 PREZISTA TABS (raltegravir potassium) 2 ISENTRESS PACK (darunavir ethanolate) 2 RESCRIPTOR TABS (raltegravir potassium) 2 ISENTRESS TABS (delavirdine mesylate) 2 RETROVIR CAPS (raltegravir potassium) GP JULUCA TABS (zidovudine) RETROVIR SYRP (dolutegravir sodium- 2 GP rilpivirine hcl) (zidovudine) KALETRA SOLN REYATAZ CAPS 150 MG, GP (lopinavir-ritonavir) 200 MG (atazanavir GP KALETRA TABS sulfate) GP REYATAZ PACK 50 MG (lopinavir-ritonavir) 2 (atazanavir sulfate) lamivudine soln 1 ritonavir tabs 1 1 lamivudine tabs RUKOBIA TB12 PA (fostemsavir SP lamivudine-zidovudine 1 tabs tromethamine) SELZENTRY SOLN 2 (maraviroc) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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53 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SELZENTRY TABS VIRACEPT TABS 2 2 (maraviroc) (nelfinavir mesylate) VIRAMUNE SUSP stavudine caps 15 mg, 1 GP 20 mg, 30 mg, 40 mg (nevirapine) VIRAMUNE TABS STAVUDINE CAPS 15 MG, GP 20 MG, 30 MG, 40 MG 2 (nevirapine) (stavudine) VIRAMUNE XR TB24 GP STRIBILD TABS (nevirapine) (elvitegravir-cobicistat- 2 VIREAD POWD 40 MG/GM emtricitabine-tenofovir (tenofovir disoproxil 2 df) fumarate) SUSTIVA CAPS GP VIREAD TABS 150 MG, (efavirenz) 200 MG, 250 MG 2 SUSTIVA TABS (tenofovir disoproxil GP (efavirenz) fumarate) SYMTUZA TABS ST ZIAGEN SOLN ( abacavir GP (darunavir-cobicistat- sulfate) 3 emtricitabine-tenofovir ZIAGEN TABS ( abacavir GP alafenamide) sulfate) tenofovir disoproxil 1 fumarate tabs zidovudine caps 1 TIVICAY TABS 50 MG 2 zidovudine syrp 1 (dolutegravir sodium) TRIUMEQ TABS zidovudine tabs 1 ( 2 abacavir-dolutegravir- CMV Agents lamivudine) PA TRIZIVIR TABS (abacavir cidofovir soln SP sulfate-lamivudine- GP foscarnet sodium soln SP PA zidovudine) FOSCAVIR SOLN PA TRUVADA TABS SP (emtricitabine-tenofovir GP (foscarnet sodium) PREVYMIS TABS PA; SP disoproxil fumarate) SP TYBOST TABS (letermovir) 2 (cobicistat) VALCYTE SOLR 50 QL(21 ml daily) VIDEX EC CPDR 125 MG MG/ML (valganciclovir GP 2 (didanosine) hcl) VALCYTE TABS 450 MG VIDEX EC CPDR 200 MG, GP 250 MG, 400 MG 3 (valganciclovir hcl) (didanosine) QL(21 ml daily) valganciclovir hcl solr 1 VIDEXPEDIATRIC SOLR 50 mg/ml 2 (didanosine) valganciclovir hcl tabs 1 450 mg
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Updated 07/01/2021 54 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA Hepatitis Agents ribavirin (hepatitis c) 1 caps (Ribavirin (Hepatitis C)) 1 PA RIBASPHERE CAPS PA ribavirin (hepatitis c) 1 (Ribavirin (Hepatitis C)) PA tabs RIBASPHERE RIBAPAK 1 SOFOSBUVIR/VELPATAS TBPK 400 MG, 600 MG VIR TABS (sofosbuvir- AC (Ribavirin (Hepatitis C)) 1 PA ) RIBASPHERE TABS velpatasvir SOVALDI TABS 200 MG, PA 3 adefovir dipivoxil tabs 1 400 MG (sofosbuvir) BARACLUDE SOLN 0.05 VEMLIDY TABS PA 2 MG/ML (entecavir) (tenofovir alafenamide SP BARACLUDE TABS 0.5 fumarate) GP MG, 1 MG (entecavir) VOSEVI TABS PA DAKLINZA TABS PA (sofosbuvir-velpatasvir- 3 (daclatasvir SP voxilaprevir) dihydrochloride) Herpes Agents entecavir tabs 1 acyclovir caps 1 EPCLUSA TABS 100 MG- PA acyclovir susp 1 400 MG (sofosbuvir- 3 velpatasvir) acyclovir tabs 1 EPIVIR HBV SOLN 5 MG/ML (lamivudine 3 famciclovir tabs 1 (hbv)) 1 EPIVIR HBV TABS 100 valacyclovir hcl tabs GP MG (lamivudine (hbv)) VALTREX TABS GP (valacyclovir hcl) lamivudine (hbv) tabs 1 ZOVIRAX CAPS OR 200 GP MAVYRET TABS PA MG (acyclovir) (glecaprevir- SP ZOVIRAX SUSP OR 200 GP pibrentasvir) MG/5ML (acyclovir) PEGASYS PROCLICK PA ZOVIRAX TABS OR 400 GP SOLN (peginterferon SP MG, 800 MG (acyclovir) alfa-2a) Influenza Agents PEGASYS SOLN PA SP (peginterferon alfa-2a) FLUMADINE TABS (rimantadine 3 PEGINTRON KIT PA SP hydrochloride) (peginterferon alfa-2b) QL(10 ea per REBETOL SOLN PA oseltamivir phosphate 1 2 180 days retail) (ribavirin (hepatitis c)) caps or 30 mg, 45 mg RIBASPHERE RIBAPAK PA oseltamivir phosphate 1 TBPK (ribavirin 3 caps or 75 mg (hepatitis c)) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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55 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(180 ml per betaxolol hcl tabs 1 oseltamivir phosphate 1 180 days susr or 6 mg/ml retail); AL(At QL(1 ea daily) bisoprolol fumarate 1 least 1 yrs old) tabs RELENZA DISKHALER Limit 20 per BYSTOLIC TABS 3 month;QL(0.67 3 AEPB (zanamivir) ea daily) (nebivolol hcl) LOPRESSOR TABS rimantadine 1 GP hydrochloride tabs (metoprolol tartrate) TAMIFLU CAPS 30 MG, 45 QL(10 ea per metoprolol succinate 1 MG (oseltamivir GP 180 days retail) tb24 phosphate) metoprolol tartrate tabs 1 QL(180 ml per TAMIFLU SUSR 6 MG/ML TENORMIN TABS GP 180 days GP (oseltamivir phosphate) retail); AL(At (atenolol) least 1 yrs old) TOPROL XL TB24 GP Respiratory Syncytial Virus (RSV) Agents (metoprolol succinate) ribavirin solr 1 Beta Blockers Non-Selective (Sotalol Hcl) SORINE VIRAZOLE SOLR 1 GP TABS (ribavirin) BETAPACE AF TABS GP BETA BLOCKERS - Drugs to Treat High Blood (sotalol hcl (afib/afl)) Pressure BETAPACE TABS ( sotalol GP Alpha-Beta Blockers hcl) CORGARD TABS carvedilol phosphate 1 GP cp24 (nadolol) HEMANGEOL SOLN AL(Up to 1 yrs carvedilol tabs 12.5 1 3 mg, 25 mg, 6.25 mg (propranolol hcl) old ) QL(2 ea daily) INDERAL LA CP24 carvedilol tabs 3.125 1 GP mg (propranolol hcl) COREG CR CP24 INDERAL XL CP24 GP (carvedilol phosphate) (propranolol hcl sustained-release 3 COREG TABS 12.5 MG, GP beads) 25 MG (carvedilol) INNOPRAN XL CP24 COREG TABS 3.125 MG QL(2 ea daily) GP (propranolol hcl (carvedilol) sustained-release 3 labetalol hcl tabs 1 beads) Beta Blockers Cardio-Selective nadolol tabs 1 acebutolol hcl caps 1 pindolol tabs 1 atenolol tabs 1 propranolol hcl cp24 1
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Updated 07/01/2021 56 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CARDIZEM TABS propranolol hcl soln 1 GP (diltiazem hcl) propranolol hcl tabs 1 diltiazem hcl coated 1 beads cp24 sotalol hcl (afib/afl) tabs 1 diltiazem hcl coated 1 sotalol hcl tabs 1 beads tb24 diltiazem hcl cp12 120 SOTYLIZE SOLN ( 1 sotalol 3 mg, 60 mg, 90 mg hcl) diltiazem hcl cp24 180 QL(2 ea daily) 1 timolol maleate tabs 10 1 mg, 240 mg mg, 20 mg, 5 mg diltiazem hcl extended 1 CALCIUM CHANNEL BLOCKERS - Drugs to release beads cp24 Treat High Blood Pressure diltiazem hcl tabs 120 Calcium Channel Blockers mg, 30 mg, 60 mg, 90 1 (Diltiazem Hcl Coated 1 mg Beads) CARTIA XT CP24 felodipine tb24 1 (Diltiazem Hcl Coated 1 Beads) MATZIM LA TB24 (Diltiazem Hcl Extended isradipine caps 1 Release Beads) TAZTIA 1 XT, TIADYLT ER CP24 nicardipine hcl caps 1 (Diltiazem Hcl) DILT-XR 1 nifedipine caps 10 mg, 1 CP24 20 mg ADALAT CC TB24 30 MG, GP nifedipine tb24 30 mg, 1 60 MG (nifedipine) 60 mg ADALAT CC TB24 90 MG QL(1 ea daily) GP nifedipine tb24 30 mg, QL(1 ea daily) (nifedipine) 1 60 mg, 90 mg QL(2 ea daily) amlodipine besylate 1 tabs nimodipine caps 1 CALAN SR TBCR GP nisoldipine tb24 1 (verapamil hcl) CALAN TABS ( NORVASC TABS QL(2 ea daily) verapamil GP GP hcl) (amlodipine besylate) CARDIZEM CD CP24 NYMALIZE SOLN 30 MG/10ML, 60 MG/20ML (diltiazem hcl coated GP 3 (nimodipine) beads) PROCARDIA CAPS CARDIZEM LA TB24 120 GP (nifedipine) MG (diltiazem hcl 2 PROCARDIA XL TB24 QL(1 ea daily) coated beads) GP ( ) CARDIZEM LA TB24 180 nifedipine SULAR TB24 MG, 240 MG, 300 MG, 360 GP MG, 420 MG (diltiazem GP (nisoldipine) hcl coated beads) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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57 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIAZAC CP24 (diltiazem tadalafil tabs 1 PA; QL(1 ea hcl extended release GP daily) beads) Peripheral Vasodilators verapamil hcl cp24 1 isoxsuprine hcl tabs 1 verapamil hcl tabs 1 Prostaglandin Vasodilators ORENITRAM TBCR PA SP verapamil hcl tbcr 1 (treprostinil diolamine) VERELAN CP24 REMODULIN SOLN PA GP SP (verapamil hcl) (treprostinil) VERELAN PM CP24 PA 3 treprostinil soln SP (verapamil hcl) VENTAVIS SOLN PA SP CARDIOTONICS - Drugs to Treat Heart Failure (iloprost) and Abnormal Heart Rhythm Pulmonary Hypertension - Endothelin Receptor Cardiac Glycosides ambrisentan tabs SP PA (Digoxin) DIGITEK, DIGOX 1 TABS bosentan tabs SP PA digoxin soln 1 LETAIRIS TABS PA SP digoxin tabs 1 (ambrisentan) LANOXIN TABS 125 MCG, OPSUMIT TABS PA 3 SP 250 MCG (digoxin) (macitentan) LANOXIN TABS 62.5 MCG TRACLEER TABS 125 PA 3 SP (digoxin) MG, 62.5 MG (bosentan) TRACLEER TBSO 32 MG PA; SP SP CARDIOVASCULAR AGENTS - MISC. - Drugs to ( ) Treat Heart and Circulation Conditions bosentan Cardiovascular Agents Misc. - Combinations Pulmonary Hypertension - Phosphodiesterase (Tadalafil (Pulmonary PA amlodipine besylate- Hypertension)) ALYQ SP atorvastatin calcium 1 TABS tabs ADCIRCA TABS (tadalafil PA BIDIL TABS (isosorbide (pulmonary SP dinitrate-hydralazine 3 hypertension)) hcl) REVATIO SOLN PA CADUET TABS (sildenafil citrate (amlodipine besylate- GP (pulmonary SP atorvastatin calcium) hypertension)) ENTRESTO TABS PA 3 REVATIO SUSR PA (sacubitril-valsartan) (sildenafil citrate SP Impotence Agents (pulmonary hypertension)) GP PA; QL(1 ea CIALIS TABS (tadalafil) daily)
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Updated 07/01/2021 58 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits REVATIO TABS PA cefadroxil caps 1 (sildenafil citrate SP (pulmonary cefadroxil susr 1 hypertension)) sildenafil citrate PA cefadroxil tabs 1 (pulmonary SP PA hypertension) soln iv cefazolin sodium solr SP 10 mg/12.5ml cephalexin caps 1 sildenafil citrate PA cephalexin susr 1 (pulmonary SP hypertension) susr or 10 mg/ml cephalexin tabs 1 SILDENAFIL CITRATE PA KEFLEX CAPS GP TABS (sildenafil citrate (cephalexin) 2 (pulmonary Cephalosporins - 2nd Generation hypertension)) 1 PA cefaclor caps tadalafil (pulmonary SP CEFACLOR ER TB12 hypertension) tabs 3 ( ) Pulmonary Hypertension - Prostacyclin Receptor cefaclor monohydrate UPTRAVI TABS PA cefaclor susr 1 SP (selexipag) CEFOTAN SOLR PA UPTRAVI TBPK PA SP SP (cefotetan disodium) (selexipag) cefotetan disodium solr SP PA Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS PA cefoxitin sodium solr ij PA SP SP (riociguat) 10 gm PA Sinus Node Inhibitors cefoxitin sodium solr iv SP CORLANOR SOLN 5 ST; QL(15 ml 1 gm, 2 gm 3 MG/5ML (ivabradine hcl) daily) CEFOXITIN SODIUM PA SOLR IV 1 GM-4 %, 2 GM- CORLANOR TABS 5 MG, ST 3 2.2 % ( SP 7.5 MG (ivabradine hcl) cefoxitin sodium and dextrose) Transthyretin Stabilizers VYNDAMAX CAPS PA; QL(1 ea cefprozil susr 1 SP daily) (tafamidis) cefprozil tabs 1 VYNDAQEL CAPS PA; QL(4 ea (tafamidis meglumine SP daily) cefuroxime axetil tabs 1 (cardiac)) SP PA CEPHALOSPORINS - Drugs to Treat Bacterial cefuroxime sodium solr Infections Cephalosporins - 3rd Generation Cephalosporins - 1st Generation (Ceftazidime) TAZICEF SP PA SOLR
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59 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cefdinir caps 1 CONTRACEPTIVES - Drugs to Prevent Pregnancy cefdinir susr 1 Combination Contraceptives - Oral (Desogestrel & Ethinyl PV cefditoren pivoxil tabs 1 Estradiol) APRI, CYRED, CYRED EQ, cefixime caps 1 EMOQUETTE, ENSKYCE, 1 ISIBLOOM, JULEBER, cefixime susr 1 KALLIGA, RECLIPSEN PA TABS cefotaxime sodium solr SP (Desogestrel-Ethinyl PV Estradiol (Biphasic)) cefpodoxime proxetil 1 AZURETTE, BEKYREE, 1 susr KARIVA, PIMTREA, cefpodoxime proxetil 1 SIMLIYA, VIORELE, tabs VOLNEA TABS PA (Desogestrel-Ethinyl PV ceftazidime solr SP Estradiol (Triphasic)) 1 CAZIANT, VELIVET TABS ceftriaxone sodium solr SP PA (Drospirenone-Ethinyl PV FORTAZ SOLR IJ 1 GM PA Estradiol) GIANVI, SP (ceftazidime) JASMIEL, LO- SUPRAX CAPS 400 MG ZUMANDIMINE, LORYNA, 1 GP NIKKI, OCELLA, SYEDA, (cefixime) VESTURA, ZARAH, SUPRAX CHEW 100 MG, ZUMANDIMINE TABS 3 200 MG (cefixime) (Drospirenone-Ethinyl PV SUPRAX SUSR 100 Estradiol-Levomefolate 1 MG/5ML, 200 MG/5ML GP Calcium) TYDEMY TABS (cefixime) (Ethynodiol Diacet & Eth PV SUPRAX SUSR 500 Estrad) KELNOR 1/35, 1 3 KELNOR 1/50, ZOVIA MG/5ML (cefixime) 1/35, ZOVIA 1/35E TABS Cephalosporins - 4th Generation (Ethynodiol Diacet & Eth PV SP PA Estrad) KELNOR 1/35, PV cefepime hcl solr KELNOR 1/50, ZOVIA CEFEPIME SOLN PA 1/35, ZOVIA 1/35E TABS SP (cefepime hcl) CEFEPIME/DEXTROSE PA SOLR (cefepime hcl- SP dextrose) MAXIPIME SOLR PA SP (cefepime hcl) Cephalosporins - 5th Generation TEFLARO SOLR PA SP (ceftaroline fosamil)
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Updated 07/01/2021 60 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Levonorgestrel & Eth PV (Norethin Acet & Estrad- PV Estradiol) AFIRMELLE, Fe) AUROVELA 24 FE, ALTAVERA, AUBRA, AUROVELA FE 1.5/30, AUBRA EQ, AVIANE, AUROVELA FE 1/20, AYUNA, CHATEAL, BLISOVI 24 FE, BLISOVI CHATEAL EQ, DELYLA, FE 1.5/30, BLISOVI FE FALMINA, KURVELO, PV 1/20, HAILEY 24 FE, LARISSIA, LESSINA, HAILEY FE 1.5/30, HAILEY LEVORA 0.15/30-28, FE 1/20, JUNEL FE 1.5/30, LILLOW, LUTERA, JUNEL FE 1/20, JUNEL FE 1 MARLISSA, ORSYTHIA, 24, LARIN 24 FE, LARIN PORTIA-28, SRONYX, FE 1.5/30, LARIN FE 1/20, VIENVA TABS LOESTRIN FE 1.5/30, (Levonorgestrel-Eth PV LOESTRIN FE 1/20, Estradiol (Triphasic)) MICROGESTIN 24 FE, ENPRESSE-28, PV MICROGESTIN FE 1.5/30, LEVONEST, TRIVORA-28 MICROGESTIN FE 1/20, TABS TARINA 24 FE, TARINA FE 1/20, TARINA FE 1/20 (Levonorgestrel-Ethinyl PV EQ TABS Estradiol (91-Day)) AMETHIA, AMETHIA LO, (Norethin Acet & Estrad- PV ASHLYNA, CAMRESE, Fe) CHARLOTTE 24 FE, 1 MELODETTA 24 FE, CAMRESE LO, DAYSEE, PV FAYOSIM, ICLEVIA, MIBELAS 24 FE CHEW INTROVALE, JAIMIESS, (Norethin Acet & Estrad- PA; QL(1 ea JOLESSA, LOJAIMIESS, Fe) GEMMILY, MERZEE 1 daily); PV RIVELSA, SETLAKIN, CAPS SIMPESSE TABS (Norethindrone & Eth PV (Levonorgestrel-Ethinyl PV Estradiol) ALYACEN 1/35, Estradiol (Continuous)) PV BALZIVA, BRIELLYN, AMETHYST, DOLISHALE CYCLAFEM 1/35, TABS DASETTA 1/35, NECON 1 0.5/35-28, NORTREL 0.5/35 (28), NORTREL 1/35, PHILITH, PIRMELLA 1/35, VYFEMLA, WERA TABS (Norethindrone & Ethinyl PV Estradiol-Fe) KAITLIB FE, 1 LAYOLIS FE, WYMZYA FE CHEW
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61 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Norethindrone Acet & Eth PV BEYAZ TABS PV Estra) AUROVELA 1.5/30, (drospirenone-ethinyl AUROVELA 1/20, HAILEY estradiol-levomefolate GP 1.5/30, JUNEL 1.5/30, ) JUNEL 1/20, LARIN 1.5/30, calcium 1 PV LARIN 1/20, LOESTRIN desogestrel & ethinyl 1 1.5/30-21, LOESTRIN estradiol tabs 1/20-21, MICROGESTIN PV 1.5/30, MICROGESTIN desogestrel-ethinyl 1 1/20 TABS estradiol (biphasic) tabs PV (Norethindrone Acetate- PV drospirenone-ethinyl 1 Ethinyl Estradiol-Fe) TILIA 1 estradiol tabs FE, TRI-LEGEST FE TABS drospirenone-ethinyl PV (Norethindrone-Eth PV estradiol-levomefolate 1 Estradiol (Triphasic)) ALYACEN 7/7/7, calcium tabs ESTROSTEP FE TABS PV ARANELLE, CYCLAFEM 1 7/7/7, DASETTA 7/7/7, (norethindrone acetate- GP LEENA, NORTREL 7/7/7, ethinyl estradiol-fe) NYLIA 7/7/7, PIRMELLA PV 7/7/7 TABS ethynodiol diacet & eth 1 (Norgestimate-Ethinyl PV estrad tabs 1 mg-35 Estradiol (Triphasic)) TRI mcg, 1 mg-50 mcg FEMYNOR, TRI- FALESSA KIT PA; PV ESTARYLLA, TRI-LINYAH, (levonorgestrel-ethinyl 3 TRI-LO-ESTARYLLA, TRI- estradiol & folic acid) LO-MARZIA, TRI-LO-MILI, 1 TRI-LO-SPRINTEC, TRI- GENERESS FE CHEW PV MILI, TRI-NYMYO, TRI- (norethindrone & GP PREVIFEM, TRI- ethinyl estradiol-fe) SPRINTEC, TRI-VYLIBRA, PV levonorgestrel & eth PV TRI-VYLIBRA LO TABS estradiol tabs (Norgestimate-Ethinyl PV Estradiol) ESTARYLLA, levonorgestrel-eth PV estradiol (triphasic) PV FEMYNOR, MILI, MONO- 1 LINYAH, NYMYO, tabs PREVIFEM, SPRINTEC PV levonorgestrel-ethinyl PV 28, VYLIBRA TABS estradiol (91-day) tabs (Norgestrel & Ethinyl PV Estradiol) CRYSELLE-28, levonorgestrel-ethinyl PV ELINEST, LOW- 1 estradiol (continuous) PV OGESTREL, OGESTREL tabs TABS LO LOESTRIN FE TABS PV BALCOLTRA TABS QL(1 ea daily); (norethindrone acetate- (levonorgestrel-ethinyl PV 3 PV ethinyl estradiol-fe fum estradiol-ferrous (biphasic)) bisglycinate) LOSEASONIQUE TABS PV (levonorgestrel-ethinyl GP estradiol (91-day)) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 62 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits MINASTRIN 24 FE CHEW PV QUARTETTE TABS PV (norethin acet & estrad- GP (levonorgestrel-ethinyl GP fe) estradiol (91-day)) MIRCETTE TABS PV SAFYRAL TABS PV (desogestrel-ethinyl GP (drospirenone-ethinyl GP estradiol (biphasic)) estradiol-levomefolate NATAZIA TABS PV calcium) (estradiol valerate- 2 SEASONIQUE TABS PV dienogest) (levonorgestrel-ethinyl GP NEXTSTELLIS TABS PV estradiol (91-day)) PV (drospirenone-estetrol) TAYTULLA CAPS PA; QL(1 ea norethin acet & estrad- PA; QL(1 ea (norethin acet & estrad- GP daily); PV fe caps 1 mg-20 mcg- 1 daily); PV fe) 75 mg TYBLUME CHEW PV norethin acet & estrad- PV (levonorgestrel & eth PV fe chew 1 mg-20 mcg- 1 estradiol) 75 mg YASMIN 28 TABS PV norethin acet & estrad- PV (drospirenone-ethinyl GP estradiol) fe tabs 1 mg-20 mcg- 1 75 mg, 1.5 mg-30 mcg- YAZ TABS PV 75 mg (drospirenone-ethinyl GP ) PV estradiol norethindrone & ethinyl 1 estradiol-fe chew Combination Contraceptives - Transdermal PV (Norelgestromin-Ethinyl PV norethindrone acet & 1 PV eth estra tabs Estradiol) XULANE PTWK QL(3 ea per 28 norgestimate-ethinyl PV TWIRLA PTWK ( PV days retail,3 ea estradiol (triphasic) 1 levonorgestrel-ethinyl per 28 days tabs estradiol) mail); PV PV Combination Contraceptives - Vaginal norgestimate-ethinyl 1 estradiol tabs (Etonogestrel-Ethinyl PV PV ORTHO TRI-CYCLEN LO PV Estradiol) ELURYNG RING TABS (norgestimate- ANNOVERA RING PV ethinyl estradiol GP (segesterone acetate- PV (triphasic)) ethinyl estradiol) ORTHO-NOVUM 1/35 PV PV etonogestrel-ethinyl PV TABS (norethindrone & GP estradiol ring eth estradiol) NUVARING RING PV ORTHO-NOVUM 7/7/7 PV (etonogestrel-ethinyl GP TABS (norethindrone- GP estradiol) eth estradiol (triphasic)) Copper Contraceptives - IUD
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63 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PARAGARD PV DEPO-SUBQ PROVERA PV INTRAUTERINE COPPER 104 SUSY 3 CONTRACEPTIVE T380A (medroxyprogesterone 3 IUD (copper (iud)) acetate (contraceptive)) Emergency Contraceptives medroxyprogesterone PV (Levonorgestrel PV acetate (contraceptive) 1 (Emergency Oc)) AFTERA, susp ECONTRA EZ, ECONTRA PV ONE-STEP, MY CHOICE, medroxyprogesterone MY WAY, NEW DAY, PV acetate (contraceptive) 1 OPCICON ONE-STEP, susy OPTION 2, PREVENTEZA, Progestin Contraceptives - Oral REACT, TAKE ACTION TABS (Norethindrone PV (Contraceptive)) CAMILA, ELLA TABS ( PV ulipristal PV DEBLITANE, ERRIN, acetate) HEATHER, INCASSIA, levonorgestrel PV JENCYCLA, JOLIVETTE, 1 PV LYLEQ, LYZA, NORA-BE, (emergency oc) tabs NORLYDA, NORLYROC, PLAN B ONE-STEP TABS PV SHAROBEL, TULANA (levonorgestrel GP TABS (emergency oc)) PV norethindrone 1 Progestin Contraceptives - IUD (contraceptive) tabs KYLEENA IUD PV ORTHO MICRONOR PV 3 (levonorgestrel (iud)) TABS (norethindrone GP LILETTA IUD PV (contraceptive)) 3 (levonorgestrel (iud)) SLYND TABS PV PV MIRENA IUD PV (drospirenone) 3 (levonorgestrel (iud)) CORTICOSTEROIDS - Steroid Hormone Drugs to SKYLA IUD PV Treat Systemic Swelling Conditions 3 (levonorgestrel (iud)) Glucocorticosteroids Progestin Contraceptives - Implants (Dexamethasone) 1 NEXPLANON IMPL PV DECADRON ELIX 3 (etonogestrel) (Dexamethasone) 1 DECADRON TABS Progestin Contraceptives - Injectable (Dexamethasone) DEXPAK DEPO-PROVERA PV 10 DAY, DEXPAK 13 DAY, CONTRACEPTIVE SUSP GP DEXPAK 6 DAY, HIDEX 6- 1 (medroxyprogesterone DAY, TAPERDEX 6-DAY acetate (contraceptive)) TBPK DEPO-PROVERA PV budesonide cpep 3 mg 1 CONTRACEPTIVE SUSY GP (medroxyprogesterone budesonide tb24 9 mg 1 PA acetate (contraceptive)) CORTEF TABS GP (hydrocortisone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 64 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits cortisone acetate tabs 1 ORAPRED ODT TBDP (prednisolone sodium GP dexamethasone elix 1 phosphate) DEXAMETHASONE prednisolone sodium INTENSOL CONC 2 phosphate soln or 10 1 (dexamethasone) mg/5ml, 15 mg/5ml, 20 dexamethasone PA mg/5ml, 25 mg/5ml sodium phosphate soln prednisolone sodium 10 mg/ml, 100 SP phosphate tbdp or 10 1 mg/10ml, 120 mg/30ml, mg, 15 mg, 30 mg 20 mg/5ml, 4 mg/ml prednisolone soln 1 DEXAMETHASONE PA PREDNISONE INTENSOL SODIUM PHOSPHATE 2 SOLN 4 MG/ML SP CONC (prednisone) (dexamethasone prednisone soln 5 1 sodium phosphate) mg/5ml dexamethasone soln 1 prednisone tabs 1 mg, 10 mg, 2.5 mg, 20 mg, 1 dexamethasone tabs 1 5 mg, 50 mg prednisone tbpk 10 mg, 1 dexamethasone tbpk 1 5 mg ENTOCORT EC CPEP RAYOS TBEC PA GP 3 (budesonide) (prednisone) UCERIS TB24 OR 9 MG PA hydrocortisone tabs 1 GP (budesonide) MEDROL DOSEPAK TBPK GP VERIPRED 20 SOLN (methylprednisolone) (prednisolone sodium GP MEDROL TABS 16 MG, 32 phosphate) MG, 4 MG, 8 MG GP (methylprednisolone) Mineralocorticoids MEDROL TABS 2 MG fludrocortisone acetate 2 1 (methylprednisolone) tabs methylprednisolone 1 COUGH/COLD/ALLERGY - Drugs to Treat tabs Cough, Cold and Allergy Symptoms Antitussives methylprednisolone 1 tbpk (Hydrocodone W/ MILLIPRED DP TBPK Homatropine) HYDROMET 1 3 (prednisolone) SYRP MILLIPRED SOLN 10 benzonatate caps 1 MG/5ML (prednisolone GP HYCODAN SYRP sodium phosphate) (hydrocodone w/ GP MILLIPRED TABS 5 MG 2 homatropine) (prednisolone) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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65 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GILTUSS COUGH & COLD RX/OTC hydrocodone w/ 1 homatropine syrp TABS (phenylephrine w/ 3 dm-gg) hydrocodone w/ 1 homatropine tabs GILTUSS SINUS & RX/OTC CONGESTION TABS TESSALON PERLES GP (phenylephrine- 3 CAPS (benzonatate) guaifenesin) Cough/Cold/Allergy Combinations GILTUSS TR TABS RX/OTC (Guaifenesin-Codeine) (phenylephrine w/ dm- 3 CHERATUSSIN AC, 1 gg) GUAIATUSSIN AC, GUAIFENESIN AC SYRP guaifenesin-codeine 1 (Guaifenesin-Codeine) G soln TUSSIN AC, MAXI-TUSS 1 HISTEX-PE SYRP AC, VIRTUSSIN A/C SOLN (triprolidine- GP (Guaifenesin-Codeine) 1 phenylephrine) VIRTUSSIN AC/ALC LIQD hydrocodone polistirex- (Pseudoephedrine W/ 1 Codeine-Gg) 1 chlorpheniramine GUAIFENESIN DAC SOLN polistirex suer ACTIDOM DMX LIQD NEOTUSS PLUS LIQD (phenylephrine w/ dm- 3 (phenylephrine- 3 gg) chlorphen-dm) BIO-DTUSS DMX LIQD promethazine & 1 (pseudoephed- 3 phenylephrine syrp bromphen-dm) promethazine 1 CLARINEX-D 12 HOUR PA w/codeine soln TB12 (desloratadine- 3 promethazine 1 pseudoephedrine) w/codeine syrp CODITUSSIN AC LIQD 3 promethazine-dm soln 1 (guaifenesin-codeine) DOCTOR MANZANILLA promethazine-dm syrp 1 PE SYRUP ANTIHISTAMINE/DECON promethazine- GESTANT LIQD 3 phenylephrine-codeine 1 (triprolidine- syrp phenylephrine) pseudoephed-cpm w/ 1 DOMETUSS-DMX LIQD hydrocod soln (phenylephrine w/ dm- 3 SEMPREX-D CAPS gg) (acrivastine & 3 GILPHEX TR TABS RX/OTC pseudoephedrine) (phenylephrine- 3 guaifenesin)
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Updated 07/01/2021 66 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TUSSICAPS CP12 acetylcysteine soln 1 (hydrocodone polistirex- 3 DERMATOLOGICALS - Drugs to Treat Skin chlorpheniramine Conditions polistirex) Acne Products TUSSIONEX Limit 45gms PENNKINETIC per EXTENDED RELEASE (Adapalene) ADAPALENE 1 TREATMENT GEL month;QL(1.5 SUER (hydrocodone GP gm daily); polistirex- RX/OTC chlorpheniramine (Benzoyl Peroxide) polistirex) BENZEPRO CREAMY WASH, BP WASH, PR 1 TUSSLIN LIQD BENZOYL PEROXIDE (phenylephrine w/ dm- 3 WASH LIQD gg) (Clindamycin Phosphate TUSSLIN PEDIATRIC (Topical)) CLINDACIN ETZ 1 LIQD (phenylephrine w/ 3 PLEDGETS, CLINDACIN-P dm-gg) SWAB VIRTUSSIN DAC SOLN (Clindamycin Phosphate- ( 2 Benzoyl Peroxide 1 pseudoephedrine w/ (Refrigerate)) NEUAC GEL codeine-gg) (Erythromycin (Acne Aid)) 1 Misc. Respiratory Inhalants ERY PADS (Sodium Chloride Greater than 5 (Inhalant)) NEBUSAL 1 (Isotretinoin) months NEBU 3 % AMNESTEEM, 1 MYORISAN, ZENATANE requires (Sodium Chloride CAPS PA;QL(2 ea (Inhalant)) PULMOSAL 1 daily) NEBU Greater than 5 HYPER-SAL NEBU (Isotretinoin) CLARAVIS months (sodium chloride GP CAPS 10 MG, 20 MG, 30 1 requires MG, 40 MG PA;QL(2 ea (inhalant)) daily) HYPERSAL NEBU 3.5 % (Sulfacetamide Sodium W/ (sodium chloride 3 Sulfur) AVAR CLEANSER, 1 (inhalant)) BP 10-1, SULFAMEZ HYPERSAL NEBU 7 % WASH EMUL (sodium chloride GP (Sulfacetamide Sodium W/ (inhalant)) Sulfur) AVAR-E EMOLLIENT, AVAR-E 1 NEBUSAL NEBU 6 % GREEN, SSS 10%-5% (sodium chloride 3 CREA (inhalant)) (Sulfacetamide Sodium W/ 1 Sulfur) SSS 10-5 FOAM sodium chloride 1 (inhalant) nebu (Sulfacetamide Sodium W/ Mucolytics Sulfur) SULFACLEANSE 1 8/4 SUSP
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67 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Sulfacetamide Sodium- AVAR LS PADS Sulfur In Urea Vehicle) BP 1 (sulfacetamide sodium 3 CLEANSING WASH EMUL w/ sulfur) (Tretinoin) AVITA CREA 1 AVAR PADS (sulfacetamide sodium 3 (Tretinoin) AVITA GEL 1 w/ sulfur) AVAR-E LS CREA ABSORICA CAPS 10 MG, PA; Limited to 20 MG, 30 MG, 40 MG 3 5 months of (sulfacetamide sodium GP treatment;QL(2 w/ sulfur) (isotretinoin) ea daily) AZELEX CREA (azelaic PA; Limited to 3 ABSORICA CAPS 25 MG, acid (acne)) GP 5 months of 35 MG (isotretinoin) treatment;QL(2 BENZACLIN GEL ea daily) (clindamycin GP PA; Limited to phosphate-benzoyl ABSORICA LD CAPS 3 5 months of peroxide) (isotretinoin micronized) treatment;QL(2 BENZACLIN WITH PUMP ea daily) GEL (clindamycin ACZONE GEL 5 % PA GP GP phosphate-benzoyl (dapsone (topical)) peroxide) ACZONE GEL 7.5 % PA; QL(2 gm BENZAMYCIN GEL GP daily) (dapsone (topical)) (benzoyl peroxide- GP Limit 45gms erythromycin) adapalene crea 0.1 % 1 per month;QL(1.5 benzoyl peroxide- 1 gm daily) erythromycin gel Limit 45gms CLEOCIN-T GEL per (clindamycin phosphate 3 adapalene gel 0.1 % 1 month;QL(1.5 (topical)) gm daily); RX/OTC CLEOCIN-T LOTN (clindamycin phosphate GP Limit 45gms (topical)) 1 per adapalene gel 0.3 % month;QL(1.5 CLINDACIN ETZ KIT gm daily) (clindamycin phosphate 3 adapalene lotn 0.1 % 1 & cleanser) CLINDACIN PAC KIT adapalene-benzoyl 1 (clindamycin phosphate 3 peroxide gel & cleanser) ATRALIN GEL (tretinoin) GP CLINDAGEL GEL (clindamycin phosphate GP AVAR LS CLEANSER (topical)) LIQD (sulfacetamide GP sodium w/ sulfur) clindamycin phosphate 1 (topical) foam
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Updated 07/01/2021 68 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clindamycin phosphate 1 erythromycin (acne aid) 1 (topical) gel pads clindamycin phosphate 1 erythromycin (acne aid) 1 (topical) lotn soln EVOCLIN FOAM clindamycin phosphate 1 (topical) soln (clindamycin phosphate GP (topical)) clindamycin phosphate 1 (topical) swab Limit 50gms FABIOR FOAM 3 per clindamycin phosphate- (tazarotene (acne)) month;QL(1.67 benzoyl peroxide 1 gm daily) (refrigerate) gel Greater than 5 clindamycin phosphate- months benzoyl peroxide gel 1 1 requires isotretinoin caps 10 mg, %-5 % 1 PA;QL(2 ea 20 mg, 30 mg, 40 mg daily)150 rtl clindamycin phosphate- 1 MAX day(s) tretinoin gel supply,365 rtl PA lmt day(s), dapsone (topical) gel 5 1 % PA; Limited to isotretinoin caps 25 mg, 5 months of PA; QL(2 gm 1 dapsone (topical) gel 1 35 mg treatment;QL(2 7.5 % daily) ea daily) Limit 45gms KLARON LOTN DIFFERIN CREA 0.1 % GP per (sulfacetamide sodium GP (adapalene) month;QL(1.5 (acne)) gm daily) NEUTROGENA CLEAR Limit 45gms PORE CLEANSER/MASK DIFFERIN GEL 0.1 % per LIQD ( 3 GP month;QL(1.5 benzoyl (adapalene) gm daily); peroxide) RX/OTC PLEXION CLEANSER Limit 45gms LIQD (sulfacetamide GP DIFFERIN GEL 0.3 % GP per sodium w/ sulfur) (adapalene) month;QL(1.5 PLEXION CLEANSING gm daily) CLOTHS PADS DIFFERIN LOTN 0.1 % 3 3 (sulfacetamide sodium (adapalene) w/ sulfur) DUAC GEL (clindamycin PLEXION CREA phosphate-benzoyl GP (sulfacetamide sodium GP peroxide (refrigerate)) w/ sulfur) ERYGEL GEL PLEXION LOTN (erythromycin (acne GP (sulfacetamide sodium GP aid)) w/ sulfur) erythromycin (acne aid) 1 RETIN-A CREA (tretinoin) GP gel
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69 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RETIN-A GEL (tretinoin) GP SUMADAN WASH LIQD (sulfacetamide sodium GP RETIN-A MICRO GEL 0.04 w/ sulfur) %, 0.1 % (tretinoin GP SUMAXIN PADS microsphere) (sulfacetamide sodium GP RETIN-A MICRO PUMP w/ sulfur) GEL 0.04 %, 0.1 % GP SUMAXIN WASH LIQD (tretinoin microsphere) (sulfacetamide sodium GP RIAX FOAM ( benzoyl 3 w/ sulfur) peroxide) Limit 50gms SODIUM TAZAROTENE FOAM 3 per SULFACETAMIDE/SULFU (tazarotene (acne)) month;QL(1.67 R CLEANSER IN UREA gm daily) EMUL (sulfacetamide 3 sodium-sulfur in urea tretinoin crea 1 vehicle) tretinoin gel 1 SODIUM SULFACETAMIDE/SULFU tretinoin microsphere 1 R SUSP (sulfacetamide 3 gel sodium w/ sulfur) VELTIN GEL (clindamycin GP sulfacetamide sodium 1 (acne) lotn phosphate-tretinoin) ZIANA GEL ( sulfacetamide sodium clindamycin GP phosphate-tretinoin) w/ sulfur crea 10 %-2 1 %, 10 %-5 %, 4.8 %- Agents for External Genital and Perianal Warts 9.8 % VEREGEN OINT Limit 30gms 3 per month;QL(1 sulfacetamide sodium (sinecatechins) w/ sulfur emul 10 %-5 1 gm daily) % Anti-inflammatory Agents - Topical sulfacetamide sodium (Diclofenac Sodium RX/OTC w/ sulfur liqd 10 %-2 %, (Topical)) ARTHRITIS 1 PAIN RELIEVER, 4 %-9 %, 4.5 %-9 %, ASPERCREME 4.8 %-9.8 % ARTHRITIS PAIN 1 QL(1 gm daily) RELIEVER, GNP sulfacetamide sodium 1 w/ sulfur lotn 10 %-5 % ARTHRITIS PAIN, GOODSENSE ARTHRITIS sulfacetamide sodium PAIN, QC DICLOFENAC w/ sulfur lotn 4.8 %-9.8 1 SODIIUM GEL % diclofenac epolamine 1 sulfacetamide sodium ptch w/ sulfur pads 10 %-10 1 RX/OTC diclofenac sodium 1 %-4 %-4 %, 10 %-4 % (topical) gel 1 % sulfacetamide sodium 1 w/ sulfur susp 4 %-8 % You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 70 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(5 ml daily) diclofenac sodium 1 ciclopirox gel 1 (topical) soln 1.5 % FLECTOR PTCH ciclopirox olamine crea 1 3 (diclofenac epolamine) ciclopirox olamine susp 1 PENNSAID SOLN PA; Limit 1 ( 3 bottle per diclofenac sodium month;QL(4 gm ciclopirox sham 1 (topical)) daily) RX/OTC clotrimazole (topical) 1 Antibiotics - Topical soln ALTABAX OINT Limit 1 tube per 3 clotrimazole w/ 1 (retapamulin) betamethasone crea month;QL(1.5 CENTANY AT KIT gm daily) 3 QL(2 ml daily) (mupirocin) clotrimazole w/ 1 CENTANY OINT betamethasone lotn 2 (mupirocin) econazole nitrate crea 1 gentamicin sulfate 1 ERTACZO CREA PA 3 (topical) crea (sertaconazole nitrate) gentamicin sulfate EXELDERM CREA 1 3 (topical) oint (sulconazole nitrate) 1 EXELDERM SOLN mupirocin oint 2 (sulconazole nitrate) NEO-SYNALAR CREA EXELDERM SOLN (neomycin sulfate- 3 GP fluocinolone acetonide) (sulconazole nitrate) EXODERM LOTN Antifungals - Topical (sodium thiosulfate- 3 (Clotrimazole (Topical)) RX/OTC salicylic acid) CVS CLOTRIMAZOLE EXTINA FOAM MAXIMUMSTRENGTH, 1 GP FUNGICURE INTENSIVE (ketoconazole (topical)) WITHNAILGUARD SOLN iodoquinol-hc crea 1 (Iodoquinol-Hc) 1 DERMAZENE CREA iodoquinol- (Iodoquinol-Hydrocortisone hydrocortisone in aloe 1 In Aloe Vehicle) 1 vehicle crea IODOQUIMEZ-HC CREA iodoquinol- (Ketoconazole (Topical)) 1 1 KETODAN FOAM hydrocortisone-aloe polysaccharide gel ALA-QUIN CREA 3 QL(2 gm daily) (clioquinol-hc) ketoconazole (topical) 1 ALCORTIN A GEL crea (iodoquinol- ketoconazole (topical) 1 hydrocortisone-aloe GP foam polysaccharide) ketoconazole (topical) 1 sham You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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71 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits LOPROX CREA QUINJA GEL GP (ciclopirox olamine) (iodoquinol-aloe 3 LOPROX SHAMPOO polysaccharides) GP SHAM (ciclopirox) sulconazole nitrate crea 1 LOPROX SUSP GP (ciclopirox olamine) sulconazole nitrate soln 1 LOTRISONE CREA Limit 1 tube per VUSION OINT (clotrimazole w/ GP month;QL(1.5 gm daily) (miconazole-zinc oxide- 3 betamethasone) white petrolatum) luliconazole crea 1 VYTONE CREA (iodoquinol- LUZU CREA GP 3 hydrocortisone in aloe (luliconazole) vehicle) miconazole-zinc oxide- 1 XOLEGEL GEL 3 white petrolatum oint (ketoconazole (topical)) naftifine hcl crea 1 Antineoplastic or Premalignant Lesion Agents - CARAC CREA naftifine hcl gel 1 GP (fluorouracil (topical)) NAFTIFINE PA diclofenac sodium 1 HYDROCHLORIDE CREA GP (actinic keratoses) gel (naftifine hcl) EFUDEX CREA NAFTIN CREA 2 % GP GP (fluorouracil (topical)) (naftifine hcl) FLUOROPLEX CREA NAFTIN GEL 1 % 2 GP (fluorouracil (topical)) (naftifine hcl) NAFTIN GEL 2 % fluorouracil (topical) 2 1 (naftifine hcl) crea NIZORAL SHAM fluorouracil (topical) GP 1 (ketoconazole (topical)) soln PANRETIN GEL PA 3 nystatin (topical) crea 1 (alitretinoin) PICATO GEL ( nystatin (topical) oint 1 ingenol 3 mebutate) nystatin-triamcinolone 1 TARGRETIN GEL EX 1 % PA SP crea (bexarotene (topical)) nystatin-triamcinolone 1 VALCHLOR GEL PA oint (mechlorethamine hcl SP oxiconazole nitrate 1 (topical)) crea Antipruritics - Topical OXISTAT LOTN 3 PRUDOXIN CREA (oxiconazole nitrate) (doxepin hcl 3 (antipruritic))
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Updated 07/01/2021 72 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STELARA SOSY PA Antipsoriatics SP (ustekinumab) (Calcipotriene) 1 QL(5 gm daily) CALCITRENE OINT TALTZ SOAJ PA SP (ixekizumab) acitretin caps 1 TALTZ SOSY PA SP calcipotriene crea 1 QL(5 gm daily) (ixekizumab) 1 calcipotriene foam 1 PA tazarotene crea TAZORAC CREA 0.05 % CALCIPOTRIENE FOAM PA 2 3 ( ) (calcipotriene) tazarotene TAZORAC GEL 0.05 %, QL(5 gm daily) 2 calcipotriene oint 1 0.1 % (tazarotene) TREMFYA SOPN PA calcipotriene soln 1 SP (guselkumab) Limited 100 TREMFYA SOSY PA SP 1 gms per (guselkumab) calcitriol (topical) oint month;QL(3.4 gm daily) Limited 100 VECTICAL OINT gms per COSENTYX PA 3 (calcitriol (topical)) month;QL(3.4 SENSOREADY PEN SOAJ 3 gm daily) (secukinumab) COSENTYX SOSY 150 PA Antiseborrheic Products 3 MG/ML (secukinumab) (Sulfacetamide Sodium) SODIUM DOVONEX CREA QL(5 gm daily) 1 GP SULFACETAMIDE WASH (calcipotriene) LIQD 10 % ILUMYA SOSY PA OVACE PLUS SHAM 10 % SP GP (tildrakizumab-asmn) (sulfacetamide sodium) methoxsalen rapid OVACE PLUS WASH LIQD 1 GP caps (sulfacetamide sodium) OXSORALEN ULTRA OVACE WASH LIQD GP CAPS (methoxsalen GP (sulfacetamide sodium) rapid) selenium sulfide lotn 1 SILIQ SOSY PA SP (brodalumab) selenium sulfide sham 1 SKYRIZI PSKT PA 3 SODIUM (risankizumab-rzaa) SULFACETAMIDE WASH SORIATANE CAPS LIQD 0.5 %-10 % GP 3 (acitretin) (sulfacetamide sodium SORILUX FOAM PA in bakuchiol vehicle) 3 (calcipotriene) sulfacetamide sodium 1 STELARA SOLN PA liqd SP (ustekinumab) sulfacetamide sodium 1 sham
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73 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Antivirals - Topical (Hydrocortisone (Topical)) ALA SCALP, ALA-SCALP 1 acyclovir topical crea 1 LOTN QL(1 gm daily) (Hydrocortisone (Topical)) 1 acyclovir topical oint 1 ALA-CORT CREA (Hydrocortisone (Topical)) RX/OTC DENAVIR CREA Limit 5gms per 3 month;QL(0.17 AQUAPHOR ITCH RELIEF (penciclovir) gm daily) MAXIMUM STRENGTH, XERESE CREA Limit 5gms per CORTIZONE-10, CVS CORTISONE MAXIMUM (acyclovir- 3 month;QL(0.17 gm daily) STRENGTH, EQL ANTI- hydrocortisone) ITCH MAXIMUM ZOVIRAX CREA EX 5 % STRENGTH, GNP GP (acyclovir topical) HYDROCORTISONE MAXIMUM STRENGTH, ZOVIRAX OINT EX 5 % QL(1 gm daily) GP HYDROCORTISONE IN 1 (acyclovir topical) ABSORBASE, KP Burn Products HYDROCORTISONE MAXIMUM STRENGTH, (Silver Sulfadiazine) SSD 1 CREA RA ANTI-ITCH/MAXIMUM STRENGTH, SB mafenide acetate pack 1 HYDROCORTISONE MAXIMUM STRENGTH, SILVADENE CREA ( silver GP SM HYDROCORTISONE sulfadiazine) MAXIMUM STRENGTH OINT silver sulfadiazine crea 1 (Pramoxine-Hc) 1 SULFAMYLON CREA 85 MEZPAROX-HC CREA MG/GM (mafenide 3 (Triamcinolone Acetonide 1 acetate) (Topical)) TRIANEX OINT SULFAMYLON PACK 5 % (Triamcinolone Acetonide 1 GP (Topical)) TRIDERM CREA (mafenide acetate) ALA-SCALP LOTN Corticosteroids - Topical (hydrocortisone 3 (Clobetasol Propionate (topical)) Emollient Base) CLOBETASOL alclometasone 1 PROPIONATE E, 1 dipropionate crea CLOBETASOL alclometasone PROPIONATE 1 EMOLLIENT CREA dipropionate oint 1 (Clobetasol Propionate 1 amcinonide crea Emulsion) TOVET FOAM amcinonide lotn 1 (Clobetasol Propionate) 1 CLODAN SHAM AMCINONIDE OINT 3 (Desonide) DESRX GEL 1 (amcinonide)
(Flurandrenolide) NOLIX 1 CREA
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Updated 07/01/2021 74 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits APEXICON E CREA clobetasol propionate 1 (diflorasone diacetate 2 crea emollient base) clobetasol propionate 1 betamethasone emollient base crea dipropionate (topical) 1 clobetasol propionate 1 crea emulsion foam betamethasone clobetasol propionate 1 dipropionate (topical) 1 foam lotn clobetasol propionate 1 betamethasone gel dipropionate (topical) 1 clobetasol propionate oint 1 liqd betamethasone clobetasol propionate dipropionate 1 1 augmented crea lotn clobetasol propionate betamethasone 1 dipropionate 1 oint augmented gel clobetasol propionate 1 betamethasone sham dipropionate 1 clobetasol propionate 1 augmented lotn soln CLOBEX LIQD betamethasone GP dipropionate 1 (clobetasol propionate) CLOBEX LOTN augmented oint GP betamethasone (clobetasol propionate) 1 CLOBEX SHAM valerate crea GP (clobetasol propionate) betamethasone 1 valerate foam clocortolone pivalate 1 crea betamethasone 1 CLODERM CREA valerate lotn 3 (clocortolone pivalate) betamethasone 1 CLODERM CREA valerate oint 3 (clocortolone pivalate) ST calcipotriene- CLODERM PUMP CREA 3 betamethasone 1 (clocortolone pivalate) dipropionate oint CORDRAN CREA 0.05 % GP calcipotriene- ST; QL(2 gm (flurandrenolide) 1 daily) betamethasone CORDRAN TAPE 4 dipropionate susp MCG/SQCM 3 CAPEX SHAM (flurandrenolide) (fluocinolone 2 acetonide)
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75 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CORTANE-B LOTN DIPROLENE OINT (hydrocortisone- (betamethasone pramoxine- 3 dipropionate GP chloroxylenol) augmented) CUTIVATE LOTN ELOCON CREA 3 GP (fluticasone propionate) (mometasone furoate) DERMA-SMOOTHE/FS EPIFOAM FOAM 3 BODY OIL (fluocinolone GP (pramoxine-hc) acetonide) fluocinolone acetonide 1 DERMA-SMOOTHE/FS crea SCALP OIL (fluocinolone GP fluocinolone acetonide 1 acetonide) oil DERMASORB TA KIT fluocinolone acetonide 1 (triamcinolone 3 oint acetonide & emollient) fluocinolone acetonide DESONATE GEL 1 GP soln (desonide) 1 desonide crea 1 fluocinonide crea fluocinonide emulsified 1 desonide gel 1 base crea desonide lotn 1 fluocinonide gel 1 desonide oint 1 fluocinonide oint 1 DESOWEN CREA GP fluocinonide soln 1 (desonide) desoximetasone crea 1 flurandrenolide crea 1 fluticasone propionate 1 desoximetasone gel 1 crea desoximetasone liqd 1 fluticasone propionate 1 lotn desoximetasone oint 1 fluticasone propionate 1 oint diflorasone diacetate 1 crea halcinonide crea 1 diflorasone diacetate 1 halobetasol propionate oint 1 crea DIPROLENE AF CREA (betamethasone halobetasol propionate 1 dipropionate GP oint HALOG CREA augmented) GP (halcinonide)
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Updated 07/01/2021 76 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits HALOG OINT LOCOID LOTN 3 (halcinonide) (hydrocortisone GP HALOG SOLN butyrate) 3 (halcinonide) LOCOID SOLN (hydrocortisone GP hydrocortisone (topical) 1 crea 2.5 % butyrate) LUXIQ FOAM hydrocortisone (topical) 1 lotn 2.5 % (betamethasone GP ) RX/OTC valerate hydrocortisone (topical) 1 oint 1 % mometasone furoate 1 crea hydrocortisone (topical) 1 oint 2.5 % mometasone furoate 1 oint hydrocortisone butyrate 1 crea mometasone furoate 1 soln hydrocortisone butyrate hydrophilic lipo base 1 NUCORT LOTN crea (hydrocortisone acetate 3 (topical)) hydrocortisone butyrate 1 OLUX FOAM (clobetasol lotn GP propionate) hydrocortisone butyrate 1 oint OLUX-E FOAM (clobetasol propionate GP hydrocortisone butyrate 1 emulsion) soln PANDEL CREA hydrocortisone valerate 1 (hydrocortisone 3 crea probutate) hydrocortisone valerate PRAMOSONE CREA 1 %- 1 3 oint 1 % (pramoxine-hc) IMPEKLO LOTN PRAMOSONE CREA 1 %- 2 GP (clobetasol propionate) 2.5 % (pramoxine-hc) KENALOG AERS PRAMOSONE LOTN 1 %- (triamcinolone GP 1 %, 1 %-2.5 % 3 acetonide (topical)) (pramoxine-hc) LOCOID CREA PRAMOSONE OINT 1 %-1 (hydrocortisone GP %, 1 %-2.5 % 3 butyrate) (pramoxine-hc) LOCOID LIPOCREAM pramoxine-hc crea 1 CREA (hydrocortisone butyrate hydrophilic lipo GP prednicarbate crea 1 base) prednicarbate oint 1
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77 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PSORCON CREA 3 triamcinolone acetonide (diflorasone diacetate) (topical) lotn 0.025 %, 1 SYNALAR CREA 0.1 % (fluocinolone GP triamcinolone acetonide acetonide) (topical) oint 0.025 %, 1 SYNALAR OINT 0.1 %, 0.5 % (fluocinolone GP TRIDESILON CREA GP acetonide) (desonide) SYNALAR SOLN ULTRAVATE CREA (fluocinolone GP (halobetasol GP acetonide) propionate) TACLONEX OINT ST ULTRAVATE OINT (calcipotriene- GP (halobetasol GP betamethasone propionate) dipropionate) VANOS CREA GP TACLONEX SUSP ST; QL(2 gm (fluocinonide) daily) (calcipotriene- VERDESO FOAM 3 3 betamethasone (desonide) dipropionate) Eczema Agents TEMOVATE CREA GP DUPIXENT SOPN PA (clobetasol propionate) SP (dupilumab) TEMOVATE OINT GP DUPIXENT SOSY PA (clobetasol propionate) SP (dupilumab) TEXACORT SOLN (hydrocortisone 3 Emollient/Keratolytic Agents (topical)) (Urea In Lactic Acid TOPICORT CREA Vehicle) UREA 1 GP HYDRATING FOAM (desoximetasone) (Urea) GORDONS UREA, RX/OTC TOPICORT GEL GP METOPIC, UREDEB, 1 (desoximetasone) UREMEZ-40, XUREA TOPICORT LIQD CREA GP (desoximetasone) (Urea) GORDONS UREA, TOPICORT OINT METOPIC, UREDEB, GP 1 ( ) UREMEZ-40, XUREA desoximetasone CREA triamcinolone (Urea) UMECTA MOUSSE 1 acetonide (topical) aers 1 FOAM 0.147 mg/gm (Urea) UREA NAIL GEL 1 triamcinolone acetonide (topical) crea 1 (Urea) UREA-C40 LOTN 1 0.025 %, 0.1 %, 0.5 % CEM-UREA SOLN (urea) 3
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Updated 07/01/2021 78 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RX/OTC CEROVEL LOTN (urea) 3 lactic acid (ammonium 1 lactate) lotn HYDRO 35 FOAM ( urea 3 LACTIC ACID LOTN in lactic acid vehicle) (lactic acid (ammonium 3 HYDRO 40 FOAM FOAM GP lactate)) (urea) Enzymes - Topical KERALAC CREA (urea) GP SANTYL OINT 3 (collagenase) URAMAXIN GEL (urea) GP Immunomodulating Agents - Topical URE-K CREA (urea) 3 ALDARA CREA GP (imiquimod) urea crea 39 %, 41 %, 1 45 %, 47 % imiquimod crea 3.75 % 1 QL(1 gm daily) RX/OTC urea crea 40 % 1 imiquimod crea 5 % 1 ZYCLARA CREA QL(1 ea daily) urea lotn 40 % 1 3 (imiquimod) urea susp 40 % 1 Limit 2 bottles ZYCLARA PUMP CREA 3 per 28 UTOPIC CREA (urea) GP 2.5 % (imiquimod) days;QL(0.6 gm daily) Emollients ZYCLARA PUMP CREA QL(1 gm daily) 3 (Lactic Acid (Ammonium RX/OTC 3.75 % (imiquimod) Lactate)) AL12, AMLACTIN, AMLACTIN Immunosuppressive Agents - Topical DAILY, CVS HYDRATING ELIDEL CREA QL(2 gm daily) GP SKIN TREATMENT, CVS 1 (pimecrolimus) SKIN TREATMENT, CVS SKIN TREATMENT BODY pimecrolimus crea 1 QL(2 gm daily) LOTION, GERI- PROTOPIC OINT HYDROLAC 12 LOTN GP (Lactic Acid (Ammonium RX/OTC (tacrolimus (topical)) Lactate)) GERI- 1 tacrolimus (topical) oint 1 HYDROLAC 12 CREA HYLINATE LOTN Keratolytic/Antimitotic Agents (hyaluronate sodium 3 (Salicylic Acid) KERALYT 1 (emollient)) SHAM LAC-HYDRIN CREA RX/OTC (Salicylic Acid) SALICYLIC (lactic acid (ammonium GP ACID WART REMOVER 1 lactate)) LIQD LAC-HYDRIN TWELVE RX/OTC (Salicylic Acid) SALISOL 1 FORTE SOLN LOTN (lactic acid GP ) (Salicylic Acid) SALITECH 1 (ammonium lactate) FORTE LOTN lactic acid (ammonium RX/OTC BENSAL HP OINT RX/OTC 1 3 lactate) crea (salicylic acid) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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79 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONDYLOX GEL VIRASAL LIQD ( 2 salicylic GP (podofilox) acid) MG217 PSORIASIS RX/OTC Liniments MULTI-SYMTOM OINT 3 MEDROX-RX OINT PA (salicylic acid) (capsaicin-menthol- 3 PODOCON 25 IN ) BENZOIN TINCTURE methyl salicylate SOLN (podophyllum 3 Local Anesthetics - Topical resin) (Cocaine Hcl) C-TOPICAL 1 SOLN 1 podofilox soln (Lidocaine Hcl) 7T LIDO RX/OTC SALEX LOTION KIT GEL, REGENECARE HA 1 (salicylic acid w/ 3 GEL cleanser) (Lidocaine Hcl) GLYDO 1 PRSY SALEX SHAM (salicylic GP (Lidocaine Hcl) LIDO-K, acid) LIDO-SORB, LIDOZION, 1 salicylic acid crea 1 ZIONODIL, ZIONODIL 100 LOTN salicylic acid foam 1 (Lidocaine Hcl) LIDOPIN 1 RX/OTC CREA 3 % salicylic acid in (Lidocaine) PREMIUM 1 ammonium lactate 1 LIDOCAINE OINT vehicle foam CRYODOSE TA AERO RX/OTC salicylic acid liqd 1 (pentafluoropropane- 3 tetrafluoroethane) salicylic acid lotn 1 ethyl chloride aero 1 salicylic acid sham 1 ETHYL CHLORIDE/FINE STREAM AERO (ethyl 3 salicylic acid soln 1 chloride) salicylic acid w/ ETHYL 1 CHLORIDE/MEDIUM cleanser kit 3 SALIMEZ CREA ( STREAM AERO (ethyl salicylic 3 acid) chloride) GEBAUERS INSTANT ICE RX/OTC SALISOL SOLN ( salicylic 3 AERO acid) (pentafluoropropane- 3 SALITECH LOTN 3 tetrafluoroethane) (salicylic acid) GEBAUERS PAIN EASE RX/OTC SALVAX FOAM (salicylic AERO GP 3 acid) (pentafluoropropane- ULTRASAL-ER SOLN tetrafluoroethane) GP (salicylic acid)
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Updated 07/01/2021 80 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GEBAUERS SPRAY AND RX/OTC EPICERAM EMUL STRETCH AERO ( 3 dermatological 3 (pentafluoropropane- products, misc.) tetrafluoroethane) ILIDERM EMUL lidocaine crea ex 3 % 1 (dermatological 3 products, misc.) RX/OTC lidocaine hcl crea 3 % 1 KAMDOY EMUL (dermatological 3 lidocaine hcl gel 2 % 1 products, misc.) lidocaine hcl lotn 3 % 1 KIVIK EMUL (dermatological 3 lidocaine hcl prsy 2 % 1 products, misc.) PENLEN EMUL lidocaine hcl soln 4 % 1 (dermatological 3 products, misc.) lidocaine oint ex 5 % 1 PHLAG SPRAY EMUL lidocaine ptch ex 5 % 1 QL(3 ea daily) (dermatological 3 products, misc.) lidocaine-prilocaine 1 SUVICORT EMUL crea (dermatological 3 LIDODERM PTCH QL(3 ea daily) GP products, misc.) (lidocaine) SYNERDERM EMUL LIDODOSE GEL RX/OTC 3 (dermatological 3 (lidocaine hcl) products, misc.) LIDODOSE PEDIATRIC RX/OTC Misc. Topical BULK PACK GEL 3 DRYSOL SOLN (lidocaine hcl) 2 (aluminum chloride) LIDORX GEL (lidocaine RX/OTC 3 XERAC AC SOLN hcl) (aluminum chloride in 3 PRAMOX GEL GEL 3 alcohol) (pramoxine hcl) SYNERA PTCH Phosphodiesterase 4 (PDE4) Inhibitors - Topical 3 EUCRISA OINT PA (lidocaine-tetracaine) 3 (crisaborole) Misc. Dermatological Products CERACADE EMUL Rosacea Agents (dermatological 3 (Metronidazole (Topical)) 1 products, misc.) ROSADAN CREA Limit 45gms EMULSION SB EMUL (Metronidazole (Topical)) 1 per (dermatological 3 ROSADAN GEL month;QL(1.5 products, misc.) gm daily) ENTTY SPRAY EMUL azelaic acid gel 1 (dermatological 3 products, misc.) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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81 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits doxycycline (rosacea) PA Limit 2 per 1 ELIMITE CREA cpdr GP month;QL(60 (permethrin) gm per 14 days FINACEA FOAM ( azelaic 3 retail) acid) EURAX CREA FINACEA GEL ( 2 azelaic GP (crotamiton) acid) EURAX LOTN 3 PA; QL(1 gm ( ) ivermectin (rosacea) 1 crotamiton crea daily) ivermectin 1 METROCREAM CREA (pediculicide) lotn (metronidazole GP (topical)) lindane sham 1 METROLOTION LOTN QL(2 ml daily) malathion lotn 1 (metronidazole GP NATROBA SUSP AL(At least 4 (topical)) 3 (spinosad) yrs old) metronidazole (topical) 1 crea 0.75 % OVIDE LOTN (malathion) GP Limit 45gms Limit 2 per metronidazole (topical) per 1 1 month;QL(60 gel 0.75 % month;QL(1.5 permethrin crea gm per 14 days gm daily) retail) metronidazole (topical) 1 SKLICE LOTN gel 1 % (ivermectin GP QL(2 ml daily) (pediculicide)) metronidazole (topical) 1 lotn 0.75 % spinosad susp 1 AL(At least 4 MIRVASO GEL PA yrs old) ULESFIA LOTN ( (brimonidine tartrate 3 benzyl 3 (topical)) alcohol (pediculicide)) NORITATE CREA PA Wound Care Products (metronidazole 3 Limit 15gms (topical)) REGRANEX GEL 3 per ORACEA CPDR PA (becaplermin) month;QL(0.5 3 (doxycycline (rosacea)) gm daily) RHOFADE CREA PA DIAGNOSTIC PRODUCTS (oxymetazoline hcl 3 (topical)) Diagnostic Drugs SOOLANTRA CREA PA; QL(1 gm GLUCAGEN DIAGNOSTIC 3 (ivermectin (rosacea)) daily) SOLR (glucagon hcl 2 rdna (diagnostic)) Scabicides & Pediculicides METOPIRONE CAPS 3 (Crotamiton) CROTAN 1 (metyrapone) LOTN Diagnostic Tests
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Updated 07/01/2021 82 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FREESTYLE INSULINX Limit 200 per ELFOLATE TABS ( l- 3 BLOODGLUCOSE TEST month;QL(6.67 methylfolate) STRIPS STRP (glucose 2 ea daily); FOLBIC RF TABS (l- blood) RX/OTC methylfolate w/ vitamin 3 FREESTYLE INSULINX Limit 200 per b6-vitamin b12) BLOODGLUCOSE TEST 2 month;QL(6.67 ea daily); FOLTX TABS (l- STRP (glucose blood) RX/OTC methylfolate w/ vitamin 3 FREESTYLE LITE TEST Limit 200 per b6-vitamin b12) STRIPS STRP (glucose 2 month;QL(6.67 L-METHYLFOLATE CA/S- ea daily); ALGAL CAPS (l- 3 blood) RX/OTC methylfolate-algae) Limit 200 per FREESTYLE TEST L-METHYLFOLATE STRIPS STRP ( 2 month;QL(6.67 glucose ea daily); FORTE CAPS (l- 3 blood) RX/OTC methylfolate-algae) PA; Limit 200 l-methylfolate tabs 15 1 MICRODOT TEST STRIPS per mg, 7.5 mg 3 month;QL(6.67 STRP (glucose blood) ea daily); LEVOMEFOLATE RX/OTC CALCIUM ALGAL POWDER CAPS (l- 3 NON PREFERRED TEST 3 PA STRIPS methylfolate-algae) Limit 200 per DIGESTIVE AIDS - Drugs to Treat Low Digestive ONETOUCH ULTRA STRP Enzymes 2 month;QL(6.67 (glucose blood) ea daily); Digestive Enzymes RX/OTC CREON CPEP Limit 200 per ONETOUCH VERIO TEST (pancrelipase (lipase- 2 STRIPS STRP ( 2 month;QL(6.67 glucose ea daily); protease-amylase)) blood) RX/OTC PANCREAZE CPEP PRECISION XTRA BLOOD Limit 200 per (pancrelipase (lipase- 3 GLUCOSE TEST STRIPS 2 month;QL(6.67 protease-amylase)) ea daily); PERTZYE CPEP STRP (glucose blood) RX/OTC (pancrelipase (lipase- 3 DIETARY PRODUCTS/DIETARY MANAGEMENT protease-amylase)) PRODUCTS SUCRAID SOLN PA 3 Dietary Management Products (sacrosidase) (Folic Acid-Pyridoxine- RX/OTC VIOKACE TABS Cyanocobalamin) FOLBIC, 1 (pancrelipase (lipase- 3 NIVA-FOL, WESTAB MAX TABS protease-amylase)) ZENPEP CPEP DEPLIN 15 CAPS (l- 3 (pancrelipase (lipase- 2 methylfolate-algae) protease-amylase)) DEPLIN 7.5 CAPS ( l- 3 methylfolate-algae) DIURETICS - Drugs to Treat Heart, Circulation Conditions and Blood Pressure
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83 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BUMEX TABS Carbonic Anhydrase Inhibitors GP (bumetanide) 1 acetazolamide cp12 DEMADEX TABS GP acetazolamide tabs 1 (torsemide) EDECRIN TABS ST KEVEYIS TABS PA GP SP (ethacrynic acid) (dichlorphenamide) ethacrynic acid tabs 1 ST methazolamide tabs 1 1 Diuretic Combinations furosemide soln ALDACTAZIDE TABS 25 furosemide tabs 1 MG-25 MG GP LASIX TABS (spironolactone & GP hydrochlorothiazide) (furosemide) ALDACTAZIDE TABS 50 torsemide tabs 1 MG-50 MG (spironolactone & 2 Potassium Sparing Diuretics hydrochlorothiazide) ALDACTONE TABS GP amiloride & (spironolactone) hydrochlorothiazide 1 amiloride hcl tabs 1 tabs DYRENIUM CAPS DYAZIDE CAPS GP (triamterene & GP (triamterene) hydrochlorothiazide) spironolactone tabs 1 MAXZIDE TABS (triamterene & GP triamterene caps 1 hydrochlorothiazide) Thiazides and Thiazide-Like Diuretics MAXZIDE-25 TABS (triamterene & GP chlorothiazide tabs 1 hydrochlorothiazide) chlorthalidone tabs 1 spironolactone & DIURIL SUSP hydrochlorothiazide 1 3 tabs (chlorothiazide) triamterene & hydrochlorothiazide 1 hydrochlorothiazide 1 caps caps hydrochlorothiazide 1 triamterene & tabs hydrochlorothiazide 1 indapamide tabs 1 tabs Loop Diuretics metolazone tabs 1 bumetanide tabs 1 ENDOCRINE AND METABOLIC AGENTS - MISC. - Drugs to Treat Bone Disease and Regulate Hormones
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Updated 07/01/2021 84 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Bone Density Regulators ibandronate sodium Limit 1 tab per 1 month;QL(0.04 ACTONEL TABS 150 MG ST; Limit 1 per tabs or 150 mg GP month;QL(0.04 ea daily) (risedronate sodium) MIACALCIN SOLN PA ea daily) SP (calcitonin (salmon)) ACTONEL TABS 35 MG ST; Limit 4 per GP month;QL(0.15 NATPARA CART PA (risedronate sodium) ea daily) (parathyroid hormone SP ACTONEL TABS 5 MG ST; QL(1 ea (recombinant)) GP (risedronate sodium) daily) pamidronate disodium PA SP alendronate sodium 1 soln 30 mg/10ml, 90 soln 70 mg/75ml mg/10ml alendronate sodium PAMIDRONATE PA DISODIUM SOLN 6 tabs 10 mg, 40 mg, 5 1 SP mg MG/ML (pamidronate disodium) alendronate sodium Limit 4 per 1 month;QL(0.15 PROLIA SOSY PA SP tabs 35 mg, 70 mg ea daily) (denosumab) Limit 4 per RECLAST SOLN PA ATELVIA TBEC SP GP month;QL(0.15 (zoledronic acid) (risedronate sodium) ea daily) risedronate sodium ST; Limit 1 per BINOSTO TBEF Limit 4 tabs per 1 month;QL(0.04 3 month;QL(0.15 tabs 150 mg ea daily) (alendronate sodium) ea daily) ST; QL(1 ea risedronate sodium 1 BONIVA SOLN IV 3 PA tabs 30 mg, 5 mg daily) MG/3ML (ibandronate SP sodium) risedronate sodium ST; Limit 4 per 1 month;QL(0.15 BONIVA TABS OR 150 MG Limit 1 tab per tabs 35 mg ea daily) GP month;QL(0.04 (ibandronate sodium) ea daily) risedronate sodium Limit 4 per 1 month;QL(0.15 PA tbec 35 mg calcitonin (salmon) soln SP ea daily) ij 200 unit/ml TYMLOS SOPN PA SP (abaloparatide) calcitonin (salmon) soln 1 na 200 unit/act XGEVA SOLN PA SP (denosumab) etidronate disodium 1 tabs PA zoledronic acid conc 4 SP FOSAMAX PLUS D TABS PA; Limit 4 per mg/5ml (alendronate sodium- 3 month;QL(0.15 ZOLEDRONIC ACID SOLN PA cholecalciferol) ea daily) 4 MG/100ML (zoledronic SP FOSAMAX TABS Limit 4 per acid) GP month;QL(0.15 PA (alendronate sodium) zoledronic acid soln 4 SP ea daily) mg/100ml, 5 mg/100ml PA ibandronate sodium SP soln iv 3 mg/3ml Fertility Regulators
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85 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Limit 15 per PA; Use ZOMACTON SOLR clomiphene citrate tabs 1 month;QL(0.5 SP preferred ea daily) (somatropin) Humatrope or Norditropin Growth Hormone Receptor Antagonists SOMAVERT SOLR PA ZORBTIVE SOLR PA SP (pegvisomant) (somatropin (non- SP refrigerated)) Growth Hormones Hormone Receptor Modulators PA; Use GENOTROPIN MINIQUICK EVISTA TABS (raloxifene QL(1 ea daily); SP preferred GP SOLR (somatropin) Humatrope or hcl) PV Norditropin OSPHENA TABS 3 PA; Use (ospemifene) GENOTROPIN SOLR preferred SP 1 QL(1 ea daily); (somatropin) Humatrope or raloxifene hcl tabs PV Norditropin HUMATROPE COMBO PA Insulin-Like Growth Factors (Somatomedins) PACK SOLR INCRELEX SOLN PA SP SP (somatropin) (mecasermin) HUMATROPE SOLR PA SP LHRH/GnRH Agonist Analog Pituitary (somatropin) FENSOLVI KIT PA NORDITROPIN FLEXPRO PA; Use (leuprolide acetate AC SOPN 10 MG/1.5ML, 5 SP preferred (cpp) (6 month)) Humatrope or MG/1.5ML (somatropin) Norditropin LUPRON DEPOT-PED (1- PA SP NORDITROPIN FLEXPRO PA MONTH) KIT (leuprolide SOPN 15 MG/1.5ML, 30 SP acetate (cpp)) MG/3ML (somatropin) LUPRON DEPOT-PED (3- PA PA; Use MONTH) KIT (leuprolide SP NUTROPIN AQ NUSPIN acetate (cpp) (3 month)) SP preferred 10 SOPN ( ) Humatrope or SYNAREL SOLN somatropin 2 Norditropin (nafarelin acetate) PA; Use Metabolic Modifiers NUTROPIN AQ NUSPIN preferred SP ALDURAZYME SOLN PA 20 SOPN (somatropin) Humatrope or SP Norditropin (laronidase) PA; Use BUPHENYL POWD PA NUTROPIN AQ NUSPIN 5 SP preferred (sodium SP SOPN (somatropin) Humatrope or phenylbutyrate) Norditropin BUPHENYL TABS PA PA; Use OMNITROPE SOLR (sodium SP SP preferred (somatropin) Humatrope or phenylbutyrate) Norditropin calcitriol caps or 0.25 1 SEROSTIM SOLR PA mcg, 0.5 mcg (somatropin (non- SP PA calcitriol soln iv 1 SP refrigerated)) mcg/ml
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Updated 07/01/2021 86 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcitriol soln or 1 1 levocarnitine (metabolic 1 mcg/ml modifiers) tabs CARBAGLU TABS PA LUMIZYME SOLR PA SP SP (carglumic acid) (alglucosidase alfa) CARNITOR SF SOLN MYALEPT SOLR PA SP (levocarnitine GP (metreleptin) (metabolic modifiers)) NAGLAZYME SOLN PA SP CARNITOR SOLN (galsulfase) (levocarnitine GP nitisinone caps SP PA (metabolic modifiers)) CARNITOR TABS NITYR TABS (nitisinone) SP PA (levocarnitine GP ORFADIN CAPS 10 MG, 2 PA (metabolic modifiers)) SP MG, 5 MG (nitisinone) cinacalcet hcl tabs 1 ORFADIN CAPS 20 MG PA SP CYSTADANE POWD PA (nitisinone) SP ORFADIN SUSP 4 MG/ML PA (betaine) SP doxercalciferol caps or (nitisinone) PALYNZIQ SOSY PA 0.5 mcg, 1 mcg, 2.5 1 SP mcg (pegvaliase-pqpz) PA paricalcitol caps or 1 doxercalciferol soln iv 4 SP 1 mcg/2ml mcg, 2 mcg, 4 mcg ELAPRASE SOLN PA paricalcitol soln iv 2 PA SP SP (idursulfase) mcg/ml, 5 mcg/ml FABRAZYME SOLR PA RAVICTI LIQD (glycerol PA SP SP (agalsidase beta) phenylbutyrate) GALAFOLD CAPS PA; QL(0.5 ea RAYALDEE CPCR PA SP SP (migalastat hcl) daily) (calcifediol) HECTOROL SOLN 2 PA ROCALTROL CAPS GP MCG/ML SP (calcitriol) (doxercalciferol) ROCALTROL SOLN GP HECTOROL SOLN 4 PA (calcitriol) MCG/2ML SP sapropterin PA (doxercalciferol) SP dihydrochloride pack KUVAN PACK PA PA (sapropterin SP sapropterin SP dihydrochloride) dihydrochloride tabs SENSIPAR TABS KUVAN TABS PA GP (sapropterin SP (cinacalcet hcl) PA dihydrochloride) sodium phenylbutyrate SP levocarnitine (metabolic powd 1 PA modifiers) soln sodium phenylbutyrate SP tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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87 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits STRENSIQ SOLN PA SIGNIFOR SOLN PA SP (asfotase alfa) (pasireotide SP XURIDEN PACK ( diaspartate) uridine SP triacetate) SOMATULINE DEPOT PA ZEMPLAR CAPS OR 1 SOLN (lanreotide SP MCG, 2 MCG GP acetate) (paricalcitol) Vasopressin Receptor Antagonists ZEMPLAR SOLN IV 2 PA JYNARQUE TABS 15 MG, PA; QL(1 ea SP MCG/ML, 5 MCG/ML SP 30 MG (tolvaptan) daily) (paricalcitol) JYNARQUE TBPK PA; SP SP Posterior Pituitary Hormones (tolvaptan) DDAVP SOLN NA 0.01 % SAMSCA TABS PA; QL(1 ea SP (desmopressin acetate 2 (tolvaptan) daily) refrigerated) SP PA; QL(1 ea DDAVP SOLN NA 0.01 % tolvaptan tabs daily) (desmopressin acetate GP ESTROGENS - Hormone Replacement/Modifying spray) Drugs DDAVP TABS OR 0.1 MG, Estrogen Combinations 0.2 MG ( GP desmopressin (Esterified Estrogens & QL(1 ea daily) acetate) Methyltestosterone) COVARYX, COVARYX HS, desmopressin acetate 1 spray refrigerated soln EEMT, EEMT HS, ESTERIFIED 1 desmopressin acetate 1 ESTROGENS/METHYLTE spray soln STOSTERONE DS, ESTERIFIED desmopressin acetate 1 tabs ESTROGENS/METHYLTE STOSTERONE HS TABS NOCTIVA EMUL PA 3 (Estradiol & Norethindrone (desmopressin acetate) Acetate) AMABELZ, 1 STIMATE SOLN PA LOPREEZA, MIMVEY, 3 (desmopressin acetate) MIMVEY LO TABS Prolactin Inhibitors (Norethindrone Acetate- Ethinyl Estradiol) 1 cabergoline tabs 1 FYAVOLV, JINTELI TABS ACTIVELLA TABS Somatostatic Agents (estradiol & GP octreotide acetate soln SP PA norethindrone acetate) ANGELIQ TABS SANDOSTATIN LAR PA 3 DEPOT KIT (octreotide SP (drospirenone-estradiol) acetate) CLIMARA PRO PTWK SANDOSTATIN SOLN PA (estradiol- 2 SP (octreotide acetate) levonorgestrel)
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OR Essential Drug List
Updated 07/01/2021 88 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits COMBIPATCH PTTW DIVIGEL GEL 0.25 MG/0.25GM, 0.5 (estradiol & 3 3 norethindrone acetate) MG/0.5GM, 1 MG/GM, 1.25 DUAVEE TABS MG/1.25GM (estradiol) ELESTRIN GEL (conjugated estrogens- 3 3 bazedoxifene) (estradiol) ESTRACE TABS esterified estrogens & QL(1 ea daily) GP methyltestosterone 1 (estradiol) tabs estradiol pttw td 0.025 Limit 8 per mg/24hr, 0.0375 month;QL(0.29 estradiol & ea daily) norethindrone acetate 1 mg/24hr, 0.05 mg/24hr, 1 tabs 0.075 mg/24hr, 0.1 mg/24hr norethindrone acetate- 1 ethinyl estradiol tabs estradiol ptwk td 0.025 Limit 4 per mg/24hr, 0.06 mg/24hr, month;QL(0.15 PREFEST TABS 3 0.075 mg/24hr, 0.1 1 ea daily) (estradiol-norgestimate) mg/24hr, 37.5 PREMPHASE TABS mcg/24hr (conjugated estrogens- 2 estradiol ptwk td 0.05 Limit 4 per 28 medroxyprogesterone 1 days;QL(0.15 acetate) mg/24hr ea daily) PREMPRO TABS estradiol tabs or 0.5 (conjugated estrogens- 1 2 mg, 1 mg, 2 mg medroxyprogesterone PA acetate) estradiol valerate oil SP Estrogens Limit 50gms ESTROGEL GEL Limit 8 per 3 per (Estradiol) DOTTI, 1 month;QL(0.29 (estradiol) month;QL(1.67 LYLLANA PTTW ea daily) gm daily) EVAMIST SOLN CLIMARA PTWK 0.025 Limit 4 per 3 MG/24HR, 0.06 MG/24HR, month;QL(0.15 (estradiol) 0.075 MG/24HR, 0.1 GP ea daily) MENEST TABS 2 MG/24HR, 37.5 (esterified estrogens) MCG/24HR (estradiol) MENOSTAR PTWK Limit 4 per DELESTROGEN OIL 10 PA 3 month;QL(0.14 (estradiol) MG/ML (estradiol SP ea daily) valerate) MINIVELLE PTTW Limit 8 per GP month;QL(0.29 DELESTROGEN OIL 20 PA (estradiol) MG/ML, 40 MG/ML SP ea daily) (estradiol valerate) PREMARIN SOLR IJ 25 PA DEPO-ESTRADIOL OIL PA MG (estrogens, SP SP (estradiol cypionate) conjugated)
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89 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PREMARIN TABS OR 0.3 OCALIVA TABS PA SP MG, 0.45 MG, 0.625 MG, (obeticholic acid) 0.9 MG, 1.25 MG 2 (estrogens, conjugated) Gallstone Solubilizing Agents ACTIGALL CAPS VIVELLE-DOT PTTW Limit 8 per GP GP month;QL(0.29 (ursodiol) (estradiol) ea daily) CHENODAL TABS PA 3 FLUOROQUINOLONES - Drugs to Treat Bacterial (chenodiol) Infections RELTONE CAPS 3 Fluoroquinolones (ursodiol) AVELOX TABS URSO 250 TABS GP GP (moxifloxacin hcl) (ursodiol) URSO FORTE TABS BAXDELA TABS ST GP (delafloxacin 3 (ursodiol) meglumine) ursodiol caps 1 CIPRO SUSR 5 GM/100ML, 500 MG/5ML 2 ursodiol tabs 1 (ciprofloxacin) Gastrointestinal Antiallergy Agents CIPRO TABS 250 MG, 500 GP MG (ciprofloxacin hcl) cromolyn sodium 1 (mastocytosis) conc ciprofloxacin hcl tabs 1 GASTROCROM CONC (cromolyn sodium GP ciprofloxacin susr 1 (mastocytosis)) LEVAQUIN TABS QL(14 ea per GP Gastrointestinal Chloride Channel Activators (levofloxacin) fill retail) AMITIZA CAPS GP levofloxacin soln 25 1 (lubiprostone) mg/ml QL(14 ea per lubiprostone caps 1 levofloxacin tabs 250 1 mg, 500 mg, 750 mg fill retail) Gastrointestinal Stimulants moxifloxacin hcl tabs 1 metoclopramide hcl 1 soln ofloxacin tabs 1 metoclopramide hcl 1 GASTROINTESTINAL AGENTS - MISC. - tabs Miscellaneous Gastrointestinal Drugs metoclopramide hcl 1 Agents for Chronic Idiopathic Constipation (CIC) tbdp TRULANCE TABS PA METOCLOPRAMIDE ODT 3 (plecanatide) TBDP (metoclopramide 3 hcl) Bile Acid Synthesis Disorder Agents REGLAN TABS CHOLBAM CAPS ( PA GP cholic SP (metoclopramide hcl) acid) Inflammatory Bowel Agents Farnesoid X Receptor (FXR) Agonists
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OR Essential Drug List
Updated 07/01/2021 90 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ASACOL HD TBEC PA ROWASA KIT 3 (mesalamine) (mesalamine w/ GP AZULFIDINE EN-TABS cleanser) GP TBEC (sulfasalazine) SFROWASA ENEM 2 AZULFIDINE TABS (mesalamine) GP (sulfasalazine) STELARA SOLN PA SP Limit 282 caps (ustekinumab (iv)) balsalazide disodium 1 per caps month;QL(9.4 sulfasalazine tabs 1 ea daily) sulfasalazine tbec 1 CANASA SUPP GP (mesalamine) Intestinal Acidifiers CIMZIA KIT PA (Lactulose SP (certolizumab pegol) (Encephalopathy)) 1 CIMZIA STARTER KIT KIT PA ENULOSE, GENERLAC SP SOLN (certolizumab pegol) Limit 282 caps lactulose 1 COLAZAL CAPS (encephalopathy) soln GP per (balsalazide disodium) month;QL(9.4 Irritable Bowel Syndrome (IBS) Agents ea daily) PA DIPENTUM CAPS alosetron hcl tabs 1 3 (olsalazine sodium) LINZESS CAPS 2 INFLECTRA SOLR PA (linaclotide) SP (infliximab-dyyb) LOTRONEX TABS PA GP (alosetron hcl) mesalamine cp24 or 1 0.375 gm VIBERZI TABS PA 3 QL(12 ea daily) (eluxadoline) mesalamine cpdr or 1 400 mg Peripheral Opioid Receptor Antagonists mesalamine enem re 4 1 alvimopan caps 1 gm ENTEREG CAPS mesalamine supp re 1 GP 1000 mg (alvimopan) MOVANTIK TABS mesalamine tbec or 1.2 3 1 (naloxegol oxalate) gm RELISTOR SOLN PA mesalamine w/ 1 (methylnaltrexone SP cleanser kit bromide) PENTASA CPCR PA 3 RELISTOR TABS PA (mesalamine) (methylnaltrexone SP REMICADE SOLR PA SP bromide) (infliximab) SYMPROIC TABS PA 3 (naldemedine tosylate) Phosphate Binder Agents
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91 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits calcium acetate (Pot & Sod Citrates (phosphate binder) 1 W/Citric Ac) CYTRA-3 1 caps SYRP FOSRENOL CHEW 1000 (Potassium Citrate-Citric MG, 500 MG, 750 MG Acid) CYTRA K 1 GP CRYSTALS, TARON- (lanthanum carbonate) CRYSTALS PACK lanthanum carbonate 1 (Potassium Citrate-Citric 1 RX/OTC chew Acid) CYTRA-K SOLN PHOSLYRA SOLN (Sodium Citrate & Citric 1 RX/OTC (calcium acetate 3 Acid) CYTRA-2 SOLN (phosphate binder)) ORACIT SOLN ( sodium 3 RENAGEL TABS PA citrate & citric acid) GP (sevelamer hcl) pot & sod citrates 1 RENVELA PACK w/citric ac soln GP (sevelamer carbonate) potassium citrate RENVELA TABS 1 GP (alkalinizer) tbcr (sevelamer carbonate) RX/OTC potassium citrate-citric 1 sevelamer carbonate 1 acid soln pack RX/OTC sodium citrate & citric 1 sevelamer carbonate 1 acid soln tabs UROCIT-K 10 TBCR sevelamer hcl tabs 1 PA (potassium citrate GP (alkalinizer)) VELPHORO CHEW PA UROCIT-K 15 TBCR (sucroferric 3 (potassium citrate GP oxyhydroxide) (alkalinizer)) Short Bowel Syndrome (SBS) Agents UROCIT-K 5 TBCR GATTEX KIT PA SP (potassium citrate GP (teduglutide (rdna)) (alkalinizer)) Tryptophan Hydroxylase Inhibitors Cystinosis Agents XERMELO TABS PA CYSTAGON CAPS SP 3 (telotristat etiprate) (cysteamine bitartrate) GENITOURINARY AGENTS - MISCELLANEOUS PROCYSBI CPDR 25 MG, - Miscellaneous Drugs to Treat Reproductive 75 MG (cysteamine 3 Organs and Urinary System bitartrate) Acidifiers Genitourinary Irrigants K-PHOS NO 2 TABS (Sodium Chloride (Gu PA (potassium & sodium 2 Irrigant)) ARGYLE acid phosphates) STERILE SALINE 100ML, SP CURITY STERILE SALINE Alkalinizers SOLN
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Updated 07/01/2021 92 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Phenazopyridine Hcl) neomycin/polymyxin b 1 1 gu soln PHENAZO TABS PA phenazopyridine hcl sodium chloride (gu SP 1 irrigant) soln tabs PYRIDIUM TABS Interstitial Cystitis Agents GP (phenazopyridine hcl) ELMIRON CAPS QL(3 ea daily) (pentosan polysulfate 3 Urinary Stone Agents LITHOSTAT TABS sodium) 3 (acetohydroxamic acid) Prostatic Hypertrophy Agents THIOLA EC TBEC SP alfuzosin hcl tb24 1 (tiopronin) AVODART CAPS AL(At least 40 GP THIOLA TABS (tiopronin) SP (dutasteride) yrs old) CARDURA XL TB24 tiopronin tabs SP (doxazosin mesylate 3 (bph)) GOUT AGENTS - Drugs to Treat Gout 1 AL(At least 40 Gout Agent Combinations dutasteride caps yrs old) colchicine w/ 1 dutasteride-tamsulosin 1 probenecid tabs hcl caps Gout Agents QL(1 ea daily); finasteride tabs 1 AL(At least 40 allopurinol tabs 1 yrs old) FLOMAX CAPS QL(2 ea daily) colchicine caps 1 GP (tamsulosin hcl) JALYN CAPS febuxostat tabs 1 (dutasteride-tamsulosin GP MITIGARE CAPS 3 hcl) (colchicine) QL(1 ea daily); ULORIC TABS PROSCAR TABS GP GP AL(At least 40 (febuxostat) (finasteride) yrs old) ZYLOPRIM TABS RAPAFLO CAPS 4 MG GP 3 (allopurinol) (silodosin) RAPAFLO CAPS 8 MG Uricosurics GP (silodosin) probenecid tabs 1 silodosin caps 4 mg, 8 1 HEMATOLOGICAL AGENTS - MISC. - Drugs to mg Treat Blood Disorders QL(2 ea daily) tamsulosin hcl caps 1 Bradykinin B2 Receptor Antagonists UROXATRAL TB24 FIRAZYR SOLN (icatibant PA GP SP (alfuzosin hcl) acetate) Urinary Analgesics icatibant acetate soln SP PA
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93 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Complement Inhibitors prasugrel hcl tabs 1 PA; SP BERINERT KIT (c1 ZONTIVITY TABS SP 2 esterase inhibitor (vorapaxar sulfate) (human)) PA HEMATOPOIETIC AGENTS - Drugs to Treat HAEGARDA SOLR (c1 Blood Disorders esterase inhibitor SP (human)) Agents for Gaucher Disease CERDELGA CAPS PA RUCONEST SOLR (c1 PA SP (eliglustat tartrate) esterase inhibitor SP ELELYSO SOLR PA (recombinant)) SP (taliglucerase alfa) Hemataologic - Tyrosine Kinase Inhibitors PA TAVALISSE TABS PA; SP miglustat caps SP SP (fostamatinib disodium) VPRIV SOLR PA SP Hematorheologic Agents (velaglucerase alfa) ZAVESCA CAPS PA pentoxifylline tbcr 1 SP (miglustat) Plasma Kallikrein Inhibitors Agents for Sickle Cell Disease TAKHZYRO SOLN PA SP DROXIA CAPS (lanadelumab-flyo) (hydroxyurea (sickle 3 Platelet Aggregation Inhibitors cell anemia)) AGGRENOX CP12 ENDARI PACK PA GP SP (aspirin-dipyridamole) (glutamine (sickle cell)) AGRYLIN CAPS SIKLOS TABS PA GP (anagrelide hcl) (hydroxyurea (sickle SP cell anemia)) anagrelide hcl caps 1 Folic Acid/Folates aspirin-dipyridamole 1 (Folic Acid) CVS FOLIC PV cp12 ACID, FOLATE, GNP BRILINTA TABS FOLIC ACID, HM FOLIC 2 (ticagrelor) ACID, PX FOLIC ACID, QC PV FOLIC ACID, RA FOLIC CABLIVI KIT PA SP ACID, SM FOLIC ACID, YL (caplacizumab-yhdp) FOLIC ACID TABS QL(2 ea daily) cilostazol tabs 1 (Folic Acid) KP FOLIC PV RX/OTC; PV ACID TABS 1 MG clopidogrel bisulfate QL(2 ea daily) 1 (Folic Acid) KP FOLIC PV PV tabs ACID TABS 800 MCG dipyridamole tabs 1 folic acid soln ij 5 mg/ml PV PV EFFIENT TABS RX/OTC; PV GP folic acid tabs or 1 mg PV (prasugrel hcl) PLAVIX TABS QL(2 ea daily) folic acid tabs or 400 PV GP PV (clopidogrel bisulfate) mcg, 800 mcg
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Updated 07/01/2021 94 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Hematopoietic Growth Factors PROMACTA PACK 12.5 PA ARANESP ALBUMIN PA MG, 25 MG (eltrombopag SP FREE SOLN SP olamine) (darbepoetin alfa) PROMACTA TABS 12.5 PA ARANESP ALBUMIN PA MG, 25 MG, 50 MG SP FREE SOSY SP (eltrombopag olamine) (darbepoetin alfa) PROMACTA TABS 75 MG PA; QL(1 ea SP DOPTELET TABS PA (eltrombopag olamine) daily) (avatrombopag SP RETACRIT SOLN 10000 PA maleate) UNIT/ML, 2000 UNIT/ML, 20000 UNIT/2ML, 20000 EPOGEN SOLN (epoetin PA SP UNIT/ML, 3000 UNIT/ML, SP alfa) 4000 UNIT/ML, 40000 GRANIX SOSY 300 PA UNIT/ML (epoetin alfa- MCG/0.5ML, 480 SP epbx) MCG/0.8ML (tbo- ZARXIO SOSY PA SP filgrastim) (filgrastim-sndz) LEUKINE SOLR PA ZIEXTENZO SOSY PA SP SP (sargramostim) (pegfilgrastim-bmez) MIRCERA SOSY PA Hematopoietic Mixtures (methoxy polyethylene SP glycol-epoetin beta) FOLIVANE-F CAPS (ferrous fumarate-iron MULPLETA TABS PA 2 SP polysaccharide (lusutrombopag) complex-folic acid-c-b3) NEULASTA ONPRO KIT PA SP PSKT (pegfilgrastim) FUSION PLUS CAPS (fe fum-iron polysacch NEULASTA SOSY PA 3 SP complex-fa-b cmplx-c- (pegfilgrastim) biotin-probiotic) NEUPOGEN SOLN PA SP INTEGRA F CAPS (filgrastim) (ferrous fumarate-iron NEUPOGEN SOSY PA 2 SP polysaccharide (filgrastim) complex-folic acid-c-b3) NIVESTYM SOSY 300 PA MCG/0.5ML, 480 Iron SP MCG/0.8ML (filgrastim- (Carbonyl Iron) WEE CARE PV PV aafi) SUSP PROCRIT SOLN 10000 PA (Ferrous Sulfate) PV UNIT/ML, 2000 UNIT/ML, BPROTECTED PEDIA 20000 UNIT/ML, 3000 IRON, FE-VITE IRON, UNIT/ML, 4000 UNIT/ML, SP IRON SUPPLEMENT PV CHILDRENS, PC 40000 UNIT/ML (epoetin PEDIATRIC IRON DROPS alfa) SOLN
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95 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Ferrous Sulfate) PV (Diphenhydramine Hcl FEROSUL, IRON PV (Sleep)) COMPOZ, CVS SUPPLEMENT ELIX SLEEP AID FER-IN-SOL SOLN PV NIGHTTIME/MAXIMUM GP (ferrous sulfate) STRENGTH, CVS SLEEP- AID NIGHTTIME, EQ ferrous sulfate elix PV PV NIGHTTIME SLEEP AID MAXIMUM STRENGTH, ferrous sulfate soln PV PV EQL SLEEP AID MAXIMUM STRENGTH, ferrous sulfate syrp PV PV GOODSENSE SLEEP AID, ORMIR, QC SLEEP AID 1 ICAR PEDIATRIC SUSP PV MAXIMUM STRENGTH, GP (carbonyl iron) QC SLEEP-AID MAXIMUM MYKIDZ IRON 10 SUSP PV STRENGTH, RA SLEEP PV AID MAXIMUM (iron) STRENGTH, SLEEP AID, Stem Cell Mobilizers SLEEP-AID, SM SLEEP MOZOBIL SOLN PA AID MAXIMUM SP STRENGTH, TGT SLEEP (plerixafor) AID MAXIMUM HEMOSTATICS - Drugs to Stop Bleeding/Treat STRENGTH, WAL-SOM Blood Disorders MAXIMUM STRENGTH CAPS Hemostatics - Systemic UNISOM SLEEPGELS AMICAR TABS 1000 MG, CAPS (diphenhydramine GP 500 MG (aminocaproic GP hcl (sleep)) acid) aminocaproic acid tabs Barbiturate Hypnotics 1 BUTISOL SODIUM TABS 1000 mg, 500 mg 3 (butabarbital sodium) CYKLOKAPRON SOLN PA SP (tranexamic acid) phenobarbital elix 20 1 LYSTEDA TABS QL(6 ea daily,5 mg/5ml GP (tranexamic acid) day(s) limit) phenobarbital soln 20 1 PA mg/5ml tranexamic acid soln iv SP 1000 mg/10ml phenobarbital tabs 100 QL(6 ea daily,5 mg, 15 mg, 16.2 mg, 30 tranexamic acid tabs or 1 1 650 mg day(s) limit) mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg HYPNOTICS/SEDATIVES/SLEEP DISORDER SECONAL SODIUM CAPS AGENTS 3 (secobarbital sodium) Antihistamine Hypnotics Hypnotics - Tricyclic Agents 1 ST; QL(1 ea doxepin hcl (sleep) tabs daily) SILENOR TABS ( ST; QL(1 ea doxepin GP hcl (sleep)) daily) Non-Barbiturate Hypnotics You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 96 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AMBIEN CR TBCR QL(1 ea daily) BELSOMRA TABS ST; QL(1 ea GP 2 (zolpidem tartrate) (suvorexant) daily) AMBIEN TABS ( QL(1 ea daily) zolpidem GP Selective Melatonin Receptor Agonists tartrate) HETLIOZ CAPS PA SP DORAL TABS ( ) 3 tasimelteon (quazepam) HETLIOZ LQ SUSP PA SP EDLUAR SUBL ST; QL(1 ea ( ) 3 tasimelteon (zolpidem tartrate) daily) ramelteon tabs 1 ST; QL(1 ea estazolam tabs 1 daily) ROZEREM TABS ST; QL(1 ea GP eszopiclone tabs 1 QL(1 ea daily) (ramelteon) daily) flurazepam hcl caps 1 LAXATIVES - Bowel Treatment Drugs HALCION TABS Laxative Combinations GP (triazolam) (Bisacodyl-Peg 3350-Pot PV INTERMEZZO SUBL PA Chloride-Sod Bicarb-Sod 1 GP Chloride) GAVILYTE-H, (zolpidem tartrate) PEG-PREP KIT LUNESTA TABS QL(1 ea daily) GP (Peg 3350-Kcl-Nacl-Na PV (eszopiclone) Sulfate-Na Ascorbate- Ascorbic Acid) PEG- 1 midazolam hcl syrp 1 3350/ELECTROLYTES/AS CORBATE SOLR quazepam tabs 1 (Peg 3350-Kcl-Sod Bicarb- PV RESTORIL CAPS Sod Chloride-Sod Sulfate) GP 1 (temazepam) GAVILYTE-C, GAVILYTE- G SOLR temazepam caps 1 (Peg 3350-Potassium PV Chloride-Sod Bicarbonate- triazolam tabs 1 Sod Chloride) GAVILYTE- 1 QL(1 ea daily) N/FLAVOR PACK, zaleplon caps 1 TRILYTE SOLR PA COLYTE-FLAVOR PACKS PV zolpidem tartrate subl 1 sl 1.75 mg, 3.5 mg SOLR (peg 3350-kcl-sod bicarb-sod chloride-sod 3 zolpidem tartrate tabs QL(1 ea daily) 1 sulfate) or 10 mg, 5 mg GOLYTELY SOLR 2.82 PA; PV QL(1 ea daily) zolpidem tartrate tbcr 1 GM-21.5 GM-227.1 GM- or 12.5 mg, 6.25 mg 5.53 GM-6.36 GM (peg ST; Limit 3350-kcl-sod bicarb- 2 ZOLPIMIST SOLN 3 7.7mls per sod chloride-sod (zolpidem tartrate) month;QL(0.26 sulfate) ml daily) Orexin Receptor Antagonists
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97 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits GOLYTELY SOLR 2.97 PV KRISTALOSE PACK 10 3 GM-22.74 GM-236 GM- GM, 20 GM (lactulose) 5.86 GM-6.74 GM (peg LACTULOSE PACK 10 GM GP 3 3350-kcl-sod bicarb- (lactulose) sod chloride-sod lactulose soln 10 1 sulfate) gm/15ml, 20 gm/30ml PV NULYTELY SOLR (peg Limit 528gms 3350-potassium MIRALAX POWD ( GP per chloride-sod GP polyethylene glycol month;QL(17.6 bicarbonate-sod 3350) gm daily) chloride) Limit 528gms NULYTELY/FLAVOR PV polyethylene glycol 1 per PACKS SOLR (peg 3350- 3350 powd month;QL(17.6 gm daily) potassium chloride-sod GP bicarbonate-sod MACROLIDES - Drugs to Treat Bacterial chloride) Infections peg 3350-kcl-nacl-na PV Azithromycin sulfate-na ascorbate- 1 azithromycin pack 1 gm 1 ascorbic acid solr PV azithromycin susr 100 1 peg 3350-kcl-sod mg/5ml, 200 mg/5ml bicarb-sod chloride-sod 1 QL(6 ea per fill sulfate solr azithromycin tabs 250 1 mg retail) peg 3350-potassium PV azithromycin tabs 500 QL(3 ea per fill chloride-sod 1 1 retail) bicarbonate-sod mg chloride solr azithromycin tabs 600 QL(10 ea per 1 fill retail) Laxatives - Miscellaneous mg ZITHROMAX PACK 1 GM (Lactulose) CONSTULOSE 1 GP SOLN (azithromycin) (Polyethylene Glycol 3350) Limit 528gms ZITHROMAX SUSR 100 CLEARLAX, CVS per MG/5ML, 200 MG/5ML GP PURELAX, EQ month;QL(17.6 (azithromycin) CLEARLAX, EQL gm daily) ZITHROMAX TABS 250 QL(6 ea per fill GP CLEARLAX, GAVILAX, MG (azithromycin) retail) GENTLELAX, GLYCOLAX, ZITHROMAX TABS 500 QL(3 ea per fill GNP CLEARLAX, GP MG (azithromycin) retail) GOODSENSE CLEARLAX, 1 HM CLEARLAX, KLS ZITHROMAX TABS 600 QL(10 ea per GP LAXACLEAR, MM MG (azithromycin) fill retail) CLEARLAX, QC NATURA- ZITHROMAX TRI-PAK QL(3 ea per fill LAX, RA LAXATIVE, SB GP POLYETHYLENE GLYCOL TABS (azithromycin) retail) 3350, SM CLEARLAX, ZITHROMAX Z-PAK TABS QL(6 ea per fill GP SMOOTH LAX, TGT (azithromycin) retail) POWDERLAX POWD Clarithromycin You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 98 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits clarithromycin susr 125 1 Contraceptives mg/5ml, 250 mg/5ml AIMSCO LUBRICATED PV MISC (condoms latex PV clarithromycin tabs 250 1 mg, 500 mg lubricated - male) QL(14 ea per clarithromycin tb24 500 1 DIAPHRAGMS PV mg fill retail) DUREX EXTRA PV Erythromycins SENSITIVE DEVI PV (Erythromycin Base) ERY- 1 (condoms latex TAB TBEC lubricated - male) (Erythromycin FANTASY LUBRICATED PV Ethylsuccinate) E.E.S. 400 1 MISC ( PV TABS condoms latex lubricated - male) (Erythromycin Stearate) ERYTHROCIN STEARATE 1 FANTASY PV LUBRICATED/SPERMICID TABS PV E.E.S. GRANULES SUSR E MISC (condoms latex (erythromycin GP lubricated - male) ethylsuccinate) FC FEMALE CONDOM PV ERYPED 200 SUSR MISC (condoms - PV (erythromycin GP female) ethylsuccinate) FC2 FEMALE CONDOM PV ERYPED 400 SUSR MISC (condoms - PV (erythromycin GP female) FEMCAP DEVI ( PV ethylsuccinate) cervical 3 caps) erythromycin base 1 cpep K-Y ME & YOU EXTRA PV LUBRICATED DEVI erythromycin base tabs 1 (condoms latex PV lubricated - male) 1 erythromycin base tbec K-Y ME & YOU INTENSE PV erythromycin DEVI (condoms latex PV ethylsuccinate susr 200 1 lubricated - male) mg/5ml, 400 mg/5ml KAMELEON LUBRICATED PV erythromycin MISC (condoms latex PV ethylsuccinate tabs 400 1 lubricated - male) mg KIMONO COLORS DEVI PV Fidaxomicin (condoms latex PV ) DIFICID SUSR lubricated - male 3 (fidaxomicin) KIMONO LUBRICATED PV MISC ( PV DIFICID TABS condoms latex 3 lubricated - male) (fidaxomicin) MEDICAL DEVICES AND SUPPLIES
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99 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits KIMONO MICRO THIN PV PREMIUM CONDOMS PV MISC ( LUBRICATED MISC condoms latex PV PV non-lubricated - male) (condoms latex KIMONO MICRO THIN PV lubricated - male) PLUS SPERMICIDE REALITY LATEX PV LUBRICATED MISC PV CONDOMS/LUBRICATED (condoms latex MISC (condoms latex PV lubricated - male) lubricated - male) KIMONO PLUS PV REALITY LATEX/ULTRA PV SPERMICIDE TEXTURED DEVI LUBRICATED MISC PV (condoms latex PV (condoms latex lubricated - male) lubricated - male) REALITY LATEX/ULTRA PV KIMONO PLUS PV THIN DEVI (condoms PV SPERMICIDE/LUBRICATE PV latex lubricated - male) D MISC (condoms latex TRUSTEX COLOR PV lubricated - male) CONDOMS + LUBE MISC KIMONO PS LUBRICATED PV (condoms latex PV MISC (condoms latex PV lubricated - male) lubricated - male) TRUSTEX LUBRICATED PV KIMONO PS PLUS PV EXTRALARGE MISC SPERMICIDE/LUBRICATE ( PV PV condoms latex D MISC (condoms latex lubricated - male) lubricated - male) TRUSTEX LUBRICATED PV KIMONO SENSATION PV EXTRASTRENGTH MISC LUBRICATED MISC ( PV PV condoms latex (condoms latex lubricated - male) lubricated - male) TRUSTEX LUBRICATED PV KIMONO SENSATION PV MISC (condoms latex PV PLUS SPERMICIDE lubricated - male) LUBRICATED MISC PV TRUSTEX PV (condoms latex LUBRICATED/RIBBED/ST lubricated - male) UDDED MISC (condoms PV KIMONO SPECIAL DEVI PV latex lubricated - male) (condoms latex PV TRUSTEX PV lubricated - male) LUBRICATED/SPERMICID MAXX LUBRICATED MISC PV E EXTRA LARGE MISC PV (condoms latex PV (condoms latex lubricated - male) lubricated - male) MAXX PLUS SPERMICIDE PV TRUSTEX PV LUBRICATED MISC LUBRICATED/SPERMICID (condoms latex PV E EXTRA STRENGTH PV lubricated - male) MISC (condoms latex lubricated - male)
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OR Essential Drug List
Updated 07/01/2021 100 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TRUSTEX PV FREESTYLE LITE BLOOD QL(1 ea per LUBRICATED/SPERMICID GLUCOSE MONITORING 365 days retail) PV E MISC (condoms latex SYSTEM DEVI (blood 2 lubricated - male) glucose monitoring TRUSTEX NATURAL PV supplies) CONDOMS LANCETS 2 +LUBE/LUBRICATED PV MISC (condoms latex ONETOUCH ULTRA 2 KIT QL(1 ea per lubricated - male) (blood glucose 2 365 days TRUSTEX NON- PV monitoring supplies) retail); RX/OTC LUBRICATED MISC PV ONETOUCH ULTRA MINI QL(1 ea per (condoms latex non- KIT (blood glucose 2 365 days lubricated - male) monitoring supplies) retail); RX/OTC TRUSTEX WITH PV ONETOUCH VERIO FLEX Limit 1 per NONOXYNOL- BLOOD GLUCOSE year;QL(1 ea 9/RIBBED/STUDDED PV MONITORING SYSTEM 2 per 365 days MISC (condoms latex KIT (blood glucose retail); RX/OTC lubricated - male) monitoring supplies) TRUSTEX/RIA PV ONETOUCH VERIO IQ QL(1 ea per LUBRICATED MISC PV BLOOD GLUCOSE 365 days (condoms latex MONITORING SYSTEM 2 retail); RX/OTC lubricated - male) KIT (blood glucose TRUSTEX/RIA PV monitoring supplies) LUBRICATED ONETOUCH VERIO KIT Limited to 1 per SPERMICIDE MISC PV ( 2 year;QL(1 ea (condoms latex blood glucose per 365 days lubricated - male) monitoring supplies) retail); RX/OTC TRUSTEX/RIA PV ONETOUCH VERIO SYNC QL(1 ea per LUBRICATED/SPERMICID BLOODGLUCOSE 365 days E MISC (condoms latex PV MONITORING SYSTEM 2 retail); RX/OTC lubricated - male) KIT (blood glucose TRUSTEX/RIA NON- PV monitoring supplies) LUBRICATED MISC PRECISION XTRA DEVI QL(1 ea per (condoms latex non- PV (blood glucose 2 365 days retail) lubricated - male) monitoring supplies) Diabetic Supplies Parenteral Therapy Supplies FREESTYLE FREEDOM QL(1 ea per ADVOCATE INSULIN LITE KIT (blood glucose 2 365 days SYRINGE/U- monitoring supplies) retail); RX/OTC 100/1ML/31GX5/16" MISC 2 (insulin syringe/needle FREESTYLE INSULINX QL(1 ea per BLOODGLUCOSE 365 days u-100) MONITORING SYSTEM 2 retail); RX/OTC B-D INSULIN SYRINGE ULTRAFINE II/1ML/31G X KIT (blood glucose 2 monitoring supplies) 5/16" MISC (insulin syringe/needle u-100)
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101 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BD AUTOSHIELD 29G X Preferred NDC CAREONE INSULIN 3/16" MISC ( SYRINGES/1ML/31GX5/16 insulin pen 2 2 needle) " MISC (insulin BD AUTOSHIELD 29G X Preferred NDC syringe/needle u-100) 5/16" MISC (insulin pen 2 CLEVER CHOICE needle) COMFORT EZINSULIN SYRINGE/U- BD AUTOSHIELD DUO Preferred NDC 100/1ML/31GX5/16" MISC 2 30G X 5MM MISC 2 (insulin syringe/needle (insulin pen needle) u-100) BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X COMFORT ASSIST INSULIN 8MM MISC (insulin 2 SYRINGE/1ML/31G X 2 syringe/needle u-100) 5/16" MISC (insulin BD INSULIN SYRINGE syringe/needle u-100) ULTRAFINE/U- 100/1ML/31G X 5/16" COMFORT EZ INSULIN 2 SYRINGE/U-100/1ML/31G MISC (insulin X 5/16" MISC (insulin 2 syringe/needle u-100) syringe/needle u-100) BD PEN Preferred NDC NEEDLE/MICRO/ULTRA- DROPLET INSULIN 2 SYRINGE U-100/1ML/31G FINE/32G X 6MM MISC 2 (insulin pen needle) X 5/16" MISC (insulin syringe/needle u-100) BD PEN Preferred NEEDLE/MINI/ULTRA- NDC;RX/OTC DROPLET INSULIN 2 SYRINGE/U-100/1ML/31G FINE/31G X 5MM MISC 2 (insulin pen needle) X 5/16" MISC (insulin BD PEN NEEDLE/NANO Preferred syringe/needle u-100) 2ND GEN/32G X 5/32" NDC;RX/OTC EASY COMFORT INSULIN 2 SYRINGE/1ML/31G X MISC (insulin pen 2 needle) 5/16" MISC (insulin BD PEN Preferred syringe/needle u-100) NEEDLE/NANO/ULTRA- NDC;RX/OTC EASY TOUCH FLIPLOCK FINE/32G X 4MM MISC 2 SAFETY INSULIN (insulin pen needle) SYRINGE 1ML/31GX5/16" 2 BD PEN Preferred NDC MISC (insulin NEEDLE/ORIGINAL/ULTR syringe/needle u-100) A-FINE/29G X 12.7MM 2 EASY TOUCH INSULIN MISC (insulin pen SYRINGE/U-100/1ML/31G 2 needle) X 5/16" MISC (insulin BD PEN Preferred syringe/needle u-100) NEEDLE/SHORT/ULTRA- NDC;RX/OTC EASY TOUCH FINE/31G X 8MM MISC 2 SHEATHLOCK SAFETY (insulin pen needle) INSULIN SYRINGE 1ML/31GX5/16" MISC 2 (insulin syringe/needle u-100) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 102 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ELITE-THIN INSULIN INSULIN SYRINGES AND 2 MO SYRINGE/U-100/1ML/31G PEN NEEDLES 2 X 5/16" MISC (insulin INSULIN syringe/needle u-100) SYRINGES/1ML/31GX5/16 2 EQL INSULIN " MISC (insulin SYRINGE/1ML/31G X syringe/needle u-100) 2 5/16" MISC (insulin KINRAY INSULIN syringe/needle u-100) SYRINGE PREFERRED FIFTY50 SUPERIOR PLUS/1ML/31G X 5/16" 2 COMFORTINSULIN MISC (insulin SYRINGE/1ML/31G X 2 syringe/needle u-100) 5/16" MISC (insulin KROGER INSULIN syringe/needle u-100) SYRINGE/1ML/31G X 2 FREESTYLE PRECISION 5/16" MISC (insulin INSULIN SYRINGE/U- syringe/needle u-100) 100/1ML/31G X 5/16" 2 LEADER INSULIN MISC (insulin SYRINGE/1ML/31G X syringe/needle u-100) 5/16" MISC (insulin 2 GLOBAL INJECT EASE syringe/needle u-100) INSULIN SYRINGE/U- LITETOUCH INSULIN 100/1ML/31G X 5/16" 2 SYRINGE/U-100/1ML/31G MISC (insulin X 5/16" MISC (insulin 2 syringe/needle u-100) syringe/needle u-100) GLUCOPRO INSULIN MM INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 2 100/1ML/31G X 5/16" X 5/16" MISC (insulin MISC (insulin 2 syringe/needle u-100) syringe/needle u-100) GNP INSULIN MONOJECT INSULIN SYRINGE/1ML/31G X 2 SYRINGE/1ML/31G X 5/16" MISC (insulin 5/16" MISC (insulin 2 syringe/needle u-100) syringe/needle u-100) HEALTHWISE INSULIN MS INSULIN SYRINGE/U-100/1ML/31G 2 SYRINGE/1ML/31G X X 5/16" MISC (insulin 5/16" MISC (insulin 2 syringe/needle u-100) syringe/needle u-100) INSULIN PRO COMFORT INSULIN SYRINGE/NEEDLE SYRINGES/1ML/31G X 1ML/31G X 5/16" MISC 2 5/16" MISC (insulin 2 (insulin syringe/needle syringe/needle u-100) u-100) RELION INSULIN INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G 100/1ML/31G X 5/16" 2 2 X 5/16" MISC (insulin MISC (insulin syringe/needle u-100) syringe/needle u-100)
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103 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SB INSULIN SYRINGE/U- ULTICARE INSULIN 100/1ML/31G X 5/16" SYRINGEULTRAFINE U- MISC (insulin 2 100/1ML/31G X 5/16" 2 syringe/needle u-100) MISC (insulin SURE COMFORT syringe/needle u-100) INSULIN SYRINGE/U- ULTIGUARD SAFEPACK 100/1ML/31G X 5/16" 2 INSULIN SYRINGE 1ML MISC (insulin 31G X 5/16"/SHARPS CO 2 syringe/needle u-100) MISC (insulin SURE-JECT INSULIN syringe/needle u-100) SYRINGE/U-100/1ML/31G ULTILET INSULIN X 5/16" MISC ( 2 SYRINGE/1ML/31G X insulin 2 syringe/needle u-100) 8MM MISC (insulin TECHLITE INSULIN syringe/needle u-100) SYRINGEU-100/1ML/31G ULTILET INSULIN X 5/16" MISC ( 2 SYRINGE/SHORT/1ML/31 insulin 2 syringe/needle u-100) G X 5/16" MISC (insulin TOPCARE ULTRA syringe/needle u-100) COMFORT INSULIN ULTRA FLO INSULIN SYRINGE/1ML/31G X 2 SYRINGE 1ML/31GX5/16" 5/16" MISC (insulin MISC (insulin 2 syringe/needle u-100) syringe/needle u-100) TRUE COMFORT INSULIN ULTRA-COMFORT SYRINGE/1ML/31G X INSULIN SYRINGE/U- 5/16" MISC (insulin 2 100/1ML/31G X 5/16" 2 syringe/needle u-100) MISC (insulin TRUE COMFORT PRO syringe/needle u-100) INSULINSYRINGE/1ML/31 ULTRA-THIN II INSULIN G X 5/16" MISC (insulin 2 SYRINGE SHORT/U- syringe/needle u-100) 100/1ML/31GX5/16" MISC 2 TRUEPLUS INSULIN (insulin syringe/needle SYRINGE/U-100/1ML/31G u-100) X 5/16" MISC (insulin 2 ULTRACARE INSULIN SYRINGE/U-100/1ML/31G syringe/needle u-100) 2 ULTICARE INSULIN X 5/16" MISC (insulin SYRINGE/SHORT/1ML/31 syringe/needle u-100) 2 G X 5/16" MISC (insulin Respiratory Therapy Supplies syringe/needle u-100) INHALER SPACERS 2 MO ULTICARE INSULIN SYRINGE/U-100/1ML/31G 2 MIGRAINE PRODUCTS - Drugs to Treat Migraine X 5/16" MISC (insulin Headaches syringe/needle u-100) Calcitonin Gene-Related Peptide (CGRP) AIMOVIG SOAJ 140 PA MG/ML (erenumab- SP aooe) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 104 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits AIMOVIG SOAJ 70 MG/ML PA; SP MIGRANAL SOLN QL(8 ml per fill SP (erenumab-aooe) (dihydroergotamine 3 retail,24 ml per EMGALITY SOAJ PA mesylate) fill mail) SP (galcanezumab-gnlm) Serotonin Agonists EMGALITY SOSY PA SP 1 QL(6 ea per 30 (galcanezumab-gnlm) almotriptan malate tabs days retail) Migraine Combinations QL(27 ea per AMERGE TABS 90 days (Ergotamine W/ Caffeine) GP 1 (naratriptan hcl) retail,27 ea per MIGERGOT SUPP 90 days mail) CAFERGOT TABS eletriptan hydrobromide Limit 6 tabs per (ergotamine w/ GP 1 month;QL(0.2 caffeine) tabs ea daily) Limit 9 per ergotamine w/ caffeine 1 FROVA TABS tabs GP month;QL(0.3 (frovatriptan succinate) ea daily) sumatriptan-naproxen PA; Limit 9 per 1 month;QL(0.3 Limit 9 per sodium tabs frovatriptan succinate 1 ea daily) tabs month;QL(0.3 TREXIMET TABS PA; Limit 9 per ea daily) (sumatriptan-naproxen GP month;QL(0.3 IMITREX SOLN NA 20 Limit 6 per MG/ACT, 5 MG/ACT month;QL(0.2 sodium) ea daily) GP (sumatriptan) ea daily) Migraine Products - NSAIDs QL(2 ml per fill CAMBIA PACK PA; Limit 9 per IMITREX SOLN SC 6 retail,6 ml per month;QL(0.3 (diclofenac potassium 3 MG/0.5ML (sumatriptan GP fill mail,4 ml per (migraine)) ea daily) 30 days succinate) retail,12 ml per Migraine Products 90 days mail) QL(10 ml per QL(2 ml per fill fill retail,30 ml D.H.E. 45 SOLN IMITREX STATDOSE retail,6 ml per ( GP per fill mail,20 fill mail,4 ml per dihydroergotamine ml per 30 days REFILL SOCT GP mesylate) 30 days retail,60 ml per (sumatriptan succinate) retail,12 ml per 90 days mail) 90 days mail) QL(10 ml per QL(2 ml per fill fill retail,30 ml dihydroergotamine IMITREX STATDOSE retail,6 ml per 1 per fill mail,20 fill mail,4 ml per mesylate soln ij 1 ml per 30 days SYSTEM SOAJ GP mg/ml 30 days retail,60 ml per (sumatriptan succinate) retail,12 ml per 90 days mail) 90 days mail) dihydroergotamine QL(8 ml per fill QL(9 ea per fill mesylate soln na 4 3 retail,24 ml per retail,27 ea per fill mail) IMITREX TABS OR 25 MG mg/ml GP fill mail,18 ea ERGOMAR SUBL (sumatriptan succinate) per 30 days 2 retail,54 ea per (ergotamine tartrate) 90 days mail)
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105 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits QL(12 ea per QL(9 ea per fill MAXALT-MLT TBDP GP 30 days retail,27 ea per (rizatriptan benzoate) retail,36 ea per zolmitriptan soln na 2.5 1 fill mail,18 ea 90 days mail) mg per 30 days QL(27 ea per retail,54 ea per 90 days mail) 1 90 days naratriptan hcl tabs retail,27 ea per QL(6 ea per 30 90 days mail) zolmitriptan soln na 5 1 days retail,18 mg ea per 90 days RELPAX TABS (eletriptan Limit 6 tabs per GP month;QL(0.2 mail) hydrobromide) ea daily) QL(9 ea per fill QL(12 ea per retail,27 ea per zolmitriptan tabs or 2.5 fill mail,18 ea rizatriptan benzoate 1 30 days 1 tabs retail,36 ea per mg, 5 mg per 30 days 90 days mail) retail,54 ea per 90 days mail) QL(12 ea per QL(9 ea per fill rizatriptan benzoate 1 30 days tbdp retail,36 ea per retail,27 ea per 90 days mail) zolmitriptan tbdp or 2.5 1 fill mail,18 ea mg, 5 mg per 30 days Limit 6 per retail,54 ea per sumatriptan soln 1 month;QL(0.2 90 days mail) ea daily) QL(9 ea per fill QL(2 ml per fill retail,27 ea per sumatriptan succinate retail,6 ml per ZOMIG SOLN NA 2.5 MG GP fill mail,18 ea 1 fill mail,4 ml per per 30 days soaj sc 4 mg/0.5ml, 6 30 days (zolmitriptan) mg/0.5ml retail,54 ea per retail,12 ml per 90 days mail) 90 days mail) QL(6 ea per 30 QL(2 ml per fill ZOMIG SOLN NA 5 MG days retail,18 retail,6 ml per GP sumatriptan succinate (zolmitriptan) ea per 90 days 1 fill mail,4 ml per mail) soct sc 4 mg/0.5ml, 6 30 days mg/0.5ml retail,12 ml per QL(9 ea per fill 90 days mail) retail,27 ea per ZOMIG TABS OR 2.5 MG, fill mail,18 ea QL(2 ml per fill GP 5 MG (zolmitriptan) per 30 days retail,6 ml per retail,54 ea per sumatriptan succinate 1 fill mail,4 ml per 90 days mail) soln sc 6 mg/0.5ml 30 days retail,12 ml per QL(9 ea per fill 90 days mail) retail,27 ea per ZOMIG ZMT TBDP fill mail,18 ea QL(9 ea per fill GP (zolmitriptan) per 30 days sumatriptan succinate retail,27 ea per retail,54 ea per 1 fill mail,18 ea 90 days mail) tabs or 100 mg, 25 mg, per 30 days 50 mg retail,54 ea per MINERALS & ELECTROLYTES 90 days mail) ZEMBRACE SYMTOUCH PA Calcium SOAJ (sumatriptan 3 succinate) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 106 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CALCIFOL WAFR magnesium sulfate soln PA (calcium carbonate-folic 3 iv 2 gm/50ml, 20 acid-vit d-b6-b12- gm/500ml, 4 gm/100ml, SP boron-magnesium) 4 gm/50ml, 40 CALCIUM-FOLIC ACID gm/1000ml PLUS D WAFR (calcium MAGNESIUM SULFATE PA carbonate-folic acid-vit 3 SOLN IV 2 GM/50ML, 20 GM/500ML, 4 GM/100ML, d-b6-b12-boron- SP magnesium) 4 GM/50ML, 40 GM/1000ML ( MAGNEBIND 400 TABS magnesium sulfate) (calcium carbonate- 3 magnesium carbonate) Phosphate Electrolyte Mixtures (Pot Phosphate Monobasic W/ Sod Phosphate Dibasic ISOLYTE-S SOLN PA SP & Monobasic) PHOSPHA (electrolyte-s) 250 NEUTRAL, 1 NORMOSOL-R SOLN PA PHOSPHO-TRIN 250 SP (electrolyte-r (ph 7.4)) NEUTRAL, VIRT-PHOS 250 NEUTRAL TABS PLASMA-LYTE A SOLN PA SP K-PHOS NEUTRAL TABS (electrolyte-a) (pot phosphate PLASMA-LYTE-148 SOLN PA SP monobasic w/ sod GP (electrolyte-148) phosphate dibasic & PA potassium chloride in SP monobasic) nacl soln K-PHOS TABS Fluoride (potassium phosphate 2 (Sodium Fluoride) PV monobasic) FLUORITAB, FLURA- 1 pot phosphate DROPS, NAFRINSE DROPS SOLN monobasic w/ sod 1 phosphate dibasic & (Sodium Fluoride) 1 PV NAFRINSE CHEW monobasic tabs FLUORABON SOLN PV Potassium 2 (sodium fluoride) (Potassium Bicarbonate) 1 sodium fluoride chew PV EFFER-K TBEF 25 MEQ 0.25 mg, 0.5 mg, 1 mg, 1 (Potassium Bicarbonate) K- PRIME, KLOR-CON/EF 1 2.2 mg TBEF RX/OTC; PV sodium fluoride soln 1 (Potassium Chloride 0.5 mg/ml Microencapsulated Crystals sodium fluoride tabs PV Er) KLOR-CON M10, 1 1 KLOR-CON M15, KLOR- 0.5 mg, 1 mg CON M20 TBCR Magnesium (Potassium Chloride) PA KLOR-CON 10, KLOR- 1 magnesium sulfate soln SP ij 50 % CON 8 TBCR
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107 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Potassium Chloride) GALZIN CAPS ( 1 zinc 3 KLOR-CON PACK acetate (oral)) (Potassium Chloride) WILZIN CAPS (zinc KLOR-CON SPRINKLE 1 3 CPCR acetate (oral)) (Potassium Chloride) PA zinc sulfate caps 1 POTASSIUM CHLORIDE SP PROAMP SOLN MISCELLANEOUS THERAPEUTIC CLASSES EFFER-K TBEF 0.84 GM-1 GM, 1.68 GM-2 GM Chelating Agents 3 (potassium (Trientine Hcl) CLOVIQUE SP PA bicarbonate-citric acid) CAPS K-TAB TBCR ( CUPRIMINE CAPS PA potassium GP GP chloride) (penicillamine) DEPEN TITRATABS TABS GP potassium chloride cpcr 1 or 10 meq, 8 meq (penicillamine) PA potassium chloride penicillamine caps 1 microencapsulated 1 crystals er tbcr penicillamine tabs 1 SYPRINE CAPS (trientine PA potassium chloride 1 SP pack or 20 meq hcl) POTASSIUM CHLORIDE PA trientine hcl caps SP PA SOLN IV 0.4 MEQ/ML, 10 MEQ/100ML, 10 SP Enzymes MEQ/50ML, 20 MEQ/50ML XIAFLEX SOLR PA (potassium chloride) (collagenase PA SP potassium chloride soln SP clostridium iv 2 meq/ml histolyticum) potassium chloride soln 1 Immunomodulators or 10 %, 20 % REVLIMID CAPS PA AC potassium chloride tbcr (lenalidomide) or 10 meq, 20 meq, 8 1 THALOMID CAPS AC meq (thalidomide) Sodium Immunosuppressive Agents PA sodium chloride soln ij SP (Cyclosporine Modified (For 2.5 meq/ml Microemulsion)) 1 sodium chloride soln iv PA GENGRAF CAPS 0.45 %, 0.9 %, 3 %, 5 SP (Cyclosporine Modified (For Microemulsion)) 1 % GENGRAF SOLN Zinc ASTAGRAF XL CP24 ST 3 (Zinc Sulfate) ORAZINC, 1 (tacrolimus) ZINC-220 CAPS
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Updated 07/01/2021 108 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ATGAM INJ ( PA lymphocyte mycophenolate mofetil 1 immune globulin,anti- SP caps thymocyte globulin PA mycophenolate mofetil SP (equine)) hcl solr AZASAN TABS 3 mycophenolate mofetil 1 (azathioprine) susr AZATHIOPRINE SOLR IJ PA mycophenolate mofetil 1 100 MG (azathioprine SP tabs sodium) mycophenolate sodium azathioprine tabs or 50 1 1 tbec mg MYFORTIC TBEC CELLCEPT CAPS (mycophenolate GP ( mycophenolate GP sodium) mofetil) NEORAL CAPS CELLCEPT PA INTRAVENOUS SOLR (cyclosporine modified GP (mycophenolate mofetil SP (for microemulsion)) hcl) NEORAL SOLN CELLCEPT SUSR (cyclosporine modified GP ) (mycophenolate GP (for microemulsion) NULOJIX SOLR PA mofetil) SP CELLCEPT TABS (belatacept) (mycophenolate GP PROGRAF CAPS OR 0.5 MG, 1 MG, 5 MG mofetil) GP (tacrolimus) cyclosporine caps or 1 PROGRAF PACK OR 0.2 PA 100 mg, 25 mg SP MG, 1 MG (tacrolimus) cyclosporine modified PROGRAF SOLN IV 5 PA SP (for microemulsion) 1 MG/ML (tacrolimus) caps 100 mg, 25 mg, RAPAMUNE SOLN 50 mg GP (sirolimus) cyclosporine modified RAPAMUNE TABS GP (for microemulsion) 1 (sirolimus) soln 100 mg/ml SANDIMMUNE CAPS OR PA cyclosporine soln iv 50 SP 100 MG, 25 MG GP mg/ml (cyclosporine) ENVARSUS XR TB24 ST SANDIMMUNE SOLN IV PA 3 SP (tacrolimus) 50 MG/ML (cyclosporine) everolimus SIMULECT SOLR PA SP (immunosuppressant) 1 (basiliximab) tabs sirolimus soln 1 IMURAN TABS GP (azathioprine) sirolimus tabs 1
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109 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BENLYSTA SOLR PA tacrolimus caps 1 SP (belimumab) THYMOGLOBULIN SOLR PA BENLYSTA SOSY PA SP (anti-thymocyte globulin SP (belimumab) (rabbit), lymphocyte immune globulin) MOUTH/THROAT/DENTAL AGENTS ZORTRESS TABS 0.25 MG, 0.5 MG, 0.75 MG Anesthetics Topical Oral (everolimus GP FIRST-MOUTHWASH BLM (immunosuppressant)) SUSP (diphenhydramine- Irrigation Solutions lidocaine-alum 3 (Irrigation Solutions, hydroxide-mg Physiological) hydroxide-simeth) PHYSIOLYTE, 1 PHYSIOSOL IRRIGATION lidocaine hcl (mouth- 1 SOLN throat) soln (Ringer'S Irrigation) TIS-U- 1 Anti-infectives - Throat SOL SOLN (Water For Irrigation, clotrimazole troc 1 Sterile) ARGYLE STERILE 1 nystatin (mouth-throat) 1 WATER 100ML SOLN susp lactated ringer's 1 ORAVIG TABS (irrigation) soln (miconazole (mouth- 3 ringer's irrigation soln 1 throat)) Antiseptics - Mouth/Throat water for irrigation, 1 sterile soln (Chlorhexidine Gluconate (Mouth-Throat)) PAROEX, 1 Potassium Removing Agents PERIOGARD SOLN (Sodium Polystyrene chlorhexidine gluconate Sulfonate) KIONEX, SPS 1 1 SUSP (mouth-throat) soln LOKELMA PACK ST DEBACTEROL SOLN (sodium zirconium 3 (sulfuric acid-sulfonated 3 cyclosilicate) phenolics) PERIDEX SOLN sodium polystyrene 1 sulfonate powd (chlorhexidine gluconate (mouth- GP sodium polystyrene 1 throat)) sulfonate susp Steroids - Mouth/Throat/Dental VELTASSA PACK ST; Try/Fail on (patiromer sorbitex 3 generic (Triamcinolone Acetonide Kayexalate (Mouth)) ORALONE 1 calcium) DENTAL PASTE PSTE Systemic Lupus Erythematosus Agents triamcinolone acetonide BENLYSTA SOAJ PA 1 SP (mouth) pste (belimumab) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 110 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Throat Products - Misc. MULTIVITAMIN/FLUORID AL(Up to 6 yrs E CHEW 0.25 MG-0.3 MG- old ); RX/OTC cevimeline hcl caps 1 1.05 MG-1.05 MG-1.2 MG- 13.5 MG-15 UNIT-2500 EVOXAC CAPS 2 GP UNIT-4.5 MCG-400 UNIT- (cevimeline hcl) 60 MG (multiple vitamins GELCLAIR GEL & fluoride-folic acid) (povidone-sodium hyaluronate- 3 Multiple Vitamins w/ Minerals glycyrrhetinic acid) ONEVITE TABS (multiple vitamins w/ minerals & 3 MUCOTROL WAFR (oral 3 folic acid) wound care products) THRIVITE 19 TABS ORAFATE PSTE 3 (multiple vitamins w/ 3 (sucralfate-malate) minerals & folic acid) pilocarpine hcl (oral) 1 UDAMIN SP TABS tabs (multiple vitamins w/ 3 PROTHELIAL PSTE 3 minerals & folic acid) (sucralfate-malate) Ped MV w/ Fluoride SALAGEN TABS GP (pilocarpine hcl (oral)) (Pediatric Multivitamins AL(Up to 6 yrs W/Fl) MULTI- 1 old ); RX/OTC MULTIVITAMINS VITAMIN/FLUORIDE DROPS SOLN Multiple Vitamins & Fluoride-Folic Acid (Pediatric Multivitamins AL(Up to 6 yrs MULTIVITAMIN WITH AL(Up to 6 yrs W/Fl) MULTIVITAMIN old ); RX/OTC FLUORIDE CHEW 0.25 old ); RX/OTC WITH FLUORIDE, MG-0.3 MG-1.05 MG-1.05 MULTIVITAMIN/FLUORID MG-1.2 MG-13.5 MG-15 E SOLN 0.25 MG/ML-0.4 UNIT-2500 UNIT-4.5 MCG- 2 MG/ML-0.5 MG/ML-0.6 400 UNIT-60 MG (multiple MG/ML-1500 UNIT/ML-2 vitamins & fluoride-folic MCG/ML-35 MG/ML-400 1 UNIT/ML-5 UNIT/ML-8 acid) MG/ML, 0.4 MG/ML-0.5 MULTIVITAMIN WITH AL(Up to 6 yrs MG/ML-0.5 MG/ML-0.6 FLUORIDE CHEW 0.3 MG- old ) MG/ML-1500 UNIT/ML-2 0.5 MG-1.05 MG-1.05 MG- MCG/ML-35 MG/ML-400 1.2 MG-13.5 MG-15 UNIT- UNIT/ML-5 UNIT/ML-8 2500 UNIT-4.5 MCG-400 MG/ML UNIT-60 MG, 0.3 MG-1 MG-1.05 MG-1.05 MG-1.2 2 MG-13.5 MG-15 UNIT- 2500 UNIT-4.5 MCG-400 UNIT-60 MG (multiple vitamins & fluoride-folic acid)
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OR Essential Drug List
111 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Pediatric Multivitamins AL(Up to 6 yrs POLY-VI-FLOR SUSP 0.25 W/Fl) old ); RX/OTC MG/ML-200 MCG/ML MULTIVITAMIN/FLUORID (pediatric multivitamins 3 E CHEW 0.25 MG-0.3 MG- w/fl) 1.05 MG-1.05 MG-1.2 MG- 13.5 MG-15 UNIT-2500 QUFLORA GUMMIES AL(Up to 6 yrs UNIT-4.5 MCG-400 UNIT- CHEW (pediatric 2 old ) 60 MG, 0.25 MG-1.05 MG- multivitamins w/fl) 1.05 MG-1.2 MG-13.5 MG- QUFLORA PEDIATRIC AL(Up to 6 yrs 15 UNIT-2500 UNIT-300 CHEW (pediatric 2 old ); RX/OTC MCG-4.5 MCG-400 UNIT- 60 MG, 0.3 MG-0.5 MG- multivitamins w/fl) 1.05 MG-1.05 MG-1.2 MG- QUFLORA PEDIATRIC AL(Up to 6 yrs 13.5 MG-15 UNIT-2500 1 SOLN (pediatric 2 old ); RX/OTC UNIT-4.5 MCG-400 UNIT- multivitamins w/fl) 60 MG, 0.3 MG-1 MG-1.05 MG-1.05 MG-1.2 MG-13.5 TRI-VI-FLOR SUSP (pediatric vitamins acd MG-15 UNIT-2500 UNIT- 3 4.5 MCG-400 UNIT-60 MG, & l-methylfolate w/ 0.5 MG-1.05 MG-1.05 MG- fluoride) 1.2 MG-13.5 MG-15 UNIT- TRI-VI-FLORO SUSP 2500 UNIT-300 MCG-4.5 (pediatric vitamins acd MCG-400 UNIT-60 MG, 1 3 MG-1.05 MG-1.05 MG-1.2 & l-methylfolate w/ MG-13.5 MG-15 UNIT- fluoride) 2500 UNIT-300 MCG-4.5 Ped Multi Vitamins w/Fl & FE MCG-400 UNIT-60 MG (Ped Multivitamins W/Fl & RX/OTC (Pediatric Multivitamins AL(Up to 6 yrs Iron) MULTI- W/Fl) 1 old ); RX/OTC VIT/IRON/FLUORIDE, MULTIVITAMINS/FLUORI MULTI- 1 DE CHEW VITAMIN/FLUORIDE/IRON (Pediatric Vitamins Acd W/ AL(Up to 6 yrs , Fluoride) TRI- 1 old ) MULTIVITAMIN/FLUORID VITE/FLUORIDE SOLN E/IRON SOLN FLORIVA PLUS SOLN AL(Up to 6 yrs POLY-VI-FLOR/IRON AL(Up to 6 yrs (pediatric multivitamins 2 old ); RX/OTC CHEW 0.5 MG-10 MG-15 old ) w/fl) UNIT-200 MCG-400 UNIT 3 AL(Up to 6 yrs (ped multivitamins w/fl pediatric vitamins acd 1 w/ fluoride soln old ) & iron) POLY-VI-FLOR CHEW AL(Up to 6 yrs POLY-VI-FLOR/IRON 0.25 MG-15 UNIT-200 old ) SUSP 0.25 MG/ML-200 MCG-400 UNIT, 0.5 MG-15 MCG/ML-7 MG/ML (ped 3 UNIT-200 MCG-400 UNIT, 3 multivitamins w/fl & 1 MG-15 UNIT-200 MCG- iron) 400 UNIT (pediatric Prenatal Vitamins multivitamins w/fl)
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OR Essential Drug List
Updated 07/01/2021 112 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Prenatal Vit W/ Docusate- RX/OTC CITRANATAL 90 DHA Fe Fumarate-Folic Acid) MISC (prenatal w/o vit a PRENATAL 19 TABS 1 w/ fe carbonyl-fe 2 MG-100 MG-1000 UNIT-12 1 ) MCG-15 MG-20 MG-20 gluconate-dss-fa-dha MG-200 MG-25 MG-29 CITRANATAL ASSURE MG-3 MG-3 MG-30 UNIT- MISC (prenatal w/o vit a 400 UNIT-7 MG w/ fe carbonyl-fe 2 (Prenatal Vit W/ Docusate- gluconate-dss-fa-dha) Iron Carbonyl-Folic Acid) 1 CITRANATAL B-CALM INATAL GT TABS MISC (prenatal w/o vit a (Prenatal Vit W/ Ferrous w/ fe carbonyl-fe 3 Fumarate-Folic Acid) PRENATAL 19 CHEW 1 gluconate-fa & vit b6) CITRANATAL BLOOM MG-100 MG-1000 UNIT-12 1 MCG-20 MG-20 MG-200 DHA MISC (prenatal w/o MG-25 MG-29 MG-3 MG-3 vit a w/ fe carbonyl-fe 2 MG-30 UNIT-400 UNIT-6 gluconate-dss-fa-dha) MG-7 MG CITRANATAL BLOOM (Prenatal Vit W/ Ferrous TABS (prenatal vit w/ Fumarate-L Methylfolate- 1 3 Folic Acid) PNV-SELECT docusate-fe carbonyl-fe TABS gluconate-folic acid) (Prenatal Vit W/ Iron CITRANATAL DHA MISC Carbonyl-Folic Acid) 1 (prenatal w/o vit a w/ fe PRENATABS RX TABS carbonyl-fe gluconate- 2 (Prenatal Without A W/ Fe dss-fa-dha) Fumarate-L Methylfolate- 1 CITRANATAL ESSENCE Fa-Dha) PNV-DHA CAPS THPK (prenatal w/o vit ATABEX EC TBEC a w/ fe carbonyl-fe 2 (prenatal vit w/ gluconate-fa-dha) docusate-iron carbonyl- 2 folic acid) CITRANATAL HARMONY CAPS (prenatal w/o vit ATABEX OB TABS a w/ fe fumarate-fe 3 (prenatal vit w/ fe carbonyl-dss-fa-dha) bisglycinate chelate- 2 folic acid) CITRANATAL MEDLEY CAPS (prenatal w/o vit BAL-CARE DHA MISC a w/ fe fumarate-fe 3 (prenatal w/fe carbonyl-fa-dha) polysacch cmplx-sod 2 feredetate-fa-omega 3) CITRANATAL RX TABS (prenatal without vit a C-NATE DHA CAPS w/ fe carbonyl-fe gluc- 3 (prenatal vit w/ ferrous docusate-fa) fumarate-fa-omega 3 3 fatty acids) COMPLETENATE CHEW (prenatal vit w/ ferrous 2 fumarate-folic acid)
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OR Essential Drug List
113 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits CONCEPT DHA CAPS MARNATAL-F CAPS (prenatal vit w/ fe fum- (prenatal without vit a iron polysacch complex 2 w/ iron polysaccharide 2 -fa-omega 3) complex-fa) CONCEPT OB CAPS MYNATAL ADVANCE (prenatal without a vit TABS (prenatal vit w/ w/ fe fum-iron 2 docusate-iron carbonyl- 2 polysacch complex -fa) folic acid) DOTHELLE DHA CAPS MYNATAL ULTRACAPLET (prenatal vit w/ fe fum- TABS (prenatal vit w/ iron polysacch complex 2 docusate-iron carbonyl- 2 -fa-omega 3) folic acid) DUET DHA 400 MISC MYNATE 90 PLUS TBCR (prenatal w/fe (prenatal vit w/ polysacch cmplx-sod 3 docusate-fe fumarate- 2 feredetate-fa-omega 3) folic acid) DUET DHA BALANCED NATACHEW CHEW MISC (prenatal w/fe (prenatal vit w/ fe fum- polysacch cmplx-sod 3 fe bisglycinate chelate- 3 feredetate-fa-omega 3) folic acid) ENBRACE HR CAPS NATELLE ONE CAPS (prenatal vit w/ fe (prenatal without vit a glycine cysteinate-fa- 3 w/ fe fum-fa-omega 3 omega 3 fatty acids) fatty acids) FOLET DHA THPK NEEVO DHA CAPS (prenatal vit w/fe (prenatal without vit a carbonyl-fe bisglyc- 3 w/ fe fumarate-l 3 methylfol-dss & dha) methylfolate-omegas) FOLET ONE CAPS NEONATAL 19 TABS (prenatal w/o a w/fe (prenatal vitamin-folic 2 3 carbonyl-fe bisglyc-l acid) methylfol-dss-dha) NEONATAL COMPLETE RX/OTC FOLIVANE-OB CAPS TABS (prenatal vit w/ 2 (prenatal without a vit ferrous fumarate-folic 2 w/ fe fum-iron acid) polysacch complex -fa) NEONATAL FE TABS KOSHER PRENATAL (prenatal multivitamins 2 PLUS IRON TABS ) 3 w/ iron-folic acid (prenatal vit w/ iron NEONATAL PLUS TABS RX/OTC carbonyl-folic acid) (prenatal vit w/ ferrous 2 M-NATAL PLUS TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous 2 fumarate-folic acid)
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OR Essential Drug List
Updated 07/01/2021 114 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NEONATAL/DHA MISC PV OBSTETRIX ONE CAPS (prenatal mv & min w/fe PV (prenatal w/o a w/fe 3 fumarate-fa-dha) carbonyl-fe bisglyc-l NESTABS DHA MISC methylfol-dss-dha) (prenatal vit without vit ONE VITE WOMENS RX/OTC a w/ fe bisglycinate-fa- 2 PRENATALVITAMIN PLUS omeg 3) TABS (prenatal vit w/ 2 NESTABS ONE CAPS ferrous fumarate-folic (prenatal w/o a w/fe acid) carbonyl-fe bisglyc-l 3 PNV TABS 29-1 TABS methylfol-dha) (prenatal vit w/ iron 3 NESTABS TABS carbonyl-folic acid) (prenatal vit without vit PNV-DHA+DOCUSATE 3 CAPS (prenatal w/o vit a w/ fe bisglycinate- 3 folic acid) a w/ fe fumarate-dss-fa- NEXA PLUS CAPS dha) (prenatal w/o vit a w/fe PNV-OMEGA CAPS fumarate-docusate ca- 3 (prenatal without a w/ folic acid-dha) fe fumarate-l 3 NIVA-PLUS TABS RX/OTC methylfolate-fa-omega (prenatal vit w/ ferrous 2 3) fumarate-folic acid) PR NATAL 400 EC MISC (prenatal mv & min w/fe O-CAL FA TABS RX/OTC 2 (prenatal vit w/ ferrous 2 bisglyc-fe prot succ-fa- fumarate-folic acid) ca-omega 3) OB COMPLETE ONE PR NATAL 430 EC MISC (prenatal mv & min w/fe CAPS (prenatal w/o vit 3 a w/ fe carbonyl-fe 3 bisglyc-fe prot succ-fa- aspart glyc-fa-fish oil) ca-omega 3) OB COMPLETE PETITE PR NATAL 430 MISC (prenatal mv & min w/fe CAPS (prenatal w/o vit 3 a w/ fe carbonyl-fe 3 bisglyc-fe prot succ-fa- aspart glyc-fa-omega 3) ca-omega 3) OB COMPLETE PREMIER PRENA 1 TRUE MISC (prenatal without a w/ TABS (prenatal vit w/ 3 iron carbonyl-fe aspart 3 fe amino acid chelate- glycinate-fa) fa-dha) OB COMPLETE/DHA PRENA1 PEARL CPCR (prenatal without a w/ CAPS (prenat vit w/ iron 3 carbonyl-fe asp glyc-fa- 3 fe fumarate-sod omega fatty acid) feredetate-fa-dha)
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OR Essential Drug List
115 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PRENAISSANCE CAPS PRENATE ELITE TABS (prenatal w/o vit a w/ fe 3 (prenatal w/ fe asparto 3 fumarate-dss-fa-dha) glycinate-l methylfolate- PRENAISSANCE PLUS folic acid) CAPS (prenatal w/o vit PRENATE ENHANCE 3 a w/ fe carbonyl-dss-fa- CAPS (prenatal without 3 dha) a w/ fe fumarate-l PRENATAL 19 CHEW 1 methylfolate-fa-dha) MG-100 MG-1000 UNIT-12 PRENATE ESSENTIAL MCG-15 MG-20 MG-20 CAPS (prenatal w/o a MG-200 MG-29 MG-3 MG- 3 3 MG-30 UNIT-400 UNIT-7 2 w/ fe asparto glyc-l ) MG (prenatal vit w/ methylfolate-fa-dha ferrous fumarate-folic PRENATE MINI CAPS (prenatal w/o vit a w/ fe acid) 3 PRENATAL 19 TABS 1 RX/OTC carbonyl-fe asp glyc- MG-100 MG-1000 UNIT-12 methfol-fa-dha) MCG-15 MG-20 MG-20 PRENATE PIXIE CAPS MG-200 MG-25 MG-29 (prenatal w/o a w/ fe MG-3 MG-3 MG-30 UNIT- 3 asparto glyc-l 3 400 UNIT-7 MG (prenatal methylfolate-fa-dha) vit w/ docusate-fe PRENATE RESTORE fumarate-folic acid) CAPS (prenatal without PRENATAL PLUS IRON a w/ fe fumarate-l 3 TABS (prenatal vit w/ 3 methylfolate-fa-dha) iron carbonyl-folic acid) PRENATRIX TABS RX/OTC PRENATAL TABS RX/OTC (prenatal vit w/ ferrous 2 (prenatal vit w/ ferrous 2 fumarate-folic acid) fumarate-folic acid) PRENATRYL TABS RX/OTC PRENATAL VITAMINS RX/OTC (prenatal vit w/ ferrous 2 PLUS LOW IRON TABS fumarate-folic acid) (prenatal vit w/ ferrous 2 PREPLUS TABS RX/OTC fumarate-folic acid) (prenatal vit w/ ferrous 2 PRENATAL-U CAPS fumarate-folic acid) (prenatal without a vit w/ fe fumarate-folic 2 PRIMACARE CAPS (prenatal without a w/ acid) fe asp glyc-l 3 PRENATE CHEW methylfolate-fa-omega (prenatal multivitamins 3) & minerals w/ l- 3 PROVIDA DHA CAPS methylfolate-fa) (prenatal without a w/fe PRENATE DHA CAPS fum-fe polysacch 3 (prenatal w/o a w/ fe complex-fa-dha) asparto glyc-l 3 methylfolate-fa-dha) You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 116 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits RELNATE DHA CAPS TL FOLATE TABS (prenatal vit w/ ferrous (prenatal vit w/ ferrous fumarate-fa-omega 3 3 fumarate-l methylfolate- 2 fatty acids) folic acid) SE-NATAL 19 CHEW TL-CARE DHA CAPS (prenatal vit w/ ferrous 2 (prenatal w/fe 3 fumarate-folic acid) fumarate-fa-dss-fish oil) SE-NATAL 19 TABS RX/OTC TL-SELECT CAPS (prenatal vit w/ (prenatal w/o vit a w/ fe 3 3 docusate-fe fumarate- fumarate-dss-fa-dha) folic acid) TRI-TABS DHA MISC SELECT-OB CHEW 1 MG- (prenatal vit without vit 1.6 MG-1.8 MG-15 MG-15 a w/ fe bisglycinate-fa- 2 MG-1700 UNIT-2.5 MG-25 omeg 3) MG-29 MG-30 UNIT-400 UNIT-5 MCG-60 MG 3 TRICARE PRENATAL DHA ONE CAPS (prenatal vit w/ iron 3 polysaccharide (prenatal w/fe fumarate-fa-dss-fish oil) complex-folic acid) TRICARE TABS RX/OTC SELECT-OB+DHA MISC (prenatal vit w/ ferrous 2 (prenatal mv & min w/fe polysaccharide 3 fumarate-folic acid) complex-fa-dha) TRISTART DHA CAPS ( TARON-BC MISC prenatal without a w/ fe carbonyl-l 3 (prenatal without vit a w/ iron carbonyl-folic 3 methylfolate-fa-dha) acid & vit b6) TRISTART FREE CAPS ( TARON-C DHA CAPS prenatal without a w/ fe carbonyl-l 3 (prenatal vit w/ fe fum- iron polysacch complex 2 methylfolate-fa-dha) -fa-omega 3) TRISTART ONE CAPS ( TARON-PREX CAPS prenatal without a w/ fe carbonyl-l 3 (prenatal w/o vit a w/ fe 3 methylfolate-fa-dha) fumarate-dss-fa-dha) ULTIMATECARE ONE THERANATAL CORE RX/OTC CAPS (prenatal vit w/ NUTRITION TABS 3 (prenatal vit w/ ferrous 2 iron carbonyl-fe aspart fumarate-folic acid) glyc-fa-omega 3) THRIVITE RX TABS VENA-BAL DHA MISC (prenatal w/fe (prenatal vit w/ iron 3 2 carbonyl-folic acid) polysacch cmplx-sod feredetate-fa-omega 3)
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OR Essential Drug List
117 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VINATE DHA RF CAPS VITAFOL-NANO TABS (prenatal without vit a (prenatal w/o a vit w/ fe w/ fe fumarate-l 3 fumarate-l methylfolate- 3 methylfolate-omegas) folic acid) VINATE II TABS VITAFOL-ONE CAPS (prenatal vit w/ fe (prenatal mv & min w/fe bisglycinate chelate- 2 polysaccharide 3 folic acid) complex-fa-dha) VIRT-C DHA CAPS VITAMEDMD ONE (prenatal vit w/ fe fum- RX/QUATREFOLIC CAPS iron polysacch complex 2 (prenatal without a w/ 3 -fa-omega 3) fe fumarate-l VIRT-NATE DHA CAPS methylfolate-fa-dha) (prenatal vit w/ ferrous VITAPEARL CPCR 3 (prenatal without a w/ fumarate-fa-omega 3 3 fatty acids) fe fumarate-sod VIRT-PN DHA CAPS feredetate-fa-dha) (prenatal without a w/ VITATHELY/GINGER RX/OTC 3 TABS (prenatal vit w/ fe fumarate-l 2 methylfolate-fa-dha) ferrous fumarate-folic VIRT-PN PLUS CAPS acid) (prenatal without a w/ VITATRUE MISC (prenatal without a w/ fe fumarate-l 3 3 methylfolate-fa-omega fe amino acid chelate- 3) fa-dha) VITAFOL FE+ CPPK 0.4 VIVA DHA CAPS MG-0.6 MG-1.6 MG-1.8 (prenatal vit w/ ferrous MG-1000 UNIT-1100 fumarate-fa-omega 3 3 UNIT-15 MG-150 MCG-2 fatty acids) MG-2.5 MG-20 MG-20 VOL-PLUS TABS RX/OTC UNIT-200 MG-25 MCG-25 3 MG-415 MG-50 MG-60 (prenatal vit w/ ferrous 2 MG-90 MG (prenatal vit fumarate-folic acid) w/ fe polysacch VOL-TAB RX TABS complex-l methylfol-fa- (prenatal vit w/ iron 3 dha-dss) carbonyl-folic acid) VITAFOL GUMMIES VP-PNV-DHA CAPS CHEW (prenatal vit w/ (prenatal vit w/ ferrous ferric phosphate-fa- 3 fumarate-fa-omega 3 3 omega 3 fatty acids) fatty acids) VITAFOL ULTRA CAPS WESTAB PLUS TABS RX/OTC (prenatal vit w/ fe (prenatal vit w/ ferrous 2 2 polysacch complex-l fumarate-folic acid) methylfolate-fa-dha)
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OR Essential Drug List
Updated 07/01/2021 118 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits WESTGEL DHA CAPS GABLOFEN SOLN PA SP (prenatal without a w/ (baclofen) 3 fe carbonyl-l LIORESAL INTRATHECAL PA methylfolate-fa-dha) SOLN 0.05 MG/ML, 10 SP ZATEAN-PN DHA CAPS MG/5ML (baclofen) (prenatal without a w/ LIORESAL INTRATHECAL PA fe fumarate-l 3 SOLN 10 MG/20ML SP methylfolate-fa-dha) (baclofen) ZATEAN-PN PLUS CAPS metaxalone tabs 1 (prenatal without a w/ fe fumarate-l 3 methocarbamol tabs 1 methylfolate-fa-omega orphenadrine citrate 3) 1 tb12 MUSCULOSKELETAL THERAPY AGENTS - ROBAXIN-750 TABS Drugs to Treat Spasms GP (methocarbamol) Central Muscle Relaxants SKELAXIN TABS GP (Carisoprodol) VANADOM 1 (metaxalone) TABS SOMA TABS GP (Chlorzoxazone) 1 (carisoprodol) LORZONE TABS tizanidine hcl caps 1 (Cyclobenzaprine Hcl) 1 FEXMID TABS tizanidine hcl tabs 1 (Metaxalone) METAXALL 1 TABS ZANAFLEX CAPS GP AMRIX CP24 ST; QL(1 ea (tizanidine hcl) GP daily) (cyclobenzaprine hcl) ZANAFLEX TABS PA GP baclofen soln it 500 SP (tizanidine hcl) mcg/ml Direct Muscle Relaxants baclofen tabs or 10 mg, DANTRIUM CAPS 1 GP 20 mg, 5 mg (dantrolene sodium) carisoprodol tabs 1 dantrolene sodium 1 CHLORZOXAZONE TABS caps 3 250 MG (chlorzoxazone) Muscle Relaxant Combinations chlorzoxazone tabs carisoprodol w/ aspirin 1 375 mg, 500 mg, 750 1 & codeine tabs mg carisoprodol w/ aspirin 1 ST; QL(1 ea tabs cyclobenzaprine hcl 1 cp24 15 mg, 30 mg daily) orphenadrine w/ aspirin cyclobenzaprine hcl & caff tabs 25 mg-30 1 tabs 10 mg, 5 mg, 7.5 1 mg-385 mg mg NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
119 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits Nasal Agent Combinations (Fluticasone Propionate Limit 2 inhalers (Nasal)) ALLERGY NASAL per azelastine hcl- Limit 1 inhaler SPRAY 24 HOUR, month;QL(1.1 1 per fluticasone propionate month;QL(0.77 ALLERGY RELIEF, ml daily); susp CLARISPRAY, CVS RX/OTC gm daily) FLUTICASONE DYMISTA SUSP Limit 1 inhaler PROPRIONATE NASAL ( GP per SPRAY, EQL azelastine hcl- month;QL(0.77 fluticasone propionate) FLUTICASONE gm daily) PROPIONATE, EQL Nasal Antiallergy FLUTICASONE PROPIONATE Limit 1 inhaler CHILDRENS, GNP 1 azelastine hcl soln 0.1 1 per FLUTICASONE %, 137 mcg/spray month;QL(1.2 PROPIONATE, GNP ml daily) FLUTICASONE QL(1 ml daily) azelastine hcl soln 0.15 1 PROPIONATE % CHILDRENS, HM ALLERGY RELIEF NASAL olopatadine hcl (nasal) 1 SPRAY 24HR, KLS soln ALLER-FLO, QC PATANASE SOLN ALLERGY RELIEF, QC (olopatadine hcl GP FLUTICASONE (nasal)) PROPIONATE, SM ALLERGY RELIEF NASAL Nasal Anticholinergics SPRAY SUSP Limit 2 inhalers ipratropium bromide 1 (Fluticasone Propionate (nasal) soln per (Nasal)) EQ ALLERGY 1 month;QL(1.1 Nasal Steroids RELIEF SUSP NA 50 ml daily); (Budesonide (Nasal)) CVS Limit 2 inhalers MCG/ACT RX/OTC BUDESONIDE NASAL per Limit 2 inhalers SPRAY, EQ BUDESONIDE month;QL(0.6 BECONASE AQ SUSP ( 3 per NASAL SPRAY, GNP ml daily) beclomethasone month;QL(1.67 BUDESONIDE NASAL 1 diprop monohyd) gm daily) SPRAY, RA BUDESONIDE NASAL SPRAY, Limit 2 inhalers RHINOCORT ALLERGY budesonide (nasal) 1 per SUSP susp month;QL(0.6 ml daily) FLONASE ALLERGY Limit 2 inhalers RELIEF CHILDRENS per SUSP ( GP month;QL(1.1 fluticasone ml daily); propionate (nasal)) RX/OTC FLONASE ALLERGY Limit 2 inhalers RELIEF SUSP per ( GP month;QL(1.1 fluticasone propionate ml daily); (nasal)) RX/OTC
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Updated 07/01/2021 120 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLONASE SENSIMIST Limit 1 inhaler Artificial Tears and Lubricants SUSP (fluticasone 3 per LACRISERT INST month;QL(0.34 3 furoate) ml daily) (artificial tear insert) flunisolide (nasal) soln 1 Beta-blockers - Ophthalmic (Timolol Maleate (Ophth)) Limit 2 inhalers TIMOLOL MALEATE IN 1 fluticasone propionate per OCUDOSE SOLN 1 month;QL(1.1 (nasal) susp ml daily); betaxolol hcl (ophth) 1 RX/OTC soln Limit 2 inhalers BETIMOL SOLN (timolol) 2 mometasone furoate per 1 BETOPTIC-S SUSP (nasal) susp month;QL(1.14 2 gm daily) (betaxolol hcl (ophth)) Limit 2 inhalers NASONEX SUSP carteolol hcl (ophth) 1 ( GP per soln mometasone furoate month;QL(1.14 (nasal)) gm daily) COMBIGAN SOLN ( 3 Limit 1 inhaler brimonidine tartrate- OMNARIS SUSP timolol maleate) 3 per (ciclesonide (nasal)) month;QL(0.42 COSOPT PF SOLN gm daily) (dorzolamide hcl-timolol GP QNASL AERS Limit 1 inhaler maleate) (beclomethasone 3 per COSOPT SOLN month;QL(0.29 ( dipropionate (nasal)) gm daily) dorzolamide hcl-timolol 3 maleate) Limit 1 inhaler QNASL CHILDRENS dorzolamide hcl-timolol AERS ( 3 per beclomethasone month;QL(0.17 maleate soln 0.5 %-2 1 dipropionate (nasal)) gm daily) %, 20 mg/ml-5 mg/ml, Limit 1 inhaler 22.3 mg/ml-6.8 mg/ml ZETONNA AERS 3 per ISTALOL SOLN (timolol (ciclesonide (nasal)) month;QL(0.3 GP gm daily) maleate (ophth)) NEUROMUSCULAR AGENTS - Drugs to levobunolol hcl soln 1 Relax/Paralyze Muscles timolol maleate (ophth) 1 ALS Agents solg 0.25 %, 0.5 % RILUTEK TABS (riluzole) GP timolol maleate (ophth) 1 soln 0.25 %, 0.5 % riluzole tabs 1 TIMOPTIC OCUDOSE Neuromuscular Blocking Agent - Neurotoxins SOLN 0.25 % (timolol 2 BOTOX SOLR PA maleate (ophth)) SP (onabotulinumtoxina) TIMOPTIC OCUDOSE SOLN 0.5 % (timolol GP OPHTHALMIC AGENTS - Drugs to Treat the Eye maleate (ophth))
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OR Essential Drug List
121 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TIMOPTIC SOLN ( ALPHAGAN P SOLN 0.15 timolol GP GP maleate (ophth)) % (brimonidine tartrate) TIMOPTIC-XE SOLG apraclonidine hcl soln 1 (timolol maleate GP (ophth)) brimonidine tartrate 1 soln Cycloplegic Mydriatics IOPIDINE SOLN (Homatropine Hbr) 1 3 HOMATROPAIRE SOLN (apraclonidine hcl) (Phenylephrine Hcl SIMBRINZA SUSP (Mydriatic)) ALTAFRIN 1 (brinzolamide- 3 SOLN brimonidine tartrate) ATROPINE SULFATE Ophthalmic Anti-infectives SOLN OP 1 % (atropine 2 (Bacitracin-Polymyxin B sulfate (ophthalmic)) (Ophth)) AK-POLY-BAC, 1 CYCLOGYL SOLN POLYCIN OINT GP (cyclopentolate hcl) (Gentamicin Sulfate 1 CYCLOMYDRIL SOLN (Ophth)) GENTAK OINT (cyclopentolate w/ 3 (Neomycin-Bacitracin Zn- phenylephrine) Polymyxin) NEO-POLYCIN 1 OINT 1 cyclopentolate hcl soln AZASITE SOLN Limit 5mls per 3 month;QL(0.17 homatropine hbr soln 1 (azithromycin (ophth)) ml daily) ISOPTO ATROPINE SOLN bacitracin (ophthalmic) 2 (atropine sulfate 2 oint (ophthalmic)) bacitracin-polymyxin b 1 MYDRIACYL SOLN (ophth) oint GP (tropicamide) BESIVANCE SUSP 3 (besifloxacin hcl) phenylephrine hcl 1 (mydriatic) soln BETADINE OPHTHALMIC PREP SOLN (povidone- 3 1 tropicamide soln iodine (ophth)) Miotics BLEPH-10 SOLN ISOPTO CARPINE SOLN (sulfacetamide sodium GP GP (pilocarpine hcl) (ophth)) PHOSPHOLINE IODIDE CILOXAN OINT SOLR (echothiophate 2 (ciprofloxacin hcl 2 iodide) (ophth)) CILOXAN SOLN pilocarpine hcl soln 1 (ciprofloxacin hcl GP Ophthalmic Adrenergic Agents (ophth)) ALPHAGAN P SOLN 0.1 % ciprofloxacin hcl (ophth) 2 1 (brimonidine tartrate) soln
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Updated 07/01/2021 122 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits TOBREX SOLN erythromycin (ophth) 1 GP oint (tobramycin (ophth)) gatifloxacin (ophth) 1 trifluridine soln 1 soln ZIRGAN GEL 3 gentamicin sulfate 1 (ganciclovir ophthalmic) (ophth) soln ZYMAXID SOLN GP KLARITY-A SOLN Limit 5mls per (gatifloxacin (ophth)) 3 month;QL(0.17 (azithromycin (ophth)) ml daily) Ophthalmic Immunomodulators RESTASIS EMUL QL(2.14 ml levofloxacin (ophth) 1 2 soln (cyclosporine (ophth)) daily) MOXEZA SOLN RESTASIS MULTIDOSE QL(2.14 ml (moxifloxacin hcl GP EMUL (cyclosporine 2 daily) (ophth)) (ophth)) Ophthalmic Local Anesthetics moxifloxacin hcl (ophth) 1 soln (Tetracaine Hcl (Ophth)) NATACYN SUSP ALTACAINE, TETCAINE, 2 1 (natamycin) TETRAVISC, TETRAVISC FORTE SOLN neomycin-bacitracin 1 AKTEN GEL (lidocaine zn-polymyxin oint 3 hcl (ophth)) neomycin-polymyxin- ALCAINE SOLN 1 GP gramicidin soln (proparacaine hcl) OCUFLOX SOLN GP (ofloxacin (ophth)) proparacaine hcl soln 1 ofloxacin (ophth) soln 1 tetracaine hcl (ophth) 1 soln polymyxin b- 1 trimethoprim soln Ophthalmic Nerve Growth Factors OXERVATE SOLN PA POLYTRIM SOLN SP (cenegermin-bkbj) (polymyxin b- GP trimethoprim) Ophthalmic Steroids POVIDONE IODINE SOLN (Bacitracin-Poly-Neomycin- QL(4 gm per fill (povidone-iodine 3 Hc) NEO-POLYCIN HC 1 retail) OINT (ophth)) ALREX SUSP 3 sulfacetamide sodium 1 (loteprednol etabonate) (ophth) oint QL(4 gm per fill bacitracin-poly- 1 sulfacetamide sodium 1 neomycin-hc oint retail) (ophth) soln BLEPHAMIDE S.O.P. tobramycin (ophth) soln 1 OINT (sulfacetamide 2 TOBREX OINT sod-prednisolone) 2 (tobramycin (ophth))
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123 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits BLEPHAMIDE SUSP neomycin-polymy- 1 (sulfacetamide sod- 2 dexameth oint prednisolone) neomycin-polymy- 1 dexamethasone dexameth susp sodium phosphate 1 neomycin-polymyxin-hc 1 (ophth) soln (ophth) susp DUREZOL EMUL 3 PRED MILD SUSP (difluprednate) (prednisolone acetate 2 FLAREX SUSP (ophth)) (fluorometholone 2 PRED-G S.O.P. OINT acetate) (gentamicin- 3 fluorometholone 1 prednisolone acetate) (ophth) susp PRED-G SUSP FML FORTE SUSP (gentamicin- 3 (fluorometholone 2 prednisolone acetate) (ophth)) prednisolone acetate 1 FML LIQUIFILM SUSP (ophth) susp (fluorometholone GP PREDNISOLONE SODIUM (ophth)) PHOSPHATE SOLN OP 1 FML OINT % (prednisolone sodium 2 (fluorometholone 2 phosphate (ophth)) (ophth)) sulfacetamide sod- LOTEMAX GEL 1 GP prednisolone soln (loteprednol etabonate) TOBRADEX OINT LOTEMAX OINT 3 (tobramycin- 3 (loteprednol etabonate) dexamethasone) LOTEMAX SUSP GP TOBRADEX ST SUSP (loteprednol etabonate) (tobramycin- 3 dexamethasone) loteprednol etabonate 1 gel TOBRADEX SUSP QL(5 ml per fill (tobramycin- GP retail) loteprednol etabonate 1 susp dexamethasone) QL(5 ml per fill MAXIDEX SUSP tobramycin- 1 (dexamethasone 2 dexamethasone susp retail) (ophth)) ZYLET SUSP Limit 5mls per MAXITROL OINT (loteprednol etabonate- 3 fill;QL(5 ml per (neomycin-polymy- GP tobramycin) fill retail) dexameth) Ophthalmic Surgical Aids MAXITROL SUSP GELFILM OP FILM (neomycin-polymy- GP (gelatin adsorbable 3 dexameth) (ophth)) Ophthalmics - Misc. You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 124 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Olopatadine Hcl) EYE QL(0.09 ml BROMSITE SOLN ALLERGY ITCH RELIEF, daily); RX/OTC (bromfenac sodium 3 EYE ALLERGY 1 (ophth)) ITCH/REDNESSRELIEF, GNP OLOPATADINE cromolyn sodium 1 HYDROCHLORIDE SOLN (ophth) soln (Olopatadine Hcl) EYE Limit 10mls per CYSTADROPS SOLN QL(0.34 ml SP ALLERGY ITCH RELIEF, month;QL(0.34 (cysteamine hcl) daily) EYE ALLERGY 1 ml daily); CYSTARAN SOLN ITCH/REDNESSRELIEF, RX/OTC SP GNP OLOPATADINE (cysteamine hcl) HYDROCHLORIDE SOLN diclofenac sodium 1 ACULAR LS SOLN (ophth) soln (ketorolac GP Limit 10mls per tromethamine (ophth)) dorzolamide hcl soln 1 month;QL(0.34 ACULAR SOLN ml daily) (ketorolac GP DORZOLAMIDE HCL Limit 10mls per ) 2 month;QL(0.34 tromethamine (ophth) SOLN (dorzolamide hcl) ml daily) ACUVAIL SOLN ELESTAT SOLN GP (ketorolac 3 (epinastine hcl (ophth)) tromethamine (ophth)) epinastine hcl (ophth) 1 ALOCRIL SOLN soln (nedocromil sodium 3 (ophth)) flurbiprofen sodium 1 ALOMIDE SOLN soln ILEVRO SUSP (lodoxamide 2 3 tromethamine) (nepafenac) ketorolac tromethamine azelastine hcl (ophth) 1 1 soln (ophth) soln LASTACAFT SOLN ST AZOPT SUSP Limit 10mls per 3 GP month;QL(0.4 (alcaftadine) (brinzolamide) ml daily) NEVANAC SUSP 3 ST; Limit 10mls (nepafenac) bepotastine besilate 1 per Limit 10mls per soln month;QL(0.34 olopatadine hcl soln 0.1 1 month;QL(0.34 ml daily) % ml daily); ST; Limit 10mls RX/OTC BEPREVE SOLN GP per olopatadine hcl soln 0.2 QL(0.09 ml (bepotastine besilate) month;QL(0.34 1 daily); RX/OTC ml daily) % Limit 10mls per PAREMYD SOLN brinzolamide susp 1 month;QL(0.4 (hydroxyamphetamine- 3 ml daily) tropicamide) bromfenac sodium PATADAY SOLN 0.2 % QL(0.09 ml 1 GP (ophth) soln (olopatadine hcl) daily); RX/OTC
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125 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROLENSA SOLN CIPRO HC SUSP (bromfenac sodium 3 (ciprofloxacin- 3 (ophth)) hydrocortisone) TRUSOPT SOLN Limit 10mls per CIPRODEX SUSP GP month;QL(0.34 (dorzolamide hcl) (ciprofloxacin- GP ml daily) dexamethasone) Prostaglandins - Ophthalmic ciprofloxacin- 1 Limit 2.5mls dexamethasone susp 1 per Limit 1 bottle bimatoprost soln month;QL(0.09 ciprofloxacin- 1 per ml daily) fluocinolone acetonide month;QL(0.5 soln latanoprost soln 1 ea daily) COLY-MYCIN S SUSP LUMIGAN SOLN 2 (neomycin-colistin-hc- 3 (bimatoprost) thonzonium) Limit 2.5mls TRAVATAN Z SOLN CORTISPORIN-TC SUSP GP per (travoprost) month;QL(0.09 (neomycin-colistin-hc- 3 ml daily) thonzonium) Limit 2.5mls neomycin-polymyxin-hc 1 1 per (otic) soln travoprost soln month;QL(0.09 ml daily) neomycin-polymyxin-hc 1 XALATAN SOLN (otic) susp 3 (latanoprost) OTICIN HC NR SOLN ZIOPTAN SOLN (pramoxine-hc- GP 3 (tafluprost) chloroxylenol) OTOVEL SOLN Limit 1 bottle OTIC AGENTS - Drugs to Treat the Ear ( 3 per ciprofloxacin- month;QL(0.5 Otic Agents - Miscellaneous fluocinolone acetonide) ea daily) acetic acid (otic) soln 1 PRAMOTIC LIQD (pramoxine- 3 Otic Anti-infectives chloroxylenol) CETRAXAL SOLN 3 Otic Steroids (ciprofloxacin hcl (otic)) (Fluocinolone Acetonide 1 ciprofloxacin hcl (otic) 1 (Otic)) FLAC OIL soln DERMOTIC OIL FLOXIN OTIC SOLN GP (fluocinolone acetonide GP (ofloxacin (otic)) (otic)) ofloxacin (otic) soln 1 fluocinolone acetonide 1 (otic) oil Otic Combinations hydrocortisone w/acetic QL(10 ml per (Pramoxine-Hc- 1 fill retail,30 ml Chloroxylenol) CORTIC- 1 acid soln per fill mail) ND, EXOTIC-HC SOLN You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 126 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits OXYTOCICS - Drugs to Prevent/Control Uterine OCTAGAM SOLN 1 PA Bleeding GM/20ML, 10 GM/200ML, 2 GM/20ML, 20 Oxytocics GM/200ML, 5 GM/50ML SP (Methylergonovine (immune globulin Maleate) METHERGINE 1 (human) iv) TABS PRIVIGEN SOLN PA methylergonovine 1 (immune globulin SP maleate tabs (human) iv) PASSIVE IMMUNIZING AND TREATMENT Passive Immunizing Agents - Combinations AGENTS - Antibody Drugs to Treat Low Immune System HYQVIA KIT (immune PA globulin (human)- SP Immune Serums hyaluronidase (human BIVIGAM SOLN ( PA immune SP recombinant)) globulin (human) iv) PENICILLINS - Drugs to Treat Bacterial Infections CUVITRU SOLN PA (immune globulin SP Aminopenicillins (human) subcutaneous) amoxicillin caps 1 FLEBOGAMMA DIF SOLN PA (immune globulin SP amoxicillin chew 1 (human) iv) GAMASTAN INJ PA amoxicillin susr 1 (immune globulin SP 1 (human) im) amoxicillin tabs GAMMAGARD LIQUID PA ampicillin caps 1 SOLN (immune globulin SP PA (human) iv or ampicillin sodium solr ij SP subcutaneous) 1 gm, 125 mg GAMMAKED SOLN PA ampicillin sodium solr iv 1 (immune globulin SP 10 gm (human) iv or Natural Penicillins subcutaneous) (Penicillin G Potassium) SP PA GAMMAPLEX SOLN PA PFIZERPEN SOLR ( immune globulin SP BICILLIN L-A SUSP PA ) iv) SP (human (penicillin g benzathine) GAMUNEX-C SOLN PA PENICILLIN G PA (immune globulin SP POTASSIUM IN ISO- (human) iv or OSMOTIC DEXTROSE SP subcutaneous) SOLN (penicillin g pot in HIZENTRA SOLN PA dextrose) (immune globulin SP PA penicillin g potassium SP (human) subcutaneous) solr
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127 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PENICILLIN G PROCAINE PA PA piperacillin sodium- SP SUSP (penicillin g SP tazobactam sodium solr procaine) UNASYN BULK PACK PA penicillin g sodium solr SP PA SOLR (ampicillin & SP sulbactam sodium) penicillin v potassium 1 UNASYN SOLR PA solr (ampicillin & sulbactam SP penicillin v potassium 1 sodium) tabs ZOSYN SOLN 0.25 PA Penicillin Combinations GM/50ML-2 GM/50ML-5 %, 0.375 GM/50ML-3 amoxicillin & pot 1 GM/50ML-5 % SP clavulanate chew (piperacillin sodium- amoxicillin & pot 1 tazobactam sodium in clavulanate susr dextrose) ZOSYN SOLR 0.25 GM-2 PA amoxicillin & pot 1 clavulanate tabs GM, 0.375 GM-3 GM, 0.5 GM-4 GM (piperacillin SP amoxicillin & pot 1 clavulanate tb12 sodium-tazobactam sodium) ampicillin & sulbactam PA sodium solr ij 1 gm-2 SP Penicillinase-Resistant Penicillins gm dicloxacillin sodium 1 ampicillin & sulbactam PA caps PA sodium solr iv 0.5 gm-1 SP nafcillin sodium solr ij 1 SP gm, 10 gm-5 gm gm AUGMENTIN ES-600 NAFCILLIN SODIUM PA SUSR (amoxicillin & pot GP SOLR IV 10 GM (nafcillin SP clavulanate) sodium) AUGMENTIN SUSR 125 nafcillin sodium solr iv PA MG/5ML-31.25 MG/5ML SP 2 10 gm, 2 gm (amoxicillin & pot NAFCILLIN SOLN PA clavulanate) (nafcillin sodium in SP AUGMENTIN SUSR 250 dextrose) MG/5ML-62.5 MG/5ML GP OXACILLIN SODIUM PA (amoxicillin & pot SOLN IV 1 GM/50ML-1.5 clavulanate) GM/50ML, 2 GM/50ML-300 SP AUGMENTIN TABS 125 MG/50ML (oxacillin MG-500 MG (amoxicillin GP sodium in dextrose) & pot clavulanate) PA oxacillin sodium solr ij 1 SP BICILLIN C-R SUSP PA gm (penicillin g benzathine SP PA oxacillin sodium solr iv SP & procaine) 10 gm
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Updated 07/01/2021 128 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PROGESTINS - Hormone Replacement/Modifying disulfiram tabs 1 Drugs PA required for Progestins more than 30 AYGESTIN TABS LUCEMYRA TABS day supply per GP 3 (norethindrone acetate) (lofexidine hcl) year;QL(224 ea PA per 14 days hydroxyprogesterone SP retail) caproate oil MAKENA OIL IM 250 PA Anti-Cataplectic Agents XYREM SOLN ( PA MG/ML sodium SP (hydroxyprogesterone SP oxybate) caproate) Antidementia Agents MAKENA SOAJ SC 275 PA ARICEPT TABS QL(1 ea daily) MG/1.1ML SP (donepezil GP (hydroxyprogesterone hydrochloride) ) caproate QL(1 ea daily) donepezil 1 medroxyprogesterone 1 hydrochloride tabs acetate tabs QL(1 ea daily) donepezil 1 MEGACE ES SUSP hydrochloride tbdp (megestrol acetate GP EXELON PT24 (appetite)) GP (rivastigmine) megestrol acetate 1 QL(1 ea daily) (appetite) susp galantamine hydrobromide cp24 16 1 norethindrone acetate 1 mg, 24 mg, 8 mg tabs galantamine QL(2 ea daily) progesterone caps or 1 hydrobromide soln 4 1 100 mg, 200 mg mg/ml progesterone oil im 50 1 galantamine mg/ml hydrobromide tabs 12 1 PROMETRIUM CAPS QL(2 ea daily) GP mg, 4 mg, 8 mg (progesterone) memantine hcl cp24 14 PA PROVERA TABS mg, 21 mg, 28 mg, 7 1 (medroxyprogesterone GP mg acetate) memantine hcl soln 10 1 PSYCHOTHERAPEUTIC AND NEUROLOGICAL mg/5ml, 2 mg/ml AGENTS - MISC. - Drugs to Treat Mental and Emotional Conditions memantine hcl tabs 10 1 mg, 5 mg, Agents for Chemical Dependency NAMENDA TABS GP acamprosate calcium 1 (memantine hcl) tbec NAMENDA TITRATION ANTABUSE TABS GP PAK TABS (memantine GP (disulfiram) hcl)
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129 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits NAMENDA XR CP24 PA GP Multiple Sclerosis Agents (memantine hcl) (Glatiramer Acetate) PA NAMENDA XR TITRATION PA GLATOPA SOSY 20 1 PACK CP24 (memantine 3 MG/ML hcl) (Glatiramer Acetate) PA RAZADYNE ER CP24 QL(1 ea daily) GLATOPA SOSY 40 SP MG/ML (galantamine GP AMPYRA TB12 PA hydrobromide) GP (dalfampridine) RAZADYNE TABS AUBAGIO TABS PA (galantamine GP 3 hydrobromide) (teriflunomide) AVONEX PEN AJKT PA SP rivastigmine pt24 1 (interferon beta-1a) AVONEX PSKT PA rivastigmine tartrate 1 SP caps (interferon beta-1a) BETASERON KIT PA Combination Psychotherapeutics SP (interferon beta-1b) chlordiazepoxide- 1 COPAXONE SOSY PA amitriptyline tabs SP (glatiramer acetate) olanzapine-fluoxetine 1 hcl caps dalfampridine tb12 1 PA perphenazine- 1 dimethyl fumarate cpdr 1 PA amitriptyline tabs SYMBYAX CAPS dimethyl fumarate misc 1 PA (olanzapine-fluoxetine GP EXTAVIA KIT ( PA hcl) interferon SP beta-1b) Fibromyalgia Agents GILENYA CAPS PA SAVELLA TABS PA; QL(2 ea 3 3 (fingolimod hcl) (milnacipran hcl) daily) PA glatiramer acetate sosy 1 SAVELLA TITRATION PA; QL(2 ea 20 mg/ml PACK MISC 3 daily) PA (milnacipran hcl) glatiramer acetate sosy SP 40 mg/ml Movement Disorder Drug Therapy MAVENCLAD TBPK PA AUSTEDO TABS PA 3 (cladribine (multiple SP (deutetrabenazine) sclerosis)) INGREZZA CAPS PA 3 MAYZENT STARTER PA (valbenazine tosylate) PACK TBPK (siponimod 3 INGREZZA CPPK PA 3 fumarate) (valbenazine tosylate) PLEGRIDY SOPN PA SP tetrabenazine tabs SP (peginterferon beta-1a) XENAZINE TABS PLEGRIDY SOSY PA SP SP (tetrabenazine) (peginterferon beta-1a)
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Updated 07/01/2021 130 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PLEGRIDY STARTER PA ergoloid mesylates tabs 1 PACK SOPN SP (peginterferon beta-1a) pimozide tabs 1 PLEGRIDY STARTER PA PACK SOSY SP Restless Leg Syndrome (RLS) Agents (peginterferon beta-1a) HORIZANT TBCR QL(1 ea daily) 3 REBIF REBIDOSE SOAJ PA (gabapentin enacarbil) SP (interferon beta-1a) Smoking Deterrents REBIF REBIDOSE PA (Nicotine Polacrilex) CVS PV TITRATIONPACK SOAJ SP NICOTINE LOZENGE, (interferon beta-1a) CVS NICOTINE REBIF SOSY (interferon PA POLACRILEX, EQ SP NICOTINE LOZENGES, beta-1a) EQ NICOTINE REBIF TITRATION PACK PA POLACRILEX, EQL SOSY (interferon beta- SP NICOTINE POLACRILEX, 1a) GNP NICOTINE MINI TECFIDERA CPDR PA LOZENGE, GNP GP NICOTINE POLACRILEX, (dimethyl fumarate) GNP NICOTINE TECFIDERA STARTER PA POLACRILEX MINI, PACK MISC (dimethyl GP GOODSENSE NICOTINE, PV fumarate) GOODSENSE NICOTINE POLACRILEX, HM TYSABRI CONC PA SP NICOTINE POLACRILEX, (natalizumab) KLS QUIT2, KLS QUIT4, Postherpetic Neuralgia (PHN)/Neuropathic Pain NICOTINE MINI LOZENGE, NICOTINE GRALISE MISC PA POLACRILEX MINI, PX (gabapentin (once- 3 STOP SMOKING AID, RA daily)) MINI NICOTINE, RA GRALISE TABS PA NICOTINE POLACRILEX, (gabapentin (once- 3 SM NICOTINE, SM NICOTINE POLACRILEX, daily)) TGT NICOTINE Premenstrual Dysphoric Disorder (PMDD) Agents POLACRILEX LOZG fluoxetine hcl (pmdd) 1 caps fluoxetine hcl (pmdd) 1 tabs SARAFEM TABS GP (fluoxetine hcl (pmdd)) Pseudobulbar Affect (PBA) Agents NUEDEXTA CAPS PA (dextromethorphan hbr- 3 quinidine sulfate) Psychotherapeutic and Neurological Agents - You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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131 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Nicotine Polacrilex) CVS PV (Nicotine) CVS NICOTINE PV NICOTINE, CVS TRANSDERMALSYSTEM, NICOTINE POLACRILEX, CVS NICOTINE CVS NICOTINE TRANSDERMALSYSTEM POLACRILEX STARTER, STEP 1, CVS NICOTINE EQ NICOTINE TRANSDERMALSYSTEM POLACRILEX, EQL STEP 2, CVS NICOTINE NICOTINE POLACRILEX, TRANSDERMALSYSTEM/ EQL NICOTINE STEP 3, EQ NICOTINE, POLACRILEX REFILL, EQ NICOTINE STEP 3, EQL NICOTINE GNP NICOTINE POLACRILEX STARTER, TRANSDERMALSYSTEM, GNP NICOTINE GUM, GNP NICOTINE GNP NICOTINE TRANSDERMALSYSTEM POLACRILEX, PV STEP 2, HABITROL, HM GOODSENSE NICOTINE NICOTINE GUM, GOODSENSE TRANSDERMAL SYSTEM, NICOTINE POLACRILEX HM NICOTINE GUM, HM NICOTINE TRANSDERMAL SYSTEM POLACRILEX, KLS QUIT2, STEP 1, HM NICOTINE KLS QUIT4, NICORELIEF, TRANSDERMAL SYSTEM PX STOP SMOKING AID, STEP 2, HM NICOTINE RA NICOTINE, RA TRANSDERMAL SYSTEM NICOTINE GUM, SM STEP 3, HM NICOTINE NICOTINE, SM NICOTINE TRANSDERMALSYSTEM, POLACRILEX, TGT NICOTINE STEP 1, PV NICOTINE GUM, TGT NICOTINE STEP 3, NICOTINE POLACRILEX, NICOTINE THRIVE GUM TRANSDERMAL SYSTEM STEP 1, NICOTINE TRANSDERMAL SYSTEM STEP 1/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 2, NICOTINE TRANSDERMAL SYSTEM STEP 2/CLEAR, NICOTINE TRANSDERMAL SYSTEM STEP 3, NICOTINE TRANSDERMAL SYSTSTEM STEP 3/CLEAR, QC NICOTINE TRANSDERMAL SYSTEM/STEP 1, QC NICOTINE TRANSDERMAL SYSTEM/STEP 2, RA NICOTINE, RA NICOTINE TRANSDERMAL SYSTEM, SM NICOTINE TRANSDERMAL SYSTEM, You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 132 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits SM NICOTINE NICOTROL NS SOLN PV 3 TRANSDERMAL (nicotine) SYSTEM/STEP 1/CLEAR, ZYBAN TB12 ( PV SM NICOTINE bupropion GP TRANSDERMAL hcl (smoking deterrent)) SYSTEM/STEP 2/CLEAR, Transthyretin Amyloidosis Agents SM NICOTINE TEGSEDI SOSY PA TRANSDERMAL SP SYSTEM/STEP 3/CLEAR, (inotersen sodium) TGT NICOTINE STEP Vasomotor Symptom Agents ONE, TGT NICOTINE STEP THREE, TGT BRISDELLE CAPS NICOTINE STEP TWO (paroxetine mesylate GP PT24 (vasomotor)) PV paroxetine mesylate bupropion hcl (smoking PV 1 deterrent) tb12 (vasomotor) caps CHANTIX CONTINUING PV RESPIRATORY AGENTS - MISC. - Drugs to MONTHPAK TABS PV Treat Lung Conditions ( ) varenicline tartrate Alpha-Proteinase Inhibitor (Human) CHANTIX STARTING PV ARALAST NP SOLR PA MONTH PAK TABS PV (alpha1-proteinase SP (varenicline tartrate) inhibitor (human)) CHANTIX TABS PV PV PA (varenicline tartrate) GLASSIA SOLN (alpha1- proteinase inhibitor SP NICODERM CQ PT24 PV GP (human)) (nicotine) PROLASTIN-C SOLN PA NICORETTE GUM PV GP (alpha1-proteinase SP (nicotine polacrilex) inhibitor (human)) NICORETTE LOZG PV GP PROLASTIN-C SOLR PA (nicotine polacrilex) (alpha1-proteinase SP NICORETTE MINI LOZG PV GP inhibitor (human)) (nicotine polacrilex) ZEMAIRA SOLR (alpha1- PA NICORETTE STARTER PV proteinase inhibitor SP KIT GUM (nicotine GP (human)) polacrilex) Cystic Fibrosis Agents PV PV nicotine polacrilex gum KALYDECO PACK PA SP nicotine polacrilex lozg PV PV (ivacaftor) KALYDECO TABS PA SP nicotine pt24 PV PV (ivacaftor) ORKAMBI PACK PA NICOTINE PV SP TRANSDERMAL SYSTEM PV (lumacaftor-ivacaftor) KIT ( ) ORKAMBI TABS PA nicotine SP NICOTROL INHALER PV (lumacaftor-ivacaftor) 3 INHA (nicotine)
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133 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA; Limited to (Minocycline Hcl) ST PULMOZYME SOLN 1 2 75mls per COREMINO TB24 (dornase alfa) month;QL(2.5 ml daily) demeclocycline hcl tabs 1 SYMDEKO TBPK PA SP doxycycline (tezacaftor-ivacaftor) (monohydrate) caps 1 TRIKAFTA TBPK PA; QL(3 ea 100 mg, 150 mg, 50 (elexacaftor-tezacaftor- SP daily) mg, 75 mg ivacaftor) doxycycline Pulmonary Fibrosis Agents (monohydrate) susr 25 1 ESBRIET CAPS PA mg/5ml SP (pirfenidone) doxycycline ESBRIET TABS PA (monohydrate) tabs 1 SP (pirfenidone) 100 mg, 50 mg OFEV CAPS ( PA doxycycline ST nintedanib SP esylate) (monohydrate) tabs 1 SULFONAMIDES - Drugs to Treat Bacterial 150 mg, 75 mg Infections doxycycline hyclate 1 Sulfonamides caps 100 mg, 50 mg SULFADIAZINE TABS doxycycline hyclate 3 1 (sulfadiazine) tabs 100 mg, 20 mg TETRACYCLINES - Drugs to Treat Bacterial doxycycline hyclate ST Infections tbec 100 mg, 150 mg, 1 Glycylcyclines 75 mg MINOCIN CAPS PA GP tigecycline solr SP (minocycline hcl) TIGECYCLINE SOLR PA SP minocycline hcl caps 1 (tigecycline) 100 mg, 50 mg, 75 mg TYGACIL SOLR PA SP minocycline hcl tabs 1 (tigecycline) 100 mg, 50 mg, 75 mg Tetracyclines minocycline hcl tb24 ST (Doxycycline 105 mg, 115 mg, 135 1 (Monohydrate)) AVIDOXY 1 mg, 45 mg, 55 mg, 65 TABS mg, 80 mg, 90 mg (Doxycycline SOLODYN TB24 ST GP (Monohydrate)) 1 MONDOXYNE NL, OKEBO (minocycline hcl) CAPS tetracycline hcl caps 1 (Doxycycline Hyclate) 250 mg, 500 mg MORGIDOX 1X100MG, VIBRAMYCIN CAPS 100 MORGIDOX 1X50MG, 1 MG (doxycycline GP MORGIDOX 2X100MG ) CAPS hyclate
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Updated 07/01/2021 134 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits VIBRAMYCIN SUSR 25 liothyronine sodium 1 MG/5ML (doxycycline GP tabs (monohydrate)) NATURE-THROID NT-2.5 2 VIBRAMYCIN SYRP 50 TABS (thyroid) MG/5ML (doxycycline 2 NATURE-THROID TABS 2 calcium) (thyroid) THYROID AGENTS - Drugs to Regulate Thyroid SYNTHROID TABS 3 Hormones (levothyroxine sodium) Antithyroid Agents thyroid tabs 1 methimazole tabs 1 TIROSINT CAPS 100 MCG, 112 MCG, 125 MCG, propylthiouracil tabs 1 13 MCG, 137 MCG, 150 3 TAPAZOLE TABS MCG, 25 MCG, 50 MCG, GP 75 MCG, 88 MCG (methimazole) (levothyroxine sodium) Thyroid Hormones TIROSINT CAPS 75 MCG 3 (Levothyroxine Sodium) (levothyroxine sodium) EUTHYROX, LEVO-T, 1 LEVOXYL, UNITHROID TIROSINT-SOL SOLN 100 TABS MCG/ML, 112 MCG/ML, 125 MCG/ML, 13 MCG/ML, (Thyroid) NP THYROID 137 MCG/ML, 150 120, NP THYROID 15 1 MCG/ML, 200 MCG/ML, 25 3 TABS MCG/ML, 50 MCG/ML, 75 ARMOUR THYROID TABS MCG/ML, 88 MCG/ML GP 120 MG, 15 MG (thyroid) (levothyroxine sodium) ARMOUR THYROID TABS WESTHROID TABS 2 180 MG, 240 MG, 30 MG, (thyroid) 300 MG, 60 MG, 90 MG 2 WP THYROID TABS (thyroid) 2 (thyroid) CYTOMEL TABS 3 (liothyronine sodium) ULCER DRUGS - Drugs to Treat Bowel, Intestine and Stomach Conditions levothyroxine sodium caps or 100 mcg, 112 Antispasmodics mcg, 125 mcg, 13 mcg, (Hyoscyamine Sulfate) ED- 1 SPAZ, NULEV, OSCIMIN 1 137 mcg, 150 mcg, 25 TBDP mcg, 50 mcg, 75 mcg, (Hyoscyamine Sulfate) 88 mcg OSCIMIN SR, SYMAX-SR 1 levothyroxine sodium TB12 tabs or 100 mcg, 112 (Hyoscyamine Sulfate) 1 mcg, 125 mcg, 137 OSCIMIN TABS mcg, 150 mcg, 175 1 (Hyoscyamine Sulfate) mcg, 200 mcg, 25 mcg, OSCIMIN, SYMAX-SL 1 300 mcg, 50 mcg, 75 SUBL mcg, 88 mcg
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135 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ANASPAZ TBDP GP methscopolamine 1 (hyoscyamine sulfate) bromide tabs atropine sulfate soln ij SP propantheline bromide 1 0.4 mg/ml, 1 mg/ml tabs BELLADONNA/OPIUM H-2 Antagonists SUPP (belladonna 3 (Cimetidine) CIMETIDINE RX/OTC alkaloids & opium) 200, CIMETIDINE ACID REDUCER, CVS chlordiazepoxide hcl- 1 clidinium bromide caps HEARTBURN RELIEF, EQ ACID REDUCER, EQ CUVPOSA SOLN 2 CIMETIDINE ACID 1 (glycopyrrolate) REDUCER, GNP 1 HEARTBURN RELIEF, dicyclomine hcl caps HEARTBURN RELIEF, PX ACID REDUCER, SB dicyclomine hcl soln 1 CIMETIDINE, SM ACID REDUCER TABS dicyclomine hcl tabs 1 GLYCATE TABS 3 (glycopyrrolate) glycopyrrolate tabs or 1 1 mg, 2 mg GLYCOPYRROLATE TABS OR 1.5 MG 3 (glycopyrrolate) hyoscyamine sulfate 1 subl hyoscyamine sulfate 1 tabs hyoscyamine sulfate 1 tb12 hyoscyamine sulfate 1 tbdp LEVBID TB12 GP (hyoscyamine sulfate) LEVSIN TABS GP (hyoscyamine sulfate) LEVSIN/SL SUBL GP (hyoscyamine sulfate) LIBRAX CAPS (chlordiazepoxide hcl- GP clidinium bromide)
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Updated 07/01/2021 136 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Famotidine) ACID RX/OTC (Ranitidine Hcl) ACID RX/OTC CONTROL MAXIMUM CONTROL MAXIMUM STRENGTH, ACID STRENGTH, ACID CONTROLLER MAXIMUM REDUCER, ACID STRENGTH, ACID REDUCER MAXIMUM REDUCER MAXIMUM STRENGTH, CVS ACID STRENGTH, CVS ACID REDUCER CONTROLLER MAXIMUM MAXIMUMSTRENGTH, STRENGTH, EQ EQ ACID REDUCER, EQL FAMOTIDINE MAXIMUM ACID REDUCER STRENGTH, EQL MAXIMUMSTRENGTH, HEARTBURN EQL HEARTBURN RELIEF PREVENTION/MAXIMUM MAXIMUM STRENGTH, STRENGTH, FAMOTIDINE GNP ACID CONTROL 150 MAXIMUM STRENGTH, MAXIMUM STRENGTH, GNP ACID REDUCER GOODSENSE ACID MAXIMUMSTRENGTH, REDUCER, HEARTBURN HEARTBURN RELIEF RELIEF 150 MAXIMUM 1 MAXIMUMSTRENGTH, 1 STRENGTH, HM ACID HM FAMOTIDINE, KLS REDUCER, HM ACID ACID CONTROLLER REDUCER MAXIMUM MAXIMUM STRENGTH, STRENGTH, KLS ACID MM ACID-PEP MAXIMUM REDUCER STRENGTH, MM MAXIMUMSTRENGTH, PX FAMOTIDINE, PX ACID ACID REDUCER REDUCER MAXIMUM MAXIMUM STRENGTH, STRENGTH, QC ACID RA ACID REDUCER CONTROLLER MAXIMUM MAXIMUM STRENGTH, STRENGTH, RA ACID RANITIDINE 150 REDUCER MAXIMUM MAXIMUM STRENGTH, STRENGTH, SB ACID SB ACID REDUCER, SM CONTROLLER MAXIMUM ACID REDUCER STRENGTH, SM ACID MAXIMUM STRENGTH, REDUCER MAXIMUM WAL-ZAN 150 MAXIMUM STRENGTH, ZANTAC 360 STRENGTH TABS MAXIMUM STRENGTH cimetidine hcl soln 300 1 TABS mg/5ml cimetidine tabs 200 mg 1 RX/OTC
cimetidine tabs 300 mg, 1 400 mg, 800 mg famotidine tabs 20 mg 1 RX/OTC famotidine tabs 40 mg 1 QL(2 ea daily) GNP ACID CONTROL 150 RX/OTC MAXIMUM STRENGTH 3 TABS (ranitidine hcl) nizatidine caps 1
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137 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits nizatidine soln 1 (Esomeprazole PA; QL(1 ea Magnesium) CVS daily); RX/OTC PEPCID AC MAXIMUM RX/OTC ESOMEPRAZOLE STRENGTH TABS GP MAGNESIUM, GNP (famotidine) ESOMEPRAZOLE MAGNESIUM, PEPCID AC TABS RX/OTC GP GOODSENSE (famotidine) ESOMEPRAZOLE PEPCID TABS 20 MG RX/OTC MAGNESIUM, HM GP (famotidine) ESOMEPRAZOLE 1 MAGNESIUM DELAYED PEPCID TABS 40 MG QL(2 ea daily) GP RELEASE, KLS (famotidine) ESOMEPRAZOLE MAGNESIUM, QC ranitidine hcl caps 150 1 mg, 300 mg ESOMEPRAZOLE MAGNESIUM, RA ranitidine hcl syrp 15 ESOMEPRAZOLE mg/ml, 150 mg/10ml, 1 MAGNESIUM, SM 75 mg/5ml ESOMEPRAZOLE RX/OTC MAGNESIUM CPDR ranitidine hcl tabs 150 1 mg QL(1 ea daily); (Lansoprazole) CVS 1 LANSOPRAZOLE TBDD AL(Up to 12 yrs ranitidine hcl tabs 300 1 old ); RX/OTC mg (Lansoprazole) CVS RX/OTC TAGAMET HB TABS RX/OTC LANSOPRAZOLE, EQ GP (cimetidine) LANSOPRAZOLE, GNP ZANTAC 150 MAXIMUM RX/OTC LANSOPRAZOLE, STRENGTH TABS GOODSENSE GP LANSOPRAZOLE, (ranitidine hcl) HEARTBURN 1 Misc. Anti-Ulcer TREATMENT 24 HOUR, CARAFATE SUSP HM LANSOPRAZOLE, GP KLS LANSOPRAZOLE, QC (sucralfate) LANSOPRAZOLE, RA CARAFATE TABS GP LANSOPRAZOLE, SM (sucralfate) LANSOPRAZOLE CPDR ACIPHEX SPRINKLE PA sucralfate susp 1 CPSP 10 MG, 5 MG 3 sucralfate tabs 1 (rabeprazole sodium) DEXILANT CPDR PA; QL(1 ea 3 Proton Pump Inhibitors (dexlansoprazole) daily) PA; QL(1 ea esomeprazole 1 magnesium cpdr 20 mg daily); RX/OTC PA; QL(1 ea esomeprazole 1 magnesium cpdr 40 mg daily) esomeprazole PA magnesium pack 10 1 mg, 20 mg, 40 mg
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Updated 07/01/2021 138 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits ESOMEPRAZOLE PA; QL(1 ea pantoprazole sodium STRONTIUM CPDR daily) 1 3 tbec (esomeprazole PREVACID CPDR 30 MG GP strontium) (lansoprazole) FIRST-LANSOPRAZOLE PA 3 PREVACID SOLUTAB QL(1 ea daily); SUSP (lansoprazole) TBDD 15 MG GP AL(Up to 12 yrs FIRST-OMEPRAZOLE old ); RX/OTC 3 (lansoprazole) SUSP (omeprazole) PREVACID SOLUTAB QL(1 ea daily); RX/OTC TBDD 30 MG GP AL(Up to 12 yrs lansoprazole cpdr 15 1 mg (lansoprazole) old ) PRILOSEC PACK PA lansoprazole cpdr 30 1 mg (omeprazole 3 QL(1 ea daily); magnesium) lansoprazole tbdd 15 PROTONIX PACK 1 AL(Up to 12 yrs GP mg old ); RX/OTC (pantoprazole sodium) QL(1 ea daily); PROTONIX TBEC lansoprazole tbdd 30 GP 1 AL(Up to 12 yrs (pantoprazole sodium) mg old ) RABEPRAZOLE SODIUM PA NEXIUM 24HR CLEAR PA; QL(1 ea DR SPRINKLE CPSP 3 MINIS CPDR daily); RX/OTC (rabeprazole sodium) (esomeprazole GP PA; QL(2 ea magnesium) rabeprazole sodium 1 tbec daily) NEXIUM 24HR CPDR PA; QL(1 ea (esomeprazole GP daily); RX/OTC Ulcer Drugs - Prostaglandins CYTOTEC TABS magnesium) GP NEXIUM CPDR 20 MG PA; QL(1 ea (misoprostol) (esomeprazole GP daily); RX/OTC misoprostol tabs 1 magnesium) NEXIUM PACK 10 MG, 20 PA Ulcer Therapy Combinations MG, 40 MG (Omeprazole-Sodium PA (esomeprazole GP Bicarbonate) OMEPPI 1 magnesium) CAPS NEXIUM PACK 2.5 MG, 5 PA amoxicillin- MG (esomeprazole 3 clarithromycin w/ 1 magnesium) lansoprazole misc OMEPRAZOLE + HELIDAC THERAPY MISC SYRSPEND SFALKA (metronidazole- 3 3 SUSP (omeprazole) tetracycline w/ bismuth subsalicylate) omeprazole cpdr 10 1 mg, 40 mg OMECLAMOX-PAK MISC RX/OTC (amoxicillin- omeprazole cpdr 20 mg 1 clarithromycin w/ 3 omeprazole) pantoprazole sodium 1 pack You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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139 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits PA omeprazole-sodium oxybutynin chloride 1 bicarbonate caps 1100 1 tb24 mg-40 mg OXYTROL FOR WOMEN RX/OTC 3 omeprazole-sodium PTTW (oxybutynin) bicarbonate pack 1680 OXYTROL PTTW RX/OTC 1 3 mg-20 mg, 1680 mg-40 (oxybutynin) mg solifenacin succinate 1 PYLERA CAPS (bismuth tabs subcitrate potassium- QL(1 ea daily) 3 tolterodine tartrate cp24 1 metronidazole- 2 mg, 4 mg tetracycline) QL(2 ea daily) tolterodine tartrate tabs 1 ZEGERID CAPS 1100 MG- PA 1 mg 40 MG (omeprazole- GP tolterodine tartrate tabs sodium bicarbonate) 1 2 mg ZEGERID PACK 1680 MG- TOVIAZ TB24 QL(1 ea daily) 20 MG, 1680 MG-40 MG 2 (omeprazole-sodium GP (fesoterodine fumarate) bicarbonate) trospium chloride cp24 1 URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms trospium chloride tabs 1 VESICARE TABS Urinary Antispasmodic - Antimuscarinics GP (solifenacin succinate) darifenacin 1 hydrobromide tb24 Urinary Antispasmodics - Beta-3 Adrenergic DETROL LA CP24 QL(1 ea daily) MYRBETRIQ TB24 PA; QL(1 ea GP 3 (tolterodine tartrate) (mirabegron) daily) DETROL TABS 1 MG QL(2 ea daily) GP Urinary Antispasmodics - Cholinergic Agonists (tolterodine tartrate) bethanechol chloride DETROL TABS 2 MG 1 GP tabs (tolterodine tartrate) URECHOLINE TABS DITROPAN XL TB24 GP GP (bethanechol chloride) (oxybutynin chloride) Urinary Antispasmodics - Direct Muscle Relaxants ENABLEX TB24 (darifenacin GP flavoxate hcl tabs 1 hydrobromide) GELNIQUE GEL VACCINES 3 (oxybutynin chloride) Bacterial Vaccines GELNIQUE PUMP GEL 3 PEDVAX HIB SUSP PV (oxybutynin chloride) (haemophilus b polysac PV conj vac) oxybutynin chloride 1 syrp Viral Vaccines oxybutynin chloride 1 tabs You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
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Updated 07/01/2021 140 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits FLUCELVAX PV OPTIONS CONCEPTROL PV QUADRIVALENT 2018- VAGINAL GP 2019 SUSY (influenza CONTRACEPTIVE GEL virus vaccine tissue- PV (nonoxynol-9) cultured subunit OPTIONS GYNOL II PV quadrivalent) VAGINALCONTRACEPTIV PV FLUCELVAX PV E GEL (nonoxynol-9) QUADRIVALENT 2019- SHUR-SEAL GEL PV PV 2020 SUSY (influenza (nonoxynol-9) PV virus vaccine tissue- TODAY SPONGE MISC PV PV cultured subunit (nonoxynol-9) quadrivalent) VCF VAGINAL PV FLUCELVAX PV CONTRACEPTIVE FILM PV QUADRIVALENT 2020- FILM (nonoxynol-9) 2021 SUSY (influenza PV VCF VAGINAL PV virus vaccine tissue- CONTRACEPTIVE FOAM PV cultured subunit FOAM (nonoxynol-9) quadrivalent) VCF VAGINAL PV GARDASIL 9 SUSP PV CONTRACEPTIVEGEL PV GEL (nonoxynol-9) (human papillomavirus PV (hpv) 9-valent recombinant Vaginal Anti-infectives vaccine) (Metronidazole Vaginal) 1 GARDASIL 9 SUSY PV VANDAZOLE GEL (human papillomavirus PV (Miconazole Nitrate (hpv) 9-valent recombinant Vaginal) MICONAZOLE 3 1 vaccine) SUPP RECOMBIVAX HB SUSP AVC CREA 3 (hepatitis b vaccine 3 (sulfanilamide vaginal) (recomb)) CLEOCIN CREA VA 2 % ROTATEQ SOLN (clindamycin phosphate GP (rotavirus vaccine, live 3 vaginal) oral pentavalent) CLEOCIN SUPP VA 100 VAGINAL AND RELATED PRODUCTS MG (clindamycin 3 phosphate vaginal) Miscellaneous Vaginal Products clindamycin phosphate 1 FEM PH GEL (acetic vaginal crea acid-oxyquinoline 3 CLINDESSE CREA vaginal) (clindamycin phosphate 3 INTRAROSA INST 3 (one dose)) (prasterone vaginal) GYNAZOLE-1 CREA Spermicides (butoconazole nitrate 3 ENCARE SUPP PV (one dose)) PV (nonoxynol-9)
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141 Updated 07/01/2021 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits METROGEL-VAGINAL VASOPRESSORS - Drugs to Treat Heart and GEL (metronidazole GP Circulation Conditions vaginal) Anaphylaxis Therapy Agents metronidazole vaginal 1 epinephrine QL(4 ea per fill gel retail) (anaphylaxis) soaj 0.15 2 terconazole vaginal 1 mg/0.15ml, 0.3 crea mg/0.3ml Limited to 4 terconazole vaginal 1 epinephrine supp 1 syringes per (anaphylaxis) soaj 0.15 fill;QL(4 ea per Vaginal Contraceptive - pH Modulators mg/0.3ml fill retail) PHEXXI GEL (lactic PV EPINEPHRINE SOAJ 0.3 QL(4 ea per fill acid-citric acid- PV MG/0.3ML (epinephrine 2 retail) potassium bitartrate) (anaphylaxis)) Vaginal Estrogens EPIPEN 2-PAK SOAJ PA; QL(4 ea (epinephrine GP per fill retail) (Estradiol Vaginal) 1 YUVAFEM TABS (anaphylaxis)) ESTRACE CREA Limited to 4 GP EPIPEN-JR 2-PAK SOAJ (estradiol vaginal) ( GP syringes per epinephrine fill;QL(4 ea per estradiol vaginal crea 1 (anaphylaxis)) fill retail) estradiol vaginal tabs 1 Neurogenic Orthostatic Hypotension (NOH) - PA ESTRING RING droxidopa caps SP 3 (estradiol vaginal) NORTHERA CAPS PA SP FEMRING RING QL(1 ea per 90 (droxidopa) days retail) (estradiol acetate 3 Vasopressors vaginal) EPINEPHRINE HCL SOLN PA SP PREMARIN CREA VA (epinephrine) 0.625 MG/GM 2 PA (estrogens, conjugated epinephrine soln 1 SP vaginal) mg/ml Vaginal Progestins midodrine hcl tabs 1 CRINONE GEL 4 % VITAMINS (progesterone 3 (vaginal)) Oil Soluble Vitamins CRINONE GEL 8 % PA (Cholecalciferol) AL(At least 65 (progesterone 3 AQUEOUS VITAMIN D yrs old); PV (vaginal)) INFANTS, BPROTECTED PEDIA D-VITE, D-VITE ENDOMETRIN INST PA PEDIATRIC, D3 VITAMIN, PV (progesterone 3 JUST D, PHARMACIST (vaginal)) CHOICE D-VITAMIN PEDIATRIC DROPS, VITAMIN D INFANT LIQD You can find information on what the symbols and abbreviations on this table mean by going to page ii-iii.
OR Essential Drug List
Updated 07/01/2021 142 Drug Requirements/ Drug Requirements/ Drug Name Tier Limits Drug Name Tier Limits (Cholecalciferol) CVS D3, AL(At least 65 VITAMIN D3 IMMUNE AL(At least 65 D3-50, DECARA, EQL yrs old); PV HEALTH LIQD PV yrs old); PV VITAMIN D3, OPTIMAL-D, PV (cholecalciferol) OPTIMAL-D PACK, VITAMIN D3 LIQD AL(At least 65 WEEKLY-D CAPS PV (cholecalciferol) yrs old); PV (Cholecalciferol) CVS D3, D3-50, DECARA, EQL Water Soluble Vitamins VITAMIN D3, OPTIMAL-D, 1 POTABA CAPS OPTIMAL-D PACK, (potassium 3 WEEKLY-D CAPS aminobenzoate) (Cholecalciferol) D 400, D- AL(At least 65 400, D3 HIGH POTENCY, yrs old); PV DELTA D3, GNP VITAMIN PV D-400, HM VITAMIN D, QC VITAMIN D3, SM VITAMIN D, VITAMIN D-400 TABS (Cholecalciferol) D 400, D3 AL(At least 65 KIDS, GNP VITAMIN D, PV yrs old); PV HEALTHY KIDS VITAMIN D3, KP VITAMIN D CHEW BABY DDROPS LIQD AL(At least 65 PV (cholecalciferol) yrs old); PV cholecalciferol caps 1 1.25 mg, 50000 unit AL(At least 65 cholecalciferol caps PV 400 unit yrs old); PV AL(At least 65 cholecalciferol chew PV 400 unit yrs old); PV AL(At least 65 cholecalciferol liqd 400 PV unit/ml yrs old); PV AL(At least 65 cholecalciferol tabs 400 PV unit yrs old); PV D-VI-SOL LIQD AL(At least 65 GP (cholecalciferol) yrs old); PV DRISDOL CAPS GP (ergocalciferol) ergocalciferol caps 1 MEPHYTON TABS GP (phytonadione) phytonadione tabs 1 VITAMIN D2 TABS AL(At least 65 PV (ergocalciferol) yrs old); PV
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OR Essential Drug List
143 Updated 07/01/2021 Index 7t lido gel 80 ADDERALL XR1 all day allergy childrens35 abacavir sulfate52 adefovir dipivoxil55 allergy childrens34 abacavir sulfate-lamivudine52 ADEMPAS59 allergy nasal spray 24 hour120 abacavir sulfate-lamivudine- adrucil42 allergy relief childrens34,35 zidovudine 52 adult aspirin regimen7 allopurinol93 ABELCET32 ADVAIR DISKUS18 almotriptan malate105 ABILIFY52 ADVAIR HFA18 ALOCRIL125 abiraterone acetate44 ADVOCATE INSULIN ALOMIDE125 ABSORICA68 SYRINGE/U- alosetron hcl91 ABSORICA LD68 100/1ML/31GX5/16" 101 ALOXI31 ABSTRAL8 AFINITOR46 ALPHAGAN P122 acamprosate calcium129 AFINITOR DISPERZ46 alprazolam16 acarbose27 afirmelle61 ALPRAZOLAM INTENSOL16 ACCOLATE17 aftera64 alprazolam xr16 ACCUPRIL37 AGGRENOX94 ALREX123 ACCURETIC39 AGRYLIN94 ALTABAX71 acebutolol hcl56 AIMOVIG104,105 altacaine123 acetaminophen w/ codeine10 AIMSCO LUBRICATED99 ALTACE37 acetazolamide84 ak-poly-bac122 altafrin122 acetic acid (otic)126 AKTEN123 ALTOPREV37 acetylcysteine67 AKYNZEO32 ALUNBRIG46 acid control maximum al1279 strength137 ala scalp74 alvimopan91 ACIPHEX SPRINKLE138 ala-cort74 alyacen 1/3561 acitretin73 ALA-QUIN71 alyacen 7/7/762 ACTEMRA4 ALA-SCALP74 alyq58 ACTIDOM DMX66 albendazole13 amabelz88 ACTIGALL90 ALBENZA13 amantadine hcl49 ACTIMMUNE48 albuterol sulfate18 AMARYL30 ACTIQ8 ALBUTEROL SULFATE18 AMBIEN97 ACTIVELLA88 albuterol sulfate18,19 AMBIEN CR97 ACTONEL85 ALCAINE123 AMBISOME32 ACTOPLUS MET27 alclometasone ambrisentan58 ACTOS28 dipropionate74 amcinonide74 ACULAR125 ALCORTIN A71 AMCINONIDE74 ACULAR LS125 ALDACTAZIDE84 AMERGE105 ACUVAIL125 ALDACTONE84 amethia61 acyclovir55 ALDARA79 amethyst61 acyclovir topical74 ALDURAZYME86 AMICAR96 ACZONE68 ALECENSA46 amikacin sulfate3 ADAGEN3 alendronate sodium85 amiloride & hydrochlorothiazide84 ADALAT CC57 ALFERON N48 amiloride hcl84 adapalene68 alfuzosin hcl93 aminocaproic acid96 adapalene treatment67 ALIMTA42 aminophylline20 adapalene-benzoyl peroxide68 ALINIA14 amiodarone hcl17 ADCIRCA58 aliskiren fumarate40 AMITIZA90 ADDERALL1 ALKERAN42
Updated 07/01/2021 Index 1 amitriptyline hcl27 apraclonidine hcl122 ATIVAN16 amlodipine besylate57 aprepitant32 atomoxetine hcl1 amlodipine besylate-atorvastatin apri60 atorvastatin calcium37 calcium58 APTIOM22 atovaquone14 amlodipine besylate-benazepril hcl39 APTIVUS52 atovaquone-proguanil hcl41 amlodipine besylate-olmesartan aqueous vitamin d infants142 ATRALIN68 medoxomil39 ARALAST NP133 ATRIPLA52 amlodipine besylate- ARANESP ALBUMIN ATROPINE SULFATE122 valsartan39 FREE95 amlodipine-valsartan- atropine sulfate136 ARAVA6 hydrochlorothiazide 39 ATROVENT HFA17 ARCALYST4 amnesteem67 AUBAGIO130 ARCAPTA NEOHALER19 amoxapine27 AUGMENTIN128 argyle sterile saline 100ml92 amoxicillin127 AUGMENTIN ES-600128 argyle sterile water 100ml110 amoxicillin & pot aurovela 1.5/3062 clavulanate128 ARICEPT129 aurovela 24 fe61 amoxicillin-clarithromycin w/ ARIKAYCE3 lansoprazole139 AUSTEDO130 ARIMIDEX44 amphetamine- AVALIDE39 dextroamphetamine1 aripiprazole52 AVANDIA28 amphotericin b32 ARIXTRA20 AVAPRO38 ampicillin127 armodafinil2 AVAR68 ampicillin & sulbactam ARMOUR THYROID135 sodium128 avar cleanser67 ARNUITY ELLIPTA18 ampicillin sodium127 AVAR LS68 AROMASIN44 AMPYRA130 AVAR LS CLEANSER68 ARRANON42 AMRIX119 avar-e emollient67 arthritis pain reliever70 ANADROL-5011 AVAR-E LS68 ARTHROTEC 504 ANAFRANIL27 AVC141 ARTHROTEC 754 anagrelide hcl94 AVELOX90 ARZERRA43 ANALPRAM-HC12 avidoxy134 ASACOL HD91 ANASPAZ136 avita68 ascomp/codeine10 anastrozole44 AVODART93 ASCRIPTIN8 ANCOBON32 AVONEX130 asenapine maleate51 ANDRODERM11 AVONEX PEN130 aspirin8 ANDROGEL11 AYGESTIN129 aspirin 81 low dose7 ANDROGEL PUMP11 AYVAKIT45 aspirin adult8 ANGELIQ88 azacitidine42 aspirin-dipyridamole94 ANNOVERA63 AZASAN109 ASTAGRAF XL108 ANORO ELLIPTA19 AZASITE122 ATABEX EC113 ANTABUSE129 AZATHIOPRINE109 ATABEX OB113 ANTARA36 azathioprine109 ATACAND38 anti-diarrheal30 azelaic acid81 ATACAND HCT39 anucort-hc12 azelastine hcl120 atazanavir sulfate52 anusol-hc12 azelastine hcl (ophth)125 ATELVIA85 ANUSOL-HC12 azelastine hcl-fluticasone atenolol56 ANZEMET31 propionate120 atenolol & chlorthalidone39 AZELEX68 APEXICON E75 ATGAM109 AZILECT50 APLENZIN25
Index 2 Updated 07/01/2021 azithromycin98 BD PEN bicalutamide44 AZOPT125 NEEDLE/ORIGINAL/ULTRA- BICILLIN C-R128 FINE/29G X 12.7MM102 AZOR39 BD PEN BICILLIN L-A127 AZULFIDINE91 NEEDLE/SHORT/ULTRA- BIDIL58 AZULFIDINE EN-TABS91 FINE/31G X 8MM102 BIKTARVY52 azurette60 BECONASE AQ120 BILTRICIDE13 B-D INSULIN SYRINGE BELBUCA11 bimatoprost126 ULTRAFINE II/1ML/31G X BELLADONNA/OPIUM136 BINOSTO85 5/16"101 BELSOMRA97 BABY DDROPS143 BIO-DTUSS DMX66 BENADRYL ALLERGY bisoprolol & bac6 CHILDRENS34 hydrochlorothiazide39 baciim13 benazepril & hydrochlorothiazide39 bisoprolol fumarate56 bacitracin13 benazepril hcl37 BIVIGAM127 bacitracin (ophthalmic)122 BENICAR HCT39 BLEPH-10122 bacitracin-poly-neomycin-hc BLEPHAMIDE124 123 BENLYSTA110 bacitracin-polymyxin b BENSAL HP79 BLEPHAMIDE S.O.P.123 (ophth)122 BENZACLIN68 BONIVA85 baclofen119 BENZACLIN WITH PUMP68 BONJESTA32 BACTRIM13 BENZAMYCIN68 bosentan58 BACTRIM DS13 benzepro creamy wash67 BOSULIF46 BAL-CARE DHA113 BENZNIDAZOLE13 BOTOX121 BALCOLTRA62 benzonatate65 bp cleansing wash68 balsalazide disodium91 benzoyl peroxide- bprotected pedia iron95 BALVERSA46 erythromycin68 BRAFTOVI46 banophen34 benztropine mesylate48 BREO ELLIPTA19 BANZEL22 bepotastine besilate125 BRILINTA94 BAQSIMI ONE PACK28 BEPREVE125 brimonidine tartrate122 BAQSIMI TWO PACK28 BERINERT94 brinzolamide125 BARACLUDE55 BESIVANCE122 BRISDELLE133 BAXDELA90 BETADINE OPHTHALMIC bromfenac sodium (ophth)125 PREP122 BD AUTOSHIELD 29G X bromocriptine mesylate49 3/16"102 betamethasone dipropionate BD AUTOSHIELD 29G X (topical)75 BROMSITE125 5/16"102 betamethasone dipropionate BRUKINSA46 augmented75 BD AUTOSHIELD DUO 30G X budesonide64 betamethasone valerate75 5MM102 budesonide (inhalation)18 BD INSULIN SYRINGE ULTRA- BETAPACE56 budesonide (nasal)120 FINE/1ML/31G X 8MM102 BETAPACE AF56 BD INSULIN SYRINGE budesonide-formoterol fumarate ULTRAFINE/U-100/1ML/31G X BETASERON130 dihydrate19 5/16"102 betaxolol hcl56 bumetanide84 BD PEN betaxolol hcl (ophth)121 BUMEX84 NEEDLE/MICRO/ULTRA- bethanechol chloride140 FINE/32G X 6MM102 BUNAVAIL11 BD PEN NEEDLE/MINI/ULTRA- BETHKIS3 bupap6 FINE/31G X 5MM102 BETIMOL121 BUPHENYL86 BD PEN NEEDLE/NANO 2ND BETOPTIC-S121 BUPRENEX11 GEN/32G X 5/32"102 BD PEN BEVYXXA20 buprenorphine11 NEEDLE/NANO/ULTRA- bexarotene48 buprenorphine hcl11 FINE/32G X 4MM102 BEYAZ62
Updated 07/01/2021 Index 3 buprenorphine hcl-naloxone hcl CANASA91 CATAPRES-TTS-338 dihydrate11 CANCIDAS32 caziant60 bupropion hcl25 candesartan cilexetil38 cefaclor59 bupropion hcl (smoking deterrent)133 candesartan cilexetil- CEFACLOR ER59 hydrochlorothiazide 39 buspirone hcl16 cefadroxil59 CAPASTAT SULFATE41 busulfan42 cefazolin sodium59 capecitabine42 BUSULFEX42 cefdinir60 CAPEX75 butalbital-acetaminophen6 cefditoren pivoxil60 CAPLYTA50 butalbital-acetaminophen- CEFEPIME60 CAPRELSA46 caffeine6 cefepime hcl60 butalbital-acetaminophen- captopril37 CEFEPIME/DEXTROSE60 caffeine w/ codeine10 captopril & butalbital-aspirin-caffeine6 hydrochlorothiazide39 cefixime60 butalbital-aspirin-caffeine CARAC72 CEFOTAN59 w/cod10 CARAFATE138 cefotaxime sodium60 BUTALBITAL/ASPIRIN/CAFFEIN cefotetan disodium59 E6 CARBAGLU87 BUTISOL SODIUM96 carbamazepine22 cefoxitin sodium59 butorphanol tartrate11 CARBATROL22 CEFOXITIN SODIUM59 BUTRANS11 carbidopa48 cefpodoxime proxetil60 BYSTOLIC56 carbidopa-levodopa49 cefprozil59 BYVALSON39 carbidopa-levodopa- ceftazidime60 entacapone 49 C-NATE DHA113 ceftriaxone sodium60 carbinoxamine maleate34 cefuroxime axetil59 c-topical80 CARDIZEM57 cabergoline88 cefuroxime sodium59 CARDIZEM CD57 CELEBREX4 CABLIVI94 CARDIZEM LA57 CABOMETYX46 celecoxib4 CARDURA38 CELEXA25 CADUET58 CARDURA XL93 CAFERGOT105 CELLCEPT109 CAREONE INSULIN CELLCEPT caffeine citrate1 SYRINGES/1ML/31GX5/16" INTRAVENOUS109 102 CALAN57 CELONTIN24 carisoprodol119 CALAN SR57 CEM-UREA78 CALCIFOL107 carisoprodol w/ aspirin119 carisoprodol w/ aspirin & CENTANY71 calcipotriene73 codeine119 CENTANY AT71 CALCIPOTRIENE73 CARNITOR87 cephalexin59 calcipotriene-betamethasone CARNITOR SF87 CERACADE81 dipropionate75 calcitonin (salmon)85 carteolol hcl (ophth)121 CERDELGA94 calcitrene73 cartia xt57 CEREBYX24 calcitriol86 carvedilol56 CEROVEL79 calcitriol (topical)73 carvedilol phosphate56 CESAMET32 calcium acetate (phosphate CASODEX44 cetirizine hcl35 binder)92 caspofungin acetate32 CETRAXAL126 CALCIUM-FOLIC ACID PLUS CASPOFUNGIN cevimeline hcl111 D107 ACETATE32 CHANTIX133 CALQUENCE46 cataflam4 CHANTIX CONTINUING CAMBIA105 CATAPRES38 MONTHPAK133 camila64 CATAPRES-TTS-138 CHANTIX STARTING MONTH CAMPATH43 CATAPRES-TTS-238 PAK133
Index 4 Updated 07/01/2021 charlotte 24 fe61 CITRANATAL ASSURE113 clobetasol propionate75 CHEMET30 CITRANATAL B-CALM113 clobetasol propionate e74 CHENODAL90 CITRANATAL BLOOM113 clobetasol propionate emollient cheratussin ac66 CITRANATAL BLOOM base75 DHA113 clobetasol propionate chloramphenicol sodium emulsion75 succinate14 CITRANATAL DHA113 CLOBEX75 chlordiazepoxide hcl16 CITRANATAL ESSENCE113 chlordiazepoxide hcl-clidinium CITRANATAL clocortolone pivalate75 bromide136 HARMONY113 clodan74 chlordiazepoxide-amitriptyline CITRANATAL MEDLEY113 CLODERM75 130 CITRANATAL RX113 CLODERM PUMP75 chlorhexidine gluconate (mouth- throat)110 cladribine42 clofarabine42 chloroquine phosphate41 claravis67 CLOLAR42 chlorothiazide84 CLARINEX35 clomiphene citrate86 chlorpromazine hcl51 CLARINEX-D 12 HOUR66 clomipramine hcl27 chlorthalidone84 clarithromycin99 clonazepam21 CHLORZOXAZONE119 clearlax98 clonidine38 chlorzoxazone119 CLEMASTINE clonidine hcl38 FUMARATE34 CHOLBAM90 clonidine hcl (adhd)1 clemastine fumarate34 cholecalciferol143 clopidogrel bisulfate94 CLEOCIN14,141 clorazepate dipotassium16 cholestyramine36 CLEOCIN PEDIATRIC cholestyramine light36 GRANULES14 clotrimazole110 choline fenofibrate36 CLEOCIN PHOSPHATE14 clotrimazole (topical)71 CIALIS58 CLEOCIN-T68 clotrimazole w/ betamethasone71 ciclopirox71 CLEVER CHOICE COMFORT clovique108 ciclopirox olamine71 EZINSULIN SYRINGE/U- 100/1ML/31GX5/16" 102 clozapine51 cidofovir54 CLIMARA89 CLOZARIL51 cilostazol94 CLIMARA PRO88 COARTEM41 CILOXAN122 CLINDACIN ETZ68 codeine sulfate8 cimetidine137 clindacin etz pledgets67 CODITUSSIN AC66 cimetidine 200136 CLINDACIN PAC68 COGENTIN48 cimetidine hcl137 CLINDAGEL68 COLAZAL91 CIMZIA91 clindamycin hcl14 colchicine93 CIMZIA STARTER KIT91 clindamycin palmitate colchicine w/ probenecid93 cinacalcet hcl87 hydrochloride14 colesevelam hcl36 CIPRO90 clindamycin phosphate14 COLESTID36 CIPRO HC126 clindamycin phosphate (topical)68 COLESTID FLAVORED36 CIPRODEX126 clindamycin phosphate in colestipol hcl36 ciprofloxacin90 d5w14 colocort12 ciprofloxacin hcl90 clindamycin phosphate COLY-MYCIN S126 ciprofloxacin hcl (ophth)122 vaginal141 clindamycin phosphate-benzoyl COLYTE-FLAVOR PACKS97 ciprofloxacin hcl (otic)126 peroxide69 COMBIGAN121 ciprofloxacin-dexamethasone clindamycin phosphate-benzoyl 126 peroxide (refrigerate)69 COMBIPATCH89 ciprofloxacin-fluocinolone clindamycin phosphate- COMBIVENT RESPIMAT19 acetonide126 tretinoin69 COMBIVIR52 citalopram hydrobromide25 CLINDESSE141 COMETRIQ46 CITRANATAL 90 DHA113 clobazam21
Updated 07/01/2021 Index 5 COMFORT ASSIST INSULIN cromolyn sodium (ophth)125 cytra-392 SYRINGE/1ML/31G X crotan82 cytra-k92 5/16"102 COMFORT EZ INSULIN CRYODOSE TA80 d 400143 SYRINGE/U-100/1ML/31G X cryselle-2862 D-VI-SOL143 5/16"102 CUBICIN14 D.H.E. 45105 COMPLERA52 CUBICIN RF14 d3-50143 COMPLETENATE113 CUPRIMINE108 DACOGEN42 compoz96 CUTIVATE76 DAKLINZA55 compro51 CUVITRU127 dalfampridine130 COMTAN49 CUVPOSA136 DALIRESP18 CONCEPT DHA114 cvs allergy relief childrens35 danazol11 CONCEPT OB114 cvs budesonide nasal DANTRIUM119 CONCERTA2 spray120 dantrolene sodium119 CONDYLOX80 cvs clotrimazole maximumstrength71 dapsone14 98 constulose cvs d3143 dapsone (topical)69 CONZIP8 cvs esomeprazole daptomycin14 COPAXONE130 magnesium138 DARAPRIM41 COPIKTRA46 cvs folic acid94 darifenacin hydrobromide140 CORDRAN75 cvs lansoprazole138 DAURISMO44 COREG56 cvs motion sickness ii31 DAYPRO4 COREG CR56 cvs nicotine132 DAYTRANA2 coremino134 cvs nicotine lozenge131 DDAVP88 cvs nicotine CORGARD56 DEBACTEROL110 CORLANOR59 transdermalsystem132 cyclobenzaprine hcl119 decadron64 CORTANE-B76 CYCLOGYL122 decitabine42 CORTEF64 CYCLOMYDRIL122 deferasirox30 CORTENEMA12 cyclopentolate hcl122 deferiprone30 cortic-nd126 cyclophosphamide42 DELESTROGEN89 CORTIFOAM12 CYCLOPHOSPHAMIDE42 DELSTRIGO52 cortisone acetate65 cycloserine41 DEMADEX84 CORTISPORIN-TC126 CYCLOSET28 demeclocycline hcl134 COSENTYX73 DEMSER38 COSENTYX SENSOREADY cyclosporine109 PEN73 cyclosporine modified (for DENAVIR74 COSOPT121 microemulsion)109 DEPAKENE24 CYKLOKAPRON96 COSOPT PF121 DEPAKOTE25 CYMBALTA26 COTELLIC46 DEPAKOTE ER25 cyproheptadine hcl35 COUMADIN20 DEPAKOTE SPRINKLES25 CYSTADANE87 covaryx88 DEPEN TITRATABS108 CYSTADROPS125 COZAAR38 DEPLIN 1583 CYSTAGON92 CREON83 DEPLIN 7.583 CYSTARAN125 CRESEMBA33 DEPO-ESTRADIOL89 cytarabine42 CRINONE142 DEPO-PROVERA44 CYTOMEL135 CRIXIVAN52 DEPO-PROVERA CYTOTEC139 CONTRACEPTIVE64 cromolyn sodium17 cytra k crystals92 DEPO-SUBQ PROVERA cromolyn sodium 10464 (mastocytosis)90 cytra-292 DEPO-TESTOSTERONE12
Index 6 Updated 07/01/2021 DERMA-SMOOTHE/FS diazepam16 disulfiram129 BODY76 diazepam (anticonvulsant)21 DITROPAN XL140 DERMA-SMOOTHE/FS SCALP76 diazepam intensol16 DIURIL84 DERMASORB TA76 diazoxide28 divalproex sodium25 dermazene71 DIBENZYLINE38 DIVIGEL89 DERMOTIC126 DICLEGIS32 DOCTOR MANZANILLA PE DICLOFENAC4 SYRUP DESCOVY52 ANTIHISTAMINE/DECONGESTA desipramine hcl27 diclofenac epolamine70 NT 66 desloratadine35 diclofenac potassium4 dofetilide17 desmopressin acetate88 diclofenac sodium4 DOLOPHINE8 desmopressin acetate spray88 diclofenac sodium (actinic DOMETUSS-DMX66 keratoses)72 desmopressin acetate spray donepezil hydrochloride129 refrigerated88 diclofenac sodium (ophth)125 desogestrel & ethinyl diclofenac sodium DOPTELET95 estradiol62 (topical)70,71 DORAL97 desogestrel-ethinyl estradiol diclofenac w/ misoprostol4 doripenem14 (biphasic)62 dicloxacillin sodium128 dorzolamide hcl125 DESONATE76 dicyclomine hcl136 DORZOLAMIDE HCL125 desonide76 didanosine52 dorzolamide hcl-timolol DESOWEN76 DIFFERIN69 maleate121 114 desoximetasone76 DIFICID99 DOTHELLE DHA 89 DESOXYN1 diflorasone diacetate76 dotti 52 desrx74 DIFLUCAN33 DOVATO 73 desvenlafaxine26 diflunisal8 DOVONEX 38 DESVENLAFAXINE ER26 digitek58 doxazosin mesylate 27 desvenlafaxine succinate26 digoxin58 doxepin hcl DETROL140 dihydroergotamine doxepin hcl (sleep)96 DETROL LA140 mesylate105 doxercalciferol87 dexamethasone65 DILANTIN24 doxycycline (monohydrate)134 DEXAMETHASONE DILANTIN INFATABS24 doxycycline (rosacea)82 INTENSOL65 DILANTIN-12524 doxycycline hyclate134 dexamethasone sodium phosphate65 DILATRATE SR15 doxylamine-pyridoxine32 DEXAMETHASONE SODIUM DILAUDID8 DRISDOL143 PHOSPHATE65 dilt-xr57 dronabinol32 dexamethasone sodium diltiazem hcl57 DROPLET INSULIN SYRINGE phosphate (ophth)124 diltiazem hcl coated beads57 U-100/1ML/31G X 5/16"102 dexchlorpheniramine DROPLET INSULIN maleate33 diltiazem hcl extended release 57 SYRINGE/U-100/1ML/31G X DEXEDRINE1 beads 5/16"102 DEXILANT138 dimethyl fumarate130 drospirenone-ethinyl dexmethylphenidate hcl2 DIOVAN38 estradiol62 drospirenone-ethinyl estradiol- dexpak 10 day64 DIOVAN HCT39 DIPENTUM91 levomefolate calcium62 dextroamphetamine sulfate1 DROXIA94 diphenhydramine hcl34 di-phen34 droxidopa142 diphenoxylate w/ atropine30 DIACOMIT22 DRYSOL81 DIPROLENE76 DIAPHRAGMS99 DUAC69 DIPROLENE AF76 DIASTAT ACUDIAL21 DUAVEE89 dipyridamole94 DIASTAT PEDIATRIC21 DUET DHA 400114 disopyramide phosphate16
Updated 07/01/2021 Index 7 DUET DHA BALANCED114 EFFIENT94 entecavir55 DUETACT27 EFUDEX72 ENTEREG91 DUEXIS4 ELAPRASE87 ENTOCORT EC65 duloxetine hcl26 ELELYSO94 ENTRESTO58 DUOPA49 ELESTAT125 ENTTY SPRAY81 DUPIXENT78 ELESTRIN89 enulose91 DURAGESIC8 eletriptan hydrobromide105 ENVARSUS XR109 duramorph8 ELFOLATE83 EPANED37 duraxin6 ELIDEL79 EPCLUSA55 DUREX EXTRA SENSITIVE99 ELIGARD44 EPICERAM81 DUREZOL124 ELIMITE82 EPIDIOLEX22 dutasteride93 ELIQUIS20 EPIFOAM76 dutasteride-tamsulosin hcl93 ELIQUIS STARTER PACK20 epinastine hcl (ophth)125 DUTOPROL39 ELITE-THIN INSULIN EPINEPHRINE142 DYAZIDE84 SYRINGE/U-100/1ML/31G X epinephrine142 5/16"103 DYMISTA120 ELIXOPHYLLIN20 epinephrine (anaphylaxis)142 DYRENIUM84 ELLA64 EPINEPHRINE HCL142 e.e.s. 40099 ELMIRON93 EPIPEN 2-PAK142 E.E.S. GRANULES99 ELOCON76 EPIPEN-JR 2-PAK142 EASY COMFORT INSULIN eluryng63 epitol21 SYRINGE/1ML/31G X EPIVIR52 5/16"102 EMBEDA8 EASY TOUCH FLIPLOCK EMCYT44 EPIVIR HBV55 SAFETY INSULIN SYRINGE EMEND32 eplerenone40 1ML/31GX5/16"102 EPOGEN95 EASY TOUCH INSULIN EMEND TRIPACK32 SYRINGE/U-100/1ML/31G X EMGALITY105 eprosartan mesylate38 5/16"102 EMSAM25 EPZICOM53 EASY TOUCH SHEATHLOCK emtricitabine52 eq allergy relief35,120 SAFETY INSULIN SYRINGE EQL INSULIN 1ML/31GX5/16"102 emtricitabine-tenofovir disoproxil fumarate52 SYRINGE/1ML/31G X EC-NAPROSYN4 5/16"103 EMTRIVA52 ec-naproxen4 EQUETRO50 EMULSION SB81 econazole nitrate71 ERAXIS32 EMVERM13 ECOTRIN8 ERBITUX44 ENABLEX140 ECOTRIN REGULAR ergocalciferol143 enalapril maleate37 STRENGTH8 ergoloid mesylates131 enalapril maleate & ed-spaz135 ERGOMAR105 EDARBI38 hydrochlorothiazide39 ENBRACE HR114 ergotamine w/ caffeine105 EDARBYCLOR39 ENBREL6 ERIVEDGE44 EDECRIN84 ENBREL MINI6 ERLEADA44 EDLUAR97 ENBREL SURECLICK6 erlotinib hcl44 EDURANT52 ENCARE141 ERTACZO71 efavirenz52 ertapenem sodium14 efavirenz-emtricitabine-tenofovir ENDARI94 disoproxil fumarate52 endocet10 ery67 effer-k107 ENDOMETRIN142 ery-tab99 EFFER-K108 enoxaparin sodium20 ERYGEL69 EFFEXOR XR26 enpresse-2861 ERYPED 20099 entacapone49 ERYPED 40099
Index 8 Updated 07/01/2021 erythrocin stearate99 EVOCLIN69 fenofibrate micronized36 erythromycin (acne aid)69 EVOTAZ53 FENOFIBRIC ACID36 erythromycin (ophth)123 EVOXAC111 FENOPROFEN CALCIUM5 erythromycin base99 EVZIO31 fenoprofen calcium5 erythromycin ethylsuccinate99 EXELDERM71 FENORTHO5 ESBRIET134 EXELON129 FENSOLVI86 escitalopram oxalate25 exemestane44 fentanyl8 esgic6 EXFORGE39 fentanyl citrate8 ESGIC6 EXFORGE HCT39 FENTORA8 esomeprazole magnesium138 EXJADE30 FER-IN-SOL96 ESOMEPRAZOLE EXODERM71 ferosul96 STRONTIUM139 EXTAVIA130 FERRIPROX30,31 estarylla62 EXTINA71 FERRIPROX TWICE-A-DAY31 estazolam97 eye allergy itch relief125 ferrous sulfate96 esterified estrogens & methyltestosterone89 eye allergy FETZIMA26 itch/rednessrelief125 ESTRACE89 FETZIMA TITRATION PACK26 ezetimibe37 estradiol89 fexmid119 ezetimibe-simvastatin36 estradiol & norethindrone FIBRICOR36 acetate89 FABIOR69 FIFTY50 SUPERIOR estradiol vaginal142 FABRAZYME87 COMFORTINSULIN estradiol valerate89 FALESSA62 SYRINGE/1ML/31G X ESTRING142 famciclovir55 5/16"103 FINACEA82 ESTROGEL89 famotidine137 finasteride93 ESTROSTEP FE62 FANAPT50 FIORICET6 eszopiclone97 FANAPT TITRATION PACK50 FIORICET/CODEINE10 ethacrynic acid84 FANTASY LUBRICATED99 FIORINAL6 ethambutol hcl41 FANTASY FIORINAL/CODEINE #310 ethosuximide24 LUBRICATED/SPERMICIDE FIRAZYR93 ethyl chloride80 99 ETHYL CHLORIDE/FINE FARESTON44 FIRDAPSE41 STREAM80 FARXIGA30 FIRMAGON44 ETHYL CHLORIDE/MEDIUM FARYDAK46 FIRST-LANSOPRAZOLE139 STREAM80 FIRST-MOUTHWASH BLM110 ethynodiol diacet & eth FASENRA PEN17 estrad62 FAZACLO51 FIRST-OMEPRAZOLE139 etidronate disodium85 FC FEMALE CONDOM99 FIRVANQ14 etodolac4 FC2 FEMALE CONDOM99 flac126 etonogestrel-ethinyl estradiol63 febuxostat93 FLAGYL13 ETOPOPHOS48 felbamate24 FLAREX124 etoposide48 FELBATOL24 flavoxate hcl140 EUCRISA81 FELDENE4 FLEBOGAMMA DIF127 EURAX82 felodipine57 flecainide acetate17 euthyrox135 FEM PH141 FLECTOR71 EVAMIST89 FEMARA44 FLOMAX93 everolimus46 FLONASE ALLERGY FEMCAP99 RELIEF120 everolimus FEMRING142 FLONASE ALLERGY RELIEF (immunosuppressant)109 fenofibrate36 CHILDRENS120 EVISTA86 FENOFIBRATE36 FLONASE SENSIMIST121
Updated 07/01/2021 Index 9 FLORIVA PLUS112 folbic83 FUZEON53 FLOVENT DISKUS18 FOLBIC RF83 fyavolv88 FLOVENT HFA18 FOLET DHA114 FYCOMPA21 FLOXIN OTIC126 FOLET ONE114 g tussin ac66 floxuridine42 folic acid94 gabapentin22 FLUCELVAX QUADRIVALENT FOLIVANE-F95 GABITRIL24 2018-2019141 FOLIVANE-OB114 GABLOFEN119 FLUCELVAX QUADRIVALENT 2019-2020141 FOLTX83 GALAFOLD87 FLUCELVAX QUADRIVALENT fondaparinux sodium20 galantamine hydrobromide129 2020-2021141 FORFIVO XL25 GALZIN108 fluconazole33 formaldehyde52 GAMASTAN127 flucytosine32 FORTAZ60 GAMMAGARD LIQUID127 fludarabine phosphate43 FORTESTA12 GAMMAKED127 fludrocortisone acetate65 FOSAMAX85 GAMMAPLEX127 FLUMADINE55 FOSAMAX PLUS D85 GAMUNEX-C127 flunisolide (nasal)121 fosamprenavir calcium53 GARDASIL 9141 fluocinolone acetonide76 foscarnet sodium54 GASTROCROM90 fluocinolone acetonide (otic)126 FOSCAVIR54 gatifloxacin (ophth)123 fluocinonide76 fosfomycin tromethamine15 GATTEX92 fluocinonide emulsified base76 fosinopril sodium37 gavilyte-c97 FLUORABON107 fosinopril sodium & gavilyte-h97 hydrochlorothiazide39 gavilyte-n/flavor pack97 fluoritab107 fosphenytoin sodium24 GEBAUERS INSTANT ICE80 fluorometholone (ophth)124 FOSRENOL92 GEBAUERS PAIN EASE80 FLUOROPLEX72 FOTIVDA46 fluorouracil43 GEBAUERS SPRAY AND FRAGMIN20 STRETCH81 fluorouracil (topical)72 FREESTYLE FREEDOM GELCLAIR111 fluoxetine hcl26 LITE101 GELFILM OP124 FREESTYLE INSULINX fluoxetine hcl (pmdd)131 GELNIQUE140 FLUOXETINE BLOODGLUCOSE HYDROCHLORIDE26 MONITORING SYSTEM101 GELNIQUE PUMP140 FREESTYLE INSULINX GEMCITABINE43 fluphenazine hcl51 BLOODGLUCOSE TEST83 flurandrenolide76 FREESTYLE INSULINX gemcitabine hcl43 flurazepam hcl97 BLOODGLUCOSE TEST GEMCITABINE HYDROCHLORIDE43 flurbiprofen5 STRIPS83 FREESTYLE LITE BLOOD gemfibrozil36 flurbiprofen sodium125 GLUCOSE MONITORING gemmily61 flutamide44 SYSTEM101 GENERESS FE62 FREESTYLE LITE TEST fluticasone propionate76 gengraf108 fluticasone propionate STRIPS83 (nasal)121 FREESTYLE PRECISION GENOTROPIN86 fluticasone-salmeterol19 INSULIN SYRINGE/U- GENOTROPIN MINIQUICK86 100/1ML/31G X 5/16"103 fluvastatin sodium37 FREESTYLE TEST gentak122 fluvoxamine maleate26 STRIPS83 gentamicin in saline3 FML124 FROVA105 gentamicin sulfate3 FML FORTE124 frovatriptan succinate105 gentamicin sulfate (ophth)123 FML LIQUIFILM124 FURADANTIN15 gentamicin sulfate (topical)71 FOCALIN2 furosemide84 GENVOYA53 FOCALIN XR2 FUSION PLUS95 GEODON50
Index 10 Updated 07/01/2021 geri-hydrolac 1279 GNP INSULIN homatropine hbr122 gianvi60 SYRINGE/1ML/31G X HORIZANT131 5/16"103 GILENYA130 GOCOVRI49 HUMALOG29 HUMALOG JUNIOR GILOTRIF44 GOLYTELY97,98 GILPHEX TR66 KWIKPEN28 GONITRO15 HUMALOG KWIKPEN28,29 GILTUSS COUGH & COLD66 gordons urea78 GILTUSS SINUS & HUMALOG MIX 50/5029 CONGESTION66 GRALISE131 HUMALOG MIX 50/50 GILTUSS TR66 granisetron hcl31 KWIKPEN29 HUMALOG MIX 75/2529 GLASSIA133 GRANIX95 GRASTEK2 HUMALOG MIX 75/25 glatiramer acetate130 KWIKPEN29 glatopa130 griseofulvin microsize32 HUMATROPE86 GLEEVEC46 griseofulvin ultramicrosize32 HUMATROPE COMBO GLEOSTINE42 guaifenesin dac66 PACK86 glimepiride30 guaifenesin-codeine66 HUMIRA3 guanfacine hcl38 HUMIRA PEDIATRIC CROHNS glipizide30 DISEASE STARTER PACK3 guanfacine hcl (adhd)1 glipizide xl30 HUMIRA PEN3 glipizide-metformin hcl27 GUANIDINE HCL41 HUMIRA PEN-CD/UC/HS GLOBAL INJECT EASE INSULIN GVOKE PFS28 STARTER3 SYRINGE/U-100/1ML/31G X GYNAZOLE-1141 HUMIRA PEN-PEDIATRIC UC 5/16"103 HAEGARDA94 STARTER PACK3 GLUCAGEN DIAGNOSTIC82 HUMIRA PEN-PS/UV halcinonide76 GLUCAGEN HYPOKIT28 STARTER3 HALCION97 HUMULIN 70/3029 glucagon (rdna)28 halobetasol propionate76 GLUCAGON EMERGENCY HUMULIN 70/30 KWIKPEN29 KIT28 HALOG76 HUMULIN N29 GLUCAGON EMERGENCY KIT haloperidol51 HUMULIN N KWIKPEN29 FOR LOW BLOOD SUGAR28 haloperidol lactate51 HUMULIN R29 GLUCOPRO INSULIN HEALTHWISE INSULIN SYRINGE/U-100/1ML/31G X HUMULIN R U-500 SYRINGE/U-100/1ML/31G X (CONCENTRATED)29 5/16"103 5/16"103 HUMULIN R U-500 GLUCOTROL30 HECTOROL87 KWIKPEN29 GLUCOTROL XL30 HELIDAC THERAPY139 HYCAMTIN48 GLUMETZA28 HEMANGEOL56 HYCODAN65 glyburide30 heparin (porcine) in sodium hydralazine hcl40 glyburide micronized30 chloride20 HYDREA48 glyburide-metformin27 heparin sod (porcine) in HYDRO 3579 d5w21 GLYCATE136 heparin sodium (porcine)21 HYDRO 40 FOAM79 glycopyrrolate136 HEPARIN SODIUM/NACL hydrochlorothiazide84 GLYCOPYRROLATE136 0.45%21 hydrocodone polistirex- glydo80 HEPARIN SODIUM/SODIUM chlorpheniramine polistirex66 hydrocodone w/ GLYNASE30 CHLORIDE21 HEPARIN SODIUM/SODIUM homatropine66 GLYSET27 CHLORIDE 0.9%21 hydrocodone- GLYXAMBI27 HETLIOZ97 acetaminophen10 GNP ACID CONTROL 150 HETLIOZ LQ97 hydrocodone-ibuprofen10 MAXIMUM STRENGTH137 HIPREX15 hydrocortisone65 gnp hydrocortisone maximum hydrocortisone (intrarectal)12 strength74 HISTEX-PE66 HIZENTRA127 hydrocortisone (rectal)12 homatropaire122 hydrocortisone (topical)77
Updated 07/01/2021 Index 11 hydrocortisone acetate IMPEKLO77 ipratropium-albuterol19 (rectal)13 IMURAN109 irbesartan38 hydrocortisone acetate w/ pramoxine12 inatal gt113 irbesartan-hydrochlorothiazide 39 hydrocortisone butyrate77 INCRELEX86 IRESSA44 hydrocortisone butyrate INCRUSE ELLIPTA17 ISENTRESS53 hydrophilic lipo base77 indapamide84 ISENTRESS HD53 hydrocortisone valerate77 INDERAL LA56 hydrocortisone w/acetic ISOLYTE-S107 INDERAL XL56 acid126 isoniazid41,42 INDOCIN5 hydromet65 ISOPTO ATROPINE122 indomethacin5 hydromorphone hcl8,9 ISOPTO CARPINE122 hydroxyprogesterone INFLECTRA91 ISORDIL TITRADOSE15 caproate129 INGREZZA130 isosorbide dinitrate15 hydroxyurea48 INHALER SPACERS104 isosorbide mononitrate15 hydroxyzine hcl16 INLYTA43 isotretinoin69 hydroxyzine pamoate16 INNOPRAN XL56 isoxsuprine hcl58 HYLINATE79 INREBIC46 isradipine57 hyoscyamine sulfate136 INSPRA40 HYPER-SAL67 INSULIN LISPRO ISTALOL121 HYPERSAL67 PROTAMINE/INSULIN LISPRO ISTODAX (OVERFILL)46 HYQVIA127 KWIKPEN29 itraconazole33 INSULIN SYRINGE/NEEDLE ivermectin13 HYZAAR39 1ML/31G X 5/16"103 ibandronate sodium85 INSULIN SYRINGE/U- ivermectin (pediculicide)82 IBRANCE46 100/1ML/31G X 5/16"103 ivermectin (rosacea)82 INSULIN SYRINGES AND PEN JADENU31 ibu4 NEEDLES103 ibudone10 INSULIN JADENU SPRINKLE31 ibuprofen5 SYRINGES/1ML/31GX5/16" JAKAFI46 ICAR PEDIATRIC96 103 JALYN93 95 icatibant acetate93 INTEGRA F jantoven20 53 ICLUSIG46 INTELENCE JANUMET27 97 icosapent ethyl36 INTERMEZZO JANUMET XR27 141 IDHIFA46 INTRAROSA JANUVIA28 48 ILEVRO125 INTRON A JARDIANCE30 1 ILIDERM81 INTUNIV JULUCA53 14 ILUMYA73 INVANZ JUXTAPID37 50 imatinib mesylate46 INVEGA JYNARQUE88 50 IMBRUVICA46 INVEGA SUSTENNA K-PHOS107 50 imipenem-cilastatin14 INVEGA TRINZA K-PHOS NEUTRAL107 53 imipramine hcl27 INVIRASE K-PHOS NO 292 71 imipramine pamoate27 iodoquimez-hc k-prime107 71 imiquimod79 iodoquinol-hc K-TAB108 iodoquinol-hydrocortisone in IMITREX105 K-Y ME & YOU EXTRA aloe vehicle71 LUBRICATED99 IMITREX STATDOSE iodoquinol-hydrocortisone-aloe K-Y ME & YOU INTENSE99 REFILL105 polysaccharide71 IMITREX STATDOSE IOPIDINE122 KADIAN9 SYSTEM105 17 KALETRA53 IMODIUM A-D30 ipratropium bromide ipratropium bromide KALYDECO133 IMPAVIDO13 (nasal)120 KAMDOY81
Index 12 Updated 07/01/2021 KAMELEON LUBRICATED99 KISQALI FEMARA 200 LAMICTAL STARTER/TAKING KAPVAY1 DOSE45 CARBAMAZEPINE/NOT TAKING KISQALI FEMARA 400 VALPROATE22 KEFLEX59 DOSE45 LAMICTAL STARTER/TAKING kelnor 1/3560 KISQALI FEMARA 600 VALPROATE22 kelnor 1/5060 DOSE45 LAMICTAL XR22 KENALOG77 KITABIS PAK3 lamivudine53 KEPIVANCE48 KIVIK81 lamivudine (hbv)55 KEPPRA22 KLARITY-A123 lamivudine-zidovudine53 KEPPRA XR22 KLARON69 lamotrigine23 KERALAC79 KLONOPIN21 LANCETS101 keralyt79 klor-con108 LANOXIN58 ketoconazole33 klor-con 10107 lansoprazole139 ketoconazole (topical)71 klor-con m10107 lanthanum carbonate92 ketodan71 klor-con sprinkle108 LANTUS29 ketoprofen5 KORLYM28 LANTUS SOLOSTAR29 KETOROLAC KOSELUGO46 lapatinib ditosylate46 TROMETHAMINE5 KOSHER PRENATAL PLUS LASIX84 IRON114 ketorolac tromethamine5 LASTACAFT125 ketorolac tromethamine kp folic acid94 (ophth)125 KRINTAFEL41 latanoprost126 KEVEYIS84 KRISTALOSE98 LATUDA50 KEVZARA4 KROGER INSULIN layolis fe61 KHEDEZLA26 SYRINGE/1ML/31G X LAZANDA9 5/16"103 KIMONO COLORS99 LEADER INSULIN KUVAN87 SYRINGE/1ML/31G X KIMONO LUBRICATED99 KYLEENA64 5/16"103 KIMONO MICRO THIN100 l-methylfolate83 leflunomide6 KIMONO MICRO THIN PLUS LENVIMA 10 MG DAILY SPERMICIDE L-METHYLFOLATE CA/S- ALGAL83 DOSE43 LUBRICATED100 LENVIMA 12MG DAILY KIMONO PLUS SPERMICIDE L-METHYLFOLATE FORTE83 DOSE43 LUBRICATED100 LENVIMA 14 MG DAILY KIMONO PLUS labetalol hcl56 DOSE43 SPERMICIDE/LUBRICATED LAC-HYDRIN79 LENVIMA 18 MG DAILY 100 LAC-HYDRIN TWELVE79 DOSE43 KIMONO PS LUBRICATED100 LACRISERT121 LENVIMA 20 MG DAILY KIMONO PS PLUS DOSE43 lactated ringer's LENVIMA 24 MG DAILY SPERMICIDE/LUBRICATED (irrigation)110 100 DOSE43 KIMONO SENSATION LACTIC ACID79 LENVIMA 4 MG DAILY LUBRICATED100 lactic acid (ammonium DOSE43 KIMONO SENSATION PLUS lactate)79 LENVIMA 8 MG DAILY SPERMICIDE LACTULOSE98 DOSE43 LUBRICATED100 lactulose98 LESCOL XL37 KIMONO SPECIAL100 lactulose (encephalopathy)91 LETAIRIS58 KINERET4 LAMICTAL22 letrozole44 KINRAY INSULIN SYRINGE LAMICTAL CHEWABLE leucovorin calcium48 PREFERRED PLUS/1ML/31G X DISPERSIBLE22 LEUKERAN42 5/16"103 LAMICTAL ODT22 LEUKINE95 kionex110 LAMICTAL STARTER/NOT KISQALI46 TAKING leuprolide acetate44 CARBAMAZEPINE22
Updated 07/01/2021 Index 13 LEUPROLIDE LINZESS91 lovastatin37 ACETATE/BUPIVACAINE LIORESAL LOVAZA36 HYDROCHLORIDE44 INTRATHECAL119 LOVENOX21 levalbuterol hcl19 liothyronine sodium135 loxapine succinate51 levalbuterol tartrate19 LIPOFEN36 lubiprostone90 LEVAQUIN90 lisinopril37 LUCEMYRA129 LEVBID136 lisinopril & LEVEMIR29 hydrochlorothiazide39 luliconazole72 LEVEMIR FLEXTOUCH29 LITETOUCH INSULIN LUMAKRAS46 SYRINGE/U-100/1ML/31G X LUMIGAN126 levetiracetam23 5/16"103 LUMIZYME87 levobunolol hcl121 LITHIUM50 LUNESTA97 levocarnitine (metabolic lithium carbonate50 modifiers)87 LUPRON DEPOT (1- LITHOBID50 levofloxacin90 MONTH)44 LITHOSTAT93 LUPRON DEPOT (3- levofloxacin (ophth)123 LIVALO37 MONTH)45 LEVOMEFOLATE CALCIUM LUPRON DEPOT (4- ALGAL POWDER83 LO LOESTRIN FE62 MONTH)45 levonorgestrel & eth LOCOID77 LUPRON DEPOT (6- estradiol62 LOCOID LIPOCREAM77 MONTH)45 levonorgestrel (emergency LODINE5 LUPRON DEPOT-PED (1- oc)64 MONTH)86 levonorgestrel-eth estradiol LODOSYN48 LUPRON DEPOT-PED (3- (triphasic)62 LOKELMA110 MONTH)86 levonorgestrel-ethinyl estradiol LUXIQ77 (91-day)62 LOMOTIL30 levonorgestrel-ethinyl estradiol LONSURF46 LUZU72 (continuous)62 loperamide hcl30 LYNPARZA46 levothyroxine sodium135 LOPID36 LYRICA23 LEVSIN136 lopinavir-ritonavir53 LYSODREN45 LEVSIN/SL136 LOPRESSOR56 LYSTEDA96 LEXAPRO26 LOPRESSOR HCT39 M-NATAL PLUS114 LEXIVA53 LOPROX72 MACROBID15 LIBRAX136 LOPROX SHAMPOO72 MACRODANTIN15 lido-k80 lorazepam16 mafenide acetate74 lidocaine81 lorazepam intensol16 MAGNEBIND 400107 lidocaine hcl81 LORBRENA46 magnesium sulfate107 lidocaine hcl (mouth-throat)110 lorcet10 MAGNESIUM SULFATE107 lidocaine-hydrocortisone acetate LORTAB10 MAKENA129 (rectal)12 MALARONE41 lidocaine-prilocaine81 lorzone119 malathion82 LIDODERM81 losartan potassium38 losartan potassium & maprotiline hcl25 LIDODOSE81 hydrochlorothiazide39 MARINOL32 LIDODOSE PEDIATRIC BULK LOSEASONIQUE62 PACK81 MARNATAL-F114 lidopin80 LOTEMAX124 MARPLAN25 LIDORX81 LOTENSIN37 MATULANE48 LILETTA64 LOTENSIN HCT39 matzim la57 LINCOCIN14 loteprednol etabonate124 MAVENCLAD130 lincomycin hcl14 LOTREL39 MAVYRET55 lindane82 LOTRISONE72 MAXALT-MLT106 linezolid14,15 LOTRONEX91 MAXIDEX124
Index 14 Updated 07/01/2021 MAXIPIME60 metformin hcl28 metronidazole in nacl13 MAXITROL124 METFORMIN metronidazole vaginal142 MAXX LUBRICATED100 HYDROCHLORIDE28 metyrosine38 methadone hcl9 MAXX PLUS SPERMICIDE mexiletine hcl17 METHADONE HCL9 LUBRICATED100 mezparox-hc74 MAXZIDE84 methadone hcl9 MG217 PSORIASIS MULTI- MAXZIDE-2584 methadone hcl intensol8 SYMTOM80 MAYZENT STARTER methadose8 MIACALCIN85 PACK130 methamphetamine hcl1 micafungin sodium32 meclizine hcl31 methazolamide84 MICARDIS38 MECLIZINE HYDROCHLORIDE31 methenamine hippurate15 MICARDIS HCT40 meclofenamate sodium5 methenamine mandelate15 miconazole 3141 MEDROL65 methergine127 miconazole-zinc oxide-white petrolatum72 MEDROL DOSEPAK65 methimazole135 MICRODOT TEST STRIPS83 MEDROX-RX80 METHITEST12 midazolam hcl97 medroxyprogesterone methocarbamol119 midodrine hcl142 acetate129 METHOTREXATE4 medroxyprogesterone acetate migergot105 methotrexate sodium43 (contraceptive)64 miglitol27 methoxsalen rapid73 mefenamic acid5 miglustat94 mefloquine hcl41 methscopolamine bromide136 MIGRANAL105 MEGACE ES129 methyldopa38 MILLIPRED65 megestrol acetate45 methyldopa & MILLIPRED DP65 megestrol acetate hydrochlorothiazide40 MINASTRIN 24 FE63 (appetite)129 methylergonovine MEKINIST46 maleate127 MINIPRESS38 MEKTOVI47 METHYLIN2 minitran15 meloxicam5 methylphenidate hcl2 MINIVELLE89 melphalan42 METHYLPHENIDATE MINOCIN134 HYDROCHLORIDE ER2 melphalan hcl42 minocycline hcl134 methylprednisolone65 memantine hcl129 minoxidil41 methyltestosterone12 MENEST89 MIRALAX98 metoclopramide hcl90 MENOSTAR89 MIRAPEX49 METOCLOPRAMIDE ODT90 meperidine hcl9 MIRAPEX ER49 metolazone84 MEPHYTON143 MIRCERA95 metopic78 meprobamate16 MIRCETTE63 METOPIRONE82 MIRENA64 MEPRON14 metoprolol & mercaptopurine43 hydrochlorothiazide40 mirtazapine25 meropenem14 metoprolol succinate56 MIRVASO82 MERREM14 METOPROLOL SUCCINATE misoprostol139 mesalamine91 ER/HYDROCHLOROTHIAZIDE MITIGARE93 40 mitoxantrone hcl45 mesalamine w/ cleanser91 metoprolol tartrate56 MESNEX48 MM INSULIN SYRINGE/U- METROCREAM82 100/1ML/31G X 5/16"103 MESTINON41 METROGEL-VAGINAL142 MOBIC5 MESTINON TIMESPAN41 METROLOTION82 modafinil2 metaproterenol sulfate19 metronidazole13 moexipril hcl38 metaxall119 metronidazole (topical)82 molindone hcl51 metaxalone119
Updated 07/01/2021 Index 15 mometasone furoate77 MYRBETRIQ140 NEBUSAL67 mometasone furoate MYSOLINE23 NEEVO DHA114 (nasal)121 MYTESI30 nefazodone hcl26 mondoxyne nl134 nabumetone5 neo-polycin122 MONOJECT INSULIN SYRINGE/1ML/31G X nadolol56 neo-polycin hc123 5/16"103 NAFCILLIN128 NEO-SYNALAR71 montelukast sodium17 nafcillin sodium128 neomycin sulfate3 MONUROL15 NAFCILLIN SODIUM128 neomycin-bacitracin zn- morgidox 1x100mg134 nafcillin sodium128 polymyxin123 neomycin-polymy- morphine sulfate9 nafrinse107 dexameth124 morphine sulfate beads9 naftifine hcl72 neomycin-polymyxin-gramicidin MOTOFEN30 NAFTIFINE 123 MOVANTIK91 HYDROCHLORIDE72 neomycin-polymyxin-hc NAFTIN72 (ophth)124 MOXEZA123 neomycin-polymyxin-hc moxifloxacin hcl90 NAGLAZYME87 (otic)126 moxifloxacin hcl (ophth)123 NALFON5 neomycin/polymyxin b gu93 MOZOBIL96 NALOCET10 NEONATAL 19114 MS CONTIN9 naloxone hcl31 NEONATAL COMPLETE114 MS INSULIN SYRINGE/1ML/31G naltrexone hcl31 NEONATAL FE114 X 5/16"103 NAMENDA129 NEONATAL PLUS114 MUCOTROL111 NAMENDA TITRATION NEONATAL/DHA115 PAK129 MULPLETA95 NEORAL109 MULTAQ17 NAMENDA XR130 NAMENDA XR TITRATION NEOTUSS PLUS66 multi-vit/iron/fluoride112 PACK130 NERLYNX47 multi-vitamin/fluoride drops111 NAPRELAN5 NESTABS115 MULTIVITAMIN WITH NAPROSYN5 FLUORIDE111 NESTABS DHA115 multivitamin with fluoride111 naproxen5 NESTABS ONE115 MULTIVITAMIN/FLUORIDE naproxen sodium5 neuac67 111 naproxen-esomeprazole NEULASTA95 magnesium5 multivitamin/fluoride112 NEULASTA ONPRO KIT95 naratriptan hcl106 multivitamins/fluoride112 NEUPOGEN95 NARCAN31 mupirocin71 NEUPRO49 NARDIL25 MYALEPT87 NEURONTIN23 NASONEX121 MYAMBUTOL42 NEUTROGENA CLEAR PORE MYCAMINE32 NATACHEW114 CLEANSER/MASK69 MYCOBUTIN42 NATACYN123 NEVANAC125 mycophenolate mofetil109 NATAZIA63 nevirapine53 mycophenolate mofetil hcl109 nateglinide29 NEXA PLUS115 mycophenolate sodium109 NATELLE ONE114 NEXAVAR47 MYDRIACYL122 NATPARA85 NEXIUM139 MYFORTIC109 NATROBA82 NEXIUM 24HR139 MYKIDZ IRON 1096 NATURE-THROID135 NEXIUM 24HR CLEAR NATURE-THROID NT- MINIS139 MYLERAN42 2.5135 NEXPLANON64 MYNATAL ADVANCE114 NAYZILAM21 NEXTSTELLIS63 MYNATAL ULTRACAPLET114 NEBUPENT13 niacin (antihyperlipidemic)37 MYNATE 90 PLUS114 nebusal67 NIASPAN37
Index 16 Updated 07/01/2021 nicardipine hcl57 norethindrone acetate129 OCTAGAM127 NICODERM CQ133 norethindrone acetate-ethinyl octreotide acetate88 NICORETTE133 estradiol89 OCUFLOX123 norgestimate-ethinyl NICORETTE MINI133 estradiol63 ODACTRA2 NICORETTE STARTER norgestimate-ethinyl estradiol ODOMZO44 KIT133 (triphasic)63 OFEV134 nicotine133 NORITATE82 ofloxacin90 nicotine polacrilex133 NORMOSOL-R107 ofloxacin (ophth)123 NICOTINE TRANSDERMAL NORPACE16 SYSTEM133 ofloxacin (otic)126 NORPACE CR17 NICOTROL INHALER133 olanzapine51 NORPRAMIN27 NICOTROL NS133 olanzapine-fluoxetine hcl130 NORTHERA142 nifedipine57 olmesartan medoxomil38 nortriptyline hcl27 NILANDRON45 olmesartan medoxomil- NORVASC57 amlodipine-hydrochlorothiazide nilutamide45 NORVIR53 40 nimodipine57 olmesartan medoxomil- NOXAFIL33 NINLARO47 hydrochlorothiazide 40 np thyroid 120135 nisoldipine57 olopatadine hcl125 NUBEQA45 nitazoxanide14 olopatadine hcl (nasal)120 NUCALA17 nitisinone87 OLUX77 NUCORT77 NITRO-BID15 OLUX-E77 NUCYNTA9 NITRO-DUR15 OMECLAMOX-PAK139 NUCYNTA ER9 nitro-time15 omega-3-acid ethyl esters36 NUEDEXTA131 nitrofurantoin15 omeppi139 NULOJIX109 nitrofurantoin macrocrystal15 omeprazole139 nitrofurantoin monohyd NULYTELY98 OMEPRAZOLE + SYRSPEND macro15 NULYTELY/FLAVOR SFALKA139 nitroglycerin16 PACKS98 omeprazole-sodium 140 NITROLINGUAL NUPLAZID50 bicarbonate PUMPSPRAY16 NUTROPIN AQ NUSPIN OMNARIS121 NITROMIST16 1086 OMNITROPE86 NUTROPIN AQ NUSPIN ondansetron31 NITROSTAT16 2086 NITYR87 NUTROPIN AQ NUSPIN 586 ondansetron hcl31 NIVA-PLUS115 ONE VITE WOMENS NUVARING63 PRENATALVITAMIN PLUS115 NIVESTYM95 NUVIGIL2 ONETOUCH ULTRA83 nizatidine137 NYMALIZE57 ONETOUCH ULTRA 2101 NIZORAL72 nystatin32 ONETOUCH ULTRA MINI101 NOCTIVA88 nystatin (mouth-throat)110 ONETOUCH VERIO101 nolix74 nystatin (topical)72 ONETOUCH VERIO FLEX NON PREFERRED TEST nystatin-triamcinolone72 BLOOD GLUCOSE STRIPS83 O-CAL FA115 MONITORING SYSTEM101 NORCO10 ONETOUCH VERIO IQ BLOOD OB COMPLETE ONE115 NORDITROPIN FLEXPRO86 GLUCOSE MONITORING OB COMPLETE PETITE115 norethin acet & estrad-fe63 SYSTEM101 OB COMPLETE ONETOUCH VERIO SYNC norethindrone & ethinyl estradiol- PREMIER115 BLOODGLUCOSE fe63 MONITORING SYSTEM101 norethindrone OB COMPLETE/DHA115 OBSTETRIX ONE115 ONETOUCH VERIO TEST (contraceptive)64 STRIPS83 norethindrone acet & eth OCALIVA90 estra63 ONEVITE111
Updated 07/01/2021 Index 17 ONFI21 oxacillin sodium128 paroxetine mesylate ONUREG43 oxandrolone11 (vasomotor)133 PASER42 OPANA9 oxaprozin5 PATADAY125 opium tincture30 OXAYDO9 PATANASE120 OPSUMIT58 oxazepam16 PAXIL26 OPTIONS CONCEPTROL oxcarbazepine23 PAXIL CR26 VAGINAL OXERVATE123 CONTRACEPTIVE141 pediatric vitamins acd w/ OPTIONS GYNOL II oxiconazole nitrate72 fluoride112 VAGINALCONTRACEPTIVE OXISTAT72 PEDVAX HIB140 141 OXSORALEN ULTRA73 peg 3350-kcl-nacl-na sulfate-na ORACEA82 OXTELLAR XR23 ascorbate-ascorbic acid98 ORACIT92 peg 3350-kcl-sod bicarb-sod oxybutynin chloride140 chloride-sod sulfate98 ORAFATE111 oxycodone hcl9 peg 3350-potassium chloride-sod ORALAIR3 oxycodone w/ bicarbonate-sod chloride98 ORALAIR ADULT SAMPLE acetaminophen10 peg-3350/electrolytes/ascorbate KIT3 oxycodone-aspirin10 97 ORALAIR ADULT STARTER oxycodone-ibuprofen10 PEGANONE24 PACK3 PEGASYS55 oralone dental paste110 OXYCODONE/ACETAMINOPH EN 10 PEGASYS PROCLICK55 ORAPRED ODT65 oxymorphone hcl9 PEGINTRON55 ORAVIG110 OXYTROL140 PEMAZYRE47 orazinc108 OXYTROL FOR WOMEN140 penicillamine108 ORENCIA6 OZEMPIC28 penicillin g potassium127 ORENCIA CLICKJECT6 pacerone17 PENICILLIN G POTASSIUM IN ORENITRAM58 paliperidone50 ISO-OSMOTIC ORFADIN87 palonosetron hcl31 DEXTROSE127 ORKAMBI133 PALONOSETRON PENICILLIN G PROCAINE128 orphenadrine citrate119 HYDROCHLORIDE31 penicillin g sodium128 orphenadrine w/ aspirin & PALYNZIQ87 penicillin v potassium128 caff119 PAMELOR27 PENLEN81 ORTHO MICRONOR64 pamidronate disodium85 PENNSAID71 ORTHO TRI-CYCLEN LO63 PAMIDRONATE pentamidine isethionate13 ORTHO-NOVUM 1/3563 DISODIUM85 PENTASA91 PANCREAZE83 ORTHO-NOVUM 7/7/763 pentazocine w/ naloxone11 PANDEL77 oscimin135 pentoxifylline94 PANRETIN72 oscimin sr135 PEPCID138 pantoprazole sodium139 oseltamivir phosphate55,56 PEPCID AC138 OSMOLEX ER49 PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE PEPCID AC MAXIMUM OSPHENA86 T380A64 STRENGTH138 OTEZLA6 paregoric30 PERCOCET10 OTICIN HC NR126 PAREMYD125 PERIDEX110 OTOVEL126 paricalcitol87 perindopril erbumine38 OTREXUP4 PARLODEL49 permethrin82 OVACE PLUS73 PARNATE25 perphenazine51 OVACE PLUS WASH73 paroex110 perphenazine-amitriptyline 130 OVACE WASH73 paromomycin sulfate3 PERSERIS50 OVIDE82 paroxetine hcl26 PERTZYE83 OXACILLIN SODIUM128 PEXEVA26
Index 18 Updated 07/01/2021 pfizerpen127 PLEGRIDY STARTER pramoxine-hc77 phenadoz35 PACK131 PRANDIN30 PLEXION69 phenazo93 prasugrel hcl94 PLEXION CLEANSER69 phenazopyridine hcl93 PRAVACHOL37 PLEXION CLEANSING phenelzine sulfate25 CLOTHS69 pravastatin sodium37 PHENERGAN35 PNV TABS 29-1115 praziquantel13 phenobarbital96 pnv-dha113 prazosin hcl38 phenoxybenzamine hcl38 PNV-DHA+DOCUSATE115 PRECISION XTRA101 phenylephrine hcl PNV-OMEGA115 PRECISION XTRA BLOOD (mydriatic)122 GLUCOSE TEST STRIPS83 pnv-select113 PHENYTEK24 PRECOSE27 PODOCON 25 IN BENZOIN phenytoin24 TINCTURE80 PRED MILD124 phenytoin infatabs24 podofilox80 PRED-G124 phenytoin sodium24 POLY-VI-FLOR112 PRED-G S.O.P.124 phenytoin sodium extended24 POLY-VI-FLOR/IRON112 prednicarbate77 PHEXXI142 polyethylene glycol 335098 prednisolone65 PHLAG SPRAY81 polymyxin b sulfate15 prednisolone acetate PHOSLYRA92 (ophth)124 polymyxin b-trimethoprim123 prednisolone sodium phospha 250 neutral107 POLYTRIM123 phosphate65 phosphasal13 POMALYST45 PREDNISOLONE SODIUM PHOSPHOLINE IODIDE122 posaconazole33 PHOSPHATE124 physiolyte110 pot & sod citrates w/citric prednisone65 phytonadione143 ac92 PREDNISONE INTENSOL65 pot phosphate monobasic w/ PICATO72 PREFEST89 sod phosphate dibasic & pregabalin23 PIFELTRO53 monobasic107 pilocarpine hcl122 POTABA143 PREMARIN90,142 PREMIUM CONDOMS pilocarpine hcl (oral)111 potassium chloride108 LUBRICATED100 pimecrolimus79 POTASSIUM CHLORIDE108 premium lidocaine80 pimozide131 potassium chloride108 PREMPHASE89 pindolol56 potassium chloride in PREMPRO89 pioglitazone hcl28 nacl107 potassium chloride PRENA 1 TRUE115 pioglitazone hcl-glimepiride27 microencapsulated crystals PRENA1 PEARL115 pioglitazone hcl-metformin er108 PRENAISSANCE116 hcl27 potassium chloride piperacillin sodium-tazobactam proamp108 PRENAISSANCE PLUS116 sodium128 potassium citrate prenatabs rx113 PIQRAY 200MG DAILY (alkalinizer)92 PRENATAL116 DOSE47 potassium citrate-citric acid92 PIQRAY 250MG DAILY prenatal 19113 DOSE47 POVIDONE IODINE123 PRENATAL 19116 PIQRAY 300MG DAILY PR NATAL 400 EC115 PRENATAL PLUS IRON116 DOSE47 PR NATAL 430115 PRENATAL VITAMINS PLUS piroxicam5 PR NATAL 430 EC115 LOW IRON116 PLAN B ONE-STEP64 PRALUENT37 PRENATAL-U116 PLAQUENIL41 pramipexole PRENATE116 PLASMA-LYTE A107 dihydrochloride49 PRENATE DHA116 PLASMA-LYTE-148107 PRAMOSONE77 PRENATE ELITE116 PLAVIX94 PRAMOTIC126 PRENATE ENHANCE116 PLEGRIDY130 PRAMOX GEL81 PRENATE ESSENTIAL116
Updated 07/01/2021 Index 19 PRENATE MINI116 PROLIA85 QUARTETTE63 PRENATE PIXIE116 PROMACTA95 quazepam97 PRENATE RESTORE116 promethazine & QUDEXY XR23 PRENATRIX116 phenylephrine66 QUESTRAN36 promethazine hcl35 PRENATRYL116 QUESTRAN LIGHT36 promethazine w/codeine66 PREPLUS116 quetiapine fumarate51 promethazine-dm66 PREVACID139 QUFLORA GUMMIES112 promethazine-phenylephrine- PREVACID SOLUTAB139 codeine 66 QUFLORA PEDIATRIC112 prevalite36 PROMETRIUM129 QUILLIVANT XR2 PREVYMIS54 propafenone hcl17 quinapril hcl38 PREZCOBIX53 propantheline bromide136 quinapril-hydrochlorothiazide 40 PREZISTA53 proparacaine hcl123 quinidine gluconate17 PRIFTIN42 propranolol & quinidine sulfate17 PRILOSEC139 hydrochlorothiazide40 quinine sulfate41 PRIMACARE116 propranolol hcl56 QUINJA72 primaquine phosphate41 propylthiouracil135 QVAR REDIHALER18 PRIMAQUINE PHOSPHATE41 PROSCAR93 ra allergy relief childrens35 PRIMAXIN IV14 PROTHELIAL111 rabeprazole sodium139 primidone23 PROTONIX139 PROTOPIC79 RABEPRAZOLE SODIUM DR PRIMLEV10 SPRINKLE139 protriptyline hcl27 PRIMSOL13 RADIOGARDASE31 PROVENTIL HFA19 PRINIVIL38 RAGWITEK3 PROVERA129 PRIVIGEN127 raloxifene hcl86 PROVIDA DHA116 PRO COMFORT INSULIN ramelteon97 SYRINGES/1ML/31G X PROVIGIL2 ramipril38 5/16"103 PROZAC26 RANEXA15 PROAIR HFA19 PRUDOXIN72 ranitidine hcl138 PROAIR RESPICLICK19 pseudoephed-cpm w/ probenecid93 hydrocod66 ranolazine15 procainamide hcl17 PSORCON78 RAPAFLO93 PROCARDIA57 PULMICORT18 RAPAMUNE109 PROCARDIA XL57 PULMICORT FLEXHALER18 rasagiline mesylate50 procentra1 pulmosal67 RASUVO4 prochlorperazine51 PULMOZYME134 RAVICTI87 prochlorperazine maleate51 PURIXAN43 RAYALDEE87 PROCORT12 PYLERA140 RAYOS65 PROCRIT95 pyrazinamide42 RAZADYNE130 procto-med hc12 PYRIDIUM93 RAZADYNE ER130 PROCTOCORT13 pyridostigmine bromide41 REALITY LATEX CONDOMS/LUBRICATED100 PROCTOFOAM HC12 pyrimethamine41 REALITY LATEX/ULTRA PROCYSBI92 QBRELIS38 TEXTURED100 progesterone129 qc allergy relief childrens35 REALITY LATEX/ULTRA THIN100 PROGLYCEM28 QDOLO9 REBETOL55 PROGRAF109 QINLOCK47 REBIF131 PROLASTIN-C133 QNASL121 REBIF REBIDOSE131 QNASL CHILDRENS121 PROLATE10 REBIF REBIDOSE PROLENSA126 QUALAQUIN41 TITRATIONPACK131
Index 20 Updated 07/01/2021 REBIF TITRATION PACK131 ribavirin56 RYDAPT47 RECLAST85 ribavirin (hepatitis c)55 RYTARY49 RECOMBIVAX HB141 RIDAURA4 RYTHMOL SR17 RECTIV13 rifabutin42 SABRIL24 REGLAN90 RIFADIN42 SAFYRAL63 REGRANEX82 RIFAMATE41 SALAGEN111 relafen4 rifampin42 SALEX80 RELENZA DISKHALER56 RIFATER41 SALEX LOTION80 RELEXXII2 RILUTEK121 salicylic acid80 RELION INSULIN SYRINGE/U- riluzole121 salicylic acid in ammonium 100/1ML/31G X 5/16"103 rimantadine hydrochloride56 lactate vehicle80 RELISTOR91 salicylic acid w/ cleanser80 ringer's irrigation110 RELNATE DHA117 salicylic acid wart remover79 RINVOQ3 RELPAX106 SALIMEZ80 RIOMET28 RELTONE90 SALISOL80 risedronate sodium85 REMERON25 salisol forte79 RISPERDAL50 REMERON SOLTAB25 SALITECH80 RISPERDAL CONSTA50 REMICADE91 salitech forte79 risperidone50 REMODULIN58 salsalate8 RITALIN2 RENAGEL92 SALVAX80 RITALIN LA2 RENVELA92 SAMSCA88 ritonavir53 repaglinide30 SANCUSO31 RITUXAN43 repaglinide-metformin hcl27 SANDIMMUNE109 RITUXAN HYCELA46 REPATHA37 SANDOSTATIN88 rivastigmine130 REPATHA PUSHTRONEX SANDOSTATIN LAR SYSTEM37 rivastigmine tartrate130 DEPOT88 REPATHA SURECLICK37 rizatriptan benzoate106 SANTYL79 REQUIP XL49 ROBAXIN-750119 SAPHRIS51 RESCRIPTOR53 ROCALTROL87 sapropterin dihydrochloride87 RESTASIS123 ROMIDEPSIN47 SARAFEM131 RESTASIS MULTIDOSE123 ropinirole hydrochloride49 SAVELLA130 RESTORIL97 rosadan81 SAVELLA TITRATION RETACRIT95 rosuvastatin calcium37 PACK130 SB INSULIN SYRINGE/U- RETEVMO47 ROTATEQ141 100/1ML/31G X 5/16"104 RETIN-A69 ROWASA91 scopolamine31 RETIN-A MICRO70 roweepra22 SE-NATAL 19117 RETIN-A MICRO PUMP70 roweepra xr22 SEASONIQUE63 RETROVIR53 ROXICODONE9 SECONAL SODIUM96 REVATIO58 ROXYBOND10 SECUADO51 REVLIMID108 ROZEREM97 SELECT-OB117 REXULTI52 ROZLYTREK47 SELECT-OB+DHA117 REYATAZ53 RUBRACA47 selegiline hcl50 RHOFADE82 RUCONEST94 selenium sulfide73 RIAX70 rufinamide23 SELZENTRY53 ribasphere55 RUKOBIA53 SEMPREX-D66 ribasphere ribapak55 RUZURGI41 SENSIPAR87 RIBASPHERE RIBAPAK55 ryclora33 SEREVENT DISKUS19
Updated 07/01/2021 Index 21 SEROQUEL51 SODIUM STIVARGA47 SEROQUEL XR51 SULFACETAMIDE/SULFUR STRATTERA1 CLEANSER IN UREA70 SEROSTIM86 SOFOSBUVIR/VELPATASVIR STRENSIQ88 sertraline hcl26 55 streptomycin sulfate3 sevelamer carbonate92 solifenacin succinate140 STRIANT12 sevelamer hcl92 SOLIQUA 100/3327 STRIBILD54 SFROWASA91 SOLODYN134 STRIVERDI RESPIMAT19 SHUR-SEAL141 SOLTAMOX45 STROMECTOL13 SIGNIFOR88 SOMA119 SUBOXONE11 SIKLOS94 SOMATULINE DEPOT88 SUBSYS10 SILDENAFIL CITRATE59 SOMAVERT86 subvenite22 sildenafil citrate (pulmonary SOOLANTRA82 subvenite starter kit/blue21 hypertension)59 SORIATANE73 SUCRAID83 SILENOR96 SORILUX73 sucralfate138 SILIQ73 sorine56 SULAR57 silodosin93 sotalol hcl57 sulconazole nitrate72 SILVADENE74 sotalol hcl (afib/afl)57 sulfacetamide sod- silver sulfadiazine74 SOTYLIZE57 prednisolone124 SIMBRINZA122 SOVALDI55 sulfacetamide sodium73 SIMPONI3 spinosad82 sulfacetamide sodium (acne)70 sulfacetamide sodium SIMPONI ARIA3 SPIRIVA HANDIHALER17 SIMULECT109 (ophth)123 SPIRIVA RESPIMAT17 sulfacetamide sodium w/ simvastatin37 spironolactone84 sulfur70 SINEMET49 spironolactone & sulfacleanse 8/467 SINEMET CR49 hydrochlorothiazide84 SULFADIAZINE134 SINGULAIR17 SPORANOX33 sulfamethoxazole-trimethoprim sirolimus109 SPORANOX PULSEPAK33 14 SIRTURO42 SPRIX5 SULFAMYLON74 SIVEXTRO15 SPRYCEL47 sulfasalazine91 SKELAXIN119 ssd74 sulfatrim pediatric13 SKLICE82 sss 10-567 sulindac5 SKYLA64 ST JOSEPH ADULT8 SUMADAN WASH70 SKYRIZI73 ST JOSEPH ADULT sumatriptan106 ANALGESICLOW DOSE BITE SLYND64 sumatriptan succinate106 SIZE8 sumatriptan-naproxen sodium chloride108 STALEVO 10049 sodium105 sodium chloride (gu irrigant)93 STALEVO 12549 SUMAXIN70 sodium chloride (inhalant)67 STALEVO 15049 SUMAXIN WASH70 sodium citrate & citric acid92 STALEVO 20049 SUPRAX60 sodium fluoride107 STALEVO 5050 SURE COMFORT INSULIN sodium phenylbutyrate87 STALEVO 7550 SYRINGE/U-100/1ML/31G X 5/16"104 sodium polystyrene STARLIX30 sulfonate110 SURE-JECT INSULIN sodium sulfacetamide wash73 stavudine54 SYRINGE/U-100/1ML/31G X SODIUM SULFACETAMIDE STAVUDINE54 5/16"104 WASH73 STELARA73 SURMONTIL27 SODIUM STIMATE88 SUSTIVA54 SULFACETAMIDE/SULFUR STIOLTO RESPIMAT19 SUTENT47 70 SUVICORT81
Index 22 Updated 07/01/2021 SYLATRON48 tazicef59 THIOLA93 SYMBICORT19 TAZORAC73 THIOLA EC93 SYMBYAX130 taztia xt57 thioridazine hcl51 SYMDEKO134 TAZVERIK47 thiothixene52 SYMLINPEN 12027 TECFIDERA131 THRIVITE 19111 SYMLINPEN 6027 TECFIDERA STARTER THRIVITE RX117 SYMPROIC91 PACK131 THYMOGLOBULIN110 TECHLITE INSULIN SYMTUZA54 SYRINGEU-100/1ML/31G X thyroid135 SYNALAR78 5/16"104 tiagabine hcl24 SYNAREL86 TEFLARO60 TIAZAC58 SYNERA81 TEGRETOL23 TIBSOVO47 SYNERDERM81 TEGRETOL-XR23 TIGAN32 SYNJARDY27 TEGSEDI133 tigecycline134 SYNJARDY XR28 TEKTURNA40 TIGECYCLINE134 SYNTHROID135 TEKTURNA HCT40 TIKOSYN17 SYPRINE108 telmisartan38 tilia fe62 TABLOID43 telmisartan-amlodipine40 timolol maleate57 TABRECTA47 telmisartan-hydrochlorothiazide timolol maleate (ophth)121 40 TACLONEX78 timolol maleate in ocudose121 temazepam97 tacrolimus110 TIMOPTIC122 TEMODAR42 tacrolimus (topical)79 TIMOPTIC OCUDOSE121 TEMOVATE78 tadalafil58 TIMOPTIC-XE122 temozolomide42 tadalafil (pulmonary tinidazole13 temsirolimus47 hypertension)59 tiopronin93 TAFINLAR47 tenofovir disoproxil fumarate54 TIROSINT135 TAGAMET HB138 TENORETIC 10040 TIROSINT-SOL135 TAGRISSO44 TENORETIC 5040 tis-u-sol110 TAKHZYRO94 TENORMIN56 TIVICAY54 TALTZ73 terazosin hcl38 TIVORBEX5 TALZENNA47 terbinafine hcl33 tizanidine hcl119 TAMIFLU56 terbutaline sulfate19 TL FOLATE117 tamoxifen citrate45 terconazole vaginal142 TL-CARE DHA117 tamsulosin hcl93 TESSALON PERLES66 TL-SELECT117 TAPAZOLE135 TESTIM12 TOBI3 TARCEVA44 testosterone12 TOBI PODHALER3 TARGRETIN48,72 testosterone cypionate12 TOBRADEX124 TARKA40 testosterone enanthate12 TOBRADEX ST124 TARON-BC117 tetrabenazine130 tobramycin3 TARON-C DHA117 tetracaine hcl (ophth)123 tobramycin (ophth)123 TARON-PREX117 tetracycline hcl134 tobramycin sulfate3 TASIGNA47 TEXACORT78 tobramycin- TASMAR49 THALOMID108 dexamethasone124 TAVALISSE94 TOBREX123 THEO-2420 TAYTULLA63 TODAY SPONGE141 theophylline20 TAZAROTENE70 THERANATAL CORE TOFRANIL27 tazarotene73 NUTRITION117 tolbutamide30
Updated 07/01/2021 Index 23 tolcapone49 tri femynor62 TRUEPLUS INSULIN tolmetin sodium5 TRI-TABS DHA117 SYRINGE/U-100/1ML/31G X 5/16"104 TOLSURA33 TRI-VI-FLOR112 TRULANCE90 tolterodine tartrate140 TRI-VI-FLORO112 TRULICITY28 tolvaptan88 tri-vite/fluoride112 TRUSELTIQ47 triamcinolone acetonide TOPAMAX23 TRUSOPT126 TOPAMAX SPRINKLE23 (mouth)110 triamcinolone acetonide TRUSTEX COLOR CONDOMS + TOPCARE ULTRA COMFORT (topical)78 LUBE100 INSULIN SYRINGE/1ML/31G X triamterene84 TRUSTEX LUBRICATED100 5/16"104 TRUSTEX LUBRICATED TOPICORT78 triamterene & hydrochlorothiazide84 EXTRALARGE100 topiramate23,24 trianex74 TRUSTEX LUBRICATED toposar48 EXTRASTRENGTH100 triazolam97 TRUSTEX topotecan hcl48 TRIBENZOR40 LUBRICATED/RIBBED/STUDDE TOPOTECAN HCL48 TRICARE117 D 100 topotecan hcl48 TRICARE PRENATAL DHA TRUSTEX TOPROL XL56 ONE117 LUBRICATED/SPERMICIDE 101 toremifene citrate45 TRICOR36 TRUSTEX TORISEL47 triderm74 LUBRICATED/SPERMICIDE torsemide84 TRIDESILON78 EXTRA LARGE100 trientine hcl108 TRUSTEX TOUJEO MAX SOLOSTAR29 LUBRICATED/SPERMICIDE TOUJEO SOLOSTAR29 trifluoperazine hcl51 EXTRA STRENGTH100 tovet74 trifluridine123 TRUSTEX NATURAL TOVIAZ140 TRIGLIDE37 CONDOMS trihexyphenidyl hcl48 +LUBE/LUBRICATED101 TRACLEER58 TRUSTEX NON- tramadol hcl10 TRIJARDY XR28 LUBRICATED101 tramadol-acetaminophen10 TRIKAFTA134 TRUSTEX WITH NONOXYNOL- TRILEPTAL24 9/RIBBED/STUDDED 101 trandolapril38 TRUSTEX/RIA trandolapril-verapamil hcl40 TRILIPIX37 LUBRICATED101 tranexamic acid96 trimethobenzamide hcl32 TRUSTEX/RIA LUBRICATED TRANXENE T16 trimethoprim13 SPERMICIDE101 trimipramine maleate27 TRUSTEX/RIA tranylcypromine sulfate25 LUBRICATED/SPERMICIDE TRAVATAN Z126 TRINTELLIX26 101 travoprost126 TRISTART DHA117 TRUSTEX/RIA NON- trazodone hcl26 TRISTART FREE117 LUBRICATED101 TRUVADA54 TRECATOR42 TRISTART ONE117 TUKYSA43 TRELEGY ELLIPTA19 TRIUMEQ54 TURALIO47 TRELSTAR MIXJECT45 TRIZIVIR54 TROKENDI XR24 TUSSICAPS67 TREMFYA73 TUSSIONEX PENNKINETIC treprostinil58 tropicamide122 EXTENDED RELEASE67 TRESIBA29 trospium chloride140 TUSSLIN67 TRESIBA FLEXTOUCH29 TRUE COMFORT INSULIN TUSSLIN PEDIATRIC67 SYRINGE/1ML/31G X tretinoin70 5/16"104 TWIRLA63 tretinoin (chemotherapy)48 TRUE COMFORT PRO TWYNSTA40 tretinoin microsphere70 INSULINSYRINGE/1ML/31G X TYBLUME63 TREXALL43 5/16"104 TYBOST54 TREXIMET105 tydemy60
Index 24 Updated 07/01/2021 TYGACIL134 urea nail78 VEMLIDY55 TYKERB47 urea-c4078 VENA-BAL DHA117 TYLENOL/CODEINE #311 URECHOLINE140 VENCLEXTA44 TYLENOL/CODEINE #411 uribel13 VENCLEXTA STARTING TYMLOS85 UROCIT-K 1092 PACK44 venlafaxine hcl26,27 TYSABRI131 UROCIT-K 1592 VENTAVIS58 UCERIS12,65 UROCIT-K 592 VENTOLIN HFA19 UDAMIN SP111 UROXATRAL93 verapamil hcl58 ULESFIA82 URSO 25090 VERDESO78 ULORIC93 URSO FORTE90 VEREGEN70 ULTICARE INSULIN ursodiol90 VERELAN58 SYRINGE/SHORT/1ML/31G X UTOPIC79 5/16"104 VERELAN PM58 UVADEX48 ULTICARE INSULIN VERIPRED 2065 SYRINGE/U-100/1ML/31G X valacyclovir hcl55 VERSACLOZ51 5/16"104 VALCHLOR72 ULTICARE INSULIN VERZENIO47 VALCYTE54 SYRINGEULTRAFINE U- VESICARE140 valganciclovir hcl54 100/1ML/31G X 5/16"104 VFEND33 ULTIGUARD SAFEPACK VALIUM16 VIBERZI91 INSULIN SYRINGE 1ML 31G X valproic acid25 5/16"/SHARPS CO104 VIBRAMYCIN134,135 valsartan38 ULTILET INSULIN VICTOZA28 SYRINGE/1ML/31G X 8MM104 valsartan-hydrochlorothiazide ULTILET INSULIN 40 VIDAZA43 SYRINGE/SHORT/1ML/31G X VALTOCO21 VIDEX EC54 5/16"104 VALTREX55 VIDEXPEDIATRIC54 ULTIMATECARE ONE117 vanadom119 vigabatrin24 ULTRA FLO INSULIN SYRINGE vanatol lq6 vigadrone24 1ML/31GX5/16"104 ULTRA-COMFORT INSULIN VANCOCIN14 VIIBRYD26 SYRINGE/U-100/1ML/31G X VANCOCIN HCL14 VIIBRYD STARTER PACK26 5/16"104 vancomycin hcl14 VIMOVO6 ULTRA-THIN II INSULIN SYRINGE SHORT/U- vandazole141 VIMPAT24 100/1ML/31GX5/16" 104 VANOS78 VINATE DHA RF118 ULTRACARE INSULIN VARUBI32 VINATE II118 SYRINGE/U-100/1ML/31G X VASCEPA36 VIOKACE83 5/16"104 ULTRACET11 VASERETIC40 VIRACEPT54 ULTRAM10 VASOTEC38 VIRAMUNE54 VCF VAGINAL ULTRASAL-ER80 VIRAMUNE XR54 CONTRACEPTIVE FILM141 VIRASAL80 ULTRAVATE78 VCF VAGINAL umecta mousse78 CONTRACEPTIVE VIRAZOLE56 UNASYN128 FOAM141 VIREAD54 VCF VAGINAL VIRT-C DHA118 UNASYN BULK PACK128 CONTRACEPTIVEGEL141 VIRT-NATE DHA118 UNISOM SLEEPGELS96 VECAMYL40 VIRT-PN DHA118 UPTRAVI59 VECTICAL73 VIRT-PN PLUS118 URAMAXIN79 VELCADE47 virtussin ac/alc66 URE-K79 VELPHORO92 VIRTUSSIN DAC67 urea79 VELTASSA110 VISTARIL16 urea hydrating78 VELTIN70
Updated 07/01/2021 Index 25 VISTOGARD31 XANAX16 zaleplon97 VITAFOL FE+118 XANAX XR16 ZANAFLEX119 VITAFOL GUMMIES118 XARELTO20 ZANOSAR42 VITAFOL ULTRA118 XARELTO STARTER ZANTAC 150 MAXIMUM VITAFOL-NANO118 PACK20 STRENGTH138 XATMEP43 ZARONTIN24 VITAFOL-ONE118 VITAMEDMD ONE XELJANZ3 ZARXIO95 RX/QUATREFOLIC118 XELJANZ XR3 ZATEAN-PN DHA119 VITAMIN D2143 XELODA43 ZATEAN-PN PLUS119 VITAMIN D3143 XENAZINE130 ZAVESCA94 VITAMIN D3 IMMUNE XERAC AC81 ZEGERID140 HEALTH143 XERESE74 ZEJULA47 VITAPEARL118 XERMELO92 ZELAPAR50 VITATHELY/GINGER118 XGEVA85 ZELBORAF47 VITATRUE118 XIAFLEX108 ZEMAIRA133 VITRAKVI47 XIFAXAN13 ZEMBRACE SYMTOUCH106 VIVA DHA118 XIGDUO XR28 ZEMPLAR88 VIVELLE-DOT90 XOLAIR17 ZENPEP83 VIZIMPRO44 XOLEGEL72 zenzedi1 VOL-PLUS118 XOPENEX20 ZESTORETIC40 VOL-TAB RX118 XOPENEX ZESTRIL38 voriconazole33 CONCENTRATE19 ZETIA37 VOSEVI55 XOPENEX HFA20 ZETONNA121 VOTRIENT47 XOSPATA47 ZIAC40 VP-PNV-DHA118 XPOVIO45 ZIAGEN54 VPRIV94 XPOVIO 100 MG ONCE ZIANA70 VRAYLAR50 WEEKLY45 XPOVIO 40 MG ONCE zidovudine54 VUSION72 WEEKLY45 ZIEXTENZO95 VYNDAMAX59 XPOVIO 40 MG TWICE zileuton18 VYNDAQEL59 WEEKLY45 XPOVIO 60 MG ONCE zinc sulfate108 VYTONE72 WEEKLY45 ZIOPTAN126 VYTORIN36 XPOVIO 60 MG TWICE ziprasidone hcl50 VYVANSE1 WEEKLY45 ziprasidone mesylate50 warfarin sodium20 XPOVIO 80 MG ONCE WEEKLY45 ZIPSOR6 water for irrigation, sterile110 XPOVIO 80 MG TWICE ZIRGAN123 wee care95 WEEKLY45 ZITHROMAX98 WELCHOL36 XTANDI45 ZITHROMAX TRI-PAK98 WELLBUTRIN SR25 xulane63 ZITHROMAX Z-PAK98 WELLBUTRIN XL25 XULTOPHY 100/3.628 ZOCOR37 WESTAB PLUS118 XURIDEN88 ZOFRAN31 WESTGEL DHA119 XYREM129 zoledronic acid85 WESTHROID135 YASMIN 2863 ZOLEDRONIC ACID85 WILZIN108 YAZ63 zoledronic acid85 wixela inhub18 YERVOY43 ZOLINZA47 WP THYROID135 YONSA45 zolmitriptan106 XALATAN126 yuvafem142 ZOLOFT26 XALKORI47 zafirlukast17
Index 26 Updated 07/01/2021 zolpidem tartrate97 ZOLPIMIST97 ZOMACTON86 ZOMIG106 ZOMIG ZMT106 ZONEGRAN24 zonisamide24 ZONTIVITY94 ZORBTIVE86 ZORTRESS110 ZORVOLEX6 ZOSYN128 ZOVIRAX55,74 ZUBSOLV11 ZUPLENZ31 ZYBAN133 ZYCLARA79 ZYCLARA PUMP79 ZYDELIG47 ZYFLO18 ZYKADIA47 ZYLET124 ZYLOPRIM93 ZYMAXID123 ZYPREXA51 ZYPREXA ZYDIS51 ZYRTEC CHILDRENS ALLERGY35 ZYTIGA45 ZYVOX15
Updated 07/01/2021 Index 27