UnitedHealthcare Community Plan

Preferred

Drug List (PDL)

Washington

Apple Health Integrated

Managed Care (IMC)

Effective Date: 7/1/2024

UnitedHealthcare Community Plan complies with all Federal civil rights laws that relate to healthcare

services. UnitedHealthcare Community Plan oﬀers healthcare services to all members without

regard to race, color, national origin, age, disability, or sex. UnitedHealthcare Community Plan does

not exclude people or treat them diﬀerently because of race, color, national origin, age, disability,

or sex. This includes gender identity, pregnancy and sex stereotyping.

UnitedHealthcare Community Plan also complies with applicable state laws and does not

discriminate on the basis of creed, gender, gender expression or identity, sexual orientation, marital

status, religion, honorably discharged veteran or military status, or the use of a trained dog guide or

service animal by a person with a disability.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin,

you can send a complaint to:

Civil Rights Coordinator

UnitedHealthcare Civil Rights Grievance

P.O. Box 30608

Salt Lake City, UT 84130

[email protected]

You can call or write us about a complaint at any time. We will let you know we received your

complaint within two business days. We will try to take care of your complaint right away. We will

resolve your complaint within 45 calendar days and tell you how it was resolved.

If you need help with your complaint, please call 1-877-542-8997, TTY 711, 8 a.m.–5 p.m.,

Monday–Friday.

You can also ﬁle a complaint with the U.S. Dept. of Health and Human Services.

Online:

https://www.hhs.gov/civil-rights/ﬁling-a-complaint/index.html

Phone:

Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail:

U.S. Dept. of Health and Human Services

200 Independence Avenue SW, Room 509F, HHH Building

Washington, D.C. 20201

We provide free services to help you communicate with us. Such

as, letters in other languages or large print. Or, you can ask for an

interpreter. To ask for help, please call 1-877-542-8997, TTY 711,

8 a.m.–5 p.m., Monday–Friday.

CSWA24MD0171124_000 HCA 2020-222 approved 061620

UnitedHealthcare Community Plan cumple con todos los requisitos de las leyes Federales de los

derechos civiles relativas a los servicios de los cuidados para la salud. UnitedHealthcare Community

Plan ofrece servicios para los cuidados de salud a todos los miembros sin distinción de su raza,

color, origen nacional, edad, discapacidad o sexo. UnitedHealthcare Community Plan no excluye

a personas ni les da un tratamiento diferente basado en su raza, color, origen nacional, edad,

discapacidad o sexo. Esto incluye su identiﬁcación de sexo, su estado de embarazo o el estereotipo

sexual que tengan.

UnitedHealthcare Community Plan también cumple con los requisitos de las leyes estatales

pertinentes y no discrimina en base a sus creencias, sexo, expresión de sexo o identidad,

orientación sexual, estado civil, religión, veterano dado de alta honorablemente o por su actual

condición militar o por el empleo de perros o animales entrenados como guías o para servicios

necesarios para una persona con una discapacidad.

Si usted piensa que ha sido tratado injustamente por razones como su sexo, edad, raza, color,

discapacidad u origen nacional, puede enviar una queja a:

Civil Rights Coordinator

UnitedHealthcare Civil Rights Grievance

P.O. Box 30608, Salt Lake City, UT 84130

[email protected]

Usted puede llamarnos o escribirnos sobre una queja en cualquier momento. Le informaremos

que recibimos su queja dentro de dos días hábiles. Trataremos de atender su queja de inmediato.

Resolveremos su queja dentro de 45 días calendario y le informaremos cómo se resolvió.

Si usted necesita ayuda con su queja, por favor llame al 1-877-542-8997, TTY 711, de 8 a.m.

a 5 p.m., de lunes a viernes.

Usted también puede presentar una queja con el Departamento de Salud y Servicios Humanos

de los Estados Unidos.

Internet:

https://www.hhs.gov/civil-rights/ﬁling-a-complaint/index.html

Teléfono:

Llamada gratuita, 1-800-368-1019, 1-800-537-7697 (TDD)

Correo:

U.S. Department of Health and Human Services

200 Independence Avenue SW, Room 509F, HHH Building

Washington, D.C. 20201

Ofrecemos servicios gratuitos para ayudarle a comunicarse con

nosotros. Tales como, cartas en otros idiomas o en letra grande. O

bien, puede solicitar un intérprete. Para pedir ayuda, por favor llame

al 1-877-542-8997, TTY 711, de 8 a.m. a 5 p.m., de lunes a viernes.

English:

If the enclosed information is not in your primary language, please

call UnitedHealthcare Community Plan at 1-877-542-8997, TTY 711.

Hmong:

Yog cov ntaub ntawv no tsis yog sau ua koj hom lus, thov hu rau UnitedHealthcare Community Plan

ntawm 1-877-542-8997, TTY 711.

Samoan:

Afai o fa’amatalaga ua tuuina atu e le’o tusia i lau gagana masani, fa’amolemole fa’afesoota’i mai le

vaega a le UnitedHealthcare Community Plan ile telefoni 1-877-542-8997,

TTY 711.

Russian:

Если прилагаемая информация представлена не на Вашем родном языке, позвоните

представителю UnitedHealthcare Community Plan по тел. 1-877-542-8997, телетайп 711.

Ukranian:

Якщо інформацію, що додається, подано не Вашою рідною мовою, зателефонуйте представнику

UnitedHealthcare Community Plan за телефоном 1-877-542-8997, телетайп 711.

Korean:

동봉한 안내 자료가 귀하의 모국어로 준비되어 있지 않으면 1-877-542-8997,

TTY 711 로 UnitedHealthcare Community Plan 에 전화주십시오 .

Romanian:

Dacă informațiile alăturate nu sunt în limba dumneavoastră principală, vă rugăm să sunați la

UnitedHealthcare Community Plan, la numărul 1-877-542-8997, TTY 711.

Amharic:

ተያይዞ ያለው መረጃ በቋንቋዎ ካልሆነ፣ እባክዎ በሚከተለው ስልክ ቁጥር ወደ UnitedHealthcare Community

Plan ይደውሉ1-877-542-8997፣መስማት ለተሳናቸው/TTY 711

Tigrinya:

ተተሓሒዙ ዘሎ ሓበሬታ ብቋንቋኹም እንተዘይኮይኑ፣ ብኽብረትኩም በዚ ዝስዕብ ቁጽሪ ስልኪ ናብ

UnitedHealthcare Community Plan ደውሉ 1-877-542-8997፣ ንፀማማት/TTY711

Spanish:

Si la información adjunta no está en su lengua materna, llame a UnitedHealthcare Community Plan

al 1-877-542-8997, TTY 711.

ﻝﺻﺎﺣ ﺱﺎﻣﺗ ﻩﺭﺎﻣﺷ ﻥﻳﺍ ﺎﺑ UnitedHealthcare Community Plan ﺎﺑ ﺎﻔﻁﻟ ،ﺩﺷﺎﺑﻳﻣﻧ ﺎﻣﺷ ﻪﻳﻟﻭﺍ ﻥﺎﺑﺯ ﻪﺑ ﺕﺳﻭﻳﭘ ﺕﺎﻋﻼﻁﺍ ﻪﮑﻧﻳﺍ ﺕﺭﻭﺻ ﺭﺩ

TTY: 711 ﻥﺎﻳﺍﻭﻧﺷﺎﻧ یﺍﺭﺑ ﯽﻁﺎﺑﺗﺭﺍ ﻪﻠﻳﺳﻭ 1-877-542-8997 :ﺩﻳﻳﺎﻣﻧ

Tagalog:

Kung ang nakalakip na impormasyon ay wala sa iyong pangunahing wika, mangyaring tumawag sa

UnitedHealthcare Community Plan sa 1-877-542-8997, TTY 711.

Farsi:

Lao:

ຖ ້ າ ຂໍ

ມ

ນ ທີ

ຕດຄດມານ

ບໍ

ແມ ນພາສາຕ ນຕຂອງທານ , ກະລ

ນາໂທຫາ UnitedHealthcare Community Plan ທີ

ເບ

1-877-542-8997, TTY:711.

້

່

ິັ ີ

້

່

້

ົໍ ່

ຸ

່

ີ

Vietnamese:

Nếu ngôn ngữ trong thông tin đính kèm này không phải là ngôn ngữ chánh của quý vị, xin gọi cho

Unitedhealthcare Community Plan theo số 1-877-542-8997, TTY 711.

Traditional Chinese:

若隨附資訊的語言不屬於您主要使用語言，請致電 UnitedHealthcare Community Plan，電話號碼

為 1-877-542-8997（聽障專線 (TTY) 為 711）

Khmer:

ູ

 បសនបរព័ត៌នែដល  រ មកប េ នះមនដមនភ ែ បមេប សូេម◌ូ រស័ពទមកន់

UnitedHealthcareCommunity Plan

ប

លខ

1-877-542-8997

បរអកថង

TTY: 711

។

UnitedHealthcare Community Plan

List of Preferred Drugs

Frequently Asked Questions (FAQ)

Find answers here to questions you have about this UnitedHealthcare Community Plan

List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question

and answer.

What drugs are on the Preferred Drug List? (We call the Preferred Drug List the

“Drug List” for short.)

The drugs on Preferred Drug List that starts on page <4> are the drugs covered by

UnitedHealthcare Community Plan. These drugs are available at pharmacies within our

network. A pharmacy is in our network if we have an agreement with them to work with

us and provide you services. We refer to these pharmacies as “network pharmacies.”

UnitedHealthcare will cover all medically necessary drugs if:

your doctor or other prescriber says you need them to get better or stay healthy,

and

you fill the prescription at a UnitedHealthcare Community Plan network

pharmacy.

UnitedHealthcare may have additional steps to access certain drugs (see question <#5>

below).

You can also see an up-to-date drug list on our website at

<myuhc.com/CommunityPlan> or call Member Services at <1-877-542-8997> TTY 711.

Does the Drug List ever change?

Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List

during the year. Generally, the Drug List will only change if:

a cheaper drug comes along that works as well as a drug on the Drug List now, or

we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

Decide to require or not require prior approval for a drug. (Prior approval is permission

from UnitedHealthcare Community Plan before you can get a drug.)

Add or change the amount of a drug you can get (called “quantity limits”).

Add or change step therapy restrictions on a drug. (Step therapy means you must

try one drug before we will cover another drug.)

Questions 3, 4, and 7 below have more information on what happens

when the Drug List changes.

You can always check the up-to-date Drug List online at <myuhc.com/CommunityPlan>

You can also call Member Services to check the current Drug List at <1-877-542-8997,

TTY 711>.

What happens when another drug comes along that works as well as

a drug on the Drug List now?

If you are taking a drug that is removed because another drug that works just as well is

available, we will tell you. You will get a letter letting you know about the change. We will

also tell you what alternate drugs are available to you. Contact your doctor or other

prescriber to make sure another drug will work for you.

What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we

will take it off the Drug List right away. We will also send you a letter telling you that.

Contact your doctor or other prescriber and ask about your other options.

Are there any restrictions or limits on drug coverage? Or are there any

required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In

some cases your doctor must do something before you can get the drug. For example:

Prior approval (or prior authorization): For some drugs, your doctor or

other prescriber must get approval from UnitedHealthcare before y

ill your prescription. If you don’t get approval, UnitedHealthcare may

not cover the drug.

Quantity limits: Sometimes UnitedHealthcare limits the amount of a

drug you can get.

Step therapy: Sometimes UnitedHealthcare requires you to do step

therapy. This means you will have to try drugs in a certain order for your medical

condition. You might have to try one drug before we will cover another drug. If

your doctor thinks the first drug doesn’t work for you, then we will cover the

second.

You can find out if your drug has any additional requirements or limits by looking in the

tables on pages <4 – 206>. You can also get more information by visiting our website

at <myuhc.com/CommunityPlan>. We have posted online documents that explain our

prior authorization and step therapy restrictions. You may also call Member Services

and ask us to send you information about our prior authorization and step therapy

restrictions.

How will you know if the drug you want has limitations or if there are

required actions to take to get the drug?

The Preferred Drug List on pages <4–206> has a column labeled “Requirements and

Limits.”

What happens if we change our rules on how we cover some drugs?

For example, if we add prior authorization (approval), quantity limits,

and/or step therapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions

on a drug. We will tell you before the restriction is added. This gives you time to talk to

your doctor or other prescriber about what to do next.

How can you find a drug on the Drug List?

There are two ways to find a drug:

You can search by medical condition.

To search by medical condition, find the section labeled “List of drugs by medical

condition” on pages <1 – 3>. The drugs in this section are grouped into

categories depending on the type of medical conditions they are used to treat.

For example, if you have a heart condition, you should look in the category,

Cardiovascular Agents. That is where you will find drugs that treat heart

conditions.

You can also search for drugs alphabetically.

To search alphabetically, go to the <Index of Covered Drugs> starting on page <207>

Find the name of your drug. The page number where you can find the drug will be next

to it.

What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services and ask about it. If you

learn that UnitedHealthcare does not prefer the drug, you can do one of these things:

Ask Member Services for a list of drugs that are similar to the one you want to take.

Then show the list to your doctor or other prescriber. He or she can prescribe a drug on

the Drug List that is like the one you want to take. Or

You can ask the health plan to make an exception to cover your drug. Please see

question 11 for more information about exceptions.

What if you just joined UnitedHealthcare Community Plan and can’t

find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary supply of your drug during the first

90 days you are a member of UnitedHealthcare. This will give you time to talk to your

doctor or other prescriber. He or she can help you decide if there is a similar drug on the

Drug List you can take instead, or whether to request an exception.

Can you ask for an exception to cover your drug?

Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to

cover a drug that is not on the Drug List.

Your doctor can also ask us to change the rules on your drug.

For example, we may limit the amount of a drug we will cover. If your drug has a limit,

your doctor can ask us to change the limit and cover more.

Other examples: Your doctor can ask us to drop step therapy restrictions or prior

approval requirements.

How long does it take to get an exception?

First, we must receive some information from your doctor supporting your request for an

exception. After we receive the information, we will give you a decision on your

exception request within the timeframes required by the state, generally within 24 hours.

How can you ask for an exception?

To ask for an exception, you can do one of two things:

Call Member Services. A Member Services representative

will work with you and your doctor to help ask for an exception.

Call your doctor and ask them to request an exception by calling the Prior

Notification Service at <1-800-310-6826>, or they can fax a request to<866-940-

7328>.

What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs.

They usually cost less than the brand name drug and usually don’t have well-known

names. Generic drugs are approved by the Food and Drug Administration (FDA). In

most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand

name drug is medically necessary, you will need to ask your doctor to submit for prior

approval.

What are OTC drugs?

OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when

they are written as prescriptions by your provider.

You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs

are preferred.

Does UnitedHealthcare cover OTC non-drug products?

UnitedHealthcare covers some OTC non-drug products when they are written as

prescriptions by your provider.

You can read the UnitedHealthcare Community Plan Drug List to see what OTC non-

drug products are covered.

What is a Specialty Pharmacy Medication?

A specialty pharmacy medication is a drug that generally has one or more of the

following characteristics:

•

It’s used by a small number of people

•

It treats rare, chronic, and/or potentially life-threatening diseases

•

It has special storage or handling requirements such as needing to be

refrigerated

•

It may need close monitoring, ongoing clinical support and management, and

omplete patient education and engagement

•

It’s a high cost medication

•

It may not be available at retail pharmacies

•

It may be oral, injectable, or inhaled

Specialty pharmacy medications are available through our specialty pharmacy network.

If you have questions, call Member Services at <1-877-542-8997, TTY 711>.

List of Preferred Drugs

The List of Preferred Drugs that begins <1> gives you information about the drugs

covered by UnitedHealthcare Community Plan. If you have trouble finding your drug in

the list, turn to the Index that begins on page <207>

The first column of the chart lists the generic name of the drug. The second column of

the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR).

The third column in the list tells you if the preferred drug covered is the brand or generic

version.

The information in the “Requirements & Limits” column tells you if UnitedHealthcare has

any rules for covering your drug.

Utilization Management Restrictions

PA - Prior approval (or prior authorization)

or some drugs, your doctor or other prescriber must get approval from

UnitedHealthcare Community Plan before you fill your prescription. If you don’t

get approval, UnitedHealthcare may not cover the drug.

QL - Quantity limits

Sometimes UnitedHealthcare Community Plan limits the amount of a drug you

can get.

ST - Step therapy

Sometimes UnitedHealthcare Community Plan requires you to do step therapy.

This means you will have to try drugs in a certain order for your medical

condition. You might have to try one drug before we will cover another drug. If

your doctor thinks the first drug doesn’t work for you, then your doctor can ask for

approval to cover the second.

Other special requirements for coverage

SP – Specialty Pharmacy

Drug needs to be accessed through a network Specialty Pharmacy.

Specialty Pharmacy Drugs may require extra handling, provider coordination or

patient education that can’t be done at a network retail pharmacy.

Drug Tiers

The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.

Tier Name Drug Tier

Tier 1 Generic

Tier 2 Brand

[ABBREVIATIONS]

OTC = Over the Counter

PA = Prior Authorization required

QL = Quantity Limit

ST = Step Therapy

SP = Specialty Pharmacy

[You can find information on what the symbols and abbreviations in this table mean by

going to page <4>]

Preguntas frecuentes

Encuentre aquí las respuestas a sus preguntas sobre esta Lista de Medicamentos

Preferidos de UnitedHealthcare Community Plan. Puede leer todas las preguntas

frecuentes para obtener más información o buscar una pregunta y su respuesta.

¿Qué medicamentos están en la Lista de Medicamentos Preferidos? (Para

abreviar, denominamos a esta lista “Lista de Medicamentos”).

Los medicamentos de la Lista de Medicamentos Preferidos que comienza en la página

<4> son los medicamentos cubiertos por UnitedHealthcare Community Plan. Estos

medicamentos están disponibles en farmacias dentro de nuestra red. Una farmacia se

encuentra en nuestra red si tenemos un acuerdo con ella para que trabaje con nosotros

y le proporcione servicios. A estas farmacias las denominamos “farmacias de la red”.

UnitedHealthcare Community Plan cubrirá todos los medicamentos médicamente

necesarios si:

su médico u otro profesional que receta dice que los necesita para mejorarse o

mantenerse en buen estado de salud,

usted surte una receta en una farmacia de la red de UnitedHealthcare

Community Plan.

UnitedHealthcare Community Plan puede requerir pasos adicionales para tener acceso

a determinados medicamentos (vea la pregunta <#5> a continuación).

También puede ver una lista de medicamentos actualizada en nuestro sitio web en

<myuhc.com/CommunityPlan> o puede llamar al Departamento de Servicio al Cliente al

<1-877-542-8997> TTY 711.

¿Cambia alguna vez la Lista de Medicamentos Preferidos?

Sí. UnitedHealthcare Community Plan puede agregar o quitar medicamentos de la Lista

de Medicamentos Preferidos durante el año. Por lo general, la Lista de Medicamentos

Preferidos solo cambiará si:

aparece un medicamento más económico que funciona igual que un medicamento que

está actualmente en la Lista de Medicamentos Preferidos, o

si tomamos conocimiento de que un medicamento no es seguro.

También podemos cambiar nuestras reglas sobre los medicamentos. Por ejemplo,

podríamos:

Decidir exigir o no exigir aprobación previa para un medicamento. (Aprobación previa

es un permiso de UnitedHealthcare Community Plan antes de que usted pueda obtener

un medicamento).

Agregar o cambiar la cantidad de un medicamento que puede obtener (denominados

“límites de cantidad”).

Agregar o cambiar las restricciones de terapia escalonada de un medicamento.

(Terapia escalonada significa que usted debe probar un medicamento antes de que

cubramos otro medicamento).

Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que sucede

cuando cambia la Lista de Medicamentos Preferidos.

Siempre puede consultar la Lista de Medicamentos Preferidos actualizada en Internet

en <myuhc.com/CommunityPlan>. También puede llamar al Departamento de Servicio

al Cliente para consultar la Lista de Medicamentos Preferidos actual al

<1-877-542-8997, TTY 711>.

¿Qué sucede cuando aparece otro medicamento que funciona igual que un

medicamento que está actualmente en la Lista de Medicamentos Preferidos?

Si está tomando un medicamento que se retira porque otro medicamento que funciona

igual está disponible, se lo informaremos. Recibirá una carta que le informará sobre el

cambio. También le informaremos qué medicamentos alternativos están disponibles

para usted. Comuníquese con su médico u otro profesional que receta para asegurarse

de que otro medicamento sea adecuado para usted.

¿Qué sucede cuando averiguamos que un medicamento no es seguro?

Si la Administración de Medicamentos y Alimentos (FDA) anuncia que un medicamento

que usted está tomando no es seguro, lo quitaremos inmediatamente de la Lista de

Medicamentos Preferidos. También le enviaremos una carta para informarle al respecto.

Comuníquese con su médico u otro profesional que receta para preguntarle sobre sus

otras opciones.

¿Se aplican restricciones o límites a la cobertura de medicamentos? ¿O se

requiere tomar alguna medida a fin de obtener determinados medicamentos?

Sí, algunos medicamentos tienen reglas de cobertura o tienen límites sobre la cantidad

que usted puede obtener. En algunos casos, su médico debe hacer algo antes de que

usted pueda obtener el medicamento. Por ejemplo:

Aprobación previa (o preautorización): Para algunos

medicamentos, su médico u otro

profesional que receta debe obtener aprobación de UnitedHealthcare Community Plan

antes de que usted pueda surtir su receta. Si no obtiene la aprobación, es posible que

UnitedHealthcare Community Plan no cubra el medicamento.

Límites de cantidad: A veces, UnitedHealthcare Community Plan limita la cantidad de

un medicamento que usted puede obtener.

Terapia escalonada: A veces, UnitedHealthcare Community Plan requiere que usted

haga una terapia escalonada. Esto significa que deberá probar los medicamentos en un

determinado orden para su condición médica. Usted podría tener que probar un

medicamento antes de que cubramos otro medicamento. Si su médico considera que el

primer medicamento no es adecuado para usted, cubriremos el segundo.

Puede averiguar si su medicamento tiene requisitos o límites adicionales consultando

las tablas de las páginas <4 – 206>. También puede obtener más información visitando

nuestro sitio web en <myuhc.com/CommunityPlan>. Hemos publicado documentos en

Internet que explican nuestras restricciones de preautorización y terapia escalonada.

También puede llamar al Departamento de Servicio al Cliente y pedirnos que le

enviemos información sobre nuestras restricciones de preautorización y terapia

escalonada.

¿Cómo sabrá si el medicamento que desea está sujeto a límites o si debe

tomar medidas adicionales para poder obtenerlo?La

Lista de Medicamentos Preferidos en las páginas <4-206 >

tiene una columna denominada “Requisitos y límites”.

¿Qué sucede si cambiamos nuestras reglas sobre cómo cubrimos algunos

medicamentos?

Por ejemplo, si agregamos un requisito de preautorización (aprobación),

límites de cantidad o restricciones de terapia escalonada a un medicamento.

Si agregamos un requisito de aprobación previa, límites de cantidad o restricciones de

terapia escalonada a un medicamento, se lo informaremos. Le informaremos antes de

que se agregue la restricción. Esto le da tiempo para hablar con su médico u otro

profesional que receta sobre qué hacer a continuación.

¿Cómo puede buscar un medicamento en la Lista de Medicamentos

Preferidos?

Hay dos formas de buscar un medicamento:

Puede buscar por condición médica.

Para buscar por condición médica, encuentre la sección “Lista de medicamentos

por condición médica” en las páginas <1– 3>. Los medicamentos en esta

sección están agrupados en categorías según el tipo de condiciones médicas

para cuyo tratamiento se utilizan. Por ejemplo, si usted tiene una condición

cardíaca, debe buscar en la categoría Agentes cardiovasculares. Allí es donde

encontrará los medicamentos que tratan las condiciones cardíacas.

También puede buscar medicamentos por orden alfabético.

Para buscar por orden alfabético, vaya a la sección <Índice alfabético de medicamentos

cubiertos> que comienza en la página <207>.

Encuentre el nombre de su medicamento. Al lado del medicamento está el número de

página donde se encuentra.

¿Qué debe hacer si el medicamento que desea tomar no está en la Lista de

Medicamentos Preferidos?

Si su medicamento no aparece en la Lista de Medicamentos Preferidos, llame al

Departamento de Servicio al Cliente y pregunte al respecto. Si UnitedHealthcare

Community Plan no incluye su medicamento dentro de los medicamentos preferidos del

plan, usted tiene dos opciones:

Solicite al Departamento de Servicio al Cliente una lista de medicamentos que sean

similares al que usted desea tomar. Luego muestre la lista a su médico u otr

ofesional que receta. Este puede recetar un medicamento que aparezca en la Lista d

edicamentos Preferidos que sea como el que desea tomar. O

Puede solicitar al plan de salud que haga una excepción y cubra su medicamento.

Consulte la pregunta 11 para obtener más información sobre las excepciones.

10.

¿Qué sucede si acaba de inscribirse en UnitedHealthcare Community Plan y

su medicamento no aparece en la Lista de Medicamentos Preferidos o tiene

roblemas para obtener su medicamento?

Podemos ayudar. Podemos cubrir un suministro temporal de 30 días de su

medicamento durante los primeros 90 días de su membresía en UnitedHealthcare

Community Plan. Esto le dará tiempo para hablar con su médico u otro profesional que

receta. Este puede ayudarle a decidir si hay un medicamento similar en la Lista de

Medicamentos Preferidos que usted puede tomar en lugar del otro, o si debe solicitar

una excepción.

11.

¿Puede solicitar una excepción para cubrir su medicamento?

Sí. Su médico puede solicitar a UnitedHealthcare Community Plan que haga

una

cepción y cubra un medicamento que no aparece en la Lista de Medicamentos

Preferidos.

Su médico también puede solicitarnos que cambiemos las reglas sobre s

edicamento.

Por ejemplo, podemos limitar la cantidad de un medicamento que cubriremos. Si su

medicamento tiene un límite, su médico puede pedirnos que cambiemos el límite y

cubramos una cantidad mayor.

Otros ejemplos: Su médico puede solicitarnos que dejemos de lado las restricciones

de terapia escalonada o los requisitos de aprobación previa.

12.

¿Cuánto tiempo demora conseguir una excepción?

Primero, debemos recibir más información de su médico que respalde su solicitud de

una excepción. Después de que recibamos la información, le daremos una decisi

ón

obre su solicitud de excepción dentro los plazos requeridos por el estado, por l

gener

al, dentro de las 24 horas.

13.

¿Cómo puede solicitar una excepción?

Para solicitar una excepción, puede hacer una de estas dos cosas:

Llame al Departamento de Servicio al Cliente. Un representante de dicho

departamento trabajará con usted y con su médico para ayudarle a solicitar una

excepción.

Llame a su médico y pídale que solicite una excepción llamando al Servicio de

Prenotificación al <1-800-310-6826>, o puede enviar una solicitud por fax al

<866-940-7328>.

14.

¿Qué son los medicamentos genéricos?

Los medicamentos genéricos están compuestos por los mismos ingredientes activos

que los medicamentos de marca.

Por lo general, cuestan menos que el medicamento de marca y no tienen nombres muy

conocidos. Los medicamentos genéricos están aprobados por la Administración de

Medicamentos y Alimentos (FDA). En la mayoría de los casos, UnitedHealthcar

ommunity Plan cubre los medicamentos genéricos primero. Si su médico consider

que

un medicamento de marca es médicamente necesario, deberá pedirle a su médico

que envíe una solicitud de aprobación previa.

15.

¿Qué son los medicamentos sin receta?

OTC son las siglas en inglés de “sin receta” (over-the-counter). UnitedHealthcar

ommunity Plan considera algunos medicamentos sin receta como medicamentos

preferidos si su proveedor extiende una receta para estos.

Puede consultar la Lista de Medicamentos Preferidos de UnitedHealthcare Community

Plan para ver qué medicamentos sin receta son los preferidos.

16.

¿Cubre UnitedHealthcare Community Plan productos sin receta que no son

medicamentos?

UnitedHealthcare Community Plan cubre algunos productos sin receta que no son

medicamentos si su proveedor extiende una receta para estos.

Puede consultar la Lista de Medicamentos Preferidos de UnitedHealthcare Community

Plan para ver qué productos sin receta que no son medicamentos están cubiertos.

17.

¿Qué es un medicamento de farmacia especializada?

Un medicamento de farmacia especializada es un medicamento que, por lo general,

tiene una o más de las siguientes características:

•

Es utilizado por una cantidad reducida de personas

•

Trata enfermedades raras, crónicas o potencialmente mortales

•

Tiene requisitos de almacenamiento o manipulación especiales, como la

necesidad de estar refrigerado

•

Es posible que requiera control de cerca, apoyo y manejo clínicos continuos, y

educación y compromiso totales del paciente

•

Es un medicamento de alto costo

•

Es posible que no esté disponible en farmacias de venta al por menor

•

Puede ser de administración oral, inyectable o inhalable

Los medicamentos de farmacia especializada están disponibles a través de nuestra red

de farmacias especializadas.

Si tiene alguna pregunta, llame al Departamento de Servicio al Cliente al <1-877-542-

8997, TTY 711>.

Lista de Medicamentos Preferidos

La Lista de Medicamentos Preferidos que comienza <en la página siguiente> le

proporciona información sobre los medicamentos cubiertos por UnitedHealthcare

Community Plan. Si tiene dificultad para encontrar su medicamento en la lista, consulte

el Índice alfabético que comienza en la página <187>.

La primera columna del cuadro indica el nombre genérico del medicamento. La segunda

columna del cuadro indica los medicamentos de marca. Los medicamentos de marca se

indican en mayúscula (p. ej., CRESTOR). La tercera columna de la lista le indica si el

medicamento preferido cubierto es la versión de marca o la genérica.

La información de la columna “Requisitos y límites” le informa si UnitedHealthcare

Community Plan tiene alguna regla para la cobertura de su medicamento.

Restricciones de administración de la utilización

PA - Aprobación previa (o preautorización)

Para algunos medicamentos, su médico u otro profesional que receta debe

obtener la aprobación de UnitedHealthcare Community Plan antes de que usted

pueda surtir su receta. Si no obtiene la aprobación, es posible que

UnitedHealthcare Community Plan no cubra el medicamento.

QL – Límites de cantidad

A veces, UnitedHealthcare Community Plan limita la cantidad de un

medicamento que usted puede obtener.

ST – Terapia escalonada

A veces, UnitedHealthcare Community Plan requiere que usted haga una terapia

escalonada. Esto significa que deberá probar los medicamentos en un

determinado orden para su condición médica. Usted podría tener que probar un

medicamento antes de que cubramos otro medicamento. Si su médico considera

que el primer medicamento no es adecuado para usted, su médico puede

solicitar la aprobación de la cobertura del segundo.

Otros requisitos especiales de cobertura

SP – Farmacia especializada

Se debe acceder a los medicamentos a través de una farmacia especializada de

la red.

Los medicamentos de farmacia especializada pueden requerir manejo adicional,

coordinación de proveedores o educación del paciente que no se puede realizar

en una farmacia de venta al por menor de la red.

[ABREVIATURAS]

OTC = Sin receta

PA = Se requiere Preautorización

QL = Límite de cantidad

ST = Terapia escalonada

SP = Farmacia especializada

Washington Apple Health

Table of Contents

Analgesics.....................................................................................................................................................................................................................4

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions....................................................................................................11

Anesthetics................................................................................................................................................................................................................. 17

Anesthetics - Drugs for Numbing................................................................................................................................................................................ 17

Anti-Addiction/Substance Abuse Treatment Agents................................................................................................................................................... 18

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence......................................................................................... 19

Antiandrogens - Hormone Suppressants....................................................................................................................................................................20

Antibacterials.............................................................................................................................................................................................................. 20

Antibacterials - Drugs to Treat Bacterial Infections.....................................................................................................................................................26

Anticonvulsants...........................................................................................................................................................................................................26

Anticonvulsants - Drugs to Treat Seizures..................................................................................................................................................................30

Antidementia Agents...................................................................................................................................................................................................30

Antidepressants.......................................................................................................................................................................................................... 32

Antiemetics................................................................................................................................................................................................................. 34

Antifungals.................................................................................................................................................................................................................. 36

Antifungals - Drugs to Treat Fungal Infections............................................................................................................................................................37

Antigout Agents...........................................................................................................................................................................................................37

Anti-HIV Agents, Other - HIV Drugs............................................................................................................................................................................38

Anti-inflammatory Agents - Drugs to Treat Inflammation............................................................................................................................................ 38

Antimigraine Agents....................................................................................................................................................................................................38

Antimigraine Agents - Drugs to Treat Migraines......................................................................................................................................................... 38

Antimyasthenic Agents............................................................................................................................................................................................... 39

Antimycobacterials......................................................................................................................................................................................................40

Antineoplastics............................................................................................................................................................................................................40

Antineoplastics - Drugs to Treat Cancer..................................................................................................................................................................... 45

Antineoplastics, Other - Chemotherapy Agents..........................................................................................................................................................45

Antiparasitics...............................................................................................................................................................................................................45

Antiparasitics - Drugs to Treat Parasitic Infections..................................................................................................................................................... 46

Antiparkinson Agents.................................................................................................................................................................................................. 47

Antipsychotics............................................................................................................................................................................................................. 50

Antispasmodics, Urinary - Bladder Control Drugs...................................................................................................................................................... 53

Antispasticity Agents...................................................................................................................................................................................................53

Antivirals..................................................................................................................................................................................................................... 53

Antivirals - Drugs to Treat Viral Infections...................................................................................................................................................................56

Anxiolytics................................................................................................................................................................................................................... 57

Anxiolytics - Drugs to Treat Anxiety............................................................................................................................................................................ 58

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs................................................................................................. 58

Bipolar Agents.............................................................................................................................................................................................................58

Blood Glucose Regulators.......................................................................................................................................................................................... 59

Blood Glucose Regulators - Drugs to Regulate Blood Sugar..................................................................................................................................... 63

Blood Products and Modifiers..................................................................................................................................................................................... 64

Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders........................................................................................................66

Cardiovascular Agents................................................................................................................................................................................................67

Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions.................................................................................................................75

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs...................................................................................................................................76

Central Nervous System Agents.................................................................................................................................................................................77

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis............................................................................................................................................... 82

Dental and Oral Agents...............................................................................................................................................................................................82

Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions..................................................................................................................... 82

Dermatological Agents................................................................................................................................................................................................83

Dermatological Agents - Drugs to Treat Skin Conditions............................................................................................................................................91

Diabetes - Glucose Monitoring....................................................................................................................................................................................93

Diabetic/Endocrine Blood: Glucose Monitoring.........................................................................................................................................................104

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs............................................................................................ 104

Electrolytes/Minerals/Metals/Vitamins...................................................................................................................................................................... 105

Estrogens - Hormone Replacement/Modifying Drugs...............................................................................................................................................113

Gastrointestinal Agents.............................................................................................................................................................................................114

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions................................................................................................ 119

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment.......................................................................................................... 127

Genitourinary Agents................................................................................................................................................................................................ 128

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...................................................................................................... 130

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)...............................................................................................................................130

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary).............................................................................................................................. 132

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones............................................................................ 133

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)................................................................................................................... 133

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones..................................................................133

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)....................................................................................................134

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones.................................................. 143

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)............................................................................................................................... 144

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones..................................................................144

Hormonal Agents, Suppressant (Adrenal)................................................................................................................................................................ 145

Hormonal Agents, Suppressant (Pituitary)................................................................................................................................................................145

Hormonal Agents, Suppressant (Thyroid).................................................................................................................................................................145

Immune Suppressants - Immune System Drugs...................................................................................................................................................... 146

Immunological Agents...............................................................................................................................................................................................146

Immunological Agents - Drugs that Stimulate or Suppress the Immune System..................................................................................................... 151

Inflammatory Bowel Disease Agents........................................................................................................................................................................ 152

Metabolic Bone Disease Agents............................................................................................................................................................................... 153

Miscellaneous Therapeutic Agents........................................................................................................................................................................... 153

Molecular Target Inhibitors - Chemotherapy Agents................................................................................................................................................ 172

Monoclonal Antibodies - Chemotherapy Agents.......................................................................................................................................................173

Multiple Sclerosis Agents - Multiple Sclerosis Drugs................................................................................................................................................ 173

Ophthalmic Agents....................................................................................................................................................................................................174

Ophthalmic Agents - Drugs to Treat Eye Conditions................................................................................................................................................ 179

Otic Agents............................................................................................................................................................................................................... 181

Otic Agents - Drugs to Treat Ear Conditions.............................................................................................................................................................182

Respiratory Tract/Pulmonary Agents........................................................................................................................................................................ 183

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions....................................................................... 191

Sedatives/Hypnotics - Drugs for Sedation and Sleep............................................................................................................................................... 200

Skeletal Muscle Relaxants........................................................................................................................................................................................200

Sleep Disorder Agents.............................................................................................................................................................................................. 201

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies........................................................... 202

Preferred Agents Non-Preferred Agents

Analgesics

Nonsteroidal Anti-inflammatory Drugs

ADVIL JUNIOR STRENGTH (brand for cvs ibuprofen childrens) - Tier

2; QL

all day pain relief oral tablet 220 mg (generic for MEDIPROXEN) - Tier

1; QL

all day relief (generic for MEDIPROXEN) - Tier 1; QL

CAMBIA (brand for diclofenac potassium(migraine)) - Tier 2; PA; QL

diclofenac potassium oral tablet 25 mg (generic for LOFENA) - Tier 1

diclofenac potassium oral tablet 50 mg - Tier 1; QL

diclofenac potassium(migraine) (generic for CAMBIA) - Tier 1; PA; QL

diclofenac sodium er - Tier 1; QL

diclofenac sodium external gel 1 % (generic for ALEVE ARTHRITIS

PAIN) - Tier 1; PA; QL

diclofenac sodium external solution 1.5 % - Tier 1; QL

diclofenac sodium oral - Tier 1; QL

ANAPROX DS (brand for naproxen sodium) - Tier 2; PA*; QL

ARTHROTEC (brand for diclofenac-misoprostol) - Tier 2; PA; QL

CALDOLOR INTRAVENOUS SOLUTION 800 MG/200ML - Tier 2; PA

CELEBREX (brand for celecoxib) - Tier 2; PA; QL

celecoxib capsule 100 mg oral (generic for CELEBREX) - Tier 1; PA; QL

celecoxib capsule 100 mg oral (generic for CELEBREX) - Tier 1; PA*; QL

celecoxib capsule 200 mg oral (generic for CELEBREX) - Tier 1; PA; QL

celecoxib capsule 200 mg oral (generic for CELEBREX) - Tier 1; PA*; QL

celecoxib capsule 50 mg oral (generic for CELEBREX) - Tier 1; PA; QL

celecoxib capsule 50 mg oral (generic for CELEBREX) - Tier 1; PA*; QL

celecoxib oral capsule 400 mg (generic for CELEBREX) - Tier 1; PA*; QL

DAYPRO (brand for oxaprozin) - Tier 2; PA; QL

DICLOFENAC PATCH 1.3% (brand for diclofenac epolamine) - Tier 2;

PA*; QL

ec-naproxen (generic for EC-NAPROSYN) - Tier 1; QL

ELYXYB - Tier 2; PA

flurbiprofen oral - Tier 1; QL

ft all day pain relief (generic for MEDIPROXEN) - Tier 1; QL

ft ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) -

Tier 1; QL

ft ibuprofen oral tablet (generic for MEDI-FIRST IBUPROFEN) - Tier 1;

ft pain relief oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN)

- Tier 1; QL

ibuprofen (generic for IBU) - Tier 1; QL

ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL

JUNIOR STRENGTH) - Tier 1; QL

diclofenac potassium oral capsule (generic for ZIPSOR) - Tier 1; PA; QL

diclofenac sodium solution 2 % external (generic for PENNSAID) - Tier 1;

PA*; QL

diclofenac sodium solution 2 % external (generic for PENNSAID) - Tier 1;

PA; QL

diclofenac-misoprostol (generic for ARTHROTEC) - Tier 1; PA*; QL

diflunisal oral - Tier 1; PA*; QL

DUEXIS (brand for ibuprofen-famotidine) - Tier 2; PA; QL

EC-NAPROSYN (brand for ec-naproxen) - Tier 2; PA; QL

etodolac (generic for LODINE) - Tier 1; PA*; QL

etodolac er - Tier 1; PA*; QL

fenoprofen calcium capsule 400 mg oral (generic for NALFON) - Tier 1;

PA*

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier

1; QL

ibuprofen ib oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN)

- Tier 1; QL

ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS

ADVIL) - Tier 1; QL

ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR

STRENGTH) - Tier 1; QL

ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL

ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) -

Tier 1; QL

ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS

ADVIL) - Tier 1; QL

fenoprofen calcium capsule 400 mg oral (generic for NALFON) - Tier 1;

fenoprofen calcium oral tablet (generic for NALFON) - Tier 1; PA*; QL

FLECTOR (brand for diclofenac epolamine) - Tier 2; PA*; QL

ibuprofen-famotidine (generic for DUEXIS) - Tier 1; PA; QL

INDOCIN (brand for indomethacin) - Tier 2; PA; QL

indomethacin er - Tier 1; PA*; QL

indomethacin oral suspension (generic for INDOCIN) - Tier 1; PA; QL

ketoprofen er - Tier 1; PA*; QL

ketoprofen oral capsule 25 mg (generic for KIPROFEN) - Tier 1; PA*; QL

KIPROFEN (brand for ketoprofen) - Tier 2; PA; QL

LICART - Tier 2; PA*; QL

LODINE (brand for etodolac) - Tier 2; PA; QL

LOFENA (brand for diclofenac potassium) - Tier 2; PA

ibuprofen oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN) -

Tier 1; QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier

1; QL

indomethacin oral capsule - Tier 1; QL

indomethacin rectal suppository 50 mg (generic for INDOCIN) - Tier 1;

infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; QL

ketorolac tromethamine injection solution 15 mg/ml - Tier 1; PA; QL

ketorolac tromethamine intramuscular solution 60 mg/2ml - Tier 1; PA;

ketorolac tromethamine oral - Tier 1; QL

ketorolac tromethamine solution 30 mg/ml injection - Tier 1; PA; QL

meclofenamate sodium oral - Tier 1; PA*; QL

mefenamic acid oral - Tier 1; PA*; QL

meloxicam oral capsule - Tier 1; PA; QL

NALFON ORAL CAPSULE (brand for fenoprofen calcium) - Tier 2; PA

NALFON ORAL TABLET (brand for fenoprofen calcium) - Tier 2; PA; QL

NAPRELAN (brand for naproxen sodium er) - Tier 2; PA

NAPROSYN (brand for naproxen) - Tier 2; PA; QL

naproxen oral suspension (generic for NAPROSYN) - Tier 1; PA; QL

naproxen sodium er (generic for NAPRELAN) - Tier 1; PA*

naproxen sodium oral tablet 275 mg - Tier 1; PA*; QL

naproxen sodium oral tablet 550 mg (generic for ANAPROX DS) - Tier 1;

PA*; QL

naproxen-esomeprazole mg (generic for VIMOVO) - Tier 1; PA; QL

oxaprozin oral tablet (generic for DAYPRO) - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

KETOROLAC TROMETHAMINE SOLUTION 30 MG/ML INJECTION -

Tier 2; PA; QL

medi-first ibuprofen (generic for MEDI-FIRST IBUPROFEN) - Tier 1;

mediproxen (generic for MEDIPROXEN) - Tier 1; QL

meloxicam oral tablet - Tier 1; QL

mm ibuprofen (generic for MEDI-FIRST IBUPROFEN) - Tier 1; QL

MOTRIN CHILDRENS (brand for cvs ibuprofen childrens) - Tier 2; QL

MOTRIN IB ORAL TABLET (brand for cvs ibuprofen) - Tier 2; QL

nabumetone oral - Tier 1; QL

naproxen dr (generic for EC-NAPROSYN) - Tier 1; QL

naproxen oral tablet (generic for NAPROSYN) - Tier 1; QL

naproxen oral tablet delayed release (generic for EC-NAPROSYN) -

Tier 1; QL

PENNSAID (brand for diclofenac sodium) - Tier 2; PA*; QL

piroxicam oral - Tier 1; PA*; QL

RELAFEN DS - Tier 2; PA; QL

SPRIX - Tier 2; PA

TOLECTIN 600 - Tier 2; PA; QL

tolmetin sodium - Tier 1; PA; QL

VIMOVO (brand for naproxen-esomeprazole mg) - Tier 2; PA; QL

ZIPSOR (brand for diclofenac potassium) - Tier 2; PA; QL

naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier

1; QL

sulindac oral - Tier 1; QL

Opioid Analgesics, Long-acting

buprenorphine (generic for BUTRANS) - Tier 1; QL

BUTRANS (brand for buprenorphine) - Tier 2; QL

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr,

50 mcg/hr, 75 mcg/hr - Tier 1; PA; QL

morphine sulfate er oral tablet extended release (generic for MS

CONTIN) - Tier 1; PA; QL

tramadol hcl er - Tier 1; PA; QL; AL

BELBUCA - Tier 2; PA*; QL

CONZIP (brand for tramadol hcl (er biphasic)) - Tier 2; PA*; QL; AL

fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr

- Tier 1; PA*; QL

hydrocodone bitartrate er (generic for HYSINGLA ER) - Tier 1; PA*; QL

hydromorphone hcl er - Tier 1; PA*; QL

HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA*; QL

levorphanol tartrate oral - Tier 1; PA*; QL

methadone hcl injection - Tier 1; PA; QL

methadone hcl intensol (generic for METHADONE HCL INTENSOL) - Tier

1; PA; QL

methadone hcl oral (generic for METHADONE HCL INTENSOL) - Tier 1;

PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

METHADOSE ORAL CONCENTRATE 10 MG/ML (brand for methadone

hcl) - Tier 2; PA; QL

methadose oral tablet soluble (generic for METHADOSE) - Tier 1; PA; QL

METHADOSE SUGAR-FREE (brand for methadone hcl) - Tier 2; PA; QL

morphine sulfate er beads - Tier 1; PA*; QL

morphine sulfate er oral capsule extended release 24 hour - Tier 1; PA*;

MS CONTIN (brand for morphine sulfate er) - Tier 2; PA; QL

NUCYNTA ER - Tier 2; PA*; QL

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-

DETERRENT 10 MG, 40 MG (brand for oxycodone hcl er) - Tier 2; PA*;

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20

MG ORAL (brand for oxycodone hcl er) - Tier 2; PA*; QL

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20

MG ORAL (brand for oxycodone hcl er) - Tier 2; PA; QL

OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA*; QL

oxymorphone hcl er - Tier 1; PA*; QL

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG

- Tier 2; PA*; QL

TRAMADOL HCL (ER BIPHASIC) ORAL CAPSULE EXTENDED

RELEASE 24 HOUR (brand for tramadol hcl (er biphasic)) - Tier 2; PA*;

QL; AL

tramadol hcl (er biphasic) oral tablet extended release 24 hour - Tier 1;

PA*; QL; AL

tramadol hcl oral tablet 25 mg - Tier 1; PA; QL; AL

XTAMPZA ER - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Opioid Analgesics, Short-acting

acetaminophen-codeine - Tier 1; QL; AL

ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL; AL

bac (generic for BAC) - Tier 1; QL

butalbital-apap-caff-cod (generic for FIORICET/CODEINE) - Tier 1; QL

butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL

butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1;

QL; AL

codeine sulfate oral tablet 30 mg, 60 mg - Tier 1; QL; AL

endocet (generic for ENDOCET) - Tier 1; QL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1;

hydrocodone-acetaminophen oral tablet (generic for XODOL) - Tier 1;

hydrocodone-ibuprofen - Tier 1; QL

ALLZITAL - Tier 2; PA*; QL

APADAZ (brand for benzhydrocodone-acetaminophen) - Tier 2; PA*; QL

apap-caff-dihydrocodeine (generic for TREZIX) - Tier 1; PA*; QL

BENZHYDROCODONE-ACETAMINOPHEN (brand for

benzhydrocodone-acetaminophen) - Tier 2; PA*; QL

BUPAP (brand for butalbital-acetaminophen) - Tier 2; PA*; QL

butalbital-acetaminophen capsule 50-300 mg oral - Tier 1; PA*; QL

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL - Tier 2;

PA*; QL

butalbital-acetaminophen tablet 50-300 mg oral (generic for BUPAP) -

Tier 1; PA*; QL

butalbital-acetaminophen tablet 50-300 mg oral (generic for BUPAP) -

Tier 1; PA; QL

hydromorphone hcl oral tablet (generic for DILAUDID) - Tier 1; QL

hydromorphone hcl rectal - Tier 1; QL

morphine sulfate oral tablet - Tier 1; QL

morphine sulfate rectal - Tier 1; QL

oxycodone hcl oral solution - Tier 1; QL

oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325

mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL

tramadol hcl oral tablet 50 mg - Tier 1; QL; AL

tramadol-acetaminophen - Tier 1; QL; AL

butalbital-acetaminophen tablet 50-325 mg oral (generic for TENCON) -

Tier 1; PA; QL

butalbital-acetaminophen tablet 50-325 mg oral (generic for TENCON) -

Tier 1; PA*; QL

butalbital-apap-caffeine capsule 50-300-40 mg oral (generic for

FIORICET) - Tier 1; PA*; QL

butalbital-apap-caffeine capsule 50-300-40 mg oral (generic for

FIORICET) - Tier 1; PA; QL

butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for ESGIC) -

Tier 1; PA*; QL

butalbital-aspirin-caffeine - Tier 1; PA*; QL

butorphanol tartrate nasal - Tier 1; PA*; QL

DILAUDID ORAL LIQUID (brand for hydromorphone hcl) - Tier 2; PA*; QL

DILAUDID ORAL TABLET (brand for hydromorphone hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ESGIC ORAL CAPSULE (brand for butalbital-apap-caffeine) - Tier 2; PA*;

ESGIC ORAL TABLET (brand for butalbital-apap-caffeine) - Tier 2; PA;

FENTANYL CITRATE (BULK) - Tier 2; PA

fentanyl citrate buccal lozenge on a handle - Tier 1; PA; QL

FENTANYL CITRATE BUCCAL TABLET (brand for fentanyl citrate) - Tier

2; PA; QL

FENTORA (brand for fentanyl citrate) - Tier 2; PA; QL

FIORICET (brand for butalbital-apap-caffeine) - Tier 2; PA*; QL

FIORICET/CODEINE (brand for butalbital-apap-caff-cod) - Tier 2; PA; QL

hydromorphone hcl oral liquid (generic for DILAUDID) - Tier 1; PA*; QL

meperidine hcl oral solution - Tier 1; PA*; QL

meperidine hcl tablet 50 mg oral - Tier 1; PA*; QL

meperidine hcl tablet 50 mg oral - Tier 1; PA; QL

MORPHINE SULFATE (BULK) - Tier 2; PA

morphine sulfate (concentrate) oral solution 20 mg/ml - Tier 1; PA*; QL

morphine sulfate (concentrate) solution 100 mg/5ml oral - Tier 1; PA; QL

morphine sulfate (concentrate) solution 100 mg/5ml oral - Tier 1; PA*; QL

morphine sulfate oral solution 20 mg/5ml - Tier 1; PA; QL

morphine sulfate solution 10 mg/5ml oral - Tier 1; PA; QL

morphine sulfate solution 10 mg/5ml oral - Tier 1; PA*; QL

NALOCET - Tier 2; PA; QL

NUCYNTA - Tier 2; PA*; QL

oxycodone hcl oral capsule - Tier 1; PA*; QL

oxycodone hcl oral concentrate - Tier 1; PA; QL

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION (brand for

oxycodone-acetaminophen) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG, 5-300

MG, 7.5-300 MG (brand for oxycodone-acetaminophen) - Tier 2; PA; QL

OXYCODONE-ACETAMINOPHEN ORAL TABLET 2.5-300 MG - Tier 2;

PA; QL

oxymorphone hcl - Tier 1; PA*; QL

pentazocine-naloxone hcl - Tier 1; PA*; QL

PERCOCET (brand for oxycodone-acetaminophen) - Tier 2; PA; QL

PROLATE (brand for oxycodone-acetaminophen) - Tier 2; PA; QL

QDOLO (brand for tramadol hcl) - Tier 2; PA; QL; AL

SEGLENTIS - Tier 2; PA; QL

TENCON (brand for butalbital-acetaminophen) - Tier 2; PA*; QL

TRAMADOL HCL ORAL SOLUTION (brand for tramadol hcl) - Tier 2; PA;

QL; AL

tramadol hcl oral tablet 100 mg - Tier 1; PA*; QL; AL

TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA*; QL

Opioid Dependence Treatments -

Antidotes/Deterrents/Protectants

buprenorphine hcl sublingual - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and

Joint Conditions

Analgesics - Miscellaneous Analgesics

8 hour arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL

8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

8 hour pain relief oral tablet extended release 650 mg (generic for

TYLENOL 8 HOUR) - Tier 1; QL

8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL

8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL

acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL

acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL

acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1;

acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier

1; QL

acetaminophen childrens (generic for MAPAP CHILDRENS) - Tier 1;

acetaminophen childrens oral suspension 160 mg/5ml (generic for

MAX RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL

acetaminophen ex st oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - Tier 1; QL

acetaminophen extra strength (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

acetaminophen infants (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

acetaminophen oral liquid 160 mg/5ml (generic for LITTLE REMEDIES

FOR FEVER) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650

mg/20.3ml - Tier 1; QL

acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic

for MAX RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1;

acetaminophen oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - Tier 1; QL

acetaminophen oral tablet chewable 160 mg (generic for MAPAP

CHILDRENS) - Tier 1; QL

acetaminophen rectal suppository 120 mg (generic for FEVERALL

CHILDRENS) - Tier 1; QL

acetaminophen rectal suppository 650 mg (generic for FEVERALL

ADULTS) - Tier 1; QL

arthritis pain oral tablet extended release 650 mg (generic for

TYLENOL 8 HOUR) - Tier 1; QL

arthritis pain relief oral tablet extended release 650 mg (generic for

TYLENOL 8 HOUR) - Tier 1; QL

arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL

betatemp childrens (generic for MAX RELIEF JR CHILD PAIN/FEVER)

- Tier 1; QL

childrens acetaminophen (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL

childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL

childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier

1; QL

childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

CURANOL - Tier 2; QL

ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL

fever reducer/pain reliever (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier

1; QL

feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL

feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL

FEVERALL INFANTS - Tier 2; QL

FEVERALL JUNIOR STRENGTH - Tier 2; QL

ft 8 hour pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

ft arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL

ft children's pain/fever (generic for MAPAP CHILDRENS) - Tier 1; QL

ft pain & fever childrens (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

ft pain & fever infants (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

ft pain relief adult extra st (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

ft pain relief extra strength (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

ft pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

ft pain reliever ex str adult (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

infants pain & fever (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

infants pain relief drops (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

infants pain/fever (generic for MAX RELIEF JR CHILD PAIN/FEVER) -

Tier 1; QL

liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) -

Tier 1; QL

liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier

1; QL

mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL

MAX RELIEF JR CHILD PAIN/FEVER (brand for acetaminophen) -

Tier 2; QL

mm acetaminophen ex str (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL

m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL

non-aspirin (generic for MM ACETAMINOPHEN EX STR) - Tier 1; QL

non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL

non-aspirin childrens (generic for MAPAP CHILDRENS) - Tier 1; QL

non-aspirin extra strength (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL

non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL

pain & fever child (generic for MAX RELIEF JR CHILD PAIN/FEVER) -

Tier 1; QL

pain & fever childrens (generic for MAPAP CHILDRENS) - Tier 1; QL

pain & fever childrens oral suspension 160 mg/5ml (generic for MAX

RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

pain & fever infants oral suspension 160 mg/5ml (generic for MAX

RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

pain and fever relief kids (generic for LITTLE REMEDIES FOR

FEVER) - Tier 1; QL

pain relief childrens oral suspension (generic for MAX RELIEF JR

CHILD PAIN/FEVER) - Tier 1; QL

pain relief childrens oral tablet chewable 160 mg (generic for MAPAP

CHILDRENS) - Tier 1; QL

pain relief extra st (generic for MM ACETAMINOPHEN EX STR) - Tier

1; QL

pain relief extra strength oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - Tier 1; QL

pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

pain relief oral tablet 500 mg (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

pain relief oral tablet extended release 650 mg (generic for TYLENOL

8 HOUR) - Tier 1; QL

pain relief regular strength (generic for PHARBETOL) - Tier 1; QL

pain reliever childrens oral suspension 160 mg/5ml (generic for MAX

RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

pain reliever ex st oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - Tier 1; QL

pain reliever extra strength oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - Tier 1; QL

pain reliever oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

pain reliever oral tablet 500 mg (generic for MM ACETAMINOPHEN

EX STR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

PANADOL CHILDRENS (brand for acetaminophen) - Tier 2; QL

PANADOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;

PANADOL INFANTS (brand for acetaminophen) - Tier 2; QL

PHARBETOL (brand for acetaminophen) - Tier 2; QL

PHARBETOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;

sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

sb pain reliever childrens (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

TYLENOL FOR CHILDREN + ADULTS (brand for acetaminophen) -

Tier 2; QL

TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for

acetaminophen) - Tier 2; QL

TYLENOL ORAL TABLET 325 MG, 500 MG (brand for

acetaminophen) - Tier 2; QL

TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for

acetaminophen) - Tier 2; QL

TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for

8 hour arthritis pain) - Tier 2; QL

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory

Drugs

inavix (generic for INFLAMMACIN) - Tier 1; PA*

INFLAMMACIN (brand for inavix) - Tier 2; PA*

NUDICLO TABPAK (brand for inavix) - Tier 2; PA*

previdolrx plus analgesic (generic for INFLAMMACIN) - Tier 1; PA*

salsalate tablet 500 mg oral - Tier 1; PA; QL

salsalate tablet 500 mg oral - Tier 1; PA*; QL

salsalate tablet 750 mg oral - Tier 1; PA; QL

salsalate tablet 750 mg oral - Tier 1; PA*; QL

Opioid Analgesics, Short-acting

oxycodone hcl oral tablet (generic for ROXICODONE) - Tier 1; QL ROXICODONE (brand for oxycodone hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anesthetics

Local Anesthetics

glydo (generic for GLYDO) - Tier 1; QL

lidocaine external ointment 5 % - Tier 1; QL

lidocaine external patch 5 % (generic for LIDOCAN) - Tier 1; QL

lidocaine hcl external cream 3 % - Tier 1; QL

lidocaine hcl external solution - Tier 1

lidocaine hcl urethral/mucosal (generic for GLYDO) - Tier 1; QL

lidocaine viscous hcl - Tier 1; QL

lidocaine-prilocaine external cream - Tier 1; QL

LIDOCAN PATCH 5 % EXTERNAL (brand for lidocaine) - Tier 2; QL

lidopin external cream 3 % - Tier 1; QL

premium lidocaine - Tier 1; QL

AGONEAZE (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

ANODYNE LPT (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

BRUSELIX EXTERNAL CREAM - Tier 2; PA

BUPIVACAINE HCL (BULK) - Tier 2; PA

LIDO BDK (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

lidocaine hcl mouth/throat - Tier 1; PA

lidocaine-prilocaine external kit (generic for LIDO BDK) - Tier 1; PA*; QL

LIDOCAN PATCH 5 % EXTERNAL (brand for lidocaine) - Tier 2; PA; QL

LIDODERM (brand for lidocaine) - Tier 2; PA; QL

LIDOTRAL EXTERNAL CREAM - Tier 2; PA*

LIDOTRAN - Tier 2; PA*

LIVIXIL PAK (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

PLIAGLIS EXTERNAL CREAM - Tier 2; PA*

PRILOVIX (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

PRILOVIX LITE (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

PRILOVIX LITE PLUS (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

PRILOVIX PLUS (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

PRILOVIX ULTRALITE (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

PRILOVIX ULTRALITE PLUS (brand for lidocaine-prilocaine) - Tier 2;

PA*; QL

RELADOR PAK (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

RELADOR PAK PLUS (brand for lidocaine-prilocaine) - Tier 2; PA*; QL

ZTLIDO - Tier 2; PA*; QL

Anesthetics - Drugs for Numbing

Local Anesthetics

LIDOPURE PATCH - Tier 2; PA*; QL

LIDOTHOL EXTERNAL PATCH 4-1 % (brand for zeruvia) - Tier 2; PA

XYLIDERM - Tier 2; PA*; QL

ZERUVIA (brand for zeruvia) - Tier 2; PA*

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-craving

acamprosate calcium - Tier 1

disulfiram oral - Tier 1

naltrexone hcl oral - Tier 1

VIVITROL - Tier 2; QL

Opioid Dependence

BRIXADI - Tier 2; QL

BRIXADI (WEEKLY) - Tier 2; QL

buprenorphine hcl-naloxone hcl sublingual tablet sublingual - Tier 1;

SUBLOCADE - Tier 2; SP; QL

SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; QL

buprenorphine hcl-naloxone hcl sublingual film (generic for SUBOXONE) -

Tier 1; PA; QL

LUCEMYRA - Tier 2; PA; QL

ZUBSOLV - Tier 2; PA; QL

Opioid Reversal Agents

KLOXXADO - Tier 2

naloxone hcl injection - Tier 1

naloxone hcl nasal (generic for NARCAN) - Tier 1

REXTOVY - Tier 2; QL

ZIMHI - Tier 2

NARCAN (brand for naloxone hcl) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Smoking Cessation Agents

bupropion hcl er (smoking det) - Tier 1; QL

habitrol (generic for HABITROL) - Tier 1; QL

nicotine step 1 (generic for HABITROL) - Tier 1; QL

nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL

nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL

nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for

NICODERM CQ) - Tier 1; QL

nicotine transdermal patch 24 hour 21 mg/24hr (generic for

HABITROL) - Tier 1; QL

nicotine transdermal system (generic for HABITROL) - Tier 1; QL

varenicline tartrate (generic for CHANTIX) - Tier 1; QL

varenicline tartrate (starter) - Tier 1; QL

varenicline tartrate(continue) (generic for CHANTIX) - Tier 1; QL

NICODERM CQ (brand for cvs nicotine) - Tier 2; PA; QL

nicotine transdermal kit 21-14-7 mg/24hr - Tier 1; PA; QL

NICOTROL - Tier 2; PA; QL

NICOTROL NS - Tier 2; PA; QL

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for

Overdose or Deterrence

Smoking Cessation Agents - Deterrents

ft nicotine (generic for KLS QUIT2) - Tier 1; QL

ft nicotine mini (generic for KLS QUIT2) - Tier 1; QL

mini nicotine (generic for KLS QUIT2) - Tier 1; QL

nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1;

nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1;

nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) -

Tier 1; QL

nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) -

Tier 1; QL

nicotine mini (generic for KLS QUIT2) - Tier 1; QL

nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL

nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL

NICORETTE (brand for cvs nicotine) - Tier 2; PA; QL

NICORETTE MINI (brand for cvs nicotine) - Tier 2; PA; QL

NICORETTE STARTER KIT (brand for cvs nicotine) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1;

nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1;

nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; QL

nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL

quit2 (generic for KLS QUIT2) - Tier 1; QL

quit4 (generic for KLS QUIT4) - Tier 1; QL

THRIVE (brand for cvs nicotine) - Tier 2; QL

Antiandrogens - Hormone Suppressants

Antineoplastics - Drugs to Treat Cancer

ORGOVYX - Tier 2; PA; SP; QL

Antibacterials

Aminoglycosides

neomycin sulfate oral - Tier 1; QL ARIKAYCE - Tier 2; PA; SP; QL

Antibacterials, Other

CLEOCIN VAGINAL SUPPOSITORY - Tier 2; QL

clindamycin hcl oral (generic for CLEOCIN) - Tier 1; QL

clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL

clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL

FIRVANQ (brand for vancomycin hcl) - Tier 2; QL

LINCOCIN (brand for lincomycin hcl) - Tier 2; PA; QL

lincomycin hcl injection (generic for LINCOCIN) - Tier 1; PA; QL

linezolid oral tablet (generic for ZYVOX) - Tier 1

methenamine hippurate (generic for HIPREX) - Tier 1; QL

metronidazole external (generic for METROCREAM) - Tier 1

metronidazole oral (generic for FLAGYL) - Tier 1; QL

metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg (generic for

MACRODANTIN) - Tier 1; QL

AEMCOLO - Tier 2; PA; QL

CLEOCIN ORAL (brand for clindamycin hcl) - Tier 2; PA; QL

CLEOCIN VAGINAL CREAM (brand for clindamycin phosphate) - Tier 2;

PA; QL

CLINDESSE - Tier 2; PA

FLAGYL (brand for metronidazole) - Tier 2; PA*; QL

fosfomycin tromethamine - Tier 1; PA

HIPREX (brand for methenamine hippurate) - Tier 2; PA; QL

LIKMEZ - Tier 2; PA; QL

linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1; PA;

MACROBID (brand for nitrofurantoin monohyd macro) - Tier 2; PA; QL

MACRODANTIN (brand for nitrofurantoin macrocrystal) - Tier 2; PA; QL

METROCREAM (brand for metronidazole) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

nitrofurantoin monohydrate macrocrystals (generic for MACROBID) -

Tier 1; QL

NUVESSA - Tier 2; QL

SOLOSEC - Tier 2; PA; QL

tigecycline (generic for TYGACIL) - Tier 1; PA

tinidazole oral - Tier 1; QL

trimethoprim oral - Tier 1; QL

vancomycin hcl oral (generic for FIRVANQ) - Tier 1; QL

XIFAXAN - Tier 2; PA; QL

METROGEL (brand for metronidazole) - Tier 2; PA

METROLOTION (brand for metronidazole) - Tier 2; PA

nitrofurantoin macrocrystal capsule 25 mg oral (generic for

MACRODANTIN) - Tier 1; PA; QL

nitrofurantoin macrocrystal capsule 25 mg oral (generic for

MACRODANTIN) - Tier 1; PA*; QL

nitrofurantoin oral suspension 25 mg/5ml - Tier 1; PA; QL; AL

NITROFURANTOIN ORAL SUSPENSION 50 MG/5ML - Tier 2; PA

NORITATE - Tier 2; PA*

SIVEXTRO ORAL - Tier 2; PA*; QL

TYGACIL (brand for tigecycline) - Tier 2; PA

VANCOCIN ORAL CAPSULE 250 MG (brand for vancomycin hcl) - Tier

2; PA; QL

VANDAZOLE (brand for metronidazole) - Tier 2; PA; QL

XACIATO - Tier 2; PA; QL

ZYVOX ORAL SUSPENSION RECONSTITUTED (brand for linezolid) -

Tier 2; PA; QL

ZYVOX ORAL TABLET (brand for linezolid) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Beta-lactam, Cephalosporins

cefaclor oral capsule - Tier 1; QL

cefadroxil - Tier 1; QL

cefazolin sodium injection solution reconstituted 1 gm, 10 gm - Tier 1;

cefazolin sodium-dextrose intravenous solution 2-4 gm/100ml-% - Tier

1; PA

cefdinir - Tier 1; QL

cefepime hcl intravenous solution reconstituted 2 gm - Tier 1; PA

cefixime oral capsule - Tier 1; QL

cefotetan disodium (generic for CEFOTAN) - Tier 1; PA

cefoxitin sodium intravenous solution reconstituted 10 gm - Tier 1; PA

cefprozil - Tier 1; QL

ceftazidime injection (generic for TAZICEF) - Tier 1; PA

ceftazidime intravenous (generic for TAZICEF) - Tier 1; PA

cefaclor er - Tier 1; PA*; QL

cefaclor oral suspension reconstituted - Tier 1; PA; QL

cefixime oral suspension reconstituted - Tier 1; PA*; QL; AL

CEFOTAN (brand for cefotetan disodium) - Tier 2; PA

cefpodoxime proxetil oral suspension reconstituted - Tier 1; PA; QL

cefpodoxime proxetil oral tablet - Tier 1; PA*; QL

cephalexin oral tablet - Tier 1; PA; QL

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250

mg, 500 mg - Tier 1; PA

cefuroxime axetil - Tier 1; QL

cephalexin oral capsule - Tier 1; QL

cephalexin oral suspension reconstituted - Tier 1; QL

FETROJA - Tier 2; PA

tazicef injection (generic for TAZICEF) - Tier 1; PA

tazicef intravenous solution reconstituted (generic for TAZICEF) - Tier

1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Beta-lactam, Penicillins

amoxicillin - Tier 1; QL

amoxicillin-potassium clavulanate oral suspension reconstituted 200-

28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml - Tier 1; QL

amoxicillin-potassium clavulanate oral suspension reconstituted 600-

42.9 mg/5ml (generic for AUGMENTIN ES-600) - Tier 1; QL

amoxicillin-potassium clavulanate oral tablet 250-125 mg, 875-125 mg

- Tier 1; QL

amoxicillin-potassium clavulanate oral tablet 500-125 mg (generic for

AUGMENTIN) - Tier 1; QL

ampicillin - Tier 1; QL

BICILLIN L-A - Tier 2; PA; QL

dicloxacillin sodium - Tier 1; QL

penicillin g potassium injection solution reconstituted 5000000 unit

(generic for PFIZERPEN) - Tier 1; PA

amoxicillin-potassium clavulanate er - Tier 1; PA; QL

amoxicillin-potassium clavulanate oral tablet chewable 200-28.5 mg, 400-

57 mg - Tier 1; PA; QL

ampicillin-sulbactam sodium injection solution reconstituted 3 (2-1) gm

(generic for UNASYN) - Tier 1; PA

AUGMENTIN (brand for amoxicillin-pot clavulanate) - Tier 2; PA; QL

AUGMENTIN ES-600 (brand for amoxicillin-pot clavulanate) - Tier 2; PA;

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 5000000 UNIT

(brand for penicillin g potassium) - Tier 2; PA

UNASYN INJECTION SOLUTION RECONSTITUTED 3 (2-1) GM (brand

for ampicillin-sulbactam sodium) - Tier 2; PA

penicillin g sodium - Tier 1; PA; QL

penicillin v potassium - Tier 1; QL

piperacillin sod-tazobactam so intravenous solution reconstituted 4-0.5

gm, 4.5 (4-0.5) gm - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Macrolides

azithromycin oral packet (generic for ZITHROMAX) - Tier 1; PA; QL

azithromycin oral suspension reconstituted (generic for ZITHROMAX) -

Tier 1; QL

azithromycin oral tablet (generic for ZITHROMAX) - Tier 1; QL

clarithromycin oral - Tier 1; QL

ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 500 MG

(brand for erythromycin) - Tier 2; QL

erythromycin base oral capsule delayed release particles - Tier 1; QL

erythromycin base oral tablet delayed release (generic for ERY-TAB) -

Tier 1; QL

erythromycin ethylsuccinate oral suspension reconstituted 200 mg/5ml

(generic for E.E.S. GRANULES) - Tier 1; QL

erythromycin ethylsuccinate oral tablet (generic for E.E.S. 400) - Tier

1; QL

clarithromycin er tablet extended release 24 hour 500 mg oral - Tier 1;

PA*; QL

clarithromycin er tablet extended release 24 hour 500 mg oral - Tier 1;

PA; QL

DIFICID ORAL SUSPENSION RECONSTITUTED - Tier 2; PA; QL

DIFICID ORAL TABLET - Tier 2; PA*; QL

E.E.S. 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL

E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; PA;

ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL

ERYPED 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL

ERY-TAB ORAL TABLET DELAYED RELEASE 333 MG (brand for

erythromycin) - Tier 2; PA; QL

erythromycin oral (generic for ERY-TAB) - Tier 1; QL ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2;

PA*; QL

erythromycin base oral tablet - Tier 1; PA*; QL

erythromycin ethylsuccinate oral suspension reconstituted 400 mg/5ml

(generic for ERYPED 400) - Tier 1; PA; QL

ZITHROMAX ORAL (brand for azithromycin) - Tier 2; PA; QL

ZITHROMAX TRI-PAK (brand for azithromycin) - Tier 2; PA; QL

ZITHROMAX Z-PAK (brand for azithromycin) - Tier 2; PA; QL

Quinolones

CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL

ciprofloxacin hcl oral (generic for CIPRO) - Tier 1; QL

levofloxacin oral tablet - Tier 1; QL

moxifloxacin hcl oral - Tier 1; QL

BAXDELA ORAL - Tier 2; PA*; QL

CIPRO ORAL TABLET (brand for ciprofloxacin hcl) - Tier 2; PA; QL

levofloxacin solution 25 mg/ml oral - Tier 1; PA

levofloxacin solution 25 mg/ml oral - Tier 1; PA*

ofloxacin oral - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Sulfonamides

sulfadiazine oral - Tier 1; QL

sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1;

sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL

BACTRIM (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL

BACTRIM DS (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL

Tetracyclines

avidoxy - Tier 1; QL

doxy 100 (generic for DOXY 100) - Tier 1; PA; QL

doxycycline hyclate intravenous (generic for DOXY 100) - Tier 1; PA;

doxycycline hyclate oral capsule (generic for VIBRAMYCIN) - Tier 1;

doxycycline hyclate oral tablet 100 mg, 150 mg, 75 mg - Tier 1; QL

doxycycline hyclate oral tablet 20 mg - Tier 1

doxycycline hyclate oral tablet 50 mg (generic for TARGADOX) - Tier 1

doxycycline monohydrate oral capsule 100 mg (generic for

MONDOXYNE NL) - Tier 1; QL

doxycycline monohydrate oral capsule 50 mg - Tier 1; QL

doxycycline monohydrate oral tablet 100 mg, 50 mg, 75 mg - Tier 1;

demeclocycline hcl - Tier 1; PA*; QL

DORYX MPC ORAL TABLET DELAYED RELEASE 120 MG - Tier 2; PA*;

DORYX MPC TABLET DELAYED RELEASE 60 MG ORAL - Tier 2; PA*;

DORYX MPC TABLET DELAYED RELEASE 60 MG ORAL - Tier 2; PA;

doxycycline capsule delayed release 40 mg oral (generic for ORACEA) -

Tier 1; PA

doxycycline capsule delayed release 40 mg oral (generic for ORACEA) -

Tier 1; PA*

doxycycline hyclate oral tablet delayed release 100 mg, 200 mg, 50 mg -

Tier 1; PA*; QL

doxycycline monohydrate oral tablet 150 mg - Tier 1

minocycline hcl oral capsule 100 mg, 50 mg - Tier 1; QL

minocycline hcl oral capsule 75 mg - Tier 1

mondoxyne nl (generic for MONDOXYNE NL) - Tier 1; QL

TARGADOX (brand for doxycycline hyclate) - Tier 2

doxycycline hyclate oral tablet delayed release 150 mg, 75 mg - Tier 1;

PA*

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

- Tier 2; PA*; QL

doxycycline monohydrate oral capsule 150 mg, 75 mg - Tier 1; PA*

doxycycline monohydrate suspension reconstituted 25 mg/5ml oral

(generic for VIBRAMYCIN) - Tier 1; PA; QL

doxycycline monohydrate suspension reconstituted 25 mg/5ml oral

(generic for VIBRAMYCIN) - Tier 1; PA*; QL

minocycline hcl er (generic for SOLODYN) - Tier 1; PA*; QL

minocycline hcl oral tablet 100 mg, 75 mg - Tier 1; PA*; QL

minocycline hcl oral tablet 50 mg - Tier 1; PA*

MINOLIRA - Tier 2; PA; QL

NUZYRA ORAL - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ORACEA (brand for doxycycline) - Tier 2; PA*

SOLODYN (brand for minocycline hcl er) - Tier 2; PA*; QL

tetracycline hcl oral capsule - Tier 1; PA*; QL; AL

TETRACYCLINE HCL ORAL TABLET - Tier 2; PA; QL

VIBRAMYCIN (brand for doxycycline hyclate) - Tier 2; PA; QL

Antibacterials - Drugs to Treat Bacterial Infections

Antibacterials, Other - Antibiotics

methenamine mandelate oral - Tier 1 LUGOLS STRONG IODINE - Tier 2; PA

SUTAB - Tier 2; PA*

TRIMO-SAN - Tier 2; PA; QL

Anticonvulsants

Anticonvulsants, Other

BRIVIACT INTRAVENOUS - Tier 2; PA

felbamate oral suspension - Tier 1; PA; QL; AL

felbamate oral tablet (generic for FELBATOL) - Tier 1; PA; QL

FELBATOL (brand for felbamate) - Tier 2; PA; QL

FYCOMPA - Tier 2; PA; QL

lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL

levetiracetam er (generic for KEPPRA XR) - Tier 1; QL

levetiracetam in nacl - Tier 1; PA

levetiracetam intravenous (generic for KEPPRA) - Tier 1; PA

levetiracetam oral solution (generic for KEPPRA) - Tier 1; QL; AL

levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL

roweepra (generic for ROWEEPRA) - Tier 1; QL

subvenite (generic for SUBVENITE) - Tier 1; QL

BRIVIACT ORAL - Tier 2; PA*; QL

ELEPSIA XR - Tier 2; PA*

EPIDIOLEX - Tier 2; PA*; SP; QL

EPRONTIA - Tier 2; PA; QL; AL

FINTEPLA - Tier 2; PA; QL

KEPPRA INTRAVENOUS (brand for levetiracetam) - Tier 2; PA

KEPPRA ORAL SOLUTION (brand for levetiracetam) - Tier 2; PA; QL; AL

KEPPRA ORAL TABLET (brand for levetiracetam) - Tier 2; PA; QL

KEPPRA XR (brand for levetiracetam er) - Tier 2; PA; QL

LAMICTAL ODT ORAL KIT (brand for lamotrigine) - Tier 2; PA; QL

LAMICTAL ODT ORAL TABLET DISPERSIBLE (brand for lamotrigine) -

Tier 2; PA*; QL

LAMICTAL ORAL TABLET (brand for lamotrigine) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) -

Tier 1; QL; AL

topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL

valproic acid oral - Tier 1; QL

LAMICTAL ORAL TABLET CHEWABLE (brand for lamotrigine) - Tier 2;

PA*; QL; AL

LAMICTAL STARTER (brand for lamotrigine starter kit-blue) - Tier 2; PA;

LAMICTAL XR ORAL KIT - Tier 2; PA; QL

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24 HOUR (brand

for lamotrigine er) - Tier 2; PA*; QL

lamotrigine er (generic for LAMICTAL XR) - Tier 1; PA*; QL

lamotrigine oral kit (generic for LAMICTAL ODT) - Tier 1; PA; QL

lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; PA*; QL;

lamotrigine oral tablet dispersible (generic for LAMICTAL ODT) - Tier 1;

PA*; QL

lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT-

BLUE) - Tier 1; PA; QL

lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT-

GREEN) - Tier 1; PA; QL

lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT-

ORANGE) - Tier 1; PA; QL

QUDEXY XR (brand for topiramate er) - Tier 2; PA; QL

SPRITAM - Tier 2; PA*; QL

subvenite starter kit-blue (generic for SUBVENITE STARTER KIT-BLUE)

- Tier 1; PA; QL

subvenite starter kit-green (generic for SUBVENITE STARTER KIT-

GREEN) - Tier 1; PA; QL

subvenite starter kit-orange (generic for SUBVENITE STARTER KIT-

ORANGE) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

TOPAMAX (brand for topiramate) - Tier 2; PA; QL

TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; PA; QL; AL

topiramate er (generic for QUDEXY XR) - Tier 1; PA; QL

TROKENDI XR (brand for topiramate er) - Tier 2; PA; QL

XCOPRI (250 MG DAILY DOSE) - Tier 2; PA; QL

XCOPRI (350 MG DAILY DOSE) - Tier 2; PA

XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG - Tier 2; PA

XCOPRI ORAL TABLET 25 MG - Tier 2; PA; QL

XCOPRI ORAL TABLET THERAPY PACK - Tier 2; PA

Calcium Channel Modifying Agents

ethosuximide oral (generic for ZARONTIN) - Tier 1; QL CELONTIN (brand for methsuximide) - Tier 2; PA; QL

methsuximide (generic for CELONTIN) - Tier 1; PA*; QL

ZARONTIN (brand for ethosuximide) - Tier 2; PA; QL

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam oral suspension (generic for ONFI) - Tier 1; QL

clobazam oral tablet 10 mg (generic for ONFI) - Tier 1; PA; QL

clobazam oral tablet 20 mg (generic for ONFI) - Tier 1; QL

diazepam rectal gel 10 mg, 2.5 mg - Tier 1; QL

diazepam rectal gel 20 mg - Tier 1

gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL

gabapentin oral solution 250 mg/5ml (generic for NEURONTIN) - Tier

1; QL

gabapentin oral tablet 600 mg, 800 mg (generic for NEURONTIN) -

Tier 1; QL

phenobarbital oral - Tier 1; QL

primidone oral (generic for MYSOLINE) - Tier 1; QL

tiagabine hcl - Tier 1; PA; QL; AL

VALTOCO 10 MG DOSE - Tier 2; QL

LIBERVANT - Tier 2; PA; QL

MYSOLINE (brand for primidone) - Tier 2; PA; QL

NAYZILAM - Tier 2; PA*; QL

NEURONTIN (brand for gabapentin) - Tier 2; PA; QL

ONFI (brand for clobazam) - Tier 2; PA; QL

SABRIL (brand for vigabatrin) - Tier 2; PA; SP; QL

SYMPAZAN - Tier 2; PA*; QL

vigabatrin (generic for VIGADRONE) - Tier 1; PA; SP; QL

vigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL

vigpoder (generic for VIGADRONE) - Tier 1; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

VALTOCO 15 MG DOSE - Tier 2; QL

VALTOCO 20 MG DOSE - Tier 2; QL

VALTOCO 5 MG DOSE - Tier 2; QL

Sodium Channel Agents

carbamazepine er (generic for CARBATROL) - Tier 1; QL

carbamazepine oral (generic for EPITOL) - Tier 1; QL

CARBATROL (brand for carbamazepine er) - Tier 2; QL

CEREBYX INJECTION SOLUTION 500 MG PE/10ML (brand for

fosphenytoin sodium) - Tier 2; PA

DILANTIN ORAL CAPSULE 30 MG - Tier 2; QL

epitol (generic for EPITOL) - Tier 1; QL

fosphenytoin sodium injection solution 500 mg pe/10ml (generic for

CEREBYX) - Tier 1; PA

lacosamide oral (generic for VIMPAT) - Tier 1; QL; AL

oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1; QL;

oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL

phenytek (generic for PHENYTEK) - Tier 1; QL

APTIOM - Tier 2; PA*; QL

BANZEL (brand for rufinamide) - Tier 2; PA; QL

DILANTIN INFATABS (brand for phenytoin) - Tier 2; PA; QL

DILANTIN ORAL CAPSULE 100 MG (brand for phenytoin sodium

extended) - Tier 2; PA; QL

DILANTIN ORAL SUSPENSION (brand for phenytoin) - Tier 2; PA; QL

DILANTIN-125 (brand for phenytoin) - Tier 2; PA; QL

lacosamide intravenous (generic for VIMPAT) - Tier 1; PA

MOTPOLY XR - Tier 2; PA; QL

OXTELLAR XR - Tier 2; PA*; QL

rufinamide suspension 40 mg/ml oral (generic for BANZEL) - Tier 1; PA*;

rufinamide suspension 40 mg/ml oral (generic for BANZEL) - Tier 1; PA;

phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL

phenytoin oral (generic for DILANTIN) - Tier 1; QL

phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL

TEGRETOL (brand for carbamazepine) - Tier 2; QL

TEGRETOL-XR (brand for carbamazepine er) - Tier 2; QL

TRILEPTAL ORAL SUSPENSION (brand for oxcarbazepine) - Tier 2;

QL; AL

zonisamide oral (generic for ZONEGRAN) - Tier 1; QL

rufinamide tablet 200 mg oral (generic for BANZEL) - Tier 1; PA*; QL

rufinamide tablet 200 mg oral (generic for BANZEL) - Tier 1; PA; QL

rufinamide tablet 400 mg oral (generic for BANZEL) - Tier 1; PA*; QL

rufinamide tablet 400 mg oral (generic for BANZEL) - Tier 1; PA; QL

TRILEPTAL ORAL TABLET (brand for oxcarbazepine) - Tier 2; PA; QL

VIMPAT INTRAVENOUS (brand for lacosamide) - Tier 2; PA

VIMPAT ORAL (brand for lacosamide) - Tier 2; PA; QL; AL

ZONEGRAN (brand for zonisamide) - Tier 2; PA; QL

ZONISADE - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anticonvulsants - Drugs to Treat Seizures

Anticonvulsants, Other

DIACOMIT - Tier 2; PA; SP; QL

Antidementia Agents

Antidementia Agents, Other

ergoloid mesylates oral - Tier 1; QL NAMZARIC - Tier 2; PA; QL; AL

Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1;

QL; AL

donepezil hcl oral tablet dispersible - Tier 1; QL

EXELON (brand for rivastigmine) - Tier 2; QL; AL

rivastigmine (generic for EXELON) - Tier 1; QL; AL

ADLARITY - Tier 2; PA; QL

ARICEPT ORAL TABLET 10 MG, 5 MG (brand for donepezil hcl) - Tier 2;

PA; QL; AL

ARICEPT ORAL TABLET 23 MG (brand for donepezil hcl) - Tier 2; PA;

ST; QL; AL

donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; PA; ST;

QL; AL

galantamine hydrobromide er - Tier 1; PA*; QL

galantamine hydrobromide oral solution - Tier 1; PA; QL; AL

galantamine hydrobromide tablet 12 mg oral - Tier 1; PA; QL; AL

galantamine hydrobromide tablet 12 mg oral - Tier 1; PA*; QL; AL

galantamine hydrobromide tablet 4 mg oral - Tier 1; PA; QL; AL

galantamine hydrobromide tablet 4 mg oral - Tier 1; PA*; QL; AL

galantamine hydrobromide tablet 8 mg oral - Tier 1; PA; QL; AL

galantamine hydrobromide tablet 8 mg oral - Tier 1; PA*; QL; AL

rivastigmine tartrate - Tier 1; PA*; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl oral tablet (generic for NAMENDA TITRATION PAK) -

Tier 1; QL; AL

memantine hcl er capsule extended release 24 hour 14 mg oral (generic

for NAMENDA XR) - Tier 1; PA*; QL; AL

memantine hcl er capsule extended release 24 hour 14 mg oral (generic

for NAMENDA XR) - Tier 1; PA; QL; AL

memantine hcl er capsule extended release 24 hour 21 mg oral (generic

for NAMENDA XR) - Tier 1; PA*; QL; AL

memantine hcl er capsule extended release 24 hour 21 mg oral (generic

for NAMENDA XR) - Tier 1; PA; QL; AL

memantine hcl er capsule extended release 24 hour 28 mg oral (generic

for NAMENDA XR) - Tier 1; PA*; QL; AL

memantine hcl er capsule extended release 24 hour 28 mg oral (generic

for NAMENDA XR) - Tier 1; PA; QL; AL

memantine hcl er capsule extended release 24 hour 7 mg oral - Tier 1;

PA*; QL; AL

memantine hcl er capsule extended release 24 hour 7 mg oral - Tier 1;

PA; QL; AL

memantine hcl oral solution - Tier 1; PA; QL; AL

NAMENDA TITRATION PAK (brand for memantine hcl) - Tier 2; PA; QL;

NAMENDA XR (brand for memantine hcl er) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antidepressants

Antidepressants, Other

bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300

mg (generic for WELLBUTRIN XL) - Tier 1; QL

bupropion hcl oral - Tier 1; QL

mirtazapine oral (generic for REMERON) - Tier 1; QL

perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50

mg - Tier 1; AL

perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; QL; AL

APLENZIN - Tier 2; PA; QL

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24

HOUR 450 MG (brand for bupropion hcl er (xl)) - Tier 2; PA; QL

chlordiazepoxide-amitriptyline - Tier 1; PA*

FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL

olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg - Tier

1; PA; AL

olanzapine-fluoxetine hcl oral capsule 3-25 mg, 6-25 mg (generic for

SYMBYAX) - Tier 1; PA; AL

REMERON (brand for mirtazapine) - Tier 2; PA; QL

REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG

(brand for mirtazapine) - Tier 2; PA; QL

SPRAVATO (56 MG DOSE) - Tier 2; PA; QL

SPRAVATO (84 MG DOSE) - Tier 2; PA; QL

SYMBYAX (brand for olanzapine-fluoxetine hcl) - Tier 2; PA; AL

WELLBUTRIN SR (brand for bupropion hcl er (sr)) - Tier 2; PA; QL

WELLBUTRIN XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL

Monoamine Oxidase Inhibitors

EMSAM - Tier 2; QL

phenelzine sulfate oral (generic for NARDIL) - Tier 1; QL

tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL

MARPLAN - Tier 2; PA*; QL

NARDIL (brand for phenelzine sulfate) - Tier 2; PA; QL

PARNATE (brand for tranylcypromine sulfate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin

and Norepinephrine Reuptake Inhibitors)

citalopram hydrobromide oral tablet (generic for CELEXA) - Tier 1; QL

escitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QL

fluoxetine hcl oral capsule (generic for PROZAC) - Tier 1; QL

fluoxetine hcl oral solution - Tier 1; QL

fluvoxamine maleate - Tier 1; QL

paroxetine hcl oral tablet (generic for PAXIL) - Tier 1; QL

sertraline hcl oral tablet (generic for ZOLOFT) - Tier 1; QL

trazodone hcl oral - Tier 1; QL

venlafaxine hcl - Tier 1; QL

venlafaxine hcl er oral capsule extended release 24 hour (generic for

EFFEXOR XR) - Tier 1; QL

CELEXA (brand for citalopram hydrobromide) - Tier 2; PA; QL

CITALOPRAM HYDROBROMIDE ORAL CAPSULE - Tier 2; PA; QL

citalopram hydrobromide oral solution - Tier 1; PA; QL

DESVENLAFAXINE ER - Tier 2; PA*; QL

desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg,

50 mg (generic for PRISTIQ) - Tier 1; PA*; QL

desvenlafaxine succinate er tablet extended release 24 hour 25 mg oral

(generic for PRISTIQ) - Tier 1; PA*; QL

desvenlafaxine succinate er tablet extended release 24 hour 25 mg oral

(generic for PRISTIQ) - Tier 1; PA; QL

EFFEXOR XR (brand for venlafaxine hcl er) - Tier 2; PA; QL

escitalopram oxalate oral solution - Tier 1; PA; QL

FETZIMA - Tier 2; PA*; QL

FETZIMA TITRATION - Tier 2; PA*; QL

fluoxetine hcl (pmdd) - Tier 1; PA; QL

fluoxetine hcl oral capsule delayed release - Tier 1; PA; QL

fluoxetine hcl oral tablet - Tier 1; PA; QL

fluvoxamine maleate er - Tier 1; PA; QL

LEXAPRO (brand for escitalopram oxalate) - Tier 2; PA; QL

nefazodone hcl - Tier 1; PA; QL

paroxetine hcl er (generic for PAXIL CR) - Tier 1; PA*; QL

paroxetine hcl oral suspension (generic for PAXIL) - Tier 1; PA; QL

paroxetine mesylate - Tier 1; PA; QL

PAXIL (brand for paroxetine hcl) - Tier 2; PA; QL

PAXIL CR (brand for paroxetine hcl er) - Tier 2; PA; QL

PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL

PROZAC (brand for fluoxetine hcl) - Tier 2; PA; QL

SERTRALINE HCL ORAL CAPSULE - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

sertraline hcl oral concentrate (generic for ZOLOFT) - Tier 1; PA; QL

TRINTELLIX - Tier 2; PA; QL

venlafaxine hcl er oral tablet extended release 24 hour - Tier 1; PA; QL

VIIBRYD (brand for vilazodone hcl) - Tier 2; PA; QL

vilazodone hcl (generic for VIIBRYD) - Tier 1; PA; QL

ZOLOFT (brand for sertraline hcl) - Tier 2; PA; QL

Tricyclics

amitriptyline hcl oral - Tier 1; QL

amoxapine - Tier 1; QL

desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL

doxepin hcl oral capsule - Tier 1; QL

doxepin hcl oral concentrate - Tier 1; QL

imipramine hcl oral - Tier 1; QL

nortriptyline hcl oral capsule (generic for PAMELOR) - Tier 1; QL

ANAFRANIL (brand for clomipramine hcl) - Tier 2; PA; QL

clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; PA*; QL

imipramine pamoate - Tier 1; PA*; QL

NORPRAMIN (brand for desipramine hcl) - Tier 2; PA; QL

nortriptyline hcl solution 10 mg/5ml oral - Tier 1; PA; QL

nortriptyline hcl solution 10 mg/5ml oral - Tier 1; PA*; QL

PAMELOR (brand for nortriptyline hcl) - Tier 2; PA; QL

protriptyline hcl - Tier 1; PA*; QL

trimipramine maleate oral - Tier 1; PA*; QL

Antiemetics

Antiemetics, Other

ANTIVERT ORAL TABLET (brand for meclizine hcl) - Tier 2

BONINE (brand for cvs motion sickness relief) - Tier 2

DICLEGIS (brand for doxylamine-pyridoxine) - Tier 2; PA; QL

doxylamine-pyridoxine (generic for DICLEGIS) - Tier 1; PA; QL

meclizine hcl oral tablet 12.5 mg - Tier 1; QL

meclizine hcl oral tablet 25 mg (generic for DRAMAMINE) - Tier 1; QL

meclizine hcl oral tablet 50 mg (generic for ANTIVERT) - Tier 1

meclizine hcl tablet chewable 25 mg oral (otc) (generic for ANTIVERT)

- Tier 1

metoclopramide hcl oral solution 5 mg/5ml - Tier 1; QL

metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL

metoclopramide hcl oral tablet dispersible - Tier 1; QL

motion sickness relief oral tablet chewable 25 mg (generic for

ANTIVERT) - Tier 1

ANTIVERT ORAL TABLET CHEWABLE (brand for cvs motion sickness

relief) - Tier 2; PA

BONJESTA - Tier 2; PA*; QL

compro (generic for COMPRO) - Tier 1; PA; QL

GIMOTI - Tier 2; PA; QL

meclizine hcl tablet chewable 25 mg oral (otc) (generic for ANTIVERT) -

Tier 1; PA

PHENERGAN (brand for promethazine hcl) - Tier 2; PA; QL

prochlorperazine (generic for COMPRO) - Tier 1; PA; QL

promethazine hcl injection (generic for PHENERGAN) - Tier 1; PA; QL

promethegan rectal suppository 50 mg - Tier 1; PA; QL

REGLAN (brand for metoclopramide hcl) - Tier 2; PA; QL

TIGAN - Tier 2; PA; QL

TRANSDERM-SCOP (brand for scopolamine) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

motion-time (generic for ANTIVERT) - Tier 1

perphenazine oral - Tier 1; QL; AL

prochlorperazine maleate oral - Tier 1; QL

promethazine hcl oral syrup 6.25 mg/5ml - Tier 1; QL

promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL

promethegan rectal suppository 12.5 mg, 25 mg (generic for

PROMETHEGAN) - Tier 1; QL

scopolamine (generic for TRANSDERM-SCOP) - Tier 1; QL

travel ease (generic for ANTIVERT) - Tier 1

trimethobenzamide hcl oral - Tier 1; QL

Emetogenic Therapy Adjuncts

AKYNZEO (READY-TO-USE) - Tier 2; PA

AKYNZEO (TO-BE-DILUTED) - Tier 2; PA

aprepitant oral capsule 125 mg, 40 mg - Tier 1; QL

aprepitant oral capsule 80 mg (generic for EMEND) - Tier 1; QL

ondansetron hcl injection - Tier 1

ondansetron hcl oral - Tier 1; QL

ondansetron odt - Tier 1; QL

AKYNZEO - Tier 2; PA; QL

ANZEMET - Tier 2; PA*; QL

APONVIE - Tier 2; PA

aprepitant oral (generic for EMEND TRI-PACK) - Tier 1; PA; QL

aprepitant pak 80 & 125mg (generic for EMEND TRI-PACK) - Tier 1; PA;

dronabinol (generic for MARINOL) - Tier 1; PA*; QL

EMEND INTRAVENOUS (brand for fosaprepitant dimeglumine) - Tier 2;

EMEND ORAL (brand for aprepitant) - Tier 2; PA; QL

EMEND TRI-PACK (brand for aprepitant) - Tier 2; PA; QL

fosaprepitant dimeglumine (generic for EMEND) - Tier 1; PA

granisetron hcl intravenous - Tier 1; PA

granisetron hcl oral - Tier 1; PA*; QL

MARINOL (brand for dronabinol) - Tier 2; PA; QL

palonosetron hcl intravenous solution 0.25 mg/2ml - Tier 1; PA; QL

palonosetron hcl intravenous solution 0.25 mg/5ml - Tier 1; PA

palonosetron hcl intravenous solution prefilled syringe - Tier 1; PA; QL

SANCUSO - Tier 2; PA*; QL

SUSTOL - Tier 2; PA*

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antifungals

amphotericin b intravenous - Tier 1; PA; QL

caspofungin acetate intravenous solution reconstituted 70 mg (generic

for CANCIDAS) - Tier 1; PA

clotrimazole mouth/throat troche 10 mg - Tier 1; QL

CRESEMBA INTRAVENOUS - Tier 2; PA; QL

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG -

Tier 2; PA; QL

fluconazole oral (generic for DIFLUCAN) - Tier 1; QL

ft miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL

griseofulvin microsize oral suspension - Tier 1; QL

micafungin sodium solution reconstituted 100 mg intravenous (generic

for MYCAMINE) - Tier 1; PA; QL

miconazole 3 - Tier 1; QL

ANCOBON (brand for flucytosine) - Tier 2; PA; QL

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 70 MG

(brand for caspofungin acetate) - Tier 2; PA

CRESEMBA ORAL CAPSULE 186 MG - Tier 2; PA; QL

DIFLUCAN ORAL SUSPENSION RECONSTITUTED (brand for

fluconazole) - Tier 2; PA; QL

DIFLUCAN ORAL TABLET 100 MG, 200 MG (brand for fluconazole) -

Tier 2; PA; QL

flucytosine oral (generic for ANCOBON) - Tier 1; PA*; QL

griseofulvin microsize oral tablet - Tier 1; PA*; QL

griseofulvin ultramicrosize - Tier 1; PA*; QL

GYNAZOLE-1 - Tier 2; PA*

itraconazole oral capsule (generic for SPORANOX) - Tier 1; PA*; QL

itraconazole oral solution (generic for SPORANOX) - Tier 1; PA; QL

miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY

CURE) - Tier 1; QL

miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) -

Tier 1; QL

nystatin mouth/throat - Tier 1; QL

nystatin oral - Tier 1; QL

terbinafine hcl oral - Tier 1; QL

terconazole vaginal cream - Tier 1; QL

ketoconazole oral - Tier 1; PA; QL

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

(brand for micafungin sodium) - Tier 2; PA; QL

NOXAFIL ORAL (brand for posaconazole) - Tier 2; PA; QL

ORAVIG - Tier 2; PA; QL

posaconazole oral suspension (generic for NOXAFIL) - Tier 1; PA*; QL

posaconazole oral tablet delayed release (generic for NOXAFIL) - Tier 1;

PA; QL

SPORANOX (brand for itraconazole) - Tier 2; PA; QL

terconazole vaginal suppository - Tier 1; PA*; QL

TOLSURA - Tier 2; PA; QL

VFEND (brand for voriconazole) - Tier 2; PA; QL

voriconazole oral tablet (generic for VFEND) - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

voriconazole suspension reconstituted 40 mg/ml oral (generic for VFEND)

- Tier 1; PA; QL

voriconazole suspension reconstituted 40 mg/ml oral (generic for VFEND)

- Tier 1; PA*; QL

Antifungals - Drugs to Treat Fungal Infections

Antifungals - Fungal Infection Drugs

3 day vaginal - Tier 1

3-day vaginal vaginal cream 2 % - Tier 1

antifungal external cream (generic for MICATIN) - Tier 1

antifungal miconazole (generic for MICATIN) - Tier 1

baza antifungal (generic for MICATIN) - Tier 1

clotrimazole 3 - Tier 1

clotrimazole 7 - Tier 1; QL

clotrimazole vaginal - Tier 1; QL

clotrimazole vaginal cream 1 % - Tier 1; QL

ft antifungal external cream 2 % (generic for MICATIN) - Tier 1

micaderm (generic for MICATIN) - Tier 1

miconazole antifungal (generic for MICATIN) - Tier 1

miconazole nitrate external cream (generic for MICATIN) - Tier 1

hydrocortisone-iodoquinol - Tier 1; PA

MICATIN (brand for antifungal) - Tier 2; PA

Antigout Agents

allopurinol oral tablet 100 mg, 300 mg - Tier 1; QL

colchicine oral tablet - Tier 1; QL

colchicine-probenecid - Tier 1; QL

probenecid - Tier 1; QL

ALLOPURINOL ORAL TABLET 200 MG - Tier 2; PA; QL

colchicine oral capsule (generic for MITIGARE) - Tier 1; PA; QL

febuxostat (generic for ULORIC) - Tier 1; PA; QL

GLOPERBA - Tier 2; PA; QL

MITIGARE (brand for colchicine) - Tier 2; PA; QL

ULORIC (brand for febuxostat) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anti-HIV Agents, Other - HIV Drugs

Antivirals - Drugs to Treat Viral Infections

VOCABRIA - Tier 2; QL

Anti-inflammatory Agents - Drugs to Treat Inflammation

Glucocorticoids - Drugs to Treat Inflammation

anucort-hc (generic for ANUSOL-HC) - Tier 1

ANUSOL-HC RECTAL (brand for anucort-hc) - Tier 2

HEMMOREX-HC (brand for anucort-hc) - Tier 2

hydrocortisone acetate rectal (generic for ANUSOL-HC) - Tier 1

PROCTOCORT RECTAL (brand for hydrocortisone acetate) - Tier 2

Antimigraine Agents

Ergot Alkaloids

dihydroergotamine mesylate injection - Tier 1; PA; QL

dihydroergotamine mesylate nasal (generic for MIGRANAL) - Tier 1;

PA; QL

ergotamine-caffeine - Tier 1; QL

MIGERGOT - Tier 2; QL

MIGRANAL (brand for dihydroergotamine mesylate) - Tier 2; PA; QL

QULIPTA - Tier 2; PA; QL

Prophylactic

AIMOVIG - Tier 2; PA; QL

AJOVY - Tier 2; PA; QL

EMGALITY - Tier 2; PA; QL

EMGALITY (300 MG DOSE) - Tier 2; PA; QL

timolol maleate oral - Tier 1; PA*; QL

VYEPTI - Tier 2; PA; QL

Antimigraine Agents - Drugs to Treat Migraines

Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist -

Migraine Drugs

UBRELVY - Tier 2; PA; QL NURTEC - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Serotonin (5-HT) Receptor Agonists - Migraine Drugs

naratriptan hcl - Tier 1; QL

rizatriptan benzoate (generic for MAXALT) - Tier 1; QL

sumatriptan nasal - Tier 1; QL

sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL

sumatriptan succinate subcutaneous solution - Tier 1; QL

almotriptan malate - Tier 1; PA*; QL

eletriptan hydrobromide (generic for RELPAX) - Tier 1; PA*; QL

FROVA (brand for frovatriptan succinate) - Tier 2; PA; QL

frovatriptan succinate (generic for FROVA) - Tier 1; PA*; QL

IMITREX (brand for sumatriptan succinate) - Tier 2; PA; QL

IMITREX STATDOSE REFILL (brand for sumatriptan succinate refill) -

Tier 2; PA; QL

IMITREX STATDOSE SYSTEM (brand for sumatriptan succinate) - Tier 2;

PA; QL

MAXALT (brand for rizatriptan benzoate) - Tier 2; PA; QL

RELPAX (brand for eletriptan hydrobromide) - Tier 2; PA; QL

REYVOW - Tier 2; PA; QL

sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL) -

Tier 1; PA; QL

sumatriptan succinate subcutaneous solution auto-injector (generic for

IMITREX STATDOSE SYSTEM) - Tier 1; PA; QL

sumatriptan-naproxen sodium (generic for TREXIMET) - Tier 1; PA; QL

TOSYMRA - Tier 2; PA; QL

TREXIMET (brand for sumatriptan-naproxen sodium) - Tier 2; PA; QL

ZEMBRACE SYMTOUCH - Tier 2; PA; QL

zolmitriptan (generic for ZOMIG) - Tier 1; PA*; QL

ZOMIG NASAL (brand for zolmitriptan) - Tier 2; PA; QL

Antimyasthenic Agents

Parasympathomimetics

pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL

pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1;

PA; QL

pyridostigmine bromide oral tablet (generic for MESTINON) - Tier 1;

MESTINON (brand for pyridostigmine bromide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antimycobacterials

Antimycobacterials, Other

dapsone oral - Tier 1; QL

rifabutin (generic for MYCOBUTIN) - Tier 1; QL

MYCOBUTIN (brand for rifabutin) - Tier 2; PA; QL

Antituberculars

cycloserine oral - Tier 1; QL

ethambutol hcl oral tablet 100 mg - Tier 1

ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1;

isoniazid oral - Tier 1; QL

PRETOMANID - Tier 2; QL

PRIFTIN - Tier 2; QL

pyrazinamide oral - Tier 1; QL

rifampin oral - Tier 1; QL

SIRTURO - Tier 2; QL

TRECATOR - Tier 2; QL

MYAMBUTOL (brand for ethambutol hcl) - Tier 2; PA; QL

Antineoplastics

Alkylating Agents

cyclophosphamide oral capsule - Tier 1

CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2

LEUKERAN - Tier 2; PA

MYLERAN - Tier 2; PA

temozolomide - Tier 1; PA; SP; QL

VALCHLOR - Tier 2; PA; SP; QL

HEPZATO W/50MM CATHETER - Tier 2; PA

HEPZATO W/62MM CATHETER - Tier 2; PA

MATULANE - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antiandrogens

abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL

bicalutamide (generic for CASODEX) - Tier 1; QL

ERLEADA ORAL TABLET 240 MG - Tier 2; PA

ERLEADA ORAL TABLET 60 MG - Tier 2; PA; SP; QL

EULEXIN - Tier 2; QL

nilutamide (generic for NILANDRON) - Tier 1; PA; QL

NUBEQA - Tier 2; PA; SP; QL

XTANDI - Tier 2; PA; SP; QL

CASODEX (brand for bicalutamide) - Tier 2; PA; QL

NILANDRON (brand for nilutamide) - Tier 2; PA; QL

ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL

Antiangiogenic Agents

lenalidomide (generic for REVLIMID) - Tier 1; PA; SP; QL

POMALYST - Tier 2; PA; SP; QL

THALOMID - Tier 2; PA; SP; QL

REVLIMID (brand for lenalidomide) - Tier 2; PA; SP; QL

Antiestrogens/Modifiers

EMCYT - Tier 2; PA

tamoxifen citrate oral - Tier 1; QL

FARESTON (brand for toremifene citrate) - Tier 2; PA; QL

SOLTAMOX - Tier 2; PA; QL

toremifene citrate (generic for FARESTON) - Tier 1; PA*; QL

Antimetabolites

hydroxyurea oral (generic for HYDREA) - Tier 1; QL

mercaptopurine oral - Tier 1; QL

ONUREG - Tier 2; PA; SP; QL

PURIXAN - Tier 2; PA; QL

TABLOID - Tier 2; SP

HYDREA (brand for hydroxyurea) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antineoplastics, Other

IDHIFA - Tier 2; PA; SP; QL

LONSURF - Tier 2; PA; SP; QL

NINLARO - Tier 2; PA; SP; QL

PEMAZYRE - Tier 2; PA; SP; QL

TAZVERIK - Tier 2; PA; SP; QL

XPOVIO (100 MG ONCE WEEKLY) - Tier 2; PA; SP

XPOVIO (40 MG ONCE WEEKLY) - Tier 2; PA; SP

XPOVIO (40 MG TWICE WEEKLY) - Tier 2; PA; SP

XPOVIO (60 MG ONCE WEEKLY) - Tier 2; PA; SP

XPOVIO (60 MG TWICE WEEKLY) - Tier 2; PA; SP; QL

XPOVIO (80 MG ONCE WEEKLY) - Tier 2; PA; SP

XPOVIO (80 MG TWICE WEEKLY) - Tier 2; PA; SP; QL

ZOLINZA - Tier 2; PA; SP; QL

bortezomib intravenous - Tier 1; PA

Aromatase Inhibitors, 3rd Generation

anastrozole oral (generic for ARIMIDEX) - Tier 1; QL

exemestane (generic for AROMASIN) - Tier 1; QL

letrozole oral (generic for FEMARA) - Tier 1; QL

ARIMIDEX (brand for anastrozole) - Tier 2; PA; QL

AROMASIN (brand for exemestane) - Tier 2; PA; QL

FEMARA (brand for letrozole) - Tier 2; PA; QL

Enzyme Inhibitors

etoposide oral - Tier 1; PA; QL

HYCAMTIN ORAL - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Molecular Target Inhibitors

BALVERSA - Tier 2; PA; SP; QL

BRAFTOVI - Tier 2; PA; SP; QL

COPIKTRA - Tier 2; PA; SP; QL

COTELLIC - Tier 2; PA; SP; QL

DAURISMO - Tier 2; PA; SP; QL

ERIVEDGE - Tier 2; PA; SP; QL

everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg (generic for

AFINITOR) - Tier 1; PA; SP; QL

everolimus oral tablet soluble (generic for AFINITOR DISPERZ) - Tier

1; PA; SP; QL

EXKIVITY - Tier 2; PA; SP; QL

IBRANCE - Tier 2; PA; SP; QL

INQOVI - Tier 2; PA; SP; QL

INREBIC - Tier 2; PA; SP; QL

AFINITOR (brand for everolimus) - Tier 2; PA; SP; QL

AFINITOR DISPERZ (brand for everolimus) - Tier 2; PA; SP; QL

JAKAFI - Tier 2; PA; SP; QL

KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL

KISQALI (400 MG DOSE) - Tier 2; PA; SP; QL

KISQALI (600 MG DOSE) - Tier 2; PA; SP; QL

KISQALI FEMARA (200 MG DOSE) - Tier 2; PA; SP; QL

KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; QL

KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; QL

KOSELUGO - Tier 2; PA; SP; QL

LYNPARZA - Tier 2; PA; SP; QL

MEKINIST - Tier 2; PA; SP; QL

MEKTOVI - Tier 2; PA; SP; QL

NEXAVAR (brand for sorafenib tosylate) - Tier 2; PA; SP; QL

ODOMZO - Tier 2; PA; SP; QL

PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL

PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL

ROZLYTREK ORAL CAPSULE - Tier 2; PA; SP; QL

ROZLYTREK ORAL PACKET - Tier 2; PA; SP; QL; AL

RUBRACA - Tier 2; PA; SP; QL

RYDAPT - Tier 2; PA; SP; QL

sorafenib tosylate (generic for NEXAVAR) - Tier 1; PA; SP; QL

STIVARGA - Tier 2; PA; SP; QL

sunitinib malate (generic for SUTENT) - Tier 1; PA; SP; QL

SUTENT (brand for sunitinib malate) - Tier 2; PA; SP; QL

TAFINLAR - Tier 2; PA; SP; QL

TALZENNA ORAL CAPSULE 0.1 MG, 0.35 MG, 0.5 MG, 0.75 MG -

Tier 2; PA

TALZENNA ORAL CAPSULE 0.25 MG, 1 MG - Tier 2; PA; SP; QL

TEPMETKO - Tier 2; PA; SP; QL

TIBSOVO - Tier 2; PA; SP; QL

VANFLYTA - Tier 2; PA; SP; QL

VENCLEXTA - Tier 2; PA; SP; QL

VENCLEXTA STARTING PACK - Tier 2; PA; SP; QL

VERZENIO - Tier 2; PA; SP; QL

VITRAKVI - Tier 2; PA; SP; QL

VONJO - Tier 2; PA; SP; QL

ZEJULA - Tier 2; PA; SP; QL; AL

ZELBORAF - Tier 2; PA; SP; QL

ZYDELIG - Tier 2; PA; SP; QL

Retinoids

bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL

tretinoin oral - Tier 1; PA; SP; QL

TARGRETIN (brand for bexarotene) - Tier 2; PA; SP; QL

Treatment Adjuncts

leucovorin calcium oral tablet 10 mg - Tier 1

leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg - Tier 1; QL

MESNEX ORAL - Tier 2; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antineoplastics - Drugs to Treat Cancer

Alkylating Agents - Chemotherapy Agents

WELIREG - Tier 2; PA; SP

Antimetabolites - Chemotherapy Agents

capecitabine (generic for XELODA) - Tier 1; PA; SP; QL XELODA (brand for capecitabine) - Tier 2; PA; SP; QL

Antineoplastics, Other - Chemotherapy Agents

BESREMI - Tier 2; PA; SP

Molecular Target Inhibitors - Chemotherapy Agents

SCEMBLIX - Tier 2; PA; SP; QL

Antineoplastics, Other - Chemotherapy Agents

Antineoplastics - Drugs to Treat Cancer

LUMAKRAS ORAL TABLET 120 MG - Tier 2; PA; SP

LUMAKRAS ORAL TABLET 320 MG - Tier 2; PA; SP; QL

ZYKADIA - Tier 2; PA; SP; QL

Antiparasitics

Anthelmintics

albendazole oral - Tier 1; QL BILTRICIDE (brand for praziquantel) - Tier 2; PA; QL

EMVERM - Tier 2; PA; QL

ivermectin oral (generic for STROMECTOL) - Tier 1; PA; QL

praziquantel oral (generic for BILTRICIDE) - Tier 1; PA; QL

STROMECTOL (brand for ivermectin) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antiprotozoals

atovaquone (generic for MEPRON) - Tier 1; QL

atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; QL

chloroquine phosphate oral - Tier 1; QL

COARTEM - Tier 2

hydroxychloroquine sulfate oral tablet 100 mg, 400 mg - Tier 1

hydroxychloroquine sulfate oral tablet 200 mg (generic for

PLAQUENIL) - Tier 1; QL

hydroxychloroquine sulfate oral tablet 300 mg (generic for SOVUNA) -

Tier 1

mefloquine hcl - Tier 1; QL

NEBUPENT (brand for pentamidine isethionate) - Tier 2; PA

pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1;

primaquine phosphate - Tier 1

ALINIA ORAL TABLET (brand for nitazoxanide) - Tier 2; PA; QL

BENZNIDAZOLE - Tier 2; PA; QL

KRINTAFEL - Tier 2; PA; QL

MALARONE (brand for atovaquone-proguanil hcl) - Tier 2; PA; QL

MEPRON (brand for atovaquone) - Tier 2; PA; QL

nitazoxanide oral (generic for ALINIA) - Tier 1; PA; QL

PLAQUENIL (brand for hydroxychloroquine sulfate) - Tier 2; PA; QL

QUALAQUIN (brand for quinine sulfate) - Tier 2; PA; QL

SOVUNA ORAL TABLET 200 MG (brand for hydroxychloroquine sulfate)

- Tier 2; PA; QL

quinine sulfate (generic for QUALAQUIN) - Tier 1; QL

SOVUNA ORAL TABLET 300 MG (brand for hydroxychloroquine

sulfate) - Tier 2

Antiparasitics - Drugs to Treat Parasitic Infections

Anthelmintics - Worm Infection Drugs

EGATEN - Tier 2; QL

Antiprotozoals - Protozoal Infection Drugs

LAMPIT - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Pediculicides/Scabicides - Scabies and Lice Drugs

ft lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier

lice killing external shampoo 0.33-4 % (generic for RID LICE KILLING

SHAMPOO) - Tier 1

lice killing max st external shampoo 0.33-4 % (generic for RID LICE

KILLING SHAMPOO) - Tier 1

lice killing max str (generic for RID LICE KILLING SHAMPOO) - Tier 1

lice killing max strength (generic for RID LICE KILLING SHAMPOO) -

Tier 1

lice killing maximum strength (generic for RID LICE KILLING

SHAMPOO) - Tier 1

lice killing shampoo max str (generic for RID LICE KILLING

SHAMPOO) - Tier 1

lice maximum strength (generic for RID LICE KILLING SHAMPOO) -

Tier 1

lice treatment external shampoo 0.33-4 % (generic for RID LICE

KILLING SHAMPOO) - Tier 1

sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier

Antiparkinson Agents

Anticholinergics

benztropine mesylate oral - Tier 1; QL

trihexyphenidyl hcl - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antiparkinson Agents, Other

amantadine hcl oral capsule - Tier 1; QL

amantadine hcl oral solution - Tier 1; QL

entacapone - Tier 1; QL

NOURIANZ - Tier 2; PA; QL

amantadine hcl oral tablet - Tier 1; PA*; QL

carbidopa-levodopa-entacapone (generic for STALEVO 150) - Tier 1;

PA*; QL

GOCOVRI - Tier 2; PA; QL

ONGENTYS - Tier 2; PA*; QL

OSMOLEX ER - Tier 2; PA; QL

STALEVO 150 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA;

TASMAR (brand for tolcapone) - Tier 2; PA; QL

tolcapone (generic for TASMAR) - Tier 1; PA*; QL

Dopamine Agonists

pramipexole dihydrochloride - Tier 1; QL

ropinirole hcl - Tier 1; QL

APOKYN (brand for apomorphine hcl) - Tier 2; PA; SP; QL

apomorphine hcl subcutaneous (generic for APOKYN) - Tier 1; PA*; SP;

bromocriptine mesylate oral (generic for PARLODEL) - Tier 1; PA*; QL

MIRAPEX ER (brand for pramipexole dihydrochloride er) - Tier 2; PA; QL

NEUPRO - Tier 2; PA*; QL

PARLODEL (brand for bromocriptine mesylate) - Tier 2; PA; QL

pramipexole dihydrochloride er (generic for MIRAPEX ER) - Tier 1; PA*;

ropinirole hcl er oral tablet extended release 24 hour 8 mg - Tier 1; PA*;

ropinirole hcl er tablet extended release 24 hour 12 mg oral - Tier 1; PA*;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ropinirole hcl er tablet extended release 24 hour 12 mg oral - Tier 1; PA;

ropinirole hcl er tablet extended release 24 hour 2 mg oral - Tier 1; PA;

ropinirole hcl er tablet extended release 24 hour 2 mg oral - Tier 1; PA*;

ropinirole hcl er tablet extended release 24 hour 4 mg oral - Tier 1; PA;

ropinirole hcl er tablet extended release 24 hour 4 mg oral - Tier 1; PA*;

ropinirole hcl er tablet extended release 24 hour 6 mg oral - Tier 1; PA*;

ropinirole hcl er tablet extended release 24 hour 6 mg oral - Tier 1; PA;

Dopamine Precursors and/or L-Amino Acid Decarboxylase

Inhibitors

carbidopa oral (generic for LODOSYN) - Tier 1; QL

carbidopa-levodopa er - Tier 1; QL

carbidopa-levodopa oral tablet (generic for DHIVY) - Tier 1; QL

DHIVY (brand for carbidopa-levodopa) - Tier 2; QL

carbidopa-levodopa oral tablet dispersible - Tier 1; PA*; QL

DUOPA - Tier 2; PA*; QL

INBRIJA - Tier 2; PA; SP; QL

LODOSYN (brand for carbidopa) - Tier 2; PA; QL

RYTARY - Tier 2; PA*; QL

SINEMET (brand for carbidopa-levodopa) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Monoamine Oxidase B (MAO-B) Inhibitors

selegiline hcl oral - Tier 1; QL AZILECT (brand for rasagiline mesylate) - Tier 2; PA; QL

rasagiline mesylate tablet 0.5 mg oral (generic for AZILECT) - Tier 1; PA;

rasagiline mesylate tablet 0.5 mg oral (generic for AZILECT) - Tier 1; PA*;

rasagiline mesylate tablet 1 mg oral (generic for AZILECT) - Tier 1; PA;

rasagiline mesylate tablet 1 mg oral (generic for AZILECT) - Tier 1; PA*;

XADAGO - Tier 2; PA*; QL

ZELAPAR - Tier 2; PA*; QL

Antipsychotics

1st Generation/Typical

chlorpromazine hcl injection - Tier 1; QL

chlorpromazine hcl oral tablet - Tier 1; QL

fluphenazine decanoate injection - Tier 1; QL

fluphenazine hcl injection - Tier 1

fluphenazine hcl oral concentrate - Tier 1

fluphenazine hcl oral elixir - Tier 1

fluphenazine hcl oral tablet - Tier 1; QL

haloperidol decanoate intramuscular (generic for HALDOL

DECANOATE) - Tier 1; QL

haloperidol lactate oral concentrate 2 mg/ml - Tier 1; AL

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 5 mg - Tier 1; AL

haloperidol oral tablet 20 mg - Tier 1; QL; AL

loxapine succinate - Tier 1; QL

molindone hcl - Tier 1

ADASUVE - Tier 2; PA; QL

chlorpromazine hcl oral concentrate - Tier 1; PA; QL

HALDOL DECANOATE (brand for haloperidol decanoate) - Tier 2; PA; QL

pimozide - Tier 1; QL

thioridazine hcl oral - Tier 1; QL

thiothixene - Tier 1; QL

trifluoperazine hcl - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

2nd Generation/Atypical

ABILIFY MAINTENA - Tier 2; QL; AL

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

(generic for ABILIFY) - Tier 1; AL

ARISTADA - Tier 2; QL; AL

GEODON INTRAMUSCULAR (brand for ziprasidone mesylate) - Tier

2; QL; AL

INVEGA HAFYERA - Tier 2; PA

INVEGA SUSTENNA - Tier 2; QL; AL

INVEGA TRINZA - Tier 2; QL; AL

lurasidone hcl oral tablet 120 mg, 20 mg, 40 mg, 60 mg, 80 mg

(generic for LATUDA) - Tier 1; QL; AL

LYBALVI - Tier 2; PA; QL; AL

NUPLAZID - Tier 2; PA; QL

olanzapine intramuscular (generic for ZYPREXA) - Tier 1; QL; AL

ABILIFY ASIMTUFII - Tier 2; PA; QL; AL

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG, 30 MG, 5 MG

(brand for aripiprazole) - Tier 2; PA; AL

aripiprazole oral solution - Tier 1; PA; AL

aripiprazole oral tablet dispersible - Tier 1; PA; AL

ARISTADA INITIO - Tier 2; PA; QL; AL

asenapine maleate (generic for SAPHRIS) - Tier 1; PA*; QL; AL

CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG - Tier 2; PA*; QL

CAPLYTA ORAL CAPSULE 42 MG - Tier 2; PA*

FANAPT ORAL TABLET 1 MG, 10 MG, 2 MG, 4 MG, 6 MG, 8 MG - Tier

2; PA*; QL; AL

FANAPT ORAL TABLET 12 MG - Tier 2; PA*; QL

FANAPT TITRATION PACK - Tier 2; PA; QL; AL

GEODON ORAL (brand for ziprasidone hcl) - Tier 2; PA; AL

olanzapine oral (generic for ZYPREXA) - Tier 1; AL

quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; QL; AL

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg, 400

mg, 50 mg (generic for SEROQUEL) - Tier 1; QL; AL

REXULTI - Tier 2; ST; QL; AL

RISPERDAL CONSTA (brand for risperidone microspheres er) - Tier

2; QL; AL

risperidone microspheres er (generic for RISPERDAL CONSTA) - Tier

1; QL; AL

risperidone oral solution (generic for RISPERDAL) - Tier 1; AL

risperidone oral tablet 0.25 mg - Tier 1; AL

risperidone oral tablet 0.5 mg, 1 mg, 2 mg, 3 mg (generic for

RISPERDAL) - Tier 1; AL

risperidone oral tablet 4 mg (generic for RISPERDAL) - Tier 1; QL; AL

INVEGA (brand for paliperidone er) - Tier 2; PA; QL; AL

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG (brand

for lurasidone hcl) - Tier 2; PA; QL; AL

paliperidone er tablet extended release 24 hour 1.5 mg oral - Tier 1; PA*;

QL; AL

paliperidone er tablet extended release 24 hour 1.5 mg oral - Tier 1; PA;

QL; AL

paliperidone er tablet extended release 24 hour 3 mg oral (generic for

INVEGA) - Tier 1; PA*; QL; AL

paliperidone er tablet extended release 24 hour 3 mg oral (generic for

INVEGA) - Tier 1; PA; QL; AL

paliperidone er tablet extended release 24 hour 6 mg oral (generic for

INVEGA) - Tier 1; PA*; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,

4 mg - Tier 1; AL

RYKINDO - Tier 2

ziprasidone hcl (generic for GEODON) - Tier 1; AL

ziprasidone mesylate (generic for GEODON) - Tier 1; QL; AL

paliperidone er tablet extended release 24 hour 6 mg oral (generic for

INVEGA) - Tier 1; PA; QL; AL

paliperidone er tablet extended release 24 hour 9 mg oral (generic for

INVEGA) - Tier 1; PA*; QL; AL

paliperidone er tablet extended release 24 hour 9 mg oral (generic for

INVEGA) - Tier 1; PA; QL; AL

PERSERIS - Tier 2; PA; QL; AL

quetiapine fumarate oral tablet 150 mg - Tier 1; PA; QL; AL

RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; PA; AL

RISPERDAL ORAL TABLET 0.5 MG, 1 MG, 2 MG, 3 MG (brand for

risperidone) - Tier 2; PA; AL

RISPERDAL ORAL TABLET 4 MG (brand for risperidone) - Tier 2; PA;

QL; AL

SAPHRIS (brand for asenapine maleate) - Tier 2; PA*; QL; AL

SECUADO - Tier 2; PA; QL; AL

SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA; QL; AL

SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL; AL

UZEDY SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 100

MG/0.28ML - Tier 2; PA; QL

VRAYLAR - Tier 2; PA; QL; AL

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG - Tier 2; PA;

QL; AL

ZYPREXA INTRAMUSCULAR (brand for olanzapine) - Tier 2; PA; QL; AL

ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA; AL

ZYPREXA RELPREVV - Tier 2; PA; QL; AL

ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; AL

Treatment-Resistant

clozapine oral tablet (generic for CLOZARIL) - Tier 1; AL clozapine oral tablet dispersible - Tier 1; PA; AL

CLOZARIL (brand for clozapine) - Tier 2; PA; AL

VERSACLOZ - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antispasmodics, Urinary - Bladder Control Drugs

Genitourinary Agents - Drugs to Treat Bladder, Genital and

Kidney Conditions

GEMTESA - Tier 2; PA*; QL

Antispasticity Agents

baclofen oral suspension (generic for FLEQSUVY) - Tier 1; PA

baclofen oral tablet 10 mg, 20 mg, 5 mg - Tier 1; QL

tizanidine hcl oral tablet (generic for ZANAFLEX) - Tier 1; QL

BACLOFEN ORAL SOLUTION (brand for baclofen) - Tier 2; PA

baclofen oral tablet 15 mg - Tier 1; PA

DANTRIUM ORAL (brand for dantrolene sodium) - Tier 2; PA; QL

dantrolene sodium oral (generic for DANTRIUM) - Tier 1; PA*; QL

FLEQSUVY (brand for baclofen) - Tier 2; PA

LYVISPAH - Tier 2; PA

OZOBAX DS (brand for baclofen) - Tier 2; PA

tizanidine hcl oral capsule 2 mg (generic for ZANAFLEX) - Tier 1; PA*; QL

tizanidine hcl oral capsule 4 mg, 6 mg (generic for ZANAFLEX) - Tier 1;

PA*

XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 200 UNIT -

Tier 2; PA

ZANAFLEX ORAL CAPSULE 2 MG (brand for tizanidine hcl) - Tier 2; PA;

ZANAFLEX ORAL CAPSULE 4 MG, 6 MG (brand for tizanidine hcl) - Tier

2; PA

ZANAFLEX ORAL TABLET (brand for tizanidine hcl) - Tier 2; PA; QL

Antivirals

Anti-cytomegalovirus (CMV) Agents

cidofovir intravenous - Tier 1; PA; QL

PREVYMIS - Tier 2; PA; QL

valganciclovir hcl (generic for VALCYTE) - Tier 1; QL

VALCYTE (brand for valganciclovir hcl) - Tier 2; PA; QL

ZIRGAN - Tier 2; PA*; QL

Anti-hepatitis B (HBV) Agents

entecavir (generic for BARACLUDE) - Tier 1; QL

lamivudine oral tablet 100 mg - Tier 1; QL

adefovir dipivoxil - Tier 1; PA*; QL

BARACLUDE (brand for entecavir) - Tier 2; PA; QL

VEMLIDY - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anti-hepatitis C (HCV) Agents

ribavirin oral - Tier 1

Antiherpetic Agents

acyclovir oral - Tier 1; QL

famciclovir oral - Tier 1; QL

valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL

acyclovir cream 5 % external (generic for ZOVIRAX) - Tier 1; PA*; QL

acyclovir cream 5 % external (generic for ZOVIRAX) - Tier 1; PA; QL

acyclovir external ointment (generic for ZOVIRAX) - Tier 1; PA*; QL

DENAVIR (brand for penciclovir) - Tier 2; PA

penciclovir (generic for DENAVIR) - Tier 1; PA*

SITAVIG - Tier 2; PA*; QL

VALTREX (brand for valacyclovir hcl) - Tier 2; PA; QL

ZOVIRAX (brand for acyclovir) - Tier 2; PA*; QL

Anti-HIV Agents, Integrase Inhibitors (INSTI)

BIKTARVY ORAL TABLET 30-120-15 MG - Tier 2

BIKTARVY ORAL TABLET 50-200-25 MG - Tier 2; QL

DOVATO - Tier 2; QL

GENVOYA - Tier 2; QL

ISENTRESS HD - Tier 2; QL

ISENTRESS ORAL PACKET - Tier 2; QL; AL

ISENTRESS ORAL TABLET - Tier 2; QL

ISENTRESS ORAL TABLET CHEWABLE - Tier 2; QL

JULUCA - Tier 2; QL

STRIBILD - Tier 2; QL

TIVICAY - Tier 2; QL

TIVICAY PD - Tier 2; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors (NNRTI)

COMPLERA - Tier 2; QL

DELSTRIGO - Tier 2; QL

EDURANT - Tier 2; QL

efavirenz (generic for SUSTIVA) - Tier 1; QL

efavirenz-emtricitab-tenofo df (generic for ATRIPLA) - Tier 1; QL

efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; QL

etravirine (generic for INTELENCE) - Tier 1; QL

INTELENCE (brand for etravirine) - Tier 2; QL

nevirapine - Tier 1; QL

nevirapine er - Tier 1; QL

PIFELTRO - Tier 2; QL

SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL

SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors (NRTI)

abacavir sulfate (generic for ZIAGEN) - Tier 1; QL

abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL

CIMDUO - Tier 2; QL

DESCOVY - Tier 2; QL

emtricitabine (generic for EMTRIVA) - Tier 1; QL

emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; QL

EMTRIVA (brand for emtricitabine) - Tier 2; QL

lamivudine oral solution (generic for EPIVIR) - Tier 1; QL

lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1;

lamivudine-zidovudine - Tier 1; QL

ODEFSEY - Tier 2; QL

tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL

TRIUMEQ - Tier 2; QL

EPIVIR (brand for lamivudine) - Tier 2; PA; QL

RETROVIR ORAL (brand for zidovudine) - Tier 2; PA; QL

TRUVADA (brand for emtricitabine-tenofovir df) - Tier 2; PA; QL

VIREAD ORAL TABLET 300 MG (brand for tenofovir disoproxil fumarate)

- Tier 2; PA; QL

ZIAGEN (brand for abacavir sulfate) - Tier 2; PA; QL

TRIUMEQ PD - Tier 2; QL

VIREAD ORAL POWDER - Tier 2; QL

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; QL

zidovudine (generic for RETROVIR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Anti-HIV Agents, Other

maraviroc (generic for SELZENTRY) - Tier 1; QL

RUKOBIA - Tier 2; QL

SELZENTRY (brand for maraviroc) - Tier 2; QL

TYBOST - Tier 2; QL

Anti-HIV Agents, Protease Inhibitors (PI)

APTIVUS - Tier 2; QL

atazanavir sulfate (generic for REYATAZ) - Tier 1; QL

EVOTAZ - Tier 2; QL

fosamprenavir calcium (generic for LEXIVA) - Tier 1; QL

KALETRA (brand for lopinavir-ritonavir) - Tier 2; QL

lopinavir-ritonavir (generic for KALETRA) - Tier 1; QL

NORVIR ORAL PACKET - Tier 2; QL

PREZCOBIX - Tier 2; QL

REYATAZ ORAL PACKET - Tier 2; QL; AL

ritonavir (generic for NORVIR) - Tier 1; QL

SYMTUZA - Tier 2; QL

VIRACEPT - Tier 2; QL

NORVIR ORAL TABLET (brand for ritonavir) - Tier 2; PA; QL

REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA;

Anti-influenza Agents

oseltamivir phosphate oral (generic for TAMIFLU) - Tier 1

rimantadine hcl - Tier 1; QL

RELENZA DISKHALER - Tier 2; PA*; QL

TAMIFLU (brand for oseltamivir phosphate) - Tier 2; PA

XOFLUZA (40 MG DOSE) - Tier 2; PA

XOFLUZA (80 MG DOSE) - Tier 2; PA

Antivirals - Drugs to Treat Viral Infections

Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral

Drugs

foscarnet sodium (generic for FOSCAVIR) - Tier 1; PA; QL

FOSCAVIR (brand for foscarnet sodium) - Tier 2; PA; QL

LIVTENCITY - Tier 2; PA; QL

Anti-Influenza Agents - Flu Drugs

RAPIVAB - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antivirals

LAGEVRIO CAPSULE 200 MG ORAL - Tier 2; QL

PAXLOVID (150/100) - Tier 2; QL

PAXLOVID (300/100) - Tier 2; QL

VEKLURY - Tier 2

LAGEVRIO CAPSULE 200 MG ORAL - Tier 2; PA; QL

Anxiolytics

Anxiolytics, Other

buspirone hcl oral - Tier 1; QL

hydroxyzine hcl oral - Tier 1; QL

hydroxyzine pamoate oral (generic for VISTARIL) - Tier 1; QL

IGALMI - Tier 2; PA; QL

meprobamate - Tier 1; PA; QL

VISTARIL (brand for hydroxyzine pamoate) - Tier 2; PA; QL

Benzodiazepines

alprazolam oral tablet (generic for XANAX) - Tier 1; QL

chlordiazepoxide hcl - Tier 1; QL

clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL

diazepam intensol (generic for DIAZEPAM INTENSOL) - Tier 1; QL

diazepam oral (generic for DIAZEPAM INTENSOL) - Tier 1; QL

lorazepam injection (generic for ATIVAN) - Tier 1

lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM

INTENSOL) - Tier 1; QL

lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL

alprazolam er (generic for XANAX XR) - Tier 1; PA*; QL

alprazolam intensol - Tier 1; PA*

alprazolam oral tablet dispersible - Tier 1; PA*; QL

alprazolam xr (generic for XANAX XR) - Tier 1; PA*; QL

ATIVAN INJECTION (brand for lorazepam) - Tier 2; PA

ATIVAN ORAL (brand for lorazepam) - Tier 2; PA; QL

clonazepam oral tablet dispersible - Tier 1; PA; QL

clorazepate dipotassium tablet 15 mg oral - Tier 1; PA*; QL

clorazepate dipotassium tablet 15 mg oral - Tier 1; PA; QL

clorazepate dipotassium tablet 3.75 mg oral - Tier 1; PA*; QL

clorazepate dipotassium tablet 3.75 mg oral - Tier 1; PA; QL

clorazepate dipotassium tablet 7.5 mg oral - Tier 1; PA*; QL

clorazepate dipotassium tablet 7.5 mg oral - Tier 1; PA; QL

KLONOPIN (brand for clonazepam) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1; PA;

LOREEV XR - Tier 2; PA

midazolam hcl oral - Tier 1; PA*; QL; AL

oxazepam - Tier 1; PA*; QL

VALIUM (brand for diazepam) - Tier 2; PA; QL

XANAX (brand for alprazolam) - Tier 2; PA; QL

XANAX XR (brand for alprazolam er) - Tier 2; PA; QL

Anxiolytics - Drugs to Treat Anxiety

Benzodiazepines - Anxiety Drugs

DORAL (brand for quazepam) - Tier 2; PA*; QL; AL

quazepam (generic for DORAL) - Tier 1; PA*; QL; AL

Attention Deficit Hyperactivity Disorder Agents, Non-

amphetamines - ADHD Drugs

Central Nervous System Agents - Drugs to Treat Nerve

Conditions

QELBREE - Tier 2; PA; QL

Bipolar Agents

Mood Stabilizers

DEPAKOTE SPRINKLES (brand for divalproex sodium) - Tier 2; QL;

divalproex sodium er (generic for DEPAKOTE ER) - Tier 1; QL

divalproex sodium oral capsule delayed release sprinkle (generic for

DEPAKOTE SPRINKLES) - Tier 1; QL; AL

divalproex sodium oral tablet delayed release (generic for

DEPAKOTE) - Tier 1; QL

EQUETRO - Tier 2; PA; QL

lithium - Tier 1; QL

lithium carbonate er (generic for LITHOBID) - Tier 1; QL

lithium carbonate oral - Tier 1; QL

DEPAKOTE (brand for divalproex sodium) - Tier 2; PA; QL

DEPAKOTE ER (brand for divalproex sodium er) - Tier 2; PA; QL

LITHOBID (brand for lithium carbonate er) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Blood Glucose Regulators

Antidiabetic Agents

acarbose oral - Tier 1; QL

BYDUREON BCISE AUTOINJECTOR - Tier 2; QL

BYETTA 10 MCG PEN - Tier 2; QL

BYETTA 5 MCG PEN - Tier 2; QL

DAPAGLIFLOZIN PRO-METFORMIN ER (brand for dapagliflozin pro-

metformin er) - Tier 2; QL

DAPAGLIFLOZIN PROPANEDIOL (brand for dapagliflozin

propanediol) - Tier 2; QL

FARXIGA (brand for dapagliflozin propanediol) - Tier 2; QL

glimepiride - Tier 1; QL

glipizide er (generic for GLUCOTROL XL) - Tier 1; QL

glipizide oral tablet 10 mg, 5 mg - Tier 1; QL

glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL

glipizide-metformin hcl - Tier 1; QL

ACTOPLUS MET (brand for pioglitazone hcl-metformin hcl) - Tier 2; PA;

ACTOS (brand for pioglitazone hcl) - Tier 2; PA; QL

ALOGLIPTIN BENZOATE - Tier 2; PA*; QL

ALOGLIPTIN-METFORMIN HCL - Tier 2; PA*; QL

ALOGLIPTIN-PIOGLITAZONE - Tier 2; PA; QL

CYCLOSET - Tier 2; PA; QL

DUETACT (brand for pioglitazone hcl-glimepiride) - Tier 2; PA; QL

glipizide oral tablet 2.5 mg - Tier 1; PA; QL

GLUCOTROL XL (brand for glipizide er) - Tier 2; PA; QL

GLUMETZA (brand for metformin hcl er (mod)) - Tier 2; PA; QL

GLYXAMBI - Tier 2; PA; QL

INVOKAMET XR - Tier 2; PA*; QL

metformin hcl er (mod) (generic for GLUMETZA) - Tier 1; PA; QL

glyburide micronized - Tier 1; QL

glyburide oral - Tier 1; QL

glyburide-metformin - Tier 1; QL

INVOKAMET - Tier 2; QL

INVOKANA - Tier 2; QL

JANUMET - Tier 2; QL

JANUMET XR - Tier 2; QL

JANUVIA - Tier 2; QL

JARDIANCE - Tier 2; QL

JENTADUETO - Tier 2; QL

JENTADUETO XR - Tier 2; QL

metformin hcl er - Tier 1; QL

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg - Tier 1; QL

nateglinide - Tier 1; QL

metformin hcl er (osm) - Tier 1; PA; QL

metformin hcl oral solution (generic for RIOMET) - Tier 1; PA*; QL

metformin hcl oral tablet 625 mg - Tier 1; PA; QL

miglitol - Tier 1; PA*; QL

OZEMPIC - Tier 2; PA; QL

OZEMPIC (2 MG/DOSE) - Tier 2; PA; QL

pioglitazone hcl-glimepiride (generic for DUETACT) - Tier 1; PA*; QL

pioglitazone hcl-metformin hcl (generic for ACTOPLUS MET) - Tier 1;

PA*; QL

QTERN - Tier 2; PA; QL

RIOMET (brand for metformin hcl) - Tier 2; PA*; QL

RYBELSUS - Tier 2; PA; QL

SEGLUROMET - Tier 2; PA*; QL

SOLIQUA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ONGLYZA (brand for saxagliptin hcl) - Tier 2; ST; QL

pioglitazone hcl (generic for ACTOS) - Tier 1; QL

repaglinide - Tier 1; QL

saxagliptin hcl (generic for ONGLYZA) - Tier 1; ST; QL

saxagliptin-metformin er - Tier 1; ST; QL

SYMLINPEN 120 - Tier 2; PA; QL

SYMLINPEN 60 - Tier 2; PA; QL

SYNJARDY - Tier 2; QL

TRADJENTA - Tier 2; QL

VICTOZA - Tier 2; QL

XIGDUO XR (brand for dapagliflozin pro-metformin er) - Tier 2; QL

STEGLATRO - Tier 2; PA*; QL

STEGLUJAN - Tier 2; PA; QL

SYNJARDY XR - Tier 2; PA*; QL

TRIJARDY XR - Tier 2; PA; QL

TRULICITY - Tier 2; PA; QL

XULTOPHY - Tier 2; PA; QL

Glycemic Agents

BAQSIMI ONE PACK - Tier 2; PA; QL

BAQSIMI TWO PACK - Tier 2; PA; QL

diazoxide oral (generic for PROGLYCEM) - Tier 1; QL

GLUCAGEN HYPOKIT - Tier 2; QL

glucagon emergency injection kit - Tier 1; QL

PROGLYCEM (brand for diazoxide) - Tier 2; QL

GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED -

Tier 2; PA; QL

GVOKE HYPOPEN 1-PACK - Tier 2; PA; QL

GVOKE HYPOPEN 2-PACK - Tier 2; PA; QL

GVOKE KIT - Tier 2; PA

GVOKE PFS - Tier 2; PA; QL

Insulins

BASAGLAR KWIKPEN (brand for insulin glargine solostar) - Tier 2;

PA; QL

BASAGLAR TEMPO PEN - Tier 2; QL

HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen)

- Tier 2; QL

HUMALOG KWIKPEN SOLUTION PEN-INJECTOR 100 UNIT/ML

SUBCUTANEOUS (brand for insulin lispro (1 unit dial)) - Tier 2; QL

HUMALOG MIX 50/50 - Tier 2; QL

HUMALOG MIX 50/50 KWIKPEN - Tier 2; QL

HUMALOG MIX 75/25 - Tier 2; QL

HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro)

- Tier 2; QL

HUMALOG SOLUTION 100 UNIT/ML INJECTION (brand for insulin

lispro) - Tier 2; Cartridges Preferred, vials Non-Preferred; QL

ADMELOG (brand for insulin lispro) - Tier 2; PA*; Cartridges Preferred,

vials Non-Preferred||Coverage requires trial and failure (or inability to try)

with preferred drugs in the same class Prior authorization (PA) may be

required to determine what drugs have been tried in the past; QL

ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; PA*;

AFREZZA - Tier 2; PA*; QL

APIDRA SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML

SUBCUTANEOUS - Tier 2; PA*; QL

APIDRA SOLOSTAR SOLUTION PEN-INJECTOR 100 UNIT/ML

SUBCUTANEOUS - Tier 2; PA; QL

APIDRA VIAL - Tier 2; PA*; QL

FIASP - Tier 2; PA*; QL

FIASP FLEXTOUCH - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

HUMALOG SUBCUTANEOUS - Tier 2; Cartridges Preferred, vials

Non-Preferred; QL

HUMULIN 70/30 KWIKPEN - Tier 2; QL

HUMULIN 70/30 VIAL - Tier 2; QL

HUMULIN N KWIKPEN - Tier 2; QL

HUMULIN N VIAL - Tier 2; QL

HUMULIN R SOLUTION 100 UNIT/ML INJECTION - Tier 2; QL

HUMULIN R U-500 KWIKPEN - Tier 2; QL

HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; QL

INSULIN ASP PROT & ASP FLEXPEN (brand for insulin asp prot &

asp flexpen) - Tier 2; QL

INSULIN LISPRO (brand for insulin lispro) - Tier 2; Cartridges

Preferred, vials Non-Preferred; QL

FIASP PENFILL - Tier 2; PA*; QL

FIASP PUMPCART - Tier 2; PA*; QL

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

200 UNIT/ML - Tier 2; PA; QL

HUMALOG SOLUTION 100 UNIT/ML INJECTION (brand for insulin

lispro) - Tier 2; PA; Cartridges Preferred, vials Non-Preferred; QL

HUMALOG TEMPO PEN - Tier 2; PA; QL

HUMULIN R SOLUTION 100 UNIT/ML INJECTION - Tier 2; PA; QL

INSULIN ASPART (brand for insulin aspart) - Tier 2; PA*; QL

INSULIN ASPART FLEXPEN (brand for insulin aspart flexpen) - Tier 2;

PA*; QL

INSULIN ASPART PENFILL (brand for insulin aspart penfill) - Tier 2; PA*;

INSULIN LISPRO (1 UNIT DIAL) (brand for insulin lispro (1 unit dial)) -

Tier 2; QL

INSULIN LISPRO JUNIOR KWIKPEN (brand for insulin lispro junior

kwikpen) - Tier 2; QL

INSULIN LISPRO PROT & LISPRO (brand for insulin lispro prot &

lispro) - Tier 2; QL

LEVEMIR FLEXPEN - Tier 2; QL

LEVEMIR U-100 VIAL - Tier 2; QL

NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; QL

NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; QL

NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; QL

INSULIN ASPART PROT & ASPART (brand for insulin aspart prot &

aspart) - Tier 2; PA; QL

INSULIN DEGLUDEC (brand for insulin degludec) - Tier 2; PA*; QL

INSULIN DEGLUDEC FLEXTOUCH (brand for insulin degludec flextouch)

- Tier 2; PA*; QL

INSULIN GLARGINE MAX SOLOSTAR (brand for insulin glargine max

solostar) - Tier 2; PA; QL

INSULIN GLARGINE SOLOSTAR SUBCUTANEOUS SOLUTION PEN-

INJECTOR 300 UNIT/ML (brand for insulin glargine solostar) - Tier 2; PA;

INSULIN GLARGINE-YFGN (brand for insulin glargine-yfgn) - Tier 2; PA;

LANTUS SOLOSTAR (brand for insulin glargine solostar) - Tier 2; PA; QL

LANTUS U-100 VIAL (brand for insulin glargine) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

LYUMJEV - Tier 2; PA*; QL

LYUMJEV KWIKPEN - Tier 2; PA*; QL

LYUMJEV TEMPO PEN - Tier 2; PA; QL

NOVOLIN 70/30 FLEXPEN - Tier 2; PA*; QL

NOVOLIN 70/30 FLEXPEN RELION - Tier 2; PA*; QL

NOVOLIN 70/30 RELION - Tier 2; PA*; QL

NOVOLIN 70/30 VIAL - Tier 2; PA*; QL

NOVOLIN N FLEXPEN - Tier 2; PA*; QL

NOVOLIN N FLEXPEN RELION - Tier 2; PA*; QL

NOVOLIN N RELION - Tier 2; PA*; QL

NOVOLIN N VIAL - Tier 2; PA*; QL

NOVOLIN R FLEXPEN - Tier 2; PA; QL

NOVOLIN R FLEXPEN RELION - Tier 2; PA; QL

NOVOLIN R RELION - Tier 2; PA*; QL

NOVOLIN R VIAL - Tier 2; PA*; QL

NOVOLOG 70/30 FLEXPEN RELION (brand for insulin asp prot & asp

flexpen) - Tier 2; PA; QL

NOVOLOG FLEXPEN RELION (brand for insulin aspart flexpen) - Tier 2;

PA*; QL

NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp

flexpen) - Tier 2; PA; QL

NOVOLOG MIX 70/30 RELION (brand for insulin aspart prot & aspart) -

Tier 2; PA; QL

NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier

2; PA; QL

NOVOLOG RELION (brand for insulin aspart) - Tier 2; PA*; QL

SEMGLEE (YFGN) (brand for insulin glargine-yfgn) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

TOUJEO MAX SOLOSTAR (brand for insulin glargine max solostar) - Tier

2; PA*; QL

TOUJEO SOLOSTAR (brand for insulin glargine solostar) - Tier 2; PA*;

TRESIBA (brand for insulin degludec) - Tier 2; PA*; QL

TRESIBA FLEXTOUCH (brand for insulin degludec flextouch) - Tier 2;

PA*; QL

Blood Glucose Regulators - Drugs to Regulate Blood Sugar

Glycemic Agents - Diabetic Drugs

GLUCO TO GO (brand for cvs glucose) - Tier 2; QL

glucose oral tablet chewable 4 gm (generic for GLUCO TO GO) - Tier

1; QL

soft glucose (generic for GLUCO TO GO) - Tier 1; QL

TRUEPLUS GLUCOSE ON THE GO (brand for cvs glucose) - Tier 2;

TRUEPLUS GLUCOSE ORAL TABLET CHEWABLE (brand for cvs

glucose) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Insulins - Diabetic Drugs

BD BLUNT FILTER NEEDLE (brand for carepoint poly hub needle) -

Tier 2; QL

BD ECLIPSE NEEDLE 18G X 1-1/2" (brand for carepoint poly hub

needle) - Tier 2; QL

BD ECLIPSE SHIELDED NEEDLE (brand for carepoint poly hub

needle) - Tier 2; QL

BD NOKOR ADMIX NEEDLE (brand for carepoint poly hub needle) -

Tier 2; QL

CAREPOINT POLY HUB NEEDLE 18G X 1" (brand for carepoint poly

hub needle) - Tier 2; QL

CARETOUCH HYPODERMIC NEEDLE 18G X 1-1/2" (brand for

carepoint poly hub needle) - Tier 2; QL

MONOJECT HYPODERMIC NEEDLE 18G X 1" (brand for carepoint

poly hub needle) - Tier 2; QL

REZVOGLAR KWIKPEN - Tier 2; PA; QL

NOKOR VENTED NEEDLE (brand for carepoint poly hub needle) -

Tier 2; QL

Blood Products and Modifiers

Anticoagulants

CEPROTIN - Tier 2; PA; QL

dabigatran etexilate mesylate (generic for PRADAXA) - Tier 1; QL

ELIQUIS - Tier 2; QL

ELIQUIS DVT/PE STARTER PACK - Tier 2; QL

enoxaparin sodium (generic for LOVENOX) - Tier 1; QL

heparin (porcine) in nacl intravenous solution 1000-0.9 ut/500ml-%,

2000-0.9 unit/l-% - Tier 1; PA

heparin sodium (porcine) - Tier 1; PA

heparin sodium (porcine) pf - Tier 1; PA

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5

mg (generic for JANTOVEN) - Tier 1; QL

jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1

PRADAXA ORAL CAPSULE (brand for dabigatran etexilate mesylate)

- Tier 2; QL

ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 7.5 MG/0.6ML

(brand for fondaparinux sodium) - Tier 2; PA; QL

ARIXTRA SUBCUTANEOUS SOLUTION 2.5 MG/0.5ML, 5 MG/0.4ML

(brand for fondaparinux sodium) - Tier 2; PA

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 7.5 mg/0.6ml

(generic for ARIXTRA) - Tier 1; PA*; QL

fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml, 5 mg/0.4ml

(generic for ARIXTRA) - Tier 1; PA*

FRAGMIN - Tier 2; PA*

LOVENOX (brand for enoxaparin sodium) - Tier 2; PA; QL

PRADAXA ORAL PACKET 110 MG, 150 MG, 20 MG, 30 MG, 40 MG, 50

MG - Tier 2; PA; QL; AL

SAVAYSA - Tier 2; PA*; QL

XARELTO ORAL SUSPENSION RECONSTITUTED - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5

mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL

warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1

XARELTO ORAL TABLET - Tier 2; QL

XARELTO STARTER PACK - Tier 2; QL

ZONTIVITY - Tier 2; PA*; QL

Blood Products and Modifiers, Other

anagrelide hcl (generic for AGRYLIN) - Tier 1

ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QL

DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2

DROXIA ORAL CAPSULE 400 MG - Tier 2; QL

GRANIX - Tier 2; PA; SP; QL

NEUPOGEN - Tier 2; PA; SP; QL

PANHEMATIN - Tier 2; PA; QL

plerixafor (generic for MOZOBIL) - Tier 1; PA; SP; QL

PROMACTA - Tier 2; PA; SP; QL

RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML,

3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; PA; SP; QL

RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA; SP

SIKLOS ORAL TABLET 100 MG - Tier 2; PA; QL; AL

SIKLOS ORAL TABLET 1000 MG - Tier 2; PA; QL

AGRYLIN (brand for anagrelide hcl) - Tier 2; PA

EPOGEN - Tier 2; PA*; SP; QL

FULPHILA - Tier 2; PA*; SP; QL

LEUKINE - Tier 2; PA; SP; QL

MOZOBIL (brand for plerixafor) - Tier 2; PA; SP; QL

MULPLETA - Tier 2; PA; SP; QL

NEULASTA - Tier 2; PA*; SP; QL

NEULASTA ONPRO - Tier 2; PA*; SP; QL

NIVESTYM INJECTION SOLUTION - Tier 2; PA*

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE - Tier 2; PA*;

SP; QL

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 125 MCG -

Tier 2; PA

NPLATE SUBCUTANEOUS SOLUTION RECONSTITUTED 250 MCG,

500 MCG - Tier 2; PA; QL

NYVEPRIA - Tier 2; PA*; SP

OXBRYTA - Tier 2; PA; SP; QL

PROCRIT - Tier 2; PA*; SP; QL

RELEUKO - Tier 2; PA*; SP

UDENYCA ONBODY - Tier 2; PA; SP

UDENYCA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;

PA*; SP

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier

2; PA*; SP; QL

ZARXIO - Tier 2; PA*; SP; QL

ZIEXTENZO - Tier 2; PA*; SP

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Hemostasis Agents

aminocaproic acid oral solution - Tier 1; PA; QL

aminocaproic acid oral tablet - Tier 1; QL

CYKLOKAPRON (brand for tranexamic acid) - Tier 2; PA

tranexamic acid intravenous (generic for CYKLOKAPRON) - Tier 1; PA

tranexamic acid oral - Tier 1; QL

Platelet Modifying Agents

aspirin-dipyridamole er - Tier 1; QL

BRILINTA - Tier 2; QL

cilostazol - Tier 1; QL

clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QL

dipyridamole oral - Tier 1; QL

prasugrel hcl (generic for EFFIENT) - Tier 1; QL

DOPTELET - Tier 2; PA; SP; QL

EFFIENT (brand for prasugrel hcl) - Tier 2; PA; QL

PLAVIX (brand for clopidogrel bisulfate) - Tier 2; PA; QL

TAVALISSE - Tier 2; PA; SP; QL

Blood Products/Modifiers/Volume Expanders - Drugs to Treat

Blood Disorders

Anticoagulants - Blood Thinners

ACTIVASE - Tier 2; PA; QL

CATHFLO ACTIVASE - Tier 2; PA

Blood Formation Modifiers - Blood Formation Drugs

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100

MCG/0.3ML, 150 MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50

MCG/0.3ML, 75 MCG/0.3ML - Tier 2; PA*; QL

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 120

MCG/0.3ML - Tier 2; PA*

Hemostasis Agents - Drugs to Stop Bleeding

tranexamic acid-nacl - Tier 1; PA; QL ASTRINGYN - Tier 2; PA

RECOTHROM EXTERNAL SOLUTION RECONSTITUTED 5000 UNIT -

Tier 2; PA

RECOTHROM SPRAY KIT - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Cardiovascular Agents

Alpha-adrenergic Agonists

CATAPRES-TTS-1 (brand for clonidine) - Tier 2; QL; AL

CATAPRES-TTS-2 (brand for clonidine) - Tier 2; QL; AL

CATAPRES-TTS-3 (brand for clonidine) - Tier 2; QL; AL

clonidine (generic for CATAPRES-TTS-1) - Tier 1; QL; AL

clonidine hcl oral - Tier 1; QL; AL

guanfacine hcl - Tier 1; QL; AL

METHYLDOPA - Tier 2; QL

midodrine hcl - Tier 1; QL

CLONIDINE HCL ER ORAL TABLET EXTENDED RELEASE 24 HOUR

(brand for clonidine hcl er) - Tier 2; PA

droxidopa capsule 100 mg oral (generic for NORTHERA) - Tier 1; PA*;

SP; QL

droxidopa capsule 100 mg oral (generic for NORTHERA) - Tier 1; PA; SP;

droxidopa capsule 200 mg oral (generic for NORTHERA) - Tier 1; PA*;

SP; QL

droxidopa capsule 200 mg oral (generic for NORTHERA) - Tier 1; PA; SP;

droxidopa capsule 300 mg oral (generic for NORTHERA) - Tier 1; PA*;

SP; QL

droxidopa capsule 300 mg oral (generic for NORTHERA) - Tier 1; PA; SP;

NEXICLON XR (brand for clonidine hcl er) - Tier 2; PA

NORTHERA (brand for droxidopa) - Tier 2; PA; SP; QL

Alpha-adrenergic Blocking Agents

doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL

phenoxybenzamine hcl oral (generic for DIBENZYLINE) - Tier 1; QL

prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL

CARDURA (brand for doxazosin mesylate) - Tier 2; PA; QL

DIBENZYLINE (brand for phenoxybenzamine hcl) - Tier 2; PA; QL

MINIPRESS (brand for prazosin hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Angiotensin II Receptor Antagonists

irbesartan (generic for AVAPRO) - Tier 1; QL

losartan potassium oral (generic for COZAAR) - Tier 1; QL

olmesartan medoxomil oral (generic for BENICAR) - Tier 1; QL

valsartan oral tablet (generic for DIOVAN) - Tier 1; QL

ATACAND (brand for candesartan cilexetil) - Tier 2; PA; QL

AVAPRO (brand for irbesartan) - Tier 2; PA; QL

BENICAR (brand for olmesartan medoxomil) - Tier 2; PA; QL

candesartan cilexetil (generic for ATACAND) - Tier 1; PA*; QL

COZAAR (brand for losartan potassium) - Tier 2; PA; QL

DIOVAN (brand for valsartan) - Tier 2; PA; QL

EDARBI - Tier 2; PA*; QL

MICARDIS (brand for telmisartan) - Tier 2; PA; QL

telmisartan tablet 20 mg oral (generic for MICARDIS) - Tier 1; PA; QL

telmisartan tablet 20 mg oral (generic for MICARDIS) - Tier 1; PA*; QL

telmisartan tablet 40 mg oral (generic for MICARDIS) - Tier 1; PA; QL

telmisartan tablet 40 mg oral (generic for MICARDIS) - Tier 1; PA*; QL

telmisartan tablet 80 mg oral (generic for MICARDIS) - Tier 1; PA; QL

telmisartan tablet 80 mg oral (generic for MICARDIS) - Tier 1; PA*; QL

VALSARTAN ORAL SOLUTION - Tier 2; PA; QL

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL

captopril oral - Tier 1; QL

enalapril maleate oral tablet (generic for VASOTEC) - Tier 1; QL

fosinopril sodium - Tier 1; QL

lisinopril oral (generic for ZESTRIL) - Tier 1; QL

quinapril hcl (generic for ACCUPRIL) - Tier 1; QL

ramipril (generic for ALTACE) - Tier 1; QL

ACCUPRIL (brand for quinapril hcl) - Tier 2; PA; QL

ALTACE (brand for ramipril) - Tier 2; PA; QL

enalapril maleate solution 1 mg/ml oral (generic for EPANED) - Tier 1;

PA*; QL; AL

enalapril maleate solution 1 mg/ml oral (generic for EPANED) - Tier 1; PA;

QL; AL

EPANED (brand for enalapril maleate) - Tier 2; PA; QL; AL

LOTENSIN (brand for benazepril hcl) - Tier 2; PA; QL

moexipril hcl - Tier 1; PA*; QL

perindopril erbumine - Tier 1; PA*; QL

QBRELIS - Tier 2; PA*; QL

trandolapril - Tier 1; PA*; QL

VASOTEC (brand for enalapril maleate) - Tier 2; PA; QL

ZESTRIL (brand for lisinopril) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Antiarrhythmics

amiodarone hcl oral (generic for PACERONE) - Tier 1; QL

disopyramide phosphate (generic for NORPACE) - Tier 1; QL

dofetilide (generic for TIKOSYN) - Tier 1; QL

flecainide acetate - Tier 1; QL

mexiletine hcl oral - Tier 1; QL

procainamide hcl injection - Tier 1; PA; QL

propafenone hcl - Tier 1; QL

propafenone hcl er - Tier 1; QL

quinidine gluconate er - Tier 1; QL

sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL

sotalol hcl oral (generic for BETAPACE) - Tier 1; QL

BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL

BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL

MULTAQ - Tier 2; PA*; QL

NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL

NORPACE CR - Tier 2; PA*; QL

PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL

quinidine sulfate - Tier 1; PA*; QL

SOTYLIZE - Tier 2; PA; QL

TIKOSYN (brand for dofetilide) - Tier 2; PA; QL

Beta-adrenergic Blocking Agents

acebutolol hcl oral - Tier 1; QL

atenolol oral (generic for TENORMIN) - Tier 1; QL

betaxolol hcl oral - Tier 1; QL

bisoprolol fumarate oral - Tier 1; QL

carvedilol (generic for COREG) - Tier 1; QL

carvedilol phosphate er (generic for COREG CR) - Tier 1; QL

labetalol hcl oral - Tier 1; QL

metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL

metoprolol tartrate oral (generic for LOPRESSOR) - Tier 1; QL

nadolol oral (generic for CORGARD) - Tier 1; QL

propranolol hcl er (generic for INDERAL LA) - Tier 1; QL

propranolol hcl oral - Tier 1; QL

BYSTOLIC (brand for nebivolol hcl) - Tier 2; PA; QL

COREG (brand for carvedilol) - Tier 2; PA; QL

COREG CR (brand for carvedilol phosphate er) - Tier 2; PA; QL

CORGARD (brand for nadolol) - Tier 2; PA; QL

HEMANGEOL - Tier 2; PA*; QL

INDERAL LA (brand for propranolol hcl er) - Tier 2; PA; QL

INDERAL XL - Tier 2; PA*; QL

INNOPRAN XL - Tier 2; PA*; QL

KAPSPARGO SPRINKLE - Tier 2; PA; QL

LOPRESSOR (brand for metoprolol tartrate) - Tier 2; PA; QL

nebivolol hcl (generic for BYSTOLIC) - Tier 1; PA*; QL

pindolol - Tier 1; PA*; QL

TENORMIN (brand for atenolol) - Tier 2; PA; QL

TOPROL XL (brand for metoprolol succinate er) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Calcium Channel Blocking Agents, Dihydropyridines

amlodipine besylate oral (generic for NORVASC) - Tier 1; QL

felodipine er - Tier 1; QL

nifedipine er - Tier 1; QL

nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1;

nifedipine oral - Tier 1; QL

isradipine - Tier 1; PA*; QL

KATERZIA - Tier 2; PA*; QL

nicardipine hcl oral - Tier 1; PA*; QL

nimodipine oral - Tier 1; PA*; QL

nisoldipine er (generic for SULAR) - Tier 1; PA*; QL

NORLIQVA - Tier 2; PA; QL

NORVASC (brand for amlodipine besylate) - Tier 2; PA; QL

NYMALIZE - Tier 2; PA*; QL

PROCARDIA XL (brand for nifedipine er osmotic release) - Tier 2; PA; QL

SULAR (brand for nisoldipine er) - Tier 2; PA; QL

Calcium Channel Blocking Agents, Nondihydropyridines

diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL

diltiazem hcl er coated beads (generic for CARDIZEM CD) - Tier 1; QL

diltiazem hcl er oral capsule extended release 12 hour - Tier 1; QL

diltiazem hcl er oral capsule extended release 24 hour - Tier 1; QL

diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL

dilt-xr - Tier 1; QL

tiadylt er (generic for TAZTIA XT) - Tier 1; QL

verapamil hcl er oral tablet extended release - Tier 1; QL

verapamil hcl oral - Tier 1; QL

CARDIZEM (brand for diltiazem hcl) - Tier 2; PA; QL

CARDIZEM CD (brand for diltiazem hcl er coated beads) - Tier 2; PA; QL

CARDIZEM LA (brand for diltiazem hcl er) - Tier 2; PA; QL

cartia xt (generic for CARTIA XT) - Tier 1; PA; QL

diltiazem hcl er oral tablet extended release 24 hour (generic for

CARDIZEM LA) - Tier 1; PA*; QL

matzim la (generic for MATZIM LA) - Tier 1; PA*; QL

taztia xt (generic for TAZTIA XT) - Tier 1; PA; QL

TIAZAC (brand for diltiazem hcl er beads) - Tier 2; PA; QL

verapamil hcl er oral capsule extended release 24 hour (generic for

VERELAN) - Tier 1; PA*; QL

VERELAN (brand for verapamil hcl er) - Tier 2; PA; QL

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100

MG (brand for verapamil hcl er) - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

VERELAN PM ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200

MG, 300 MG (brand for verapamil hcl er) - Tier 2; PA; QL

Cardiovascular Agents, Other

acetazolamide er - Tier 1; QL

acetazolamide oral - Tier 1; QL

amiloride-hydrochlorothiazide - Tier 1; QL

amlodipine besylate-benazepril hcl (generic for LOTREL) - Tier 1; PA;

amlodipine besylate-valsartan (generic for EXFORGE) - Tier 1; PA; QL

atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL

benazepril-hydrochlorothiazide (generic for LOTENSIN HCT) - Tier 1;

bisoprolol-hydrochlorothiazide - Tier 1; QL

CORLANOR - Tier 2; PA; QL

digoxin oral solution - Tier 1; QL

digoxin oral tablet 125 mcg, 250 mcg (generic for LANOXIN) - Tier 1;

ACCURETIC (brand for quinapril-hydrochlorothiazide) - Tier 2; PA; QL

aliskiren fumarate (generic for TEKTURNA) - Tier 1; PA; QL

amlodipine-atorvastatin (generic for CADUET) - Tier 1; PA; QL

amlodipine-olmesartan (generic for AZOR) - Tier 1; PA*; QL

amlodipine-valsartan-hctz (generic for EXFORGE HCT) - Tier 1; PA*; QL

ASPRUZYO SPRINKLE - Tier 2; PA; QL

ATACAND HCT (brand for candesartan cilexetil-hctz) - Tier 2; PA; QL

AVALIDE (brand for irbesartan-hydrochlorothiazide) - Tier 2; PA; QL

AZOR (brand for amlodipine-olmesartan) - Tier 2; PA; QL

BENICAR HCT (brand for olmesartan medoxomil-hctz) - Tier 2; PA; QL

BIDIL (brand for isosorb dinitrate-hydralazine) - Tier 2; PA; QL

CADUET (brand for amlodipine-atorvastatin) - Tier 2; PA; QL

candesartan cilexetil-hctz (generic for ATACAND HCT) - Tier 1; PA*; QL

captopril-hydrochlorothiazide - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL

ENTRESTO - Tier 2; PA; QL

fosinopril sodium-hctz - Tier 1; QL

irbesartan-hydrochlorothiazide (generic for AVALIDE) - Tier 1; QL

KERENDIA - Tier 2; PA

lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL

losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL

metoprolol-hydrochlorothiazide - Tier 1; QL

olmesartan medoxomil-hctz (generic for BENICAR HCT) - Tier 1; QL

pentoxifylline er - Tier 1; QL

quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL

ranolazine er (generic for RANEXA) - Tier 1; PA; QL

spironolactone-hctz - Tier 1; QL

triamterene-hctz - Tier 1; QL

DEMSER (brand for metyrosine) - Tier 2; PA; QL

digoxin oral tablet 62.5 mcg (generic for LANOXIN) - Tier 1; PA*; QL

DIOVAN HCT (brand for valsartan-hydrochlorothiazide) - Tier 2; PA; QL

EDARBYCLOR - Tier 2; PA*; QL

EXFORGE (brand for amlodipine besylate-valsartan) - Tier 2; PA; QL

EXFORGE HCT (brand for amlodipine-valsartan-hctz) - Tier 2; PA; QL

HYZAAR (brand for losartan potassium-hctz) - Tier 2; PA; QL

isosorb dinitrate-hydralazine (generic for BIDIL) - Tier 1; PA; QL

LANOXIN ORAL (brand for digoxin) - Tier 2; PA; QL

LOTENSIN HCT (brand for benazepril-hydrochlorothiazide) - Tier 2; PA;

LOTREL (brand for amlodipine besy-benazepril hcl) - Tier 2; PA; QL

metyrosine (generic for DEMSER) - Tier 1; PA*; QL

MICARDIS HCT (brand for telmisartan-hctz) - Tier 2; PA; QL

valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1; QL olmesartan-amlodipine-hctz (generic for TRIBENZOR) - Tier 1; PA*; QL

TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA; QL

telmisartan-amlodipine - Tier 1; PA*; QL

telmisartan-hctz (generic for MICARDIS HCT) - Tier 1; PA*; QL

TENORETIC 100 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL

TENORETIC 50 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL

trandolapril-verapamil hcl er - Tier 1; PA*; QL

TRIBENZOR (brand for olmesartan-amlodipine-hctz) - Tier 2; PA; QL

VASERETIC (brand for enalapril-hydrochlorothiazide) - Tier 2; PA; QL

VECAMYL - Tier 2; PA*; QL

ZESTORETIC (brand for lisinopril-hydrochlorothiazide) - Tier 2; PA; QL

Diuretics, Loop

bumetanide injection - Tier 1; PA

bumetanide oral (generic for BUMEX) - Tier 1; QL

furosemide oral (generic for LASIX) - Tier 1; QL

torsemide (generic for SOAANZ) - Tier 1; QL

BUMEX (brand for bumetanide) - Tier 2; PA; QL

EDECRIN (brand for ethacrynic acid) - Tier 2; PA; QL

ethacrynic acid (generic for EDECRIN) - Tier 1; PA*; QL

FUROSCIX - Tier 2; PA; QL

LASIX (brand for furosemide) - Tier 2; PA; QL

SOAANZ ORAL TABLET 20 MG (brand for torsemide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Diuretics, Potassium-sparing

amiloride hcl oral - Tier 1; QL

eplerenone (generic for INSPRA) - Tier 1; QL

spironolactone oral tablet (generic for ALDACTONE) - Tier 1; QL

ALDACTONE (brand for spironolactone) - Tier 2; PA; QL

CAROSPIR (brand for spironolactone) - Tier 2; PA*; QL

DYRENIUM (brand for triamterene) - Tier 2; PA*; QL

INSPRA (brand for eplerenone) - Tier 2; PA; QL

spironolactone oral suspension (generic for CAROSPIR) - Tier 1; PA; QL

triamterene oral (generic for DYRENIUM) - Tier 1; PA*; QL

Diuretics, Thiazide

chlorthalidone - Tier 1; QL

hydrochlorothiazide oral - Tier 1; QL

indapamide - Tier 1; QL

metolazone - Tier 1; QL

THALITONE - Tier 2; QL

DIURIL - Tier 2; PA*; QL

Dyslipidemics, Fibric Acid Derivatives

fenofibrate oral tablet (generic for FENOGLIDE) - Tier 1; QL

gemfibrozil oral (generic for LOPID) - Tier 1; QL

fenofibrate micronized - Tier 1; PA; QL

fenofibrate oral capsule (generic for LIPOFEN) - Tier 1; PA; QL

fenofibric acid oral capsule delayed release (generic for TRILIPIX) - Tier

1; PA*; QL

FENOGLIDE (brand for fenofibrate) - Tier 2; PA; QL

LIPOFEN (brand for fenofibrate) - Tier 2; PA; QL

LOPID (brand for gemfibrozil) - Tier 2; PA; QL

TRICOR (brand for fenofibrate) - Tier 2; PA; QL

TRILIPIX (brand for fenofibric acid) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL

lovastatin oral - Tier 1; QL; AL

pravastatin sodium - Tier 1; QL

rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL

simvastatin oral (generic for ZOCOR) - Tier 1; QL

ALTOPREV - Tier 2; PA*; QL

ATORVALIQ - Tier 2; PA; QL

CRESTOR (brand for rosuvastatin calcium) - Tier 2; PA; QL

EZALLOR SPRINKLE - Tier 2; PA; QL

fluvastatin sodium - Tier 1; PA*; QL

fluvastatin sodium er (generic for LESCOL XL) - Tier 1; PA*; QL

LESCOL XL (brand for fluvastatin sodium er) - Tier 2; PA; QL

LIPITOR (brand for atorvastatin calcium) - Tier 2; PA; QL

LIVALO (brand for pitavastatin calcium) - Tier 2; PA*; QL

pitavastatin calcium (generic for LIVALO) - Tier 1; PA; QL

ZOCOR (brand for simvastatin) - Tier 2; PA; QL

ZYPITAMAG - Tier 2; PA*; QL

Dyslipidemics, Other

cholestyramine light (generic for PREVALITE) - Tier 1; QL

cholestyramine oral (generic for QUESTRAN) - Tier 1; QL

colestipol hcl oral tablet (generic for COLESTID) - Tier 1; QL

ezetimibe (generic for ZETIA) - Tier 1; QL

JUXTAPID - Tier 2; PA; SP; QL; AL

NEXLETOL - Tier 2; PA; QL

niacin er (antihyperlipidemic) - Tier 1; QL

prevalite (generic for PREVALITE) - Tier 1; QL

REPATHA - Tier 2; PA; SP; QL

colesevelam hcl (generic for WELCHOL) - Tier 1; PA*; QL

COLESTID (brand for colestipol hcl) - Tier 2; PA; QL

colestipol hcl oral granules (generic for COLESTID) - Tier 1; PA*; QL

colestipol hcl oral packet - Tier 1; PA*; QL

ezetimibe-simvastatin (generic for VYTORIN) - Tier 1; PA*; QL

icosapent ethyl (generic for VASCEPA) - Tier 1; PA; QL

LEQVIO - Tier 2; PA; SP

LOVAZA (brand for omega-3-acid ethyl esters) - Tier 2; PA; QL

NEXLIZET - Tier 2; PA; QL

omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL

PRALUENT - Tier 2; PA; SP; QL

QUESTRAN (brand for cholestyramine) - Tier 2; PA; QL

QUESTRAN LIGHT (brand for cholestyramine light) - Tier 2; PA; QL

VASCEPA (brand for icosapent ethyl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

VYTORIN (brand for ezetimibe-simvastatin) - Tier 2; PA; QL

WELCHOL (brand for colesevelam hcl) - Tier 2; PA; QL

ZETIA (brand for ezetimibe) - Tier 2; PA; QL

Vasodilators, Direct-acting Arterial

hydralazine hcl oral - Tier 1; QL

minoxidil oral - Tier 1; QL

Vasodilators, Direct-acting Arterial/Venous

ISORDIL TITRADOSE ORAL TABLET 5 MG (brand for isosorbide

dinitrate) - Tier 2; QL

isosorbide dinitrate (generic for ISORDIL TITRADOSE) - Tier 1; QL

isosorbide mononitrate - Tier 1; QL

isosorbide mononitrate er - Tier 1; QL

NITRO-BID - Tier 2; QL

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8

MG/HR - Tier 2; QL

nitroglycerin rectal (generic for RECTIV) - Tier 1; PA; QL

nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL

nitroglycerin transdermal (generic for NITRO-DUR) - Tier 1; QL

NITRO-TIME - Tier 2; QL

ISORDIL TITRADOSE ORAL TABLET 40 MG (brand for isosorbide

dinitrate) - Tier 2; PA; QL

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2

MG/HR, 0.4 MG/HR, 0.6 MG/HR (brand for nitroglycerin) - Tier 2; PA; QL

nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; PA; QL

NITROLINGUAL (brand for nitroglycerin) - Tier 2; PA; QL

NITROSTAT (brand for nitroglycerin) - Tier 2; PA; QL

RECTIV (brand for nitroglycerin) - Tier 2; PA; QL

Cardiovascular Agents - Drugs to Treat Heart and Circulation

Conditions

Calcium Channel Blocking Agents - Blood Pressure Drugs

CONJUPRI (brand for levamlodipine maleate) - Tier 2; PA*; QL

LEVAMLODIPINE MALEATE (brand for levamlodipine maleate) - Tier 2;

PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs

ephedrine sulfate (pressors) intravenous solution 50 mg/ml (generic for

AKOVAZ) - Tier 1; PA

AKOVAZ INTRAVENOUS SOLUTION (brand for ephedrine sulfate

(pressors)) - Tier 2; PA

Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs

fenofibric acid oral tablet (generic for FIBRICOR) - Tier 1; PA*; QL

FIBRICOR (brand for fenofibric acid) - Tier 2; PA*; QL

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs

Cardiovascular Agents - Drugs to Treat Heart and Circulation

Conditions

milrinone lactate - Tier 1; PA; QL

milrinone lactate in dextrose intravenous solution 20-5 mg/100ml-% -

Tier 1; PA; QL

milrinone lactate in dextrose intravenous solution 40-5 mg/200ml-% -

Tier 1; PA

VERQUVO - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Non-

amphetamines

atomoxetine hcl (generic for STRATTERA) - Tier 1; QL; AL

clonidine hcl er oral tablet extended release 12 hour - Tier 1; QL; AL

CONCERTA ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG,

36 MG (brand for methylphenidate hcl er (osm)) - Tier 2; AL

CONCERTA ORAL TABLET EXTENDED RELEASE 54 MG (brand for

methylphenidate hcl er (osm)) - Tier 2; QL; AL

dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; AL

dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; AL

FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; AL

guanfacine hcl er (generic for INTUNIV) - Tier 1; QL; AL

METHYLIN (brand for methylphenidate hcl) - Tier 2; AL

methylphenidate hcl er (cd) (generic for METADATE CD) - Tier 1; AL

methylphenidate hcl er (la) oral capsule extended release 24 hour 10

mg, 20 mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; AL

APTENSIO XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10

MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG (brand for

methylphenidate hcl er (xr)) - Tier 2; PA; QL; AL

COTEMPLA XR-ODT - Tier 2; PA*; QL; AL

DAYTRANA (brand for methylphenidate) - Tier 2; PA; QL; AL

FOCALIN XR (brand for dexmethylphenidate hcl er) - Tier 2; PA; AL

INTUNIV (brand for guanfacine hcl er) - Tier 2; PA; QL; AL

JORNAY PM - Tier 2; PA*; QL; AL

methylphenidate (generic for DAYTRANA) - Tier 1; PA; QL; AL

METHYLPHENIDATE HCL ER (OSM) ORAL TABLET EXTENDED

RELEASE 45 MG, 63 MG (brand for methylphenidate hcl er (osm)) - Tier

2; PA*

methylphenidate hcl er (osm) oral tablet extended release 72 mg (generic

for RELEXXII) - Tier 1; PA*; AL

methylphenidate hcl er (la) oral capsule extended release 24 hour 60

mg - Tier 1; QL; AL

methylphenidate hcl er (osm) oral tablet extended release 18 mg, 27

mg, 36 mg (generic for CONCERTA) - Tier 1; AL

methylphenidate hcl er (osm) oral tablet extended release 54 mg

(generic for CONCERTA) - Tier 1; QL; AL

methylphenidate hcl er oral tablet extended release - Tier 1; AL

methylphenidate hcl er oral tablet extended release 24 hour 18 mg, 27

mg, 36 mg - Tier 1; AL

methylphenidate hcl er oral tablet extended release 24 hour 54 mg -

Tier 1; QL; AL

methylphenidate hcl oral solution (generic for METHYLIN) - Tier 1; AL

methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; AL

methylphenidate hcl er (xr) oral capsule extended release 24 hour 10 mg,

15 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg (generic for APTENSIO XR) -

Tier 1; PA; QL; AL

methylphenidate hcl oral tablet chewable - Tier 1; PA; AL

QUILLICHEW ER - Tier 2; PA; QL; AL

QUILLIVANT XR - Tier 2; PA; QL; AL

RELEXXII ORAL TABLET EXTENDED RELEASE 45 MG, 63 MG (brand

for methylphenidate hcl er (osm)) - Tier 2; PA*

RELEXXII ORAL TABLET EXTENDED RELEASE 72 MG (brand for

methylphenidate hcl er (osm)) - Tier 2; PA*; AL

RITALIN (brand for methylphenidate hcl) - Tier 2; PA; AL

RITALIN LA (brand for methylphenidate hcl er (la)) - Tier 2; PA; AL

STRATTERA (brand for atomoxetine hcl) - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

RELEXXII ORAL TABLET EXTENDED RELEASE 18 MG, 27 MG, 36

MG (brand for methylphenidate hcl er (osm)) - Tier 2; AL

RELEXXII ORAL TABLET EXTENDED RELEASE 54 MG (brand for

methylphenidate hcl er (osm)) - Tier 2; QL; AL

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

ADDERALL ORAL TABLET 10 MG, 15 MG, 30 MG, 5 MG (brand for

amphetamine-dextroamphetamine) - Tier 2; AL

ADDERALL ORAL TABLET 12.5 MG, 20 MG, 7.5 MG (brand for

amphetamine-dextroamphetamine) - Tier 2; QL; AL

ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2;

QL; AL

amphetamine-dextroamphetamine er (generic for ADDERALL XR) -

Tier 1; QL; AL

amphetamine-dextroamphetamine oral tablet 10 mg, 15 mg, 30 mg, 5

mg (generic for ADDERALL) - Tier 1; AL

amphetamine-dextroamphetamine oral tablet 12.5 mg, 20 mg, 7.5 mg

(generic for ADDERALL) - Tier 1; QL; AL

dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1; AL

ADZENYS XR-ODT - Tier 2; PA*; QL; AL

amphetamine sulfate (generic for EVEKEO) - Tier 1; PA*; QL; AL

amphet-dextroamphet 3-bead er (generic for MYDAYIS) - Tier 1; PA; QL;

AZSTARYS - Tier 2; PA*; QL; AL

DESOXYN (brand for methamphetamine hcl) - Tier 2; PA; QL; AL

DEXEDRINE (brand for dextroamphetamine sulfate er) - Tier 2; PA; AL

dextroamphetamine sulfate oral solution (generic for PROCENTRA) - Tier

1; PA*; AL

dextroamphetamine sulfate oral tablet 10 mg, 5 mg (generic for ZENZEDI)

- Tier 1; PA*; AL

dextroamphetamine sulfate oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg, 7.5

mg (generic for ZENZEDI) - Tier 1; PA; AL

lisdexamfetamine dimesylate oral capsule 10 mg (generic for

VYVANSE) - Tier 1; QL; AL

lisdexamfetamine dimesylate oral capsule 20 mg, 30 mg, 40 mg, 50

mg, 60 mg, 70 mg (generic for VYVANSE) - Tier 1; AL

lisdexamfetamine dimesylate oral tablet chewable (generic for

VYVANSE) - Tier 1; QL; AL

VYVANSE ORAL TABLET CHEWABLE (brand for lisdexamfetamine

dimesylate) - Tier 2; QL; AL

DYANAVEL XR ORAL SUSPENSION EXTENDED RELEASE - Tier 2;

PA*; QL; AL

DYANAVEL XR ORAL TABLET CHEWABLE EXTENDED RELEASE -

Tier 2; PA*; AL

EVEKEO (brand for amphetamine sulfate) - Tier 2; PA*; QL; AL

methamphetamine hcl (generic for DESOXYN) - Tier 1; PA; QL; AL

MYDAYIS (brand for amphet-dextroamphet 3-bead er) - Tier 2; PA*; QL;

PROCENTRA (brand for dextroamphetamine sulfate) - Tier 2; PA*; AL

VYVANSE ORAL CAPSULE 10 MG (brand for lisdexamfetamine

dimesylate) - Tier 2; PA; QL; AL

VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70

MG (brand for lisdexamfetamine dimesylate) - Tier 2; PA; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ZENZEDI ORAL TABLET 10 MG, 5 MG (brand for dextroamphetamine

sulfate) - Tier 2; PA*; AL

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG (brand

for dextroamphetamine sulfate) - Tier 2; PA; AL

Central Nervous System, Other

AUSTEDO - Tier 2; SP; QL; AL

AUSTEDO XR - Tier 2; PA; SP; QL

AUSTEDO XR PATIENT TITRATION - Tier 2; PA

caffeine citrate oral - Tier 1; QL; AL

riluzole (generic for RILUTEK) - Tier 1; QL

tetrabenazine (generic for XENAZINE) - Tier 1; SP; QL; AL

EXSERVAN - Tier 2; PA; QL

gabapentin (once-daily) (generic for GRALISE) - Tier 1; PA; QL

GRALISE ORAL - Tier 2; PA; QL

GRALISE ORAL TABLET 300 MG, 600 MG (brand for gabapentin (once-

daily)) - Tier 2; PA; QL

GRALISE ORAL TABLET 450 MG, 750 MG, 900 MG - Tier 2; PA; QL; AL

HORIZANT - Tier 2; PA; QL

INGREZZA ORAL CAPSULE 40 MG, 80 MG - Tier 2; PA*; SP; QL; AL

INGREZZA ORAL CAPSULE 60 MG - Tier 2; PA*

INGREZZA ORAL CAPSULE SPRINKLE - Tier 2; PA; SP; QL

INGREZZA ORAL CAPSULE THERAPY PACK - Tier 2; PA*; SP; QL

NUEDEXTA - Tier 2; PA; QL

RILUTEK (brand for riluzole) - Tier 2; PA; QL

TEGLUTIK - Tier 2; PA; QL

XENAZINE (brand for tetrabenazine) - Tier 2; PA; SP; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Fibromyalgia Agents

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60

mg (generic for CYMBALTA) - Tier 1; QL

pregabalin oral (generic for LYRICA) - Tier 1; QL

CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL

duloxetine hcl oral capsule delayed release particles 40 mg - Tier 1; PA;

LYRICA (brand for pregabalin) - Tier 2; PA; QL

LYRICA CR (brand for pregabalin er) - Tier 2; PA; QL

pregabalin er (generic for LYRICA CR) - Tier 1; PA; QL

SAVELLA - Tier 2; PA; QL

SAVELLA TITRATION PACK - Tier 2; PA; QL

Multiple Sclerosis Agents

AVONEX PEN - Tier 2; SP; QL

AVONEX PREFILLED - Tier 2; SP; QL

BETASERON - Tier 2; SP; QL

COPAXONE (brand for glatiramer acetate) - Tier 2; SP; QL

dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; SP; QL

dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; SP;

KESIMPTA - Tier 2; PA; SP; QL

TECFIDERA ORAL CAPSULE DELAYED RELEASE THERAPY

PACK (brand for dimethyl fumarate starter pack) - Tier 2; SP; QL

AMPYRA (brand for dalfampridine er) - Tier 2; PA; SP; QL

AUBAGIO (brand for teriflunomide) - Tier 2; PA; SP; QL

BAFIERTAM - Tier 2; PA*; SP; QL

dalfampridine er (generic for AMPYRA) - Tier 1; PA; SP; QL

EXTAVIA - Tier 2; PA*; SP; QL

fingolimod hcl capsule 0.5 mg oral (generic for GILENYA) - Tier 1; PA*;

SP; QL

fingolimod hcl capsule 0.5 mg oral (generic for GILENYA) - Tier 1; PA;

SP; QL

GILENYA ORAL CAPSULE 0.25 MG - Tier 2; PA*; SP; QL

GILENYA ORAL CAPSULE 0.5 MG (brand for fingolimod hcl) - Tier 2; PA;

SP; QL

glatiramer acetate (generic for GLATOPA) - Tier 1; PA*; SP; QL

glatopa (generic for GLATOPA) - Tier 1; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

LEMTRADA - Tier 2; PA*; SP; QL

MAVENCLAD (10 TABS) - Tier 2; PA*; SP; QL

MAVENCLAD (4 TABS) - Tier 2; PA*; SP; QL

MAVENCLAD (5 TABS) - Tier 2; PA*; SP; QL

MAVENCLAD (6 TABS) - Tier 2; PA*; SP; QL

MAVENCLAD (7 TABS) - Tier 2; PA*; SP; QL

MAVENCLAD (8 TABS) - Tier 2; PA*; SP; QL

MAVENCLAD (9 TABS) - Tier 2; PA*; SP; QL

MAYZENT - Tier 2; PA*; SP; QL

MAYZENT STARTER PACK - Tier 2; PA*; SP; QL

OCREVUS - Tier 2; PA*; SP; QL

PLEGRIDY - Tier 2; PA*; SP; QL

PLEGRIDY STARTER PACK - Tier 2; PA*; SP; QL

REBIF - Tier 2; PA*; SP; QL

REBIF REBIDOSE - Tier 2; PA*; SP; QL

REBIF REBIDOSE TITRATION PACK - Tier 2; PA*; SP; QL

REBIF TITRATION PACK - Tier 2; PA*; SP; QL

TECFIDERA ORAL CAPSULE DELAYED RELEASE (brand for dimethyl

fumarate) - Tier 2; PA; SP; QL

teriflunomide tablet 14 mg oral (generic for AUBAGIO) - Tier 1; PA*; SP;

teriflunomide tablet 14 mg oral (generic for AUBAGIO) - Tier 1; PA; SP;

teriflunomide tablet 7 mg oral (generic for AUBAGIO) - Tier 1; PA*; SP;

teriflunomide tablet 7 mg oral (generic for AUBAGIO) - Tier 1; PA; SP; QL

TYSABRI - Tier 2; PA*; SP; QL

VUMERITY - Tier 2; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ZEPOSIA - Tier 2; PA*; SP; QL

ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA*; SP; QL

ZEPOSIA STARTER KIT - Tier 2; PA*; QL

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,

Cough, Cold and Lung Conditions

BRONCHITOL - Tier 2; PA; QL

BRONCHITOL TOLERANCE TEST - Tier 2; PA; QL

Dental and Oral Agents

cevimeline hcl (generic for EVOXAC) - Tier 1; QL

chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier

1; QL

kourzeq (generic for KOURZEQ) - Tier 1; QL

oralone (generic for KOURZEQ) - Tier 1; QL

periogard (generic for PERIOGARD) - Tier 1; QL

pilocarpine hcl oral (generic for SALAGEN) - Tier 1; QL

triamcinolone acetonide mouth/throat (generic for KOURZEQ) - Tier 1;

EVOXAC (brand for cevimeline hcl) - Tier 2; PA; QL

PERIDEX (brand for chlorhexidine gluconate) - Tier 2; PA; QL

SALAGEN (brand for pilocarpine hcl) - Tier 2; PA; QL

Dental and Oral Agents - Drugs to Treat Mouth and Throat

Conditions

EPISIL - Tier 2; PA

GELX - Tier 2; PA

MUCOTROL - Tier 2; PA

MUGARD - Tier 2; PA

ORAMAGICRX - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Dermatological Agents

Acne and Rosacea Agents

accutane (generic for ACCUTANE) - Tier 1; PA; QL

acitretin - Tier 1; QL

adapalene external cream (generic for DIFFERIN) - Tier 1; QL; AL

adapalene external gel (generic for DIFFERIN) - Tier 1; QL; AL

adapalene-benzoyl peroxide external gel 0.1-2.5 % (generic for

EPIDUO) - Tier 1; QL

amnesteem (generic for ACCUTANE) - Tier 1; PA; QL

azelaic acid external (generic for FINACEA) - Tier 1; QL

benzoyl peroxide-erythromycin (generic for BENZAMYCIN) - Tier 1;

claravis (generic for ACCUTANE) - Tier 1; PA; QL

clindamycin phos-benzoyl perox external gel 1.2-2.5 % (generic for

ACANYA) - Tier 1; QL

ABSORICA LD - Tier 2; PA; QL

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG (brand for

isotretinoin) - Tier 2; PA; QL

ABSORICA ORAL CAPSULE 25 MG, 35 MG (brand for isotretinoin) - Tier

2; PA

ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL

adapalene-benzoyl peroxide external gel 0.3-2.5 % (generic for EPIDUO

FORTE) - Tier 1; PA; QL

ALTRENO - Tier 2; PA*; QL

ARAZLO - Tier 2; PA*; QL

ATRALIN (brand for tretinoin) - Tier 2; PA; QL

BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL

brimonidine tartrate external (generic for MIRVASO) - Tier 1; PA; QL

clindamycin phos-benzoyl perox external gel 1.2-5 % (generic for

NEUAC) - Tier 1; QL

clindamycin phosphate-benzoyl peroxide external gel 1-5 % - Tier 1;

DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; QL; AL

DIFFERIN EXTERNAL GEL (brand for adapalene) - Tier 2; QL; AL

FINACEA EXTERNAL FOAM - Tier 2; QL

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg (generic for

ACCUTANE) - Tier 1; PA; QL

isotretinoin oral capsule 25 mg, 35 mg (generic for ABSORICA) - Tier

1; PA

neuac (generic for NEUAC) - Tier 1; QL

RETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; QL

tretinoin external cream (generic for RETIN-A) - Tier 1; ST; QL

clindamycin phos-benzoyl perox external gel 1.2-3.75 % (generic for

ONEXTON) - Tier 1; PA; QL

clindamycin-tretinoin (generic for ZIANA) - Tier 1; PA; QL

EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL

EPIDUO FORTE (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL

FABIOR (brand for tazarotene) - Tier 2; PA*; QL

MIRVASO (brand for brimonidine tartrate) - Tier 2; PA; QL

ONEXTON (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL

RETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL

RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) -

Tier 2; PA; QL; AL

RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 % (brand for

tretinoin microsphere) - Tier 2; PA; QL; AL

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

tretinoin external gel (generic for ATRALIN) - Tier 1; QL

zenatane (generic for ACCUTANE) - Tier 1; PA; QL

RETIN-A MICRO PUMP EXTERNAL GEL 0.08 % (brand for tretinoin

microsphere) - Tier 2; PA; QL

RHOFADE - Tier 2; PA*; QL

tazarotene external cream (generic for TAZORAC) - Tier 1; PA*; QL

TAZAROTENE EXTERNAL FOAM (brand for tazarotene) - Tier 2; PA*;

tazarotene gel 0.05 % external (generic for TAZORAC) - Tier 1; PA*; QL

tazarotene gel 0.05 % external (generic for TAZORAC) - Tier 1; PA; QL

tazarotene gel 0.1 % external (generic for TAZORAC) - Tier 1; PA*; QL

tazarotene gel 0.1 % external (generic for TAZORAC) - Tier 1; PA; QL

TAZORAC EXTERNAL CREAM 0.1 % (brand for tazarotene) - Tier 2; PA;

TAZORAC EXTERNAL GEL (brand for tazarotene) - Tier 2; PA; QL

tretinoin microsphere external gel 0.04 %, 0.1 % (generic for RETIN-A

MICRO) - Tier 1; PA; QL; AL

tretinoin microsphere external gel 0.08 % (generic for RETIN-A MICRO

PUMP) - Tier 1; PA; QL

tretinoin microsphere pump external gel 0.04 %, 0.1 % (generic for

RETIN-A MICRO) - Tier 1; PA; QL; AL

tretinoin microsphere pump external gel 0.08 % (generic for RETIN-A

MICRO PUMP) - Tier 1; PA; QL

ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Dermatitis and Pruitus Agents

ala-cort (generic for MEDI-FIRST HYDROCORTISONE) - Tier 1; QL

ammonium lactate external (generic for AL12) - Tier 1; PA; QL

anti-itch aloe (generic for MEDI-FIRST HYDROCORTISONE) - Tier 1;

anti-itch intensive heal (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

anti-itch max str external cream 1 % (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

anti-itch maximum strength external cream 1 % (generic for MEDI-

FIRST HYDROCORTISONE) - Tier 1; QL

betamethasone dipropionate external lotion - Tier 1

betamethasone valerate external cream - Tier 1; QL

betamethasone valerate external lotion - Tier 1

betamethasone valerate external ointment - Tier 1; QL

alclometasone dipropionate - Tier 1; PA*; QL

amcinonide external cream - Tier 1; PA

APEXICON E - Tier 2; PA*; QL

betamethasone dipropionate aug (generic for DIPROLENE) - Tier 1; PA*;

betamethasone dipropionate external cream - Tier 1; PA*; QL

betamethasone dipropionate external ointment - Tier 1; PA*; QL

betamethasone valerate external foam - Tier 1; PA*; QL

BRYHALI - Tier 2; PA*; QL

clobetasol propionate emulsion (generic for TOVET) - Tier 1; PA*; QL

clobetasol propionate external foam - Tier 1; PA*; QL

clobetasol propionate external liquid (generic for CLOBEX SPRAY) - Tier

1; PA*; QL

clobetasol propionate e - Tier 1; QL

clobetasol propionate external cream - Tier 1; QL

clobetasol propionate external gel - Tier 1; QL

clobetasol propionate external ointment - Tier 1; QL

clobetasol propionate external solution - Tier 1; QL

cortisone maximum strength external cream (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

desonide external cream (generic for DESOWEN) - Tier 1; QL

desonide external ointment - Tier 1; QL

doxepin hcl external (generic for PRUDOXIN) - Tier 1; PA; QL

EUCRISA - Tier 2; QL; AL

fluticasone propionate external cream - Tier 1; QL

fluticasone propionate external ointment - Tier 1

clobetasol propionate external lotion (generic for CLOBEX) - Tier 1; PA*;

clobetasol propionate shampoo 0.05 % external (generic for CLODAN) -

Tier 1; PA; QL

clobetasol propionate shampoo 0.05 % external (generic for CLODAN) -

Tier 1; PA*; QL

CLOBEX (brand for clobetasol propionate) - Tier 2; PA*; QL

CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA*; QL

clocortolone pivalate (generic for CLODERM) - Tier 1; PA; QL

clodan (generic for CLODAN) - Tier 1; PA*; QL

CLODERM (brand for clocortolone pivalate) - Tier 2; PA; QL

DERMA-SMOOTHE/FS BODY (brand for fluocinolone acetonide body) -

Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ft itch relief max strength external cream (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

ft itch relief/aloe max str (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

halobetasol propionate external cream - Tier 1; QL

halobetasol propionate external ointment - Tier 1; QL

hydrocortisone anti-itch (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL

hydrocortisone external cream 1 % (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone external ointment 0.5 % - Tier 1

hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH

RELIEF CHILDREN) - Tier 1; QL

DERMA-SMOOTHE/FS SCALP (brand for fluocinolone acetonide scalp) -

Tier 2; PA*; QL

desonide external lotion - Tier 1; PA; QL

DESOWEN (brand for desonide) - Tier 2; PA; QL

desoximetasone external (generic for TOPICORT) - Tier 1; PA*; QL

diflorasone diacetate - Tier 1; PA*; QL

DIPROLENE (brand for betamethasone dipropionate aug) - Tier 2; PA*;

ELIDEL (brand for pimecrolimus) - Tier 2; PA; QL; AL

fluocinolone acetonide body oil 0.01 % external (generic for DERMA-

SMOOTHE/FS BODY) - Tier 1; PA; QL

fluocinolone acetonide body oil 0.01 % external (generic for DERMA-

SMOOTHE/FS BODY) - Tier 1; PA*; QL

hydrocortisone external ointment 2.5 % - Tier 1; QL

hydrocortisone max st external cream (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone max st/12 moist (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone plus external cream 1 % (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone/aloe (generic for MEDI-FIRST HYDROCORTISONE) -

Tier 1; QL

hydrocortisone/aloe max str (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

instacort 5 - Tier 1; QL

lactic acid external - Tier 1; PA

fluocinolone acetonide external cream (generic for SYNALAR) - Tier 1;

PA*; QL

fluocinolone acetonide external solution - Tier 1; PA*; QL

fluocinolone acetonide ointment 0.025 % external (generic for SYNALAR)

- Tier 1; PA; QL

fluocinolone acetonide ointment 0.025 % external (generic for SYNALAR)

- Tier 1; PA*; QL

fluocinolone acetonide scalp oil 0.01 % external (generic for DERMA-

SMOOTHE/FS SCALP) - Tier 1; PA; QL

fluocinolone acetonide scalp oil 0.01 % external (generic for DERMA-

SMOOTHE/FS SCALP) - Tier 1; PA*; QL

fluocinonide emulsified base - Tier 1; PA*; QL

fluocinonide external cream (generic for VANOS) - Tier 1; PA*; QL

fluocinonide external gel - Tier 1; PA*

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

medi-first hydrocortisone (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

mometasone furoate external cream - Tier 1; QL

mometasone furoate external ointment - Tier 1; QL

mometasone furoate external solution - Tier 1

selenium sulfide external lotion - Tier 1; QL

tacrolimus external ointment 0.03 %, 0.1 % - Tier 1; PA; QL; AL

triamcinolone acetonide external cream (generic for TRIDERM) - Tier

1; QL

triamcinolone acetonide external lotion 0.025 % - Tier 1

triamcinolone acetonide external lotion 0.1 % - Tier 1; QL

triamcinolone acetonide external ointment - Tier 1; QL

triamcinolone in absorbase - Tier 1; QL

triderm (generic for TRIDERM) - Tier 1; QL

fluocinonide external ointment - Tier 1; PA*; QL

fluocinonide external solution - Tier 1; PA*; QL

flurandrenolide - Tier 1; PA*; QL

fluticasone propionate external lotion - Tier 1; PA*; QL

halcinonide (generic for HALOG) - Tier 1; PA*; QL

halobetasol propionate foam 0.05 % external (generic for LEXETTE) -

Tier 1; PA*; QL

halobetasol propionate foam 0.05 % external (generic for LEXETTE) -

Tier 1; PA; QL

HALOG (brand for halcinonide) - Tier 2; PA; QL

hydrocortisone butyrate external cream - Tier 1; PA*; QL

hydrocortisone butyrate external ointment - Tier 1; PA*; QL

hydrocortisone butyrate external solution - Tier 1; PA*; QL

hydrocortisone butyrate lotion 0.1 % external (generic for LOCOID) - Tier

1; PA*; QL

hydrocortisone butyrate lotion 0.1 % external (generic for LOCOID) - Tier

1; PA; QL

hydrocortisone external lotion 2.5 % - Tier 1; PA; QL

hydrocortisone valerate - Tier 1; PA*; QL

KENALOG EXTERNAL (brand for triamcinolone acetonide) - Tier 2; PA*;

LEXETTE (brand for halobetasol propionate) - Tier 2; PA; QL

LOCOID (brand for hydrocortisone butyrate) - Tier 2; PA*; QL

LOCOID LIPOCREAM - Tier 2; PA*; QL

PANDEL - Tier 2; PA*

pimecrolimus (generic for ELIDEL) - Tier 1; PA; QL; AL

PRUDOXIN (brand for doxepin hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

SERNIVO - Tier 2; PA*; QL

SYNALAR (brand for fluocinolone acetonide) - Tier 2; PA*; QL

TEXACORT - Tier 2; PA

TOPICORT (brand for desoximetasone) - Tier 2; PA*; QL

TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA*; QL

tovet (generic for TOVET) - Tier 1; PA*; QL

triamcinolone acetonide external aerosol solution (generic for KENALOG)

- Tier 1; PA*; QL

ULTRAVATE - Tier 2; PA*; QL

VANOS (brand for fluocinonide) - Tier 2; PA*; QL

ZONALON (brand for doxepin hcl) - Tier 2; PA; QL

Dermatological Agents, Other

AMELUZ - Tier 2; PA

ANALPRAM HC (brand for hydrocort-pramoxine (perianal)) - Tier 2

ANALPRAM HC SINGLES (brand for hydrocort-pramoxine (perianal)) -

Tier 2

calcipotriene external cream - Tier 1; QL

calcipotriene external ointment (generic for CALCITRENE) - Tier 1; QL

calcipotriene external solution - Tier 1; QL

calcipotriene-betameth diprop external ointment - Tier 1; QL

CALCITRENE (brand for calcipotriene) - Tier 2; QL

clotrimazole-betamethasone external cream - Tier 1; QL

diclofenac sodium external gel 3 % - Tier 1; PA; QL

fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL

fluorouracil external solution - Tier 1; PA

ANALPRAM-HC (brand for hydrocortisone ace-pramoxine) - Tier 2; PA

CALCIPOTRIENE EXTERNAL FOAM (brand for calcipotriene) - Tier 2;

PA; QL

calcipotriene-betameth diprop external suspension (generic for

TACLONEX) - Tier 1; PA*; QL

calcitriol external (generic for VECTICAL) - Tier 1; PA*; QL

CARAC (brand for fluorouracil) - Tier 2; PA; QL

clotrimazole-betamethasone external lotion - Tier 1; PA; QL

DUOBRII - Tier 2; PA*; QL

EFUDEX (brand for fluorouracil) - Tier 2; PA; QL

ENSTILAR - Tier 2; PA*; QL

EPIFOAM - Tier 2; PA

FLUOROURACIL EXTERNAL CREAM 0.5 % (brand for fluorouracil) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

hydrocortisone ace-pramoxine external cream 1-1 % (generic for

ANALPRAM-HC) - Tier 1

hydrocort-pramoxine (perianal) (generic for ANALPRAM HC) - Tier 1

imiquimod external cream 5 % - Tier 1; QL

LEVULAN KERASTICK - Tier 2; PA

nystatin-triamcinolone - Tier 1; QL; AL

podofilox external (generic for CONDYLOX) - Tier 1; QL

silver sulfadiazine external (generic for SSD) - Tier 1; QL

ssd (generic for SSD) - Tier 1; QL

hydrocortisone ace-pramoxine external cream 2.5-1 % (generic for

PRAMOSONE) - Tier 1; PA

imiquimod external cream 3.75 % (generic for ZYCLARA) - Tier 1; PA; QL

imiquimod pump (generic for ZYCLARA) - Tier 1; PA; QL

methoxsalen rapid - Tier 1; PA*

NEO-SYNALAR - Tier 2; PA*

PRAMOSONE (brand for hydrocortisone ace-pramoxine) - Tier 2; PA

PROCORT - Tier 2; PA

PROCTOFOAM HC - Tier 2; PA*

QUTENZA - Tier 2; PA*

QUTENZA (2 PATCH) - Tier 2; PA*

QUTENZA (4 PATCH) - Tier 2; PA*

SILVADENE (brand for silver sulfadiazine) - Tier 2; PA; QL

SORILUX (brand for calcipotriene) - Tier 2; PA; QL

TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA*; QL

VECTICAL (brand for calcitriol) - Tier 2; PA*; QL

VEREGEN - Tier 2; PA; QL

XERESE - Tier 2; PA*; QL

ZYCLARA (brand for imiquimod) - Tier 2; PA; QL

ZYCLARA PUMP (brand for imiquimod) - Tier 2; PA; QL

Pediculicides/Scabicides

lice killing external liquid 1 % (generic for NIX CREME RINSE) - Tier 1;

lice treatment external liquid 1 % (generic for NIX CREME RINSE) -

Tier 1; QL

lice treatment external lotion 1 % - Tier 1; QL

NATROBA (brand for spinosad) - Tier 2; QL

permethrin external - Tier 1; QL

spinosad (generic for NATROBA) - Tier 1; QL

CROTAN - Tier 2; PA*; QL

ivermectin cream 1 % external (generic for SOOLANTRA) - Tier 1; PA*;

ivermectin cream 1 % external (generic for SOOLANTRA) - Tier 1; PA; QL

malathion (generic for OVIDE) - Tier 1; PA*; QL

OVIDE (brand for malathion) - Tier 2; PA; QL

SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Topical Anti-infectives

ciclopirox external shampoo - Tier 1

ciclopirox olamine external - Tier 1; QL

clindamycin phosphate external solution - Tier 1; QL

clotrimazole external cream 1 % (generic for DESENEX) - Tier 1; QL

clotrimazole external solution 1 % - Tier 1; QL

erythromycin external solution - Tier 1; QL

gentamicin sulfate external - Tier 1; QL

ketoconazole external cream - Tier 1; QL

ketoconazole external shampoo - Tier 1; QL

klayesta (generic for KLAYESTA) - Tier 1; QL

mafenide acetate external (generic for SULFAMYLON) - Tier 1; PA

mupirocin external - Tier 1; QL

nyamyc (generic for KLAYESTA) - Tier 1; QL

nystatin external (generic for KLAYESTA) - Tier 1; QL

ACZONE (brand for dapsone) - Tier 2; PA; QL

ciclodan (generic for CICLODAN) - Tier 1; PA; QL

ciclopirox external gel - Tier 1; PA*

ciclopirox external solution (generic for CICLODAN) - Tier 1; PA; QL

ciclopirox treatment - Tier 1; PA

CLEOCIN-T (brand for clindamycin phosphate) - Tier 2; PA; QL

clindacin (generic for CLINDACIN) - Tier 1; PA; QL

clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; PA; QL

clindacin-p (generic for CLINDACIN ETZ) - Tier 1; PA; QL

CLINDAGEL (brand for clindamycin phosphate) - Tier 2; PA; QL

clindamycin phosphate external foam (generic for CLINDACIN) - Tier 1;

PA; QL

clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1;

PA; QL

nystop (generic for KLAYESTA) - Tier 1; QL

tgt clotrimazole external cream 1 % (generic for DESENEX) - Tier 1;

clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier 1;

PA; QL

clindamycin phosphate external swab (generic for CLINDACIN ETZ) - Tier

1; PA; QL

dapsone external gel 7.5 % (generic for ACZONE) - Tier 1; PA; QL

dapsone gel 5 % external (generic for ACZONE) - Tier 1; PA*; QL

dapsone gel 5 % external (generic for ACZONE) - Tier 1; PA; QL

econazole nitrate external - Tier 1; PA*; QL

ERTACZO - Tier 2; PA

ery - Tier 1; PA

ERYGEL (brand for erythromycin) - Tier 2; PA

erythromycin external gel (generic for ERYGEL) - Tier 1; PA*

JUBLIA - Tier 2; PA; QL

ketoconazole external foam (generic for KETODAN) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ketodan (generic for KETODAN) - Tier 1; PA

KLARON (brand for sulfacetamide sodium (acne)) - Tier 2; PA

LULICONAZOLE (brand for luliconazole) - Tier 2; PA; QL

LUZU (brand for luliconazole) - Tier 2; PA; QL

MICONAZOLE-ZINC OXIDE-PETROLAT (brand for miconazole-zinc

oxide-petrolat) - Tier 2; PA

mupirocin calcium - Tier 1; PA; QL

naftifine hcl (generic for NAFTIN) - Tier 1; PA*

NAFTIN EXTERNAL GEL 1 % - Tier 2; PA*

NAFTIN EXTERNAL GEL 2 % (brand for naftifine hcl) - Tier 2; PA

oxiconazole nitrate (generic for OXISTAT) - Tier 1; PA*; QL

OXISTAT EXTERNAL CREAM (brand for oxiconazole nitrate) - Tier 2;

PA; QL

OXISTAT EXTERNAL LOTION - Tier 2; PA*

sulfacetamide sodium (acne) (generic for KLARON) - Tier 1; PA*

SULFAMYLON (brand for mafenide acetate) - Tier 2; PA

tavaborole - Tier 1; PA; QL

VUSION (brand for miconazole-zinc oxide-petrolat) - Tier 2; PA

XEPI - Tier 2; PA*; QL

Dermatological Agents - Drugs to Treat Skin Conditions

AVAR CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2

hydrocortisone acetate external cream - Tier 1

lidocaine-hydrocort (perianal) (generic for LIDOCORT) - Tier 1

LIDOCORT (brand for lidocaine-hydrocort (perianal)) - Tier 2

sulfacetamide sodium-sulfur external liquid 10-2 % (generic for AVAR

LS CLEANSER) - Tier 1

sulfacetamide sodium-sulfur external liquid 10-5 % (generic for AVAR

CLEANSER) - Tier 1

ana-lex (generic for ANA-LEX) - Tier 1; PA*; QL

AVAR LS CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2;

AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2; PA*

AVAR-E GREEN (brand for sss 10-5) - Tier 2; PA*

AVAR-E LS (brand for sulfacetamide sodium-sulfur) - Tier 2; PA

bp 10-1 - Tier 1; PA*

CABTREO - Tier 2; PA

hydrocortisone acetate external ointment - Tier 1; PA

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL - Tier 2; PA*

lidocaine-hydrocortisone ace rectal kit 2-2 % (generic for ANA-LEX) - Tier

1; PA*; QL

lidocaine-hydrocortisone ace rectal kit 3-0.5 % - Tier 1; PA*

lidocaine-hydrocortisone ace rectal kit 3-1 %, 3-2.5 % - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

PLEXION CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2;

sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1; PA*

SSS 10-5 EXTERNAL FOAM - Tier 2; PA

sulfacetamide sodium-sulfur external cream 10-2 % (generic for AVAR-E

LS) - Tier 1; PA*

sulfacetamide sodium-sulfur external cream 10-5 % (generic for AVAR-E

EMOLLIENT) - Tier 1; PA*

sulfacetamide sodium-sulfur external liquid 9.8-4.8 % (generic for

PLEXION CLEANSER) - Tier 1; PA*

sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for

SUMADAN WASH) - Tier 1; PA*; QL

sulfacetamide sodium-sulfur external lotion 10-5 % - Tier 1; PA

sulfacetamide sodium-sulfur external suspension 8-4 % (generic for

SULFACLEANSE 8/4) - Tier 1; PA*

sulfacetamide sodium-sulfur liquid 9-4 % external - Tier 1; PA*

sulfacetamide sodium-sulfur liquid 9-4 % external - Tier 1; PA

sulfacetamide sodium-sulfur suspension 10-5 % external - Tier 1; PA; QL

sulfacetamide sodium-sulfur suspension 10-5 % external - Tier 1; PA*; QL

sulfacetamide sod-sulfur wash external liquid 9-4 % - Tier 1; PA*

sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for

SUMADAN WASH) - Tier 1; PA*; QL

sulfacetamide-sulfur in urea - Tier 1; PA

SULFACLEANSE 8/4 (brand for sulfacetamide sodium-sulfur) - Tier 2;

PA*

sulfamez wash - Tier 1; PA*

SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; PA;

SUMAXIN - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

Dermatological Agents - Skin Agents

CIBINQO - Tier 2; PA

OPZELURA - Tier 2; PA; SP; QL

urea external cream 40 % - Tier 1; PA; QL

urea external lotion 40 % - Tier 1; QL

XERAC AC - Tier 2

NUTRIARX CREAMPAK (brand for sanadermrx skin repair) - Tier 2; PA;

SANADERMRX SKIN REPAIR (brand for sanadermrx skin repair) - Tier 2;

PA; QL

TRIADIME (brand for sanadermrx skin repair) - Tier 2; PA; QL

TRIVIX (brand for sanadermrx skin repair) - Tier 2; PA; QL

UREMEZ-40 - Tier 2; PA; QL

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA DEVICE (brand for element compact control 2) -

Tier 2; QL

ACCU-CHEK GUIDE CONTROL (brand for element compact control

2) - Tier 2; QL

ACCU-CHEK SMARTVIEW CONTROL (brand for element compact

control 2) - Tier 2; QL

ACCUTREND GLUCOSE CONTROL (brand for element compact

control 2) - Tier 2; QL

BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL

BD ULTRA-FINE PEN NEEDLES (brand for aum mini insulin pen

needle) - Tier 2; QL

CARESENS CONTROL SOLUTION A/B (brand for element compact

control 2) - Tier 2; QL

ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for blood glucose test

strips 333) - Tier 2; PA; QL

ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite

device/lancets) - Tier 2; PA; QL

ACCU-CHEK GUIDE TEST STRIPS (brand for blood glucose monitor

system) - Tier 2; PA; QL

ACCU-CHEK GUIDE KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

ACCU-CHEK LINKASSIST - Tier 2; PA

ACCU-CHEK SMARTVIEW (brand for blood glucose test strips 333) - Tier

2; PA; QL

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite

device/lancets) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

CARETOUCH CONTROL SOL LEVEL 2 (brand for element compact

control 2) - Tier 2; QL

CHEMSTRIP 10 MD - Tier 2

CHEMSTRIP 10/SG - Tier 2

CHEMSTRIP 2 GP - Tier 2

CHEMSTRIP 5 OB - Tier 2

CHEMSTRIP 7 - Tier 2

CHEMSTRIP 9 - Tier 2

CHEMSTRIP K (brand for ketone test) - Tier 2; QL

CHEMSTRIP UGK - Tier 2; QL

DEXCOM G6 RECEIVER - Tier 2; PA; QL

DEXCOM G6 SENSOR (brand for guardian sensor 3) - Tier 2; PA; QL

DEXCOM G7 RECEIVER - Tier 2; PA; QL

DEXCOM G7 SENSOR (brand for guardian sensor 3) - Tier 2; PA; QL

ACCUTREND GLUCOSE (brand for blood glucose test strips 333) - Tier

2; PA; QL

ADVANCED GLUCOSE TEST (brand for blood glucose test strips 333) -

Tier 2; PA; QL

ADVOCATE INSULIN PEN NEEDLE (brand for aqinject pen needle) -

Tier 2; PA; QL

AQINJECT PEN NEEDLE 32G X 4 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

AUM MINI INSULIN PEN NEEDLE 32G X 4 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

AUM MINI INSULIN PEN NEEDLE 32G X 5 MM , 32G X 6 MM (brand for

aum mini insulin pen needle) - Tier 2; PA; QL

AUM PEN NEEDLE 32G X 4 MM (brand for aqinject pen needle) - Tier 2;

PA; QL

EASYMAX 15 LEVEL 2 CONTROL (brand for element compact

control 2) - Tier 2; QL

EASYMAX 15 LEVEL 2-3 CONTROL (brand for element compact

control 2) - Tier 2; QL

GLUCOSE CONTROL SOLUTIONS (brand for element compact

control 2) - Tier 2; QL

FREESTYLE LIBRE 14 DAY READER - Tier 2; PA; QL

FREESTYLE LIBRE 14 DAY SENSOR (brand for guardian sensor 3) -

Tier 2; PA; QL

FREESTYLE LIBRE 2 READER - Tier 2; PA; QL

FREESTYLE LIBRE 2 SENSOR (brand for guardian sensor 3) - Tier 2;

PA; QL

FREESTYLE LIBRE READER - Tier 2; PA; QL

KETO-DIASTIX - Tier 2; QL

AUM PEN NEEDLE 32G X 5 MM , 32G X 6 MM (brand for aum mini

insulin pen needle) - Tier 2; PA; QL

AUM READYGARD DUO PEN NEEDLE (brand for aqinject pen needle) -

Tier 2; PA; QL

BD ULTRA-FINE PEN NEEDLES (brand for aqinject pen needle) - Tier 2;

PA; QL

BIOTEL CARE TEST STRIPS (brand for blood glucose test strips 333) -

Tier 2; PA; QL

BLOOD GLUCOSE MONITORING 333 (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

BLOOD GLUCOSE TEST IN VITRO STRIP (brand for blood glucose test

strips 333) - Tier 2; PA; QL

BLOOD GLUCOSE TEST STRIPS (brand for blood glucose test strips

333) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

KETONE CARE - Tier 2; QL

KETONE TEST (brand for ketone test) - Tier 2; QL

KETOSTIX (brand for ketone test) - Tier 2; QL

LANCETS (brand for advanced mobile lancet) - Tier 2; QL

LANCETS MICRO THIN 33G (brand for advanced mobile lancet) - Tier

2; QL

MEDISENSE GLUCOSE KETONE CONTR (brand for element

compact control 2) - Tier 2; QL

MEDISENSE HI/MID/LOW CONTROL (brand for element compact

control 2) - Tier 2; QL

NEUTEK 2TEK CONTROL (brand for element compact control 2) -

Tier 2; QL

ONETOUCH DELICA PLUS LANCET30G (brand for advanced mobile

lancet) - Tier 2; QL

BLOOD GLUCOSE TEST STRIPS 333 (brand for blood glucose test

strips 333) - Tier 2; PA; QL

CARESENS LANCETS 30G (brand for advanced mobile lancet) - Tier 2;

PA; QL

CARESENS N FELIZ (brand for blood glucose monitoring 333) - Tier 2;

PA; QL

CARESENS N FELIZ BT (brand for blood glucose monitoring 333) - Tier

2; PA; QL

CARESENS N GLUCOSE SYSTEM (brand for blood glucose monitoring

333) - Tier 2; PA; QL

CARESENS N VOICE SYSTEM (brand for blood glucose monitoring 333)

- Tier 2; PA; QL

CARETOUCH MONITOR SYSTEM (brand for blood glucose monitor

system) - Tier 2; PA; QL

ONETOUCH DELICA PLUS LANCET33G (brand for advanced mobile

lancet) - Tier 2; QL

ONETOUCH ULTRA 2 KIT W/DEVICE (brand for blood glucose

monitor system) - Tier 2; QL

ONETOUCH ULTRA IN VITRO LIQUID (brand for element compact

control 2) - Tier 2; QL

ONETOUCH ULTRA STRIP IN VITRO (brand for blood glucose test

strips 333) - Tier 2; QL

ONETOUCH ULTRA TEST (brand for blood glucose test strips 333) -

Tier 2; QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for blood

glucose monitor system) - Tier 2; QL

ONETOUCH VERIO IN VITRO LIQUID (brand for element compact

control 2) - Tier 2; QL

CARETOUCH TEST (brand for blood glucose test strips 333) - Tier 2; PA;

CARETOUCH TWIST MC LANCETS 30G (brand for advanced mobile

lancet) - Tier 2; PA; QL

CHEMSTRIP MICRAL - Tier 2; PA

CHOSEN LANCETS 30G (brand for advanced mobile lancet) - Tier 2; PA;

CHOSEN SAFETY LANCETS 28G (brand for advanced mobile lancet) -

Tier 2; PA; QL

COMFORT EZ PRO PEN NEEDLES 30G X 8 MM (brand for pen

needles) - Tier 2; PA; QL

COMFORT TOUCH LANCETS 31G (brand for advanced mobile lancet) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood

glucose monitor system) - Tier 2; QL

ONETOUCH VERIO STRIP IN VITRO (brand for blood glucose test

strips 333) - Tier 2; QL

PIP GLUCOSE CONTROL SOLUTION (brand for element compact

control 2) - Tier 2; QL

PRECISION GLUCOSE KETONE CONTR (brand for element

compact control 2) - Tier 2; QL

QUINTET CONTROL HIGH/NORMAL (brand for element compact

control 2) - Tier 2; QL

SAFE-T-LANCE (brand for advanced mobile lancet) - Tier 2; QL

TRUECONTROL GLUCOSE CONT LEV 0 (brand for element

compact control 2) - Tier 2; QL

COMFORT TOUCH PLUS LANCETS 28G (brand for advanced mobile

lancet) - Tier 2; PA; QL

COMFORT TOUCH PLUS LANCETS 30G (brand for advanced mobile

lancet) - Tier 2; PA; QL

COMFORT TOUCH TWIST LANCET 30G (brand for advanced mobile

lancet) - Tier 2; PA; QL

CONTOUR MONITOR (brand for blood glucose monitor system) - Tier 2;

PA; QL

CONTOUR MONITOR (brand for blood glucose monitoring 333) - Tier 2;

PA; QL

CONTOUR NEXT EZ KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

CONTOUR NEXT GEN MONITOR (brand for blood glucose monitor

system) - Tier 2; PA; QL

TRUECONTROL GLUCOSE CONT LEV 1 (brand for element

compact control 2) - Tier 2; QL

TRUEPLUS LANCETS 30G (brand for advanced mobile lancet) - Tier

2; QL

TRUEPLUS SAFETY LANCETS 28G (brand for advanced mobile

lancet) - Tier 2; QL

VIVAGUARD INO CONTROL SOLUTION (brand for element compact

control 2) - Tier 2; QL

CONTOUR NEXT LINK KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

CONTOUR NEXT MONITOR KIT W/DEVICE (brand for blood glucose

monitor system) - Tier 2; PA; QL

CONTOUR NEXT ONE KIT (brand for blood glucose monitoring 333) -

Tier 2; PA; QL

CONTOUR NEXT GEN TEST STRIPS (brand for blood glucose test strips

333) - Tier 2; PA; QL

CONTOUR TEST STRIPS (brand for blood glucose test strips 333) - Tier

2; PA; QL

D-CARE BLOOD GLUCOSE (brand for blood glucose test strips 333) -

Tier 2; PA; QL

D-CARE GLUCOMETER (brand for blood glucose monitor system) - Tier

2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

DIASTIX - Tier 2; PA

DIASTIX REAGENT - Tier 2; PA

EASY TOUCH HEALTHPRO GLUCOSE (brand for blood glucose monitor

system) - Tier 2; PA; QL

EASY TOUCH TEST (brand for blood glucose test strips 333) - Tier 2;

PA; QL

EASYGLUCO - Tier 2; PA; QL

EASYMAX 15 TEST (brand for blood glucose test strips 333) - Tier 2; PA;

EASYMAX NG BLOOD GLUCOSE (brand for blood glucose monitor

system) - Tier 2; PA; QL

BLOOD GLUCOSE TEST STRIPS (brand for blood glucose test strips

333) - Tier 2; PA; QL

EASYMAX V BLOOD GLUCOSE (brand for blood glucose monitoring

333) - Tier 2; PA; QL

EMBRACE BLOOD GLUCOSE TEST (brand for blood glucose test strips

333) - Tier 2; PA; QL

EMBRACE PEN NEEDLES 30G X 8 MM (brand for pen needles) - Tier 2;

PA; QL

EMBRACE PEN NEEDLES 32G X 4 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

EMBRACE WAVE BLOOD GLUCOSE (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

EMBRACE WAVE GLUCOSE METER (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

ENLITE GLUCOSE SENSOR (brand for guardian sensor 3) - Tier 2; PA;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

EVERSENSE E3 SENSOR/HOLDER (brand for guardian sensor 3) - Tier

2; PA; QL

EVERSENSE SENSOR/HOLDER (brand for guardian sensor 3) - Tier 2;

PA; QL

FORA 6 CONNECT/GTEL TEST (brand for blood glucose test strips 333)

- Tier 2; PA; QL

FORTISCARE G1 TEST STRIP IN VITRO STRIP (brand for blood

glucose test strips 333) - Tier 2; PA; QL

FORTISCARE T1 GLUCOSE SYSTEM DEVICE (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

FORTISCARE TEST IN VITRO STRIP (brand for blood glucose test strips

333) - Tier 2; PA; QL

FREESTYLE LIBRE 3 READER - Tier 2; PA; QL

FREESTYLE LIBRE 3 SENSOR (brand for guardian sensor 3) - Tier 2;

PA; QL

FREESTYLE PRECISION NEO SYSTEM (brand for blood glucose

monitor system) - Tier 2; PA; QL

FREESTYLE PRECISION NEO TEST (brand for blood glucose test strips

333) - Tier 2; PA; QL

FREESTYLE TEST (brand for blood glucose test strips 333) - Tier 2; PA;

GLUCOCARD EXPRESSION TEST (brand for blood glucose test strips

333) - Tier 2; PA; QL

GLUCOCARD SHINE TEST (brand for blood glucose test strips 333) -

Tier 2; PA; QL

GLUCOCARD VITAL TEST (brand for blood glucose test strips 333) - Tier

2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

GLUCOSE METER TEST STRIPS (brand for blood glucose test strips

333) - Tier 2; PA; QL

GUARDIAN 4 GLUCOSE SENSOR (brand for guardian sensor 3) - Tier 2;

PA; QL

GUARDIAN REAL-TIME REPLACE PED - Tier 2; PA; QL

GUARDIAN SENSOR (3) (brand for guardian sensor 3) - Tier 2; PA; QL

GUARDIAN SENSOR 3 (brand for guardian sensor 3) - Tier 2; PA; QL

HEALTHPRO BLOOD GLUCOSE MONITO (brand for blood glucose

monitor system) - Tier 2; PA; QL

INSULIN PEN NEEDLES (brand for advanced mobile lancet) - Tier 2; PA;

INSULIN PEN NEEDLES (brand for pen needles) - Tier 2; PA; QL

INSULIN PEN NEEDLES 32G X 4 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

INSULIN PEN NEEDLES (brand for aum mini insulin pen needle) - Tier 2;

PA; QL

LANCETS (brand for advanced mobile lancet) - Tier 2; PA; QL

LANCETS MICRO THIN 33G (brand for advanced mobile lancet) - Tier 2;

PA; QL

MICRODOT TEST (brand for blood glucose test strips 333) - Tier 2; PA;

MM BLOOD GLUCOSE SYSTEM (brand for blood glucose monitor

system) - Tier 2; PA; QL

MM BLOOD GLUCOSE SYSTEM REFILL - Tier 2; PA; QL

MM BLULINK GLUCOSE MONIT SYS (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

MM BLULINK GLUCOSE TEST (brand for blood glucose test strips 333) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

Preferred Agents Non-Preferred Agents

MM EASY TOUCH GLUCOSE METER (brand for blood glucose monitor

system) - Tier 2; PA; QL

NEUTEK 2TEK TEST (brand for blood glucose test strips 333) - Tier 2;

PA; QL

ON CALL EXPRESS BLOOD GLUCOSE (brand for blood glucose test

strips 333) - Tier 2; PA; QL

ON CALL EXPRESS MONITORING SYS (brand for blood glucose

monitor system) - Tier 2; PA; QL

ONETOUCH DELICA PLUS LANCET30G (brand for advanced mobile

lancet) - Tier 2; PA; QL

ONETOUCH DELICA PLUS LANCET33G (brand for advanced mobile

lancet) - Tier 2; PA; QL

ONETOUCH DELICA SAFETY LANCING (brand for advanced mobile

lancet) - Tier 2; PA; QL

ONETOUCH ULTRA 2 KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

ONETOUCH ULTRA STRIP IN VITRO (brand for blood glucose test strips

333) - Tier 2; PA; QL

ONETOUCH ULTRASOFT 2 LANCETS (brand for advanced mobile

lancet) - Tier 2; PA; QL

ONETOUCH VERIO FLEX SYSTEM DEVICE (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for blood

glucose monitor system) - Tier 2; PA; QL

ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood glucose

monitor system) - Tier 2; PA; QL

ONETOUCH VERIO STRIP IN VITRO (brand for blood glucose test strips

333) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

100

Preferred Agents Non-Preferred Agents

OPTIUMEZ TEST (brand for blood glucose test strips 333) - Tier 2; PA;

PIP BLOOD GLUCOSE MONITORING (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

PIP BLOOD GLUCOSE TEST STRIP (brand for blood glucose test strips

333) - Tier 2; PA; QL

PRECISION XTRA (brand for blood glucose monitor system) - Tier 2; PA;

PRECISION XTRA BLOOD GLUCOSE (brand for blood glucose test

strips 333) - Tier 2; PA; QL

PREMIUM BLOOD GLUCOSE TEST (brand for blood glucose test strips

333) - Tier 2; PA; QL

PRO COMFORT SAFETY LANCETS 30G (brand for advanced mobile

lancet) - Tier 2; PA; QL

PTS PANELS EGLU TEST (brand for blood glucose test strips 333) - Tier

2; PA; QL

PURE COMFORT SAFETY PEN NEEDLE 32G X 4 MM (brand for

aqinject pen needle) - Tier 2; PA; QL

QUINTET AC BLOOD GLUCOSE (brand for blood glucose monitoring

333) - Tier 2; PA; QL

QUINTET AC BLOOD GLUCOSE TEST (brand for blood glucose test

strips 333) - Tier 2; PA; QL

QUINTET BLOOD GLUCOSE SYSTEM (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

QUINTET BLOOD GLUCOSE TEST (brand for blood glucose test strips

333) - Tier 2; PA; QL

RELION TRUE MET AIR GLUC METER (brand for blood glucose monitor

system) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

101

Preferred Agents Non-Preferred Agents

RELION TRUE METRIX TEST STRIPS (brand for blood glucose test

strips 333) - Tier 2; PA; QL

RELION ULTIMA GLUCOSE SYSTEM (brand for blood glucose monitor

system) - Tier 2; PA; QL

RELION ULTIMA TEST (brand for blood glucose test strips 333) - Tier 2;

PA; QL

RIGHTEST GT333 GLUCOSE TEST (brand for blood glucose test strips

333) - Tier 2; PA; QL

SAFE-T-LANCE (brand for advanced mobile lancet) - Tier 2; PA; QL

SAFETY LANCETS 23G (brand for advanced mobile lancet) - Tier 2; PA;

SAFETY PEN NEEDLES 30G X 8 MM (brand for pen needles) - Tier 2;

PA; QL

TECHLITE LANCETS 26G (brand for advanced mobile lancet) - Tier 2;

PA; QL

TEMPO REFILL - Tier 2; PA; QL

TEMPO WELCOME (brand for blood glucose monitor system) - Tier 2;

PA; QL

TRUE FOCUS BLOOD GLUCOSE STRIP (brand for blood glucose test

strips 333) - Tier 2; PA; QL

TRUE METRIX AIR GLUCOSE METER (brand for blood glucose monitor

system) - Tier 2; PA; QL

TRUE METRIX GO GLUCOSE METER (brand for blood glucose monitor

system) - Tier 2; PA; QL

TRUE METRIX METER KIT (brand for blood glucose monitor system) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

102

Preferred Agents Non-Preferred Agents

TRUEPLUS LANCETS 30G (brand for advanced mobile lancet) - Tier 2;

PA; QL

TRUEPLUS SAFETY LANCETS 28G (brand for advanced mobile lancet)

- Tier 2; PA; QL

TRUETRACK BLOOD GLUCOSE DEVICE (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

TRUETRACK TEST (brand for blood glucose test strips 333) - Tier 2; PA;

TWIST TOP LANCETS 30G (brand for advanced mobile lancet) - Tier 2;

PA; QL

UNIFINE PROTECT PEN NEEDLE 30G X 8 MM (brand for pen needles)

- Tier 2; PA; QL

UNIFINE PROTECT PEN NEEDLE 32G X 4 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

UNISTRIP1 GENERIC (brand for blood glucose test strips 333) - Tier 2;

PA; QL

VERIFINE INSULIN PEN NEEDLE 32G X 4 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

VERIFINE INSULIN PEN NEEDLE 32G X 6 MM (brand for aum mini

insulin pen needle) - Tier 2; PA; QL

VERIFINE PLUS PEN NEEDLE 32G X 4 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

VERIFINE SAFE LANCET MINI 21G (brand for advanced mobile lancet) -

Tier 2; PA; QL

VERIFINE SAFE LANCET MINI 23G (brand for advanced mobile lancet) -

Tier 2; PA; QL

VERIFINE SAFE LANCET MINI 28G (brand for advanced mobile lancet) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

103

Preferred Agents Non-Preferred Agents

VERIFINE SAFE LANCET MINI 30G (brand for advanced mobile lancet) -

Tier 2; PA; QL

VERIFINE UNIVERSAL LANCETS 28G (brand for advanced mobile

lancet) - Tier 2; PA; QL

VERIFINE UNIVERSAL LANCETS 30G (brand for advanced mobile

lancet) - Tier 2; PA; QL

VERIFINE UNIVERSAL LANCETS 33G (brand for advanced mobile

lancet) - Tier 2; PA; QL

VIVAGUARD INO GLUCOSE METER KIT - Tier 2; PA; QL

VIVAGUARD INO SMART GLUC METER (brand for blood glucose

monitoring 333) - Tier 2; PA; QL

VIVAGUARD INO TEST STRIPS (brand for blood glucose test strips 333)

- Tier 2; PA; QL

VIVAGUARD LANCETS 30G (brand for advanced mobile lancet) - Tier 2;

PA; QL

VIVAGUARD SAFETY LANCETS 28G (brand for advanced mobile

lancet) - Tier 2; PA; QL

Diabetic/Endocrine Blood: Glucose Monitoring

GENTLE-LET PLATFORMS (brand for lancet transporter case) - Tier 2;

PA; QL

LANCETS (brand for lancet transporter case) - Tier 2; PA; QL

PSS SELECT PLATFORMS (brand for lancet transporter case) - Tier 2;

PA; QL

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body

Fluid Deficiency Drugs

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat

Vitamin, Mineral and Body Fluid Deficiencies

ACCRUFER - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

104

Preferred Agents Non-Preferred Agents

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

DENTA 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL

DENTAGEL (brand for sf) - Tier 2

ENDARI - Tier 2; PA; QL

fluoridex daily renewal - Tier 1

klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL

klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL

klor-con m15 (generic for KLOR-CON M15) - Tier 1; QL

klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL

klor-con oral tablet extended release (generic for KLOR-CON) - Tier 1;

potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL

potassium chloride er oral capsule extended release - Tier 1; QL

potassium chloride er oral tablet extended release 10 meq (generic for

KLOR-CON 10) - Tier 1; QL

CLINPRO 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA

DENTA 5000 PLUS SENSITIVE (brand for denta 5000 plus sensitive) -

Tier 2; PA

FLUORIDEX (brand for sodium fluoride 5000 ppm) - Tier 2; PA

FLUORIDEX ENHANCED WHITENING (brand for sodium fluoride 5000

ppm) - Tier 2; PA

FLUORIDEX SENSITIVITY RELIEF (brand for denta 5000 plus sensitive)

- Tier 2; PA

FLUORIMAX 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA

FLUORIMAX 5000 SENSITIVE (brand for denta 5000 plus sensitive) -

Tier 2; PA

FRAICHE 5000 SENSITIVE - Tier 2; PA

JUST RIGHT 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA

klor-con oral packet (generic for KLOR-CON) - Tier 1; PA; QL

potassium chloride er oral tablet extended release 15 meq (generic for

KLOR-CON M15) - Tier 1; QL

potassium chloride er oral tablet extended release 8 meq (generic for

KLOR-CON) - Tier 1; QL

potassium chloride oral solution 10 %, 20 meq/15ml (10%) - Tier 1; QL

potassium chloride oral solution 40 meq/15ml (20%) - Tier 1; PA; QL

potassium citrate er oral tablet extended release 10 meq (1080 mg)

(generic for UROCIT-K 10) - Tier 1; QL

potassium citrate er oral tablet extended release 15 meq (1620 mg)

(generic for UROCIT-K 15) - Tier 1

potassium citrate er oral tablet extended release 5 meq (540 mg)

(generic for UROCIT-K 5) - Tier 1

PREVIDENT (brand for sf) - Tier 2

PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2

K-TAB (brand for potassium chloride er) - Tier 2; PA*; QL

POKONZA - Tier 2; PA

potassium chloride er oral tablet extended release 20 meq (generic for K-

TAB) - Tier 1; PA*; QL

potassium chloride oral packet (generic for KLOR-CON) - Tier 1; PA; QL

PREVIDENT 5000 BOOSTER PLUS (brand for sodium fluoride 5000

ppm) - Tier 2; PA

PREVIDENT 5000 ENAMEL PROTECT - Tier 2; PA

PREVIDENT 5000 KIDS (brand for sodium fluoride 5000 ppm) - Tier 2;

PREVIDENT 5000 ORTHO DEFENSE (brand for sodium fluoride 5000

ppm) - Tier 2; PA

PREVIDENT 5000 SENSITIVE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

105

Preferred Agents Non-Preferred Agents

PREVIDENT 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL

sf (generic for DENTAGEL) - Tier 1

sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL

sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1;

sodium fluoride 5000 ppm dental cream (generic for DENTA 5000

PLUS) - Tier 1; QL

sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1;

sodium fluoride dental gel (generic for DENTAGEL) - Tier 1

sodium fluoride oral solution - Tier 1; QL

sodium fluoride oral tablet 1.1 (0.5 f) mg - Tier 1

sodium fluoride oral tablet 2.2 (1 f) mg - Tier 1; QL

sodium fluoride oral tablet chewable - Tier 1; QL

sodium fluoride 5000 ppm dental paste (generic for CLINPRO 5000) - Tier

1; PA

UROCIT-K 10 (brand for potassium citrate er) - Tier 2; PA; QL

UROCIT-K 15 (brand for potassium citrate er) - Tier 2; PA

UROCIT-K 5 (brand for potassium citrate er) - Tier 2; PA

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body

Fluid Deficiency Drugs

abatron af - Tier 1

BPROTECTED PEDIA IRON (brand for fe-vite iron) - Tier 2; QL

calcium + vitamin d3 oral tablet 500-5 mg-mcg (generic for OYSCO

500+D) - Tier 1; QL

calcium 500/vitamin d3 - Tier 1

calcium 600/vitamin d - Tier 1

calcium 600/vitamin d-3 - Tier 1

calcium 600+d oral tablet 600-10 mg-mcg - Tier 1

calcium carb-cholecalciferol oral tablet 600-10 mg-mcg - Tier 1

calcium carb-cholecalciferol oral tablet 600-5 mg-mcg - Tier 1; QL

calcium high potency/vitamin d - Tier 1; QL

calcium plus vitamin d oral tablet 500-5 mg-mcg (generic for OYSCO

500+D) - Tier 1; QL

calcium plus vitamin d oral tablet 600-10 mg-mcg - Tier 1

GALZIN ORAL CAPSULE 25 MG - Tier 2; PA

GALZIN ORAL CAPSULE 50 MG - Tier 2; PA; QL

K-PHOS-NEUTRAL (brand for phosphorous) - Tier 2; PA; QL

ORACIT (brand for oral citrate) - Tier 2; PA*

ORAL CITRATE (brand for oral citrate) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

106

Preferred Agents Non-Preferred Agents

calcium plus vitamin d oral tablet 600-5 mg-mcg - Tier 1; QL

calcium plus vitamin d3 - Tier 1

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ - Tier

2; QL

ferate (generic for FERATE) - Tier 1

FER-IN-SOL (brand for fe-vite iron) - Tier 2; QL

ferocon (generic for TRICON) - Tier 1

ferosul (generic for FEROSUL) - Tier 1; QL

ferotrinsic (generic for TRICON) - Tier 1

ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) -

Tier 1

ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; QL

ferrous sulfate (generic for FEROSUL) - Tier 1; QL

ferrous sulfate oral solution (generic for BPROTECTED PEDIA IRON)

- Tier 1; QL

ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier

1; QL

ferrous sulfate oral tablet delayed release 324 (65 fe) mg, 324 mg -

Tier 1

ferrous sulfate oral tablet delayed release 325 (65 fe) mg - Tier 1; QL

fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; QL

foltrin (generic for TRICON) - Tier 1

HEMATOGEN (brand for iron complex) - Tier 2

HEMAX - Tier 2

hi cal (generic for OYSCO 500+D) - Tier 1; QL

iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

107

Preferred Agents Non-Preferred Agents

INJECTAFER INTRAVENOUS SOLUTION 750 MG/15ML - Tier 2; PA;

iron (ferrous sulfate) oral solution (generic for BPROTECTED PEDIA

IRON) - Tier 1; QL

iron infant/toddler (generic for BPROTECTED PEDIA IRON) - Tier 1;

iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1

iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL

iron supplement childrens (generic for BPROTECTED PEDIA IRON) -

Tier 1; QL

iron supplement oral solution 220 (44 fe) mg/5ml (generic for ONE

VITE FERROUS SULFATE) - Tier 1; QL

K-PHOS - Tier 2; QL

K-PHOS NO 2 - Tier 2

k-tan plus (generic for K-TAN PLUS) - Tier 1

ONE VITE FERROUS SULFATE (brand for ferrous sulfate) - Tier 2;

OS-CAL CALCIUM + D3 (brand for calcium + vitamin d3) - Tier 2; QL

oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL

oyster shell calcium + d oral tablet 500-10 mg-mcg - Tier 1

oyster shell calcium + d3 - Tier 1

oyster shell calcium plus d (generic for OYSCO 500+D) - Tier 1; QL

oyster shell calcium w/d (generic for OYSCO 500+D) - Tier 1; QL

oyster shell calcium/vit d (generic for OYSCO 500+D) - Tier 1; QL

oyster shell calcium/vit d3 - Tier 1

oyster shell calcium/vit d3 oral tablet 500-5 mg-mcg (generic for

OYSCO 500+D) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

108

Preferred Agents Non-Preferred Agents

oyster shell calcium/vitamin d oral tablet 500-5 mg-mcg (generic for

OYSCO 500+D) - Tier 1; QL

PHOSPHA 250 NEUTRAL (brand for phosphorous) - Tier 2; QL

phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1;

phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL)

- Tier 1; QL

PHOSPHO-TRIN K500 - Tier 2; QL

poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1

polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1

potassium citrate-citric acid - Tier 1

purevit dualfe plus (generic for K-TAN PLUS) - Tier 1

se-tan plus (generic for K-TAN PLUS) - Tier 1

sod citrate-citric acid oral solution 500-334 mg/5ml - Tier 1

TANDEM PLUS (brand for purevit dualfe plus) - Tier 2

TRICON (brand for ferocon) - Tier 2

TRUE FERROUS SULFATE - Tier 2

ultra calcium + vitamin d3 - Tier 1

VENOFER - Tier 2; PA; QL

wes-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) -

Tier 1; QL

Electrolyte/Mineral/Metal Modifiers

CHEMET - Tier 2; QL

deferasirox (generic for EXJADE) - Tier 1; SP; QL

deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; SP;

JYNARQUE (brand for tolvaptan) - Tier 2; PA; SP; QL

tolvaptan (generic for JYNARQUE) - Tier 1; PA; SP; QL

trientine hcl (generic for SYPRINE) - Tier 1; PA; SP; QL

deferiprone (generic for FERRIPROX) - Tier 1; PA; SP; QL

EXJADE (brand for deferasirox) - Tier 2; PA; SP; QL

FERRIPROX (brand for deferiprone) - Tier 2; PA; SP; QL

FERRIPROX TWICE-A-DAY - Tier 2; PA; SP; QL

JADENU (brand for deferasirox) - Tier 2; PA; SP; QL

JADENU SPRINKLE (brand for deferasirox) - Tier 2; PA; SP; QL

SAMSCA (brand for tolvaptan) - Tier 2; PA; SP; QL

SYPRINE (brand for trientine hcl) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

109

Preferred Agents Non-Preferred Agents

Phosphate Binders

calcium acetate (phos binder) oral capsule - Tier 1; QL

sevelamer carbonate oral packet (generic for RENVELA) - Tier 1; PA;

sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; QL

AURYXIA - Tier 2; PA*; QL

calcium acetate (phos binder) oral tablet (generic for CALPHRON) - Tier

1; PA; QL

calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1; PA;

FOSRENOL ORAL PACKET - Tier 2; PA*; QL

FOSRENOL ORAL TABLET CHEWABLE (brand for lanthanum

carbonate) - Tier 2; PA; QL

lanthanum carbonate (generic for FOSRENOL) - Tier 1; PA; QL

RENVELA (brand for sevelamer carbonate) - Tier 2; PA; QL

sevelamer hcl (generic for RENAGEL) - Tier 1; PA; QL

VELPHORO - Tier 2; PA; QL

Potassium Binders

LOKELMA - Tier 2; QL

sodium polystyrene sulfonate - Tier 1

SPS - Tier 2; QL

VELTASSA - Tier 2; PA*; QL

Vitamins

ACTIVITE (brand for activite) - Tier 2; QL

airavite (generic for AIRAVITE) - Tier 1

aqueous vitamin d (generic for D-VI-SOL) - Tier 1

b-plex - Tier 1

classic prenatal - Tier 1; QL

COMPLETE NATAL DHA - Tier 2; QL

COMPLETENATE - Tier 2; QL

CO-NATAL FA (brand for neonatal complete) - Tier 2; QL

d3 high potency oral capsule 25 mcg, 25 mcg (1000 ut) (generic for

PRONUTRIENTS VITAMIN D3) - Tier 1

d3 high potency oral capsule 250 mcg (10000 ut) (generic for IS-D

10,000) - Tier 1

d3 max st (generic for IS-D 10,000) - Tier 1

FOLBIC RF - Tier 2; PA

FOLTANX - Tier 2; PA

FOLTANX RF (brand for l-methylfolate-algae-b12-b6) - Tier 2; PA; QL

FOLTX - Tier 2; PA

l-methylfolate-algae-b12-b6 (generic for FOLTANX RF) - Tier 1; PA; QL

METAFOLBIC PLUS RF (brand for methylfol-algae-b12-acetylcyst) - Tier

2; PA; QL

methylfol-algae-b12-acetylcyst (generic for METAFOLBIC PLUS RF) -

Tier 1; PA; QL

multivitamin w/fluoride (generic for MULTI-VIT-FLOR) - Tier 1; PA; QL

multivitamin/fluoride tablet chewable 0.25 mg oral (rx) (generic for MULTI-

VIT-FLOR) - Tier 1; PA; QL

MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 0.25 MG ORAL (RX)

(brand for multivitamin w/fluoride) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

110

Preferred Agents Non-Preferred Agents

d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS

VITAMIN D3) - Tier 1

d3 oral capsule 250 mcg (generic for IS-D 10,000) - Tier 1

DIALYVITE (brand for activite) - Tier 2; QL

D-VI-SOL (brand for aqueous vitamin d) - Tier 2

folbee (generic for AIRAVITE) - Tier 1

HYLAVITE - Tier 2

M-NATAL PLUS (brand for prenatal) - Tier 2; QL

multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QL

multivitamin/fluoride tablet chewable 0.25 mg oral (rx) (generic for

MULTI-VIT-FLOR) - Tier 1; QL

multivitamin/fluoride tablet chewable 0.5 mg oral (rx) (generic for

MULTI-VIT-FLOR) - Tier 1; QL

multivitamin/fluoride tablet chewable 1 mg oral (rx) (generic for MULTI-

VIT-FLOR) - Tier 1; PA; QL

MULTIVITAMIN/FLUORIDE TABLET CHEWABLE 1 MG ORAL (RX)

(brand for multivitamin w/fluoride) - Tier 2; PA; QL

MULTI-VIT-FLOR (brand for multivitamin w/fluoride) - Tier 2; PA; QL

POLY-VI-FLOR ORAL TABLET CHEWABLE 0.5 MG (brand for

multivitamin w/fluoride) - Tier 2; PA; QL

POLY-VI-FLOR TABLET CHEWABLE 0.25 MG ORAL (brand for

multivitamin w/fluoride) - Tier 2; PA; QL

POLY-VI-FLOR TABLET CHEWABLE 1 MG ORAL (brand for multivitamin

w/fluoride) - Tier 2; PA; QL

PRENATOL-M - Tier 2; PA

QUFLORA FE - Tier 2; PA

multivitamin/fluoride tablet chewable 1 mg oral (rx) (generic for MULTI-

VIT-FLOR) - Tier 1; QL

multi-vitamin/fluoride/iron - Tier 1; QL

mynephrocaps oral capsule 1 mg (generic for MYNEPHRON) - Tier 1

MYNEPHRON (brand for triphrocaps) - Tier 2

NATALVIT - Tier 2

NEONATAL COMPLETE (brand for neonatal complete) - Tier 2; QL

NEONATAL PLUS (brand for prenatal) - Tier 2; QL

NEONATAL PRENATAL (brand for cvs prenatal) - Tier 2; QL

NEONATAL VITAMIN (brand for cvs prenatal) - Tier 2; QL

nephronex oral tablet (generic for NEPHRONEX) - Tier 1; QL

niacin er oral tablet extended release 500 mg (generic for ENDUR-

ACIN) - Tier 1

NIVA-PLUS (brand for prenatal) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

111

Preferred Agents Non-Preferred Agents

nufol (generic for AIRAVITE) - Tier 1

ONE VITE WOMENS (brand for cvs prenatal) - Tier 2; QL

ONE VITE WOMENS PLUS (brand for prenatal) - Tier 2; QL

phytonadione oral - Tier 1; QL

POLY-VI-FLOR TABLET CHEWABLE 0.25 MG ORAL (brand for

multivitamin w/fluoride) - Tier 2; QL

POLY-VI-FLOR TABLET CHEWABLE 1 MG ORAL (brand for

multivitamin w/fluoride) - Tier 2; QL

PRENATABS RX (brand for thrivite rx) - Tier 2; QL

prenatal 19 - Tier 1; QL

prenatal formula oral tablet 28-0.8 mg - Tier 1; QL

prenatal multivitamins - Tier 1; QL

prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier

1; QL

prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1;

prenatal oral tablet 28-0.8 mg - Tier 1; QL

prenatal plus (generic for NEONATAL PLUS) - Tier 1; QL

prenatal plus vitamin/mineral (generic for NEONATAL PLUS) - Tier 1;

prenatal vitamins oral tablet 28-0.8 mg - Tier 1; QL

prenatal/iron oral tablet 28-0.8 mg - Tier 1; QL

PRENATRYL (brand for prenatal) - Tier 2; QL

PRONUTRIENTS VITAMIN D3 (brand for cvs d3) - Tier 2

QUFLORA FE PEDIATRIC - Tier 2; QL

RENAL (brand for triphrocaps) - Tier 2

SE-NATAL 19 - Tier 2; QL

THRIVITE RX (brand for thrivite rx) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

112

Preferred Agents Non-Preferred Agents

TM-VITE RX (brand for activite) - Tier 2; QL

TRINATAL RX 1 (brand for trinatal rx 1) - Tier 2; QL

triphrocaps (generic for MYNEPHRON) - Tier 1

TRONVITE (brand for activite) - Tier 2; QL

TRUE VITAMIN D3 ORAL CAPSULE 25 MCG (1000 UT) (brand for

cvs d3) - Tier 2

TRUE VITAMIN D3 ORAL CAPSULE 250 MCG (10000 UT) - Tier 2

TRUE VITAMIN D3 ORAL TABLET 25 MCG (1000 UT) - Tier 2

VINATE ONE (brand for trinatal rx 1) - Tier 2; QL

virt-caps (generic for MYNEPHRON) - Tier 1

vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for

VITAMIN D-1000 MAX ST) - Tier 1

vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS

VITAMIN D3) - Tier 1

vitamin d3 oral capsule 25 mcg (1000 ut) (generic for

PRONUTRIENTS VITAMIN D3) - Tier 1

vitamin d3 oral capsule 250 mcg (10000 ut) (generic for IS-D 10,000) -

Tier 1

vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000

MAX ST) - Tier 1

vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000

MAX ST) - Tier 1

VITASURE (brand for activite) - Tier 2; QL

VITATHELY WITH GINGER (brand for prenatal) - Tier 2; QL

wescaps (generic for MYNEPHRON) - Tier 1

WESNATAL DHA COMPLETE - Tier 2; QL

westab one (generic for AIRAVITE) - Tier 1

WESTAB PLUS (brand for prenatal) - Tier 2; QL

Estrogens - Hormone Replacement/Modifying Drugs

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers) - Drugs to Regulate Hormones

MYFEMBREE - Tier 2; PA

NEXTSTELLIS - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

113

Preferred Agents Non-Preferred Agents

Gastrointestinal Agents

VOQUEZNA TRIPLE PAK - Tier 2; PA*; QL

Anti-Constipation Agents

AMITIZA (brand for lubiprostone) - Tier 2; PA; QL; AL

constulose - Tier 1; QL

enulose - Tier 1; QL

generlac - Tier 1; QL

lactulose encephalopathy - Tier 1; QL

lactulose oral solution - Tier 1; QL

LINZESS - Tier 2; PA; QL; AL

lubiprostone (generic for AMITIZA) - Tier 1; PA; QL; AL

MOVANTIK - Tier 2; PA; QL

KRISTALOSE (brand for lactulose) - Tier 2; PA*; QL

lactulose oral packet (generic for KRISTALOSE) - Tier 1; PA*; QL

MOTEGRITY - Tier 2; PA; QL

RELISTOR - Tier 2; PA; QL; AL

SYMPROIC - Tier 2; PA; QL; AL

TRULANCE - Tier 2; PA; QL; AL

Anti-Constipation AgentsOther

IBSRELA - Tier 2; PA; QL

Anti-Diarrheal Agents

anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1

diamode (generic for IMODIUM A-D) - Tier 1

ft anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1

loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1

meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1

alosetron hcl (generic for LOTRONEX) - Tier 1; PA; QL; AL

diphenoxylate-atropine oral liquid - Tier 1; PA

diphenoxylate-atropine oral tablet (generic for LOMOTIL) - Tier 1; PA*; QL

LOMOTIL (brand for diphenoxylate-atropine) - Tier 2; PA; QL

loperamide hcl capsule 2 mg oral (generic for IMODIUM A-D) - Tier 1; PA;

loperamide hcl capsule 2 mg oral (generic for IMODIUM A-D) - Tier 1;

PA*; QL

LOTRONEX (brand for alosetron hcl) - Tier 2; PA; QL; AL

MOTOFEN - Tier 2; PA*; QL

MYTESI - Tier 2; PA*; QL

opium - Tier 1; PA; QL

VIBERZI - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

114

Preferred Agents Non-Preferred Agents

Antispasmodics, Gastrointestinal

dicyclomine hcl oral capsule - Tier 1; QL

dicyclomine hcl oral solution - Tier 1

dicyclomine hcl oral tablet - Tier 1; QL

glycopyrrolate oral solution (generic for CUVPOSA) - Tier 1; PA; QL

glycopyrrolate oral tablet 1 mg (generic for ROBINUL) - Tier 1

glycopyrrolate oral tablet 2 mg (generic for ROBINUL-FORTE) - Tier 1

methscopolamine bromide oral tablet 2.5 mg - Tier 1

methscopolamine bromide oral tablet 5 mg - Tier 1; QL

chlordiazepoxide-clidinium capsule 5-2.5 mg oral (generic for LIBRAX) -

Tier 1; PA*; QL

chlordiazepoxide-clidinium capsule 5-2.5 mg oral (generic for LIBRAX) -

Tier 1; PA; QL

CUVPOSA (brand for glycopyrrolate) - Tier 2; PA; QL

GLYCATE (brand for glycopyrrolate) - Tier 2; PA; QL

GLYCOPYRROLATE ORAL TABLET 1.5 MG (brand for glycopyrrolate) -

Tier 2; PA; QL

LIBRAX (brand for chlordiazepoxide-clidinium) - Tier 2; PA; QL

ROBINUL (brand for glycopyrrolate) - Tier 2; PA

ROBINUL-FORTE (brand for glycopyrrolate) - Tier 2; PA

Gastrointestinal Agents, Other

bis subcit-metronid-tetracyc (generic for PYLERA) - Tier 1

bismuth/metronidaz/tetracyclin (generic for PYLERA) - Tier 1

gavilyte-c - Tier 1; QL

gavilyte-g (generic for GAVILYTE-G) - Tier 1; QL

HELIDAC THERAPY - Tier 2

peg 3350-kcl-na bicarb-nacl - Tier 1; QL

peg-3350/electrolytes (generic for GAVILYTE-G) - Tier 1; QL

ursodiol oral capsule 300 mg - Tier 1; QL

ursodiol oral tablet (generic for URSO 250) - Tier 1

amoxicill-clarithro-lansopraz - Tier 1; PA; QL

CHENODAL - Tier 2; PA*; SP; QL

CLENPIQ - Tier 2; PA*; QL

GOLYTELY (brand for peg-3350/electrolytes) - Tier 2; PA*; QL

MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA; QL

na sulfate-k sulfate-mg sulf solution 17.5-3.13-1.6 gm/177ml oral (generic

for SUPREP BOWEL PREP KIT) - Tier 1; PA*; QL

na sulfate-k sulfate-mg sulf solution 17.5-3.13-1.6 gm/177ml oral (generic

for SUPREP BOWEL PREP KIT) - Tier 1; PA; QL

OCALIVA - Tier 2; PA*; SP; QL

OMECLAMOX-PAK - Tier 2; PA

peg-3350/electrolytes/ascorbat (generic for MOVIPREP) - Tier 1; PA*; QL

peg-kcl-nacl-nasulf-na asc-c (generic for MOVIPREP) - Tier 1; PA*; QL

PLENVU - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

115

Preferred Agents Non-Preferred Agents

PYLERA (brand for bis subcit-metronid-tetracyc) - Tier 2; PA

RELTONE (brand for ursodiol) - Tier 2; PA; QL

SUPREP BOWEL PREP KIT (brand for na sulfate-k sulfate-mg sulf) - Tier

2; PA*; QL

TALICIA - Tier 2; PA; QL

URSO 250 (brand for ursodiol) - Tier 2; PA

URSO FORTE (brand for ursodiol) - Tier 2; PA

URSODIOL ORAL CAPSULE 200 MG, 400 MG (brand for ursodiol) - Tier

2; PA; QL

Histamine2 (H2) Receptor Antagonists

acid controller oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL

acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL

famotidine acid reducer oral tablet 10 mg (generic for PEPCID AC) -

Tier 1; QL

famotidine oral (generic for PEPCID) - Tier 1; QL

famotidine orig st (generic for PEPCID AC) - Tier 1; QL

ft acid reducer oral tablet (generic for PEPCID AC) - Tier 1; QL

heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier

1; QL

heartburn relief (generic for PEPCID AC) - Tier 1; QL

PEPCID AC (brand for acid controller) - Tier 2; QL

cimetidine hcl - Tier 1; PA; QL

cimetidine tablet 200 mg oral (rx) (generic for TAGAMET HB 200) - Tier 1;

PA; QL

cimetidine tablet 200 mg oral (rx) (generic for TAGAMET HB 200) - Tier 1;

PA*; QL

cimetidine tablet 300 mg oral - Tier 1; PA; QL

cimetidine tablet 300 mg oral - Tier 1; PA*; QL

cimetidine tablet 400 mg oral - Tier 1; PA; QL

cimetidine tablet 400 mg oral - Tier 1; PA*; QL

cimetidine tablet 800 mg oral - Tier 1; PA; QL

cimetidine tablet 800 mg oral - Tier 1; PA*; QL

nizatidine - Tier 1; PA*; QL

PEPCID (brand for famotidine) - Tier 2; PA; QL

TAGAMET HB 200 (brand for cimetidine) - Tier 2; PA; QL

Protectants

CARAFATE ORAL SUSPENSION (brand for sucralfate) - Tier 2; QL

misoprostol oral (generic for CYTOTEC) - Tier 1; QL

sucralfate oral (generic for CARAFATE) - Tier 1; QL

CARAFATE ORAL TABLET (brand for sucralfate) - Tier 2; PA; QL

CYTOTEC (brand for misoprostol) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

116

Preferred Agents Non-Preferred Agents

Proton Pump Inhibitors

esomeprazole magnesium capsule delayed release 20 mg oral (rx)

(generic for NEXIUM) - Tier 1; QL

esomeprazole magnesium capsule delayed release 20 mg oral (rx)

(generic for NEXIUM) - Tier 1; ST; QL

ft omeprazole - Tier 1; QL

omeprazole oral capsule delayed release 20 mg, 40 mg - Tier 1; QL

omeprazole oral tablet delayed release 20 mg - Tier 1; QL

pantoprazole sodium oral tablet delayed release (generic for

PROTONIX) - Tier 1; QL

PROTONIX ORAL PACKET (brand for pantoprazole sodium) - Tier 2;

acid reducer oral tablet delayed release 20 mg (generic for PRILOSEC

OTC) - Tier 1; PA; QL

ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL

DEXILANT (brand for dexlansoprazole) - Tier 2; PA; QL

dexlansoprazole capsule delayed release 30 mg oral (generic for

DEXILANT) - Tier 1; PA*; QL

dexlansoprazole capsule delayed release 30 mg oral (generic for

DEXILANT) - Tier 1; PA; QL

dexlansoprazole capsule delayed release 60 mg oral (generic for

DEXILANT) - Tier 1; PA*; QL

dexlansoprazole capsule delayed release 60 mg oral (generic for

DEXILANT) - Tier 1; PA; QL

esomeprazole magnesium capsule delayed release 20 mg oral (rx)

(generic for NEXIUM) - Tier 1; PA; QL

esomeprazole magnesium oral capsule delayed release 40 mg (generic

for NEXIUM) - Tier 1; PA; QL

esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1; PA;

QL; AL

ft acid reducer capsule delayed release 15 mg oral (generic for

PREVACID 24HR) - Tier 1; PA*; QL

ft acid reducer capsule delayed release 15 mg oral (generic for

PREVACID 24HR) - Tier 1; PA; QL

KONVOMEP - Tier 2; PA; QL

lansoprazole capsule delayed release 15 mg oral (otc) (generic for

PREVACID 24HR) - Tier 1; PA*; QL

lansoprazole capsule delayed release 15 mg oral (otc) (generic for

PREVACID 24HR) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

117

Preferred Agents Non-Preferred Agents

lansoprazole capsule delayed release 15 mg oral (rx) (generic for

PREVACID 24HR) - Tier 1; PA*; QL

lansoprazole oral capsule delayed release 15 mg (generic for PREVACID

24HR) - Tier 1; PA*; QL

lansoprazole oral capsule delayed release 30 mg (generic for PREVACID)

- Tier 1; PA*; QL

lansoprazole oral tablet delayed release dispersible 15 mg (generic for

PREVACID SOLUTAB) - Tier 1; PA; QL; AL

lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg

(generic for PREVACID SOLUTAB) - Tier 1; PA*; QL; AL

NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for

esomeprazole magnesium) - Tier 2; PA; QL

NEXIUM ORAL PACKET (brand for esomeprazole magnesium) - Tier 2;

PA; QL; AL

omep/sod bicarb (generic for ZEGERID) - Tier 1; PA; QL

omeprazole capsule delayed release 10 mg oral - Tier 1; PA*; QL

omeprazole capsule delayed release 10 mg oral - Tier 1; PA; QL

omeprazole magnesium oral tablet delayed release (generic for

PRILOSEC OTC) - Tier 1; PA; QL

omeprazole-sod bicarbonate (generic for ZEGERID) - Tier 1; PA; QL

omeprazole-sodium bicarb oral capsule 20-1100 mg (generic for

ZEGERID) - Tier 1; PA; QL

omeprazole-sodium bicarbonate oral capsule (generic for ZEGERID) -

Tier 1; PA*; QL

omeprazole-sodium bicarbonate oral packet (generic for ZEGERID) - Tier

1; PA; QL

pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

118

Preferred Agents Non-Preferred Agents

PREVACID (brand for lansoprazole) - Tier 2; PA*; QL

PREVACID 24HR (brand for eq lansoprazole) - Tier 2; PA*; QL

PREVACID SOLUTAB (brand for cvs lansoprazole) - Tier 2; PA*; QL; AL

PRILOSEC - Tier 2; PA; QL

PRILOSEC OTC (brand for acid reducer) - Tier 2; PA; QL

PROTONIX ORAL TABLET DELAYED RELEASE (brand for pantoprazole

sodium) - Tier 2; PA; QL

rabeprazole sodium oral tablet delayed release (generic for ACIPHEX) -

Tier 1; PA*; QL

ZEGERID (brand for cvs omeprazole-sod bicarbonate) - Tier 2; PA; QL

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and

Stomach Conditions

Antispasmodics, Gastrointestinal - Bowel Treatment Drugs

DONNATAL (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA

pb-hyoscy-atropine-scopolamine (generic for DONNATAL) - Tier 1; PA

PHENOHYTRO (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA

Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal

Drugs

antacid calcium (generic for CAL-GEST ANTACID) - Tier 1

antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1

antacid extra str (generic for CVS CHEWY NOT CHALKY FLAVOR) -

Tier 1

antacid extra strength oral tablet chewable 750 mg (generic for CVS

CHEWY NOT CHALKY FLAVOR) - Tier 1

antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier

antacid maximum (generic for TUMS ULTRA 1000) - Tier 1

antacid maximum strength oral tablet chewable 1000 mg (generic for

TUMS ULTRA 1000) - Tier 1

antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA

1000) - Tier 1

advanced probiotic oral capsule (generic for FLORASTOR ADVANCED)

- Tier 1; PA

alvimopan - Tier 1; PA

BILAC (brand for cvs daily probiotic) - Tier 2; PA

daily probiotic oral capsule (generic for FLORASTOR ADVANCED) -

Tier 1; PA

FLORASTOR ADVANCED (brand for cvs daily probiotic) - Tier 2; PA

ft gas relief infants (generic for MYLICON INFANTS GAS RELIEF) - Tier

1; PA

gas relief infants (generic for MYLICON INFANTS GAS RELIEF) - Tier 1;

gas relief infants drops oral suspension 40 mg/0.6ml (generic for

MYLICON INFANTS GAS RELIEF) - Tier 1; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

119

Preferred Agents Non-Preferred Agents

antacid oral tablet chewable 500 mg (generic for CAL-GEST

ANTACID) - Tier 1

antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT

CHALKY FLAVOR) - Tier 1

antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1

antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS

ULTRA 1000) - Tier 1

anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) -

Tier 1

bismuth (generic for SOOTHE) - Tier 1

bismuth subsalicylate oral (generic for SOOTHE) - Tier 1

calcium antacid (generic for CAL-GEST ANTACID) - Tier 1

calcium antacid ex st oral tablet chewable 750 mg (generic for CVS

CHEWY NOT CHALKY FLAVOR) - Tier 1

gas relief infants oral suspension 20 mg/0.3ml (generic for MYLICON

INFANTS GAS RELIEF) - Tier 1; PA

GENORAVANCE (brand for cvs daily probiotic) - Tier 2; PA

infant gas relief (generic for MYLICON INFANTS GAS RELIEF) - Tier 1;

infants gas relief (generic for MYLICON INFANTS GAS RELIEF) - Tier 1;

MICROFLOR 33 (brand for cvs daily probiotic) - Tier 2; PA

MYLICON INFANTS GAS RELIEF (brand for cvs gas relief infants) - Tier

2; PA

PROBIONEXX (brand for cvs daily probiotic) - Tier 2; PA

PROBIZEN (brand for cvs daily probiotic) - Tier 2; PA

simeped (generic for MYLICON INFANTS GAS RELIEF) - Tier 1; PA

calcium antacid extra strength (generic for CVS CHEWY NOT

CHALKY FLAVOR) - Tier 1

calcium carbonate antacid oral suspension - Tier 1; QL

calcium carbonate antacid oral tablet - Tier 1

calcium carbonate antacid oral tablet chewable (generic for CAL-

GEST ANTACID) - Tier 1

cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1

chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY

FLAVOR) - Tier 1

diarrhea (generic for SOOTHE) - Tier 1

diarrhea relief (generic for SOOTHE) - Tier 1

diotame instydose (generic for SOOTHE) - Tier 1

enema (generic for FLEET ENEMA) - Tier 1

enema disposable (generic for FLEET ENEMA) - Tier 1

simethicone drops infants (generic for MYLICON INFANTS GAS RELIEF)

- Tier 1; PA

simethicone oral suspension (generic for MYLICON INFANTS GAS

RELIEF) - Tier 1; PA

TEENY TUMMY GAS RELIEF DROPS (brand for cvs gas relief infants) -

Tier 2; PA

XYBIOTIC (brand for cvs daily probiotic) - Tier 2; PA

ZELAC (brand for cvs daily probiotic) - Tier 2; PA*

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

120

Preferred Agents Non-Preferred Agents

enema ready-to-use (generic for FLEET ENEMA) - Tier 1

enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for

FLEET ENEMA) - Tier 1

ft antacid extra strength (generic for CVS CHEWY NOT CHALKY

FLAVOR) - Tier 1

ft antacid regular strength (generic for CAL-GEST ANTACID) - Tier 1

ft enema saline (generic for FLEET ENEMA) - Tier 1

ft gas relief - Tier 1

ft gas relief extra strength (generic for GAS-X EXTRA STRENGTH) -

Tier 1

ft milk of magnesia (generic for DULCOLAX) - Tier 1

ft stomach relief (generic for KAOPECTATE) - Tier 1

gas relief extra strength (generic for GAS-X EXTRA STRENGTH) -

Tier 1

gas relief extra strength oral tablet chewable 125 mg (generic for

PHAZYME) - Tier 1

gas relief extstrength (generic for PHAZYME) - Tier 1

gas relief oral capsule 125 mg (generic for GAS-X EXTRA

STRENGTH) - Tier 1

gas relief oral tablet chewable 125 mg (generic for PHAZYME) - Tier 1

gas relief oral tablet chewable 80 mg - Tier 1

GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for eq gas relief)

- Tier 2

heartland gas relief - Tier 1

long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1

milk of magnesia (generic for DULCOLAX) - Tier 1

milk of magnesia oral suspension 1200 mg/15ml (generic for

DULCOLAX) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

121

Preferred Agents Non-Preferred Agents

PHAZYME (brand for cvs gas relief extra strength) - Tier 2

pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) -

Tier 1

pink bismuth oral tablet 262 mg (generic for KAOPECTATE) - Tier 1

pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier

pink-bismuth (generic for SOOTHE) - Tier 1

ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier

saline enema (generic for FLEET ENEMA) - Tier 1

simethicone oral capsule 125 mg (generic for GAS-X EXTRA

STRENGTH) - Tier 1

simethicone oral tablet chewable (generic for PHAZYME) - Tier 1

smooth antacid ex st oral tablet chewable 750 mg (generic for CVS

CHEWY NOT CHALKY FLAVOR) - Tier 1

smooth antacid extra st (generic for CVS CHEWY NOT CHALKY

FLAVOR) - Tier 1

smooth antacid extra strength (generic for CVS CHEWY NOT

CHALKY FLAVOR) - Tier 1

soothe oral (generic for SOOTHE) - Tier 1

stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527

mg/30ml (generic for SOOTHE) - Tier 1

stomach relief oral tablet 262 mg (generic for KAOPECTATE) - Tier 1

stomach relief oral tablet chewable 262 mg (generic for SOOTHE) -

Tier 1

TUMS SMOOTHIES (brand for antacid) - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

122

Preferred Agents Non-Preferred Agents

Laxatives - Bowel Treatment Drugs

clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;

daily fiber oral powder 43 % (generic for REGULOID) - Tier 1

fiber oral powder (generic for METAMUCIL SMOOTH TEXTURE) -

Tier 1; QL

fiber oral powder 43 % (generic for REGULOID) - Tier 1

fiber powder oral powder 43 % (generic for REGULOID) - Tier 1

ft clearlax (generic for CLEARLAX) - Tier 1; QL

ft fiber oral powder 43 % (generic for REGULOID) - Tier 1

gavilax oral powder (generic for CLEARLAX) - Tier 1; QL

gentlelax (generic for CLEARLAX) - Tier 1; QL

glycolax (generic for CLEARLAX) - Tier 1; QL

laxaclear (generic for CLEARLAX) - Tier 1; QL

ft mineral oil - Tier 1; PA

mineral oil heavy oral - Tier 1; PA*

laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;

METAMUCIL 4 IN 1 FIBER ORAL POWDER 43 % (brand for daily

fiber) - Tier 2

METAMUCIL FREE & NATURAL (brand for daily fiber) - Tier 2

mm clearlax (generic for CLEARLAX) - Tier 1; QL

natural daily fiber oral powder 48.57 % - Tier 1

natural daily fiber oral powder 58.6 % (generic for METAMUCIL

SMOOTH TEXTURE) - Tier 1

natural fiber oral powder 28.3 % (generic for METAMUCIL SMOOTH

TEXTURE) - Tier 1; QL

natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH

TEXTURE) - Tier 1

natural vegetable (generic for HYDROCIL) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

123

Preferred Agents Non-Preferred Agents

natura-lax (generic for CLEARLAX) - Tier 1; QL

peg 3350 oral powder (generic for CLEARLAX) - Tier 1; QL

polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1;

polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) -

Tier 1; QL

psyldex - Tier 1

purelax oral powder (generic for CLEARLAX) - Tier 1; QL

reguloid oral powder 43 % (generic for REGULOID) - Tier 1

smooth lax oral powder (generic for CLEARLAX) - Tier 1; QL

Laxatives - Drugs to treat Constipation

AVEDANA GLYCERIN (ADULT) (brand for cvs glycerin adult) - Tier 2

citroma (generic for CITROMA) - Tier 1

col-rite oral capsule 250 mg - Tier 1; QL

docusate calcium (generic for SURFAK) - Tier 1

docusate sodium oral capsule (generic for COLACE) - Tier 1; QL

docusate sodium oral liquid (generic for ONELAX DOCUSATE

SODIUM) - Tier 1; QL

docusate sodium oral syrup - Tier 1

dok oral tablet (generic for DOK) - Tier 1

dss (generic for COLACE) - Tier 1; QL

EX-LAX MAXIMUM STRENGTH (brand for cvs laxative pills max st) -

Tier 2

ft magnesium citrate (generic for CITROMA) - Tier 1

ft senna laxative (generic for SENOKOT) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

124

Preferred Agents Non-Preferred Agents

ft senna laxatives (generic for SENOKOT) - Tier 1

ft stool softener oral capsule (generic for COLACE) - Tier 1; QL

ft stool softener oral tablet 100 mg (generic for DOK) - Tier 1

geri-kot (generic for SENOKOT) - Tier 1

glycerin (adult) rectal suppository 2 gm (generic for AVEDANA

GLYCERIN (ADULT)) - Tier 1

glycerin (infants & children) rectal suppository 1 gm - Tier 1

glycerin adult rectal suppository 2 gm (generic for AVEDANA

GLYCERIN (ADULT)) - Tier 1

glycerin child rectal suppository 1 gm, 1.2 gm - Tier 1

glycerin childrens - Tier 1

glycerin pediatric rectal suppository 1.2 gm - Tier 1

laxative max str (generic for EX-LAX MAXIMUM STRENGTH) - Tier 1

laxative pills max st (generic for EX-LAX MAXIMUM STRENGTH) -

Tier 1

laxative pills oral tablet 25 mg (generic for EX-LAX MAXIMUM

STRENGTH) - Tier 1

laxative regular strength (generic for SENNA SMOOTH) - Tier 1

magnesium citrate oral solution (generic for CITROMA) - Tier 1

mm stool softener laxative (generic for COLACE) - Tier 1; QL

natural senna laxative (generic for SENOKOT) - Tier 1

natural vegetable laxative oral tablet 8.6 mg (generic for SENOKOT) -

Tier 1

ONELAX DOCUSATE SODIUM (brand for docusate sodium) - Tier 2;

ONELAX MAGNESIUM CITRATE (brand for cvs magnesium citrate) -

Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

125

Preferred Agents Non-Preferred Agents

ONELAX SENNA (brand for senna) - Tier 2

PERDIEM OVERNIGHT RELIEF (brand for laxative regular strength) -

Tier 2

senna lax (generic for SENOKOT) - Tier 1

senna laxative (generic for SENOKOT) - Tier 1

senna oral liquid (generic for ONELAX SENNA) - Tier 1

senna oral syrup 8.8 mg/5ml (generic for ONELAX SENNA) - Tier 1

senna oral tablet (generic for SENOKOT) - Tier 1

senna smooth (generic for SENNA SMOOTH) - Tier 1

senna-extra (generic for SENOKOT EXTRA STRENGTH) - Tier 1

senna-lax (generic for SENOKOT) - Tier 1

senna-tabs (generic for SENOKOT) - Tier 1

senna-time (generic for SENOKOT) - Tier 1

sennazon (generic for ONELAX SENNA) - Tier 1

SENOKOT (brand for cvs senna) - Tier 2

SENOKOT EXTRA STRENGTH (brand for cvs senna-extra) - Tier 2

stool softener laxative oral capsule (generic for COLACE) - Tier 1; QL

stool softener oral capsule 100 mg (generic for COLACE) - Tier 1; QL

stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1

stool softener oral capsule 250 mg - Tier 1; QL

stool softener oral tablet 100 mg (generic for DOK) - Tier 1

vegetable laxative (generic for SENOKOT) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

126

Preferred Agents Non-Preferred Agents

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers,

Treatment

ARALAST NP - Tier 2; PA; QL

betaine (generic for CYSTADANE) - Tier 1; PA; SP; QL

CREON - Tier 2; QL

GLASSIA - Tier 2; PA; QL

levocarnitine oral solution (generic for CARNITOR) - Tier 1; QL

levocarnitine sf (generic for CARNITOR) - Tier 1; QL

nitisinone oral capsule 20 mg (generic for ORFADIN) - Tier 1

ORFADIN ORAL CAPSULE 20 MG (brand for nitisinone) - Tier 2

PROLASTIN-C - Tier 2; PA

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG -

Tier 2; PA; QL

ZEMAIRA INTRAVENOUS SOLUTION RECONSTITUTED 4000 MG,

5000 MG - Tier 2; PA; SP

CARNITOR ORAL SOLUTION (brand for levocarnitine) - Tier 2; PA; QL

CARNITOR ORAL TABLET (brand for levocarnitine) - Tier 2; PA

CARNITOR SF (brand for levocarnitine) - Tier 2; PA; QL

CHOLBAM - Tier 2; PA*; SP; QL

cromolyn sodium oral (generic for GASTROCROM) - Tier 1; PA; QL

CYSTADANE (brand for betaine) - Tier 2; PA; SP; QL

dichlorphenamide (generic for KEVEYIS) - Tier 1; PA*; SP; QL

GASTROCROM (brand for cromolyn sodium) - Tier 2; PA; QL

KEVEYIS (brand for dichlorphenamide) - Tier 2; PA; SP; QL

OLPRUVA (2 GM DOSE) - Tier 2; PA

OLPRUVA (3 GM DOSE) - Tier 2; PA

OLPRUVA (4 GM DOSE) - Tier 2; PA

OLPRUVA (5 GM DOSE) - Tier 2; PA

OLPRUVA (6 GM DOSE) - Tier 2; PA

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-

32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000

UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT -

Tier 2; QL

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 60000-

189600 UNIT - Tier 2

OLPRUVA (6.67 GM DOSE) - Tier 2; PA

ORMALVI (brand for dichlorphenamide) - Tier 2; PA; SP; QL

PERTZYE CAPSULE DELAYED RELEASE PARTICLES 16000-57500

UNIT ORAL - Tier 2; PA*; QL

PERTZYE CAPSULE DELAYED RELEASE PARTICLES 16000-57500

UNIT ORAL - Tier 2; PA; QL

PERTZYE CAPSULE DELAYED RELEASE PARTICLES 4000-14375

UNIT ORAL - Tier 2; PA*; QL

PERTZYE CAPSULE DELAYED RELEASE PARTICLES 4000-14375

UNIT ORAL - Tier 2; PA; QL

PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 24000-

86250 UNIT, 8000-28750 UNIT - Tier 2; PA*; QL

VIOKACE - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

127

Preferred Agents Non-Preferred Agents

Genitourinary Agents

Antispasmodics, Urinary

fesoterodine fumarate er (generic for TOVIAZ) - Tier 1; QL

oxybutynin chloride er - Tier 1; QL

oxybutynin chloride oral tablet 2.5 mg - Tier 1

oxybutynin chloride oral tablet 5 mg - Tier 1; QL

solifenacin succinate (generic for VESICARE) - Tier 1; QL

TOVIAZ (brand for fesoterodine fumarate er) - Tier 2; QL

darifenacin hydrobromide er tablet extended release 24 hour 15 mg oral -

Tier 1; PA*; QL

darifenacin hydrobromide er tablet extended release 24 hour 15 mg oral -

Tier 1; PA; QL

darifenacin hydrobromide er tablet extended release 24 hour 7.5 mg oral -

Tier 1; PA*; QL

darifenacin hydrobromide er tablet extended release 24 hour 7.5 mg oral -

Tier 1; PA; QL

DETROL (brand for tolterodine tartrate) - Tier 2; PA; ST; QL

DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL

flavoxate hcl - Tier 1; PA*; QL

GELNIQUE - Tier 2; PA; QL

mirabegron er (generic for MYRBETRIQ) - Tier 1; PA; QL

MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER - Tier 2; PA;

QL; AL

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR (brand

for mirabegron er) - Tier 2; PA*; QL

oxybutynin chloride oral solution - Tier 1; PA

OXYTROL - Tier 2; PA; QL

OXYTROL FOR WOMEN - Tier 2; PA; QL

tolterodine tartrate (generic for DETROL) - Tier 1; PA*; ST; QL

tolterodine tartrate er capsule extended release 24 hour 2 mg oral

(generic for DETROL LA) - Tier 1; PA; QL

tolterodine tartrate er capsule extended release 24 hour 2 mg oral

(generic for DETROL LA) - Tier 1; PA*; QL

tolterodine tartrate er capsule extended release 24 hour 4 mg oral

(generic for DETROL LA) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

128

Preferred Agents Non-Preferred Agents

tolterodine tartrate er capsule extended release 24 hour 4 mg oral

(generic for DETROL LA) - Tier 1; PA*; QL

trospium chloride - Tier 1; PA*; ST; QL

trospium chloride er - Tier 1; PA*; QL

VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL

VESICARE LS - Tier 2; PA; QL

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL

dutasteride oral (generic for AVODART) - Tier 1; QL

finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL

tamsulosin hcl (generic for FLOMAX) - Tier 1; QL

terazosin hcl - Tier 1; QL

AVODART (brand for dutasteride) - Tier 2; PA; QL

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR 8 MG -

Tier 2; PA; QL

CARDURA XL TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL -

Tier 2; PA*; QL

CARDURA XL TABLET EXTENDED RELEASE 24 HOUR 4 MG ORAL -

Tier 2; PA; QL

CIALIS ORAL TABLET 5 MG (brand for tadalafil) - Tier 2; PA; QL; GE

dutasteride-tamsulosin hcl (generic for JALYN) - Tier 1; PA; QL

FLOMAX (brand for tamsulosin hcl) - Tier 2; PA; QL

JALYN (brand for dutasteride-tamsulosin hcl) - Tier 2; PA; QL

PROSCAR (brand for finasteride) - Tier 2; PA; QL

RAPAFLO (brand for silodosin) - Tier 2; PA*; QL

silodosin (generic for RAPAFLO) - Tier 1; PA*; QL

tadalafil tablet 5 mg oral (generic for CIALIS) - Tier 1; PA*; QL; GE

tadalafil tablet 5 mg oral (generic for CIALIS) - Tier 1; PA; QL; GE

UROXATRAL (brand for alfuzosin hcl er) - Tier 2; PA; QL

Genitourinary Agents, Other

bethanechol chloride oral - Tier 1

DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP; QL

ELMIRON - Tier 2; PA; QL

LITHOSTAT - Tier 2; PA

penicillamine oral (generic for CUPRIMINE) - Tier 1; PA; SP; QL

RIMSO-50 - Tier 2; PA; QL

tiopronin (generic for THIOLA) - Tier 1; PA; SP; QL

CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL

THIOLA (brand for tiopronin) - Tier 2; PA; SP; QL

THIOLA EC (brand for tiopronin) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

129

Preferred Agents Non-Preferred Agents

Genitourinary Agents - Drugs to Treat Bladder, Genital and

Kidney Conditions

Genitourinary Agents, Other - Miscellaneous Bladder, Genital,

and Kidney Conditions Drugs

phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL

phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier

1; QL

phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier

1; QL

PHEXXI - Tier 2; QL

me/naphos/mb/hyo1 (generic for UROGESIC-BLUE) - Tier 1; PA*

PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; PA; QL

URELLE - Tier 2; PA

uretron d/s (generic for URETRON D/S) - Tier 1; PA*; QL

URIBEL ORAL CAPSULE (brand for uro-mp) - Tier 2; PA*

URIBEL ORAL TABLET - Tier 2; PA

URIMAR-T (brand for urneva) - Tier 2; PA*

urin ds (generic for URETRON D/S) - Tier 1; PA*; QL

URNEVA (brand for urneva) - Tier 2; PA*

UROGESIC-BLUE (brand for me/naphos/mb/hyo1) - Tier 2; PA

URO-MP (brand for uro-mp) - Tier 2; PA*

VILAMIT MB (brand for uro-mp) - Tier 2; PA*

VILEVEV MB - Tier 2; PA*

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

ACTHAR - Tier 2; PA; SP; QL

BETAMETHASONE SOD PHOS & ACET SUSPENSION 6 (3-3)

MG/ML INJECTION (brand for betamethasone sod phos & acet) - Tier

2; PA; QL

betamethasone sod phos & acet suspension 6 (3-3) mg/ml injection

(generic for CELESTONE SOLUSPAN) - Tier 1; PA; QL

CORTISONE ACETATE ORAL - Tier 2; QL

CORTROPHIN - Tier 2; PA; SP; QL

dexamethasone intensol - Tier 1

dexamethasone oral elixir - Tier 1; QL

dexamethasone oral solution - Tier 1; PA; QL

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 2 mg - Tier 1

dexamethasone oral tablet 1.5 mg, 4 mg, 6 mg - Tier 1; QL

dexamethasone sod phosphate pf injection solution - Tier 1; PA

ALKINDI SPRINKLE - Tier 2; PA; QL

BETAMETHASONE COMBO INJECTION SUSPENSION 6 (3-3) MG/ML

(brand for betamethasone sod phos & acet) - Tier 2; PA; QL

CELESTONE SOLUSPAN (brand for betamethasone sod phos & acet) -

Tier 2; PA; QL

CORTEF (brand for hydrocortisone) - Tier 2; PA; QL

deflazacort oral tablet (generic for EMFLAZA) - Tier 1; PA; SP; QL

DEPO-MEDROL (brand for methylprednisolone acetate) - Tier 2; PA

dexamethasone oral tablet therapy pack (generic for HIDEX 6-DAY) - Tier

1; PA

EMFLAZA (brand for deflazacort) - Tier 2; PA*; SP; QL

HEMADY - Tier 2; PA; QL

HIDEX 6-DAY (brand for dexamethasone) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

130

Preferred Agents Non-Preferred Agents

dexamethasone sod phosphate pf injection solution prefilled syringe -

Tier 1; PA; QL

dexamethasone sodium phosphate injection solution 100 mg/10ml,

120 mg/30ml, 20 mg/5ml, 4 mg/ml - Tier 1; PA

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MG/ML

INJECTION - Tier 2; PA

dexamethasone sodium phosphate solution 10 mg/ml injection - Tier 1;

fludrocortisone acetate oral - Tier 1; QL

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) -

Tier 1; QL

KENALOG-80 (brand for triamcinolone acetonide) - Tier 2; PA; QL

methylprednisolone acetate suspension 40 mg/ml injection (generic for

DEPO-MEDROL) - Tier 1; PA

KENALOG INJECTION (brand for triamcinolone acetonide) - Tier 2; PA;

MEDROL ORAL TABLET 16 MG, 4 MG, 8 MG (brand for

methylprednisolone) - Tier 2; PA; QL

MEDROL ORAL TABLET 2 MG - Tier 2; PA

MEDROL ORAL TABLET THERAPY PACK (brand for

methylprednisolone) - Tier 2; PA; QL

ORAPRED ODT (brand for prednisolone sodium phosphate) - Tier 2; PA;

PEDIAPRED (brand for prednisolone sodium phosphate) - Tier 2; PA; QL

prednisolone oral tablet - Tier 1; PA; QL

prednisone oral solution - Tier 1; PA; QL

RAYOS - Tier 2; PA*; QL

TAPERDEX 12-DAY - Tier 2; PA; QL

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MG/ML

INJECTION (brand for methylprednisolone acetate) - Tier 2; PA

methylprednisolone acetate suspension 80 mg/ml injection (generic for

DEPO-MEDROL) - Tier 1; PA

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MG/ML

INJECTION (brand for methylprednisolone acetate) - Tier 2; PA

methylprednisolone oral (generic for MEDROL) - Tier 1; QL

prednisolone oral solution - Tier 1; QL

prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml,

25 mg/5ml - Tier 1; QL

prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

(generic for PEDIAPRED) - Tier 1; QL

TAPERDEX 6-DAY (brand for dexamethasone) - Tier 2; PA

TAPERDEX 7-DAY - Tier 2; PA; QL

ZILRETTA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

131

Preferred Agents Non-Preferred Agents

prednisolone sodium phosphate oral tablet dispersible (generic for

ORAPRED ODT) - Tier 1; QL

prednisone intensol - Tier 1; QL

prednisone oral tablet - Tier 1; QL

prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL

prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) -

Tier 1

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG -

Tier 2; PA

TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 80

MG/ML (brand for triamcinolone acetonide) - Tier 2; PA; QL

triamcinolone acetonide suspension 40 mg/ml injection (generic for

KENALOG) - Tier 1; QL

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML

INJECTION (brand for triamcinolone acetonide) - Tier 2; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

CHORIONIC GONADOTROPIN INTRAMUSCULAR (brand for

chorionic gonadotropin) - Tier 2; PA

desmopressin ace spray refrig - Tier 1; QL

desmopressin acetate injection (generic for DDAVP) - Tier 1; PA

desmopressin acetate oral (generic for DDAVP) - Tier 1; QL

desmopressin acetate pf (generic for DDAVP PF) - Tier 1; PA

desmopressin acetate spray - Tier 1; QL

EGRIFTA SV - Tier 2; PA; SP; QL

GENOTROPIN - Tier 2; PA; SP; QL

GENOTROPIN MINIQUICK - Tier 2; PA; SP; QL

INCRELEX - Tier 2; PA; SP; QL; AL

NORDITROPIN FLEXPRO - Tier 2; PA; SP; QL

NOVAREL - Tier 2; PA

PREGNYL (brand for chorionic gonadotropin) - Tier 2; PA

DDAVP INJECTION (brand for desmopressin acetate) - Tier 2; PA

DDAVP ORAL (brand for desmopressin acetate) - Tier 2; PA; QL

DDAVP PF (brand for desmopressin acetate pf) - Tier 2; PA

DESMOPRESSIN ACETATE NASAL - Tier 2; PA; QL

HUMATROPE - Tier 2; PA*; SP; QL

NOCDURNA - Tier 2; PA; QL

NUTROPIN AQ NUSPIN 10 - Tier 2; PA*; SP; QL

NUTROPIN AQ NUSPIN 20 - Tier 2; PA*; SP; QL

NUTROPIN AQ NUSPIN 5 - Tier 2; PA*; SP; QL

OMNITROPE - Tier 2; PA*; SP; QL

SAIZEN - Tier 2; PA*; SP; QL

SEROSTIM - Tier 2; PA*; SP; QL

ZOMACTON - Tier 2; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

132

Preferred Agents Non-Preferred Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -

Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -

Hormone Replacement/Modifying Drugs

SKYTROFA - Tier 2; PA*; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

KORLYM (brand for mifepristone) - Tier 2; PA; SP; QL

methergine (generic for METHERGINE) - Tier 1; QL

methylergonovine maleate oral (generic for METHERGINE) - Tier 1;

mifepristone oral tablet 300 mg (generic for KORLYM) - Tier 1; PA;

SP; QL

CERVIDIL - Tier 2; PA

PREPIDIL - Tier 2; PA

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins) - Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins) - Hormone Replacement/Modifying Drugs

mifepristone oral tablet 200 mg (generic for MIFEPREX) - Tier 1 MIFEPREX (brand for mifepristone) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

133

Preferred Agents Non-Preferred Agents

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers)

Androgens

ANDRODERM - Tier 2; PA; QL

danazol oral - Tier 1; QL

DEPO-TESTOSTERONE (brand for testosterone cypionate) - Tier 2;

PA; QL

TESTIM (brand for testosterone) - Tier 2; PA; QL

testosterone cypionate intramuscular (generic for DEPO-

TESTOSTERONE) - Tier 1; PA; QL

testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO

PUMP) - Tier 1; PA; QL

testosterone transdermal gel 25 mg/2.5gm (1%) - Tier 1; PA; QL

testosterone transdermal gel 50 mg/5gm (1%) (generic for TESTIM) -

Tier 1; PA; QL

ANDROGEL PUMP (brand for testosterone) - Tier 2; PA; QL

AVEED - Tier 2; PA*; QL

FORTESTA (brand for testosterone) - Tier 2; PA; QL

JATENZO - Tier 2; PA*; QL

METHITEST - Tier 2; PA*; QL

methyltestosterone oral - Tier 1; PA*; QL

NATESTO - Tier 2; PA*

TESTOPEL - Tier 2; PA*; QL

testosterone enanthate intramuscular - Tier 1; PA*; QL

TESTOSTERONE IMPLANT PELLET 37.5 MG, 87.5 MG - Tier 2; PA

testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) (generic for

ANDROGEL PUMP) - Tier 1; PA*; QL

testosterone transdermal gel 10 mg/act (2%) (generic for FORTESTA) -

Tier 1; PA*; QL

testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 40.5 mg/2.5gm

(1.62%) - Tier 1; PA*; QL

testosterone transdermal solution - Tier 1; PA*

TLANDO - Tier 2; PA; QL

VOGELXO (brand for testosterone) - Tier 2; PA; QL

VOGELXO PUMP (brand for testosterone) - Tier 2; PA; QL

XYOSTED - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

134

Preferred Agents Non-Preferred Agents

Estrogens

afirmelle (generic for AFIRMELLE) - Tier 1; QL; AL

altavera (generic for ALTAVERA) - Tier 1; QL; AL

alyacen 1/35 (generic for DASETTA 1/35) - Tier 1; QL; AL

alyacen 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; AL

amabelz (generic for AMABELZ) - Tier 1; QL

amethyst (generic for AMETHYST) - Tier 1; QL; AL

ANGELIQ - Tier 2; QL

ANNOVERA - Tier 2; QL

apri - Tier 1; QL; AL

aranelle - Tier 1; QL; AL

ashlyna (generic for ASHLYNA) - Tier 1; QL; AL

aubra eq (generic for AFIRMELLE) - Tier 1; QL; AL

aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; AL

aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; AL

ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL

ALORA (brand for estradiol) - Tier 2; PA; QL

BIJUVA CAPSULE 1-100 MG ORAL - Tier 2; PA*; QL

BIJUVA CAPSULE 1-100 MG ORAL - Tier 2; PA; QL

BIJUVA ORAL CAPSULE 0.5-100 MG - Tier 2; PA; QL; AL

CLIMARA (brand for estradiol) - Tier 2; PA; QL

DELESTROGEN (brand for estradiol valerate) - Tier 2; PA

DIVIGEL (brand for estradiol) - Tier 2; PA; QL

ELESTRIN - Tier 2; PA*

ESTRACE (brand for estradiol) - Tier 2; PA; QL

estradiol gel 0.25 mg/0.25gm transdermal (generic for DIVIGEL) - Tier 1;

PA*; QL

estradiol gel 0.25 mg/0.25gm transdermal (generic for DIVIGEL) - Tier 1;

PA; QL

aurovela 24 fe - Tier 1; QL; AL

aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; AL

aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; AL

aviane (generic for AFIRMELLE) - Tier 1; QL; AL

ayuna (generic for ALTAVERA) - Tier 1; QL; AL

azurette (generic for AZURETTE) - Tier 1; QL; AL

BALCOLTRA (brand for levonorgest-eth estradiol-iron) - Tier 2; QL; AL

balziva (generic for BALZIVA) - Tier 1; QL; AL

BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; QL; AL

blisovi 24 fe - Tier 1; QL; AL

blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; AL

blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; AL

briellyn (generic for BALZIVA) - Tier 1; QL; AL

camrese (generic for ASHLYNA) - Tier 1; QL; AL

estradiol gel 0.5 mg/0.5gm transdermal (generic for DIVIGEL) - Tier 1;

PA*; QL

estradiol gel 0.5 mg/0.5gm transdermal (generic for DIVIGEL) - Tier 1;

PA; QL

estradiol gel 0.75 mg/0.75gm transdermal (generic for DIVIGEL) - Tier 1;

PA*; QL

estradiol gel 0.75 mg/0.75gm transdermal (generic for DIVIGEL) - Tier 1;

PA; QL

estradiol gel 1 mg/gm transdermal (generic for DIVIGEL) - Tier 1; PA*; QL

estradiol gel 1 mg/gm transdermal (generic for DIVIGEL) - Tier 1; PA; QL

estradiol gel 1.25 mg/1.25gm transdermal (generic for DIVIGEL) - Tier 1;

PA*; QL

estradiol gel 1.25 mg/1.25gm transdermal (generic for DIVIGEL) - Tier 1;

PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

135

Preferred Agents Non-Preferred Agents

camrese lo (generic for CAMRESE LO) - Tier 1; QL; AL

charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL; AL

chateal eq (generic for ALTAVERA) - Tier 1; QL; AL

CLIMARA PRO - Tier 2; QL

COMBIPATCH - Tier 2; QL

cryselle-28 - Tier 1; QL; AL

cyred eq - Tier 1; QL; AL

dasetta 1/35 (generic for DASETTA 1/35) - Tier 1; QL; AL

dasetta 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; AL

daysee (generic for ASHLYNA) - Tier 1; QL; AL

delyla (generic for AFIRMELLE) - Tier 1; QL; AL

DEPO-ESTRADIOL - Tier 2

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

(generic for AZURETTE) - Tier 1; QL; AL

EVAMIST - Tier 2; PA*; QL

FEMRING - Tier 2; PA*; QL

MENOSTAR - Tier 2; PA*; QL

MINIVELLE (brand for estradiol) - Tier 2; PA; QL

VAGIFEM (brand for estradiol) - Tier 2; PA; QL

VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL

dolishale (generic for AMETHYST) - Tier 1; QL; AL

dotti (generic for DOTTI) - Tier 1; QL

drospiren-eth estrad-levomefol (generic for BEYAZ) - Tier 1; QL; AL

drospirenone-ethinyl estradiol (generic for JASMIEL) - Tier 1; QL; AL

DUAVEE - Tier 2; PA; QL

elinest - Tier 1; QL; AL

eluryng (generic for ELURYNG) - Tier 1; QL; AL

enilloring (generic for ELURYNG) - Tier 1; QL; AL

enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; AL

enskyce - Tier 1; QL; AL

estarylla (generic for ESTARYLLA) - Tier 1; QL; AL

estradiol oral (generic for ESTRACE) - Tier 1; QL

estradiol transdermal patch twice weekly (generic for DOTTI) - Tier 1;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

136

Preferred Agents Non-Preferred Agents

estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL

estradiol vaginal (generic for ESTRACE) - Tier 1; QL

estradiol valerate intramuscular (generic for DELESTROGEN) - Tier 1

estradiol-norethindrone acet (generic for AMABELZ) - Tier 1; QL

ESTRING - Tier 2; QL

ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL;

etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; AL

falmina (generic for AFIRMELLE) - Tier 1; QL; AL

finzala (generic for CHARLOTTE 24 FE) - Tier 1; QL; AL

fyavolv (generic for FYAVOLV) - Tier 1; QL

gemmily (generic for GEMMILY) - Tier 1; QL; AL

hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; AL

hailey 24 fe - Tier 1; QL; AL

hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; AL

hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; AL

haloette (generic for ELURYNG) - Tier 1; QL; AL

iclevia (generic for ICLEVIA) - Tier 1; QL; AL

introvale (generic for ICLEVIA) - Tier 1; QL; AL

isibloom - Tier 1; QL; AL

jaimiess (generic for ASHLYNA) - Tier 1; QL; AL

jasmiel (generic for JASMIEL) - Tier 1; QL; AL

jinteli (generic for FYAVOLV) - Tier 1; QL

jolessa (generic for ICLEVIA) - Tier 1; QL; AL

joyeaux (generic for JOYEAUX) - Tier 1; QL; AL

juleber - Tier 1; QL; AL

junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; AL

junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

137

Preferred Agents Non-Preferred Agents

junel fe (generic for AUROVELA FE 1.5/30) - Tier 1; QL; AL

kaitlib fe (generic for KAITLIB FE) - Tier 1; QL; AL

kalliga - Tier 1; QL; AL

kariva (generic for AZURETTE) - Tier 1; QL; AL

kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; AL

kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; AL

kurvelo (generic for ALTAVERA) - Tier 1; QL; AL

larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; AL

larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; AL

larin 24 fe - Tier 1; QL; AL

larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; AL

larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; AL

layolis fe (generic for KAITLIB FE) - Tier 1; QL; AL

leena - Tier 1; QL; AL

lessina (generic for AFIRMELLE) - Tier 1; QL; AL

levonest (generic for ENPRESSE-28) - Tier 1; QL; AL

levonorgest-eth est & eth est (generic for RIVELSA) - Tier 1; QL; AL

levonorgest-eth estrad 91-day (generic for ASHLYNA) - Tier 1; QL; AL

levonorgest-eth estradiol-iron (generic for JOYEAUX) - Tier 1; QL; AL

levonorgestrel-ethinyl estrad (generic for AFIRMELLE) - Tier 1; QL; AL

levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL;

levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; AL

LO LOESTRIN FE - Tier 2; QL; AL

LOESTRIN 1.5/30 (21) (brand for norethindrone acet-ethinyl est) - Tier

2; QL; AL

LOESTRIN 1/20 (21) (brand for norethindrone acet-ethinyl est) - Tier

2; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

138

Preferred Agents Non-Preferred Agents

LOESTRIN FE 1.5/30 (brand for norethin ace-eth estrad-fe) - Tier 2;

QL; AL

LOESTRIN FE 1/20 (brand for norethin ace-eth estrad-fe) - Tier 2; QL;

lojaimiess (generic for CAMRESE LO) - Tier 1; QL; AL

loryna (generic for JASMIEL) - Tier 1; QL; AL

low-ogestrel - Tier 1; QL; AL

lo-zumandimine (generic for JASMIEL) - Tier 1; QL; AL

lutera (generic for AFIRMELLE) - Tier 1; QL; AL

lyllana (generic for DOTTI) - Tier 1; QL

marlissa (generic for ALTAVERA) - Tier 1; QL; AL

MENEST - Tier 2; QL

merzee (generic for GEMMILY) - Tier 1; QL; AL

mibelas 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL; AL

microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; AL

microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; AL

microgestin 24 fe - Tier 1; QL; AL

microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL;

microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; AL

mili (generic for ESTARYLLA) - Tier 1; QL; AL

mimvey (generic for MIMVEY) - Tier 1; QL

mono-linyah (generic for ESTARYLLA) - Tier 1; QL; AL

NATAZIA - Tier 2; QL; AL

necon 0.5/35 (28) - Tier 1; QL; AL

nikki (generic for JASMIEL) - Tier 1; QL; AL

norelgestromin-eth estradiol (generic for XULANE) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

139

Preferred Agents Non-Preferred Agents

norethin ace-eth estrad-fe (generic for AUROVELA FE 1.5/30) - Tier 1;

QL; AL

norethindrone acet-ethinyl est (generic for AUROVELA 1.5/30) - Tier 1;

QL; AL

norethindrone-eth estradiol (generic for FYAVOLV) - Tier 1; QL

norethindron-ethinyl estrad-fe (generic for TILIA FE) - Tier 1; QL; AL

norethin-eth estradiol-fe (generic for KAITLIB FE) - Tier 1; QL; AL

norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; AL

norgestimate-ethinyl estradiol triphasic (generic for TRI-ESTARYLLA) -

Tier 1; QL; AL

nortrel 0.5/35 (28) - Tier 1; QL; AL

nortrel 1/35 (21) (generic for DASETTA 1/35) - Tier 1; QL; AL

nortrel 1/35 (28) (generic for DASETTA 1/35) - Tier 1; QL; AL

nortrel 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; AL

NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; QL; AL

nylia 1/35 (generic for DASETTA 1/35) - Tier 1; QL; AL

nylia 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; AL

nymyo (generic for ESTARYLLA) - Tier 1; QL; AL

ocella (generic for OCELLA) - Tier 1; QL; AL

philith (generic for BALZIVA) - Tier 1; QL; AL

pimtrea (generic for AZURETTE) - Tier 1; QL; AL

portia-28 (generic for ALTAVERA) - Tier 1; QL; AL

PREMARIN ORAL - Tier 2; QL

PREMARIN VAGINAL - Tier 2; QL

PREMPHASE - Tier 2; QL

PREMPRO - Tier 2; QL

reclipsen - Tier 1; QL; AL

rivelsa (generic for RIVELSA) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

140

Preferred Agents Non-Preferred Agents

SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; QL; AL

setlakin (generic for ICLEVIA) - Tier 1; QL; AL

simliya (generic for AZURETTE) - Tier 1; QL; AL

simpesse (generic for ASHLYNA) - Tier 1; QL; AL

sprintec 28 (generic for ESTARYLLA) - Tier 1; QL; AL

sronyx (generic for AFIRMELLE) - Tier 1; QL; AL

syeda (generic for OCELLA) - Tier 1; QL; AL

tarina 24 fe - Tier 1; QL; AL

tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; AL

taysofy (generic for GEMMILY) - Tier 1; QL; AL

TAYTULLA (brand for norethin ace-eth estrad-fe) - Tier 2; QL; AL

tilia fe (generic for TILIA FE) - Tier 1; QL; AL

tri-estarylla (generic for TRI-ESTARYLLA) - Tier 1; QL; AL

tri-legest fe (generic for TILIA FE) - Tier 1; QL; AL

tri-linyah (generic for TRI-ESTARYLLA) - Tier 1; QL; AL

tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; AL

tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; AL

tri-lo-mili (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; AL

tri-lo-sprintec (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; AL

tri-mili (generic for TRI-ESTARYLLA) - Tier 1; QL; AL

tri-nymyo (generic for TRI-ESTARYLLA) - Tier 1; QL; AL

tri-sprintec (generic for TRI-ESTARYLLA) - Tier 1; QL; AL

trivora (28) (generic for ENPRESSE-28) - Tier 1; QL; AL

tri-vylibra (generic for TRI-ESTARYLLA) - Tier 1; QL; AL

tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; AL

turqoz - Tier 1; QL; AL

TYBLUME - Tier 2; QL; AL

tydemy (generic for TYDEMY) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

141

Preferred Agents Non-Preferred Agents

velivet - Tier 1; QL; AL

vestura (generic for JASMIEL) - Tier 1; QL; AL

vienva (generic for AFIRMELLE) - Tier 1; QL; AL

viorele (generic for AZURETTE) - Tier 1; QL; AL

volnea (generic for AZURETTE) - Tier 1; QL; AL

vyfemla (generic for BALZIVA) - Tier 1; QL; AL

vylibra (generic for ESTARYLLA) - Tier 1; QL; AL

wera - Tier 1; QL; AL

wymzya fe (generic for WYMZYA FE) - Tier 1; QL; AL

xulane (generic for XULANE) - Tier 1; QL; AL

YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2; QL; AL

YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2; QL; AL

yuvafem (generic for YUVAFEM) - Tier 1; QL

zafemy (generic for XULANE) - Tier 1; QL; AL

zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL; AL

zumandimine (generic for OCELLA) - Tier 1; QL; AL

Progestins

camila (generic for CAMILA) - Tier 1; QL; AL

deblitane (generic for CAMILA) - Tier 1; QL; AL

DEPO-PROVERA (brand for medroxyprogesterone acetate) - Tier 2;

QL; AL

DEPO-SUBQ PROVERA 104 - Tier 2; QL; AL

ELLA - Tier 2; QL; AL

emzahh (generic for CAMILA) - Tier 1; QL; AL

errin (generic for CAMILA) - Tier 1; QL; AL

heather (generic for CAMILA) - Tier 1; QL; AL

incassia (generic for CAMILA) - Tier 1; QL; AL

jencycla (generic for CAMILA) - Tier 1; QL; AL

KYLEENA - Tier 2; QL; AL

LILETTA (52 MG) - Tier 2; QL; AL

lyleq (generic for CAMILA) - Tier 1; QL; AL

CRINONE - Tier 2; PA

PROMETRIUM (brand for progesterone) - Tier 2; PA; QL

PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

142

Preferred Agents Non-Preferred Agents

lyza (generic for CAMILA) - Tier 1; QL; AL

medroxyprogesterone acetate intramuscular (generic for DEPO-

PROVERA) - Tier 1; QL; AL

medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1;

megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml - Tier 1; QL

megestrol acetate oral tablet 20 mg - Tier 1

megestrol acetate oral tablet 40 mg - Tier 1; QL

MIRENA (52 MG) - Tier 2; QL; AL

NEXPLANON - Tier 2; QL; AL

nora-be (generic for CAMILA) - Tier 1; QL; AL

norethindrone acetate oral - Tier 1; QL

norethindrone oral (generic for CAMILA) - Tier 1; QL; AL

norlyroc (generic for CAMILA) - Tier 1; QL; AL

progesterone intramuscular - Tier 1

progesterone oral (generic for PROMETRIUM) - Tier 1; QL

sharobel (generic for CAMILA) - Tier 1; QL; AL

SKYLA - Tier 2; QL; AL

SLYND - Tier 2; QL

Selective Estrogen Receptor Modifying Agents

raloxifene hcl (generic for EVISTA) - Tier 1; QL EVISTA (brand for raloxifene hcl) - Tier 2; PA; QL

OSPHENA - Tier 2; PA; QL; GE

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers) - Drugs to Regulate Hormones

Estrogens - Hormone Replacement/Modifying Drugs

COVARYX (brand for est estrogens-methyltest) - Tier 2; QL

COVARYX HS (brand for est estrogens-methyltest hs) - Tier 2; QL

EEMT (brand for est estrogens-methyltest) - Tier 2; QL

est estrogens-methyltest (generic for COVARYX) - Tier 1; QL

est estrogens-methyltest ds (generic for COVARYX) - Tier 1; QL

est estrogens-methyltest hs (generic for COVARYX HS) - Tier 1; QL

TWIRLA - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

143

Preferred Agents Non-Preferred Agents

Progestins - Hormone Replacement/Modifying Drugs

aftera (generic for AFTERA) - Tier 1; QL; AL

curae (generic for AFTERA) - Tier 1; QL; AL

econtra one-step (generic for AFTERA) - Tier 1; QL; AL

her style (generic for AFTERA) - Tier 1; QL; AL

levonorgestrel (generic for AFTERA) - Tier 1; QL; AL

my choice (generic for AFTERA) - Tier 1; QL; AL

my way (generic for AFTERA) - Tier 1; QL; AL

new day (generic for AFTERA) - Tier 1; QL; AL

opcicon one-step (generic for AFTERA) - Tier 1; QL; AL

option 2 (generic for AFTERA) - Tier 1; QL; AL

PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; AL

react (generic for AFTERA) - Tier 1; QL; AL

take action (generic for AFTERA) - Tier 1; QL; AL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

euthyrox (generic for EUTHYROX) - Tier 1; QL

levo-t (generic for EUTHYROX) - Tier 1; QL

levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL

levoxyl (generic for EUTHYROX) - Tier 1; QL

liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL

unithroid (generic for EUTHYROX) - Tier 1; QL

CYTOMEL (brand for liothyronine sodium) - Tier 2; PA*; QL

ERMEZA - Tier 2; PA*; QL

LEVOTHYROXINE SODIUM ORAL CAPSULE (brand for levothyroxine

sodium) - Tier 2; PA*; QL

SYNTHROID (brand for levothyroxine sodium) - Tier 2; PA; QL

THYQUIDITY - Tier 2; PA*; QL

TIROSINT (brand for levothyroxine sodium) - Tier 2; PA*; QL

TIROSINT-SOL - Tier 2; PA*; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) -

Drugs to Replace Thyroid Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) -

Thyroid Replacement Drugs

ADTHYZA (brand for thyroid) - Tier 2; QL

ARMOUR THYROID (brand for thyroid) - Tier 2; QL

NIVA THYROID (brand for thyroid) - Tier 2; QL

np thyroid (generic for NP THYROID) - Tier 1; QL

thyroid oral (generic for NP THYROID) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

144

Preferred Agents Non-Preferred Agents

Hormonal Agents, Suppressant (Adrenal)

LYSODREN - Tier 2; PA; QL

Hormonal Agents, Suppressant (Pituitary)

cabergoline - Tier 1; QL

ELIGARD - Tier 2; PA; SP; QL

FENSOLVI (6 MONTH) - Tier 2; PA; SP

LEUPROLIDE ACETATE (3 MONTH) - Tier 2; PA; SP; QL

leuprolide acetate injection - Tier 1; PA; SP; QL

LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL

LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2;

PA; SP; QL

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2;

PA; SP; QL

LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL

LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL

LUPRON DEPOT-PED (6-MONTH) - Tier 2; PA; SP; QL

SANDOSTATIN (brand for octreotide acetate) - Tier 2; PA; SP; QL

TRIPTODUR - Tier 2; PA; SP; QL

MYCAPSSA - Tier 2; PA; SP; QL

octreotide acetate (generic for SANDOSTATIN) - Tier 1; PA; SP; QL

ORIAHNN - Tier 2; PA; QL

ORILISSA - Tier 2; PA

SIGNIFOR - Tier 2; PA; SP; QL

SOMAVERT - Tier 2; PA; SP; QL

SUPPRELIN LA - Tier 2; PA

SYNAREL - Tier 2; PA

TRELSTAR MIXJECT - Tier 2; PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents

methimazole oral - Tier 1; QL

propylthiouracil oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

145

Preferred Agents Non-Preferred Agents

Immune Suppressants - Immune System Drugs

Immunological Agents - Drugs that Stimulate or Suppress the

Immune System

LUPKYNIS - Tier 2; PA; SP; QL

Immunological Agents

Immunoglobulins

GAMUNEX-C INJECTION SOLUTION 40 GM/400ML - Tier 2; PA

HYPERRAB INJECTION SOLUTION 900 UNIT/3ML - Tier 2; PA

Immunological Agents, Other

BENLYSTA INTRAVENOUS - Tier 2; PA; QL

BENLYSTA SUBCUTANEOUS - Tier 2; PA; SP; QL

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR - Tier 2;

PA; SP; QL

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

200 MG/1.14ML - Tier 2; PA; SP; QL

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

300 MG/2ML - Tier 2; PA; SP; QL; AL

GRASTEK - Tier 2; PA; QL

ODACTRA - Tier 2; PA; QL

ORALAIR - Tier 2; PA; QL; AL

ORALAIR ADULT STARTER PACK - Tier 2; PA; QL; AL

ORALAIR CHILDRENS STARTER PACK - Tier 2; PA; QL; AL

RAGWITEK - Tier 2; PA; QL

ACTEMRA - Tier 2; PA*; SP; QL

ACTEMRA ACTPEN - Tier 2; PA*; SP; QL

ADBRY - Tier 2; PA; SP; QL

ARCALYST - Tier 2; PA*; SP; QL

COSENTYX INTRAVENOUS SOLUTION 125 MG/5ML - Tier 2; PA

COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150

MG/ML - Tier 2; PA*; SP; QL

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150

MG/ML, 75 MG/0.5ML - Tier 2; PA*; SP; QL

COSENTYX UNOREADY - Tier 2; PA*; QL

ENTYVIO INTRAVENOUS - Tier 2; PA*; SP; QL

ENTYVIO SUBCUTANEOUS - Tier 2; PA*

ILARIS - Tier 2; PA*; SP; QL

ILUMYA - Tier 2; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

146

Preferred Agents Non-Preferred Agents

RIDAURA - Tier 2; QL

SYNAGIS - Tier 2; PA; SP; QL

XOLAIR - Tier 2; PA; SP; QL

KEVZARA - Tier 2; PA*; SP; QL

KINERET - Tier 2; PA*; SP; QL

OLUMIANT ORAL TABLET 1 MG, 2 MG - Tier 2; PA*; SP; QL

OLUMIANT ORAL TABLET 4 MG - Tier 2; PA*

ORENCIA - Tier 2; PA*; SP; QL

ORENCIA CLICKJECT - Tier 2; PA*; SP; QL

OTEZLA - Tier 2; PA*; SP; QL

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 15 MG, 45

MG - Tier 2; PA*; SP; QL

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR 30 MG - Tier

2; PA*; SP

SILIQ - Tier 2; PA*; SP; QL

SKYRIZI PEN - Tier 2; PA*; SP; QL

SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;

PA*; SP; QL

STELARA - Tier 2; PA*; SP; QL

TALTZ - Tier 2; PA*; SP; QL

TREMFYA - Tier 2; PA*; SP; QL

XELJANZ - Tier 2; PA*; SP; QL

XELJANZ XR - Tier 2; PA*; SP; QL

Immunostimulants

PEGASYS - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

147

Preferred Agents Non-Preferred Agents

Immunosuppressants

azathioprine oral tablet 50 mg (generic for IMURAN) - Tier 1; QL

CELLCEPT ORAL SUSPENSION RECONSTITUTED (brand for

mycophenolate mofetil) - Tier 2; QL

cyclosporine modified oral capsule 100 mg, 25 mg (generic for

GENGRAF) - Tier 1; QL

cyclosporine modified oral solution (generic for GENGRAF) - Tier 1;

cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML - Tier 2; PA;

SP; QL

ENBREL SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;

PA; Sureclick Preferred, Mini Non-Preferred; SP; QL

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier

2; PA; SP; QL

ARAVA (brand for leflunomide) - Tier 2; PA; QL

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5

MG, 1 MG - Tier 2; PA; QL

ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG

- Tier 2; PA

AVSOLA - Tier 2; PA*

AZASAN (brand for azathioprine) - Tier 2; PA

azathioprine oral tablet 100 mg, 75 mg (generic for AZASAN) - Tier 1; PA

CELLCEPT ORAL CAPSULE (brand for mycophenolate mofetil) - Tier 2;

PA; QL

CELLCEPT ORAL TABLET (brand for mycophenolate mofetil) - Tier 2;

PA; QL

CIMZIA VIAL KIT - Tier 2; PA*; SP; QL

gengraf (generic for GENGRAF) - Tier 1; QL

HUMIRA (2 PEN) PEN-INJECTOR KIT 80 MG/0.8ML

SUBCUTANEOUS - Tier 2; PA; SP; QL

HUMIRA (2 PEN) SUBCUTANEOUS PEN-INJECTOR KIT 40

MG/0.4ML - Tier 2; PA; SP; QL

HUMIRA (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT

10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML - Tier 2; PA; SP; QL

HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML, 80

MG/0.8ML - Tier 2; PA; SP; QL

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML

- Tier 2; PA; SP; QL

HUMIRA-PED<40KG CROHNS STARTER - Tier 2; PA; SP; QL

HUMIRA-PED>/=40KG CROHNS START - Tier 2; PA; SP; QL

HUMIRA-PED>/=40KG UC STARTER - Tier 2; PA; SP; QL

CIMZIA SUBCUTANEOUS PREFILLED SYRINGE KIT 2 X 200 MG/ML, 6

X 200 MG/ML - Tier 2; PA*; SP; QL

cyclosporine modified oral capsule 50 mg - Tier 1; PA

ENBREL SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; PA;

Sureclick Preferred, Mini Non-Preferred; SP; QL

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 0.75

MG, 1 MG - Tier 2; PA; QL

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR 4 MG -

Tier 2; PA

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (generic for

ZORTRESS) - Tier 1; PA*

IMURAN (brand for azathioprine) - Tier 2; PA; QL

INFLECTRA - Tier 2; PA*; SP; QL

INFLIXIMAB (brand for infliximab) - Tier 2; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

148

Preferred Agents Non-Preferred Agents

HUMIRA-PSORIASIS/UVEIT STARTER - Tier 2; PA; SP; QL

leflunomide oral (generic for ARAVA) - Tier 1; QL

methotrexate sodium - Tier 1

methotrexate sodium (pf) - Tier 1

mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL

PROGRAF INTRAVENOUS - Tier 2; PA

RAPAMUNE ORAL SOLUTION (brand for sirolimus) - Tier 2; PA

RAPAMUNE ORAL TABLET 0.5 MG (brand for sirolimus) - Tier 2; QL

RAPAMUNE ORAL TABLET 1 MG, 2 MG (brand for sirolimus) - Tier 2

RASUVO - Tier 2; PA; QL

sirolimus oral solution (generic for RAPAMUNE) - Tier 1; PA

sirolimus oral tablet 0.5 mg (generic for RAPAMUNE) - Tier 1; QL

sirolimus oral tablet 1 mg, 2 mg (generic for RAPAMUNE) - Tier 1

tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1

JYLAMVO - Tier 2; PA

mycophenolate sodium (generic for MYFORTIC) - Tier 1; PA; QL

mycophenolic acid (generic for MYFORTIC) - Tier 1; PA; QL

MYFORTIC (brand for mycophenolate sodium) - Tier 2; PA; QL

NEORAL (brand for cyclosporine modified) - Tier 2; PA; QL

OTREXUP - Tier 2; PA; QL

PROGRAF ORAL CAPSULE 0.5 MG, 5 MG (brand for tacrolimus) - Tier

2; PA

PROGRAF ORAL CAPSULE 1 MG (brand for tacrolimus) - Tier 2; PA; QL

PROGRAF ORAL PACKET - Tier 2; PA

REMICADE (brand for infliximab) - Tier 2; PA*; SP; QL

RENFLEXIS - Tier 2; PA*; SP; QL

SANDIMMUNE ORAL (brand for cyclosporine) - Tier 2; PA; QL

SIMPONI - Tier 2; PA*; SP; QL

tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QL

TREXALL - Tier 2

XATMEP - Tier 2; QL

SIMPONI ARIA - Tier 2; PA*; SP; QL

ZORTRESS (brand for everolimus) - Tier 2; PA

ZYMFENTRA (1 PEN) - Tier 2; PA; SP

ZYMFENTRA (2 PEN) - Tier 2; PA; SP

ZYMFENTRA (2 SYRINGE) - Tier 2; PA; SP; QL

Vaccines

ACTHIB - Tier 2; QL

ADACEL - Tier 2; QL

BEXSERO - Tier 2; QL

BOOSTRIX - Tier 2; QL

DAPTACEL - Tier 2; QL

ENGERIX-B - Tier 2; QL

GARDASIL 9 - Tier 2; QL

HAVRIX - Tier 2; QL

HIBERIX - Tier 2; QL

INFANRIX - Tier 2; QL

IPOL - Tier 2; QL

IXIARO - Tier 2

MENQUADFI - Tier 2; QL

MENVEO - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

149

Preferred Agents Non-Preferred Agents

M-M-R II - Tier 2; QL

PEDIARIX - Tier 2; QL

PEDVAX HIB - Tier 2; QL

PENTACEL - Tier 2; QL

PREHEVBRIO - Tier 2; QL

PRIORIX - Tier 2; QL

PROQUAD - Tier 2; QL

QUADRACEL INTRAMUSCULAR SUSPENSION - Tier 2; QL

RECOMBIVAX HB - Tier 2; QL

ROTATEQ - Tier 2; QL

SHINGRIX - Tier 2; QL; AL

STAMARIL - Tier 2

TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL

TENIVAC - Tier 2; QL

TETANUS-DIPHTHERIA TOXOIDS TD (brand for tetanus-diphtheria

toxoids td) - Tier 2; QL

TRUMENBA - Tier 2; QL

TWINRIX - Tier 2; QL

TYPHIM VI - Tier 2

VAQTA - Tier 2; QL

VARIVAX - Tier 2; QL

VAXNEUVANCE - Tier 2; QL

YF-VAX - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

150

Preferred Agents Non-Preferred Agents

Immunological Agents - Drugs that Stimulate or Suppress the

Immune System

Vaccines

AFLURIA QUADRIVALENT - Tier 2; QL

BIOTHRAX - Tier 2

DENGVAXIA - Tier 2; QL

FLUAD QUADRIVALENT - Tier 2; QL

FLUARIX QUADRIVALENT - Tier 2; QL

FLUBLOK QUADRIVALENT - Tier 2; QL

FLUCELVAX QUADRIVALENT - Tier 2; QL

FLULAVAL QUADRIVALENT - Tier 2; QL

FLUMIST QUADRIVALENT - Tier 2; QL

FLUZONE HIGH-DOSE QUADRIVALENT - Tier 2; QL

FLUZONE QUADRIVALENT - Tier 2; QL

HEPLISAV-B - Tier 2; AL

HYPERTET - Tier 2; QL

NOVAVAX COVID-19 VACCINE - Tier 2; QL

PNEUMOVAX 23 - Tier 2; QL

PREVNAR 20 - Tier 2; QL

VAXCHORA - Tier 2

VIVOTIF - Tier 2

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

151

Preferred Agents Non-Preferred Agents

Inflammatory Bowel Disease Agents

Aminosalicylates

APRISO (brand for mesalamine er) - Tier 2; QL

balsalazide disodium (generic for COLAZAL) - Tier 1; QL

DELZICOL (brand for mesalamine) - Tier 2; QL

LIALDA (brand for mesalamine) - Tier 2; QL

mesalamine er (generic for APRISO) - Tier 1; QL

mesalamine oral capsule delayed release 400 mg (generic for

DELZICOL) - Tier 1; QL

mesalamine oral tablet delayed release 1.2 gm (generic for LIALDA) -

Tier 1; QL

mesalamine rectal (generic for CANASA) - Tier 1; QL

PENTASA (brand for mesalamine er) - Tier 2; QL

sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL

AZULFIDINE (brand for sulfasalazine) - Tier 2; PA; QL

AZULFIDINE EN-TABS (brand for sulfasalazine) - Tier 2; PA; QL

CANASA (brand for mesalamine) - Tier 2; PA; QL

COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL

DIPENTUM - Tier 2; PA*; QL

mesalamine oral tablet delayed release 800 mg - Tier 1; PA*; QL

mesalamine-cleanser (generic for ROWASA) - Tier 1; PA; QL

ROWASA (brand for mesalamine-cleanser) - Tier 2; PA; QL

SFROWASA - Tier 2; PA*; QL

Glucocorticoids

budesonide er (generic for UCERIS) - Tier 1; QL

budesonide oral - Tier 1; QL

EOHILIA - Tier 2; PA; QL

hydrocortisone (perianal) (generic for PREPARATION H) - Tier 1; QL

hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA)

- Tier 1

PREPARATION H EXTERNAL CREAM 1 % (brand for hydrocortisone

(perianal)) - Tier 2; QL

procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL

proctosol hc (generic for PROCTO-MED HC) - Tier 1; QL

proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL

TARPEYO - Tier 2; PA

UCERIS ORAL (brand for budesonide er) - Tier 2; QL

ANUSOL-HC EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2;

PA; QL

budesonide rectal foam 2 mg (generic for UCERIS) - Tier 1; PA*; QL

budesonide rectal foam 2 mg/act (generic for UCERIS) - Tier 1; PA; QL

CORTENEMA (brand for hydrocortisone) - Tier 2; PA

CORTIFOAM - Tier 2; PA*; QL

UCERIS RECTAL (brand for budesonide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

152

Preferred Agents Non-Preferred Agents

Metabolic Bone Disease Agents

alendronate sodium (generic for FOSAMAX) - Tier 1; QL

calcitonin (salmon) injection (generic for MIACALCIN) - Tier 1; PA; QL

calcitonin (salmon) nasal - Tier 1; QL

calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL

calcitriol oral solution (generic for ROCALTROL) - Tier 1; QL; AL

cinacalcet hcl (generic for SENSIPAR) - Tier 1; QL

ibandronate sodium oral - Tier 1; QL

teriparatide (generic for FORTEO) - Tier 1; PA; SP; QL; AL

teriparatide (recombinant) subcutaneous solution pen-injector 600

mcg/2.4ml (generic for FORTEO) - Tier 1; PA; SP; QL; AL

TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION

PEN-INJECTOR 620 MCG/2.48ML - Tier 2; PA; SP; QL; AL

XGEVA - Tier 2; PA

zoledronic acid intravenous concentrate - Tier 1; PA; QL

ACTONEL (brand for risedronate sodium) - Tier 2; PA; QL

ATELVIA (brand for risedronate sodium) - Tier 2; PA; QL

BINOSTO - Tier 2; PA; QL

doxercalciferol oral - Tier 1; PA

EVENITY - Tier 2; PA; QL

FORTEO (brand for teriparatide) - Tier 2; PA; SP; QL; AL

FOSAMAX (brand for alendronate sodium) - Tier 2; PA; QL

FOSAMAX PLUS D - Tier 2; PA; QL

MIACALCIN (brand for calcitonin (salmon)) - Tier 2; PA; QL

paricalcitol oral (generic for ZEMPLAR) - Tier 1; PA

RAYALDEE - Tier 2; PA; QL

RECLAST (brand for zoledronic acid) - Tier 2; PA

risedronate sodium (generic for ACTONEL) - Tier 1; PA*; QL

ROCALTROL ORAL CAPSULE (brand for calcitriol) - Tier 2; PA; QL

zoledronic acid intravenous solution (generic for RECLAST) - Tier 1;

ROCALTROL ORAL SOLUTION (brand for calcitriol) - Tier 2; PA; QL; AL

SENSIPAR (brand for cinacalcet hcl) - Tier 2; PA; QL

TYMLOS - Tier 2; PA; SP; QL

ZEMPLAR ORAL (brand for paricalcitol) - Tier 2; PA

Miscellaneous Therapeutic Agents

ABRYSVO - Tier 2; AL

AKEEGA - Tier 2; PA; SP; QL; AL

ALCOHOL PREP PADS PAD , 70 % (brand for alcohol prep) - Tier 2;

ALCOHOL PREP PADS SHEET 70 % - Tier 2; QL

ALCOH-WIPE - Tier 2; QL

ALVAIZ - Tier 2; PA

antibiotic (generic for BACITRAYCIN PLUS) - Tier 1; QL

antibiotic external ointment 500 unit/gm - Tier 1

antifungal (tolnaftate) (generic for TINACTIN) - Tier 1; QL

antifungal tolnaftate (generic for TINACTIN) - Tier 1; QL

APHEXDA - Tier 2; PA

AREXVY - Tier 2; AL

aspirin adults (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

ABILIFY MYCITE MAINTENANCE KIT - Tier 2; PA

ABILIFY MYCITE STARTER KIT - Tier 2; PA

ABRILADA (1 PEN) - Tier 2; PA; SP; QL

ABRILADA (2 PEN) - Tier 2; PA; SP; QL

ABRILADA (2 SYRINGE) - Tier 2; PA; SP; QL

ABRILADA SUBCUTANEOUS AUTO-INJECTOR KIT 40 MG/0.8ML - Tier

2; PA; SP; QL

ABRILADA SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML,

40 MG/0.8ML - Tier 2; PA; SP; QL

ACCU-CHEK TENDER 1 INFUSION - Tier 2; PA

ACE AEROSOL CLOUD ENHANCER (brand for adult aerosol mask) -

Tier 2; PA; QL

ACTIFOAM COLLAGEN SPONGE - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

153

Preferred Agents Non-Preferred Agents

aspirin childrens (generic for BAYER LOW DOSE) - Tier 1; QL

aspirin ec oral tablet 325 mg (generic for MEDI-FIRST ASPIRIN) - Tier

1; QL

aspirin ec oral tablet delayed release 325 mg (generic for BAYER

ASPIRIN) - Tier 1; QL

aspirin ec oral tablet delayed release 81 mg (generic for BAYER

ASPIRIN EC LOW DOSE) - Tier 1; QL

aspirin oral tablet 325 mg (generic for MEDI-FIRST ASPIRIN) - Tier 1;

aspirin oral tablet chewable 81 mg (generic for BAYER LOW DOSE) -

Tier 1; QL

aspirin oral tablet delayed release 325 mg (generic for BAYER

ASPIRIN) - Tier 1; QL

ADALIMUMAB-AACF (2 PEN) (brand for adalimumab-aacf (2 pen)) - Tier

2; PA

ADALIMUMAB-AATY (1 PEN) SUBCUTANEOUS AUTO-INJECTOR KIT

40 MG/0.4ML (brand for adalimumab-aaty (1 pen)) - Tier 2; PA; SP

ADALIMUMAB-AATY (1 PEN) SUBCUTANEOUS AUTO-INJECTOR KIT

80 MG/0.8ML (brand for adalimumab-aaty (1 pen)) - Tier 2; PA

ADALIMUMAB-AATY (2 PEN) (brand for adalimumab-aaty (1 pen)) - Tier

2; PA; SP

ADALIMUMAB-AATY (2 SYRINGE) (brand for adalimumab-aaty (2

syringe)) - Tier 2; PA; SP; QL

ADALIMUMAB-ADAZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR

(brand for adalimumab-adaz) - Tier 2; PA; SP

ADALIMUMAB-ADAZ SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE (brand for adalimumab-adaz) - Tier 2; PA; SP; QL

aspirin oral tablet delayed release 81 mg (generic for BAYER ASPIRIN

EC LOW DOSE) - Tier 1; QL

ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for

aspirin) - Tier 2; QL

aspirin regimen (generic for BAYER ASPIRIN EC LOW DOSE) - Tier

1; QL

athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) -

Tier 1; QL

AUGTYRO - Tier 2; PA; SP; QL

AUM ALCOHOL PREP PADS (brand for alcohol prep) - Tier 2; QL

bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1; QL

bacitracin external ointment 500 unit/gm - Tier 1

bacitracin zinc external - Tier 1

bacitracin zinc first aid - Tier 1

ADALIMUMAB-ADBM (2 PEN) (brand for adalimumab-adbm (2 pen)) -

Tier 2; PA; SP

ADALIMUMAB-ADBM (2 SYRINGE) SUBCUTANEOUS PREFILLED

SYRINGE KIT 40 MG/0.4ML (brand for adalimumab-adbm (2 syringe)) -

Tier 2; PA; SP

ADALIMUMAB-ADBM (2 SYRINGE) SUBCUTANEOUS PREFILLED

SYRINGE KIT 40 MG/0.8ML (brand for adalimumab-adbm (2 syringe)) -

Tier 2; PA; SP; QL

ADALIMUMAB-ADBM SUBCUTANEOUS AUTO-INJECTOR KIT 40

MG/0.8ML (brand for adalimumab-adbm (2 pen)) - Tier 2; PA; SP

ADALIMUMAB-ADBM SUBCUTANEOUS PREFILLED SYRINGE KIT

(brand for adalimumab-adbm (2 syringe)) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

154

Preferred Agents Non-Preferred Agents

bacitracin zinc-aloe - Tier 1

BAYER ASPIRIN (brand for aspirin) - Tier 2; QL

BAYER LOW DOSE ORAL TABLET CHEWABLE (brand for aspirin) -

Tier 2; QL

BD ECLIPSE LUER-LOK NEEDLE (brand for carepoint poly hub

needle) - Tier 2; QL

BD ECLIPSE NEEDLE 21G X 1" , 21G X 1-1/2" , 23G X 1" , 25G X

5/8" , 27G X 1/2" (brand for carepoint poly hub needle) - Tier 2; QL

BD ECLIPSE NEEDLE 25G X 1-1/2" (brand for carepoint safety 1st

needle) - Tier 2; QL

BD SAFETYGLIDE NEEDLE 21G X 1" (brand for carepoint poly hub

needle) - Tier 2; QL

BD SAFETYGLIDE SHIELDED NEEDLE 21G X 1-1/2" (brand for

carepoint poly hub needle) - Tier 2; QL

ADALIMUMAB-ADBM(CD/UC/HS STRT) SUBCUTANEOUS AUTO-

INJECTOR KIT 40 MG/0.4ML (brand for adalimumab-adbm (2 pen)) - Tier

2; PA; SP

ADALIMUMAB-ADBM(PS/UV STARTER) SUBCUTANEOUS AUTO-

INJECTOR KIT 40 MG/0.4ML (brand for adalimumab-adbm (2 pen)) - Tier

2; PA; SP

ADALIMUMAB-FKJP (brand for adalimumab-fkjp) - Tier 2; PA

ADALIMUMAB-FKJP (2 SYRINGE) (brand for adalimumab-fkjp) - Tier 2;

ADALIMUMAB-RYVK (2 PEN) (brand for adalimumab-ryvk (2 pen)) - Tier

2; PA; SP; QL

ADULT AEROSOL MASK (brand for adult aerosol mask) - Tier 2; PA; QL

AEROCHAMBER HOLDING CHAMBER (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for

easy comfort insulin syringe) - Tier 2; QL

BD ULTRA-FINE PEN NEEDLES 31G X 5 MM (brand for aqinject pen

needle) - Tier 2; QL

BINAXNOW COVID-19 AG HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1; QL

bisacodyl laxative (generic for EX-LAX ULTRA) - Tier 1; QL

bisacodyl oral (generic for EX-LAX ULTRA) - Tier 1; QL

bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; QL

BREATHE COMFORT HUMIDIFIER (brand for breathe ease

humidifier) - Tier 2; QL

BREATHE EASE HUMIDIFIER (brand for breathe ease humidifier) -

Tier 2; QL

AEROCHAMBER PLS FLOVU MTHPIECE (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

AEROCHAMBER PLUS FLO-VU INTERM (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

AEROCHAMBER PLUS FLO-VU LARGE DEVICE (brand for breathe

comfort chamber/adult) - Tier 2; PA; QL

AEROCHAMBER PLUS FLO-VU MEDIUM DEVICE (brand for breathe

comfort chamber/adult) - Tier 2; PA; QL

AEROCHAMBER PLUS FLO-VU SMALL DEVICE (brand for breathe

comfort chamber/adult) - Tier 2; PA; QL

AEROECLIPSE EZ TWIST TUBING (brand for adult aerosol mask) - Tier

2; PA; QL

AEROECLIPSE MASK LARGE (brand for adult aerosol mask) - Tier 2;

PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

155

Preferred Agents Non-Preferred Agents

CALQUENCE - Tier 2; PA; SP

CAMCEVI - Tier 2; PA

CAMZYOS - Tier 2; PA

CANTHARIDIN EXTERNAL (brand for cantharidin) - Tier 2; PA; QL

CAREPOINT POLY HUB NEEDLE 20G X 1" , 21G X 1" , 22G X 1" ,

23G X 1" , 25G X 1" , 25G X 5/8" (brand for carepoint poly hub needle)

- Tier 2; QL

CAREPOINT POLY HUB NEEDLE 22G X 1-1/2" - Tier 2; QL

CAREPOINT SAFETY 1ST NEEDLE (brand for carepoint poly hub

needle) - Tier 2; QL

CARESTART COVID-19 HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

AEROECLIPSE MASK MEDIUM (brand for adult aerosol mask) - Tier 2;

PA; QL

AEROECLIPSE MASK SMALL (brand for adult aerosol mask) - Tier 2;

PA; QL

AGAMREE - Tier 2; PA

AIRSUPRA AEROSOL 90-80 MCG/ACT INHALATION - Tier 2; PA*; QL

AIRSUPRA AEROSOL 90-80 MCG/ACT INHALATION - Tier 2; PA; QL

AMJEVITA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40

MG/0.4ML, 80 MG/0.8ML - Tier 2; PA

AMJEVITA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40

MG/0.8ML - Tier 2; PA; SP; QL

AMJEVITA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40

MG/0.4ML - Tier 2; PA; SP

CARETOUCH HYPODERMIC NEEDLE 20G X 1" , 22G X 1" , 23G X

1" , 25G X 1" , 25G X 5/8" (brand for carepoint poly hub needle) - Tier

2; QL

CARETOUCH HYPODERMIC NEEDLE 23G X 1-1/2" , 25G X 1-1/2"

(brand for carepoint safety 1st needle) - Tier 2; QL

CARETOUCH HYPODERMIC NEEDLE 27G X 1-1/2" (brand for

hypodermic needle) - Tier 2; QL

CAYA - Tier 2; QL

childrens aspirin oral tablet chewable 81 mg (generic for BAYER LOW

DOSE) - Tier 1; QL

c-lax laxative (generic for EX-LAX ULTRA) - Tier 1; QL

CLEARDETECT COVID-19 AG HOME (brand for covid-19 at home

antigen test) - Tier 2; QL

AMJEVITA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40

MG/0.8ML - Tier 2; PA; SP; QL

AMJEVITA-PED 10KG TO <15KG - Tier 2; PA; SP; QL

AMJEVITA-PED 15KG TO <30KG SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 20 MG/0.2ML - Tier 2; PA; SP

AMJEVITA-PED 15KG TO <30KG SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 20 MG/0.4ML - Tier 2; PA; SP; QL

ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; PA; QL

AQ INSULIN SYRINGE (brand for aq insulin syringe) - Tier 2; PA; QL

AQINJECT PEN NEEDLE 31G X 5 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

ASPARTAME (FOR COMPOUNDING) (brand for aspartame (for

compounding)) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

156

Preferred Agents Non-Preferred Agents

CLINITEST RAPID COVID-19 TEST KIT IN VITRO (brand for covid-19

at home antigen test) - Tier 2

CLINITEST RAPID COVID-19 TEST KIT IN VITRO (brand for covid-19

at home antigen test) - Tier 2; QL

COMIRNATY - Tier 2; QL

COOL MIST HUMIDIFER (brand for breathe ease humidifier) - Tier 2;

COVID-19 AT HOME ANTIGEN TEST (brand for covid-19 at home

antigen test) - Tier 2

COVID-19 AT HOME TEST KIT (brand for covid-19 at home antigen

test) - Tier 2

COVID-19 AT-HOME TEST KIT IN VITRO (brand for covid-19 at home

antigen test) - Tier 2

ASPARTAME (NUTRASWEET) (brand for aspartame (for compounding))

- Tier 2; PA

ASSURE ID DUO PRO PEN NEEDLES (brand for aqinject pen needle) -

Tier 2; PA; QL

ASSURE ID PRO PEN NEEDLES (brand for pen needles) - Tier 2; PA

AUM INSULIN SAFETY PEN NEEDLE 31G X 4 MM (brand for aum

insulin safety pen needle) - Tier 2; PA

AUM INSULIN SAFETY PEN NEEDLE 31G X 5 MM (brand for aqinject

pen needle) - Tier 2; PA; QL

AUM MINI INSULIN PEN NEEDLE 32G X 8 MM , 33G X 4 MM , 33G X 5

MM , 33G X 6 MM (brand for aum mini insulin pen needle) - Tier 2; PA

AUM PEN NEEDLE 33G X 4 MM , 33G X 5 MM , 33G X 6 MM (brand for

aum mini insulin pen needle) - Tier 2; PA

COVID-19 AT-HOME TEST KIT IN VITRO (brand for covid-19 at home

antigen test) - Tier 2; QL

COVID-19 SPECIMEN COLLECTION - Tier 2; QL

darunavir (generic for PREZISTA) - Tier 1; QL

DEXCOM G6 TRANSMITTER - Tier 2; PA; QL

DIATRUST COVID-19 HOME TEST (brand for covid-19 at home

antigen test) - Tier 2

double antibiotic external ointment 500-10000 unit/gm (generic for

NEOSPORIN) - Tier 1

DROPSAFE ALCOHOL PREP (brand for alcohol prep) - Tier 2; QL

DROPSAFE SICURA (brand for carepoint poly hub needle) - Tier 2;

EASIVENT (brand for breathe comfort chamber/adult) - Tier 2; QL

AUM SAFETY PEN NEEDLE 31G X 4 MM (brand for aum insulin safety

pen needle) - Tier 2; PA

AUM SAFETY PEN NEEDLE 31G X 5 MM (brand for aqinject pen needle)

- Tier 2; PA; QL

AUVELITY - Tier 2; PA; QL

AVITENE - Tier 2; PA

AVITENE FLOUR - Tier 2; PA

BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier 2;

BD ULTRA-FINE INSULIN SYRINGES (brand for careone insulin syringe)

- Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 0.5 ML (brand for true

comfort insulin syringe) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

157

Preferred Agents Non-Preferred Agents

EASIVENT MASK LARGE (brand for breathe comfort chamber/adult) -

Tier 2; QL

EASIVENT MASK MEDIUM (brand for breathe comfort chamber/adult)

- Tier 2; QL

EASIVENT MASK SMALL (brand for breathe comfort chamber/adult) -

Tier 2; QL

ELLUME COVID-19 HOME TEST (brand for covid-19 at home antigen

test) - Tier 2; QL

enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL

EX-LAX ULTRA (brand for bisacodyl) - Tier 2; QL

fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL

FASTEP COVID-19 ANTIGEN TEST (brand for covid-19 at home

antigen test) - Tier 2

FC2 FEMALE CONDOM - Tier 2; QL

BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 1 ML, 31G X 5/16" 0.5

ML (brand for insulin syringe-needle u-100) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES (brand for techlite insulin syringe)

- Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 31G X 15/64" 0.5 ML, 31G X

15/64" 1 ML (brand for global easy glide insulin syr) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for

easy comfort insulin syringe) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 31G X 5/16" 1 ML (brand for aq

insulin syringe) - Tier 2; PA; QL

BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM (brand for sure comfort

pen needles) - Tier 2; PA; QL

BD ULTRA-FINE PEN NEEDLES 31G X 8 MM (brand for gnp ulticare pen

needles) - Tier 2; PA; QL

FLOW-EZE VENTED NEEDLE - Tier 2; QL

FLOWFLEX COVID-19 AG HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

folic acid injection solution 5 mg/ml - Tier 1; PA; QL

folic acid oral tablet 1 mg - Tier 1; QL

folic acid oral tablet 800 mcg - Tier 1

FRUZAQLA - Tier 2; PA

ft antibiotic - Tier 1

ft antifungal external cream 1 % (generic for TINACTIN) - Tier 1; QL

ft aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

ft aspirin low dose (generic for BAYER ASPIRIN EC LOW DOSE) -

Tier 1; QL

ft double antibiotic (generic for NEOSPORIN) - Tier 1

ft enteric coated aspirin (generic for BAYER ASPIRIN) - Tier 1; QL

BENZOYL PEROXIDE EXTERNAL GEL 8 % - Tier 2; PA

BIGFOOT UNITY PROGRAM (brand for diabetes monitor digit add-on) -

Tier 2; PA

BILAYER MATRIX WOUND DRESSING - Tier 2; PA

BIMZELX - Tier 2; PA; SP; QL

BLUESTAR - Tier 2; PA

BREATHE COMFORT CHAMBER/ADULT (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

BREATHE COMFORT CHAMBER/CHILD (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

BREATHE EASE NEB MASK/CHILD (brand for adult aerosol mask) - Tier

2; PA; QL

BREATHE EASE NEB MASK/INFANT (brand for adult aerosol mask) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

158

Preferred Agents Non-Preferred Agents

ft gentle laxative (generic for THE MAGIC BULLET) - Tier 1; QL

ft laxative (generic for EX-LAX ULTRA) - Tier 1; QL

fungi-guard (generic for TINACTIN) - Tier 1; QL

gentle laxative (generic for EX-LAX ULTRA) - Tier 1; QL

gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1; QL

genuine aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1;

heparin na (pork) lock flsh pf intravenous solution 10 unit/ml, 100

unit/ml (generic for BD HEPARIN POSIFLUSH) - Tier 1; PA

heparin sod (pork) lock flush - Tier 1; PA

HEPMED - Tier 2; PA; QL

HYFTOR - Tier 2; PA; QL

hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL

BREXAFEMME - Tier 2; PA; QL

BRIUMVI - Tier 2; PA

BUBBLES THE FISH II PEDI MASK (brand for adult aerosol mask) - Tier

2; PA; QL

CARETOUCH 2 CPAP HOSE HANGER (brand for adult aerosol mask) -

Tier 2; PA; QL

CARETOUCH CPAP & BIPAP HOSE (brand for adult aerosol mask) -

Tier 2; PA; QL

CARETOUCH CPAP MASK WIPES (brand for adult aerosol mask) - Tier

2; PA; QL

CARETOUCH CPAP PRE-WASH SOLN (brand for adult aerosol mask) -

Tier 2; PA; QL

CARETOUCH CPAP TUBE BRUSH (brand for adult aerosol mask) - Tier

2; PA; QL

hyoscyamine sulfate oral elixir - Tier 1; QL

hyoscyamine sulfate oral solution - Tier 1; QL

hyoscyamine sulfate oral tablet (generic for LEVSIN) - Tier 1; QL

hyoscyamine sulfate sl sublingual tablet sublingual 0.125 mg (generic

for LEVSIN/SL) - Tier 1; QL

hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL

hyoscyamine sulfate tablet dispersible 0.125 mg oral (generic for

ANASPAZ) - Tier 1; QL

hyosyne - Tier 1; QL

IHEALTH COVID-19 RAPID TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

INDICAID COVID-19 RAPID TEST (brand for covid-19 at home

antigen test) - Tier 2

INSPIREASE (brand for breathe comfort chamber/adult) - Tier 2; QL

CARETOUCH UNIVERSL CPAP FILTER (brand for adult aerosol mask) -

Tier 2; PA; QL

CEQUR SIMPLICITY 2U 10PK (brand for autopen) - Tier 2; PA

COMFORT EZ PRO PEN NEEDLES 31G X 4 MM (brand for aum insulin

safety pen needle) - Tier 2; PA

COMFORT EZ PRO PEN NEEDLES 31G X 5 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

CONDOMS - Tier 2; PA

CONTOUR CONTROL SOLUTION (brand for control) - Tier 2; PA; QL

CUVRIOR - Tier 2; PA; SP; QL

CYLTEZO (2 PEN) (brand for adalimumab-adbm (2 pen)) - Tier 2; PA; SP

CYLTEZO (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT

10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.8ML (brand for adalimumab-adbm

(2 syringe)) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

159

Preferred Agents Non-Preferred Agents

INSPIREASE RESERVOIR BAGS - Tier 2; QL

INTELISWAB COVID-19 RAPID TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

IWILFIN - Tier 2; PA; SP; QL

JAYPIRCA - Tier 2; PA; SP; QL

JESDUVROQ - Tier 2; PA; SP; QL

KRAZATI - Tier 2; PA; SP; QL

LATANOPROST OIL - Tier 2; PA

laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA)

- Tier 1; QL

laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) -

Tier 1; QL

LYTGOBI (12 MG DAILY DOSE) - Tier 2; PA; SP; QL

LYTGOBI (16 MG DAILY DOSE) - Tier 2; PA; SP; QL

CYLTEZO (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT

40 MG/0.4ML (brand for adalimumab-adbm (2 syringe)) - Tier 2; PA; SP

CYLTEZO-CD/UC/HS STARTER (brand for adalimumab-adbm (2 pen)) -

Tier 2; PA; SP

CYLTEZO-PSORIASIS/UV STARTER (brand for adalimumab-adbm (2

pen)) - Tier 2; PA; SP

DEPLIN 15 (brand for l-methylfolate forte) - Tier 2; PA

DEPLIN 7.5 (brand for l-methylfolate forte) - Tier 2; PA

DIABETES MONITOR DIGIT ADD-ON (brand for diabetes monitor digit

add-on) - Tier 2; PA

DIABETES MONITOR DIGIT SOLN (brand for diabetes monitor digit add-

on) - Tier 2; PA

DROPLET MICRON - Tier 2; PA

LYTGOBI (20 MG DAILY DOSE) - Tier 2; PA; SP; QL

MASK VORTEX/CHILD/FROG - Tier 2; QL

MASK VORTEX/TODDLER/LADYBUG - Tier 2; QL

medi-first aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

medique aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

mm aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL

MODERNA COVID-19 VAC 6M-11Y - Tier 2; QL

NEODOT THERMOMETER - Tier 2; QL

NULEV (brand for hyoscyamine sulfate) - Tier 2; QL

OGSIVEO ORAL TABLET 100 MG, 150 MG - Tier 2; PA

OGSIVEO ORAL TABLET 50 MG - Tier 2; PA; SP; QL

OJEMDA ORAL SUSPENSION RECONSTITUTED - Tier 2; PA; SP;

OJEMDA ORAL TABLET - Tier 2; PA; SP

DROPSAFE SAFETY SYRINGE/NEEDLE (brand for aq insulin syringe) -

Tier 2; PA; QL

DUREX EXTRA SENSITIVE THIN (brand for true cover) - Tier 2; PA

DUROLANE - Tier 2; PA

EASYMAX CONTROL (brand for control) - Tier 2; PA; QL

EBASE CONTROLLER KIT (brand for adult aerosol mask) - Tier 2; PA;

ELFABRIO - Tier 2; PA; SP

EMBRACE PEN NEEDLES 29G X 12MM (brand for raya sure pen

needle) - Tier 2; PA; QL

EMBRACE PEN NEEDLES 30G X 5 MM (brand for pen needles) - Tier 2;

EMBRACE PEN NEEDLES 31G X 5 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

160

Preferred Agents Non-Preferred Agents

OMNIFLEX DIAPHRAGM - Tier 2

ON/GO COVID-19 ANTIGEN TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

ON/GO ONE COVID-19 HOME TEST (brand for covid-19 at home

antigen test) - Tier 2

ONELAX (brand for bisacodyl) - Tier 2; QL

OPVEE - Tier 2; QL

ORSERDU - Tier 2; PA; SP; QL

OSCIMIN (brand for hyoscyamine sulfate) - Tier 2; QL

PALFORZIA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (120 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (160 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (200 MG DAILY DOSE) - Tier 2; PA; SP; QL

EMBRACE PEN NEEDLES 31G X 6 MM (brand for easy comfort pen

needles) - Tier 2; PA; QL

EMBRACE PEN NEEDLES 31G X 8 MM (brand for gnp ulticare pen

needles) - Tier 2; PA; QL

ENDO AVITENE - Tier 2; PA

ENTADFI - Tier 2; PA; QL; GE; AL

EVERSENSE E3 SMART TRANSMITTER - Tier 2; PA; QL

EVERSENSE SMART TRANSMITTER - Tier 2; PA; QL

FEMCAP - Tier 2; PA

FILTER AIR PP (brand for adult aerosol mask) - Tier 2; PA; QL

FLEXICHAMBER (brand for breathe comfort chamber/adult) - Tier 2; PA;

FLEXICHAMBER ADULT MASK/SMALL - Tier 2; PA; QL

FLEXICHAMBER CHILD MASK/LARGE - Tier 2; PA; QL

PALFORZIA (240 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (3 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (300 MG MAINTENANCE) - Tier 2; PA; SP; QL

PALFORZIA (300 MG TITRATION) - Tier 2; PA; SP; QL

PALFORZIA (40 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (6 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA (80 MG DAILY DOSE) - Tier 2; PA; SP; QL

PALFORZIA INITIAL ESCALATION - Tier 2; PA; SP; QL

PARAGARD INTRAUTERINE COPPER - Tier 2; QL; AL

PENBRAYA - Tier 2

PFIZER COVID-19 VAC-TRIS 5-11Y - Tier 2; QL

PFIZER COVID-19 VAC-TRIS 6M-4Y - Tier 2; QL

PILOT COVID-19 AT-HOME TEST (brand for covid-19 at home

antigen test) - Tier 2

FLEXICHAMBER CHILD MASK/SMALL - Tier 2; PA; QL

FORTISCARE CONTROL IN VITRO SOLUTION HIGH (brand for diatrue

control level 3) - Tier 2; PA; QL

FORTISCARE CONTROL IN VITRO SOLUTION LOW (brand for diatrue

control level 1) - Tier 2; PA; QL

FORTISCARE CONTROL IN VITRO SOLUTION NORMAL (brand for

control) - Tier 2; PA; QL

FRAICHE 5000 PREVI - Tier 2; PA

FYLNETRA - Tier 2; PA*; SP

GELFILM EXTERNAL - Tier 2; PA

GELFOAM - Tier 2; PA

GELFOAM COMPRESSED SIZE 100 - Tier 2; PA

GELFOAM DENTAL PACK SIZE 4 - Tier 2; PA

GELFOAM SPONGE SIZE 200 - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

161

Preferred Agents Non-Preferred Agents

poly bacitracin (generic for NEOSPORIN) - Tier 1

PREZISTA ORAL SUSPENSION - Tier 2; QL

PREZISTA ORAL TABLET 150 MG, 75 MG - Tier 2; QL

QUICKVUE AT-HOME COVID-19 TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

REZDIFFRA - Tier 2; PA; SP; QL

REZLIDHIA - Tier 2; PA; SP; QL

REZZAYO - Tier 2; PA

salicylic acid external foam (generic for SALVAX) - Tier 1

SALIMEZ (brand for salimez) - Tier 2

SALYCIM (brand for salimez) - Tier 2

sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1

SPEEDY SWAB COVID-19 ANTIGEN (brand for covid-19 at home

antigen test) - Tier 2

GELFOAM SPONGE SIZE 50 - Tier 2; PA

GELSYN-3 - Tier 2; PA

GENADUR COMBINATION - Tier 2; PA

GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION HIGH (brand

for diatrue control level 3) - Tier 2; PA; QL

GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION LOW (brand for

diatrue control level 1) - Tier 2; PA; QL

GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION NORMAL

(brand for control) - Tier 2; PA; QL

GUARDIAN 4 TRANSMITTER - Tier 2; PA; QL

GUARDIAN CONNECT TRANSMITTER - Tier 2; PA; QL

GUARDIAN LINK 3 TRANSMITTER - Tier 2; PA; QL

GUARDIAN REAL-TIME CHARGER (brand for oval tape) - Tier 2; PA; QL

SPEVIGO INTRAVENOUS - Tier 2; PA; SP

SPEVIGO SUBCUTANEOUS - Tier 2; PA

SPIKEVAX - Tier 2; QL

ST JOSEPH LOW DOSE (brand for aspirin) - Tier 2; QL

STRIVE DUAL ZONE PEAK FLOW MTR (brand for breathe ease peak

flow meter) - Tier 2; QL

sulfacetamide sodium external (generic for OVACE PLUS WASH) -

Tier 1

SUNLENCA ORAL - Tier 2; QL

the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL

tolnaftate antifungal external cream (generic for TINACTIN) - Tier 1;

tolnaftate external cream (generic for TINACTIN) - Tier 1; QL

true folic acid tablet 1 mg oral - Tier 1; QL

GUARDIAN REAL-TIME TEST PLUG (brand for oval tape) - Tier 2; PA;

HADLIMA - Tier 2; PA; SP; QL

HADLIMA PUSHTOUCH - Tier 2; PA; SP; QL

HULIO (2 PEN) (brand for adalimumab-fkjp) - Tier 2; PA

HULIO SUBCUTANEOUS PREFILLED SYRINGE KIT 20 MG/0.4ML, 40

MG/0.8ML (brand for adalimumab-fkjp) - Tier 2; PA

HUMATROPEN FOR 12MG (brand for inject-ease) - Tier 2; PA; QL

HUMATROPEN FOR 24MG (brand for inject-ease) - Tier 2; PA; QL

HUMATROPEN FOR 6MG (brand for inject-ease) - Tier 2; PA; QL

HYMOVIS - Tier 2; PA

hyoscyamine sulfate tablet dispersible 0.125 mg oral (generic for

ANASPAZ) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

162

Preferred Agents Non-Preferred Agents

TRUE FOLIC ACID TABLET 1 MG ORAL - Tier 2; QL

TRUQAP - Tier 2; PA

VAPORIZER WARM STEAM - Tier 2; QL

VAXELIS - Tier 2; QL

VEOZAH - Tier 2; PA; QL

VERSAPENN (AL) ANHYD LIPID - Tier 2; PA

VIVJOA - Tier 2; PA; QL

VOWST - Tier 2; QL

WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL

WIDE-SEAL DIAPHRAGM 65 - Tier 2; QL

WIDE-SEAL DIAPHRAGM 70 - Tier 2; QL

WIDE-SEAL DIAPHRAGM 75 - Tier 2; QL

WIDE-SEAL DIAPHRAGM 80 - Tier 2; QL

WIDE-SEAL DIAPHRAGM 85 - Tier 2; QL

HYRIMOZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40

MG/0.4ML (brand for adalimumab-adaz) - Tier 2; PA; SP

HYRIMOZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80

MG/0.8ML - Tier 2; PA; SP

HYRIMOZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10

MG/0.1 ML, 20 MG/0.2ML - Tier 2; PA; SP; QL

HYRIMOZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40

MG/0.4ML (brand for adalimumab-adaz) - Tier 2; PA; SP; QL

HYRIMOZ-CROHNS/UC STARTER - Tier 2; PA; SP

HYRIMOZ-PED<40KG CROHN STARTER - Tier 2; PA; SP; QL

HYRIMOZ-PED>/=40KG CROHN START - Tier 2; PA; SP; QL

HYRIMOZ-PLAQUE PSORIASIS START - Tier 2; PA; SP; QL

IDACIO (2 PEN) (brand for adalimumab-aacf (2 pen)) - Tier 2; PA

IDACIO (2 SYRINGE) - Tier 2; PA

WIDE-SEAL DIAPHRAGM 90 - Tier 2; QL

WIDE-SEAL DIAPHRAGM 95 - Tier 2; QL

womans laxative (generic for EX-LAX ULTRA) - Tier 1; QL

womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1; QL

womens laxative (generic for EX-LAX ULTRA) - Tier 1; QL

XDEMVY - Tier 2; QL

XPHOZAH - Tier 2; PA; SP; QL; AL

YCANTH (brand for cantharidin) - Tier 2; PA; QL

ZURZUVAE - Tier 2; PA; QL; AL

IDACIO-CROHNS/UC STARTER (brand for adalimumab-aacf (2 pen)) -

Tier 2; PA

IDACIO-PSORIASIS STARTER (brand for adalimumab-aacf (2 pen)) -

Tier 2; PA

INFINITY CONTROL IN VITRO SOLUTION HIGH (brand for diatrue

control level 3) - Tier 2; PA; QL

INFINITY CONTROL IN VITRO SOLUTION LOW (brand for diatrue

control level 1) - Tier 2; PA; QL

INPEFA ORAL TABLET 200 MG - Tier 2; PA; QL; AL

INPEFA ORAL TABLET 400 MG - Tier 2; PA

INPEN 100-BLUE-LILLY-HUMALOG (brand for autopen) - Tier 2; PA

INPEN 100-BLUE-NOVOLOG-FIASP (brand for autopen) - Tier 2; PA

INPEN 100-GREY-LILLY-HUMALOG (brand for autopen) - Tier 2; PA

INPEN 100-GREY-NOVOLOG-FIASP (brand for autopen) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

163

Preferred Agents Non-Preferred Agents

INPEN 100-PINK-LILLY-HUMALOG (brand for autopen) - Tier 2; PA

INPEN 100-PINK-NOVOLOG-FIASP (brand for autopen) - Tier 2; PA

INSULIN PEN NEEDLES 29G X 12.7MM (brand for sure comfort pen

needles) - Tier 2; PA; QL

INSULIN PEN NEEDLES 29G X 12MM (brand for raya sure pen needle) -

Tier 2; PA; QL

INSULIN PEN NEEDLES 29G X 5MM , 29G X 8MM - Tier 2; PA; QL

INSULIN PEN NEEDLES 30G X 5 MM (brand for pen needles) - Tier 2;

INSULIN PEN NEEDLES 31G X 4 MM (brand for aum insulin safety pen

needle) - Tier 2; PA

INSULIN PEN NEEDLES 31G X 5 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

INSULIN PEN NEEDLES 31G X 6 MM (brand for easy comfort pen

needles) - Tier 2; PA; QL

INSULIN PEN NEEDLES 31G X 8 MM (brand for gnp ulticare pen

needles) - Tier 2; PA; QL

INSULIN PEN NEEDLES 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G

X 6 MM (brand for aum mini insulin pen needle) - Tier 2; PA

INSULIN SYRINGES 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML, 28G X 1/2"

0.5 ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X

5/16" 0.5 ML (brand for insulin syringe-needle u-100) - Tier 2; PA; QL

INSULIN SYRINGES 28G X 5/16" 1 ML, 29G X 5/16" 1 ML, 31G X 1/2"

0.3 ML, 32G X 5/16" 1 ML - Tier 2; PA; QL

INSULIN SYRINGES 29G X 1/2" 0.3 ML (brand for eql insulin syringe) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

164

Preferred Agents Non-Preferred Agents

INSULIN SYRINGES 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 31G X 5/16"

1 ML (brand for aq insulin syringe) - Tier 2; PA; QL

INSULIN SYRINGES 30G X 1/2" 0.3 ML (brand for careone insulin

syringe) - Tier 2; PA; QL

INSULIN SYRINGES 30G X 1/2" 0.5 ML (brand for true comfort insulin

syringe) - Tier 2; PA; QL

INSULIN SYRINGES 30G X 5/16" 0.3 ML (brand for mm insulin

syringe/needle) - Tier 2; PA; QL

INSULIN SYRINGES 30G X 5/16" 1 ML (brand for ra insulin syringe) -

Tier 2; PA; QL

INSULIN SYRINGES 31G X 15/64" 0.3 ML (brand for techlite insulin

syringe) - Tier 2; PA; QL

INSULIN SYRINGES 31G X 15/64" 0.5 ML (brand for global easy glide

insulin syr) - Tier 2; PA; QL

INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for easy comfort insulin

syringe) - Tier 2; PA; QL

KERALYT EXTERNAL GEL 6 % (brand for salicylic acid) - Tier 2; PA; QL

L-CYSTINE - Tier 2; PA

LEVBID (brand for hyoscyamine sulfate er) - Tier 2; PA; QL

LEVSIN (brand for hyoscyamine sulfate) - Tier 2; PA; QL

LEVSIN/SL (brand for hyoscyamine sulfate) - Tier 2; PA; QL

LITFULO - Tier 2; PA

l-methylfolate forte (generic for DEPLIN 15) - Tier 1; PA

l-methylfolate-algae (generic for DEPLIN 15) - Tier 1; PA

LUCIRA COVID-19 & FLU TEST - Tier 2; PA

METOPIRONE - Tier 2; PA

MICROCHAMBER (brand for breathe comfort chamber/adult) - Tier 2; PA;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

165

Preferred Agents Non-Preferred Agents

MIEBO - Tier 2; PA*

MINILINK REAL-TIME TRANSMITTER - Tier 2; PA; QL

MINIMED 630G GUARDIAN PRESS - Tier 2; PA; QL

MIRO3D WOUND MATRIX - Tier 2; PA

MOUNJARO - Tier 2; PA; QL

NEBULIZER MASK ADULT (brand for adult aerosol mask) - Tier 2; PA;

NEBULIZER MASK CHILD (brand for adult aerosol mask) - Tier 2; PA;

NGENLA - Tier 2; PA*; AL

NORDIPEN 5 INJECTION DEVICE (brand for inject-ease) - Tier 2; PA;

NORDIPEN DELIVERY SYSTEM (brand for inject-ease) - Tier 2; PA; QL

NOVOPEN ECHO (brand for autopen) - Tier 2; PA

OJJAARA - Tier 2; PA; SP; QL

OMBRA COMPRESSOR AIR FILTERS (brand for adult aerosol mask) -

Tier 2; PA; QL

OMNIPOD 5 G6 INTRO (GEN 5) - Tier 2; PA; QL

OMNIPOD 5 G6 PODS (GEN 5) - Tier 2; PA; QL

OMVOH INTRAVENOUS - Tier 2; PA; SP

OMVOH SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA;

ONETOUCH VERIO IN VITRO LIQUID HIGH (brand for diatrue control

level 3) - Tier 2; PA; QL

OPILL - Tier 2; PA; QL; AL

OPSYNVI - Tier 2; PA; SP; QL

OVACE PLUS WASH EXTERNAL LIQUID (brand for sodium

sulfacetamide wash) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

166

Preferred Agents Non-Preferred Agents

OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2; PA

PARADIGM REAL-TIME TRANSMITTER - Tier 2; PA; QL

PARI ALTERA NEBULIZER HANDSET (brand for adult aerosol mask) -

Tier 2; PA; QL

PARI BABY CONVERSION KIT (brand for adult aerosol mask) - Tier 2;

PA; QL

PARI ERAPID NEBULIZER HANDSET (brand for adult aerosol mask) -

Tier 2; PA; QL

PARI SMARTMASK BABY/ELBOW (brand for adult aerosol mask) - Tier

2; PA; QL

PARI TREK S COMBO PACK (brand for adult mask) - Tier 2; PA

PARI VORTEX ADULT MASK - Tier 2; PA; QL

PREZISTA ORAL TABLET 600 MG, 800 MG (brand for darunavir) - Tier

2; PA; QL

PROCHAMBER VHC (brand for breathe comfort chamber/adult) - Tier 2;

PA; QL

PRONEB ULTRA FILTER SET (brand for adult aerosol mask) - Tier 2;

PA; QL

PURE COMFORT SAFETY PEN NEEDLE 31G X 5 MM (brand for

aqinject pen needle) - Tier 2; PA; QL

PURE COMFORT SAFETY PEN NEEDLE 31G X 6 MM (brand for easy

comfort pen needles) - Tier 2; PA; QL

QALSODY - Tier 2; PA

QUVIVIQ - Tier 2; PA; QL

RAYA SURE PEN NEEDLE 29G X 12MM (brand for raya sure pen

needle) - Tier 2; PA; QL

RAYA SURE PEN NEEDLE 31G X 4 MM (brand for aum insulin safety

pen needle) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

167

Preferred Agents Non-Preferred Agents

RAYA SURE PEN NEEDLE 31G X 5 MM (brand for aqinject pen needle) -

Tier 2; PA; QL

RAYA SURE PEN NEEDLE 31G X 6 MM (brand for easy comfort pen

needles) - Tier 2; PA; QL

RAYA SURE PEN NEEDLE 31G X 8 MM (brand for gnp ulticare pen

needles) - Tier 2; PA; QL

REPLACEMENT FILTERS (brand for adult aerosol mask) - Tier 2; PA; QL

REUSABLE COMFORTSEAL MASK-LRG (brand for adult aerosol mask)

- Tier 2; PA; QL

REUSABLE COMFORTSEAL MASK-MED (brand for adult aerosol mask)

- Tier 2; PA; QL

REUSABLE COMFORTSEAL MASK-SML (brand for adult aerosol mask)

- Tier 2; PA; QL

REZUROCK - Tier 2; PA

ROLVEDON - Tier 2; PA*; SP

RYALTRIS - Tier 2; PA*; QL; AL

SAFETY PEN NEEDLES 30G X 5 MM (brand for pen needles) - Tier 2;

salicylic acid external gel (generic for KERALYT) - Tier 1; PA; QL

SALVAX (brand for salicylic acid) - Tier 2; PA

SALYNTRA (brand for salicylic acid) - Tier 2; PA; QL

SIMLANDI (1 PEN) (brand for adalimumab-ryvk (2 pen)) - Tier 2; PA; SP;

SIMLANDI (2 PEN) (brand for adalimumab-ryvk (2 pen)) - Tier 2; PA; SP;

SITAGLIPTIN - Tier 2; PA; QL

SKYRIZI INTRAVENOUS - Tier 2; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

168

Preferred Agents Non-Preferred Agents

SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; PA*; SP;

SOGROYA - Tier 2; PA*; SP; QL

SOTYKTU - Tier 2; PA*; SP; QL

STIMUFEND - Tier 2; PA*; SP

SUFLAVE - Tier 2; PA*

SYRINGE AVITENE - Tier 2; PA

TASCENSO ODT ORAL TABLET DISPERSIBLE 0.25 MG - Tier 2; PA*;

TASCENSO ODT ORAL TABLET DISPERSIBLE 0.5 MG - Tier 2; PA*;

SP; QL

THROMBI-GEL 10 - Tier 2; PA

THROMBI-GEL 100 - Tier 2; PA

THROMBI-GEL 40 - Tier 2; PA

THROMBI-PAD - Tier 2; PA

TOFIDENCE - Tier 2; PA; SP

TRUE COVER (brand for true cover) - Tier 2; PA

TUBING/WING TIP (brand for adult aerosol mask) - Tier 2; PA; QL

TYENNE - Tier 2; PA; SP

UDSX MEDICATED SYSTEM - Tier 2; PA

UDSXMP MEDICATED SYSTEM - Tier 2; PA

ULTRA NEB ACCESSORIES KIT (brand for adult aerosol mask) - Tier 2;

PA; QL

ULTRAFOAM SPONGE 2X6.25X7CM - Tier 2; PA

ULTRAFOAM SPONGE 8X12.5X1CM - Tier 2; PA

ULTRAFOAM SPONGE 8X12.5X3CM - Tier 2; PA

ULTRAFOAM SPONGE 8X25X1CM - Tier 2; PA

ULTRAFOAM SPONGE 8X6.25X1CM - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

169

Preferred Agents Non-Preferred Agents

UNIFINE PROTECT PEN NEEDLE 30G X 5 MM (brand for pen needles)

- Tier 2; PA

UNISTRIP CONTROL (brand for diatrue control level 1) - Tier 2; PA; QL

VELSIPITY - Tier 2; PA; SP; QL

VENLAFAXINE BESYLATE ER - Tier 2; PA; QL

VERIFINE INSULIN PEN NEEDLE 29G X 12MM (brand for raya sure pen

needle) - Tier 2; PA; QL

VERIFINE INSULIN PEN NEEDLE 31G X 5 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

VERIFINE INSULIN PEN NEEDLE 31G X 8 MM (brand for gnp ulticare

pen needles) - Tier 2; PA; QL

VERIFINE INSULIN SYRINGE (brand for aq insulin syringe) - Tier 2; PA;

VERIFINE PLUS PEN NEEDLE 31G X 5 MM (brand for aqinject pen

needle) - Tier 2; PA; QL

VERIFINE PLUS PEN NEEDLE 31G X 8 MM (brand for gnp ulticare pen

needles) - Tier 2; PA; QL

VERSAPAP (brand for adult mask) - Tier 2; PA

VERSAPAP W/UNIVERSAL TUBING (brand for adult mask) - Tier 2; PA

VOQUEZNA - Tier 2; PA; QL; AL

VOQUEZNA DUAL PAK - Tier 2; PA*; QL

VORTEX HOLD CHMBR/MASK/CHILD (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

VORTEX HOLD CHMBR/MASK/TODDLER (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

VORTEX VALVED HOLDING CHAMBER (brand for breathe comfort

chamber/adult) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

170

Preferred Agents Non-Preferred Agents

VTAMA - Tier 2; PA*

WINLEVI - Tier 2; PA*; QL

WINREVAIR - Tier 2; PA; SP; QL

XELSTRYM - Tier 2; PA; AL

YONSA - Tier 2; PA; SP; QL

YUFLYMA (1 PEN) SUBCUTANEOUS AUTO-INJECTOR KIT 40

MG/0.4ML (brand for adalimumab-aaty (1 pen)) - Tier 2; PA; SP

YUFLYMA (1 PEN) SUBCUTANEOUS AUTO-INJECTOR KIT 80

MG/0.8ML (brand for adalimumab-aaty (1 pen)) - Tier 2; PA

YUFLYMA (2 PEN) (brand for adalimumab-aaty (1 pen)) - Tier 2; PA; SP

YUFLYMA (2 SYRINGE) (brand for adalimumab-aaty (2 syringe)) - Tier 2;

PA; SP; QL

YUFLYMA-CD/UC/HS STARTER (brand for adalimumab-aaty (1 pen)) -

Tier 2; PA

YUSIMRY - Tier 2; PA; SP; QL

ZAVZPRET - Tier 2; PA; QL; AL

ZITUVIO - Tier 2; PA; QL

ZORYVE - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

171

Preferred Agents Non-Preferred Agents

Molecular Target Inhibitors - Chemotherapy Agents

Antineoplastics - Drugs to Treat Cancer

ALECENSA - Tier 2; PA; SP; QL

ALUNBRIG - Tier 2; PA; SP; QL

AYVAKIT ORAL TABLET 100 MG, 200 MG, 300 MG - Tier 2; PA; SP;

AYVAKIT ORAL TABLET 25 MG, 50 MG - Tier 2; PA; SP

BOSULIF ORAL CAPSULE - Tier 2; PA

BOSULIF ORAL TABLET - Tier 2; PA; SP; QL

BRUKINSA - Tier 2; PA; SP; QL

CABOMETYX - Tier 2; PA; SP; QL

CAPRELSA - Tier 2; PA; SP; QL

COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL

COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL

COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL

erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL

GLEEVEC (brand for imatinib mesylate) - Tier 2; PA; SP; QL

IRESSA (brand for gefitinib) - Tier 2; PA; SP; QL

TARCEVA (brand for erlotinib hcl) - Tier 2; PA; SP; QL

FOTIVDA - Tier 2; PA; SP

GAVRETO - Tier 2; PA; SP; QL

gefitinib (generic for IRESSA) - Tier 1; PA; SP; QL

GILOTRIF - Tier 2; PA; SP; QL

ICLUSIG ORAL TABLET 10 MG, 30 MG - Tier 2; PA

ICLUSIG ORAL TABLET 15 MG, 45 MG - Tier 2; PA; SP; QL

imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QL

IMBRUVICA - Tier 2; PA; SP; QL

INLYTA - Tier 2; PA; SP; QL

lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL

LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

172

Preferred Agents Non-Preferred Agents

LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL

LORBRENA - Tier 2; PA; SP; QL

NERLYNX - Tier 2; PA; SP; QL

pazopanib hcl (generic for VOTRIENT) - Tier 1; PA; SP; QL

QINLOCK - Tier 2; PA; SP; QL

RETEVMO - Tier 2; PA; SP; QL

SPRYCEL - Tier 2; PA; SP; QL

TABRECTA - Tier 2; PA; SP; QL

TAGRISSO - Tier 2; PA; SP; QL

TASIGNA - Tier 2; PA; SP; QL

TUKYSA - Tier 2; PA; SP; QL

TURALIO - Tier 2; SP; QL

TYKERB (brand for lapatinib ditosylate) - Tier 2; PA; SP; QL

VIZIMPRO - Tier 2; PA; SP; QL

VOTRIENT (brand for pazopanib hcl) - Tier 2; PA; SP; QL

XALKORI ORAL CAPSULE - Tier 2; PA; SP; QL

XALKORI ORAL CAPSULE SPRINKLE - Tier 2; PA

XOSPATA - Tier 2; PA; SP; QL

Monoclonal Antibodies - Chemotherapy Agents

Antineoplastics - Drugs to Treat Cancer

HERZUMA - Tier 2; PA

MARGENZA - Tier 2; PA

SARCLISA - Tier 2; PA

TRAZIMERA - Tier 2; PA

Multiple Sclerosis Agents - Multiple Sclerosis Drugs

Central Nervous System Agents - Drugs to Treat Nerve

Conditions

PONVORY - Tier 2; PA*; SP; QL

PONVORY STARTER PACK - Tier 2; PA*; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

173

Preferred Agents Non-Preferred Agents

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL bimatoprost solution 0.03 % ophthalmic - Tier 1; PA*; QL

bimatoprost solution 0.03 % ophthalmic - Tier 1; PA; QL

IYUZEH - Tier 2; PA

LUMIGAN - Tier 2; PA*; QL

tafluprost (pf) (generic for ZIOPTAN) - Tier 1; PA*; QL

TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QL

travoprost (bak free) (generic for TRAVATAN Z) - Tier 1; PA*; QL

VYZULTA - Tier 2; PA*; QL

XALATAN (brand for latanoprost) - Tier 2; PA; QL

XELPROS - Tier 2; PA; QL

ZIOPTAN (brand for tafluprost (pf)) - Tier 2; PA; QL

Ophthalmic Agents, Other

ALTACAINE (brand for tetracaine hcl) - Tier 2; QL

altafrin (generic for ALTAFRIN) - Tier 1; PA

atropine sulfate ophthalmic ointment - Tier 1

atropine sulfate ophthalmic solution 1 % - Tier 1; QL

brimonidine tartrate-timolol (generic for COMBIGAN) - Tier 1; QL

COMBIGAN (brand for brimonidine tartrate-timolol) - Tier 2; QL

CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % - Tier 2

cyclopentolate hcl ophthalmic (generic for CYCLOGYL) - Tier 1; QL

cyclosporine ophthalmic (generic for RESTASIS) - Tier 1; QL

CYSTARAN - Tier 2; PA; SP; QL

dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL

dorzolamide hcl-timolol mal pf (generic for COSOPT PF) - Tier 1; QL

LACRISERT - Tier 2

AKTEN - Tier 2; PA*; QL

ALCAINE (brand for proparacaine hcl) - Tier 2; PA

bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier 1;

PA*; QL

CEQUA - Tier 2; PA*; QL

COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL

COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA; QL

CYCLOGYL OPHTHALMIC SOLUTION 1 % (brand for cyclopentolate

hcl) - Tier 2; PA; QL

CYCLOSPORINE IN KLARITY OPHTHALMIC EMULSION 0.1 % - Tier 2;

PA*; QL

CYSTADROPS - Tier 2; PA; SP; QL

MAXITROL OPHTHALMIC OINTMENT (brand for neomycin-polymyxin-

dexameth) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

174

Preferred Agents Non-Preferred Agents

neomycin-polymyxin-dexameth ophthalmic ointment (generic for

MAXITROL) - Tier 1; QL

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

(generic for MAXITROL) - Tier 1; QL

phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1; PA

proparacaine hcl ophthalmic (generic for ALCAINE) - Tier 1; PA

RESTASIS (brand for cyclosporine) - Tier 2; QL

RESTASIS MULTIDOSE (brand for cyclosporine) - Tier 2; QL

ROCKLATAN - Tier 2; QL

sulfacetamide-prednisolone - Tier 1

tetracaine hcl ophthalmic (generic for ALTACAINE) - Tier 1; QL

TOBRADEX - Tier 2; QL

tobramycin-dexamethasone - Tier 1; QL

TYRVAYA - Tier 2; PA

MAXITROL OPHTHALMIC SUSPENSION 0.1 % (brand for neomycin-

polymyxin-dexameth) - Tier 2; PA; QL

neomycin-polymyxin-hc ophthalmic - Tier 1; PA*; QL

neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; PA*; QL

TOBRADEX ST - Tier 2; PA; QL

VERKAZIA - Tier 2; PA*; QL

VEVYE - Tier 2; PA; QL

XIIDRA - Tier 2; PA; QL

ZYLET - Tier 2; PA*; QL

Ophthalmic Anti-allergy Agents

cromolyn sodium ophthalmic - Tier 1; QL

ALOCRIL - Tier 2; PA*

ALOMIDE - Tier 2; PA*

azelastine hcl ophthalmic - Tier 1; PA*

bepotastine besilate solution 1.5 % ophthalmic (generic for BEPREVE) -

Tier 1; PA*; QL

bepotastine besilate solution 1.5 % ophthalmic (generic for BEPREVE) -

Tier 1; PA; QL

BEPREVE (brand for bepotastine besilate) - Tier 2; PA; QL

epinastine hcl - Tier 1; PA*

olopatadine hcl ophthalmic solution 0.1 % (generic for PATADAY) - Tier 1;

PA; QL

olopatadine hcl solution 0.2 % ophthalmic (otc) (generic for PATADAY) -

Tier 1; PA; QL

olopatadine hcl solution 0.2 % ophthalmic (rx) (generic for PATADAY) -

Tier 1; PA*; QL

PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % (brand for

olopatadine hcl) - Tier 2; PA; QL

ZERVIATE - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

175

Preferred Agents Non-Preferred Agents

Ophthalmic Anti-Infectives

ciprofloxacin hcl ophthalmic - Tier 1; QL

erythromycin ophthalmic - Tier 1; QL

gentamicin sulfate ophthalmic - Tier 1; QL

moxifloxacin hcl ophthalmic (generic for VIGAMOX) - Tier 1; QL

NATACYN - Tier 2

ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL

polymyxin b-trimethoprim - Tier 1; QL

sulfacetamide sodium ophthalmic solution - Tier 1; QL

tobramycin ophthalmic - Tier 1; QL

trifluridine - Tier 1; QL

AZASITE - Tier 2; PA*

bacitracin ophthalmic - Tier 1; PA*; QL

bacitracin-polymyxin b (generic for POLYCIN) - Tier 1; PA*

BESIVANCE - Tier 2; PA*; QL

CILOXAN - Tier 2; PA*

gatifloxacin ophthalmic - Tier 1; PA*; QL

KLARITY-A - Tier 2; PA*

moxifloxacin hcl (2x day) - Tier 1; PA; QL

neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1; PA*

neomycin-polymyxin-gramicidin - Tier 1; PA*; QL

neo-polycin (generic for NEO-POLYCIN) - Tier 1; PA*

OCUFLOX (brand for ofloxacin) - Tier 2; PA; QL

polycin (generic for POLYCIN) - Tier 1; PA*

sulfacetamide sodium ophthalmic ointment - Tier 1; PA; QL

TOBREX - Tier 2; PA*; QL

VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

176

Preferred Agents Non-Preferred Agents

Ophthalmic Anti-inflammatories

dexamethasone sodium phosphate ophthalmic - Tier 1

diclofenac sodium ophthalmic - Tier 1; QL

difluprednate (generic for DUREZOL) - Tier 1; QL

fluorometholone (generic for FML LIQUIFILM) - Tier 1

flurbiprofen sodium - Tier 1; QL

ILEVRO - Tier 2; QL

ketorolac tromethamine ophthalmic solution 0.4 % (generic for

ACULAR LS) - Tier 1

ketorolac tromethamine ophthalmic solution 0.5 % (generic for

ACULAR) - Tier 1; QL

prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1;

PREDNISOLONE ACETATE P-F (brand for prednisolone acetate) -

Tier 2; QL

ACULAR (brand for ketorolac tromethamine) - Tier 2; PA; QL

ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA

ACUVAIL - Tier 2; PA*; QL

ALREX (brand for loteprednol etabonate) - Tier 2; PA; QL

bromfenac sodium (once-daily) solution 0.09 % ophthalmic - Tier 1; PA*

bromfenac sodium (once-daily) solution 0.09 % ophthalmic - Tier 1; PA

bromfenac sodium ophthalmic (generic for BROMSITE) - Tier 1; PA; QL

BROMSITE (brand for bromfenac sodium) - Tier 2; PA*; QL

DEXTENZA - Tier 2; PA

DUREZOL (brand for difluprednate) - Tier 2; PA; QL

EYSUVIS - Tier 2; PA; QL

FLAREX - Tier 2; PA*; QL

FML FORTE - Tier 2; PA*; QL

FML LIQUIFILM (brand for fluorometholone) - Tier 2; PA

ILUVIEN - Tier 2; PA

INVELTYS - Tier 2; PA*; QL

LOTEMAX (brand for loteprednol etabonate) - Tier 2; PA; QL

LOTEMAX SM - Tier 2; PA

loteprednol etabonate ophthalmic gel (generic for LOTEMAX) - Tier 1; PA;

loteprednol etabonate ophthalmic suspension 0.2 % (generic for ALREX) -

Tier 1; PA; QL

loteprednol etabonate suspension 0.5 % ophthalmic (generic for

LOTEMAX) - Tier 1; PA*; QL

loteprednol etabonate suspension 0.5 % ophthalmic (generic for

LOTEMAX) - Tier 1; PA; QL

MAXIDEX - Tier 2; PA*

NEVANAC - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

177

Preferred Agents Non-Preferred Agents

PRED FORTE (brand for prednisolone acetate) - Tier 2; PA; QL

PRED MILD - Tier 2; PA*

prednisolone sodium phosphate ophthalmic - Tier 1; PA*

PROLENSA (brand for bromfenac sodium) - Tier 2; PA*; QL

Ophthalmic Beta-Adrenergic Blocking Agents

levobunolol hcl - Tier 1; QL

timolol maleate ophthalmic - Tier 1; QL

timolol maleate pf ophthalmic solution 0.5 % (generic for TIMOPTIC

OCUDOSE) - Tier 1; QL

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.5 % (brand for

timolol maleate pf) - Tier 2; QL

betaxolol hcl ophthalmic - Tier 1; PA*; QL

BETIMOL - Tier 2; PA; QL

BETOPTIC-S - Tier 2; PA*; QL

carteolol hcl - Tier 1; PA*; QL

ISTALOL (brand for timolol maleate (once-daily)) - Tier 2; PA; QL

timolol maleate (once-daily) (generic for ISTALOL) - Tier 1; PA; QL

timolol maleate pf ophthalmic solution 0.25 % (generic for TIMOPTIC

OCUDOSE) - Tier 1; PA*; QL

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25 % (brand for

timolol maleate pf) - Tier 2; PA; QL

Ophthalmic Intraocular Pressure Lowering Agents, Other

ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; QL

brimonidine tartrate ophthalmic (generic for ALPHAGAN P) - Tier 1;

brinzolamide (generic for AZOPT) - Tier 1; QL

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL

dorzolamide hcl solution 2 % ophthalmic - Tier 1; QL

methazolamide oral - Tier 1; QL

PHOSPHOLINE IODIDE - Tier 2

RHOPRESSA - Tier 2; QL

SIMBRINZA - Tier 2; QL

VUITY - Tier 2; PA

apraclonidine hcl - Tier 1; PA*; QL

AZOPT (brand for brinzolamide) - Tier 2; PA; QL

IOPIDINE - Tier 2; PA*; QL

pilocarpine hcl ophthalmic - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

178

Preferred Agents Non-Preferred Agents

Ophthalmic Agents - Drugs to Treat Eye Conditions

Ophthalmic Agents, Other - Miscellaneous Eye Drugs

altalube (generic for ALTALUBE) - Tier 1; QL

BIOLLE TEARS (brand for cvs lubricant eye drops (pf)) - Tier 2

carboxymethylcellulose sodium ophthalmic solution (generic for

ULTRA FRESH) - Tier 1; QL

dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL

eye lubricant (generic for ALTALUBE) - Tier 1; QL

eye lubricant nighttime (generic for ALTALUBE) - Tier 1; QL

for sty relief (generic for ALTALUBE) - Tier 1; QL

ft lubricant eye drops ophthalmic solution 0.5 % (generic for BIOLLE

TEARS) - Tier 1

GENTEAL TEARS NIGHT-TIME (brand for cvs dry-eye relief

nighttime) - Tier 2; QL

HYPOTEARS (brand for cvs dry-eye relief nighttime) - Tier 2; QL

BIO GLO - Tier 2; PA

FLUORESCEIN SODIUM/BENOXINATE - Tier 2; PA

fluor-i-strips a.t. - Tier 1; PA

GELFILM OPHTHALMIC - Tier 2; PA

GLOSTRIPS OPHTHALMIC STRIP 1 MG - Tier 2; PA

MYDRIACYL (brand for tropicamide) - Tier 2; PA; QL

lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE

TEARS) - Tier 1

lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA

FRESH) - Tier 1; QL

lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1

lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL

lubricant pm (generic for ALTALUBE) - Tier 1; QL

lubricating eye drop (generic for BIOLLE TEARS) - Tier 1

lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL

lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1

lubricating plus ophthalmic solution 0.5 % (generic for BIOLLE

TEARS) - Tier 1

lubricating plus pf (generic for BIOLLE TEARS) - Tier 1

lubrifresh p.m. (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

179

Preferred Agents Non-Preferred Agents

nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL

nighttime relief lub eye (generic for ALTALUBE) - Tier 1; QL

polyvinyl alcohol ophthalmic - Tier 1

REFRESH LACRI-LUBE (brand for cvs dry-eye relief nighttime) - Tier

2; QL

REFRESH PLUS (brand for cvs lubricant eye drops (pf)) - Tier 2

REFRESH TEARS (brand for carboxymethylcellulose sodium) - Tier 2;

restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1

restore pm (generic for ALTALUBE) - Tier 1; QL

SYSTANE NIGHTTIME (brand for cvs dry-eye relief nighttime) - Tier 2;

tropicamide ophthalmic (generic for MYDRIACYL) - Tier 1; PA; QL

ultra fresh (generic for ULTRA FRESH) - Tier 1; QL

ultra fresh pm (generic for ALTALUBE) - Tier 1; QL

VENTIVA TEARS (brand for carboxymethylcellulose sodium) - Tier 2;

Ophthalmic Anti-allergy Agents - Allergy, Infection and

Inflammation Drugs

CYCLOMYDRIL - Tier 2

Ophthalmic Antibiotics - Drugs to treat Eye Infections

BETADINE OPHTHALMIC PREP (brand for povidone-iodine) - Tier 2; PA

POVIDONE-IODINE OPHTHALMIC (brand for povidone-iodine) - Tier 2;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

180

Preferred Agents Non-Preferred Agents

Ophthalmic Anti-Inflammatories - Allergy, Infection and

Inflammation Drugs

ALAWAY (brand for cvs allergy eye drops) - Tier 2; QL

ALAWAY CHILDRENS ALLERGY (brand for cvs allergy eye drops) -

Tier 2; QL

allergy eye drops (generic for ALAWAY) - Tier 1; QL

eye itch relief ophthalmic solution 0.035 % (generic for ALAWAY) -

Tier 1; QL

ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1; QL

Otic Agents

acetic acid otic - Tier 1

CIPRO HC - Tier 2; QL

ciprofloxacin-dexamethasone - Tier 1; QL

DERMOTIC (brand for fluocinolone acetonide) - Tier 2; QL

flac (generic for FLAC) - Tier 1; QL

fluocinolone acetonide otic (generic for FLAC) - Tier 1; QL

hydrocortisone-acetic acid - Tier 1

neomycin-polymyxin-hc otic - Tier 1; QL

ofloxacin otic - Tier 1; QL

CETRAXAL (brand for ciprofloxacin hcl) - Tier 2; PA*; QL

ciprofloxacin hcl otic (generic for CETRAXAL) - Tier 1; PA*; QL

CIPROFLOXACIN-FLUOCINOLONE PF (brand for ciprofloxacin-

fluocinolone pf) - Tier 2; PA*; QL

CORTISPORIN-TC - Tier 2; PA*; QL

OTOVEL (brand for ciprofloxacin-fluocinolone pf) - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

181

Preferred Agents Non-Preferred Agents

Otic Agents - Drugs to Treat Ear Conditions

Otic Agents - Drugs for the Ear

CLEARCANAL EARWAX SOFTENER (brand for cvs ear drops) - Tier

CLINERE EARWAX REMOVAL KIT OTIC SOLUTION (brand for cvs

ear drops) - Tier 2

ear drops otic solution 6.5 % (generic for CLEARCANAL EARWAX

SOFTENER) - Tier 1

ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1

ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) -

Tier 1

ear wax removal system (generic for CLEARCANAL EARWAX

SOFTENER) - Tier 1

earwax removal drops (generic for CLEARCANAL EARWAX

SOFTENER) - Tier 1

earwax removal kit otic solution 6.5 % (generic for CLEARCANAL

EARWAX SOFTENER) - Tier 1

earwax removal otic solution 6.5 % (generic for CLEARCANAL

EARWAX SOFTENER) - Tier 1

ft earwax removal (generic for CLEARCANAL EARWAX SOFTENER)

- Tier 1

ft earwax removal kit (generic for CLEARCANAL EARWAX

SOFTENER) - Tier 1

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

182

Preferred Agents Non-Preferred Agents

Respiratory Tract/Pulmonary Agents

Antihistamines

all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1;

allergy (cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL

allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1;

allergy childrens oral liquid (generic for RA DIPHEDRYL ALLERGY) -

Tier 1; QL

allergy medication (generic for BANOPHEN) - Tier 1; QL

allergy medicine (generic for BANOPHEN) - Tier 1; QL

allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL

allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL

azelastine-fluticasone (generic for DYMISTA) - Tier 1; PA*; QL

carbinoxamine maleate oral solution - Tier 1; PA*; QL

carbinoxamine maleate oral tablet 4 mg - Tier 1; PA*; QL

carbinoxamine maleate oral tablet 6 mg (generic for RYVENT) - Tier 1;

PA; QL

CLARINEX (brand for desloratadine) - Tier 2; PA; QL

clemastine fumarate oral - Tier 1; PA*; QL

desloratadine oral tablet dispersible 5 mg - Tier 1; PA; QL

desloratadine tablet 5 mg oral (generic for CLARINEX) - Tier 1; PA; QL

desloratadine tablet 5 mg oral (generic for CLARINEX) - Tier 1; PA*; QL

DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA*; QL

KARBINAL ER - Tier 2; PA*; QL

levocetirizine dihydrochloride oral solution (generic for XYZAL ALLERGY

24HR CHILDRENS) - Tier 1; PA*

allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER-

TEC) - Tier 1; QL

allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1;

allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL

allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA

DIPHEDRYL ALLERGY) - Tier 1; QL

allergy relief max st (generic for RA DIPHEDRYL ALLERGY) - Tier 1;

allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL

allergy relief oral liquid 25 mg/10ml (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL

allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL

levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY

24HR) - Tier 1; PA*; QL

olopatadine hcl nasal - Tier 1; PA*; QL

RYCLORA - Tier 2; PA*; QL

ryvent (generic for RYVENT) - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

183

Preferred Agents Non-Preferred Agents

allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER-

TEC) - Tier 1; QL

aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL

anti-hist allergy (generic for BANOPHEN) - Tier 1; QL

ASTEPRO (brand for azelastine hcl) - Tier 2

ASTEPRO CHILDRENS (brand for azelastine hcl) - Tier 2

azelastine hcl nasal solution 0.1 %, 137 mcg/spray - Tier 1; QL

azelastine hcl nasal solution 0.15 % (generic for ASTEPRO) - Tier 1

banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL

banophen oral tablet (generic for BANOPHEN) - Tier 1; QL

BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for allergy

childrens) - Tier 2; QL

BENADRYL ALLERGY ULTRATABS (brand for allergy relief) - Tier 2;

cetirizine allergy relief (generic for KLS ALLER-TEC) - Tier 1; QL

cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS)

- Tier 1; QL

cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1; QL

childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

complete allergy (generic for BANOPHEN) - Tier 1; QL

complete allergy medicine (generic for BANOPHEN) - Tier 1; QL

complete allergy medicine oral capsule (generic for BANOPHEN) -

Tier 1; QL

complete allergy relief (generic for BANOPHEN) - Tier 1; QL

CURELIEF (brand for allergy childrens) - Tier 2; QL

cyproheptadine hcl oral - Tier 1; QL

diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

184

Preferred Agents Non-Preferred Agents

diphen (generic for BANOPHEN) - Tier 1; QL

diphenhydramine hcl childrens (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

diphenhydramine hcl injection - Tier 1; PA; QL

diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1;

diphenhydramine hcl oral elixir - Tier 1; QL

diphenhydramine hcl oral liquid (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1; QL

ft all day allergy (generic for KLS ALLER-TEC) - Tier 1; QL

ft all day allergy 24 hour (generic for KLS ALLER-TEC) - Tier 1; QL

ft allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL

ft allergy relief childrens oral liquid (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

ft allergy relief oral capsule (generic for BANOPHEN) - Tier 1; QL

ft allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL

geri-dryl (generic for BANOPHEN) - Tier 1; QL

h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier

1; QL

indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; QL

liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1;

MAXALLERGY KIDS (brand for allergy childrens) - Tier 2; QL

m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

MM ALLER-BEN (brand for allergy relief) - Tier 2; QL

NARAMIN (brand for allergy childrens) - Tier 2; QL

pharbedryl (generic for BANOPHEN) - Tier 1; QL

siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

total allergy (generic for BANOPHEN) - Tier 1; QL

total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1;

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

185

Preferred Agents Non-Preferred Agents

Anti-inflammatories, Inhaled Corticosteroids

budesonide inhalation (generic for PULMICORT) - Tier 1; QL

FLUTICASONE PROPIONATE DISKUS - Tier 2; QL

FLUTICASONE PROPIONATE HFA - Tier 2; QL

fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL

PULMICORT FLEXHALER - Tier 2; QL

ALVESCO - Tier 2; PA*; QL

ARNUITY ELLIPTA - Tier 2; PA*; QL

ASMANEX (120 METERED DOSES) - Tier 2; PA*; QL

ASMANEX (14 METERED DOSES) - Tier 2; PA*; QL

ASMANEX (30 METERED DOSES) - Tier 2; PA*; QL

ASMANEX (60 METERED DOSES) - Tier 2; PA*; QL

ASMANEX HFA - Tier 2; PA*; QL

flunisolide nasal - Tier 1; PA*; QL

mometasone furoate suspension 50 mcg/act nasal (rx) (generic for

NASONEX 24HR) - Tier 1; PA*; QL

mometasone furoate suspension 50 mcg/act nasal (rx) (generic for

NASONEX 24HR) - Tier 1; PA; QL

OMNARIS - Tier 2; PA*; QL

PROPEL - Tier 2; PA

PROPEL MINI - Tier 2; PA

PROPEL MINI SDS - Tier 2; PA

PULMICORT SUSPENSION (brand for budesonide) - Tier 2; PA; QL

QNASL - Tier 2; PA*; QL

QNASL CHILDRENS - Tier 2; PA*; QL

QVAR REDIHALER - Tier 2; PA*; QL

XHANCE - Tier 2; PA*; QL

ZETONNA - Tier 2; PA*; QL

Antileukotrienes

montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL

zafirlukast (generic for ACCOLATE) - Tier 1; QL

ACCOLATE (brand for zafirlukast) - Tier 2; PA; QL

SINGULAIR (brand for montelukast sodium) - Tier 2; PA; QL

zileuton er tablet extended release 12 hour 600 mg oral - Tier 1; PA*; QL

zileuton er tablet extended release 12 hour 600 mg oral - Tier 1; PA; QL

ZYFLO - Tier 2; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

186

Preferred Agents Non-Preferred Agents

Bronchodilators, Anticholinergic

ATROVENT HFA - Tier 2; QL

ipratropium bromide inhalation - Tier 1; QL

ipratropium bromide nasal - Tier 1; QL

SPIRIVA HANDIHALER (brand for tiotropium bromide monohydrate) -

Tier 2; QL

tiotropium bromide monohydrate (generic for SPIRIVA HANDIHALER)

- Tier 1; QL

INCRUSE ELLIPTA - Tier 2; PA*; QL

SPIRIVA RESPIMAT - Tier 2; PA; QL

TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400

MCG/ACT INHALATION - Tier 2; PA*; QL

TUDORZA PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400

MCG/ACT INHALATION - Tier 2; PA; QL

YUPELRI - Tier 2; PA*; QL

Bronchodilators, Sympathomimetic

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

(generic for PROVENTIL HFA) - Tier 1; QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%,

2.5 mg/0.5ml - Tier 1; QL

albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25

mg/3ml - Tier 1; QL; AL

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier

1; QL

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5%

INHALATION - Tier 2; QL

albuterol sulfate oral syrup - Tier 1; QL

albuterol sulfate oral tablet 2 mg - Tier 1

albuterol sulfate oral tablet 4 mg - Tier 1; QL

ADRENALIN INJECTION SOLUTION 1 MG/ML (brand for epinephrine

(anaphylaxis)) - Tier 2; PA; QL

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

(generic for PROVENTIL HFA) - Tier 1; PA; QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE)

MCG/ACT INHALATION (brand for albuterol sulfate hfa) - Tier 2; PA*; QL

arformoterol tartrate (generic for BROVANA) - Tier 1; PA*; QL

AUVI-Q (brand for epinephrine) - Tier 2; PA; QL

BROVANA (brand for arformoterol tartrate) - Tier 2; PA; QL

EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL

EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL

formoterol fumarate nebulization solution 20 mcg/2ml inhalation (generic

for PERFOROMIST) - Tier 1; PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

187

Preferred Agents Non-Preferred Agents

epinephrine (anaphylaxis) injection solution 1 mg/ml (generic for

ADRENALIN) - Tier 1; QL

epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier

1; QL

SEREVENT DISKUS - Tier 2; QL

formoterol fumarate nebulization solution 20 mcg/2ml inhalation (generic

for PERFOROMIST) - Tier 1; PA; QL

levalbuterol hcl inhalation - Tier 1; PA*; QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT (brand for

levalbuterol tartrate) - Tier 2; PA*; QL

PERFOROMIST (brand for formoterol fumarate) - Tier 2; PA; QL

PROAIR RESPICLICK - Tier 2; PA*; QL

PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA*; QL

STRIVERDI RESPIMAT - Tier 2; PA*; QL

terbutaline sulfate oral - Tier 1; PA*; QL

terbutaline sulfate solution 1 mg/ml injection - Tier 1; PA*

terbutaline sulfate solution 1 mg/ml injection - Tier 1; PA

VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA*; QL

XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA*; QL

Cystic Fibrosis Agents

CAYSTON - Tier 2; PA; SP; QL; AL

KALYDECO ORAL PACKET 13.4 MG, 5.8 MG - Tier 2; PA; SP; QL

KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG - Tier 2; PA; SP;

QL; AL

KALYDECO ORAL TABLET - Tier 2; PA; SP; QL; AL

KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL; AL

ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG - Tier 2; PA; SP;

ORKAMBI ORAL PACKET 75-94 MG - Tier 2; PA; SP

ORKAMBI ORAL TABLET - Tier 2; PA; SP; QL; AL

PULMOZYME - Tier 2; PA; SP; QL

SYMDEKO ORAL TABLET THERAPY PACK 100-150 & 150 MG -

Tier 2; PA; SP; QL; AL

BETHKIS (brand for tobramycin) - Tier 2; PA; SP; QL; AL

TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL; AL

TOBI PODHALER - Tier 2; PA; SP; QL; AL

tobramycin inhalation nebulization solution 300 mg/4ml (generic for

BETHKIS) - Tier 1; PA; SP; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

188

Preferred Agents Non-Preferred Agents

SYMDEKO ORAL TABLET THERAPY PACK 50-75 & 75 MG - Tier 2;

PA; SP; QL

tobramycin nebulization solution 300 mg/5ml inhalation (generic for

KITABIS PAK) - Tier 1; PA; SP; QL; AL

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML

INHALATION (brand for tobramycin) - Tier 2; PA; SP; QL; AL

TRIKAFTA ORAL TABLET THERAPY PACK - Tier 2; PA; SP; QL

TRIKAFTA ORAL THERAPY PACK - Tier 2; PA; SP; QL; AL

Mast Cell Stabilizers

cromolyn sodium inhalation - Tier 1; QL

Phosphodiesterase Inhibitors, Airways Disease

roflumilast (generic for DALIRESP) - Tier 1; PA; QL

theophylline er - Tier 1; QL

theophylline oral solution - Tier 1; QL

DALIRESP (brand for roflumilast) - Tier 2; PA; QL

elixophyllin (generic for ELIXOPHYLLIN) - Tier 1; PA*; QL

THEO-24 - Tier 2; PA*; QL

theophylline oral elixir (generic for ELIXOPHYLLIN) - Tier 1; PA; QL

Pulmonary Antihypertensives

ADEMPAS - Tier 2; PA; SP; QL

alyq (generic for ALYQ) - Tier 1; PA; SP; QL

ambrisentan (generic for LETAIRIS) - Tier 1; PA; SP; QL

bosentan (generic for TRACLEER) - Tier 1; PA; SP; QL

sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; PA;

SP; QL

tadalafil (pah) (generic for ALYQ) - Tier 1; PA; SP; QL

TRACLEER 32 MG - Tier 2; PA; SP; QL; AL

TYVASO - Tier 2; PA; SP; QL

TYVASO DPI INSTITUTIONAL KIT - Tier 2; PA

TYVASO DPI MAINTENANCE KIT - Tier 2; PA

TYVASO DPI TITRATION KIT - Tier 2; PA

TYVASO REFILL - Tier 2; PA; SP; QL

TYVASO STARTER - Tier 2; PA; SP; QL

ADCIRCA (brand for tadalafil (pah)) - Tier 2; PA; SP; QL

LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP; QL

LIQREV - Tier 2; PA; SP; QL

OPSUMIT - Tier 2; PA*; SP; QL

ORENITRAM - Tier 2; PA; SP; QL

ORENITRAM MONTH 1 - Tier 2; PA; SP; QL; AL

ORENITRAM MONTH 2 - Tier 2; PA; SP; QL; AL

ORENITRAM MONTH 3 - Tier 2; PA; SP; QL; AL

REVATIO ORAL (brand for sildenafil citrate) - Tier 2; PA; SP; QL

sildenafil citrate oral suspension reconstituted (generic for REVATIO) -

Tier 1; PA; SP; QL

TADLIQ - Tier 2; PA; SP; QL

TRACLEER 62.5 MG, 125 MG (brand for bosentan) - Tier 2; PA; SP; QL

UPTRAVI INTRAVENOUS - Tier 2; PA; SP

VENTAVIS - Tier 2; PA; SP; QL UPTRAVI ORAL - Tier 2; PA; SP; QL

UPTRAVI TITRATION - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

189

Preferred Agents Non-Preferred Agents

Pulmonary Fibrosis Agents

OFEV - Tier 2; PA; SP; QL

pirfenidone oral capsule (generic for ESBRIET) - Tier 1; SP; QL

pirfenidone oral tablet (generic for ESBRIET) - Tier 1; PA; SP; QL

ESBRIET (brand for pirfenidone) - Tier 2; PA; SP; QL

Respiratory Tract Agents, Other

acetylcysteine inhalation - Tier 1

CINQAIR - Tier 2; PA; SP; QL; AL

FASENRA PEN - Tier 2; PA; SP; QL

FASENRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 30

MG/ML - Tier 2; PA; SP; QL; AL

ribavirin inhalation (generic for VIRAZOLE) - Tier 1; PA

CLARINEX-D 12 HOUR - Tier 2; PA*

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA;

SP; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100

MG/ML - Tier 2; PA; SP; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40

MG/0.4ML - Tier 2; PA; SP

NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED - Tier 2; PA;

SP; QL; AL

TEZSPIRE SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;

PA; SP; QL

TEZSPIRE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier

2; PA; SP

VIRAZOLE (brand for ribavirin) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

190

Preferred Agents Non-Preferred Agents

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,

Cough, Cold and Lung Conditions

AFRIN SALINE NASAL MIST (brand for altamist spray) - Tier 2

altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1

altarussin (generic for TUSNEL-EX) - Tier 1; QL; AL

AYR (brand for altamist spray) - Tier 2

BABY AYR SALINE (brand for altamist spray) - Tier 2

BUCKLEYS CHEST CONGESTION (brand for altarussin) - Tier 2; QL;

chest congestion relief oral liquid (generic for TUSNEL-EX) - Tier 1;

QL; AL

cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH

LONG ACTING) - Tier 1; AL

deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier

ft nasal decongestant pe (generic for SUDAFED PE MAXIMUM

STRENGTH) - Tier 1

ft tussin adult (generic for TUSNEL-EX) - Tier 1; QL; AL

geri-tussin oral liquid (generic for TUSNEL-EX) - Tier 1; QL; AL

guaifenesin oral liquid (generic for TUSNEL-EX) - Tier 1; QL; AL

MAX TUSSIN MUCUS & CHEST CONG (brand for altarussin) - Tier 2;

QL; AL

medifin mucus relief child (generic for TUSNEL-EX) - Tier 1; QL; AL

MUCINEX FAST-MAX CHEST CONG MS (brand for altarussin) - Tier

2; QL; AL

mucus relief childrens oral liquid 100 mg/5ml (generic for TUSNEL-EX)

- Tier 1; QL; AL

mucus+chest congestion (generic for TUSNEL-EX) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

191

Preferred Agents Non-Preferred Agents

nasal decongestant pe max st (generic for SUDAFED PE MAXIMUM

STRENGTH) - Tier 1

nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE

MAXIMUM STRENGTH) - Tier 1

NASAL MOIST NASAL SOLUTION (brand for altamist spray) - Tier 2

nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) -

Tier 1

nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1

non-pseudo sinus decongestant (generic for SUDAFED PE MAXIMUM

STRENGTH) - Tier 1

OCEAN FOR KIDS (brand for altamist spray) - Tier 2

phenylephrine hcl oral (generic for SUDAFED PE MAXIMUM

STRENGTH) - Tier 1

saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1

saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1

siltussin sa (generic for TUSNEL-EX) - Tier 1; QL; AL

sinus pe decongestant (generic for SUDAFED PE MAXIMUM

STRENGTH) - Tier 1

sinus/congestion relief pe (generic for SUDAFED PE MAXIMUM

STRENGTH) - Tier 1

TRUE NASAL MOISTURIZING (brand for altamist spray) - Tier 2

tusnel-ex (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin adult chest congest (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin chest congestion oral liquid 100 mg/5ml (generic for TUSNEL-

EX) - Tier 1; QL; AL

tussin cough long acting (generic for WAL-TUSSIN COUGH LONG

ACTING) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

192

Preferred Agents Non-Preferred Agents

tussin cough oral syrup (generic for WAL-TUSSIN COUGH LONG

ACTING) - Tier 1; AL

tussin expectorant adult (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin maximum strength oral syrup 15 mg/5ml (generic for WAL-

TUSSIN COUGH LONG ACTING) - Tier 1; AL

tussin mucus & chest cong (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus & chest congest (generic for TUSNEL-EX) - Tier 1; QL;

tussin mucus/chest congest (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus/congestion (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus+chest congest (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus+chest congestion (generic for TUSNEL-EX) - Tier 1; QL;

tussin oral liquid 100 mg/5ml (generic for TUSNEL-EX) - Tier 1; QL; AL

Antihistamines - Allergy Drugs

12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

all day allergy-d oral tablet extended release 12 hour 5-120 mg

(generic for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief d oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief/nasal decongest oral tablet extended release 12 hour

(generic for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLER-TEC D) - Tier 1; QL; AL

aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier

1; QL; AL

ft all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

ZYRTEC-D ALLERGY & SINUS (brand for 12 hour allergy-d) - Tier 2;

QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

193

Preferred Agents Non-Preferred Agents

Antihistamines - Drugs to Treat Allergies

all day allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR)

- Tier 1; QL

aller-chlor (generic for WAL-FINATE) - Tier 1; QL

allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL

allerg rel child (lorat) (generic for CLARITIN) - Tier 1; QL

allerg relief child (lorat) (generic for CLARITIN) - Tier 1; QL

allergy childrens oral solution (generic for CLARITIN) - Tier 1; QL

allergy oral tablet 4 mg (generic for WAL-FINATE) - Tier 1; QL

allergy rel child (loratadine) (generic for CLARITIN) - Tier 1; QL

allergy relief (loratadine) oral tablet (generic for KLS ALLERCLEAR) -

Tier 1; QL

allergy relief child (generic for CLARITIN) - Tier 1; QL

allergy relief childrens oral solution 5 mg/5ml (generic for CLARITIN) -

Tier 1; QL

allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier

1; QL

allergy relief oral tablet 4 mg (generic for WAL-FINATE) - Tier 1; QL

childrens loratadine (generic for CLARITIN) - Tier 1; QL

chlor-pheniramine (generic for WAL-FINATE) - Tier 1; QL

chlorpheniramine maleate (generic for WAL-FINATE) - Tier 1; QL

chlorpheniramine maleate oral (generic for WAL-FINATE) - Tier 1; QL

ft all day allergy relief (generic for KLS ALLERCLEAR) - Tier 1; QL

ft allergy childrens (generic for CLARITIN) - Tier 1; QL

ft allergy relief loratadine (generic for KLS ALLERCLEAR) - Tier 1; QL

ft allergy relief oral tablet 4 mg (generic for WAL-FINATE) - Tier 1; QL

loradamed (generic for KLS ALLERCLEAR) - Tier 1; QL

loratadine allergy relief oral tablet 10 mg (generic for KLS

ALLERCLEAR) - Tier 1; QL

loratadine childrens oral solution (generic for CLARITIN) - Tier 1; QL

loratadine oral solution 5 mg/5ml (generic for CLARITIN) - Tier 1; QL

loratadine oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier 1;

pharbechlor (generic for WAL-FINATE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

194

Preferred Agents Non-Preferred Agents

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung

Drugs

24 hour nasal allergy (generic for NASACORT ALLERGY 24HR) - Tier

1; QL

allergy spray 24 hour nasal aerosol (generic for NASACORT

ALLERGY 24HR) - Tier 1; QL

ft 24 hour nasal allergy (generic for NASACORT ALLERGY 24HR) -

Tier 1; QL

nasal allergy 24 hour (generic for NASACORT ALLERGY 24HR) - Tier

1; QL

nasal allergy nasal aerosol 55 mcg/act (generic for NASACORT

ALLERGY 24HR) - Tier 1; QL

nasal allergy spray (generic for NASACORT ALLERGY 24HR) - Tier 1;

triamcinolone acetonide nasal (generic for NASACORT ALLERGY

24HR) - Tier 1; QL

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs

ANORO ELLIPTA - Tier 2; QL

breyna (generic for BREYNA) - Tier 1; QL

budesonide-formoterol fumarate (generic for BREYNA) - Tier 1; QL

COMBIVENT RESPIMAT - Tier 2; QL

DULERA - Tier 2; QL

fluticasone-salmeterol aerosol powder breath activated 100-50

mcg/act inhalation (generic for WIXELA INHUB) - Tier 1; QL

fluticasone-salmeterol aerosol powder breath activated 500-50

mcg/act inhalation (generic for WIXELA INHUB) - Tier 1; QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL (brand for

fluticasone-salmeterol) - Tier 2; QL

fluticasone-salmeterol inhalation aerosol powder breath activated 250-

50 mcg/act (generic for WIXELA INHUB) - Tier 1; QL

ipratropium-albuterol - Tier 1; QL

ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL

ADVAIR HFA (brand for fluticasone-salmeterol) - Tier 2; PA; QL

AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2;

PA; QL

AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2;

PA; QL

AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2;

PA; QL

BEVESPI AEROSPHERE - Tier 2; PA*; QL

BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-25

MCG/ACT INHALATION (brand for fluticasone furoate-vilanterol) - Tier 2;

PA*; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

195

Preferred Agents Non-Preferred Agents

STIOLTO RESPIMAT - Tier 2; QL

SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; QL

BREO ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-25

MCG/ACT INHALATION (brand for fluticasone furoate-vilanterol) - Tier 2;

PA; QL

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH

ACTIVATED 200-25 MCG/ACT (brand for fluticasone furoate-vilanterol) -

Tier 2; PA*; QL

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH

ACTIVATED 50-25 MCG/INH - Tier 2; PA*; QL

BREZTRI AEROSPHERE - Tier 2; PA*; QL

DUAKLIR PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400-

12 MCG/ACT INHALATION - Tier 2; PA*; QL

DUAKLIR PRESSAIR AEROSOL POWDER BREATH ACTIVATED 400-

12 MCG/ACT INHALATION - Tier 2; PA; QL

FLUTICASONE FUROATE-VILANTEROL (brand for fluticasone furoate-

vilanterol) - Tier 2; PA*; QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcg/act

inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL

fluticasone-salmeterol aerosol powder breath activated 500-50 mcg/act

inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER

BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14

MCG/ACT (brand for fluticasone-salmeterol) - Tier 2; PA; QL

TRELEGY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-

62.5-25 MCG/ACT INHALATION - Tier 2; PA*; QL

TRELEGY ELLIPTA AEROSOL POWDER BREATH ACTIVATED 100-

62.5-25 MCG/ACT INHALATION - Tier 2; PA; QL

TRELEGY ELLIPTA INHALATION AEROSOL POWDER BREATH

ACTIVATED 200-62.5-25 MCG/ACT - Tier 2; PA*; QL

wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

196

Preferred Agents Non-Preferred Agents

Respiratory Tract Agents, Other - Asthma/Lung Drugs

allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL

allerclear d-24hr (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

allergy & congestion oral tablet extended release 24 hour 10-240 mg

(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; AL

allergy & congestion relief (generic for KLS ALLERCLEAR D-12HR) -

Tier 1; AL

allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

allergy relief d-24 (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

allergy relief nasal decong (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

HYPERSAL (brand for sodium chloride) - Tier 2; PA

allergy relief/nasal decong (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

allergy relief/nasal decongest oral tablet extended release 24 hour

(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; AL

allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLERCLEAR D-12HR) - Tier 1; AL

allergy relief-d oral tablet extended release 24 hour 10-240 mg

(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; AL

allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL

allergy/congestion relief (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1;

QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

197

Preferred Agents Non-Preferred Agents

chest congestion relief dm oral syrup (generic for ROBAFEN DM

COUGH CLEAR) - Tier 1; QL; AL

CLARITIN-D 24 HOUR (brand for allergy relief d-24) - Tier 2; AL

dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM

COUGH CLEAR) - Tier 1; QL; AL

ft allergy d-12 hour (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

ft allergy relief-d (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

ft nasal decongestant max str oral tablet (generic for SUDOGEST) -

Tier 1; QL

geri-tussin dm oral syrup (generic for ROBAFEN DM COUGH CLEAR)

- Tier 1; QL; AL

guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH

CLEAR) - Tier 1; QL; AL

lorata-d (generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier

1; AL

lorata-dine d (generic for EQ ALLERGY RELIEF NASAL DECONG) -

Tier 1; AL

loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL

loratadine-d (generic for EQ ALLERGY RELIEF NASAL DECONG) -

Tier 1; AL

loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; AL

loratadine-d 24hr (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; AL

meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier

1; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

198

Preferred Agents Non-Preferred Agents

nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL

nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier

1; QL

nasal decongestant pe oral tablet 30 mg (generic for SUDOGEST) -

Tier 1; QL

NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % (brand for

sodium chloride) - Tier 2

pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier

1; QL

PULMOSAL (brand for sodium chloride) - Tier 2

sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL

sodium chloride inhalation nebulization solution 0.9 % - Tier 1; QL

sodium chloride inhalation nebulization solution 10 % - Tier 1

sodium chloride inhalation nebulization solution 3 % (generic for

NEBUSAL) - Tier 1

sodium chloride inhalation nebulization solution 7 % (generic for

HYPERSAL) - Tier 1

SUDAFED SINUS CONGESTION (brand for cvs nasal decongestant)

- Tier 2; QL

sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL

sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL

suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL

tussin cough dm sugar free (generic for ROBAFEN DM COUGH

CLEAR) - Tier 1; QL; AL

tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for

ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

tussin dm cough/chest cong (generic for ROBAFEN DM COUGH

CLEAR) - Tier 1; QL; AL

tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for

ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM

COUGH CLEAR) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

199

Preferred Agents Non-Preferred Agents

Sedatives/Hypnotics - Drugs for Sedation and Sleep

Sleep Disorders, Other - Miscellaneous Sedation and Sleep

Drugs

XYWAV - Tier 2; PA; QL

Skeletal Muscle Relaxants

cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL

metaxalone oral tablet 400 mg - Tier 1

metaxalone oral tablet 800 mg - Tier 1; QL

methocarbamol oral - Tier 1; QL

AMRIX (brand for cyclobenzaprine hcl er) - Tier 2; PA

carisoprodol oral (generic for SOMA) - Tier 1; PA; QL

chlorzoxazone oral tablet 250 mg - Tier 1; PA*; QL

chlorzoxazone tablet 375 mg oral (generic for LORZONE) - Tier 1; PA*

chlorzoxazone tablet 375 mg oral (generic for LORZONE) - Tier 1; PA

chlorzoxazone tablet 500 mg oral - Tier 1; PA; QL

chlorzoxazone tablet 500 mg oral - Tier 1; PA*; QL

chlorzoxazone tablet 750 mg oral (generic for LORZONE) - Tier 1; PA*

chlorzoxazone tablet 750 mg oral (generic for LORZONE) - Tier 1; PA

cyclobenzaprine hcl er (generic for AMRIX) - Tier 1; PA

cyclobenzaprine hcl oral tablet 7.5 mg (generic for FEXMID) - Tier 1; PA

FEXMID (brand for cyclobenzaprine hcl) - Tier 2; PA

LORZONE (brand for chlorzoxazone) - Tier 2; PA*

NORGESIC (brand for orphenadrine-aspirin-caffeine) - Tier 2; PA; QL

NORGESIC FORTE (brand for norgesic forte) - Tier 2; PA; QL

orphenadrine citrate er - Tier 1; PA*; QL

orphenadrine-aspirin-caffeine (generic for NORGESIC) - Tier 1; PA; QL

ORPHENGESIC FORTE (brand for norgesic forte) - Tier 2; PA*; QL

SOMA (brand for carisoprodol) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

200

Preferred Agents Non-Preferred Agents

Sleep Disorder Agents

Sleep Promoting Agents

ramelteon (generic for ROZEREM) - Tier 1; PA; QL; AL

temazepam oral capsule 15 mg, 30 mg, 7.5 mg (generic for

RESTORIL) - Tier 1; QL; AL

temazepam oral capsule 22.5 mg (generic for RESTORIL) - Tier 1; AL

triazolam (generic for HALCION) - Tier 1; QL; AL

zolpidem tartrate er (generic for AMBIEN CR) - Tier 1; QL; AL

zolpidem tartrate oral tablet (generic for AMBIEN) - Tier 1; QL; AL

AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QL; AL

AMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PA; QL; AL

BELSOMRA - Tier 2; PA; QL; AL

DAYVIGO - Tier 2; PA; QL

doxepin hcl oral tablet (generic for SILENOR) - Tier 1; PA; QL; AL

EDLUAR - Tier 2; PA; QL; AL

estazolam tablet 1 mg oral - Tier 1; PA; QL; AL

estazolam tablet 1 mg oral - Tier 1; PA*; QL; AL

estazolam tablet 2 mg oral - Tier 1; PA; QL; AL

estazolam tablet 2 mg oral - Tier 1; PA*; QL; AL

eszopiclone (generic for LUNESTA) - Tier 1; PA; QL; AL

flurazepam hcl capsule 15 mg oral - Tier 1; PA*; QL; AL

flurazepam hcl capsule 15 mg oral - Tier 1; PA; QL; AL

flurazepam hcl capsule 30 mg oral - Tier 1; PA*; QL; AL

flurazepam hcl capsule 30 mg oral - Tier 1; PA; QL; AL

HALCION (brand for triazolam) - Tier 2; PA; QL; AL

HETLIOZ (brand for tasimelteon) - Tier 2; PA; SP; QL; AL

HETLIOZ LQ - Tier 2; PA; SP; QL

LUNESTA (brand for eszopiclone) - Tier 2; PA; QL; AL

RESTORIL ORAL CAPSULE 15 MG, 30 MG, 7.5 MG (brand for

temazepam) - Tier 2; PA; QL; AL

RESTORIL ORAL CAPSULE 22.5 MG (brand for temazepam) - Tier 2;

PA; AL

ROZEREM (brand for ramelteon) - Tier 2; PA; QL; AL

SILENOR (brand for doxepin hcl) - Tier 2; PA; QL; AL

tasimelteon capsule 20 mg oral (generic for HETLIOZ) - Tier 1; PA*; SP;

QL; AL

tasimelteon capsule 20 mg oral (generic for HETLIOZ) - Tier 1; PA; SP;

QL; AL

zaleplon - Tier 1; PA; QL; AL

ZOLPIDEM TARTRATE ORAL CAPSULE - Tier 2; PA; QL

zolpidem tartrate sublingual - Tier 1; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

201

Preferred Agents Non-Preferred Agents

Wakefulness Promoting Agents

armodafinil (generic for NUVIGIL) - Tier 1; PA; QL; AL

modafinil oral (generic for PROVIGIL) - Tier 1; PA; QL; AL

NUVIGIL (brand for armodafinil) - Tier 2; PA; QL; AL

PROVIGIL (brand for modafinil) - Tier 2; PA; QL; AL

SODIUM OXYBATE (brand for sodium oxybate) - Tier 2; PA; SP; QL

SUNOSI - Tier 2; PA; QL

WAKIX - Tier 2; PA; QL

XYREM (brand for sodium oxybate) - Tier 2; PA; SP; QL

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat

Vitamin, Mineral and Body Fluid Deficiencies

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body

Fluid Deficiency Drugs

adc/f (0.5mg/ml) - Tier 1

animal shapes complete (generic for CEROVITE JR) - Tier 1; QL

BACMIN (brand for b-plex plus) - Tier 2; QL

biocel (generic for LYSIPLEX PLUS) - Tier 1; QL

b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL

calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL

calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL

calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1

calcium fast dissolution - Tier 1; QL

calcium high potency - Tier 1; QL

calcium oral tablet 1500 (600 ca) mg - Tier 1; QL

cerovite jr (generic for CEROVITE JR) - Tier 1; QL

chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL

childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL

BPROTECTED PEDIA POLY-VITE (brand for multivitamin infant &

toddler) - Tier 2; PA; QL

effer-k oral tablet effervescent 25 meq - Tier 1; PA; QL

ELFOLATE (brand for l-methylfolate) - Tier 2; PA

klor-con/ef - Tier 1; PA; QL

k-prime - Tier 1; PA; QL

L-ISOLEUCINE - Tier 2; PA

l-methylfolate (generic for ELFOLATE) - Tier 1; PA

l-methylfolate calcium oral (generic for ELFOLATE) - Tier 1; PA

l-methyl-mc (generic for METAFOLBIC) - Tier 1; PA

METAFOLBIC (brand for l-methyl-mc) - Tier 2; PA

METAFOLBIC PLUS - Tier 2; PA

multivitamin infant & toddler oral solution (generic for BPROTECTED

PEDIA POLY-VITE) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

202

Preferred Agents Non-Preferred Agents

childrens chewables/iron (generic for LAND BEFORE TIME

MULTIVITAMIN) - Tier 1; QL

childrens complete oral tablet chewable 18 mg (generic for CEROVITE

JR) - Tier 1; QL

childrens vitamins/iron (generic for LAND BEFORE TIME

MULTIVITAMIN) - Tier 1; QL

CORVITA (brand for b-plex plus) - Tier 2; QL

DERMACINRX MULTITAM (brand for b-plex plus) - Tier 2; QL

DERMACINRX RIBOTIN-E (brand for b-plex plus) - Tier 2; QL

DIALYVITE SUPREME D (brand for b-plex plus) - Tier 2; QL

DIATROL (brand for b-plex plus) - Tier 2; QL

ergocalciferol oral capsule (generic for DRISDOL) - Tier 1; QL

FOLAGENT DHA (brand for v-c forte) - Tier 2

FOLAMAX (brand for b-plex plus) - Tier 2; QL

POLY-VI-SOL (brand for multivitamin infant & toddler) - Tier 2; PA; QL

POLY-VITE PEDIATRIC (brand for multivitamin infant & toddler) - Tier 2;

PA; QL

STROVITE FORTE - Tier 2; PA

FOLAMED DHA (brand for v-c forte) - Tier 2

FOLIFLEX (brand for b-plex plus) - Tier 2; QL

FOLITIN-Z (brand for b-plex plus) - Tier 2; QL

INFED - Tier 2; PA; QL

KEYFOLIC (brand for b-plex plus) - Tier 2; QL

KEYLOSA (brand for b-plex plus) - Tier 2; QL

lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL

MENATROL (brand for v-c forte) - Tier 2

MULTIPRO (brand for v-c forte) - Tier 2

MULTITOL-M (brand for b-plex plus) - Tier 2; QL

NUTRICAP (brand for b-plex plus) - Tier 2; QL

nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL

OCUVEL (brand for v-c forte) - Tier 2

ONEVITE (brand for b-plex plus) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

203

Preferred Agents Non-Preferred Agents

oyster shell calcium oral tablet 500 mg - Tier 1; QL

SIDEROL (brand for b-plex plus) - Tier 2; QL

STROVITE ONE (brand for b-plex plus) - Tier 2; PA; QL

tricitrates - Tier 1

tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; QL

tri-vite/fluoride oral solution 0.5 mg/ml - Tier 1

UDAMIN SP (brand for b-plex plus) - Tier 2; QL

v-c forte (generic for VIC-FORTE) - Tier 1

VENEXA (brand for b-plex plus) - Tier 2; QL

VENEXA FE (brand for b-plex plus) - Tier 2; QL

vic-forte (generic for VIC-FORTE) - Tier 1

vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL

vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL

vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit

(generic for DRISDOL) - Tier 1; QL

vitamins acd-fluoride - Tier 1; QL

vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL

VITAROCA PLUS (brand for b-plex plus) - Tier 2; QL

VITRAMYN (brand for b-plex plus) - Tier 2; QL

VITRANOL (brand for b-plex plus) - Tier 2; QL

VITRANOL FE (brand for b-plex plus) - Tier 2; QL

VITREXYL (brand for b-plex plus) - Tier 2; QL

VITREXYL + IRON (brand for b-plex plus) - Tier 2; QL

WELLFOLA (brand for b-plex plus) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

204

Preferred Agents Non-Preferred Agents

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs

b-1 - Tier 1; QL

cyanocobalamin injection solution 1000 mcg/ml (generic for DODEX) -

Tier 1; QL

DODEX (brand for cyanocobalamin) - Tier 2; QL

pyridoxine hcl oral tablet 50 mg - Tier 1; QL

thiamine hcl injection - Tier 1; PA; QL

thiamine hcl oral - Tier 1; QL

TRUE VITAMIN B6 ORAL TABLET 50 MG - Tier 2; QL

vitamin b1 - Tier 1; QL

vitamin b-6 oral tablet 50 mg - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

205

Prior Authorization / Class Criteria

Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth

Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy; PA*: Preferred Alternative Trial Requirements

206

Index of Drugs

12 hour allergy-d........................................ 193

24 hour nasal allergy..................................195

3 day vaginal................................................ 37

3-day vaginal vaginal cream 2 %................. 37

8 hour arthritis pain...................................... 11

8 hour arthritis relief..................................... 11

8 hour pain relief oral tablet extended

release 650 mg............................................ 11

8 hour pain reliever...................................... 11

8 hr arthritis pain relief..................................11

8hr arthritis pain relief...................................11

8hr muscle aches & pain..............................11

abacavir sulfate............................................ 55

abacavir sulfate-lamivudine..........................55

abatron af................................................... 106

ABILIFY ASIMTUFII..................................... 51

ABILIFY MAINTENA.................................... 51

ABILIFY MYCITE MAINTENANCE KIT..... 153

ABILIFY MYCITE STARTER KIT...............153

ABILIFY ORAL TABLET 10 MG, 15 MG, 2

MG, 20 MG, 30 MG, 5 MG........................... 51

abiraterone acetate...................................... 41

ABRILADA (1 PEN)....................................153

ABRILADA (2 PEN)....................................153

ABRILADA (2 SYRINGE)...........................153

ABRILADA SUBCUTANEOUS AUTO-

INJECTOR KIT 40 MG/0.8ML....................153

ABRILADA SUBCUTANEOUS

PREFILLED SYRINGE KIT 20 MG/0.4ML,

40 MG/0.8ML............................................. 153

ABRYSVO..................................................153

ABSORICA LD............................................. 83

ABSORICA ORAL CAPSULE 10 MG, 20

MG, 30 MG, 40 MG......................................83

ABSORICA ORAL CAPSULE 25 MG, 35

MG............................................................... 83

acamprosate calcium................................... 18

ACANYA...................................................... 83

acarbose oral............................................... 59

ACCOLATE................................................186

ACCRUFER............................................... 104

ACCU-CHEK AVIVA DEVICE......................93

ACCU-CHEK AVIVA PLUS TEST STRIPS..93

ACCU-CHEK FASTCLIX LANCET KIT........93

ACCU-CHEK GUIDE CONTROL.................93

ACCU-CHEK GUIDE KIT W/DEVICE.......... 93

ACCU-CHEK GUIDE TEST STRIPS........... 93

ACCU-CHEK LINKASSIST.......................... 93

ACCU-CHEK SMARTVIEW......................... 93

ACCU-CHEK SMARTVIEW CONTROL...... 93

ACCU-CHEK SOFTCLIX LANCET

DEVICE KIT................................................. 93

ACCU-CHEK TENDER 1 INFUSION.........153

ACCUPRIL................................................... 68

ACCURETIC................................................ 71

accutane.......................................................83

ACCUTREND GLUCOSE............................ 93

ACCUTREND GLUCOSE CONTROL......... 94

ACE AEROSOL CLOUD ENHANCER.......153

acebutolol hcl oral........................................ 69

acetaminophen 8 hour................................. 11

acetaminophen 8 hours................................11

acetaminophen 8hr arth pain....................... 11

acetaminophen 8hr musc ache.................... 11

acetaminophen childrens............................. 11

acetaminophen childrens oral suspension

160 mg/5ml.................................................. 11

acetaminophen er........................................ 11

acetaminophen ex st oral tablet 500 mg...... 11

acetaminophen extra strength......................11

acetaminophen infants................................. 11

acetaminophen oral liquid 160 mg/5ml........ 11

acetaminophen oral solution 160 mg/5ml,

325 mg/10.15ml, 650 mg/20.3ml..................11

acetaminophen oral suspension 160

mg/5ml, 650 mg/20.3ml................................12

acetaminophen oral tablet 325 mg...............12

acetaminophen oral tablet 500 mg...............12

acetaminophen oral tablet chewable 160

mg................................................................ 12

acetaminophen rectal suppository 120 mg.. 12

acetaminophen rectal suppository 650 mg.. 12

acetaminophen-codeine.................................8

acetazolamide er..........................................71

acetazolamide oral....................................... 71

acetic acid otic............................................181

acetylcysteine inhalation............................ 190

acid controller oral tablet 10 mg................. 116

acid reducer oral tablet 10 mg....................116

acid reducer oral tablet delayed release 20

mg.............................................................. 117

ACIPHEX................................................... 117

acitretin.........................................................83

ACTEMRA..................................................146

ACTEMRA ACTPEN.................................. 146

ACTHAR.................................................... 130

ACTHIB...................................................... 149

ACTIFOAM COLLAGEN SPONGE............153

ACTIVASE................................................... 66

ACTIVELLA................................................135

ACTIVITE................................................... 110

ACTONEL.................................................. 153

ACTOPLUS MET......................................... 59

ACTOS.........................................................59

ACULAR.....................................................177

ACULAR LS............................................... 177

ACUVAIL....................................................177

acyclovir cream 5 % external....................... 54

acyclovir external ointment...........................54

acyclovir oral................................................ 54

ACZONE...................................................... 90

ADACEL.....................................................149

ADALIMUMAB-AACF (2 PEN)...................153

207

ADALIMUMAB-AATY (1 PEN)

SUBCUTANEOUS AUTO-INJECTOR KIT

40 MG/0.4ML............................................. 154

ADALIMUMAB-AATY (1 PEN)

SUBCUTANEOUS AUTO-INJECTOR KIT

80 MG/0.8ML............................................. 154

ADALIMUMAB-AATY (2 PEN)................... 154

ADALIMUMAB-AATY (2 SYRINGE).......... 154

ADALIMUMAB-ADAZ SUBCUTANEOUS

SOLUTION AUTO-INJECTOR...................154

ADALIMUMAB-ADAZ SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE........... 154

ADALIMUMAB-ADBM (2 PEN).................. 154

ADALIMUMAB-ADBM (2 SYRINGE)

SUBCUTANEOUS PREFILLED SYRINGE

KIT 40 MG/0.4ML.......................................154

ADALIMUMAB-ADBM (2 SYRINGE)

SUBCUTANEOUS PREFILLED SYRINGE

KIT 40 MG/0.8ML.......................................154

ADALIMUMAB-ADBM SUBCUTANEOUS

AUTO-INJECTOR KIT 40 MG/0.8ML.........154

ADALIMUMAB-ADBM SUBCUTANEOUS

PREFILLED SYRINGE KIT........................154

ADALIMUMAB-ADBM(CD/UC/HS STRT)

SUBCUTANEOUS AUTO-INJECTOR KIT

40 MG/0.4ML............................................. 154

ADALIMUMAB-ADBM(PS/UV STARTER)

SUBCUTANEOUS AUTO-INJECTOR KIT

40 MG/0.4ML............................................. 155

ADALIMUMAB-FKJP................................. 155

ADALIMUMAB-FKJP (2 SYRINGE)...........155

ADALIMUMAB-RYVK (2 PEN)...................155

adapalene external cream............................83

adapalene external gel.................................83

adapalene-benzoyl peroxide external gel

0.1-2.5 %......................................................83

adapalene-benzoyl peroxide external gel

0.3-2.5 %......................................................83

ADASUVE.................................................... 50

ADBRY.......................................................146

adc/f (0.5mg/ml)......................................... 202

ADCIRCA................................................... 189

ADDERALL ORAL TABLET 10 MG, 15

MG, 30 MG, 5 MG........................................78

ADDERALL ORAL TABLET 12.5 MG, 20

MG, 7.5 MG..................................................78

ADDERALL XR............................................ 78

adefovir dipivoxil...........................................53

ADEMPAS..................................................189

ADLARITY....................................................30

ADMELOG................................................... 60

ADMELOG SOLOSTAR...............................60

ADRENALIN INJECTION SOLUTION 1

MG/ML....................................................... 187

ADTHYZA.................................................. 144

ADULT AEROSOL MASK..........................155

ADVAIR DISKUS....................................... 195

ADVAIR HFA..............................................195

ADVANCED GLUCOSE TEST.................... 94

advanced probiotic oral capsule ...............119

ADVIL JUNIOR STRENGTH..........................4

ADVOCATE INSULIN PEN NEEDLE.......... 94

ADZENYS XR-ODT..................................... 78

AEMCOLO................................................... 20

AEROCHAMBER HOLDING CHAMBER...155

AEROCHAMBER PLS FLOVU MTHPIECE

....................................................................155

AEROCHAMBER PLUS FLO-VU INTERM155

AEROCHAMBER PLUS FLO-VU LARGE

DEVICE......................................................155

AEROCHAMBER PLUS FLO-VU MEDIUM

DEVICE......................................................155

AEROCHAMBER PLUS FLO-VU SMALL

DEVICE......................................................155

AEROECLIPSE EZ TWIST TUBING......... 155

AEROECLIPSE MASK LARGE................. 155

AEROECLIPSE MASK MEDIUM............... 155

AEROECLIPSE MASK SMALL..................156

AFINITOR.................................................... 43

AFINITOR DISPERZ....................................43

afirmelle......................................................135

AFLURIA QUADRIVALENT....................... 151

AFREZZA.....................................................60

AFRIN SALINE NASAL MIST.................... 191

aftera.......................................................... 144

AGAMREE................................................. 156

AGONEAZE................................................. 17

AGRYLIN..................................................... 65

AIMOVIG......................................................38

airavite........................................................110

AIRDUO RESPICLICK 113/14...................195

AIRDUO RESPICLICK 232/14...................195

AIRDUO RESPICLICK 55/14.....................195

AIRSUPRA AEROSOL 90-80 MCG/ACT

INHALATION..............................................156

AJOVY......................................................... 38

AKEEGA.................................................... 156

AKOVAZ INTRAVENOUS SOLUTION........ 76

AKTEN....................................................... 174

AKYNZEO.................................................... 35

AKYNZEO (READY-TO-USE)..................... 35

AKYNZEO (TO-BE-DILUTED)..................... 35

ala-cort......................................................... 85

ALAWAY.................................................... 181

ALAWAY CHILDRENS ALLERGY.............181

albendazole oral...........................................45

albuterol sulfate hfa aerosol solution 108

(90 base) mcg/act inhalation...................... 187

ALBUTEROL SULFATE HFA AEROSOL

SOLUTION 108 (90 BASE) MCG/ACT

INHALATION..............................................187

albuterol sulfate inhalation nebulization

solution (2.5 mg/3ml) 0.083%, 2.5

mg/0.5ml.................................................... 187

albuterol sulfate inhalation nebulization

solution 0.63 mg/3ml, 1.25 mg/3ml............ 187

208

albuterol sulfate nebulization solution (5

mg/ml) 0.5% inhalation...............................187

ALBUTEROL SULFATE NEBULIZATION

SOLUTION (5 MG/ML) 0.5% INHALATION

....................................................................187

albuterol sulfate oral syrup......................... 187

albuterol sulfate oral tablet 2 mg................ 187

albuterol sulfate oral tablet 4 mg................ 187

ALCAINE....................................................174

alclometasone dipropionate......................... 85

ALCOHOL PREP PADS PAD , 70 %........156

ALCOHOL PREP PADS SHEET 70 %...... 156

ALCOH-WIPE............................................ 156

ALDACTONE............................................... 73

ALECENSA................................................ 172

alendronate sodium....................................153

alfuzosin hcl er........................................... 129

ALINIA ORAL TABLET................................ 46

aliskiren fumarate.........................................71

ALKINDI SPRINKLE.................................. 130

all day allergy d.......................................... 193

all day allergy oral tablet 10 mg................. 183

all day allergy relief oral tablet 10 mg.........194

all day allergy-d oral tablet extended

release 12 hour 5-120 mg.......................... 193

all day pain relief oral tablet 220 mg.............. 4

all day relief.................................................... 4

aller-chlor................................................... 194

allerclear.....................................................194

allerclear d-12hr......................................... 197

allerclear d-24hr......................................... 197

allerg rel child (lorat)...................................194

allerg relief child (lorat)...............................194

allergy & congestion oral tablet extended

release 24 hour 10-240 mg........................ 197

allergy & congestion relief.......................... 197

allergy (cetirizine)....................................... 183

allergy 24hour indoor/outdoor.................... 183

allergy childrens oral liquid.........................183

allergy childrens oral solution.....................194

allergy eye drops........................................181

allergy medication...................................... 183

allergy medicine......................................... 183

allergy oral capsule 25 mg......................... 183

allergy oral liquid 12.5 mg/5ml................... 183

allergy oral tablet 25 mg.............................183

allergy oral tablet 4 mg...............................194

allergy rel child (loratadine)........................ 194

allergy relief (cetirizine) oral tablet 10 mg.. 183

allergy relief (loratadine) oral tablet............194

allergy relief adult....................................... 183

allergy relief cetirizine.................................183

allergy relief child....................................... 194

allergy relief childrens oral liquid 12.5

mg/5ml....................................................... 183

allergy relief childrens oral solution 5

mg/5ml....................................................... 194

allergy relief d oral tablet extended release

12 hour 5-120 mg.......................................193

allergy relief d-12........................................197

allergy relief d-24........................................197

allergy relief max st.................................... 183

allergy relief nasal decong......................... 197

allergy relief oral capsule 25 mg................ 183

allergy relief oral liquid 25 mg/10ml............183

allergy relief oral tablet 10 mg.................... 194

allergy relief oral tablet 25 mg.................... 183

allergy relief oral tablet 4 mg...................... 194

allergy relief oral tablet extended release

12 hour 5-120 mg.......................................193

allergy relief(cetirizine)............................... 183

allergy relief/indoor/outdoor oral tablet 10

mg.............................................................. 183

allergy relief/nasal decong......................... 197

allergy relief/nasal decongest oral tablet

extended release 12 hour.......................... 193

allergy relief/nasal decongest oral tablet

extended release 24 hour.......................... 197

allergy relief-d oral tablet extended release

12 hour 5-120 mg...............................193, 197

allergy relief-d oral tablet extended release

24 hour 10-240 mg.....................................197

allergy relief-d12.........................................197

allergy spray 24 hour nasal aerosol........... 195

allergy/congestion relief............................. 197

aller-tec...................................................... 184

aller-tec d................................................... 193

allopurinol oral tablet 100 mg, 300 mg......... 37

ALLOPURINOL ORAL TABLET 200 MG.....37

ALLZITAL....................................................... 8

almotriptan malate........................................39

ALOCRIL....................................................175

ALOGLIPTIN BENZOATE............................59

ALOGLIPTIN-METFORMIN HCL.................59

ALOGLIPTIN-PIOGLITAZONE.................... 59

ALOMIDE................................................... 175

ALORA....................................................... 135

alosetron hcl...............................................114

ALPHAGAN P............................................ 178

alprazolam er............................................... 57

alprazolam intensol...................................... 57

alprazolam oral tablet...................................57

alprazolam oral tablet dispersible.................57

alprazolam xr................................................57

ALREX....................................................... 177

ALTACAINE............................................... 174

ALTACE....................................................... 68

altafrin........................................................ 174

altalube.......................................................179

altamist spray............................................. 191

altarussin....................................................191

altarussin dm..............................................197

altavera...................................................... 135

ALTOPREV.................................................. 74

ALTRENO.................................................... 83

ALUNBRIG.................................................172

ALVAIZ.......................................................156

209

ALVESCO.................................................. 186

alvimopan...................................................119

alyacen 1/35...............................................135

alyacen 7/7/7..............................................135

alyq.............................................................189

amabelz......................................................135

amantadine hcl oral capsule........................ 48

amantadine hcl oral solution........................ 48

amantadine hcl oral tablet............................ 48

AMBIEN..................................................... 201

AMBIEN CR............................................... 201

ambrisentan............................................... 189

amcinonide external cream.......................... 85

AMELUZ.......................................................88

amethyst.....................................................135

amiloride hcl oral.......................................... 73

amiloride-hydrochlorothiazide...................... 71

aminocaproic acid oral solution....................66

aminocaproic acid oral tablet....................... 66

amiodarone hcl oral......................................69

AMITIZA..................................................... 114

amitriptyline hcl oral..................................... 34

AMJEVITA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 40 MG/0.4ML, 80

MG/0.8ML.................................................. 156

AMJEVITA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 40 MG/0.8ML............... 156

AMJEVITA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 40 MG/0.4ML........156

AMJEVITA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 40 MG/0.8ML........156

AMJEVITA-PED 10KG TO .............156

AMJEVITA-PED 15KG TO ........156

amlodipine besylate oral.............................. 70

amlodipine besylate-benazepril hcl.............. 71

amlodipine besylate-valsartan......................71

amlodipine-atorvastatin................................ 71

amlodipine-olmesartan.................................71

amlodipine-valsartan-hctz............................ 71

ammonium lactate external.......................... 85

amnesteem.................................................. 83

amoxapine....................................................34

amoxicill-clarithro-lansopraz.......................115

amoxicillin.....................................................23

amoxicillin-potassium clavulanate er............23

amoxicillin-potassium clavulanate oral

suspension reconstituted 200-28.5 mg/5ml,

250-62.5 mg/5ml, 400-57 mg/5ml................ 23

amoxicillin-potassium clavulanate oral

suspension reconstituted 600-42.9 mg/5ml. 23

amoxicillin-potassium clavulanate oral

tablet 250-125 mg, 875-125 mg................... 23

amoxicillin-potassium clavulanate oral

tablet 500-125 mg........................................ 23

amoxicillin-potassium clavulanate oral

tablet chewable 200-28.5 mg, 400-57 mg....23

amphetamine sulfate....................................78

amphetamine-dextroamphetamine er.......... 78

amphetamine-dextroamphetamine oral

tablet 10 mg, 15 mg, 30 mg, 5 mg............... 78

amphetamine-dextroamphetamine oral

tablet 12.5 mg, 20 mg, 7.5 mg..................... 78

amphet-dextroamphet 3-bead er..................78

amphotericin b intravenous.......................... 36

ampicillin...................................................... 23

ampicillin-sulbactam sodium injection

solution reconstituted 3 (2-1) gm..................23

AMPYRA...................................................... 80

AMRIX........................................................200

ANAFRANIL................................................. 34

anagrelide hcl...............................................65

ana-lex......................................................... 91

ANALPRAM HC........................................... 88

ANALPRAM HC SINGLES...........................88

ANALPRAM-HC........................................... 88

ANAPROX DS................................................4

ANASPAZ.................................................. 156

anastrozole oral............................................42

ANCOBON................................................... 36

ANDRODERM............................................134

ANDROGEL PUMP....................................134

ANGELIQ................................................... 135

animal shapes complete............................ 202

ANNOVERA............................................... 135

ANODYNE LPT............................................17

ANORO ELLIPTA.......................................195

antacid calcium.......................................... 119

antacid calcium rich....................................119

antacid extra str..........................................119

antacid extra strength oral tablet chewable

750 mg....................................................... 119

antacid kids................................................ 119

antacid maximum....................................... 119

antacid maximum strength oral tablet

chewable 1000 mg..................................... 119

antacid oral tablet chewable 1000 mg........119

antacid oral tablet chewable 500 mg..........119

antacid oral tablet chewable 750 mg..........120

antacid ultra strength..................................120

antacid ultra strength oral tablet chewable

1000 mg..................................................... 120

antibiotic..................................................... 156

antibiotic external ointment 500 unit/gm.....156

anti-diarrheal oral suspension 262 mg/15ml

....................................................................120

anti-diarrheal oral tablet 2 mg.................... 114

antifungal (tolnaftate)................................. 156

antifungal external cream.............................37

antifungal miconazole.................................. 37

antifungal tolnaftate....................................156

anti-hist allergy........................................... 184

anti-itch aloe.................................................85

anti-itch intensive heal..................................85

anti-itch max str external cream 1 %............85

anti-itch maximum strength external cream

1 %............................................................... 85

210

ANTIVERT ORAL TABLET.......................... 34

ANTIVERT ORAL TABLET CHEWABLE.....34

anucort-hc.................................................... 38

ANUSOL-HC EXTERNAL.......................... 152

ANUSOL-HC RECTAL.................................38

ANZEMET.................................................... 35

APADAZ.........................................................8

apap-caff-dihydrocodeine...............................8

APEXICON E............................................... 85

APHEXDA.................................................. 156

APIDRA SOLOSTAR SOLUTION PEN-

INJECTOR 100 UNIT/ML

SUBCUTANEOUS....................................... 60

APIDRA VIAL............................................... 60

APLENZIN....................................................32

APOKYN...................................................... 48

apomorphine hcl subcutaneous................... 48

APONVIE..................................................... 35

apraclonidine hcl........................................ 178

aprepitant oral.............................................. 35

aprepitant oral capsule 125 mg, 40 mg........35

aprepitant oral capsule 80 mg......................35

aprepitant pak 80 & 125mg.......................... 35

apri............................................................. 135

APRISO......................................................152

APTENSIO XR ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG,

15 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60

MG............................................................... 77

APTIOM....................................................... 29

APTIVUS......................................................56

AQ INSULIN SYRINGE..............................156

AQINJECT PEN NEEDLE 31G X 5 MM.... 156

AQINJECT PEN NEEDLE 32G X 4 MM...... 94

aqueous vitamin d...................................... 110

ARALAST NP.............................................127

aranelle...................................................... 135

ARANESP (ALBUMIN FREE)...................... 65

ARAVA....................................................... 148

ARAZLO.......................................................83

ARCALYST................................................ 146

AREXVY.....................................................156

arformoterol tartrate................................... 187

ARICEPT ORAL TABLET 10 MG, 5 MG......30

ARICEPT ORAL TABLET 23 MG................ 30

ARIKAYCE................................................... 20

ARIMIDEX....................................................42

aripiprazole oral solution.............................. 51

aripiprazole oral tablet 10 mg, 15 mg, 2

mg, 20 mg, 30 mg, 5 mg.............................. 51

aripiprazole oral tablet dispersible................51

ARISTADA................................................... 51

ARISTADA INITIO........................................51

ARIXTRA SUBCUTANEOUS SOLUTION

10 MG/0.8ML, 7.5 MG/0.6ML.......................64

ARIXTRA SUBCUTANEOUS SOLUTION

2.5 MG/0.5ML, 5 MG/0.4ML.........................64

armodafinil..................................................202

ARMOUR THYROID.................................. 144

ARNUITY ELLIPTA.................................... 186

AROMASIN.................................................. 42

arthritis pain oral tablet extended release

650 mg......................................................... 12

arthritis pain relief oral tablet extended

release 650 mg............................................ 12

arthritis pain reliever oral..............................12

ARTHROTEC.................................................4

ascomp-codeine.............................................8

asenapine maleate.......................................51

ashlyna.......................................................135

ASMANEX (120 METERED DOSES)........ 186

ASMANEX (14 METERED DOSES).......... 186

ASMANEX (30 METERED DOSES).......... 186

ASMANEX (60 METERED DOSES).......... 186

ASMANEX HFA......................................... 186

ASPARTAME (FOR COMPOUNDING)..... 156

ASPARTAME (NUTRASWEET)................ 156

aspirin adults.............................................. 157

aspirin childrens......................................... 157

aspirin ec oral tablet 325 mg...................... 157

aspirin ec oral tablet delayed release 325

mg.............................................................. 157

aspirin ec oral tablet delayed release 81

mg.............................................................. 157

aspirin oral tablet 325 mg...........................157

aspirin oral tablet chewable 81 mg.............157

aspirin oral tablet delayed release 325 mg 157

aspirin oral tablet delayed release 81 mg.. 157

ASPIRIN ORAL TABLET DELAYED

RELEASE 81 MG.......................................157

aspirin regimen...........................................157

aspirin-dipyridamole er.................................66

ASPRUZYO SPRINKLE...............................71

ASSURE ID DUO PRO PEN NEEDLES....157

ASSURE ID PRO PEN NEEDLES.............157

ASTAGRAF XL ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 0.5 MG,

1 MG.......................................................... 148

ASTAGRAF XL ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 5 MG....148

ASTEPRO.................................................. 184

ASTEPRO CHILDRENS............................ 184

ASTRINGYN................................................ 66

ATACAND.................................................... 68

ATACAND HCT............................................71

atazanavir sulfate......................................... 56

ATELVIA.................................................... 153

atenolol oral..................................................69

atenolol-chlorthalidone................................. 71

athletes foot (tolnaftate) external cream 1

%................................................................ 157

ATIVAN INJECTION.................................... 57

ATIVAN ORAL............................................. 57

atomoxetine hcl............................................ 77

ATORVALIQ.................................................74

atorvastatin calcium oral.............................. 74

atovaquone.................................................. 46

211

atovaquone-proguanil hcl.............................46

ATRALIN...................................................... 83

atropine sulfate ophthalmic ointment......... 174

atropine sulfate ophthalmic solution 1 %....174

ATROVENT HFA....................................... 187

AUBAGIO.....................................................80

aubra eq..................................................... 135

AUGMENTIN................................................23

AUGMENTIN ES-600...................................23

AUGTYRO................................................. 157

AUM ALCOHOL PREP PADS................... 157

AUM INSULIN SAFETY PEN NEEDLE

31G X 4 MM............................................... 157

AUM INSULIN SAFETY PEN NEEDLE

31G X 5 MM............................................... 157

AUM MINI INSULIN PEN NEEDLE 32G X

4 MM............................................................ 94

AUM MINI INSULIN PEN NEEDLE 32G X

5 MM , 32G X 6 MM..................................... 94

AUM MINI INSULIN PEN NEEDLE 32G X

8 MM , 33G X 4 MM , 33G X 5 MM , 33G X

6 MM.......................................................... 157

AUM PEN NEEDLE 32G X 4 MM................ 94

AUM PEN NEEDLE 32G X 5 MM , 32G X

6 MM............................................................ 94

AUM PEN NEEDLE 33G X 4 MM , 33G X

5 MM , 33G X 6 MM................................... 157

AUM READYGARD DUO PEN NEEDLE.....94

AUM SAFETY PEN NEEDLE 31G X 4 MM157

AUM SAFETY PEN NEEDLE 31G X 5 MM157

aurovela 1.5/30.......................................... 135

aurovela 1/20............................................. 135

aurovela 24 fe............................................ 135

aurovela fe 1.5/30...................................... 135

aurovela fe 1/20......................................... 135

AURYXIA................................................... 110

AUSTEDO....................................................79

AUSTEDO XR..............................................79

AUSTEDO XR PATIENT TITRATION..........79

AUVELITY..................................................157

AUVI-Q.......................................................187

AVALIDE...................................................... 71

AVAPRO...................................................... 68

AVAR CLEANSER....................................... 91

AVAR LS CLEANSER..................................91

AVAR-E EMOLLIENT.................................. 91

AVAR-E GREEN.......................................... 91

AVAR-E LS.................................................. 91

AVEDANA GLYCERIN (ADULT)............... 124

AVEED....................................................... 134

aviane.........................................................135

avidoxy......................................................... 25

AVITENE....................................................157

AVITENE FLOUR.......................................157

AVODART..................................................129

AVONEX PEN..............................................80

AVONEX PREFILLED..................................80

AVSOLA.....................................................148

AYR............................................................191

ayuna......................................................... 135

AYVAKIT ORAL TABLET 100 MG, 200

MG, 300 MG...............................................172

AYVAKIT ORAL TABLET 25 MG, 50 MG.. 172

AZASAN.....................................................148

AZASITE.................................................... 176

azathioprine oral tablet 100 mg, 75 mg......148

azathioprine oral tablet 50 mg....................148

azelaic acid external.....................................83

azelastine hcl nasal solution 0.1 %, 137

mcg/spray...................................................184

azelastine hcl nasal solution 0.15 %.......... 184

azelastine hcl ophthalmic........................... 175

azelastine-fluticasone.................................184

AZILECT...................................................... 50

azithromycin oral packet.............................. 24

azithromycin oral suspension reconstituted. 24

azithromycin oral tablet................................ 24

AZOPT....................................................... 178

AZOR........................................................... 71

AZSTARYS.................................................. 78

AZULFIDINE.............................................. 152

AZULFIDINE EN-TABS..............................152

azurette...................................................... 135

b-1.............................................................. 205

BABY AYR SALINE................................... 191

bac................................................................. 8

bacitracin external...................................... 157

bacitracin external ointment 500 unit/gm... 157

bacitracin ophthalmic................................. 176

bacitracin zinc external...............................157

bacitracin zinc first aid................................157

bacitracin zinc-aloe.................................... 157

bacitracin-polymyxin b................................176

bacitra-neomycin-polymyxin-hc..................174

BACLOFEN ORAL SOLUTION....................53

baclofen oral suspension............................. 53

baclofen oral tablet 10 mg, 20 mg, 5 mg......53

baclofen oral tablet 15 mg............................53

BACMIN..................................................... 202

BACTRIM..................................................... 25

BACTRIM DS............................................... 25

BAFIERTAM.................................................80

BALCOLTRA..............................................135

balsalazide disodium..................................152

BALVERSA.................................................. 43

balziva........................................................ 135

banophen oral capsule 25 mg....................184

banophen oral tablet.................................. 184

BANZEL....................................................... 29

BAQSIMI ONE PACK...................................60

BAQSIMI TWO PACK.................................. 60

BARACLUDE............................................... 53

BASAGLAR KWIKPEN................................ 60

BASAGLAR TEMPO PEN............................60

BAXDELA ORAL..........................................24

BAYER ASPIRIN........................................157

212

BAYER LOW DOSE ORAL TABLET

CHEWABLE............................................... 157

baza antifungal.............................................37

BD AUTOSHIELD DUO PEN NEEDLES... 157

BD BLUNT FILTER NEEDLE.......................64

BD ECLIPSE LUER-LOK NEEDLE............157

BD ECLIPSE NEEDLE 18G X 1-1/2"........... 64

BD ECLIPSE NEEDLE 21G X 1" , 21G X

1-1/2" , 23G X 1" , 25G X 5/8" , 27G X 1/2"157

BD ECLIPSE NEEDLE 25G X 1-1/2"......... 157

BD ECLIPSE SHIELDED NEEDLE..............64

BD NOKOR ADMIX NEEDLE...................... 64

BD SAFETYGLIDE NEEDLE 21G X 1"......157

BD SAFETYGLIDE SHIELDED NEEDLE

21G X 1-1/2"...............................................157

BD ULTRA-FINE INSULIN SYRINGES

......................................................94, 157, 158

BD ULTRA-FINE INSULIN SYRINGES

30G X 1/2" 0.5 ML......................................157

BD ULTRA-FINE INSULIN SYRINGES

30G X 1/2" 1 ML, 31G X 5/16" 0.5 ML....... 157

BD ULTRA-FINE INSULIN SYRINGES

31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML. 158

BD ULTRA-FINE INSULIN SYRINGES

31G X 5/16" 0.3 ML....................................158

BD ULTRA-FINE INSULIN SYRINGES

31G X 5/16" 1 ML.......................................158

BD ULTRA-FINE PEN NEEDLES................94

BD ULTRA-FINE PEN NEEDLES 29G X

12.7MM...................................................... 158

BD ULTRA-FINE PEN NEEDLES 31G X 5

MM............................................................. 158

BD ULTRA-FINE PEN NEEDLES 31G X 8

MM............................................................. 158

BELBUCA...................................................... 6

BELSOMRA............................................... 201

BENADRYL ALLERGY CHILDRENS

ORAL LIQUID............................................ 184

BENADRYL ALLERGY ULTRATABS........ 184

benazepril hcl oral........................................ 68

benazepril-hydrochlorothiazide.................... 71

BENICAR..................................................... 68

BENICAR HCT.............................................71

BENLYSTA INTRAVENOUS..................... 146

BENLYSTA SUBCUTANEOUS................. 146

BENZAMYCIN..............................................83

BENZHYDROCODONE-

ACETAMINOPHEN........................................8

BENZNIDAZOLE..........................................46

BENZOYL PEROXIDE EXTERNAL GEL 8

%................................................................ 158

benzoyl peroxide-erythromycin.................... 83

benztropine mesylate oral............................ 47

bepotastine besilate solution 1.5 %

ophthalmic..................................................175

BEPREVE.................................................. 175

BESIVANCE...............................................176

BESREMI..................................................... 45

BETADINE OPHTHALMIC PREP..............180

betaine....................................................... 127

BETAMETHASONE COMBO INJECTION

SUSPENSION 6 (3-3) MG/ML................... 130

betamethasone dipropionate aug.................85

betamethasone dipropionate external

cream........................................................... 85

betamethasone dipropionate external lotion 85

betamethasone dipropionate external

ointment....................................................... 85

BETAMETHASONE SOD PHOS & ACET

SUSPENSION 6 (3-3) MG/ML INJECTION130

betamethasone sod phos & acet

suspension 6 (3-3) mg/ml injection............ 130

betamethasone valerate external cream......85

betamethasone valerate external foam........85

betamethasone valerate external lotion....... 85

betamethasone valerate external ointment.. 85

BETAPACE.................................................. 69

BETAPACE AF............................................ 69

BETASERON............................................... 80

betatemp childrens.......................................12

betaxolol hcl ophthalmic.............................178

betaxolol hcl oral.......................................... 69

bethanechol chloride oral........................... 129

BETHKIS....................................................188

BETIMOL................................................... 178

BETOPTIC-S..............................................178

BEVESPI AEROSPHERE..........................195

bexarotene................................................... 44

BEXSERO..................................................149

BEYAZ....................................................... 135

bicalutamide................................................. 41

BICILLIN L-A................................................ 23

BIDIL............................................................ 71

BIGFOOT UNITY PROGRAM....................158

BIJUVA CAPSULE 1-100 MG ORAL......... 135

BIJUVA ORAL CAPSULE 0.5-100 MG...... 135

BIKTARVY ORAL TABLET 30-120-15 MG..54

BIKTARVY ORAL TABLET 50-200-25 MG..54

BILAC.........................................................120

BILAYER MATRIX WOUND DRESSING...158

BILTRICIDE................................................. 45

bimatoprost solution 0.03 % ophthalmic.... 174

BIMZELX....................................................158

BINAXNOW COVID-19 AG HOME TEST..158

BINOSTO................................................... 153

BIO GLO.................................................... 179

biocel..........................................................202

BIOLLE TEARS..........................................179

BIOTEL CARE TEST STRIPS..................... 94

BIOTHRAX.................................................151

bis subcit-metronid-tetracyc....................... 115

bisacodyl ec............................................... 158

bisacodyl laxative....................................... 158

bisacodyl oral............................................. 158

bisacodyl rectal.......................................... 158

bismuth.......................................................120

bismuth subsalicylate oral.......................... 120

213

bismuth/metronidaz/tetracyclin...................115

bisoprolol fumarate oral................................69

bisoprolol-hydrochlorothiazide..................... 71

blisovi 24 fe................................................ 135

blisovi fe 1.5/30.......................................... 135

blisovi fe 1/20............................................. 135

BLOOD GLUCOSE MONITORING 333.......94

BLOOD GLUCOSE TEST IN VITRO

STRIP...........................................................94

BLOOD GLUCOSE TEST STRIPS........94, 97

BLOOD GLUCOSE TEST STRIPS 333.......94

BLUESTAR................................................ 158

BONINE....................................................... 34

BONJESTA.................................................. 34

BOOSTRIX.................................................149

bortezomib intravenous................................42

bosentan.................................................... 189

BOSULIF ORAL CAPSULE....................... 172

BOSULIF ORAL TABLET.......................... 172

bp 10-1......................................................... 91

b-plex......................................................... 110

b-plex plus..................................................202

BPROTECTED PEDIA IRON.....................106

BPROTECTED PEDIA POLY-VITE........... 202

BRAFTOVI................................................... 43

BREATHE COMFORT CHAMBER/ADULT158

BREATHE COMFORT CHAMBER/CHILD 158

BREATHE COMFORT HUMIDIFIER......... 158

BREATHE EASE HUMIDIFIER..................158

BREATHE EASE NEB MASK/CHILD........ 158

BREATHE EASE NEB MASK/INFANT...... 158

BREO ELLIPTA AEROSOL POWDER

BREATH ACTIVATED 100-25 MCG/ACT

INHALATION..............................................195

BREO ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 200-25

MCG/ACT...................................................196

BREO ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 50-25

MCG/INH....................................................196

BREXAFEMME.......................................... 158

breyna........................................................ 196

BREZTRI AEROSPHERE..........................196

briellyn........................................................135

BRILINTA..................................................... 66

brimonidine tartrate external........................ 83

brimonidine tartrate ophthalmic..................178

brimonidine tartrate-timolol.........................174

brinzolamide...............................................178

BRIUMVI.................................................... 159

BRIVIACT INTRAVENOUS..........................26

BRIVIACT ORAL..........................................26

BRIXADI.......................................................18

BRIXADI (WEEKLY).................................... 18

bromfenac sodium (once-daily) solution

0.09 % ophthalmic......................................177

bromfenac sodium ophthalmic................... 177

bromocriptine mesylate oral......................... 48

BROMSITE................................................ 177

BRONCHITOL..............................................82

BRONCHITOL TOLERANCE TEST............ 82

BROVANA..................................................187

BRUKINSA.................................................172

BRUSELIX EXTERNAL CREAM................. 17

BRYHALI......................................................85

BUBBLES THE FISH II PEDI MASK..........159

BUCKLEYS CHEST CONGESTION..........191

budesonide er............................................ 152

budesonide inhalation................................ 186

budesonide oral..........................................152

budesonide rectal foam 2 mg.....................152

budesonide rectal foam 2 mg/act............... 152

budesonide-formoterol fumarate................ 196

bumetanide injection.................................... 72

bumetanide oral........................................... 72

BUMEX........................................................ 72

BUPAP........................................................... 8

BUPIVACAINE HCL (BULK)........................ 17

buprenorphine................................................ 6

buprenorphine hcl sublingual....................... 10

buprenorphine hcl-naloxone hcl sublingual

film................................................................18

buprenorphine hcl-naloxone hcl sublingual

tablet sublingual........................................... 18

bupropion hcl er (smoking det).....................19

bupropion hcl er (sr)..................................... 32

bupropion hcl er (xl) oral tablet extended

release 24 hour 150 mg, 300 mg................. 32

BUPROPION HCL ER (XL) ORAL TABLET

EXTENDED RELEASE 24 HOUR 450 MG..32

bupropion hcl oral.........................................32

buspirone hcl oral.........................................57

butalbital-acetaminophen capsule 50-300

mg oral........................................................... 8

BUTALBITAL-ACETAMINOPHEN

CAPSULE 50-300 MG ORAL.........................8

butalbital-acetaminophen tablet 50-300 mg

oral................................................................. 8

butalbital-acetaminophen tablet 50-325 mg

oral................................................................. 8

butalbital-apap-caff-cod..................................8

butalbital-apap-caffeine capsule 50-300-40

mg oral........................................................... 8

butalbital-apap-caffeine oral capsule 50-

325-40 mg...................................................... 8

butalbital-apap-caffeine oral tablet................. 8

butalbital-asa-caff-codeine............................. 8

butalbital-aspirin-caffeine............................... 8

butorphanol tartrate nasal.............................. 8

BUTRANS...................................................... 6

BYDUREON BCISE AUTOINJECTOR........ 59

BYETTA 10 MCG PEN................................ 59

BYETTA 5 MCG PEN.................................. 59

BYSTOLIC................................................... 69

cabergoline.................................................145

214

CABOMETYX.............................................172

CABTREO....................................................91

CADUET...................................................... 71

caffeine citrate oral.......................................79

calcipotriene external cream........................ 88

CALCIPOTRIENE EXTERNAL FOAM.........88

calcipotriene external ointment.................... 88

calcipotriene external solution......................88

calcipotriene-betameth diprop external

ointment....................................................... 88

calcipotriene-betameth diprop external

suspension................................................... 88

calcitonin (salmon) injection....................... 153

calcitonin (salmon) nasal............................153

CALCITRENE.............................................. 88

calcitriol external.......................................... 88

calcitriol oral capsule..................................153

calcitriol oral solution..................................153

calcium + vitamin d3 oral tablet 500-5 mg-

mcg............................................................ 106

calcium 500/vitamin d3...............................106

calcium 600 oral tablet 1500 (600 ca) mg.. 202

calcium 600/vitamin d.................................106

calcium 600/vitamin d-3............................. 106

calcium 600+d oral tablet 600-10 mg-mcg.106

calcium acetate (phos binder) oral capsule110

calcium acetate (phos binder) oral tablet... 110

calcium acetate oral tablet 667 mg............ 110

calcium antacid.......................................... 120

calcium antacid ex st oral tablet chewable

750 mg....................................................... 120

calcium antacid extra strength................... 120

calcium carb-cholecalciferol oral tablet

600-10 mg-mcg.......................................... 106

calcium carb-cholecalciferol oral tablet

600-5 mg-mcg............................................ 106

calcium carbonate antacid oral suspension120

calcium carbonate antacid oral tablet.........120

calcium carbonate antacid oral tablet

chewable.................................................... 120

calcium carbonate oral tablet 1500 (600

ca) mg........................................................ 202

calcium carbonate oral tablet chewable

1250 (500 ca) mg....................................... 202

calcium fast dissolution.............................. 202

calcium high potency..................................202

calcium high potency/vitamin d.................. 106

calcium oral tablet 1500 (600 ca) mg......... 202

calcium plus vitamin d oral tablet 500-5

mg-mcg...................................................... 106

calcium plus vitamin d oral tablet 600-10

mg-mcg...................................................... 106

calcium plus vitamin d oral tablet 600-5

mg-mcg...................................................... 106

calcium plus vitamin d3.............................. 107

CALDOLOR INTRAVENOUS SOLUTION

800 MG/200ML.............................................. 4

cal-gest antacid.......................................... 120

CALQUENCE.............................................159

CAMBIA......................................................... 4

CAMCEVI...................................................159

camila.........................................................142

camrese..................................................... 135

camrese lo..................................................135

CAMZYOS................................................. 159

CANASA.................................................... 152

CANCIDAS INTRAVENOUS SOLUTION

RECONSTITUTED 70 MG...........................36

candesartan cilexetil.....................................68

candesartan cilexetil-hctz.............................71

CANTHARIDIN EXTERNAL.......................159

capecitabine................................................. 45

CAPLYTA ORAL CAPSULE 10.5 MG, 21

MG............................................................... 51

CAPLYTA ORAL CAPSULE 42 MG............ 51

CAPRELSA................................................ 172

captopril oral.................................................68

captopril-hydrochlorothiazide....................... 71

CARAC.........................................................88

CARAFATE ORAL SUSPENSION.............116

CARAFATE ORAL TABLET.......................116

carbamazepine er........................................ 29

carbamazepine oral......................................29

CARBATROL............................................... 29

carbidopa oral.............................................. 49

carbidopa-levodopa er................................. 49

carbidopa-levodopa oral tablet.....................49

carbidopa-levodopa oral tablet dispersible...49

carbidopa-levodopa-entacapone..................48

carbinoxamine maleate oral solution..........184

carbinoxamine maleate oral tablet 4 mg.... 184

carbinoxamine maleate oral tablet 6 mg.... 184

carboxymethylcellulose sodium ophthalmic

solution.......................................................179

CARDIZEM.................................................. 70

CARDIZEM CD............................................ 70

CARDIZEM LA............................................. 70

CARDURA................................................... 67

CARDURA XL ORAL TABLET

EXTENDED RELEASE 24 HOUR 8 MG....129

CARDURA XL TABLET EXTENDED

RELEASE 24 HOUR 4 MG ORAL............. 129

CAREPOINT POLY HUB NEEDLE 18G X

1"..................................................................64

CAREPOINT POLY HUB NEEDLE 20G X

1" , 21G X 1" , 22G X 1" , 23G X 1" , 25G X

1" , 25G X 5/8"........................................... 159

CAREPOINT POLY HUB NEEDLE 22G X

1-1/2"..........................................................159

CAREPOINT SAFETY 1ST NEEDLE........ 159

CARESENS CONTROL SOLUTION A/B.....95

CARESENS LANCETS 30G........................ 95

CARESENS N FELIZ................................... 95

CARESENS N FELIZ BT............................. 95

CARESENS N GLUCOSE SYSTEM........... 95

CARESENS N VOICE SYSTEM..................95

215

CARESTART COVID-19 HOME TEST......159

CARETOUCH 2 CPAP HOSE HANGER... 159

CARETOUCH CONTROL SOL LEVEL 2.... 95

CARETOUCH CPAP & BIPAP HOSE....... 159

CARETOUCH CPAP MASK WIPES..........159

CARETOUCH CPAP PRE-WASH SOLN.. 159

CARETOUCH CPAP TUBE BRUSH......... 159

CARETOUCH HYPODERMIC NEEDLE

18G X 1-1/2".................................................64

CARETOUCH HYPODERMIC NEEDLE

20G X 1" , 22G X 1" , 23G X 1" , 25G X 1" ,

25G X 5/8"..................................................159

CARETOUCH HYPODERMIC NEEDLE

23G X 1-1/2" , 25G X 1-1/2".......................159

CARETOUCH HYPODERMIC NEEDLE

27G X 1-1/2"...............................................159

CARETOUCH MONITOR SYSTEM.............95

CARETOUCH TEST.................................... 95

CARETOUCH TWIST MC LANCETS 30G.. 95

CARETOUCH UNIVERSL CPAP FILTER. 159

carisoprodol oral.........................................200

CARNITOR ORAL SOLUTION.................. 127

CARNITOR ORAL TABLET....................... 127

CARNITOR SF...........................................127

CAROSPIR.................................................. 73

carteolol hcl................................................ 178

cartia xt.........................................................70

carvedilol...................................................... 69

carvedilol phosphate er................................ 69

CASODEX....................................................41

caspofungin acetate intravenous solution

reconstituted 70 mg......................................36

CATAPRES-TTS-1.......................................67

CATAPRES-TTS-2.......................................67

CATAPRES-TTS-3.......................................67

CATHFLO ACTIVASE..................................66

CAYA......................................................... 159

CAYSTON..................................................188

cefaclor er.................................................... 22

cefaclor oral capsule.................................... 22

cefaclor oral suspension reconstituted.........22

cefadroxil......................................................22

cefazolin sodium injection solution

reconstituted 1 gm, 10 gm............................22

cefazolin sodium-dextrose intravenous

solution 2-4 gm/100ml-%............................. 22

cefdinir..........................................................22

cefepime hcl intravenous solution

reconstituted 2 gm........................................22

cefixime oral capsule....................................22

cefixime oral suspension reconstituted........ 22

CEFOTAN.................................................... 22

cefotetan disodium....................................... 22

cefoxitin sodium intravenous solution

reconstituted 10 gm......................................22

cefpodoxime proxetil oral suspension

reconstituted.................................................22

cefpodoxime proxetil oral tablet................... 22

cefprozil........................................................22

ceftazidime injection.....................................22

ceftazidime intravenous............................... 22

ceftriaxone sodium injection solution

reconstituted 1 gm, 2 gm, 250 mg, 500 mg..22

cefuroxime axetil.......................................... 22

CELEBREX.................................................... 4

celecoxib capsule 100 mg oral.......................4

celecoxib capsule 200 mg oral.......................4

celecoxib capsule 50 mg oral.........................4

celecoxib oral capsule 400 mg.......................4

CELESTONE SOLUSPAN.........................130

CELEXA....................................................... 33

CELLCEPT ORAL CAPSULE.................... 148

CELLCEPT ORAL SUSPENSION

RECONSTITUTED.....................................148

CELLCEPT ORAL TABLET....................... 148

CELONTIN................................................... 28

cephalexin oral capsule................................22

cephalexin oral suspension reconstituted.... 22

cephalexin oral tablet................................... 22

CEPROTIN...................................................64

CEQUA...................................................... 174

CEQUR SIMPLICITY 2U 10PK..................159

CEREBYX INJECTION SOLUTION 500

MG PE/10ML................................................29

cerovite jr....................................................202

CERVIDIL...................................................133

cetiri-d........................................................ 193

cetirizine allergy relief.................................184

cetirizine hcl oral solution........................... 184

cetirizine hcl oral tablet...............................184

cetirizine-pseudoephedrine er....................193

CETRAXAL................................................ 181

cevimeline hcl...............................................82

charlotte 24 fe............................................ 136

chateal eq...................................................136

CHEMET.................................................... 109

CHEMSTRIP 10 MD.................................... 95

CHEMSTRIP 10/SG.....................................95

CHEMSTRIP 2 GP.......................................95

CHEMSTRIP 5 OB.......................................95

CHEMSTRIP 7............................................. 95

CHEMSTRIP 9............................................. 95

CHEMSTRIP K.............................................95

CHEMSTRIP MICRAL................................. 95

CHEMSTRIP UGK....................................... 95

CHENODAL............................................... 115

chest congestion relief dm oral syrup.........197

chest congestion relief oral liquid............... 191

chewable childrens vitamin........................ 202

chewy not chalky flavor.............................. 120

childrens acetaminophen............................. 12

childrens allergy oral liquid 12.5 mg/5ml.... 184

childrens animal shapes.............................202

childrens apap..............................................12

childrens aspirin oral tablet chewable 81

mg.............................................................. 159

childrens chewables/iron............................202

216

childrens complete oral tablet chewable 18

mg.............................................................. 203

childrens loratadine.................................... 194

childrens non-aspirin.................................... 12

childrens silapap.......................................... 12

childrens vitamins/iron................................203

childs non-aspirin......................................... 12

chlordiazepoxide hcl.....................................57

chlordiazepoxide-amitriptyline......................32

chlordiazepoxide-clidinium capsule 5-2.5

mg oral....................................................... 115

chlorhexidine gluconate mouth/throat.......... 82

chloroquine phosphate oral..........................46

chlor-pheniramine...................................... 194

chlorpheniramine maleate..........................194

chlorpheniramine maleate oral...................194

chlorpromazine hcl injection.........................50

chlorpromazine hcl oral concentrate............ 50

chlorpromazine hcl oral tablet...................... 50

chlorthalidone...............................................73

chlorzoxazone oral tablet 250 mg.............. 200

chlorzoxazone tablet 375 mg oral.............. 200

chlorzoxazone tablet 500 mg oral.............. 200

chlorzoxazone tablet 750 mg oral.............. 200

CHOLBAM................................................. 127

cholestyramine light..................................... 74

cholestyramine oral...................................... 74

CHORIONIC GONADOTROPIN

INTRAMUSCULAR.................................... 132

CHOSEN LANCETS 30G............................ 95

CHOSEN SAFETY LANCETS 28G............. 95

CIALIS ORAL TABLET 5 MG.....................129

CIBINQO...................................................... 93

ciclodan........................................................ 90

ciclopirox external gel...................................90

ciclopirox external shampoo.........................90

ciclopirox external solution........................... 90

ciclopirox olamine external...........................90

ciclopirox treatment...................................... 90

cidofovir intravenous.................................... 53

cilostazol...................................................... 66

CILOXAN................................................... 176

CIMDUO.......................................................55

cimetidine hcl............................................. 116

cimetidine tablet 200 mg oral (rx)...............116

cimetidine tablet 300 mg oral..................... 116

cimetidine tablet 400 mg oral..................... 116

cimetidine tablet 800 mg oral..................... 116

CIMZIA SUBCUTANEOUS PREFILLED

SYRINGE KIT 2 X 200 MG/ML, 6 X 200

MG/ML....................................................... 148

CIMZIA VIAL KIT........................................148

cinacalcet hcl..............................................153

CINQAIR.................................................... 190

CIPRO HC..................................................181

CIPRO ORAL SUSPENSION

RECONSTITUTED.......................................24

CIPRO ORAL TABLET................................ 24

ciprofloxacin hcl ophthalmic....................... 176

ciprofloxacin hcl oral.....................................24

ciprofloxacin hcl otic................................... 181

ciprofloxacin-dexamethasone.................... 181

CIPROFLOXACIN-FLUOCINOLONE PF...181

CITALOPRAM HYDROBROMIDE ORAL

CAPSULE.................................................... 33

citalopram hydrobromide oral solution......... 33

citalopram hydrobromide oral tablet.............33

citroma....................................................... 124

claravis......................................................... 83

CLARINEX................................................. 184

CLARINEX-D 12 HOUR.............................190

clarithromycin er tablet extended release

24 hour 500 mg oral..................................... 24

clarithromycin oral........................................ 24

CLARITIN-D 24 HOUR.............................. 198

classic prenatal.......................................... 110

c-lax laxative.............................................. 159

CLEARCANAL EARWAX SOFTENER...... 182

CLEARDETECT COVID-19 AG HOME..... 159

clearlax oral powder 17 gm/scoop............. 123

clemastine fumarate oral............................184

CLENPIQ................................................... 115

CLEOCIN ORAL.......................................... 20

CLEOCIN VAGINAL CREAM.......................20

CLEOCIN VAGINAL SUPPOSITORY..........20

CLEOCIN-T..................................................90

CLIMARA................................................... 136

CLIMARA PRO.......................................... 136

clindacin....................................................... 90

clindacin etz external swab.......................... 90

clindacin-p.................................................... 90

CLINDAGEL.................................................90

clindamycin hcl oral......................................20

clindamycin palmitate hcl............................. 20

clindamycin phos-benzoyl perox external

gel 1.2-2.5 %................................................ 83

clindamycin phos-benzoyl perox external

gel 1.2-3.75 %.............................................. 83

clindamycin phos-benzoyl perox external

gel 1.2-5 %................................................... 83

clindamycin phosphate external foam..........90

clindamycin phosphate external gel............. 90

clindamycin phosphate external lotion......... 90

clindamycin phosphate external solution..... 90

clindamycin phosphate external swab......... 90

clindamycin phosphate vaginal.................... 20

clindamycin phosphate-benzoyl peroxide

external gel 1-5 %........................................ 83

clindamycin-tretinoin.................................... 83

CLINDESSE.................................................20

CLINERE EARWAX REMOVAL KIT OTIC

SOLUTION.................................................182

CLINITEST RAPID COVID-19 TEST KIT

IN VITRO....................................................159

CLINPRO 5000.......................................... 105

clobazam oral suspension............................28

clobazam oral tablet 10 mg.......................... 28

217

clobazam oral tablet 20 mg.......................... 28

clobetasol propionate e................................ 85

clobetasol propionate emulsion....................85

clobetasol propionate external cream.......... 85

clobetasol propionate external foam............ 85

clobetasol propionate external gel............... 85

clobetasol propionate external liquid............85

clobetasol propionate external lotion............85

clobetasol propionate external ointment...... 85

clobetasol propionate external solution........85

clobetasol propionate shampoo 0.05 %

external........................................................ 85

CLOBEX.......................................................85

CLOBEX SPRAY......................................... 85

clocortolone pivalate.................................... 85

clodan...........................................................85

CLODERM................................................... 85

clomipramine hcl oral................................... 34

clonazepam oral tablet................................. 57

clonazepam oral tablet dispersible...............57

clonidine....................................................... 67

clonidine hcl er oral tablet extended

release 12 hour............................................ 77

CLONIDINE HCL ER ORAL TABLET

EXTENDED RELEASE 24 HOUR............... 67

clonidine hcl oral.......................................... 67

clopidogrel bisulfate oral.............................. 66

clorazepate dipotassium tablet 15 mg oral...57

clorazepate dipotassium tablet 3.75 mg

oral............................................................... 57

clorazepate dipotassium tablet 7.5 mg oral..57

clotrimazole 3............................................... 37

clotrimazole 7............................................... 37

clotrimazole external cream 1 %.................. 90

clotrimazole external solution 1 %................90

clotrimazole mouth/throat troche 10 mg.......36

clotrimazole vaginal......................................37

clotrimazole vaginal cream 1 %................... 37

clotrimazole-betamethasone external

cream........................................................... 88

clotrimazole-betamethasone external lotion.88

clozapine oral tablet..................................... 52

clozapine oral tablet dispersible................... 52

CLOZARIL....................................................52

COARTEM................................................... 46

codeine sulfate oral tablet 30 mg, 60 mg....... 8

COLAZAL...................................................152

colchicine oral capsule................................. 37

colchicine oral tablet.....................................37

colchicine-probenecid.................................. 37

colesevelam hcl............................................74

COLESTID................................................... 74

colestipol hcl oral granules...........................74

colestipol hcl oral packet.............................. 74

colestipol hcl oral tablet................................74

col-rite oral capsule 250 mg....................... 124

COMBIGAN................................................174

COMBIPATCH........................................... 136

COMBIVENT RESPIMAT.......................... 196

COMETRIQ (100 MG DAILY DOSE)......... 172

COMETRIQ (140 MG DAILY DOSE)......... 172

COMETRIQ (60 MG DAILY DOSE)........... 172

COMFORT EZ PRO PEN NEEDLES 30G

X 8 MM.........................................................95

COMFORT EZ PRO PEN NEEDLES 31G

X 4 MM.......................................................159

COMFORT EZ PRO PEN NEEDLES 31G

X 5 MM.......................................................159

COMFORT TOUCH LANCETS 31G............95

COMFORT TOUCH PLUS LANCETS 28G. 95

COMFORT TOUCH PLUS LANCETS 30G. 96

COMFORT TOUCH TWIST LANCET 30G.. 96

COMIRNATY..............................................159

COMPLERA................................................. 55

complete allergy......................................... 184

complete allergy medicine..........................184

complete allergy medicine oral capsule..... 184

complete allergy relief................................ 184

COMPLETE NATAL DHA.......................... 110

COMPLETENATE......................................110

compro......................................................... 34

CO-NATAL FA........................................... 110

CONCERTA ORAL TABLET EXTENDED

RELEASE 18 MG, 27 MG, 36 MG............... 77

CONCERTA ORAL TABLET EXTENDED

RELEASE 54 MG.........................................77

CONDOMS................................................ 159

CONJUPRI...................................................75

constulose.................................................. 114

CONTOUR CONTROL SOLUTION........... 159

CONTOUR MONITOR................................. 96

CONTOUR NEXT EZ KIT W/DEVICE......... 96

CONTOUR NEXT GEN MONITOR..............96

CONTOUR NEXT GEN TEST STRIPS....... 96

CONTOUR NEXT LINK KIT W/DEVICE...... 96

CONTOUR NEXT MONITOR KIT

W/DEVICE................................................... 96

CONTOUR NEXT ONE KIT......................... 96

CONTOUR TEST STRIPS...........................96

CONZIP..........................................................6

COOL MIST HUMIDIFER.......................... 159

COPAXONE.................................................80

COPIKTRA...................................................43

COREG........................................................ 69

COREG CR..................................................69

CORGARD...................................................69

CORLANOR.................................................71

CORTEF.................................................... 130

CORTENEMA............................................ 152

CORTIFOAM..............................................152

CORTISONE ACETATE ORAL................. 130

cortisone maximum strength external

cream........................................................... 85

CORTISPORIN-TC.................................... 181

CORTROPHIN........................................... 130

CORVITA................................................... 203

218

COSENTYX INTRAVENOUS SOLUTION

125 MG/5ML.............................................. 146

COSENTYX SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 150 MG/ML

....................................................................146

COSENTYX SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 150

MG/ML, 75 MG/0.5ML................................146

COSENTYX UNOREADY.......................... 146

COSOPT.................................................... 174

COSOPT PF.............................................. 174

COTELLIC....................................................43

COTEMPLA XR-ODT...................................77

cough relief oral syrup 15 mg/5ml.............. 191

COVARYX..................................................143

COVARYX HS............................................143

COVID-19 AT HOME ANTIGEN TEST...... 159

COVID-19 AT HOME TEST KIT................ 159

COVID-19 AT-HOME TEST KIT IN VITRO159

COVID-19 SPECIMEN COLLECTION.......159

COZAAR...................................................... 68

CREON...................................................... 127

CRESEMBA INTRAVENOUS...................... 36

CRESEMBA ORAL CAPSULE 186 MG.......36

CRESTOR....................................................74

CRINONE...................................................142

cromolyn sodium inhalation........................189

cromolyn sodium ophthalmic......................175

cromolyn sodium oral................................. 127

CROTAN...................................................... 89

cryselle-28..................................................136

CUPRIMINE............................................... 129

curae.......................................................... 144

CURANOL....................................................12

CURELIEF................................................. 184

CUVPOSA..................................................115

CUVRIOR...................................................159

cyanocobalamin injection solution 1000

mcg/ml........................................................205

cyclobenzaprine hcl er............................... 200

cyclobenzaprine hcl oral tablet 10 mg, 5

mg.............................................................. 200

cyclobenzaprine hcl oral tablet 7.5 mg.......200

CYCLOGYL OPHTHALMIC SOLUTION

0.5 %, 2 %..................................................174

CYCLOGYL OPHTHALMIC SOLUTION 1

%................................................................ 174

CYCLOMYDRIL......................................... 180

cyclopentolate hcl ophthalmic.................... 174

cyclophosphamide oral capsule................... 40

CYCLOPHOSPHAMIDE ORAL TABLET.....40

cycloserine oral............................................ 40

CYCLOSET..................................................59

CYCLOSPORINE IN KLARITY

OPHTHALMIC EMULSION 0.1 %..............174

cyclosporine modified oral capsule 100 mg,

25 mg......................................................... 148

cyclosporine modified oral capsule 50 mg. 148

cyclosporine modified oral solution............ 148

cyclosporine ophthalmic.............................174

cyclosporine oral........................................ 148

CYKLOKAPRON..........................................66

CYLTEZO (2 PEN).....................................159

CYLTEZO (2 SYRINGE)

SUBCUTANEOUS PREFILLED SYRINGE

KIT 10 MG/0.2ML, 20 MG/0.4ML, 40

MG/0.8ML.................................................. 159

CYLTEZO (2 SYRINGE)

SUBCUTANEOUS PREFILLED SYRINGE

KIT 40 MG/0.4ML.......................................159

CYLTEZO-CD/UC/HS STARTER.............. 160

CYLTEZO-PSORIASIS/UV STARTER...... 160

CYMBALTA..................................................80

cyproheptadine hcl oral.............................. 184

cyred eq..................................................... 136

CYSTADANE............................................. 127

CYSTADROPS.......................................... 174

CYSTARAN................................................174

CYTOMEL..................................................144

CYTOTEC.................................................. 116

d3 high potency oral capsule 25 mcg, 25

mcg (1000 ut)............................................. 110

d3 high potency oral capsule 250 mcg

(10000 ut)...................................................110

d3 max st....................................................110

d3 oral capsule 25 mcg (1000 ut)...............110

d3 oral capsule 250 mcg............................ 111

dabigatran etexilate mesylate...................... 64

daily fiber oral powder 43 %.......................123

daily probiotic oral capsule .......................120

dalfampridine er........................................... 80

DALIRESP................................................. 189

danazol oral................................................134

DANTRIUM ORAL....................................... 53

dantrolene sodium oral.................................53

DAPAGLIFLOZIN PRO-METFORMIN ER... 59

DAPAGLIFLOZIN PROPANEDIOL..............59

dapsone external gel 7.5 %..........................90

dapsone gel 5 % external.............................90

dapsone oral................................................ 40

DAPTACEL................................................ 149

darifenacin hydrobromide er tablet

extended release 24 hour 15 mg oral........ 128

darifenacin hydrobromide er tablet

extended release 24 hour 7.5 mg oral....... 128

darunavir.................................................... 160

dasetta 1/35............................................... 136

dasetta 7/7/7.............................................. 136

DAURISMO..................................................43

DAYPRO........................................................ 4

daysee........................................................136

DAYTRANA..................................................77

DAYVIGO...................................................201

D-CARE BLOOD GLUCOSE....................... 96

D-CARE GLUCOMETER............................. 96

DDAVP INJECTION...................................132

DDAVP ORAL............................................ 132

219

DDAVP PF................................................. 132

deblitane.....................................................142

deep sea nasal spray................................. 191

deferasirox................................................. 109

deferasirox granules...................................109

deferiprone................................................. 109

deflazacort oral tablet.................................130

DELESTROGEN........................................ 136

DELSTRIGO................................................ 55

delyla..........................................................136

DELZICOL..................................................152

demeclocycline hcl....................................... 25

DEMSER......................................................71

DENAVIR..................................................... 54

DENGVAXIA.............................................. 151

DENTA 5000 PLUS....................................105

DENTA 5000 PLUS SENSITIVE................105

DENTAGEL................................................105

DEPAKOTE..................................................58

DEPAKOTE ER............................................58

DEPAKOTE SPRINKLES............................ 58

DEPEN TITRATABS.................................. 129

DEPLIN 15................................................. 160

DEPLIN 7.5................................................ 160

DEPO-ESTRADIOL................................... 136

DEPO-MEDROL........................................ 130

DEPO-PROVERA...................................... 142

DEPO-SUBQ PROVERA 104.................... 142

DEPO-TESTOSTERONE.......................... 134

DERMACINRX MULTITAM........................203

DERMACINRX RIBOTIN-E........................203

DERMA-SMOOTHE/FS BODY.................... 85

DERMA-SMOOTHE/FS SCALP.................. 85

DERMOTIC................................................ 181

DESCOVY....................................................55

desipramine hcl oral..................................... 34

desloratadine oral tablet dispersible 5 mg..184

desloratadine tablet 5 mg oral....................184

desmopressin ace spray refrig................... 132

desmopressin acetate injection..................132

DESMOPRESSIN ACETATE NASAL........132

desmopressin acetate oral......................... 132

desmopressin acetate pf............................ 132

desmopressin acetate spray...................... 132

desogestrel-ethinyl estradiol oral tablet

0.15-0.02/0.01 mg (21/5)............................136

desonide external cream..............................86

desonide external lotion............................... 86

desonide external ointment.......................... 86

DESOWEN...................................................86

desoximetasone external............................. 86

DESOXYN....................................................78

DESVENLAFAXINE ER............................... 33

desvenlafaxine succinate er oral tablet

extended release 24 hour 100 mg, 50 mg... 33

desvenlafaxine succinate er tablet

extended release 24 hour 25 mg oral.......... 33

DETROL.....................................................128

DETROL LA............................................... 128

dexamethasone intensol............................ 130

dexamethasone oral elixir.......................... 130

dexamethasone oral solution..................... 130

dexamethasone oral tablet 0.5 mg, 0.75

mg, 1 mg, 2 mg.......................................... 130

dexamethasone oral tablet 1.5 mg, 4 mg, 6

mg.............................................................. 130

dexamethasone oral tablet therapy pack... 130

dexamethasone sod phosphate pf injection

solution.......................................................130

dexamethasone sod phosphate pf injection

solution prefilled syringe.............................130

dexamethasone sodium phosphate

injection solution 100 mg/10ml, 120

mg/30ml, 20 mg/5ml, 4 mg/ml....................131

dexamethasone sodium phosphate

ophthalmic..................................................177

DEXAMETHASONE SODIUM

PHOSPHATE SOLUTION 10 MG/ML

INJECTION................................................ 131

dexamethasone sodium phosphate

solution 10 mg/ml injection.........................131

DEXCOM G6 RECEIVER............................ 96

DEXCOM G6 SENSOR............................... 96

DEXCOM G6 TRANSMITTER................... 160

DEXCOM G7 RECEIVER............................ 96

DEXCOM G7 SENSOR............................... 96

DEXEDRINE................................................ 78

DEXILANT..................................................117

dexlansoprazole capsule delayed release

30 mg oral.................................................. 117

dexlansoprazole capsule delayed release

60 mg oral.................................................. 117

dexmethylphenidate hcl............................... 77

dexmethylphenidate hcl er........................... 77

DEXTENZA................................................ 177

dextroamphetamine sulfate er......................78

dextroamphetamine sulfate oral solution..... 78

dextroamphetamine sulfate oral tablet 10

mg, 5 mg...................................................... 78

dextroamphetamine sulfate oral tablet 15

mg, 2.5 mg, 20 mg, 30 mg, 7.5 mg.............. 78

dextromethorphan-guaifenesin oral syrup..198

DHIVY.......................................................... 49

DIABETES MONITOR DIGIT ADD-ON......160

DIABETES MONITOR DIGIT SOLN.......... 160

DIACOMIT....................................................30

DIALYVITE.................................................111

DIALYVITE SUPREME D.......................... 203

diamode..................................................... 114

diarrhea...................................................... 120

diarrhea relief............................................. 120

DIASTIX....................................................... 96

DIASTIX REAGENT.....................................97

DIATROL....................................................203

DIATRUST COVID-19 HOME TEST..........160

220

diazepam intensol........................................ 57

diazepam oral...............................................57

diazepam rectal gel 10 mg, 2.5 mg.............. 28

diazepam rectal gel 20 mg........................... 28

diazoxide oral............................................... 60

DIBENZYLINE..............................................67

dichlorphenamide.......................................127

DICLEGIS.................................................... 34

DICLOFENAC PATCH 1.3%..........................4

diclofenac potassium oral capsule................. 4

diclofenac potassium oral tablet 25 mg..........4

diclofenac potassium oral tablet 50 mg..........4

diclofenac potassium(migraine)..................... 4

diclofenac sodium er...................................... 4

diclofenac sodium external gel 1 %................4

diclofenac sodium external gel 3 %..............88

diclofenac sodium external solution 1.5 %..... 4

diclofenac sodium ophthalmic.................... 177

diclofenac sodium oral................................... 4

diclofenac sodium solution 2 % external........ 4

diclofenac-misoprostol................................... 4

dicloxacillin sodium...................................... 23

dicyclomine hcl oral capsule...................... 115

dicyclomine hcl oral solution...................... 115

dicyclomine hcl oral tablet.......................... 115

DIFFERIN EXTERNAL CREAM...................83

DIFFERIN EXTERNAL GEL........................ 83

DIFICID ORAL SUSPENSION

RECONSTITUTED.......................................24

DIFICID ORAL TABLET...............................24

diflorasone diacetate.................................... 86

DIFLUCAN ORAL SUSPENSION

RECONSTITUTED.......................................36

DIFLUCAN ORAL TABLET 100 MG, 200

MG............................................................... 36

diflunisal oral.................................................. 4

difluprednate.............................................. 177

digoxin oral solution..................................... 72

digoxin oral tablet 125 mcg, 250 mcg.......... 72

digoxin oral tablet 62.5 mcg......................... 72

dihydroergotamine mesylate injection..........38

dihydroergotamine mesylate nasal.............. 38

DILANTIN INFATABS.................................. 29

DILANTIN ORAL CAPSULE 100 MG.......... 29

DILANTIN ORAL CAPSULE 30 MG............ 29

DILANTIN ORAL SUSPENSION................. 29

DILANTIN-125..............................................29

DILAUDID ORAL LIQUID...............................8

DILAUDID ORAL TABLET............................. 8

diltiazem hcl er beads.................................. 70

diltiazem hcl er coated beads.......................70

diltiazem hcl er oral capsule extended

release 12 hour............................................ 70

diltiazem hcl er oral capsule extended

release 24 hour............................................ 70

diltiazem hcl er oral tablet extended

release 24 hour............................................ 70

diltiazem hcl oral.......................................... 70

dilt-xr............................................................ 70

dimethyl fumarate oral..................................80

dimethyl fumarate starter pack.....................80

diotame instydose...................................... 120

DIOVAN....................................................... 68

DIOVAN HCT............................................... 72

DIPENTUM................................................ 152

diphedryl allergy......................................... 184

diphen........................................................ 184

diphenhydramine hcl childrens...................185

diphenhydramine hcl injection....................185

diphenhydramine hcl oral capsule..............185

diphenhydramine hcl oral elixir...................185

diphenhydramine hcl oral liquid..................185

diphenhydramine hcl oral tablet................. 185

diphenoxylate-atropine oral liquid.............. 114

diphenoxylate-atropine oral tablet.............. 114

DIPROLENE................................................ 86

dipyridamole oral..........................................66

disopyramide phosphate.............................. 69

disulfiram oral...............................................18

DIURIL......................................................... 73

divalproex sodium er.................................... 58

divalproex sodium oral capsule delayed

release sprinkle............................................ 58

divalproex sodium oral tablet delayed

release......................................................... 58

DIVIGEL..................................................... 136

docusate calcium....................................... 124

docusate sodium oral capsule....................124

docusate sodium oral liquid........................124

docusate sodium oral syrup....................... 124

DODEX...................................................... 205

dofetilide.......................................................69

dok oral tablet.............................................124

dolishale..................................................... 136

donepezil hcl oral tablet 10 mg, 5 mg.......... 30

donepezil hcl oral tablet 23 mg.................... 30

donepezil hcl oral tablet dispersible............. 30

DONNATAL................................................119

DOPTELET.................................................. 66

DORAL.........................................................58

DORYX MPC ORAL TABLET DELAYED

RELEASE 120 MG.......................................25

DORYX MPC TABLET DELAYED

RELEASE 60 MG ORAL.............................. 25

DORZOLAMIDE HCL SOLUTION 2 %

OPHTHALMIC............................................178

dorzolamide hcl solution 2 % ophthalmic... 178

dorzolamide hcl-timolol mal........................174

dorzolamide hcl-timolol mal pf....................174

dotti............................................................ 136

double antibiotic external ointment 500-

10000 unit/gm............................................ 160

DOVATO...................................................... 54

doxazosin mesylate oral...............................67

doxepin hcl external..................................... 86

doxepin hcl oral capsule...............................34

doxepin hcl oral concentrate........................ 34

221

doxepin hcl oral tablet................................ 201

doxercalciferol oral..................................... 153

doxy 100.......................................................25

doxycycline capsule delayed release 40

mg oral......................................................... 25

doxycycline hyclate intravenous...................25

doxycycline hyclate oral capsule..................25

doxycycline hyclate oral tablet 100 mg, 150

mg, 75 mg.................................................... 25

doxycycline hyclate oral tablet 20 mg.......... 25

doxycycline hyclate oral tablet 50 mg.......... 25

doxycycline hyclate oral tablet delayed

release 100 mg, 200 mg, 50 mg.................. 25

doxycycline hyclate oral tablet delayed

release 150 mg, 75 mg................................ 25

DOXYCYCLINE HYCLATE ORAL TABLET

DELAYED RELEASE 80 MG....................... 25

doxycycline monohydrate oral capsule 100

mg................................................................ 25

doxycycline monohydrate oral capsule 150

mg, 75 mg.................................................... 25

doxycycline monohydrate oral capsule 50

mg................................................................ 25

doxycycline monohydrate oral tablet 100

mg, 50 mg, 75 mg........................................ 25

doxycycline monohydrate oral tablet 150

mg................................................................ 25

doxycycline monohydrate suspension

reconstituted 25 mg/5ml oral........................25

doxylamine-pyridoxine................................. 34

dronabinol.................................................... 35

DROPLET MICRON...................................160

DROPSAFE ALCOHOL PREP.................. 160

DROPSAFE SAFETY SYRINGE/NEEDLE 160

DROPSAFE SICURA.................................160

drospiren-eth estrad-levomefol.................. 136

drospirenone-ethinyl estradiol.................... 136

DROXIA ORAL CAPSULE 200 MG, 300

MG............................................................... 65

DROXIA ORAL CAPSULE 400 MG............. 65

droxidopa capsule 100 mg oral.................... 67

droxidopa capsule 200 mg oral.................... 67

droxidopa capsule 300 mg oral.................... 67

dry-eye relief nighttime...............................179

dss..............................................................124

DUAKLIR PRESSAIR AEROSOL

POWDER BREATH ACTIVATED 400-12

MCG/ACT INHALATION............................ 196

DUAVEE.................................................... 136

DUETACT.................................................... 59

DUEXIS..........................................................4

DULERA.....................................................196

duloxetine hcl oral capsule delayed release

particles 20 mg, 30 mg, 60 mg.....................80

duloxetine hcl oral capsule delayed release

particles 40 mg.............................................80

DUOBRII...................................................... 88

DUOPA........................................................ 49

DUPIXENT SUBCUTANEOUS SOLUTION

PEN-INJECTOR.........................................146

DUPIXENT SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 200 MG/1.14ML....146

DUPIXENT SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 300 MG/2ML.........146

DUREX EXTRA SENSITIVE THIN............ 160

DUREZOL.................................................. 177

DUROLANE............................................... 160

dutasteride oral.......................................... 129

dutasteride-tamsulosin hcl......................... 129

D-VI-SOL....................................................111

DYANAVEL XR ORAL SUSPENSION

EXTENDED RELEASE................................ 78

DYANAVEL XR ORAL TABLET

CHEWABLE EXTENDED RELEASE...........78

DYMISTA................................................... 185

DYRENIUM.................................................. 73

E.E.S. 400.................................................... 24

E.E.S. GRANULES...................................... 24

ear drops otic solution 6.5 %......................182

ear wax kit.................................................. 182

ear wax removal.........................................182

ear wax removal system............................ 182

earwax removal drops................................182

earwax removal kit otic solution 6.5 %....... 182

earwax removal otic solution 6.5 %............182

EASIVENT................................................. 160

EASIVENT MASK LARGE......................... 160

EASIVENT MASK MEDIUM.......................160

EASIVENT MASK SMALL......................... 160

EASY TOUCH HEALTHPRO GLUCOSE.... 97

EASY TOUCH TEST....................................97

EASYGLUCO...............................................97

EASYMAX 15 LEVEL 2 CONTROL............. 97

EASYMAX 15 LEVEL 2-3 CONTROL..........97

EASYMAX 15 TEST.....................................97

EASYMAX CONTROL............................... 160

EASYMAX NG BLOOD GLUCOSE............. 97

EASYMAX V BLOOD GLUCOSE................ 97

EBASE CONTROLLER KIT....................... 160

EC-NAPROSYN.............................................4

ec-naproxen................................................... 4

econazole nitrate external............................ 90

econtra one-step........................................ 144

ed-apap........................................................ 13

EDARBI........................................................68

EDARBYCLOR............................................ 72

EDECRIN..................................................... 72

EDLUAR.....................................................201

EDURANT....................................................55

EEMT......................................................... 143

efavirenz.......................................................55

efavirenz-emtricitab-tenofo df.......................55

efavirenz-lamivudine-tenofovir..................... 55

EFFER-K ORAL TABLET

EFFERVESCENT 10 MEQ, 20 MEQ......... 107

effer-k oral tablet effervescent 25 meq.......203

EFFEXOR XR.............................................. 33

222

EFFIENT...................................................... 66

EFUDEX.......................................................88

EGATEN...................................................... 46

EGRIFTA SV..............................................132

ELEPSIA XR................................................ 26

ELESTRIN..................................................136

eletriptan hydrobromide............................... 39

ELFABRIO................................................. 160

ELFOLATE.................................................203

ELIDEL.........................................................86

ELIGARD................................................... 145

elinest.........................................................136

ELIQUIS....................................................... 64

ELIQUIS DVT/PE STARTER PACK............ 64

elixophyllin..................................................189

ELLA.......................................................... 142

ELLUME COVID-19 HOME TEST............. 160

ELMIRON...................................................129

eluryng....................................................... 136

ELYXYB......................................................... 4

EMBRACE BLOOD GLUCOSE TEST......... 97

EMBRACE PEN NEEDLES 29G X 12MM. 160

EMBRACE PEN NEEDLES 30G X 5 MM.. 160

EMBRACE PEN NEEDLES 30G X 8 MM.... 97

EMBRACE PEN NEEDLES 31G X 5 MM.. 160

EMBRACE PEN NEEDLES 31G X 6 MM.. 160

EMBRACE PEN NEEDLES 31G X 8 MM.. 161

EMBRACE PEN NEEDLES 32G X 4 MM.... 97

EMBRACE WAVE BLOOD GLUCOSE........97

EMBRACE WAVE GLUCOSE METER........97

EMCYT.........................................................41

EMEND INTRAVENOUS............................. 35

EMEND ORAL............................................. 35

EMEND TRI-PACK...................................... 35

EMFLAZA...................................................131

EMGALITY................................................... 38

EMGALITY (300 MG DOSE)........................38

EMSAM........................................................ 32

emtricitabine.................................................55

emtricitabine-tenofovir df..............................55

EMTRIVA..................................................... 55

EMVERM..................................................... 45

emzahh...................................................... 142

enalapril maleate oral tablet......................... 68

enalapril maleate solution 1 mg/ml oral........68

enalapril-hydrochlorothiazide....................... 72

ENBREL SUBCUTANEOUS SOLUTION

25 MG/0.5ML............................................. 148

ENBREL SUBCUTANEOUS SOLUTION

AUTO-INJECTOR...................................... 148

ENBREL SUBCUTANEOUS SOLUTION

CARTRIDGE.............................................. 148

ENBREL SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE.............................. 148

ENDARI......................................................105

ENDO AVITENE........................................ 161

endocet.......................................................... 8

enema........................................................ 120

enema disposable...................................... 120

enema ready-to-use................................... 120

enema rectal enema 16-6 gm/133ml, 19-7

gm/118ml................................................... 121

ENGERIX-B............................................... 149

enilloring.....................................................136

ENLITE GLUCOSE SENSOR......................97

enoxaparin sodium.......................................64

enpresse-28............................................... 136

enskyce...................................................... 136

ENSTILAR....................................................88

entacapone.................................................. 48

ENTADFI....................................................161

entecavir.......................................................53

enteric aspirin.............................................161

ENTRESTO..................................................72

ENTYVIO INTRAVENOUS........................ 146

ENTYVIO SUBCUTANEOUS.................... 146

enulose.......................................................114

ENVARSUS XR ORAL TABLET

EXTENDED RELEASE 24 HOUR 0.75

MG, 1 MG...................................................148

ENVARSUS XR ORAL TABLET

EXTENDED RELEASE 24 HOUR 4 MG....148

EOHILIA..................................................... 152

EPANED...................................................... 68

ephedrine sulfate (pressors) intravenous

solution 50 mg/ml......................................... 76

EPIDIOLEX.................................................. 26

EPIDUO....................................................... 83

EPIDUO FORTE.......................................... 83

EPIFOAM..................................................... 88

epinastine hcl............................................. 175

epinephrine (anaphylaxis) injection solution

1 mg/ml...................................................... 187

epinephrine injection solution auto-injector 188

EPIPEN 2-PAK...........................................188

EPIPEN JR 2-PAK..................................... 188

EPISIL.......................................................... 82

epitol.............................................................29

EPIVIR......................................................... 55

eplerenone................................................... 73

EPOGEN......................................................65

EPRONTIA...................................................26

EQUETRO................................................... 58

ERAXIS INTRAVENOUS SOLUTION

RECONSTITUTED 100 MG.........................36

ergocalciferol oral capsule......................... 203

ergoloid mesylates oral................................ 30

ergotamine-caffeine..................................... 38

ERIVEDGE...................................................43

ERLEADA ORAL TABLET 240 MG............. 41

ERLEADA ORAL TABLET 60 MG............... 41

erlotinib hcl................................................. 172

ERMEZA.................................................... 144

errin............................................................ 142

ERTACZO.................................................... 90

ery................................................................ 90

223

ERYGEL.......................................................90

ERYPED 200............................................... 24

ERYPED 400............................................... 24

ERY-TAB ORAL TABLET DELAYED

RELEASE 250 MG, 500 MG........................ 24

ERY-TAB ORAL TABLET DELAYED

RELEASE 333 MG.......................................24

ERYTHROCIN STEARATE......................... 24

erythromycin base oral capsule delayed

release particles........................................... 24

erythromycin base oral tablet....................... 24

erythromycin base oral tablet delayed

release......................................................... 24

erythromycin ethylsuccinate oral

suspension reconstituted 200 mg/5ml..........24

erythromycin ethylsuccinate oral

suspension reconstituted 400 mg/5ml..........24

erythromycin ethylsuccinate oral tablet........ 24

erythromycin external gel............................. 90

erythromycin external solution..................... 90

erythromycin ophthalmic............................ 176

erythromycin oral..........................................24

ESBRIET....................................................190

escitalopram oxalate oral solution................33

escitalopram oxalate oral tablet................... 33

ESGIC ORAL CAPSULE............................... 8

ESGIC ORAL TABLET...................................9

esomeprazole magnesium capsule

delayed release 20 mg oral (rx)................. 117

esomeprazole magnesium oral capsule

delayed release 40 mg...............................117

esomeprazole magnesium oral packet...... 117

est estrogens-methyltest............................ 143

est estrogens-methyltest ds....................... 143

est estrogens-methyltest hs....................... 143

estarylla......................................................136

estazolam tablet 1 mg oral......................... 201

estazolam tablet 2 mg oral......................... 201

ESTRACE.................................................. 136

estradiol gel 0.25 mg/0.25gm transdermal.136

estradiol gel 0.5 mg/0.5gm transdermal.....136

estradiol gel 0.75 mg/0.75gm transdermal.136

estradiol gel 1 mg/gm transdermal.............136

estradiol gel 1.25 mg/1.25gm transdermal.136

estradiol oral...............................................136

estradiol transdermal patch twice weekly...136

estradiol transdermal patch weekly............136

estradiol vaginal......................................... 137

estradiol valerate intramuscular................. 137

estradiol-norethindrone acet...................... 137

ESTRING................................................... 137

eszopiclone................................................ 201

ethacrynic acid............................................. 72

ethambutol hcl oral tablet 100 mg................ 40

ethambutol hcl oral tablet 400 mg................ 40

ethosuximide oral......................................... 28

ethynodiol diac-eth estradiol...................... 137

etodolac..........................................................4

etodolac er..................................................... 4

etonogestrel-ethinyl estradiol..................... 137

etoposide oral...............................................42

etravirine...................................................... 55

EUCRISA..................................................... 86

EULEXIN......................................................41

euthyrox..................................................... 144

EVAMIST................................................... 137

EVEKEO...................................................... 78

EVENITY....................................................153

everolimus oral tablet 0.25 mg, 0.5 mg,

0.75 mg, 1 mg............................................ 148

everolimus oral tablet 10 mg, 2.5 mg, 5

mg, 7.5 mg................................................... 43

everolimus oral tablet soluble.......................43

EVERSENSE E3 SENSOR/HOLDER..........97

EVERSENSE E3 SMART TRANSMITTER161

EVERSENSE SENSOR/HOLDER............... 98

EVERSENSE SMART TRANSMITTER..... 161

EVISTA...................................................... 143

EVOTAZ.......................................................56

EVOXAC...................................................... 82

EXELON.......................................................30

exemestane..................................................42

EXFORGE....................................................72

EXFORGE HCT........................................... 72

EXJADE..................................................... 109

EXKIVITY..................................................... 43

EX-LAX MAXIMUM STRENGTH............... 124

EX-LAX ULTRA..........................................161

EXSERVAN..................................................79

EXTAVIA...................................................... 80

eye itch relief ophthalmic solution 0.035 % 181

eye lubricant...............................................179

eye lubricant nighttime............................... 179

EYSUVIS....................................................177

EZALLOR SPRINKLE.................................. 74

ezetimibe......................................................74

ezetimibe-simvastatin...................................74

FABIOR........................................................83

falmina........................................................137

famciclovir oral............................................. 54

famotidine acid reducer oral tablet 10 mg.. 116

famotidine oral............................................116

famotidine orig st........................................116

FANAPT ORAL TABLET 1 MG, 10 MG, 2

MG, 4 MG, 6 MG, 8 MG............................... 51

FANAPT ORAL TABLET 12 MG..................51

FANAPT TITRATION PACK........................ 51

FARESTON..................................................41

FARXIGA..................................................... 59

FASENRA PEN..........................................190

FASENRA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 30 MG/ML.............190

fast relief laxative....................................... 161

FASTEP COVID-19 ANTIGEN TEST........ 161

FC2 FEMALE CONDOM............................161

febuxostat.....................................................37

felbamate oral suspension........................... 26

224

felbamate oral tablet.....................................26

FELBATOL...................................................26

felodipine er..................................................70

FEMARA...................................................... 42

FEMCAP.................................................... 161

FEMRING...................................................137

fenofibrate micronized..................................73

fenofibrate oral capsule................................73

fenofibrate oral tablet................................... 73

fenofibric acid oral capsule delayed release 73

fenofibric acid oral tablet.............................. 76

FENOGLIDE................................................ 73

fenoprofen calcium capsule 400 mg oral....... 4

fenoprofen calcium oral tablet........................ 5

FENSOLVI (6 MONTH)..............................145

FENTANYL CITRATE (BULK)....................... 9

fentanyl citrate buccal lozenge on a handle... 9

FENTANYL CITRATE BUCCAL TABLET......9

fentanyl transdermal patch 72 hour 100

mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,

75 mcg/hr....................................................... 6

fentanyl transdermal patch 72 hour 37.5

mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr.................. 6

FENTORA...................................................... 9

ferate.......................................................... 107

FER-IN-SOL...............................................107

ferocon....................................................... 107

ferosul........................................................ 107

ferotrinsic....................................................107

FERRIPROX.............................................. 109

FERRIPROX TWICE-A-DAY..................... 109

ferrous gluconate oral tablet 240 (27 fe) mg

....................................................................107

ferrous gluconate oral tablet 324 (38 fe) mg

....................................................................107

ferrous sulfate............................................ 107

ferrous sulfate oral solution........................ 107

ferrous sulfate oral tablet 325 (65 fe) mg... 107

ferrous sulfate oral tablet delayed release

324 (65 fe) mg, 324 mg..............................107

ferrous sulfate oral tablet delayed release

325 (65 fe) mg............................................107

fesoterodine fumarate er............................ 128

FETROJA.....................................................22

FETZIMA......................................................33

FETZIMA TITRATION..................................33

fever reducer/pain reliever........................... 13

fever reducing childrens............................... 13

feverall adults............................................... 13

feverall childrens.......................................... 13

FEVERALL INFANTS.................................. 13

FEVERALL JUNIOR STRENGTH................13

fe-vite iron.................................................. 107

FEXMID......................................................200

FIASP...........................................................60

FIASP FLEXTOUCH.................................... 60

FIASP PENFILL........................................... 60

FIASP PUMPCART......................................61

fiber oral powder........................................ 123

fiber oral powder 43 %............................... 123

fiber powder oral powder 43 %.................. 123

FIBRICOR.................................................... 76

FILTER AIR PP.......................................... 161

FINACEA EXTERNAL FOAM...................... 83

finasteride oral tablet 5 mg.........................129

fingolimod hcl capsule 0.5 mg oral...............80

FINTEPLA.................................................... 26

finzala.........................................................137

FIORICET...................................................... 9

FIORICET/CODEINE..................................... 9

FIRVANQ..................................................... 20

flac..............................................................181

FLAGYL....................................................... 20

FLAREX..................................................... 177

flavoxate hcl............................................... 128

flecainide acetate......................................... 69

FLECTOR...................................................... 5

FLEQSUVY.................................................. 53

FLEXICHAMBER....................................... 161

FLEXICHAMBER ADULT MASK/SMALL.. 161

FLEXICHAMBER CHILD MASK/LARGE... 161

FLEXICHAMBER CHILD MASK/SMALL... 161

FLOMAX.................................................... 129

FLORASTOR ADVANCED........................ 121

FLOW-EZE VENTED NEEDLE..................161

FLOWFLEX COVID-19 AG HOME TEST.. 161

FLUAD QUADRIVALENT.......................... 151

FLUARIX QUADRIVALENT....................... 151

FLUBLOK QUADRIVALENT......................151

FLUCELVAX QUADRIVALENT................. 151

fluconazole oral............................................ 36

flucytosine oral............................................. 36

fludrocortisone acetate oral........................131

FLULAVAL QUADRIVALENT.................... 151

FLUMIST QUADRIVALENT.......................151

flunisolide nasal..........................................186

fluocinolone acetonide body oil 0.01 %

external........................................................ 86

fluocinolone acetonide external cream.........86

fluocinolone acetonide external solution...... 86

fluocinolone acetonide ointment 0.025 %

external........................................................ 86

fluocinolone acetonide otic.........................181

fluocinolone acetonide scalp oil 0.01 %

external........................................................ 86

fluocinonide emulsified base........................ 86

fluocinonide external cream......................... 86

fluocinonide external gel.............................. 86

fluocinonide external ointment..................... 86

fluocinonide external solution.......................87

FLUORESCEIN SODIUM/BENOXINATE.. 179

FLUORIDEX...............................................105

fluoridex daily renewal................................105

FLUORIDEX ENHANCED WHITENING....105

FLUORIDEX SENSITIVITY RELIEF.......... 105

FLUORIMAX 5000..................................... 105

225

FLUORIMAX 5000 SENSITIVE................. 105

fluor-i-strips a.t........................................... 179

fluorometholone......................................... 177

FLUOROURACIL EXTERNAL CREAM 0.5

%.................................................................. 88

fluorouracil external cream 5 %....................88

fluorouracil external solution........................ 88

fluoxetine hcl (pmdd)....................................33

fluoxetine hcl oral capsule............................33

fluoxetine hcl oral capsule delayed release. 33

fluoxetine hcl oral solution............................33

fluoxetine hcl oral tablet............................... 33

fluphenazine decanoate injection.................50

fluphenazine hcl injection............................. 50

fluphenazine hcl oral concentrate................ 50

fluphenazine hcl oral elixir............................50

fluphenazine hcl oral tablet.......................... 50

flurandrenolide............................................. 87

flurazepam hcl capsule 15 mg oral............ 201

flurazepam hcl capsule 30 mg oral............ 201

flurbiprofen oral.............................................. 5

flurbiprofen sodium.....................................177

FLUTICASONE FUROATE-VILANTEROL 196

FLUTICASONE PROPIONATE DISKUS... 186

fluticasone propionate external cream......... 87

fluticasone propionate external lotion...........87

fluticasone propionate external ointment..... 87

FLUTICASONE PROPIONATE HFA......... 186

fluticasone propionate nasal...................... 186

fluticasone-salmeterol aerosol powder

breath activated 100-50 mcg/act inhalation196

fluticasone-salmeterol aerosol powder

breath activated 500-50 mcg/act inhalation196

FLUTICASONE-SALMETEROL

INHALATION AEROSOL........................... 196

FLUTICASONE-SALMETEROL

INHALATION AEROSOL POWDER

BREATH ACTIVATED 113-14 MCG/ACT,

232-14 MCG/ACT, 55-14 MCG/ACT..........196

fluticasone-salmeterol inhalation aerosol

powder breath activated 250-50 mcg/act... 196

fluvastatin sodium........................................ 74

fluvastatin sodium er.................................... 74

fluvoxamine maleate.................................... 33

fluvoxamine maleate er................................ 33

FLUZONE HIGH-DOSE QUADRIVALENT 151

FLUZONE QUADRIVALENT..................... 151

FML FORTE...............................................177

FML LIQUIFILM......................................... 177

FOCALIN......................................................77

FOCALIN XR................................................77

FOLAGENT DHA....................................... 203

FOLAMAX.................................................. 203

FOLAMED DHA......................................... 203

folbee......................................................... 111

FOLBIC RF................................................ 111

folic acid injection solution 5 mg/ml............161

folic acid oral tablet 1 mg........................... 161

folic acid oral tablet 800 mcg......................161

FOLIFLEX.................................................. 203

FOLITIN-Z.................................................. 203

FOLTANX...................................................111

FOLTANX RF.............................................111

foltrin.......................................................... 107

FOLTX........................................................111

fondaparinux sodium subcutaneous

solution 10 mg/0.8ml, 7.5 mg/0.6ml............. 64

fondaparinux sodium subcutaneous

solution 2.5 mg/0.5ml, 5 mg/0.4ml............... 64

for sty relief.................................................179

FORA 6 CONNECT/GTEL TEST.................98

FORFIVO XL................................................32

formoterol fumarate nebulization solution

20 mcg/2ml inhalation................................ 188

FORTEO.................................................... 153

FORTESTA................................................ 134

FORTISCARE CONTROL IN VITRO

SOLUTION HIGH.......................................161

FORTISCARE CONTROL IN VITRO

SOLUTION LOW........................................161

FORTISCARE CONTROL IN VITRO

SOLUTION NORMAL................................ 161

FORTISCARE G1 TEST STRIP IN VITRO

STRIP...........................................................98

FORTISCARE T1 GLUCOSE SYSTEM

DEVICE........................................................98

FORTISCARE TEST IN VITRO STRIP........98

FOSAMAX..................................................153

FOSAMAX PLUS D....................................153

fosamprenavir calcium................................. 56

fosaprepitant dimeglumine........................... 35

foscarnet sodium..........................................56

FOSCAVIR...................................................56

fosfomycin tromethamine............................. 20

fosinopril sodium.......................................... 68

fosinopril sodium-hctz.................................. 72

fosphenytoin sodium injection solution 500

mg pe/10ml.................................................. 29

FOSRENOL ORAL PACKET..................... 110

FOSRENOL ORAL TABLET CHEWABLE.110

FOTIVDA....................................................172

FRAGMIN.....................................................64

FRAICHE 5000 PREVI...............................161

FRAICHE 5000 SENSITIVE.......................105

FREESTYLE LIBRE 14 DAY READER....... 98

FREESTYLE LIBRE 14 DAY SENSOR....... 98

FREESTYLE LIBRE 2 READER..................98

FREESTYLE LIBRE 2 SENSOR..................98

FREESTYLE LIBRE 3 READER..................98

FREESTYLE LIBRE 3 SENSOR..................98

FREESTYLE LIBRE READER.....................98

FREESTYLE PRECISION NEO SYSTEM...98

FREESTYLE PRECISION NEO TEST........ 98

FREESTYLE TEST...................................... 98

FROVA.........................................................39

frovatriptan succinate................................... 39

FRUZAQLA................................................ 161

226

ft 24 hour nasal allergy...............................195

ft 8 hour pain relief....................................... 13

ft acid reducer capsule delayed release 15

mg oral....................................................... 117

ft acid reducer oral tablet............................116

ft all day allergy.......................................... 185

ft all day allergy 24 hour............................. 185

ft all day allergy relief................................. 194

ft all day allergy-d....................................... 193

ft all day pain relief......................................... 5

ft allergy childrens...................................... 194

ft allergy d-12 hour..................................... 198

ft allergy relief cetirizine..............................185

ft allergy relief childrens oral liquid............. 185

ft allergy relief loratadine............................ 194

ft allergy relief oral capsule........................ 185

ft allergy relief oral tablet 25 mg................. 185

ft allergy relief oral tablet 4 mg................... 194

ft allergy relief-d..........................................198

ft antacid extra strength..............................121

ft antacid regular strength.......................... 121

ft antibiotic.................................................. 161

ft anti-diarrheal oral tablet.......................... 114

ft antifungal external cream 1 %.................161

ft antifungal external cream 2 %...................37

ft arthritis pain reliever..................................13

ft aspirin......................................................161

ft aspirin low dose...................................... 161

ft children's pain/fever.................................. 13

ft clearlax....................................................123

ft double antibiotic...................................... 161

ft earwax removal.......................................182

ft earwax removal kit.................................. 182

ft enema saline...........................................121

ft enteric coated aspirin.............................. 161

ft fiber oral powder 43 %............................ 123

ft gas relief..................................................121

ft gas relief extra strength...........................121

ft gas relief infants...................................... 121

ft gentle laxative......................................... 161

ft ibuprofen ib childrens.................................. 5

ft ibuprofen oral tablet.................................... 5

ft itch relief max strength external cream..... 87

ft itch relief/aloe max str............................... 87

ft laxative.................................................... 161

ft lice killing max st....................................... 47

ft lubricant eye drops ophthalmic solution

0.5 %.......................................................... 179

ft magnesium citrate...................................124

ft miconazole 7............................................. 36

ft milk of magnesia..................................... 121

ft mineral oil................................................123

ft nasal decongestant max str oral tablet... 198

ft nasal decongestant pe............................ 191

ft nicotine......................................................19

ft nicotine mini.............................................. 19

ft omeprazole............................................. 117

ft pain & fever childrens................................13

ft pain & fever infants................................... 13

ft pain relief adult extra st............................. 13

ft pain relief extra strength............................13

ft pain relief oral tablet 200 mg.......................5

ft pain relief oral tablet 325 mg.....................13

ft pain reliever ex str adult............................ 13

ft senna laxative......................................... 124

ft senna laxatives....................................... 124

ft stomach relief..........................................121

ft stool softener oral capsule...................... 125

ft stool softener oral tablet 100 mg.............125

ft tussin adult.............................................. 191

FULPHILA.................................................... 65

fungi-guard................................................. 161

FUROSCIX...................................................72

furosemide oral............................................ 72

fyavolv........................................................ 137

FYCOMPA................................................... 26

FYLNETRA................................................ 161

gabapentin (once-daily)................................79

gabapentin oral capsule............................... 28

gabapentin oral solution 250 mg/5ml........... 28

gabapentin oral tablet 600 mg, 800 mg........28

galantamine hydrobromide er...................... 30

galantamine hydrobromide oral solution...... 30

galantamine hydrobromide tablet 12 mg

oral............................................................... 30

galantamine hydrobromide tablet 4 mg oral.30

galantamine hydrobromide tablet 8 mg oral.30

GALZIN ORAL CAPSULE 25 MG..............107

GALZIN ORAL CAPSULE 50 MG..............107

GAMUNEX-C INJECTION SOLUTION 40

GM/400ML................................................. 146

GARDASIL 9.............................................. 149

gas relief extra strength..............................121

gas relief extra strength oral tablet

chewable 125 mg....................................... 121

gas relief extstrength..................................121

gas relief infants......................................... 121

gas relief infants drops oral suspension 40

mg/0.6ml.................................................... 121

gas relief infants oral suspension 20

mg/0.3ml.................................................... 121

gas relief oral capsule 125 mg................... 121

gas relief oral tablet chewable 125 mg.......121

gas relief oral tablet chewable 80 mg.........121

GASTROCROM......................................... 127

GAS-X EXTRA STRENGTH ORAL

CAPSULE.................................................. 121

gatifloxacin ophthalmic...............................176

gavilax oral powder.................................... 123

gavilyte-c.................................................... 115

gavilyte-g....................................................115

GAVRETO..................................................172

gefitinib.......................................................172

GELFILM EXTERNAL................................161

GELFILM OPHTHALMIC........................... 179

GELFOAM..................................................161

GELFOAM COMPRESSED SIZE 100....... 161

227

GELFOAM DENTAL PACK SIZE 4............161

GELFOAM SPONGE SIZE 200................. 161

GELFOAM SPONGE SIZE 50................... 161

GELNIQUE.................................................128

GELSYN-3................................................. 162

GELX............................................................82

gemfibrozil oral.............................................73

gemmily......................................................137

GEMTESA....................................................53

GENADUR COMBINATION.......................162

generlac..................................................... 114

gengraf....................................................... 148

GENORAVANCE....................................... 121

GENOTROPIN........................................... 132

GENOTROPIN MINIQUICK....................... 132

gentamicin sulfate external.......................... 90

gentamicin sulfate ophthalmic....................176

GENTEAL TEARS NIGHT-TIME............... 179

gentle laxative............................................ 162

gentle laxative womens..............................162

gentlelax.....................................................123

GENTLE-LET PLATFORMS...................... 104

genuine aspirin...........................................162

GENVOYA................................................... 54

GEODON INTRAMUSCULAR..................... 51

GEODON ORAL.......................................... 51

geri-dryl...................................................... 185

geri-kot....................................................... 125

geri-tussin dm oral syrup............................198

geri-tussin oral liquid.................................. 191

GILENYA ORAL CAPSULE 0.25 MG.......... 80

GILENYA ORAL CAPSULE 0.5 MG............ 80

GILOTRIF...................................................172

GIMOTI........................................................ 34

GLASSIA....................................................127

glatiramer acetate........................................ 80

glatopa......................................................... 80

GLEEVEC.................................................. 172

glimepiride....................................................59

glipizide er.................................................... 59

glipizide oral tablet 10 mg, 5 mg.................. 59

glipizide oral tablet 2.5 mg........................... 59

glipizide xl.....................................................59

glipizide-metformin hcl................................. 59

GLOPERBA................................................. 37

GLOSTRIPS OPHTHALMIC STRIP 1 MG.179

GLUCAGEN HYPOKIT................................ 60

glucagon emergency injection kit................. 60

GLUCAGON EMERGENCY INJECTION

SOLUTION RECONSTITUTED................... 60

GLUCO TO GO............................................63

GLUCOCARD EXPRESSION TEST............98

GLUCOCARD SHINE TEST........................ 98

GLUCOCARD VITAL TEST......................... 98

GLUCOSE CONTROL SOLUTION IN

VITRO SOLUTION HIGH...........................162

GLUCOSE CONTROL SOLUTION IN

VITRO SOLUTION LOW............................162

GLUCOSE CONTROL SOLUTION IN

VITRO SOLUTION NORMAL.................... 162

GLUCOSE CONTROL SOLUTIONS........... 97

GLUCOSE METER TEST STRIPS..............98

glucose oral tablet chewable 4 gm...............63

GLUCOTROL XL......................................... 59

GLUMETZA..................................................59

glyburide micronized.................................... 59

glyburide oral................................................59

glyburide-metformin..................................... 59

GLYCATE.................................................. 115

glycerin (adult) rectal suppository 2 gm..... 125

glycerin (infants & children) rectal

suppository 1 gm........................................125

glycerin adult rectal suppository 2 gm........125

glycerin child rectal suppository 1 gm, 1.2

gm.............................................................. 125

glycerin childrens....................................... 125

glycerin pediatric rectal suppository 1.2 gm

....................................................................125

glycolax...................................................... 123

glycopyrrolate oral solution........................ 115

glycopyrrolate oral tablet 1 mg................... 115

GLYCOPYRROLATE ORAL TABLET 1.5

MG............................................................. 115

glycopyrrolate oral tablet 2 mg................... 115

glydo.............................................................17

GLYXAMBI...................................................59

GOCOVRI.................................................... 48

GOLYTELY................................................ 115

GRALISE ORAL...........................................79

GRALISE ORAL TABLET 300 MG, 600

MG............................................................... 79

GRALISE ORAL TABLET 450 MG, 750

MG, 900 MG.................................................79

granisetron hcl intravenous.......................... 35

granisetron hcl oral.......................................35

GRANIX....................................................... 65

GRASTEK.................................................. 146

griseofulvin microsize oral suspension.........36

griseofulvin microsize oral tablet.................. 36

griseofulvin ultramicrosize............................36

guaifenesin oral liquid................................ 191

guaifenesin-dm oral syrup..........................198

guanfacine hcl.............................................. 67

guanfacine hcl er..........................................77

GUARDIAN 4 GLUCOSE SENSOR............ 99

GUARDIAN 4 TRANSMITTER...................162

GUARDIAN CONNECT TRANSMITTER...162

GUARDIAN LINK 3 TRANSMITTER..........162

GUARDIAN REAL-TIME CHARGER......... 162

GUARDIAN REAL-TIME REPLACE PED....99

GUARDIAN REAL-TIME TEST PLUG....... 162

GUARDIAN SENSOR (3).............................99

GUARDIAN SENSOR 3............................... 99

GVOKE HYPOPEN 1-PACK........................60

GVOKE HYPOPEN 2-PACK........................60

228

GVOKE KIT..................................................60

GVOKE PFS................................................ 60

GYNAZOLE-1.............................................. 36

habitrol......................................................... 19

HADLIMA................................................... 162

HADLIMA PUSHTOUCH........................... 162

hailey 1.5/30...............................................137

hailey 24 fe.................................................137

hailey fe 1.5/30...........................................137

hailey fe 1/20..............................................137

halcinonide................................................... 87

HALCION................................................... 201

HALDOL DECANOATE............................... 50

halobetasol propionate external cream........ 87

halobetasol propionate external ointment.... 87

halobetasol propionate foam 0.05 %

external........................................................ 87

haloette...................................................... 137

HALOG.........................................................87

haloperidol decanoate intramuscular........... 50

haloperidol lactate oral concentrate 2

mg/ml........................................................... 50

haloperidol oral tablet 0.5 mg, 1 mg, 10

mg, 2 mg, 5 mg............................................ 50

haloperidol oral tablet 20 mg........................50

HAVRIX......................................................149

HEALTHPRO BLOOD GLUCOSE

MONITO.......................................................99

heartburn prevention oral tablet 10 mg...... 116

heartburn relief........................................... 116

heartland gas relief.....................................121

heather....................................................... 142

h-e-b aspirin............................................... 162

h-e-b childrens allergy................................185

HELIDAC THERAPY..................................115

HEMADY....................................................131

HEMANGEOL.............................................. 69

HEMATOGEN............................................ 107

HEMAX...................................................... 107

HEMMOREX-HC..........................................38

heparin (porcine) in nacl intravenous

solution 1000-0.9 ut/500ml-%, 2000-0.9

unit/l-%......................................................... 64

heparin na (pork) lock flsh pf intravenous

solution 10 unit/ml, 100 unit/ml...................162

heparin sod (pork) lock flush...................... 162

heparin sodium (porcine)............................. 64

heparin sodium (porcine) pf......................... 64

HEPLISAV-B.............................................. 151

HEPMED....................................................162

HEPZATO W/50MM CATHETER................ 40

HEPZATO W/62MM CATHETER................ 40

her style......................................................144

HERZUMA................................................. 173

HETLIOZ.................................................... 201

HETLIOZ LQ.............................................. 201

hi cal...........................................................107

HIBERIX.....................................................149

HIDEX 6-DAY.............................................131

HIPREX........................................................20

HORIZANT...................................................79

HULIO (2 PEN).......................................... 162

HULIO SUBCUTANEOUS PREFILLED

SYRINGE KIT 20 MG/0.4ML, 40

MG/0.8ML.................................................. 162

HUMALOG JUNIOR KWIKPEN................... 61

HUMALOG KWIKPEN SOLUTION PEN-

INJECTOR 100 UNIT/ML

SUBCUTANEOUS....................................... 61

HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 200 UNIT/ML.61

HUMALOG MIX 50/50..................................61

HUMALOG MIX 50/50 KWIKPEN................ 61

HUMALOG MIX 75/25..................................61

HUMALOG MIX 75/25 KWIKPEN................ 61

HUMALOG SOLUTION 100 UNIT/ML

INJECTION.................................................. 61

HUMALOG SUBCUTANEOUS.................... 61

HUMALOG TEMPO PEN.............................61

HUMATROPE............................................ 132

HUMATROPEN FOR 12MG...................... 162

HUMATROPEN FOR 24MG...................... 162

HUMATROPEN FOR 6MG........................ 162

HUMIRA (2 PEN) PEN-INJECTOR KIT 80

MG/0.8ML SUBCUTANEOUS................... 148

HUMIRA (2 PEN) SUBCUTANEOUS PEN-

INJECTOR KIT 40 MG/0.4ML....................148

HUMIRA (2 SYRINGE) SUBCUTANEOUS

PREFILLED SYRINGE KIT 10 MG/0.1ML,

20 MG/0.2ML, 40 MG/0.4ML......................148

HUMIRA SUBCUTANEOUS PEN-

INJECTOR KIT 40 MG/0.8ML, 80

MG/0.8ML.................................................. 148

HUMIRA SUBCUTANEOUS PREFILLED

SYRINGE KIT 40 MG/0.8ML......................148

HUMIRA-PED

....................................................................148

HUMIRA-PED>/=40KG CROHNS START.148

HUMIRA-PED>/=40KG UC STARTER...... 148

HUMIRA-PSORIASIS/UVEIT STARTER... 148

HUMULIN 70/30 KWIKPEN......................... 61

HUMULIN 70/30 VIAL.................................. 61

HUMULIN N KWIKPEN................................61

HUMULIN N VIAL........................................ 61

HUMULIN R SOLUTION 100 UNIT/ML

INJECTION.................................................. 61

HUMULIN R U-500 KWIKPEN.....................61

HUMULIN R U-500 VIAL

(CONCENTRATED).....................................61

HYCAMTIN ORAL........................................42

hydralazine hcl oral...................................... 75

HYDREA...................................................... 41

hydrochlorothiazide oral............................... 73

hydrocodone bitartrate er............................... 6

hydrocodone-acetaminophen oral solution

7.5-325 mg/15ml............................................ 9

hydrocodone-acetaminophen oral tablet........9

229

hydrocodone-ibuprofen.................................. 9

hydrocortisone (perianal)........................... 152

hydrocortisone ace-pramoxine external

cream 1-1 %.................................................88

hydrocortisone ace-pramoxine external

cream 2.5-1 %..............................................89

hydrocortisone acetate external cream........ 91

hydrocortisone acetate external ointment.... 91

hydrocortisone acetate rectal....................... 38

hydrocortisone anti-itch................................ 87

hydrocortisone butyrate external cream.......87

hydrocortisone butyrate external ointment... 87

hydrocortisone butyrate external solution.... 87

hydrocortisone butyrate lotion 0.1 %

external........................................................ 87

hydrocortisone external cream 0.5 %, 2.5

%.................................................................. 87

hydrocortisone external cream 1 %..............87

hydrocortisone external lotion 2.5 %............ 87

hydrocortisone external ointment 0.5 %.......87

hydrocortisone external ointment 1 %..........87

hydrocortisone external ointment 2.5 %.......87

hydrocortisone max st external cream......... 87

hydrocortisone max st/12 moist................... 87

hydrocortisone oral tablet 10 mg, 20 mg, 5

mg.............................................................. 131

hydrocortisone plus external cream 1 %...... 87

hydrocortisone rectal enema 100 mg/60ml 152

hydrocortisone valerate................................87

hydrocortisone/aloe......................................87

hydrocortisone/aloe max str......................... 87

hydrocortisone-acetic acid......................... 181

hydrocortisone-iodoquinol............................ 37

hydrocort-pramoxine (perianal).................... 89

hydromorphone hcl er.................................... 6

hydromorphone hcl oral liquid........................ 9

hydromorphone hcl oral tablet........................9

hydromorphone hcl rectal...............................9

hydroxychloroquine sulfate oral tablet 100

mg, 400 mg.................................................. 46

hydroxychloroquine sulfate oral tablet 200

mg................................................................ 46

hydroxychloroquine sulfate oral tablet 300

mg................................................................ 46

hydroxyurea oral.......................................... 41

hydroxyzine hcl oral..................................... 57

hydroxyzine pamoate oral............................ 57

HYFTOR.................................................... 162

HYLAVITE..................................................111

HYMOVIS...................................................162

hyoscyamine sulfate er.............................. 162

hyoscyamine sulfate oral elixir................... 162

hyoscyamine sulfate oral solution.............. 162

hyoscyamine sulfate oral tablet..................162

hyoscyamine sulfate sl sublingual tablet

sublingual 0.125 mg................................... 162

hyoscyamine sulfate sublingual................. 162

hyoscyamine sulfate tablet dispersible

0.125 mg oral............................................. 162

hyosyne......................................................162

HYPERRAB INJECTION SOLUTION 900

UNIT/3ML...................................................146

HYPERSAL................................................ 198

HYPERTET................................................ 151

HYPOTEARS............................................. 179

HYRIMOZ SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 40 MG/0.4ML............... 162

HYRIMOZ SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 80 MG/0.8ML............... 163

HYRIMOZ SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 10 MG/0.1 ML, 20

MG/0.2ML.................................................. 163

HYRIMOZ SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 40 MG/0.4ML........163

HYRIMOZ-CROHNS/UC STARTER..........163

HYRIMOZ-PED

....................................................................163

HYRIMOZ-PED>/=40KG CROHN START.163

HYRIMOZ-PLAQUE PSORIASIS START..163

HYSINGLA ER............................................... 6

HYZAAR.......................................................72

ibandronate sodium oral.............................153

IBRANCE..................................................... 43

IBSRELA.................................................... 114

ibuprofen........................................................ 5

ibuprofen childrens oral tablet chewable

100 mg........................................................... 5

ibuprofen ib childrens..................................... 5

ibuprofen ib oral tablet 200 mg.......................5

ibuprofen infants oral suspension 50

mg/1.25ml...................................................... 5

ibuprofen jr oral tablet 100 mg....................... 5

ibuprofen junior.............................................. 5

ibuprofen junior strength................................ 5

ibuprofen oral suspension 100 mg/5ml.......... 5

ibuprofen oral tablet 200 mg.......................... 5

ibuprofen oral tablet 400 mg, 600 mg, 800

mg.................................................................. 5

ibuprofen-famotidine...................................... 5

iclevia......................................................... 137

ICLUSIG ORAL TABLET 10 MG, 30 MG...172

ICLUSIG ORAL TABLET 15 MG, 45 MG...172

icosapent ethyl............................................. 74

IDACIO (2 PEN)......................................... 163

IDACIO (2 SYRINGE)................................ 163

IDACIO-CROHNS/UC STARTER.............. 163

IDACIO-PSORIASIS STARTER................ 163

IDHIFA......................................................... 42

iferex 150 forte........................................... 107

IGALMI......................................................... 57

IHEALTH COVID-19 RAPID TEST............ 163

ILARIS........................................................146

ILEVRO...................................................... 177

ILUMYA......................................................146

230

ILUVIEN..................................................... 177

imatinib mesylate....................................... 172

IMBRUVICA............................................... 172

imipramine hcl oral....................................... 34

imipramine pamoate.....................................34

imiquimod external cream 3.75 %................89

imiquimod external cream 5 %.....................89

imiquimod pump...........................................89

IMITREX.......................................................39

IMITREX STATDOSE REFILL..................... 39

IMITREX STATDOSE SYSTEM.................. 39

IMURAN..................................................... 149

inavix............................................................ 16

INBRIJA....................................................... 49

incassia...................................................... 142

INCRELEX................................................. 132

INCRUSE ELLIPTA....................................187

indapamide...................................................73

INDERAL LA................................................ 69

INDERAL XL................................................ 69

INDICAID COVID-19 RAPID TEST............163

INDOCIN........................................................ 5

indomethacin er..............................................5

indomethacin oral capsule............................. 5

indomethacin oral suspension........................5

indomethacin rectal suppository 50 mg..........5

indoor/outdoor allergy rlf............................ 185

INFANRIX.................................................. 149

infant gas relief...........................................121

infants gas relief......................................... 121

infants ibuprofen.............................................5

infants pain & fever...................................... 13

infants pain relief drops................................ 13

infants pain/fever..........................................14

INFED........................................................ 203

INFINITY CONTROL IN VITRO

SOLUTION HIGH.......................................163

INFINITY CONTROL IN VITRO

SOLUTION LOW........................................163

INFLAMMACIN............................................ 16

INFLECTRA............................................... 149

INFLIXIMAB............................................... 149

INGREZZA ORAL CAPSULE 40 MG, 80

MG............................................................... 79

INGREZZA ORAL CAPSULE 60 MG...........79

INGREZZA ORAL CAPSULE SPRINKLE....79

INGREZZA ORAL CAPSULE THERAPY

PACK........................................................... 79

INJECTAFER INTRAVENOUS SOLUTION

750 MG/15ML............................................ 107

INLYTA.......................................................172

INNOPRAN XL.............................................69

INPEFA ORAL TABLET 200 MG............... 163

INPEFA ORAL TABLET 400 MG............... 163

INPEN 100-BLUE-LILLY-HUMALOG.........163

INPEN 100-BLUE-NOVOLOG-FIASP........163

INPEN 100-GREY-LILLY-HUMALOG........163

INPEN 100-GREY-NOVOLOG-FIASP.......163

INPEN 100-PINK-LILLY-HUMALOG..........163

INPEN 100-PINK-NOVOLOG-FIASP.........164

INQOVI.........................................................43

INREBIC.......................................................43

INSPIREASE..............................................164

INSPIREASE RESERVOIR BAGS............ 164

INSPRA........................................................73

instacort 5.....................................................87

INSULIN ASP PROT & ASP FLEXPEN.......61

INSULIN ASPART........................................61

INSULIN ASPART FLEXPEN...................... 61

INSULIN ASPART PENFILL........................ 61

INSULIN ASPART PROT & ASPART..........61

INSULIN DEGLUDEC.................................. 61

INSULIN DEGLUDEC FLEXTOUCH........... 61

INSULIN GLARGINE MAX SOLOSTAR...... 61

INSULIN GLARGINE SOLOSTAR

SUBCUTANEOUS SOLUTION PEN-

INJECTOR 300 UNIT/ML.............................61

INSULIN GLARGINE-YFGN........................ 61

INSULIN LISPRO.........................................61

INSULIN LISPRO (1 UNIT DIAL)................. 61

INSULIN LISPRO JUNIOR KWIKPEN.........61

INSULIN LISPRO PROT & LISPRO............ 61

INSULIN PEN NEEDLES.............................99

INSULIN PEN NEEDLES 29G X 12.7MM..164

INSULIN PEN NEEDLES 29G X 12MM.....164

INSULIN PEN NEEDLES 29G X 5MM ,

29G X 8MM................................................ 164

INSULIN PEN NEEDLES 30G X 5 MM......164

INSULIN PEN NEEDLES 31G X 4 MM......164

INSULIN PEN NEEDLES 31G X 5 MM......164

INSULIN PEN NEEDLES 31G X 6 MM......164

INSULIN PEN NEEDLES 31G X 8 MM......164

INSULIN PEN NEEDLES 32G X 4 MM........99

INSULIN PEN NEEDLES 32G X 8 MM ,

33G X 4 MM , 33G X 5 MM , 33G X 6 MM.164

INSULIN SYRINGES 27G X 1/2" 0.5 ML,

27G X 1/2" 1 ML, 28G X 1/2" 0.5 ML, 28G

X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 30G X

1/2" 1 ML, 31G X 5/16" 0.5 ML.................. 164

INSULIN SYRINGES 28G X 5/16" 1 ML,

29G X 5/16" 1 ML, 31G X 1/2" 0.3 ML, 32G

X 5/16" 1 ML...............................................164

INSULIN SYRINGES 29G X 1/2" 0.3 ML... 164

INSULIN SYRINGES 29G X 1/2" 1 ML,

30G X 5/16" 0.5 ML, 31G X 5/16" 1 ML..... 164

INSULIN SYRINGES 30G X 1/2" 0.3 ML... 165

INSULIN SYRINGES 30G X 1/2" 0.5 ML... 165

INSULIN SYRINGES 30G X 5/16" 0.3 ML. 165

INSULIN SYRINGES 30G X 5/16" 1 ML.... 165

INSULIN SYRINGES 31G X 15/64" 0.3 ML

....................................................................165

INSULIN SYRINGES 31G X 15/64" 0.5 ML

....................................................................165

INSULIN SYRINGES 31G X 5/16" 0.3 ML. 165

INTELENCE................................................. 55

INTELISWAB COVID-19 RAPID TEST......165

introvale......................................................137

231

INTUNIV.......................................................77

INVEGA........................................................51

INVEGA HAFYERA......................................51

INVEGA SUSTENNA................................... 51

INVEGA TRINZA..........................................51

INVELTYS..................................................177

INVOKAMET................................................ 59

INVOKAMET XR.......................................... 59

INVOKANA...................................................59

IOPIDINE................................................... 178

IPOL........................................................... 149

ipratropium bromide inhalation...................187

ipratropium bromide nasal..........................187

ipratropium-albuterol.................................. 196

irbesartan..................................................... 68

irbesartan-hydrochlorothiazide.....................72

IRESSA...................................................... 172

iron (ferrous sulfate) oral solution...............108

iron infant/toddler....................................... 108

iron oral tablet 240 (27 fe) mg.................... 108

iron oral tablet 325 (65 fe) mg.................... 108

iron supplement childrens.......................... 108

iron supplement oral solution 220 (44 fe)

mg/5ml....................................................... 108

ISENTRESS HD...........................................54

ISENTRESS ORAL PACKET.......................54

ISENTRESS ORAL TABLET....................... 54

ISENTRESS ORAL TABLET CHEWABLE.. 54

isibloom...................................................... 137

isoniazid oral................................................ 40

ISORDIL TITRADOSE ORAL TABLET 40

MG............................................................... 75

ISORDIL TITRADOSE ORAL TABLET 5

MG............................................................... 75

isosorb dinitrate-hydralazine........................ 72

isosorbide dinitrate....................................... 75

isosorbide mononitrate.................................75

isosorbide mononitrate er.............................75

isotretinoin oral capsule 10 mg, 20 mg, 30

mg, 40 mg.................................................... 83

isotretinoin oral capsule 25 mg, 35 mg........ 83

isradipine......................................................70

ISTALOL.................................................... 178

itraconazole oral capsule............................. 36

itraconazole oral solution............................. 36

ivermectin cream 1 % external.....................89

ivermectin oral..............................................45

IWILFIN...................................................... 165

IXIARO....................................................... 149

IYUZEH...................................................... 174

JADENU.....................................................109

JADENU SPRINKLE.................................. 109

jaimiess...................................................... 137

JAKAFI......................................................... 43

JALYN........................................................ 129

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5

mg, 3 mg, 4 mg, 5 mg, 7.5 mg..................... 64

jantoven oral tablet 6 mg..............................64

JANUMET.................................................... 59

JANUMET XR.............................................. 59

JANUVIA...................................................... 59

JARDIANCE.................................................59

jasmiel........................................................ 137

JATENZO...................................................134

JAYPIRCA..................................................165

jencycla...................................................... 142

JENTADUETO............................................. 59

JENTADUETO XR....................................... 59

JESDUVROQ.............................................165

jinteli........................................................... 137

jolessa........................................................ 137

JORNAY PM................................................ 77

joyeaux.......................................................137

JUBLIA......................................................... 90

juleber........................................................ 137

JULUCA....................................................... 54

junel 1.5/30.................................................137

junel 1/20....................................................137

junel fe........................................................137

JUST RIGHT 5000..................................... 105

JUXTAPID....................................................74

JYLAMVO.................................................. 149

JYNARQUE................................................109

kaitlib fe...................................................... 138

KALETRA.....................................................56

kalliga......................................................... 138

KALYDECO ORAL PACKET 13.4 MG, 5.8

MG............................................................. 188

KALYDECO ORAL PACKET 25 MG, 50

MG, 75 MG.................................................188

KALYDECO ORAL TABLET...................... 188

KAPSPARGO SPRINKLE............................69

KARBINAL ER........................................... 185

kariva..........................................................138

KATERZIA....................................................70

kelnor 1/35................................................. 138

kelnor 1/50................................................. 138

KENALOG EXTERNAL................................87

KENALOG INJECTION..............................131

KENALOG-80.............................................131

KEPPRA INTRAVENOUS............................26

KEPPRA ORAL SOLUTION........................ 26

KEPPRA ORAL TABLET............................. 26

KEPPRA XR.................................................26

KERALYT EXTERNAL GEL 6 %............... 165

KERENDIA...................................................72

KESIMPTA................................................... 80

ketoconazole external cream....................... 90

ketoconazole external foam......................... 90

ketoconazole external shampoo.................. 90

ketoconazole oral......................................... 36

ketodan........................................................ 90

KETO-DIASTIX............................................ 99

KETONE CARE........................................... 99

KETONE TEST............................................ 99

ketoprofen er.................................................. 5

232

ketoprofen oral capsule 25 mg.......................5

ketorolac tromethamine injection solution

15 mg/ml........................................................ 5

ketorolac tromethamine intramuscular

solution 60 mg/2ml......................................... 5

ketorolac tromethamine ophthalmic

solution 0.4 %.............................................177

ketorolac tromethamine ophthalmic

solution 0.5 %.............................................177

ketorolac tromethamine oral...........................5

ketorolac tromethamine solution 30 mg/ml

injection.......................................................... 5

KETOROLAC TROMETHAMINE

SOLUTION 30 MG/ML INJECTION............... 5

KETOSTIX................................................... 99

ketotifen fumarate ophthalmic.................... 181

KEVEYIS....................................................127

KEVZARA.................................................. 146

KEYFOLIC................................................. 203

KEYLOSA.................................................. 203

KINERET....................................................147

KIPROFEN.....................................................6

KISQALI (200 MG DOSE)............................43

KISQALI (400 MG DOSE)............................43

KISQALI (600 MG DOSE)............................43

KISQALI FEMARA (200 MG DOSE)............43

KISQALI FEMARA (400 MG DOSE)............43

KISQALI FEMARA (600 MG DOSE)............43

KITABIS PAK............................................. 188

KLARITY-A.................................................176

KLARON...................................................... 91

klayesta........................................................ 91

KLONOPIN...................................................57

klor-con 10................................................. 105

klor-con m10.............................................. 105

klor-con m15.............................................. 105

klor-con m20.............................................. 105

klor-con oral packet....................................105

klor-con oral tablet extended release......... 105

klor-con/ef.................................................. 203

KLOXXADO................................................. 18

KONVOMEP.............................................. 117

KORLYM.................................................... 133

KOSELUGO................................................. 43

kourzeq........................................................ 82

K-PHOS..................................................... 108

K-PHOS NO 2............................................ 108

K-PHOS-NEUTRAL................................... 108

k-prime....................................................... 203

KRAZATI.................................................... 165

KRINTAFEL................................................. 46

KRISTALOSE.............................................114

K-TAB.........................................................105

k-tan plus....................................................108

kurvelo........................................................138

KYLEENA...................................................142

labetalol hcl oral........................................... 69

lacosamide intravenous............................... 29

lacosamide oral............................................ 29

LACRISERT............................................... 174

lactic acid external........................................87

lactulose encephalopathy...........................114

lactulose oral packet.................................. 114

lactulose oral solution.................................114

LAGEVRIO CAPSULE 200 MG ORAL........ 57

LAMICTAL ODT ORAL KIT..........................26

LAMICTAL ODT ORAL TABLET

DISPERSIBLE..............................................26

LAMICTAL ORAL TABLET.......................... 26

LAMICTAL ORAL TABLET CHEWABLE..... 26

LAMICTAL STARTER..................................27

LAMICTAL XR ORAL KIT............................ 27

LAMICTAL XR ORAL TABLET

EXTENDED RELEASE 24 HOUR............... 27

lamivudine oral solution................................55

lamivudine oral tablet 100 mg...................... 53

lamivudine oral tablet 150 mg, 300 mg........ 55

lamivudine-zidovudine..................................55

lamotrigine er............................................... 27

lamotrigine oral kit........................................ 27

lamotrigine oral tablet...................................27

lamotrigine oral tablet chewable...................27

lamotrigine oral tablet dispersible.................27

lamotrigine starter kit-blue............................27

lamotrigine starter kit-green......................... 27

lamotrigine starter kit-orange....................... 27

LAMPIT........................................................ 46

LANCETS.............................................99, 104

LANCETS MICRO THIN 33G...................... 99

LANOXIN ORAL...........................................72

lansoprazole capsule delayed release 15

mg oral (otc)............................................... 117

lansoprazole capsule delayed release 15

mg oral (rx).................................................117

lansoprazole oral capsule delayed release

15 mg......................................................... 118

lansoprazole oral capsule delayed release

30 mg......................................................... 118

lansoprazole oral tablet delayed release

dispersible 15 mg....................................... 118

lansoprazole oral tablet delayed release

dispersible 15 mg, 30 mg........................... 118

lanthanum carbonate................................. 110

LANTUS SOLOSTAR.................................. 61

LANTUS U-100 VIAL................................... 61

lapatinib ditosylate......................................172

larin 1.5/30................................................. 138

larin 1/20.................................................... 138

larin 24 fe................................................... 138

larin fe 1.5/30............................................. 138

larin fe 1/20................................................ 138

LASIX........................................................... 72

LATANOPROST OIL..................................165

latanoprost ophthalmic............................... 174

LATUDA ORAL TABLET 120 MG, 20 MG,

40 MG, 60 MG, 80 MG.................................51

laxaclear.....................................................123

233

laxative max str.......................................... 125

laxative oral powder 17 gm/scoop..............123

laxative oral tablet delayed release 5 mg...165

laxative pills max st.................................... 125

laxative pills oral tablet 25 mg.................... 125

laxative rectal suppository 10 mg...............165

laxative regular strength.............................125

layolis fe..................................................... 138

L-CYSTINE................................................ 165

leena.......................................................... 138

leflunomide oral..........................................149

LEMTRADA..................................................80

lenalidomide................................................. 41

LENVIMA (10 MG DAILY DOSE)...............172

LENVIMA (12 MG DAILY DOSE)...............172

LENVIMA (14 MG DAILY DOSE)...............172

LENVIMA (18 MG DAILY DOSE)...............172

LENVIMA (20 MG DAILY DOSE)...............172

LENVIMA (24 MG DAILY DOSE)...............173

LENVIMA (4 MG DAILY DOSE).................173

LENVIMA (8 MG DAILY DOSE).................173

LEQVIO........................................................74

LESCOL XL..................................................74

lessina........................................................ 138

LETAIRIS................................................... 189

letrozole oral.................................................42

leucovorin calcium oral tablet 10 mg............44

leucovorin calcium oral tablet 15 mg, 25

mg, 5 mg...................................................... 44

LEUKERAN..................................................40

LEUKINE......................................................65

LEUPROLIDE ACETATE (3 MONTH)....... 145

leuprolide acetate injection.........................145

levalbuterol hcl inhalation...........................188

LEVALBUTEROL HFA INHALATION

AEROSOL 45 MCG/ACT........................... 188

LEVAMLODIPINE MALEATE...................... 75

LEVBID...................................................... 165

LEVEMIR FLEXPEN.................................... 61

LEVEMIR U-100 VIAL..................................61

levetiracetam er............................................27

levetiracetam in nacl.................................... 27

levetiracetam intravenous............................ 27

levetiracetam oral solution........................... 27

levetiracetam oral tablet............................... 27

levobunolol hcl........................................... 178

levocarnitine oral solution...........................127

levocarnitine sf........................................... 127

levocetirizine dihydrochloride oral solution.185

levocetirizine dihydrochloride oral tablet.... 185

levofloxacin oral tablet..................................24

levofloxacin solution 25 mg/ml oral.............. 24

levonest......................................................138

levonorgest-eth est & eth est..................... 138

levonorgest-eth estrad 91-day................... 138

levonorgest-eth estradiol-iron.....................138

levonorgestrel.............................................144

levonorgestrel-ethinyl estrad...................... 138

levonorg-eth estrad triphasic......................138

levora 0.15/30 (28)..................................... 138

levorphanol tartrate oral................................. 6

levo-t.......................................................... 144

LEVOTHYROXINE SODIUM ORAL

CAPSULE.................................................. 144

levothyroxine sodium oral tablet.................144

levoxyl........................................................ 144

LEVSIN...................................................... 165

LEVSIN/SL................................................. 165

LEVULAN KERASTICK............................... 89

LEXAPRO.................................................... 33

LEXETTE..................................................... 87

LIALDA.......................................................152

LIBERVANT................................................. 28

LIBRAX...................................................... 115

LICART.......................................................... 6

lice killing external liquid 1 %....................... 89

lice killing external shampoo 0.33-4 %.........47

lice killing max st external shampoo 0.33-4

%.................................................................. 47

lice killing max str......................................... 47

lice killing max strength................................ 47

lice killing maximum strength....................... 47

lice killing shampoo max str......................... 47

lice maximum strength................................. 47

lice treatment external liquid 1 %................. 89

lice treatment external lotion 1 %................. 89

lice treatment external shampoo 0.33-4 %...47

LIDO BDK.................................................... 17

lidocaine external ointment 5 %................... 17

lidocaine external patch 5 %........................ 17

lidocaine hcl external cream 3 %................. 17

lidocaine hcl external solution...................... 17

lidocaine hcl mouth/throat............................ 17

lidocaine hcl urethral/mucosal......................17

lidocaine viscous hcl.................................... 17

lidocaine-hydrocort (perianal).......................91

LIDOCAINE-HYDROCORTISONE ACE

RECTAL GEL...............................................91

lidocaine-hydrocortisone ace rectal kit 2-2

%.................................................................. 91

lidocaine-hydrocortisone ace rectal kit 3-

0.5 %............................................................ 91

lidocaine-hydrocortisone ace rectal kit 3-1

%, 3-2.5 %....................................................91

lidocaine-prilocaine external cream..............17

lidocaine-prilocaine external kit.................... 17

LIDOCAN PATCH 5 % EXTERNAL.............17

LIDOCORT...................................................91

LIDODERM.................................................. 17

lidopin external cream 3 %...........................17

LIDOPURE PATCH......................................17

LIDOTHOL EXTERNAL PATCH 4-1 %........17

LIDOTRAL EXTERNAL CREAM..................17

LIDOTRAN................................................... 17

LIKMEZ........................................................ 20

LILETTA (52 MG).......................................142

234

LINCOCIN.................................................... 20

lincomycin hcl injection.................................20

linezolid oral suspension reconstituted........ 20

linezolid oral tablet....................................... 20

LINZESS.................................................... 114

liothyronine sodium oral............................. 144

LIPITOR....................................................... 74

LIPOFEN......................................................73

LIQREV...................................................... 189

liquid acetaminophen................................... 14

liquid allergy relief...................................... 185

liquid pain relief............................................ 14

lisdexamfetamine dimesylate oral capsule

10 mg........................................................... 78

lisdexamfetamine dimesylate oral capsule

20 mg, 30 mg, 40 mg, 50 mg, 60 mg, 70

mg................................................................ 78

lisdexamfetamine dimesylate oral tablet

chewable...................................................... 78

lisinopril oral................................................. 68

lisinopril-hydrochlorothiazide........................72

L-ISOLEUCINE.......................................... 203

LITFULO.................................................... 165

lithium...........................................................58

lithium carbonate er......................................58

lithium carbonate oral...................................58

LITHOBID.....................................................58

LITHOSTAT............................................... 129

LIVALO.........................................................74

LIVIXIL PAK................................................. 17

LIVTENCITY................................................ 56

l-methylfolate..............................................203

l-methylfolate calcium oral..........................203

l-methylfolate forte......................................165

l-methylfolate-algae....................................165

l-methylfolate-algae-b12-b6....................... 111

l-methyl-mc.................................................203

LO LOESTRIN FE......................................138

LOCOID....................................................... 87

LOCOID LIPOCREAM................................. 87

LODINE..........................................................6

LODOSYN....................................................49

LOESTRIN 1.5/30 (21)...............................138

LOESTRIN 1/20 (21)..................................138

LOESTRIN FE 1.5/30.................................138

LOESTRIN FE 1/20....................................139

LOFENA.........................................................6

lojaimiess................................................... 139

LOKELMA.................................................. 110

LOMOTIL................................................... 114

long lasting antacid.................................... 121

LONSURF.................................................... 42

loperamide hcl capsule 2 mg oral.............. 114

loperamide hcl oral tablet........................... 114

LOPID.......................................................... 73

lopinavir-ritonavir..........................................56

LOPRESSOR...............................................69

loradamed.................................................. 194

lorata-d....................................................... 198

loratadine allergy relief oral tablet 10 mg... 194

loratadine childrens oral solution................194

lorata-dine d............................................... 198

loratadine d 12hr........................................ 198

loratadine oral solution 5 mg/5ml............... 194

loratadine oral tablet 10 mg........................194

loratadine-d................................................ 198

loratadine-d 12hr........................................ 198

loratadine-d 24hr........................................ 198

lorazepam injection...................................... 57

lorazepam intensol....................................... 57

lorazepam oral concentrate 2 mg/ml............58

lorazepam oral tablet....................................58

LORBRENA............................................... 173

LOREEV XR.................................................58

loryna......................................................... 139

LORZONE..................................................200

losartan potassium oral................................ 68

losartan potassium-hctz............................... 72

LOTEMAX.................................................. 177

LOTEMAX SM............................................177

LOTENSIN................................................... 68

LOTENSIN HCT...........................................72

loteprednol etabonate ophthalmic gel........ 177

loteprednol etabonate ophthalmic

suspension 0.2 %.......................................177

loteprednol etabonate suspension 0.5 %

ophthalmic..................................................177

LOTREL....................................................... 72

LOTRONEX............................................... 114

lovastatin oral............................................... 74

LOVAZA....................................................... 74

LOVENOX....................................................64

low-ogestrel................................................139

loxapine succinate........................................50

lo-zumandimine..........................................139

lubiprostone................................................114

lubricant eye drops (pf) ophthalmic solution

0.5 %.......................................................... 179

lubricant eye drops ophthalmic solution 0.5

%................................................................ 179

lubricant eye drops pf.................................179

lubricant eye nighttime............................... 179

lubricant pm................................................179

lubricating eye drop....................................179

lubricating eye/overnight............................ 179

lubricating plus eye drops.......................... 179

lubricating plus ophthalmic solution 0.5 %. 179

lubricating plus pf....................................... 179

lubrifresh p.m............................................. 179

LUCEMYRA................................................. 18

LUCIRA COVID-19 & FLU TEST............... 165

LUGOLS STRONG IODINE.........................26

LULICONAZOLE..........................................91

LUMAKRAS ORAL TABLET 120 MG.......... 45

LUMAKRAS ORAL TABLET 320 MG.......... 45

LUMIGAN...................................................174

LUNESTA...................................................201

235

LUPKYNIS................................................. 146

LUPRON DEPOT (1-MONTH)................... 145

LUPRON DEPOT (3-MONTH)................... 145

LUPRON DEPOT (4-MONTH)

INTRAMUSCULAR KIT 30MG...................145

LUPRON DEPOT (6-MONTH)

INTRAMUSCULAR KIT 45MG...................145

LUPRON DEPOT-PED (1-MONTH).......... 145

LUPRON DEPOT-PED (3-MONTH).......... 145

LUPRON DEPOT-PED (6-MONTH).......... 145

lurasidone hcl oral tablet 120 mg, 20 mg,

40 mg, 60 mg, 80 mg................................... 51

lutera.......................................................... 139

LUZU............................................................91

LYBALVI.......................................................51

lyleq............................................................142

lyllana......................................................... 139

LYNPARZA.................................................. 43

LYRICA........................................................ 80

LYRICA CR.................................................. 80

lysiplex plus oral tablet............................... 203

LYSODREN............................................... 145

LYTGOBI (12 MG DAILY DOSE)...............165

LYTGOBI (16 MG DAILY DOSE)...............165

LYTGOBI (20 MG DAILY DOSE)...............165

LYUMJEV.....................................................61

LYUMJEV KWIKPEN................................... 62

LYUMJEV TEMPO PEN.............................. 62

LYVISPAH....................................................53

lyza.............................................................142

MACROBID..................................................20

MACRODANTIN.......................................... 20

mafenide acetate external............................91

magnesium citrate oral solution................. 125

MALARONE................................................. 46

malathion......................................................89

mapap childrens...........................................14

maraviroc..................................................... 56

MARGENZA...............................................173

MARINOL.....................................................35

marlissa......................................................139

MARPLAN....................................................32

MASK VORTEX/CHILD/FROG.................. 165

MASK VORTEX/TODDLER/LADYBUG.....165

MATULANE..................................................40

matzim la......................................................70

MAVENCLAD (10 TABS)............................. 81

MAVENCLAD (4 TABS)............................... 81

MAVENCLAD (5 TABS)............................... 81

MAVENCLAD (6 TABS)............................... 81

MAVENCLAD (7 TABS)............................... 81

MAVENCLAD (8 TABS)............................... 81

MAVENCLAD (9 TABS)............................... 81

MAX RELIEF JR CHILD PAIN/FEVER........ 14

MAX TUSSIN MUCUS & CHEST CONG...191

MAXALLERGY KIDS................................. 185

MAXALT.......................................................39

MAXIDEX................................................... 177

MAXITROL OPHTHALMIC OINTMENT.... 174

MAXITROL OPHTHALMIC SUSPENSION

0.1 %.......................................................... 174

MAYZENT.................................................... 81

MAYZENT STARTER PACK....................... 81

m-dryl......................................................... 185

me/naphos/mb/hyo1...................................130

meclizine hcl oral tablet 12.5 mg..................34

meclizine hcl oral tablet 25 mg.....................34

meclizine hcl oral tablet 50 mg.....................34

meclizine hcl tablet chewable 25 mg oral

(otc).............................................................. 34

meclofenamate sodium oral........................... 6

medifin mucus relief child...........................191

medi-first aspirin.........................................165

medi-first hydrocortisone..............................87

medi-first ibuprofen........................................ 6

mediproxen.................................................... 6

medique aspirin..........................................165

MEDISENSE GLUCOSE KETONE

CONTR........................................................ 99

MEDISENSE HI/MID/LOW CONTROL........ 99

MEDROL ORAL TABLET 16 MG, 4 MG, 8

MG............................................................. 131

MEDROL ORAL TABLET 2 MG.................131

MEDROL ORAL TABLET THERAPY

PACK......................................................... 131

medroxyprogesterone acetate

intramuscular..............................................143

medroxyprogesterone acetate oral............ 143

mefenamic acid oral....................................... 6

mefloquine hcl.............................................. 46

megestrol acetate oral suspension 40

mg/ml, 625 mg/5ml.....................................143

megestrol acetate oral tablet 20 mg...........143

megestrol acetate oral tablet 40 mg...........143

meijer allergy relief-d..................................198

meijer anti-diarrheal................................... 114

MEKINIST.................................................... 43

MEKTOVI..................................................... 43

meloxicam oral capsule..................................6

meloxicam oral tablet..................................... 6

memantine hcl er capsule extended

release 24 hour 14 mg oral.......................... 31

memantine hcl er capsule extended

release 24 hour 21 mg oral.......................... 31

memantine hcl er capsule extended

release 24 hour 28 mg oral.......................... 31

memantine hcl er capsule extended

release 24 hour 7 mg oral............................ 31

memantine hcl oral solution......................... 31

memantine hcl oral tablet............................. 31

MENATROL............................................... 203

MENEST.................................................... 139

MENOSTAR...............................................139

MENQUADFI..............................................149

MENVEO....................................................149

meperidine hcl oral solution........................... 9

236

meperidine hcl tablet 50 mg oral.................... 9

meprobamate............................................... 57

MEPRON..................................................... 46

mercaptopurine oral..................................... 41

merzee....................................................... 139

mesalamine er............................................152

mesalamine oral capsule delayed release

400 mg....................................................... 152

mesalamine oral tablet delayed release 1.2

gm.............................................................. 152

mesalamine oral tablet delayed release

800 mg....................................................... 152

mesalamine rectal...................................... 152

mesalamine-cleanser................................. 152

MESNEX ORAL........................................... 44

MESTINON.................................................. 39

METAFOLBIC............................................ 203

METAFOLBIC PLUS..................................203

METAFOLBIC PLUS RF............................ 111

METAMUCIL 4 IN 1 FIBER ORAL

POWDER 43 %..........................................123

METAMUCIL FREE & NATURAL.............. 123

metaxalone oral tablet 400 mg...................200

metaxalone oral tablet 800 mg...................200

metformin hcl er........................................... 59

metformin hcl er (mod)................................. 59

metformin hcl er (osm)................................. 59

metformin hcl oral solution........................... 59

metformin hcl oral tablet 1000 mg, 500 mg,

850 mg......................................................... 59

metformin hcl oral tablet 625 mg..................59

methadone hcl injection................................. 6

methadone hcl intensol.................................. 6

methadone hcl oral.........................................6

METHADOSE ORAL CONCENTRATE 10

MG/ML........................................................... 6

methadose oral tablet soluble........................ 7

METHADOSE SUGAR-FREE........................7

methamphetamine hcl..................................78

methazolamide oral....................................178

methenamine hippurate............................... 20

methenamine mandelate oral.......................26

methergine................................................. 133

methimazole oral........................................145

METHITEST...............................................134

methocarbamol oral................................... 200

methotrexate sodium..................................149

methotrexate sodium (pf)........................... 149

methoxsalen rapid........................................89

methscopolamine bromide oral tablet 2.5

mg.............................................................. 115

methscopolamine bromide oral tablet 5 mg115

methsuximide............................................... 28

METHYLDOPA............................................ 67

methylergonovine maleate oral.................. 133

methylfol-algae-b12-acetylcyst...................111

METHYLIN................................................... 77

methylphenidate...........................................77

methylphenidate hcl er (cd)..........................77

methylphenidate hcl er (la) oral capsule

extended release 24 hour 10 mg, 20 mg,

30 mg, 40 mg............................................... 77

methylphenidate hcl er (la) oral capsule

extended release 24 hour 60 mg................. 77

methylphenidate hcl er (osm) oral tablet

extended release 18 mg, 27 mg, 36 mg.......77

METHYLPHENIDATE HCL ER (OSM)

ORAL TABLET EXTENDED RELEASE 45

MG, 63 MG...................................................77

methylphenidate hcl er (osm) oral tablet

extended release 54 mg...............................77

methylphenidate hcl er (osm) oral tablet

extended release 72 mg...............................77

methylphenidate hcl er (xr) oral capsule

extended release 24 hour 10 mg, 15 mg,

20 mg, 30 mg, 40 mg, 50 mg, 60 mg........... 77

methylphenidate hcl er oral tablet extended

release......................................................... 77

methylphenidate hcl er oral tablet extended

release 24 hour 18 mg, 27 mg, 36 mg......... 77

methylphenidate hcl er oral tablet extended

release 24 hour 54 mg................................. 77

methylphenidate hcl oral solution.................77

methylphenidate hcl oral tablet.................... 77

methylphenidate hcl oral tablet chewable.... 77

methylprednisolone acetate suspension 40

mg/ml injection........................................... 131

METHYLPREDNISOLONE ACETATE

SUSPENSION 40 MG/ML INJECTION......131

methylprednisolone acetate suspension 80

mg/ml injection........................................... 131

METHYLPREDNISOLONE ACETATE

SUSPENSION 80 MG/ML INJECTION......131

methylprednisolone oral............................. 131

methyltestosterone oral..............................134

metoclopramide hcl oral solution 5 mg/5ml..34

metoclopramide hcl oral tablet..................... 34

metoclopramide hcl oral tablet dispersible... 34

metolazone...................................................73

METOPIRONE........................................... 165

metoprolol succinate er................................ 69

metoprolol tartrate oral................................. 69

metoprolol-hydrochlorothiazide.................... 72

METROCREAM........................................... 20

METROGEL................................................. 20

METROLOTION...........................................21

metronidazole external.................................21

metronidazole oral........................................21

metronidazole vaginal.................................. 21

metyrosine....................................................72

mexiletine hcl oral........................................ 69

MIACALCIN................................................153

mibelas 24 fe..............................................139

micaderm..................................................... 37

micafungin sodium solution reconstituted

100 mg intravenous......................................36

MICARDIS....................................................68

237

MICARDIS HCT........................................... 72

MICATIN...................................................... 37

miconazole 3................................................ 36

miconazole 7 vaginal cream 2 %................. 36

miconazole antifungal.................................. 37

miconazole nitrate external cream............... 37

miconazole nitrate vaginal............................36

MICONAZOLE-ZINC OXIDE-PETROLAT... 91

MICROCHAMBER..................................... 165

MICRODOT TEST....................................... 99

MICROFLOR 33.........................................121

microgestin 1.5/30......................................139

microgestin 1/20.........................................139

microgestin 24 fe........................................139

microgestin fe 1.5/30..................................139

microgestin fe 1/20.....................................139

midazolam hcl oral....................................... 58

midodrine hcl................................................67

MIEBO........................................................165

MIFEPREX.................................................133

mifepristone oral tablet 200 mg..................133

mifepristone oral tablet 300 mg..................133

MIGERGOT..................................................38

miglitol.......................................................... 59

MIGRANAL.................................................. 38

mili..............................................................139

milk of magnesia........................................ 121

milk of magnesia oral suspension 1200

mg/15ml..................................................... 121

milrinone lactate........................................... 76

milrinone lactate in dextrose intravenous

solution 20-5 mg/100ml-%........................... 76

milrinone lactate in dextrose intravenous

solution 40-5 mg/200ml-%........................... 76

mimvey.......................................................139

mineral oil heavy oral................................. 123

mini nicotine................................................. 19

MINILINK REAL-TIME TRANSMITTER.....166

MINIMED 630G GUARDIAN PRESS.........166

MINIPRESS................................................. 67

MINIVELLE................................................ 139

minocycline hcl er.........................................25

minocycline hcl oral capsule 100 mg, 50

mg................................................................ 25

minocycline hcl oral capsule 75 mg............. 25

minocycline hcl oral tablet 100 mg, 75 mg... 25

minocycline hcl oral tablet 50 mg................. 25

MINOLIRA....................................................25

minoxidil oral................................................ 75

mirabegron er.............................................128

MIRAPEX ER............................................... 48

MIRCERA INJECTION SOLUTION

PREFILLED SYRINGE 100 MCG/0.3ML,

150 MCG/0.3ML, 200 MCG/0.3ML, 30

MCG/0.3ML, 50 MCG/0.3ML, 75

MCG/0.3ML..................................................66

MIRCERA INJECTION SOLUTION

PREFILLED SYRINGE 120 MCG/0.3ML..... 66

MIRENA (52 MG)....................................... 143

MIRO3D WOUND MATRIX........................166

mirtazapine oral............................................32

MIRVASO.....................................................83

misoprostol oral..........................................116

MITIGARE....................................................37

mm acetaminophen ex str............................14

MM ALLER-BEN........................................ 185

mm arthritis pain...........................................14

mm aspirin..................................................166

MM BLOOD GLUCOSE SYSTEM............... 99

MM BLOOD GLUCOSE SYSTEM REFILL.. 99

MM BLULINK GLUCOSE MONIT SYS........99

MM BLULINK GLUCOSE TEST.................. 99

mm clearlax................................................123

MM EASY TOUCH GLUCOSE METER.......99

mm ibuprofen................................................. 6

mm stool softener laxative......................... 125

M-M-R II..................................................... 149

M-NATAL PLUS......................................... 111

modafinil oral..............................................202

MODERNA COVID-19 VAC 6M-11Y......... 166

moexipril hcl................................................. 68

molindone hcl............................................... 50

mometasone furoate external cream........... 87

mometasone furoate external ointment........87

mometasone furoate external solution......... 87

mometasone furoate suspension 50

mcg/act nasal (rx).......................................186

mondoxyne nl...............................................25

MONOJECT HYPODERMIC NEEDLE 18G

X 1"...............................................................64

mono-linyah................................................139

montelukast sodium oral............................ 186

MORPHINE SULFATE (BULK)......................9

morphine sulfate (concentrate) oral

solution 20 mg/ml........................................... 9

morphine sulfate (concentrate) solution

100 mg/5ml oral............................................. 9

morphine sulfate er beads..............................7

morphine sulfate er oral capsule extended

release 24 hour.............................................. 7

morphine sulfate er oral tablet extended

release........................................................... 7

morphine sulfate oral solution 20 mg/5ml...... 9

morphine sulfate oral tablet............................9

morphine sulfate rectal...................................9

morphine sulfate solution 10 mg/5ml oral...... 9

MOTEGRITY..............................................114

motion sickness relief oral tablet chewable

25 mg........................................................... 34

motion-time.................................................. 34

MOTOFEN................................................. 114

MOTPOLY XR..............................................29

MOTRIN CHILDRENS................................... 6

MOTRIN IB ORAL TABLET........................... 6

MOUNJARO...............................................166

MOVANTIK................................................ 114

MOVIPREP................................................ 115

238

moxifloxacin hcl (2x day)............................176

moxifloxacin hcl ophthalmic....................... 176

moxifloxacin hcl oral.....................................24

MOZOBIL..................................................... 65

m-pap........................................................... 14

MS CONTIN................................................... 7

MUCINEX FAST-MAX CHEST CONG MS 191

MUCOTROL.................................................82

mucus relief childrens oral liquid 100

mg/5ml....................................................... 191

mucus+chest congestion............................191

MUGARD..................................................... 82

MULPLETA.................................................. 65

MULTAQ...................................................... 69

MULTIPRO.................................................203

MULTITOL-M............................................. 203

multivitamin infant & toddler oral solution .203

multivitamin w/fluoride................................111

multi-vitamin/fluoride.................................. 111

multivitamin/fluoride tablet chewable 0.25

mg oral (rx).................................................111

MULTIVITAMIN/FLUORIDE TABLET

CHEWABLE 0.25 MG ORAL (RX)............. 111

multivitamin/fluoride tablet chewable 0.5

mg oral (rx).................................................111

multivitamin/fluoride tablet chewable 1 mg

oral (rx).......................................................111

MULTIVITAMIN/FLUORIDE TABLET

CHEWABLE 1 MG ORAL (RX).................. 111

multi-vitamin/fluoride/iron........................... 111

MULTI-VIT-FLOR.......................................111

mupirocin calcium........................................ 91

mupirocin external........................................91

my choice................................................... 144

my way....................................................... 144

MYAMBUTOL.............................................. 40

MYCAMINE INTRAVENOUS SOLUTION

RECONSTITUTED 100 MG.........................36

MYCAPSSA............................................... 145

MYCOBUTIN................................................40

mycophenolate mofetil oral........................ 149

mycophenolate sodium.............................. 149

mycophenolic acid......................................149

MYDAYIS..................................................... 78

MYDRIACYL.............................................. 179

MYFEMBREE............................................ 113

MYFORTIC................................................ 149

MYLERAN....................................................40

MYLICON INFANTS GAS RELIEF............ 121

mynephrocaps oral capsule 1 mg.............. 111

MYNEPHRON............................................111

MYRBETRIQ ORAL SUSPENSION

RECONSTITUTED ER...............................128

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HOUR.................................. 128

MYSOLINE...................................................28

MYTESI......................................................114

na sulfate-k sulfate-mg sulf solution 17.5-

3.13-1.6 gm/177ml oral.............................. 115

nabumetone oral............................................ 6

nadolol oral...................................................69

naftifine hcl................................................... 91

NAFTIN EXTERNAL GEL 1 %.....................91

NAFTIN EXTERNAL GEL 2 %.....................91

NALFON ORAL CAPSULE............................ 6

NALFON ORAL TABLET............................... 6

NALOCET...................................................... 9

naloxone hcl injection...................................18

naloxone hcl nasal....................................... 18

naltrexone hcl oral........................................18

NAMENDA TITRATION PAK....................... 31

NAMENDA XR............................................. 31

NAMZARIC.................................................. 30

NAPRELAN....................................................6

NAPROSYN................................................... 6

naproxen dr.................................................... 6

naproxen oral suspension.............................. 6

naproxen oral tablet....................................... 6

naproxen oral tablet delayed release............. 6

naproxen sodium er....................................... 6

naproxen sodium oral tablet 220 mg..............6

naproxen sodium oral tablet 275 mg..............6

naproxen sodium oral tablet 550 mg..............6

naproxen-esomeprazole mg.......................... 6

NARAMIN...................................................185

naratriptan hcl.............................................. 39

NARCAN...................................................... 18

NARDIL........................................................ 32

nasal allergy 24 hour..................................195

nasal allergy nasal aerosol 55 mcg/act...... 195

nasal allergy spray..................................... 195

nasal decongestant max st........................ 198

nasal decongestant oral tablet 30 mg........ 199

nasal decongestant pe max st................... 191

nasal decongestant pe oral tablet 10 mg... 192

nasal decongestant pe oral tablet 30 mg... 199

NASAL MOIST NASAL SOLUTION...........192

nasal moisturizing spray.............................192

nasal spray saline...................................... 192

NATACYN.................................................. 176

NATALVIT.................................................. 111

NATAZIA.................................................... 139

nateglinide....................................................59

NATESTO.................................................. 134

NATROBA....................................................89

natural daily fiber oral powder 48.57 %......123

natural daily fiber oral powder 58.6 %........123

natural fiber oral powder 28.3 %................ 123

natural fiber oral powder 58.6 %................ 123

natural senna laxative................................ 125

natural vegetable........................................123

natural vegetable laxative oral tablet 8.6

mg.............................................................. 125

natura-lax................................................... 123

NAYZILAM................................................... 28

nebivolol hcl................................................. 69

NEBULIZER MASK ADULT....................... 166

239

NEBULIZER MASK CHILD........................ 166

NEBUPENT..................................................46

NEBUSAL INHALATION NEBULIZATION

SOLUTION 3 %..........................................199

necon 0.5/35 (28)....................................... 139

nefazodone hcl.............................................33

NEODOT THERMOMETER.......................166

neomycin sulfate oral................................... 20

neomycin-bacitracin zn-polymyx................ 176

neomycin-polymyxin-dexameth ophthalmic

ointment..................................................... 175

neomycin-polymyxin-dexameth ophthalmic

suspension 3.5-10000-0.1 .........................175

neomycin-polymyxin-gramicidin................. 176

neomycin-polymyxin-hc ophthalmic........... 175

neomycin-polymyxin-hc otic....................... 181

NEONATAL COMPLETE........................... 111

NEONATAL PLUS..................................... 111

NEONATAL PRENATAL............................111

NEONATAL VITAMIN................................ 111

neo-polycin.................................................176

neo-polycin hc............................................ 175

NEORAL.................................................... 149

NEO-SYNALAR........................................... 89

nephronex oral tablet................................. 111

NERLYNX.................................................. 173

neuac........................................................... 83

NEULASTA.................................................. 65

NEULASTA ONPRO.................................... 65

NEUPOGEN.................................................65

NEUPRO......................................................48

NEURONTIN................................................28

NEUTEK 2TEK CONTROL........................ 100

NEUTEK 2TEK TEST................................ 100

NEVANAC..................................................177

nevirapine.....................................................55

nevirapine er................................................ 55

new day......................................................144

NEXAVAR.................................................... 43

NEXICLON XR.............................................67

NEXIUM ORAL CAPSULE DELAYED

RELEASE...................................................118

NEXIUM ORAL PACKET........................... 118

NEXLETOL.................................................. 74

NEXLIZET.................................................... 74

NEXPLANON............................................. 143

NEXTSTELLIS........................................... 113

NGENLA.................................................... 166

niacin er (antihyperlipidemic)....................... 74

niacin er oral tablet extended release 500

mg.............................................................. 111

nicardipine hcl oral....................................... 70

NICODERM CQ........................................... 19

NICORETTE................................................ 19

NICORETTE MINI........................................19

NICORETTE STARTER KIT........................ 19

nicotine gum mouth/throat gum 2 mg...........19

nicotine gum mouth/throat gum 4 mg...........19

nicotine gum mouth/throat lozenge 2 mg..... 19

nicotine gum mouth/throat lozenge 4 mg..... 19

nicotine mini................................................. 19

nicotine mouth/throat gum 2 mg...................19

nicotine mouth/throat gum 4 mg...................19

nicotine mouth/throat lozenge 2 mg............. 19

nicotine mouth/throat lozenge 4 mg............. 20

nicotine polacrilex mini................................. 20

nicotine polacrilex mouth/throat................... 20

nicotine step 1.............................................. 19

nicotine step 2.............................................. 19

nicotine step 3.............................................. 19

nicotine transdermal kit 21-14-7 mg/24hr.....19

nicotine transdermal patch 24 hour 14

mg/24hr, 7 mg/24hr......................................19

nicotine transdermal patch 24 hour 21

mg/24hr........................................................ 19

nicotine transdermal system........................ 19

NICOTROL...................................................19

NICOTROL NS.............................................19

nifedipine er..................................................70

nifedipine er osmotic release....................... 70

nifedipine oral...............................................70

nighttime dry-eye relief...............................179

nighttime relief lub eye............................... 180

nikki............................................................ 139

NILANDRON................................................ 41

nilutamide.....................................................41

nimodipine oral.............................................70

NINLARO..................................................... 42

nisoldipine er................................................ 70

nitazoxanide oral.......................................... 46

nitisinone oral capsule 20 mg.....................127

NITRO-BID...................................................75

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4

MG/HR, 0.6 MG/HR..................................... 75

NITRO-DUR TRANSDERMAL PATCH 24

HOUR 0.3 MG/HR, 0.8 MG/HR....................75

nitrofurantoin macrocrystal capsule 25 mg

oral............................................................... 21

nitrofurantoin macrocrystal oral capsule

100 mg, 50 mg............................................. 21

nitrofurantoin monohydrate macrocrystals... 21

nitrofurantoin oral suspension 25 mg/5ml.... 21

NITROFURANTOIN ORAL SUSPENSION

50 MG/5ML.................................................. 21

nitroglycerin rectal........................................ 75

nitroglycerin sublingual.................................75

nitroglycerin transdermal..............................75

nitroglycerin translingual.............................. 75

NITROLINGUAL...........................................75

NITROSTAT.................................................75

NITRO-TIME................................................ 75

NIVA THYROID..........................................144

NIVA-PLUS................................................ 111

NIVESTYM INJECTION SOLUTION........... 65

NIVESTYM INJECTION SOLUTION

PREFILLED SYRINGE................................ 65

240

nizatidine.................................................... 116

NOCDURNA.............................................. 132

NOKOR VENTED NEEDLE......................... 64

non-aspirin................................................... 14

non-aspirin 8 hour........................................ 14

non-aspirin childrens.................................... 14

non-aspirin extra strength............................ 14

non-aspirin jr strength.................................. 14

non-aspirin pain relief...................................14

non-pseudo sinus decongestant................ 192

nora-be.......................................................143

NORDIPEN 5 INJECTION DEVICE...........166

NORDIPEN DELIVERY SYSTEM..............166

NORDITROPIN FLEXPRO........................ 132

norelgestromin-eth estradiol.......................139

norethin ace-eth estrad-fe.......................... 139

norethindrone acetate oral......................... 143

norethindrone acet-ethinyl est....................140

norethindrone oral...................................... 143

norethindrone-eth estradiol........................ 140

norethindron-ethinyl estrad-fe.................... 140

norethin-eth estradiol-fe............................. 140

NORGESIC................................................ 200

NORGESIC FORTE...................................200

norgestimate-eth estradiol..........................140

norgestimate-ethinyl estradiol triphasic......140

NORITATE................................................... 21

NORLIQVA...................................................70

norlyroc...................................................... 143

NORPACE................................................... 69

NORPACE CR............................................. 69

NORPRAMIN............................................... 34

NORTHERA................................................. 67

nortrel 0.5/35 (28).......................................140

nortrel 1/35 (21)..........................................140

nortrel 1/35 (28)..........................................140

nortrel 7/7/7................................................ 140

nortriptyline hcl oral capsule.........................34

nortriptyline hcl solution 10 mg/5ml oral.......34

NORVASC................................................... 70

NORVIR ORAL PACKET............................. 56

NORVIR ORAL TABLET..............................56

NOURIANZ.................................................. 48

NOVAREL.................................................. 132

NOVAVAX COVID-19 VACCINE............... 151

NOVOLIN 70/30 FLEXPEN..........................62

NOVOLIN 70/30 FLEXPEN RELION........... 62

NOVOLIN 70/30 RELION.............................62

NOVOLIN 70/30 VIAL.................................. 62

NOVOLIN N FLEXPEN................................ 62

NOVOLIN N FLEXPEN RELION..................62

NOVOLIN N RELION................................... 62

NOVOLIN N VIAL.........................................62

NOVOLIN R FLEXPEN................................ 62

NOVOLIN R FLEXPEN RELION..................62

NOVOLIN R RELION................................... 62

NOVOLIN R VIAL.........................................62

NOVOLOG 70/30 FLEXPEN RELION......... 62

NOVOLOG FLEXPEN..................................62

NOVOLOG FLEXPEN RELION................... 62

NOVOLOG MIX 70/30 FLEXPEN................ 62

NOVOLOG MIX 70/30 RELION................... 62

NOVOLOG MIX 70/30 VIAL.........................62

NOVOLOG PENFILL................................... 62

NOVOLOG RELION.....................................62

NOVOLOG U-100 VIAL............................... 62

NOVOPEN ECHO......................................166

NOXAFIL ORAL........................................... 36

np thyroid................................................... 144

NPLATE SUBCUTANEOUS SOLUTION

RECONSTITUTED 125 MCG...................... 65

NPLATE SUBCUTANEOUS SOLUTION

RECONSTITUTED 250 MCG, 500 MCG.....65

NUBEQA...................................................... 41

NUCALA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR...................................... 190

NUCALA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 100 MG/ML...........190

NUCALA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 40 MG/0.4ML........190

NUCALA SUBCUTANEOUS SOLUTION

RECONSTITUTED.....................................190

NUCYNTA......................................................9

NUCYNTA ER................................................7

NUDICLO TABPAK......................................16

NUEDEXTA..................................................79

nufol........................................................... 111

NULEV....................................................... 166

NUPLAZID................................................... 51

NURTEC...................................................... 38

NUTRIARX CREAMPAK..............................93

NUTRICAP.................................................203

nutrifac zx...................................................203

NUTROPIN AQ NUSPIN 10.......................132

NUTROPIN AQ NUSPIN 20.......................132

NUTROPIN AQ NUSPIN 5.........................132

NUVARING................................................ 140

NUVESSA.................................................... 21

NUVIGIL.....................................................202

NUZYRA ORAL............................................25

nyamyc.........................................................91

nylia 1/35....................................................140

nylia 7/7/7...................................................140

NYMALIZE................................................... 70

nymyo.........................................................140

nystatin external........................................... 91

nystatin mouth/throat....................................36

nystatin oral..................................................36

nystatin-triamcinolone.................................. 89

nystop...........................................................91

NYVEPRIA................................................... 65

OCALIVA....................................................115

OCEAN FOR KIDS.................................... 192

ocella..........................................................140

OCREVUS................................................... 81

octreotide acetate.......................................145

OCUFLOX..................................................176

241

OCUVEL.................................................... 203

ODACTRA..................................................147

ODEFSEY.................................................... 55

ODOMZO..................................................... 43

OFEV......................................................... 190

ofloxacin ophthalmic...................................176

ofloxacin oral................................................ 24

ofloxacin otic.............................................. 181

OGSIVEO ORAL TABLET 100 MG, 150

MG............................................................. 166

OGSIVEO ORAL TABLET 50 MG............. 166

OJEMDA ORAL SUSPENSION

RECONSTITUTED.....................................166

OJEMDA ORAL TABLET...........................166

OJJAARA................................................... 166

olanzapine intramuscular............................. 51

olanzapine oral.............................................51

olanzapine-fluoxetine hcl oral capsule 12-

25 mg, 12-50 mg, 6-50 mg...........................32

olanzapine-fluoxetine hcl oral capsule 3-25

mg, 6-25 mg................................................. 32

olmesartan medoxomil oral.......................... 68

olmesartan medoxomil-hctz......................... 72

olmesartan-amlodipine-hctz......................... 72

olopatadine hcl nasal................................. 185

olopatadine hcl ophthalmic solution 0.1 %. 175

olopatadine hcl solution 0.2 % ophthalmic

(otc)............................................................ 175

olopatadine hcl solution 0.2 % ophthalmic

(rx)..............................................................175

OLPRUVA (2 GM DOSE)...........................127

OLPRUVA (3 GM DOSE)...........................127

OLPRUVA (4 GM DOSE)...........................127

OLPRUVA (5 GM DOSE)...........................127

OLPRUVA (6 GM DOSE)...........................127

OLPRUVA (6.67 GM DOSE)......................127

OLUMIANT ORAL TABLET 1 MG, 2 MG...147

OLUMIANT ORAL TABLET 4 MG............. 147

OMBRA COMPRESSOR AIR FILTERS.... 166

OMECLAMOX-PAK................................... 115

omega-3-acid ethyl esters............................74

omep/sod bicarb.........................................118

omeprazole capsule delayed release 10

mg oral....................................................... 118

omeprazole magnesium oral tablet delayed

release....................................................... 118

omeprazole oral capsule delayed release

20 mg, 40 mg............................................. 118

omeprazole oral tablet delayed release 20

mg.............................................................. 118

omeprazole-sod bicarbonate......................118

omeprazole-sodium bicarb oral capsule 20-

1100 mg..................................................... 118

omeprazole-sodium bicarbonate oral

capsule.......................................................118

omeprazole-sodium bicarbonate oral

packet.........................................................118

OMNARIS.................................................. 186

OMNIFLEX DIAPHRAGM.......................... 166

OMNIPOD 5 G6 INTRO (GEN 5)...............166

OMNIPOD 5 G6 PODS (GEN 5)................166

OMNITROPE............................................. 132

OMVOH INTRAVENOUS...........................166

OMVOH SUBCUTANEOUS SOLUTION

AUTO-INJECTOR...................................... 166

ON CALL EXPRESS BLOOD GLUCOSE..100

ON CALL EXPRESS MONITORING SYS. 100

ON/GO COVID-19 ANTIGEN TEST.......... 166

ON/GO ONE COVID-19 HOME TEST.......166

ondansetron hcl injection............................. 35

ondansetron hcl oral.....................................35

ondansetron odt........................................... 35

ONE VITE FERROUS SULFATE...............108

ONE VITE WOMENS.................................112

ONE VITE WOMENS PLUS...................... 112

ONELAX.....................................................166

ONELAX DOCUSATE SODIUM................ 125

ONELAX MAGNESIUM CITRATE............. 125

ONELAX SENNA....................................... 125

ONETOUCH DELICA PLUS LANCET30G 100

ONETOUCH DELICA PLUS LANCET33G 100

ONETOUCH DELICA SAFETY LANCING.100

ONETOUCH ULTRA 2 KIT W/DEVICE..... 100

ONETOUCH ULTRA IN VITRO LIQUID.... 100

ONETOUCH ULTRA STRIP IN VITRO......100

ONETOUCH ULTRA TEST........................100

ONETOUCH ULTRASOFT 2 LANCETS....100

ONETOUCH VERIO FLEX SYSTEM

DEVICE......................................................100

ONETOUCH VERIO FLEX SYSTEM KIT

W/DEVICE................................................. 100

ONETOUCH VERIO IN VITRO LIQUID.....100

ONETOUCH VERIO IN VITRO LIQUID

HIGH.......................................................... 166

ONETOUCH VERIO REFLECT KIT

W/DEVICE................................................. 100

ONETOUCH VERIO STRIP IN VITRO...... 100

ONEVITE................................................... 203

ONEXTON................................................... 83

ONFI.............................................................28

ONGENTYS................................................. 48

ONGLYZA.................................................... 59

ONUREG..................................................... 41

opcicon one-step........................................144

OPILL......................................................... 166

opium......................................................... 114

OPSUMIT...................................................189

OPSYNVI................................................... 166

option 2...................................................... 144

OPTIUMEZ TEST...................................... 100

OPVEE.......................................................166

OPZELURA..................................................93

ORACEA...................................................... 25

ORACIT......................................................108

ORAL CITRATE......................................... 108

ORALAIR................................................... 147

ORALAIR ADULT STARTER PACK.......... 147

242

ORALAIR CHILDRENS STARTER PACK. 147

oralone......................................................... 82

ORAMAGICRX.............................................82

ORAPRED ODT.........................................131

ORAVIG....................................................... 36

ORENCIA...................................................147

ORENCIA CLICKJECT.............................. 147

ORENITRAM..............................................189

ORENITRAM MONTH 1............................ 189

ORENITRAM MONTH 2............................ 189

ORENITRAM MONTH 3............................ 189

ORFADIN ORAL CAPSULE 20 MG...........127

ORGOVYX................................................... 20

ORIAHNN...................................................145

ORILISSA...................................................145

ORKAMBI ORAL PACKET 100-125 MG,

150-188 MG............................................... 188

ORKAMBI ORAL PACKET 75-94 MG....... 188

ORKAMBI ORAL TABLET......................... 188

ORMALVI................................................... 127

orphenadrine citrate er............................... 200

orphenadrine-aspirin-caffeine.................... 200

ORPHENGESIC FORTE........................... 200

ORSERDU................................................. 166

OS-CAL CALCIUM + D3............................108

OSCIMIN....................................................166

oseltamivir phosphate oral........................... 56

OSMOLEX ER............................................. 48

OSPHENA..................................................143

OTEZLA..................................................... 147

OTOVEL.....................................................181

OTREXUP..................................................149

OVACE PLUS WASH EXTERNAL LIQUID166

OVACE WASH...........................................166

OVIDE.......................................................... 89

oxaprozin oral tablet.......................................6

oxazepam.....................................................58

OXBRYTA.................................................... 65

oxcarbazepine oral suspension....................29

oxcarbazepine oral tablet............................. 29

oxiconazole nitrate....................................... 91

OXISTAT EXTERNAL CREAM....................91

OXISTAT EXTERNAL LOTION................... 91

OXTELLAR XR............................................ 29

oxybutynin chloride er................................ 128

oxybutynin chloride oral solution................ 128

oxybutynin chloride oral tablet 2.5 mg........128

oxybutynin chloride oral tablet 5 mg...........128

OXYCODONE HCL ER ORAL TABLET ER

12 HOUR ABUSE-DETERRENT 10 MG,

40 MG............................................................ 7

OXYCODONE HCL ER TABLET ER 12

HOUR ABUSE-DETERRENT 20 MG

ORAL............................................................. 7

oxycodone hcl oral capsule............................9

oxycodone hcl oral concentrate..................... 9

oxycodone hcl oral solution............................9

oxycodone hcl oral tablet............................. 16

OXYCODONE-ACETAMINOPHEN ORAL

SOLUTION.....................................................9

OXYCODONE-ACETAMINOPHEN ORAL

TABLET 10-300 MG, 5-300 MG, 7.5-300

MG................................................................. 9

oxycodone-acetaminophen oral tablet 10-

325 mg, 2.5-325 mg, 5-325 mg, 7.5-325

mg................................................................ 10

OXYCODONE-ACETAMINOPHEN ORAL

TABLET 2.5-300 MG....................................10

OXYCONTIN..................................................7

oxymorphone hcl..........................................10

oxymorphone hcl er........................................7

OXYTROL.................................................. 128

OXYTROL FOR WOMEN.......................... 128

oysco 500+d...............................................108

oyster shell calcium + d oral tablet 500-10

mg-mcg...................................................... 108

oyster shell calcium + d3............................108

oyster shell calcium oral tablet 500 mg...... 203

oyster shell calcium plus d......................... 108

oyster shell calcium w/d............................. 108

oyster shell calcium/vit d............................ 108

oyster shell calcium/vit d3.......................... 108

oyster shell calcium/vit d3 oral tablet 500-5

mg-mcg...................................................... 108

oyster shell calcium/vitamin d oral tablet

500-5 mg-mcg............................................ 108

OZEMPIC.....................................................60

OZEMPIC (2 MG/DOSE)............................. 60

OZOBAX DS................................................ 53

PACERONE................................................. 69

pain & fever child..........................................14

pain & fever childrens...................................14

pain & fever childrens oral suspension 160

mg/5ml......................................................... 14

pain & fever infants oral suspension 160

mg/5ml......................................................... 14

pain and fever relief kids.............................. 15

pain relief childrens oral suspension............ 15

pain relief childrens oral tablet chewable

160 mg......................................................... 15

pain relief extra st.........................................15

pain relief extra strength oral tablet 500 mg.15

pain relief oral tablet 325 mg........................15

pain relief oral tablet 500 mg........................15

pain relief oral tablet extended release 650

mg................................................................ 15

pain relief regular strength........................... 15

pain reliever childrens oral suspension 160

mg/5ml......................................................... 15

pain reliever ex st oral tablet 500 mg........... 15

pain reliever extra strength oral tablet 500

mg................................................................ 15

pain reliever oral tablet 325 mg....................15

pain reliever oral tablet 500 mg....................15

PALFORZIA (12 MG DAILY DOSE).......... 167

PALFORZIA (120 MG DAILY DOSE)........ 167

PALFORZIA (160 MG DAILY DOSE)........ 167

243

PALFORZIA (20 MG DAILY DOSE).......... 167

PALFORZIA (200 MG DAILY DOSE)........ 167

PALFORZIA (240 MG DAILY DOSE)........ 167

PALFORZIA (3 MG DAILY DOSE)............ 167

PALFORZIA (300 MG MAINTENANCE)....167

PALFORZIA (300 MG TITRATION)........... 167

PALFORZIA (40 MG DAILY DOSE).......... 167

PALFORZIA (6 MG DAILY DOSE)............ 167

PALFORZIA (80 MG DAILY DOSE).......... 167

PALFORZIA INITIAL ESCALATION.......... 167

paliperidone er tablet extended release 24

hour 1.5 mg oral........................................... 51

paliperidone er tablet extended release 24

hour 3 mg oral.............................................. 51

paliperidone er tablet extended release 24

hour 6 mg oral.............................................. 51

paliperidone er tablet extended release 24

hour 9 mg oral.............................................. 52

palonosetron hcl intravenous solution 0.25

mg/2ml......................................................... 35

palonosetron hcl intravenous solution 0.25

mg/5ml......................................................... 35

palonosetron hcl intravenous solution

prefilled syringe............................................ 35

PAMELOR....................................................34

PANADOL CHILDRENS.............................. 15

PANADOL EXTRA STRENGTH.................. 16

PANADOL INFANTS....................................16

PANDEL.......................................................87

PANHEMATIN..............................................65

pantoprazole sodium oral packet............... 118

pantoprazole sodium oral tablet delayed

release....................................................... 118

PARADIGM REAL-TIME TRANSMITTER. 167

PARAGARD INTRAUTERINE COPPER... 167

PARI ALTERA NEBULIZER HANDSET.... 167

PARI BABY CONVERSION KIT................ 167

PARI ERAPID NEBULIZER HANDSET..... 167

PARI SMARTMASK BABY/ELBOW.......... 167

PARI TREK S COMBO PACK................... 167

PARI VORTEX ADULT MASK................... 167

paricalcitol oral........................................... 153

PARLODEL.................................................. 48

PARNATE.................................................... 32

paroxetine hcl er...........................................33

paroxetine hcl oral suspension.....................33

paroxetine hcl oral tablet.............................. 33

paroxetine mesylate..................................... 33

PATADAY OPHTHALMIC SOLUTION 0.1

%, 0.2 %.....................................................175

PAXIL........................................................... 33

PAXIL CR.....................................................33

PAXLOVID (150/100)...................................57

PAXLOVID (300/100)...................................57

pazopanib hcl............................................. 173

pb-hyoscy-atropine-scopolamine............... 119

PEDIAPRED.............................................. 131

PEDIARIX.................................................. 150

PEDVAX HIB..............................................150

peg 3350 oral powder................................ 124

peg 3350-kcl-na bicarb-nacl.......................115

peg-3350/electrolytes.................................115

peg-3350/electrolytes/ascorbat.................. 115

PEGASYS.................................................. 147

peg-kcl-nacl-nasulf-na asc-c...................... 115

PEMAZYRE................................................. 42

PENBRAYA................................................167

penciclovir.................................................... 54

penicillamine oral....................................... 129

penicillin g potassium injection solution

reconstituted 5000000 unit...........................23

penicillin g sodium........................................23

penicillin v potassium................................... 23

PENNSAID.....................................................6

PENTACEL................................................ 150

pentamidine isethionate inhalation...............46

PENTASA.................................................. 152

pentazocine-naloxone hcl............................ 10

pentoxifylline er............................................ 72

PEPCID......................................................116

PEPCID AC................................................116

PERCOCET................................................. 10

PERDIEM OVERNIGHT RELIEF...............126

PERFOROMIST.........................................188

PERIDEX..................................................... 82

perindopril erbumine.................................... 68

periogard...................................................... 82

permethrin external...................................... 89

perphenazine oral........................................ 35

perphenazine-amitriptyline oral tablet 2-10

mg, 4-10 mg, 4-25 mg, 4-50 mg...................32

perphenazine-amitriptyline oral tablet 2-25

mg................................................................ 32

PERSERIS................................................... 52

PERTZYE CAPSULE DELAYED

RELEASE PARTICLES 16000-57500

UNIT ORAL................................................ 127

PERTZYE CAPSULE DELAYED

RELEASE PARTICLES 4000-14375 UNIT

ORAL......................................................... 127

PERTZYE ORAL CAPSULE DELAYED

RELEASE PARTICLES 24000-86250

UNIT, 8000-28750 UNIT............................ 127

PFIZER COVID-19 VAC-TRIS 5-11Y........ 167

PFIZER COVID-19 VAC-TRIS 6M-4Y....... 167

PFIZERPEN INJECTION SOLUTION

RECONSTITUTED 5000000 UNIT.............. 23

pharbechlor................................................ 194

pharbedryl.................................................. 185

PHARBETOL............................................... 16

PHARBETOL EXTRA STRENGTH..............16

PHAZYME..................................................121

phenazo oral tablet 200 mg........................130

phenazopyridine hcl oral tablet 100 mg..... 130

phenazopyridine hcl oral tablet 200 mg..... 130

phenelzine sulfate oral................................. 32

PHENERGAN.............................................. 35

244

phenobarbital oral........................................ 28

PHENOHYTRO..........................................119

phenoxybenzamine hcl oral......................... 67

phenylephrine hcl ophthalmic.....................175

phenylephrine hcl oral................................ 192

phenytek.......................................................29

phenytoin infatabs........................................ 29

phenytoin oral...............................................29

phenytoin sodium extended......................... 29

PHEXXI...................................................... 130

philith..........................................................140

PHOSPHA 250 NEUTRAL.........................109

PHOSPHOLINE IODIDE............................178

phosphorous.............................................. 109

phospho-trin 250 neutral............................ 109

PHOSPHO-TRIN K500.............................. 109

phytonadione oral.......................................112

PIFELTRO....................................................55

pilocarpine hcl ophthalmic..........................178

pilocarpine hcl oral....................................... 82

PILOT COVID-19 AT-HOME TEST........... 167

pimecrolimus................................................ 87

pimozide.......................................................50

pimtrea....................................................... 140

pindolol.........................................................69

pink bismuth oral suspension 262 mg/15ml

....................................................................122

pink bismuth oral tablet 262 mg................. 122

pink bismuth oral tablet chewable 262 mg. 122

pink-bismuth...............................................122

pioglitazone hcl............................................ 60

pioglitazone hcl-glimepiride..........................60

pioglitazone hcl-metformin hcl......................60

PIP BLOOD GLUCOSE MONITORING.....101

PIP BLOOD GLUCOSE TEST STRIP....... 101

PIP GLUCOSE CONTROL SOLUTION.....101

piperacillin sod-tazobactam so intravenous

solution reconstituted 4-0.5 gm, 4.5 (4-0.5)

gm................................................................ 23

PIQRAY (200 MG DAILY DOSE).................43

PIQRAY (250 MG DAILY DOSE).................43

PIQRAY (300 MG DAILY DOSE).................44

pirfenidone oral capsule............................. 190

pirfenidone oral tablet.................................190

piroxicam oral.................................................6

pitavastatin calcium......................................74

PLAN B ONE-STEP................................... 144

PLAQUENIL................................................. 46

PLAVIX.........................................................66

PLEGRIDY................................................... 81

PLEGRIDY STARTER PACK...................... 81

PLENVU.....................................................115

plerixafor...................................................... 65

PLEXION CLEANSER................................. 91

PLIAGLIS EXTERNAL CREAM................... 17

PNEUMOVAX 23....................................... 151

podofilox external......................................... 89

POKONZA..................................................105

poly bacitracin............................................ 167

polycin........................................................ 176

polyethylene glycol 3350 oral powder........ 124

polyethylene glycol 3350-grx oral powder 124

poly-iron 150 forte...................................... 109

polymyxin b-trimethoprim........................... 176

polysaccharide iron forte............................ 109

POLY-VI-FLOR ORAL TABLET

CHEWABLE 0.5 MG.................................. 112

POLY-VI-FLOR TABLET CHEWABLE 0.25

MG ORAL...................................................112

POLY-VI-FLOR TABLET CHEWABLE 1

MG ORAL...................................................112

polyvinyl alcohol ophthalmic.......................180

POLY-VI-SOL.............................................204

POLY-VITE PEDIATRIC............................ 204

POMALYST..................................................41

PONVORY................................................. 173

PONVORY STARTER PACK.....................173

portia-28..................................................... 140

posaconazole oral suspension.....................36

posaconazole oral tablet delayed release....36

potassium chloride crys er......................... 105

potassium chloride er oral capsule

extended release........................................105

potassium chloride er oral tablet extended

release 10 meq.......................................... 105

potassium chloride er oral tablet extended

release 15 meq.......................................... 105

potassium chloride er oral tablet extended

release 20 meq.......................................... 105

potassium chloride er oral tablet extended

release 8 meq............................................ 105

potassium chloride oral packet...................105

potassium chloride oral solution 10 %, 20

meq/15ml (10%).........................................105

potassium chloride oral solution 40

meq/15ml (20%).........................................105

potassium citrate er oral tablet extended

release 10 meq (1080 mg)......................... 105

potassium citrate er oral tablet extended

release 15 meq (1620 mg)......................... 105

potassium citrate er oral tablet extended

release 5 meq (540 mg)............................. 105

potassium citrate-citric acid........................109

POVIDONE-IODINE OPHTHALMIC.......... 180

PRADAXA ORAL CAPSULE....................... 64

PRADAXA ORAL PACKET 110 MG, 150

MG, 20 MG, 30 MG, 40 MG, 50 MG............ 64

PRALUENT.................................................. 74

pramipexole dihydrochloride........................ 48

pramipexole dihydrochloride er.................... 48

PRAMOSONE..............................................89

prasugrel hcl.................................................66

pravastatin sodium....................................... 74

praziquantel oral...........................................45

prazosin hcl oral........................................... 67

PRECISION GLUCOSE KETONE CONTR101

PRECISION XTRA.....................................101

245

PRECISION XTRA BLOOD GLUCOSE.....101

PRED FORTE............................................ 177

PRED MILD................................................178

prednisolone acetate ophthalmic............... 178

PREDNISOLONE ACETATE P-F.............. 178

prednisolone oral solution.......................... 131

prednisolone oral tablet..............................131

prednisolone sodium phosphate

ophthalmic..................................................178

prednisolone sodium phosphate oral

solution 10 mg/5ml, 20 mg/5ml, 25 mg/5ml131

prednisolone sodium phosphate oral

solution 15 mg/5ml..................................... 131

prednisolone sodium phosphate oral

solution 6.7 (5 base) mg/5ml......................131

prednisolone sodium phosphate oral tablet

dispersible.................................................. 131

prednisone intensol.................................... 132

prednisone oral solution............................. 132

prednisone oral tablet.................................132

prednisone oral tablet therapy pack 10 mg

(21).............................................................132

prednisone oral tablet therapy pack 10 mg

(48), 5 mg (21), 5 mg (48).......................... 132

pregabalin er................................................ 80

pregabalin oral............................................. 80

PREGNYL.................................................. 132

PREHEVBRIO............................................150

PREMARIN ORAL..................................... 140

PREMARIN VAGINAL................................140

PREMIUM BLOOD GLUCOSE TEST........101

premium lidocaine........................................ 17

PREMPHASE.............................................140

PREMPRO................................................. 140

PRENATABS RX....................................... 112

prenatal 19................................................. 112

prenatal formula oral tablet 28-0.8 mg....... 112

prenatal multivitamins................................ 112

prenatal oral tablet 27-0.8 mg.................... 112

prenatal oral tablet 27-1 mg....................... 112

prenatal oral tablet 28-0.8 mg.................... 112

prenatal plus...............................................112

prenatal plus vitamin/mineral..................... 112

prenatal vitamins oral tablet 28-0.8 mg...... 112

prenatal/iron oral tablet 28-0.8 mg............. 112

PRENATOL-M............................................112

PRENATRYL..............................................112

PREPARATION H EXTERNAL CREAM 1

%................................................................ 152

PREPIDIL...................................................133

PRETOMANID............................................. 40

PREVACID.................................................118

PREVACID 24HR.......................................119

PREVACID SOLUTAB............................... 119

prevalite........................................................74

PREVIDENT...............................................105

PREVIDENT 5000 BOOSTER PLUS.........105

PREVIDENT 5000 DRY MOUTH...............105

PREVIDENT 5000 ENAMEL PROTECT....105

PREVIDENT 5000 KIDS............................ 105

PREVIDENT 5000 ORTHO DEFENSE......105

PREVIDENT 5000 PLUS........................... 105

PREVIDENT 5000 SENSITIVE..................106

previdolrx plus analgesic..............................16

PREVNAR 20.............................................151

PREVYMIS...................................................53

PREZCOBIX................................................ 56

PREZISTA ORAL SUSPENSION.............. 167

PREZISTA ORAL TABLET 150 MG, 75

MG............................................................. 167

PREZISTA ORAL TABLET 600 MG, 800

MG............................................................. 167

PRIFTIN....................................................... 40

PRILOSEC................................................. 119

PRILOSEC OTC........................................ 119

PRILOVIX.....................................................17

PRILOVIX LITE............................................ 17

PRILOVIX LITE PLUS..................................17

PRILOVIX PLUS.......................................... 17

PRILOVIX ULTRALITE................................ 17

PRILOVIX ULTRALITE PLUS......................17

primaquine phosphate..................................46

primidone oral.............................................. 28

PRIORIX.................................................... 150

PRISTIQ.......................................................33

PRO COMFORT SAFETY LANCETS 30G 101

PROAIR RESPICLICK............................... 188

probenecid................................................... 37

PROBIONEXX........................................... 122

PROBIZEN.................................................122

procainamide hcl injection............................69

PROCARDIA XL.......................................... 70

PROCENTRA...............................................78

PROCHAMBER VHC.................................167

prochlorperazine.......................................... 35

prochlorperazine maleate oral......................35

PROCORT................................................... 89

PROCRIT..................................................... 65

PROCTOCORT RECTAL............................ 38

PROCTOFOAM HC..................................... 89

procto-med hc............................................ 152

proctosol hc................................................152

proctozone-hc............................................ 152

progesterone intramuscular....................... 143

progesterone oral....................................... 143

PROGLYCEM.............................................. 60

PROGRAF INTRAVENOUS...................... 149

PROGRAF ORAL CAPSULE 0.5 MG, 5

MG............................................................. 149

PROGRAF ORAL CAPSULE 1 MG........... 149

PROGRAF ORAL PACKET....................... 149

PROLASTIN-C........................................... 127

PROLATE.................................................... 10

PROLENSA................................................178

PROMACTA.................................................65

promethazine hcl injection............................35

promethazine hcl oral syrup 6.25 mg/5ml.... 35

246

promethazine hcl rectal................................ 35

promethegan rectal suppository 12.5 mg,

25 mg........................................................... 35

promethegan rectal suppository 50 mg........35

PROMETRIUM...........................................143

PRONEB ULTRA FILTER SET..................167

PRONUTRIENTS VITAMIN D3..................112

propafenone hcl........................................... 69

propafenone hcl er....................................... 69

proparacaine hcl ophthalmic...................... 175

PROPEL.....................................................186

PROPEL MINI............................................ 186

PROPEL MINI SDS....................................186

propranolol hcl er......................................... 69

propranolol hcl oral.......................................69

propylthiouracil oral.................................... 145

PROQUAD................................................. 150

PROSCAR................................................. 129

PROTONIX ORAL PACKET...................... 119

PROTONIX ORAL TABLET DELAYED

RELEASE...................................................119

protriptyline hcl............................................. 34

PROVENTIL HFA.......................................188

PROVERA..................................................143

PROVIGIL.................................................. 202

PROZAC...................................................... 33

PRUDOXIN.................................................. 87

pseudoephedrine hcl oral tablet 30 mg...... 199

PSS SELECT PLATFORMS...................... 104

psyldex....................................................... 124

PTS PANELS EGLU TEST........................ 101

PULMICORT FLEXHALER........................ 186

PULMICORT SUSPENSION..................... 186

PULMOSAL................................................199

PULMOZYME............................................ 188

PURE COMFORT SAFETY PEN NEEDLE

31G X 5 MM............................................... 167

PURE COMFORT SAFETY PEN NEEDLE

31G X 6 MM............................................... 167

PURE COMFORT SAFETY PEN NEEDLE

32G X 4 MM............................................... 101

purelax oral powder....................................124

purevit dualfe plus...................................... 109

PURIXAN..................................................... 41

PYLERA..................................................... 115

pyrazinamide oral.........................................40

PYRIDIUM..................................................130

pyridostigmine bromide er............................39

pyridostigmine bromide oral solution............39

pyridostigmine bromide oral tablet............... 39

pyridoxine hcl oral tablet 50 mg................. 205

QALSODY..................................................167

QBRELIS......................................................68

QDOLO........................................................ 10

QELBREE.................................................... 58

QINLOCK................................................... 173

QNASL....................................................... 186

QNASL CHILDRENS................................. 186

QTERN.........................................................60

QUADRACEL INTRAMUSCULAR

SUSPENSION............................................150

QUALAQUIN................................................ 46

quazepam.................................................... 58

QUDEXY XR................................................ 27

QUESTRAN................................................. 74

QUESTRAN LIGHT......................................74

quetiapine fumarate er................................. 52

quetiapine fumarate oral tablet 100 mg,

200 mg, 25 mg, 300 mg, 400 mg, 50 mg..... 52

quetiapine fumarate oral tablet 150 mg........52

QUFLORA FE............................................ 112

QUFLORA FE PEDIATRIC........................ 112

QUICKVUE AT-HOME COVID-19 TEST... 167

QUILLICHEW ER.........................................77

QUILLIVANT XR.......................................... 77

quinapril hcl.................................................. 68

quinapril-hydrochlorothiazide....................... 72

quinidine gluconate er.................................. 69

quinidine sulfate........................................... 69

quinine sulfate.............................................. 46

QUINTET AC BLOOD GLUCOSE............. 101

QUINTET AC BLOOD GLUCOSE TEST... 101

QUINTET BLOOD GLUCOSE SYSTEM... 101

QUINTET BLOOD GLUCOSE TEST......... 101

QUINTET CONTROL HIGH/NORMAL...... 101

quit2............................................................. 20

quit4............................................................. 20

QULIPTA......................................................38

QUTENZA.................................................... 89

QUTENZA (2 PATCH)................................. 89

QUTENZA (4 PATCH)................................. 89

QUVIVIQ.................................................... 167

QVAR REDIHALER................................... 186

rabeprazole sodium oral tablet delayed

release....................................................... 119

RAGWITEK................................................ 147

raloxifene hcl.............................................. 143

ramelteon................................................... 201

ramipril......................................................... 68

ranolazine er................................................ 72

RAPAFLO.................................................. 129

RAPAMUNE ORAL SOLUTION.................149

RAPAMUNE ORAL TABLET 0.5 MG.........149

RAPAMUNE ORAL TABLET 1 MG, 2 MG.149

RAPIVAB......................................................56

rasagiline mesylate tablet 0.5 mg oral..........50

rasagiline mesylate tablet 1 mg oral.............50

RASUVO.................................................... 149

RAYA SURE PEN NEEDLE 29G X 12MM 167

RAYA SURE PEN NEEDLE 31G X 4 MM. 167

RAYA SURE PEN NEEDLE 31G X 5 MM. 167

RAYA SURE PEN NEEDLE 31G X 6 MM. 168

RAYA SURE PEN NEEDLE 31G X 8 MM. 168

RAYALDEE................................................ 153

RAYOS.......................................................132

react........................................................... 144

ready-to-use enema rectal enema ........... 122

247

REBIF...........................................................81

REBIF REBIDOSE....................................... 81

REBIF REBIDOSE TITRATION PACK........ 81

REBIF TITRATION PACK............................81

RECLAST...................................................153

reclipsen.....................................................140

RECOMBIVAX HB..................................... 150

RECOTHROM EXTERNAL SOLUTION

RECONSTITUTED 5000 UNIT.................... 66

RECOTHROM SPRAY KIT..........................66

RECTIV........................................................ 75

REFRESH LACRI-LUBE............................180

REFRESH PLUS........................................180

REFRESH TEARS..................................... 180

REGLAN...................................................... 35

reguloid oral powder 43 %......................... 124

RELADOR PAK............................................17

RELADOR PAK PLUS................................. 17

RELAFEN DS.................................................6

RELENZA DISKHALER............................... 56

RELEUKO.................................................... 65

RELEXXII ORAL TABLET EXTENDED

RELEASE 18 MG, 27 MG, 36 MG............... 77

RELEXXII ORAL TABLET EXTENDED

RELEASE 45 MG, 63 MG............................ 78

RELEXXII ORAL TABLET EXTENDED

RELEASE 54 MG.........................................78

RELEXXII ORAL TABLET EXTENDED

RELEASE 72 MG.........................................78

RELION TRUE MET AIR GLUC METER...101

RELION TRUE METRIX TEST STRIPS.... 101

RELION ULTIMA GLUCOSE SYSTEM..... 102

RELION ULTIMA TEST............................. 102

RELISTOR................................................. 114

RELPAX....................................................... 39

RELTONE.................................................. 116

REMERON...................................................32

REMERON SOLTAB ORAL TABLET

DISPERSIBLE 15 MG, 30 MG..................... 32

REMICADE................................................ 149

RENAL....................................................... 112

RENFLEXIS............................................... 149

RENVELA.................................................. 110

repaglinide....................................................60

REPATHA.................................................... 74

REPLACEMENT FILTERS........................ 168

RESTASIS................................................. 175

RESTASIS MULTIDOSE........................... 175

restore plus lubricant eye........................... 180

restore pm.................................................. 180

RESTORIL ORAL CAPSULE 15 MG, 30

MG, 7.5 MG................................................201

RESTORIL ORAL CAPSULE 22.5 MG......201

RETACRIT INJECTION SOLUTION 10000

UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML,

4000 UNIT/ML, 40000 UNIT/ML.................. 65

RETACRIT INJECTION SOLUTION 20000

UNIT/ML.......................................................65

RETEVMO................................................. 173

RETIN-A EXTERNAL CREAM.....................83

RETIN-A EXTERNAL GEL...........................83

RETIN-A MICRO GEL 0.04 %, 0.1 %.......... 83

RETIN-A MICRO PUMP EXTERNAL GEL

0.04 %, 0.1 %...............................................83

RETIN-A MICRO PUMP EXTERNAL GEL

0.06 %.......................................................... 83

RETIN-A MICRO PUMP EXTERNAL GEL

0.08 %.......................................................... 83

RETROVIR ORAL........................................55

REUSABLE COMFORTSEAL MASK-LRG 168

REUSABLE COMFORTSEAL MASK-MED168

REUSABLE COMFORTSEAL MASK-SML 168

REVATIO ORAL.........................................189

REVLIMID.................................................... 41

REXTOVY.................................................... 18

REXULTI...................................................... 52

REYATAZ ORAL CAPSULE........................ 56

REYATAZ ORAL PACKET.......................... 56

REYVOW..................................................... 39

REZDIFFRA............................................... 168

REZLIDHIA................................................ 168

REZUROCK............................................... 168

REZVOGLAR KWIKPEN............................. 64

REZZAYO.................................................. 168

RHOFADE....................................................84

RHOPRESSA.............................................178

ribavirin inhalation...................................... 190

ribavirin oral..................................................54

RIDAURA................................................... 147

rifabutin........................................................ 40

rifampin oral................................................. 40

RIGHTEST GT333 GLUCOSE TEST........ 102

RILUTEK...................................................... 79

riluzole..........................................................79

rimantadine hcl.............................................56

RIMSO-50.................................................. 129

RINVOQ ORAL TABLET EXTENDED

RELEASE 24 HOUR 15 MG, 45 MG......... 147

RINVOQ ORAL TABLET EXTENDED

RELEASE 24 HOUR 30 MG...................... 147

RIOMET....................................................... 60

risedronate sodium.....................................153

RISPERDAL CONSTA.................................52

RISPERDAL ORAL SOLUTION...................52

RISPERDAL ORAL TABLET 0.5 MG, 1

MG, 2 MG, 3 MG..........................................52

RISPERDAL ORAL TABLET 4 MG..............52

risperidone microspheres er.........................52

risperidone oral solution............................... 52

risperidone oral tablet 0.25 mg.....................52

risperidone oral tablet 0.5 mg, 1 mg, 2 mg,

3 mg............................................................. 52

risperidone oral tablet 4 mg..........................52

risperidone oral tablet dispersible 0.25 mg,

0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg.................. 52

RITALIN....................................................... 78

RITALIN LA.................................................. 78

248

ritonavir........................................................ 56

rivastigmine.................................................. 30

rivastigmine tartrate......................................30

rivelsa.........................................................140

rizatriptan benzoate......................................39

ROBINUL................................................... 115

ROBINUL-FORTE......................................115

ROCALTROL ORAL CAPSULE.................153

ROCALTROL ORAL SOLUTION............... 153

ROCKLATAN............................................. 175

roflumilast...................................................189

ROLVEDON............................................... 168

ropinirole hcl.................................................48

ropinirole hcl er oral tablet extended

release 24 hour 8 mg................................... 48

ropinirole hcl er tablet extended release 24

hour 12 mg oral............................................ 48

ropinirole hcl er tablet extended release 24

hour 2 mg oral.............................................. 49

ropinirole hcl er tablet extended release 24

hour 4 mg oral.............................................. 49

ropinirole hcl er tablet extended release 24

hour 6 mg oral.............................................. 49

rosuvastatin calcium.....................................74

ROTATEQ..................................................150

ROWASA................................................... 152

roweepra...................................................... 27

ROXICODONE.............................................16

ROXYBOND ORAL TABLET ABUSE-

DETERRENT 15 MG, 30 MG, 5 MG..............7

ROZEREM................................................. 201

ROZLYTREK ORAL CAPSULE................... 44

ROZLYTREK ORAL PACKET..................... 44

RUBRACA....................................................44

rufinamide suspension 40 mg/ml oral.......... 29

rufinamide tablet 200 mg oral.......................29

rufinamide tablet 400 mg oral.......................29

RUKOBIA..................................................... 56

RYALTRIS..................................................168

RYBELSUS.................................................. 60

RYCLORA..................................................185

RYDAPT.......................................................44

RYKINDO.....................................................52

RYTARY.......................................................49

ryvent......................................................... 185

SABRIL........................................................ 28

SAFE-T-LANCE......................................... 102

SAFETY LANCETS 23G............................102

SAFETY PEN NEEDLES 30G X 5 MM......168

SAFETY PEN NEEDLES 30G X 8 MM......102

SAFYRAL...................................................140

SAIZEN...................................................... 132

SALAGEN.................................................... 82

salicylic acid external foam........................ 168

salicylic acid external gel............................168

SALIMEZ....................................................168

saline enema..............................................122

saline mist spray........................................ 192

saline nasal spray...................................... 192

salsalate tablet 500 mg oral......................... 16

salsalate tablet 750 mg oral......................... 16

SALVAX..................................................... 168

SALYCIM................................................... 168

SALYNTRA................................................ 168

SAMSCA.................................................... 109

SANADERMRX SKIN REPAIR.................... 93

SANCUSO................................................... 35

SANDIMMUNE ORAL................................149

SANDOSTATIN..........................................145

SAPHRIS..................................................... 52

SARCLISA................................................. 173

SAVAYSA.................................................... 64

SAVELLA..................................................... 80

SAVELLA TITRATION PACK...................... 80

saxagliptin hcl...............................................60

saxagliptin-metformin er...............................60

sb arthritis pain relief.................................... 16

sb lice killing max st..................................... 47

sb pain reliever childrens............................. 16

SCEMBLIX................................................... 45

scopolamine................................................. 35

SECUADO................................................... 52

SEGLENTIS................................................. 10

SEGLUROMET............................................ 60

selegiline hcl oral..........................................50

selenium sulfide external lotion.................... 87

SELZENTRY................................................ 56

SEMGLEE (YFGN)...................................... 62

SE-NATAL 19.............................................112

senna lax....................................................126

senna laxative............................................ 126

senna oral liquid......................................... 126

senna oral syrup 8.8 mg/5ml......................126

senna oral tablet.........................................126

senna smooth.............................................126

senna-extra................................................ 126

senna-lax....................................................126

senna-tabs................................................. 126

senna-time................................................. 126

sennazon....................................................126

SENOKOT..................................................126

SENOKOT EXTRA STRENGTH................126

SENSIPAR................................................. 153

SEREVENT DISKUS................................. 188

SERNIVO..................................................... 87

SEROQUEL................................................. 52

SEROQUEL XR........................................... 52

SEROSTIM................................................ 132

SERTRALINE HCL ORAL CAPSULE..........33

sertraline hcl oral concentrate...................... 33

sertraline hcl oral tablet................................ 34

se-tan plus..................................................109

setlakin....................................................... 141

sevelamer carbonate oral packet............... 110

sevelamer carbonate oral tablet.................110

sevelamer hcl............................................. 110

sf................................................................ 106

249

sf 5000 plus................................................106

SFROWASA...............................................152

sharobel..................................................... 143

SHINGRIX..................................................150

SIDEROL................................................... 204

SIGNIFOR..................................................145

SIKLOS ORAL TABLET 100 MG................. 65

SIKLOS ORAL TABLET 1000 MG............... 65

siladryl allergy............................................ 185

sildenafil citrate oral suspension

reconstituted...............................................189

sildenafil citrate oral tablet 20 mg...............189

SILENOR................................................... 201

SILIQ.......................................................... 147

silodosin..................................................... 129

siltussin sa..................................................192

SILVADENE................................................. 89

silver sulfadiazine external........................... 89

SIMBRINZA................................................178

simeped......................................................122

simethicone drops infants.......................... 122

simethicone oral capsule 125 mg...............122

simethicone oral suspension......................122

simethicone oral tablet chewable............... 122

SIMLANDI (1 PEN).................................... 168

SIMLANDI (2 PEN).................................... 168

simliya........................................................ 141

simpesse.................................................... 141

SIMPONI.................................................... 149

SIMPONI ARIA...........................................149

simvastatin oral............................................ 74

SINEMET..................................................... 49

SINGULAIR................................................186

sinus congestion max strength...................199

sinus pe decongestant............................... 192

sinus/congestion relief pe...........................192

sirolimus oral solution.................................149

sirolimus oral tablet 0.5 mg........................ 149

sirolimus oral tablet 1 mg, 2 mg................. 149

SIRTURO..................................................... 40

SITAGLIPTIN............................................. 168

SITAVIG....................................................... 54

SIVEXTRO ORAL........................................ 21

SKYLA........................................................143

SKYRIZI INTRAVENOUS.......................... 168

SKYRIZI PEN.............................................147

SKYRIZI SUBCUTANEOUS SOLUTION

CARTRIDGE.............................................. 168

SKYRIZI SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE.............................. 147

SKYTROFA................................................133

SLYND....................................................... 143

smooth antacid ex st oral tablet chewable

750 mg....................................................... 122

smooth antacid extra st.............................. 122

smooth antacid extra strength....................122

smooth lax oral powder.............................. 124

SOAANZ ORAL TABLET 20 MG................. 72

sod citrate-citric acid oral solution 500-334

mg/5ml....................................................... 109

sodium chloride inhalation nebulization

solution 0.9 %.............................................199

sodium chloride inhalation nebulization

solution 10 %..............................................199

sodium chloride inhalation nebulization

solution 3 %................................................199

sodium chloride inhalation nebulization

solution 7 %................................................199

sodium fluoride 5000 plus.......................... 106

sodium fluoride 5000 ppm dental cream.... 106

sodium fluoride 5000 ppm dental paste..... 106

sodium fluoride dental cream..................... 106

sodium fluoride dental gel.......................... 106

sodium fluoride oral solution...................... 106

sodium fluoride oral tablet 1.1 (0.5 f) mg....106

sodium fluoride oral tablet 2.2 (1 f) mg.......106

sodium fluoride oral tablet chewable..........106

SODIUM OXYBATE...................................202

sodium polystyrene sulfonate.....................110

sodium sulfacetamide wash....................... 169

soft glucose.................................................. 63

SOGROYA................................................. 169

solifenacin succinate.................................. 128

SOLIQUA..................................................... 60

SOLODYN....................................................26

SOLOSEC....................................................21

SOLTAMOX................................................. 41

SOLU-CORTEF INJECTION SOLUTION

RECONSTITUTED 100 MG.......................132

SOMA.........................................................200

SOMAVERT............................................... 145

SOOLANTRA............................................... 89

soothe oral................................................. 122

sorafenib tosylate......................................... 44

SORILUX..................................................... 89

sotalol hcl (af)...............................................69

sotalol hcl oral.............................................. 69

SOTYKTU.................................................. 169

SOTYLIZE....................................................69

SOVUNA ORAL TABLET 200 MG...............46

SOVUNA ORAL TABLET 300 MG...............46

SPEEDY SWAB COVID-19 ANTIGEN...... 169

SPEVIGO INTRAVENOUS........................ 169

SPEVIGO SUBCUTANEOUS.................... 169

SPIKEVAX................................................. 169

spinosad.......................................................89

SPIRIVA HANDIHALER.............................187

SPIRIVA RESPIMAT..................................187

spironolactone oral suspension....................73

spironolactone oral tablet............................. 73

spironolactone-hctz...................................... 72

SPORANOX.................................................36

SPRAVATO (56 MG DOSE)........................ 32

SPRAVATO (84 MG DOSE)........................ 32

sprintec 28..................................................141

SPRITAM..................................................... 27

SPRIX............................................................ 6

250

SPRYCEL.................................................. 173

SPS............................................................ 110

sronyx.........................................................141

ssd................................................................89

sss 10-5 external cream...............................92

SSS 10-5 EXTERNAL FOAM...................... 92

ST JOSEPH LOW DOSE...........................169

STALEVO 150..............................................48

STAMARIL................................................. 150

STEGLATRO............................................... 60

STEGLUJAN................................................ 60

STELARA...................................................147

STIMUFEND.............................................. 169

STIOLTO RESPIMAT................................ 196

STIVARGA................................................... 44

stomach relief oral suspension 262

mg/15ml, 525 mg/30ml, 527 mg/30ml........122

stomach relief oral tablet 262 mg............... 122

stomach relief oral tablet chewable 262 mg

....................................................................122

stool softener laxative oral capsule............ 126

stool softener oral capsule 100 mg............ 126

stool softener oral capsule 240 mg............ 126

stool softener oral capsule 250 mg............ 126

stool softener oral tablet 100 mg................126

STRATTERA................................................78

STRIBILD..................................................... 54

STRIVE DUAL ZONE PEAK FLOW MTR..169

STRIVERDI RESPIMAT.............................188

STROMECTOL............................................ 45

STROVITE FORTE.................................... 204

STROVITE ONE........................................ 204

SUBLOCADE............................................... 18

SUBOXONE.................................................18

subvenite......................................................27

subvenite starter kit-blue.............................. 27

subvenite starter kit-green............................27

subvenite starter kit-orange..........................27

sucralfate oral.............................................116

SUDAFED SINUS CONGESTION.............199

sudogest maximum strength...................... 199

sudogest oral tablet 30 mg.........................199

SUFLAVE...................................................169

SULAR......................................................... 70

sulfacetamide sodium (acne)....................... 91

sulfacetamide sodium external...................169

sulfacetamide sodium ophthalmic ointment176

sulfacetamide sodium ophthalmic solution.176

sulfacetamide sodium-sulfur external

cream 10-2 %...............................................92

sulfacetamide sodium-sulfur external

cream 10-5 %...............................................92

sulfacetamide sodium-sulfur external liquid

10-2 %..........................................................92

sulfacetamide sodium-sulfur external liquid

10-5 %..........................................................92

sulfacetamide sodium-sulfur external liquid

9.8-4.8 %......................................................92

sulfacetamide sodium-sulfur external liquid

9-4.5 %.........................................................92

sulfacetamide sodium-sulfur external lotion

10-5 %..........................................................92

sulfacetamide sodium-sulfur external

suspension 8-4 %.........................................92

sulfacetamide sodium-sulfur liquid 9-4 %

external........................................................ 92

sulfacetamide sodium-sulfur suspension

10-5 % external............................................ 92

sulfacetamide sod-sulfur wash external

liquid 9-4 %.................................................. 92

sulfacetamide sod-sulfur wash external

liquid 9-4.5 %............................................... 92

sulfacetamide-prednisolone....................... 175

sulfacetamide-sulfur in urea......................... 92

SULFACLEANSE 8/4...................................92

sulfadiazine oral........................................... 25

sulfamethoxazole-trimethoprim oral............. 25

sulfamez wash............................................. 92

SULFAMYLON.............................................91

sulfasalazine oral....................................... 152

sulfatrim pediatric......................................... 25

sulindac oral................................................... 6

SUMADAN WASH....................................... 92

sumatriptan nasal.........................................39

sumatriptan succinate oral........................... 39

sumatriptan succinate refill...........................39

sumatriptan succinate subcutaneous

solution.........................................................39

sumatriptan succinate subcutaneous

solution auto-injector.................................... 39

sumatriptan-naproxen sodium......................39

SUMAXIN.....................................................92

sunitinib malate............................................ 44

SUNLENCA ORAL.....................................169

SUNOSI..................................................... 202

suphedrine oral tablet 30 mg......................199

SUPPRELIN LA......................................... 145

SUPREP BOWEL PREP KIT..................... 116

SUSTOL.......................................................35

SUTAB......................................................... 26

SUTENT.......................................................44

syeda..........................................................141

SYMBICORT..............................................196

SYMBYAX....................................................32

SYMDEKO ORAL TABLET THERAPY

PACK 100-150 & 150 MG.......................... 188

SYMDEKO ORAL TABLET THERAPY

PACK 50-75 & 75 MG................................ 188

SYMFI.......................................................... 55

SYMFI LO.................................................... 55

SYMLINPEN 120......................................... 60

SYMLINPEN 60........................................... 60

SYMPAZAN................................................. 28

SYMPROIC................................................ 114

SYMTUZA.................................................... 56

SYNAGIS................................................... 147

SYNALAR.................................................... 88

251

SYNAREL.................................................. 145

SYNJARDY.................................................. 60

SYNJARDY XR............................................ 60

SYNTHROID.............................................. 144

SYPRINE................................................... 109

SYRINGE AVITENE...................................169

SYSTANE NIGHTTIME..............................180

TABLOID......................................................41

TABRECTA................................................ 173

TACLONEX..................................................89

tacrolimus external ointment 0.03 %, 0.1 %.88

tacrolimus oral capsule 0.5 mg, 5 mg........ 149

tacrolimus oral capsule 1 mg..................... 149

tadalafil (pah)............................................. 189

tadalafil tablet 5 mg oral............................. 129

TADLIQ...................................................... 189

TAFINLAR....................................................44

tafluprost (pf).............................................. 174

TAGAMET HB 200.....................................116

TAGRISSO.................................................173

take action..................................................144

TALICIA......................................................116

TALTZ........................................................ 147

TALZENNA ORAL CAPSULE 0.1 MG,

0.35 MG, 0.5 MG, 0.75 MG..........................44

TALZENNA ORAL CAPSULE 0.25 MG, 1

MG............................................................... 44

TAMIFLU......................................................56

tamoxifen citrate oral....................................41

tamsulosin hcl............................................ 129

TANDEM PLUS..........................................109

TAPERDEX 12-DAY.................................. 132

TAPERDEX 6-DAY.................................... 132

TAPERDEX 7-DAY.................................... 132

TARCEVA.................................................. 173

TARGADOX................................................. 26

TARGRETIN................................................ 44

tarina 24 fe................................................. 141

tarina fe 1/20 eq......................................... 141

TARPEYO.................................................. 152

TASCENSO ODT ORAL TABLET

DISPERSIBLE 0.25 MG.............................169

TASCENSO ODT ORAL TABLET

DISPERSIBLE 0.5 MG...............................169

TASIGNA................................................... 173

tasimelteon capsule 20 mg oral................. 201

TASMAR...................................................... 48

tavaborole.................................................... 91

TAVALISSE..................................................66

taysofy........................................................141

TAYTULLA................................................. 141

tazarotene external cream........................... 84

TAZAROTENE EXTERNAL FOAM..............84

tazarotene gel 0.05 % external.................... 84

tazarotene gel 0.1 % external...................... 84

tazicef injection.............................................22

tazicef intravenous solution reconstituted.... 22

TAZORAC EXTERNAL CREAM 0.1 %........84

TAZORAC EXTERNAL GEL........................84

taztia xt.........................................................70

TAZVERIK....................................................42

TDVAX....................................................... 150

TECFIDERA ORAL CAPSULE DELAYED

RELEASE.....................................................81

TECFIDERA ORAL CAPSULE DELAYED

RELEASE THERAPY PACK........................81

TECHLITE LANCETS 26G........................ 102

TEENY TUMMY GAS RELIEF DROPS..... 122

TEGLUTIK....................................................79

TEGRETOL..................................................29

TEGRETOL-XR............................................29

TEKTURNA..................................................72

telmisartan tablet 20 mg oral........................68

telmisartan tablet 40 mg oral........................68

telmisartan tablet 80 mg oral........................68

telmisartan-amlodipine................................. 72

telmisartan-hctz............................................72

temazepam oral capsule 15 mg, 30 mg,

7.5 mg........................................................ 201

temazepam oral capsule 22.5 mg.............. 201

temozolomide...............................................40

TEMPO REFILL......................................... 102

TEMPO WELCOME...................................102

TENCON...................................................... 10

TENIVAC....................................................150

tenofovir disoproxil fumarate........................ 55

TENORETIC 100......................................... 72

TENORETIC 50........................................... 72

TENORMIN.................................................. 69

TEPMETKO................................................. 44

terazosin hcl............................................... 129

terbinafine hcl oral........................................36

terbutaline sulfate oral................................188

terbutaline sulfate solution 1 mg/ml

injection...................................................... 188

terconazole vaginal cream........................... 36

terconazole vaginal suppository...................36

teriflunomide tablet 14 mg oral.....................81

teriflunomide tablet 7 mg oral.......................81

teriparatide................................................. 153

teriparatide (recombinant) subcutaneous

solution pen-injector 600 mcg/2.4ml.......... 153

TERIPARATIDE (RECOMBINANT)

SUBCUTANEOUS SOLUTION PEN-

INJECTOR 620 MCG/2.48ML....................153

TESTIM...................................................... 134

TESTOPEL................................................ 134

testosterone cypionate intramuscular........ 134

testosterone enanthate intramuscular........134

TESTOSTERONE IMPLANT PELLET 37.5

MG, 87.5 MG..............................................134

testosterone transdermal gel 1.62 %, 20.25

mg/act (1.62%)...........................................134

testosterone transdermal gel 10 mg/act

(2%)............................................................134

252

testosterone transdermal gel 12.5 mg/act

(1%)............................................................134

testosterone transdermal gel 20.25

mg/1.25gm (1.62%), 40.5 mg/2.5gm

(1.62%).......................................................134

testosterone transdermal gel 25 mg/2.5gm

(1%)............................................................134

testosterone transdermal gel 50 mg/5gm

(1%)............................................................134

testosterone transdermal solution.............. 134

TETANUS-DIPHTHERIA TOXOIDS TD.... 150

tetrabenazine............................................... 79

tetracaine hcl ophthalmic........................... 175

tetracycline hcl oral capsule......................... 26

TETRACYCLINE HCL ORAL TABLET........ 26

TEXACORT..................................................88

TEZSPIRE SUBCUTANEOUS SOLUTION

AUTO-INJECTOR...................................... 190

TEZSPIRE SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE.............................. 190

tgt clotrimazole external cream 1 %............. 91

THALITONE................................................. 73

THALOMID...................................................41

the magic bullet.......................................... 169

THEO-24.................................................... 189

theophylline er............................................189

theophylline oral elixir.................................189

theophylline oral solution............................189

thiamine hcl injection..................................205

thiamine hcl oral......................................... 205

THIOLA...................................................... 129

THIOLA EC................................................ 129

thioridazine hcl oral...................................... 50

thiothixene....................................................50

THRIVE........................................................ 20

THRIVITE RX.............................................112

THROMBI-GEL 10..................................... 169

THROMBI-GEL 100................................... 169

THROMBI-GEL 40..................................... 169

THROMBI-PAD.......................................... 169

THYQUIDITY............................................. 144

thyroid oral................................................. 144

tiadylt er........................................................70

tiagabine hcl................................................. 28

TIAZAC........................................................ 70

TIBSOVO..................................................... 44

TIGAN.......................................................... 35

tigecycline.................................................... 21

TIKOSYN..................................................... 69

tilia fe..........................................................141

timolol maleate (once-daily)....................... 178

timolol maleate ophthalmic.........................178

timolol maleate oral...................................... 38

timolol maleate pf ophthalmic solution 0.25

%................................................................ 178

timolol maleate pf ophthalmic solution 0.5

%................................................................ 178

TIMOPTIC OCUDOSE OPHTHALMIC

SOLUTION 0.25 %.....................................178

TIMOPTIC OCUDOSE OPHTHALMIC

SOLUTION 0.5 %.......................................178

tinidazole oral............................................... 21

tiopronin..................................................... 129

tiotropium bromide monohydrate............... 187

TIROSINT.................................................. 144

TIROSINT-SOL.......................................... 144

TIVICAY....................................................... 54

TIVICAY PD................................................. 54

tizanidine hcl oral capsule 2 mg................... 53

tizanidine hcl oral capsule 4 mg, 6 mg......... 53

tizanidine hcl oral tablet................................53

TLANDO.....................................................134

TM-VITE RX...............................................112

TOBI NEBULIZER......................................189

TOBI PODHALER...................................... 189

TOBRADEX............................................... 175

TOBRADEX ST..........................................175

tobramycin inhalation nebulization solution

300 mg/4ml................................................ 189

tobramycin nebulization solution 300

mg/5ml inhalation....................................... 189

TOBRAMYCIN NEBULIZATION

SOLUTION 300 MG/5ML INHALATION.... 189

tobramycin ophthalmic............................... 176

tobramycin-dexamethasone.......................175

TOBREX.................................................... 176

TOFIDENCE.............................................. 169

tolcapone......................................................48

TOLECTIN 600.............................................. 6

tolmetin sodium.............................................. 6

tolnaftate antifungal external cream........... 169

tolnaftate external cream............................169

TOLSURA.................................................... 36

tolterodine tartrate...................................... 128

tolterodine tartrate er capsule extended

release 24 hour 2 mg oral.......................... 128

tolterodine tartrate er capsule extended

release 24 hour 4 mg oral.......................... 128

tolvaptan.....................................................109

TOPAMAX....................................................27

TOPAMAX SPRINKLE.................................28

TOPICORT...................................................88

TOPICORT SPRAY..................................... 88

topiramate er................................................ 28

topiramate oral capsule sprinkle.................. 28

topiramate oral tablet................................... 28

TOPROL XL................................................. 69

toremifene citrate......................................... 41

torsemide..................................................... 72

TOSYMRA................................................... 39

total allergy.................................................185

total allergy medicine................................. 185

TOUJEO MAX SOLOSTAR......................... 62

TOUJEO SOLOSTAR.................................. 63

tovet............................................................. 88

TOVIAZ...................................................... 129

253

TRACLEER 32 MG.................................... 189

TRACLEER 62.5 MG, 125 MG.................. 189

TRADJENTA................................................ 60

TRAMADOL HCL (ER BIPHASIC) ORAL

CAPSULE EXTENDED RELEASE 24

HOUR.............................................................7

tramadol hcl (er biphasic) oral tablet

extended release 24 hour.............................. 7

tramadol hcl er............................................... 7

TRAMADOL HCL ORAL SOLUTION...........10

tramadol hcl oral tablet 100 mg....................10

tramadol hcl oral tablet 25 mg........................7

tramadol hcl oral tablet 50 mg......................10

tramadol-acetaminophen............................. 10

trandolapril................................................... 68

trandolapril-verapamil hcl er.........................72

tranexamic acid intravenous........................ 66

tranexamic acid oral..................................... 66

tranexamic acid-nacl.................................... 66

TRANSDERM-SCOP................................... 35

tranylcypromine sulfate................................ 32

TRAVATAN Z.............................................174

travel ease....................................................35

travoprost (bak free)...................................174

TRAZIMERA.............................................. 173

trazodone hcl oral.........................................34

TRECATOR................................................. 40

TRELEGY ELLIPTA AEROSOL POWDER

BREATH ACTIVATED 100-62.5-25

MCG/ACT INHALATION............................ 196

TRELEGY ELLIPTA INHALATION

AEROSOL POWDER BREATH

ACTIVATED 200-62.5-25 MCG/ACT......... 196

TRELSTAR MIXJECT................................ 145

TREMFYA.................................................. 147

TRESIBA......................................................63

TRESIBA FLEXTOUCH............................... 63

tretinoin external cream................................84

tretinoin external gel.....................................84

tretinoin microsphere external gel 0.04 %,

0.1 %............................................................ 84

tretinoin microsphere external gel 0.08 %....84

tretinoin microsphere pump external gel

0.04 %, 0.1 %...............................................84

tretinoin microsphere pump external gel

0.08 %.......................................................... 84

tretinoin oral................................................. 44

TREXALL................................................... 149

TREXIMET................................................... 39

TREZIX........................................................ 10

TRIADIME.................................................... 93

triamcinolone acetonide external aerosol

solution.........................................................88

triamcinolone acetonide external cream...... 88

triamcinolone acetonide external lotion

0.025 %........................................................ 88

triamcinolone acetonide external lotion 0.1

%.................................................................. 88

triamcinolone acetonide external ointment...88

TRIAMCINOLONE ACETONIDE

INJECTION SUSPENSION 80 MG/ML......132

triamcinolone acetonide mouth/throat.......... 82

triamcinolone acetonide nasal....................195

triamcinolone acetonide suspension 40

mg/ml injection........................................... 132

TRIAMCINOLONE ACETONIDE

SUSPENSION 40 MG/ML INJECTION......132

triamcinolone in absorbase.......................... 88

triamterene oral............................................ 73

triamterene-hctz........................................... 72

triazolam.....................................................201

TRIBENZOR................................................ 72

tricitrates.....................................................204

TRICON..................................................... 109

TRICOR....................................................... 73

triderm.......................................................... 88

trientine hcl.................................................109

tri-estarylla..................................................141

trifluoperazine hcl......................................... 50

trifluridine....................................................176

trihexyphenidyl hcl........................................47

TRIJARDY XR..............................................60

TRIKAFTA ORAL TABLET THERAPY

PACK......................................................... 189

TRIKAFTA ORAL THERAPY PACK.......... 189

tri-legest fe................................................. 141

TRILEPTAL ORAL SUSPENSION...............29

TRILEPTAL ORAL TABLET.........................29

tri-linyah......................................................141

TRILIPIX.......................................................73

tri-lo-estarylla..............................................141

tri-lo-marzia................................................ 141

tri-lo-mili......................................................141

tri-lo-sprintec.............................................. 141

trimethobenzamide hcl oral.......................... 35

trimethoprim oral.......................................... 21

tri-mili..........................................................141

trimipramine maleate oral.............................34

TRIMO-SAN................................................. 26

TRINATAL RX 1.........................................113

TRINTELLIX.................................................34

tri-nymyo.................................................... 141

triphrocaps................................................. 113

TRIPTODUR.............................................. 145

tri-sprintec.................................................. 141

TRIUMEQ.....................................................55

TRIUMEQ PD...............................................55

tri-vite/fluoride oral solution 0.25 mg/ml..... 204

tri-vite/fluoride oral solution 0.5 mg/ml....... 204

TRIVIX..........................................................93

trivora (28)..................................................141

tri-vylibra.....................................................141

tri-vylibra lo.................................................141

TROKENDI XR.............................................28

TRONVITE................................................. 113

tropicamide ophthalmic.............................. 180

trospium chloride........................................129

254

trospium chloride er....................................129

TRUE COVER............................................169

TRUE FERROUS SULFATE......................109

TRUE FOCUS BLOOD GLUCOSE STRIP 102

true folic acid tablet 1 mg oral.................... 169

TRUE FOLIC ACID TABLET 1 MG ORAL. 169

TRUE METRIX AIR GLUCOSE METER....102

TRUE METRIX GO GLUCOSE METER.... 102

TRUE METRIX METER KIT.......................102

TRUE NASAL MOISTURIZING................. 192

TRUE VITAMIN B6 ORAL TABLET 50 MG205

TRUE VITAMIN D3 ORAL CAPSULE 25

MCG (1000 UT)..........................................113

TRUE VITAMIN D3 ORAL CAPSULE 250

MCG (10000 UT)........................................113

TRUE VITAMIN D3 ORAL TABLET 25

MCG (1000 UT)..........................................113

TRUECONTROL GLUCOSE CONT LEV 0102

TRUECONTROL GLUCOSE CONT LEV 1102

TRUEPLUS GLUCOSE ON THE GO.......... 63

TRUEPLUS GLUCOSE ORAL TABLET

CHEWABLE................................................. 63

TRUEPLUS LANCETS 30G.......................102

TRUEPLUS SAFETY LANCETS 28G........103

TRUETRACK BLOOD GLUCOSE DEVICE

....................................................................103

TRUETRACK TEST................................... 103

TRULANCE................................................114

TRULICITY...................................................60

TRUMENBA............................................... 150

TRUQAP.................................................... 169

TRUVADA.................................................... 55

TUBING/WING TIP.................................... 169

TUDORZA PRESSAIR AEROSOL

POWDER BREATH ACTIVATED 400

MCG/ACT INHALATION............................ 187

TUKYSA.....................................................173

TUMS SMOOTHIES.................................. 122

TURALIO....................................................173

turqoz......................................................... 141

tusnel-ex.....................................................192

tussin adult chest congest..........................192

tussin chest congestion oral liquid 100

mg/5ml....................................................... 192

tussin cough dm sugar free........................199

tussin cough long acting.............................192

tussin cough oral syrup.............................. 192

tussin cough/chest congest oral syrup 100-

10 mg/5ml.................................................. 199

tussin dm cough/chest cong.......................199

tussin dm cough/chest oral syrup 10-100

mg/5ml....................................................... 199

tussin dm oral syrup 100-10 mg/5ml.......... 199

tussin expectorant adult............................. 193

tussin maximum strength oral syrup 15

mg/5ml....................................................... 193

tussin mucus & chest cong........................ 193

tussin mucus & chest congest....................193

tussin mucus/chest congest....................... 193

tussin mucus/congestion............................193

tussin mucus+chest congest......................193

tussin mucus+chest congestion................. 193

tussin oral liquid 100 mg/5ml......................193

TWINRIX.................................................... 150

TWIRLA......................................................143

TWIST TOP LANCETS 30G...................... 103

TYBLUME.................................................. 141

TYBOST.......................................................56

tydemy........................................................141

TYENNE.....................................................169

TYGACIL......................................................21

TYKERB.....................................................173

TYLENOL FOR CHILDREN + ADULTS.......16

TYLENOL ORAL SUSPENSION 160

MG/5ML....................................................... 16

TYLENOL ORAL TABLET 325 MG, 500

MG............................................................... 16

TYLENOL ORAL TABLET CHEWABLE

160 MG........................................................ 16

TYLENOL ORAL TABLET EXTENDED

RELEASE 650 MG.......................................16

TYMLOS.................................................... 153

TYPHIM VI................................................. 150

TYRVAYA.................................................. 175

TYSABRI......................................................81

TYVASO.....................................................189

TYVASO DPI INSTITUTIONAL KIT........... 189

TYVASO DPI MAINTENANCE KIT............189

TYVASO DPI TITRATION KIT................... 189

TYVASO REFILL....................................... 189

TYVASO STARTER...................................189

UBRELVY.................................................... 38

UCERIS ORAL...........................................152

UCERIS RECTAL...................................... 152

UDAMIN SP............................................... 204

UDENYCA ONBODY................................... 65

UDENYCA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR........................................ 65

UDENYCA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE................................ 65

UDSX MEDICATED SYSTEM................... 169

UDSXMP MEDICATED SYSTEM..............169

ULORIC........................................................37

ultra calcium + vitamin d3...........................109

ultra fresh................................................... 180

ultra fresh pm............................................. 180

ULTRA NEB ACCESSORIES KIT............. 169

ULTRAFOAM SPONGE 2X6.25X7CM...... 169

ULTRAFOAM SPONGE 8X12.5X1CM...... 169

ULTRAFOAM SPONGE 8X12.5X3CM...... 169

ULTRAFOAM SPONGE 8X25X1CM......... 169

ULTRAFOAM SPONGE 8X6.25X1CM...... 169

ULTRAVATE................................................ 88

UNASYN INJECTION SOLUTION

RECONSTITUTED 3 (2-1) GM.................... 23

255

UNIFINE PROTECT PEN NEEDLE 30G X

5 MM.......................................................... 169

UNIFINE PROTECT PEN NEEDLE 30G X

8 MM.......................................................... 103

UNIFINE PROTECT PEN NEEDLE 32G X

4 MM.......................................................... 103

UNISTRIP CONTROL................................170

UNISTRIP1 GENERIC............................... 103

unithroid..................................................... 144

UPTRAVI INTRAVENOUS.........................189

UPTRAVI ORAL.........................................189

UPTRAVI TITRATION................................189

urea external cream 40 %............................ 93

urea external lotion 40 %............................. 93

URELLE..................................................... 130

UREMEZ-40.................................................93

uretron d/s.................................................. 130

URIBEL ORAL CAPSULE..........................130

URIBEL ORAL TABLET.............................130

URIMAR-T..................................................130

urin ds........................................................ 130

URNEVA.................................................... 130

UROCIT-K 10.............................................106

UROCIT-K 15.............................................106

UROCIT-K 5...............................................106

UROGESIC-BLUE..................................... 130

URO-MP.....................................................130

UROXATRAL............................................. 129

URSO 250..................................................116

URSO FORTE............................................116

URSODIOL ORAL CAPSULE 200 MG,

400 MG...................................................... 116

ursodiol oral capsule 300 mg..................... 116

ursodiol oral tablet......................................116

UZEDY SUBCUTANEOUS SUSPENSION

PREFILLED SYRINGE 100 MG/0.28ML......52

VAGIFEM................................................... 141

valacyclovir hcl oral...................................... 54

VALCHLOR..................................................40

VALCYTE.....................................................53

valganciclovir hcl.......................................... 53

VALIUM........................................................58

valproic acid oral.......................................... 28

VALSARTAN ORAL SOLUTION..................68

valsartan oral tablet......................................68

valsartan-hydrochlorothiazide...................... 72

VALTOCO 10 MG DOSE............................. 28

VALTOCO 15 MG DOSE............................. 28

VALTOCO 20 MG DOSE............................. 29

VALTOCO 5 MG DOSE............................... 29

VALTREX.....................................................54

VANCOCIN ORAL CAPSULE 250 MG........21

vancomycin hcl oral......................................21

VANDAZOLE............................................... 21

VANFLYTA...................................................44

VANOS.........................................................88

VAPORIZER WARM STEAM.....................170

VAQTA....................................................... 150

varenicline tartrate........................................19

varenicline tartrate (starter).......................... 19

varenicline tartrate(continue)........................19

VARIVAX....................................................150

VASCEPA.................................................... 74

VASERETIC.................................................72

VASOTEC.................................................... 68

VAXCHORA............................................... 151

VAXELIS.................................................... 170

VAXNEUVANCE........................................ 150

v-c forte...................................................... 204

VECAMYL.................................................... 72

VECTICAL....................................................89

vegetable laxative...................................... 126

VEKLURY.................................................... 57

velivet......................................................... 141

VELPHORO............................................... 110

VELSIPITY................................................. 170

VELTASSA.................................................110

VEMLIDY..................................................... 53

VENCLEXTA................................................44

VENCLEXTA STARTING PACK..................44

VENEXA.....................................................204

VENEXA FE............................................... 204

VENLAFAXINE BESYLATE ER.................170

venlafaxine hcl............................................. 34

venlafaxine hcl er oral capsule extended

release 24 hour............................................ 34

venlafaxine hcl er oral tablet extended

release 24 hour............................................ 34

VENOFER..................................................109

VENTAVIS................................................. 189

VENTIVA TEARS.......................................180

VENTOLIN HFA......................................... 188

VEOZAH.................................................... 170

verapamil hcl er oral capsule extended

release 24 hour............................................ 70

verapamil hcl er oral tablet extended

release......................................................... 70

verapamil hcl oral......................................... 70

VEREGEN....................................................89

VERELAN.................................................... 70

VERELAN PM ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 100 MG..70

VERELAN PM ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 200 MG,

300 MG........................................................ 70

VERIFINE INSULIN PEN NEEDLE 29G X

12MM......................................................... 170

VERIFINE INSULIN PEN NEEDLE 31G X

5 MM.......................................................... 170

VERIFINE INSULIN PEN NEEDLE 31G X

8 MM.......................................................... 170

VERIFINE INSULIN PEN NEEDLE 32G X

4 MM.......................................................... 103

VERIFINE INSULIN PEN NEEDLE 32G X

6 MM.......................................................... 103

VERIFINE INSULIN SYRINGE.................. 170

256

VERIFINE PLUS PEN NEEDLE 31G X 5

MM............................................................. 170

VERIFINE PLUS PEN NEEDLE 31G X 8

MM............................................................. 170

VERIFINE PLUS PEN NEEDLE 32G X 4

MM............................................................. 103

VERIFINE SAFE LANCET MINI 21G.........103

VERIFINE SAFE LANCET MINI 23G.........103

VERIFINE SAFE LANCET MINI 28G.........103

VERIFINE SAFE LANCET MINI 30G.........103

VERIFINE UNIVERSAL LANCETS 28G....104

VERIFINE UNIVERSAL LANCETS 30G....104

VERIFINE UNIVERSAL LANCETS 33G....104

VERKAZIA................................................. 175

VERQUVO................................................... 76

VERSACLOZ............................................... 52

VERSAPAP................................................170

VERSAPAP W/UNIVERSAL TUBING....... 170

VERSAPENN (AL) ANHYD LIPID..............170

VERZENIO...................................................44

VESICARE................................................. 129

VESICARE LS............................................129

vestura....................................................... 142

VEVYE....................................................... 175

VFEND......................................................... 36

VIBERZI..................................................... 114

VIBRAMYCIN...............................................26

vic-forte...................................................... 204

VICTOZA......................................................60

vienva.........................................................142

vigabatrin......................................................29

vigadrone..................................................... 29

VIGAMOX.................................................. 176

vigpoder....................................................... 29

VIIBRYD.......................................................34

VILAMIT MB...............................................130

vilazodone hcl.............................................. 34

VILEVEV MB..............................................130

VIMOVO.........................................................6

VIMPAT INTRAVENOUS.............................29

VIMPAT ORAL............................................. 29

VINATE ONE............................................. 113

VIOKACE................................................... 127

viorele.........................................................142

VIRACEPT................................................... 56

VIRAZOLE................................................. 190

VIREAD ORAL POWDER............................55

VIREAD ORAL TABLET 150 MG, 200 MG,

250 MG........................................................ 55

VIREAD ORAL TABLET 300 MG.................55

virt-caps......................................................113

VISTARIL..................................................... 57

vita s forte...................................................204

vitacel......................................................... 204

vitamin b1...................................................205

vitamin b-6 oral tablet 50 mg......................205

vitamin d (cholecalciferol) oral tablet 25

mcg (1000 ut)............................................. 113

vitamin d (ergocalciferol) oral capsule 1.25

mg (50000 ut), 50000 unit.......................... 204

vitamin d oral capsule 25 mcg (1000 ut).... 113

vitamin d3 oral capsule 25 mcg (1000 ut).. 113

vitamin d3 oral capsule 250 mcg (10000 ut)

....................................................................113

vitamin d3 oral tablet 25 mcg (1000 ut)......113

vitamin d-3 oral tablet 25 mcg (1000 ut).....113

vitamins acd-fluoride.................................. 204

vitamins complete childrens....................... 204

VITAROCA PLUS...................................... 204

VITASURE................................................. 113

VITATHELY WITH GINGER...................... 113

VITRAKVI.....................................................44

VITRAMYN.................................................204

VITRANOL................................................. 204

VITRANOL FE............................................204

VITREXYL..................................................204

VITREXYL + IRON.....................................204

VIVAGUARD INO CONTROL SOLUTION.104

VIVAGUARD INO GLUCOSE METER KIT 104

VIVAGUARD INO SMART GLUC METER 104

VIVAGUARD INO TEST STRIPS.............. 104

VIVAGUARD LANCETS 30G.....................104

VIVAGUARD SAFETY LANCETS 28G......104

VIVELLE-DOT............................................142

VIVITROL.....................................................18

VIVJOA...................................................... 170

VIVOTIF..................................................... 151

VIZIMPRO..................................................173

VOCABRIA...................................................38

VOGELXO..................................................134

VOGELXO PUMP...................................... 134

volnea.........................................................142

VONJO.........................................................44

VOQUEZNA............................................... 170

VOQUEZNA DUAL PAK............................ 170

VOQUEZNA TRIPLE PAK......................... 114

voriconazole oral tablet................................ 36

voriconazole suspension reconstituted 40

mg/ml oral.............................................. 36, 37

VORTEX HOLD CHMBR/MASK/CHILD.... 170

VORTEX HOLD

CHMBR/MASK/TODDLER.........................170

VORTEX VALVED HOLDING CHAMBER.170

VOTRIENT................................................. 173

VOWST...................................................... 170

VRAYLAR.................................................... 52

VRAYLAR ORAL CAPSULE THERAPY

PACK 1.5 & 3 MG........................................ 52

VTAMA.......................................................170

VUITY.........................................................178

VUMERITY...................................................81

VUSION....................................................... 91

VYEPTI........................................................ 38

vyfemla.......................................................142

vylibra.........................................................142

VYTORIN..................................................... 74

VYVANSE ORAL CAPSULE 10 MG............78

257

VYVANSE ORAL CAPSULE 20 MG, 30

MG, 40 MG, 50 MG, 60 MG, 70 MG............ 78

VYVANSE ORAL TABLET CHEWABLE......78

VYZULTA................................................... 174

WAKIX........................................................202

warfarin sodium oral tablet 1 mg, 10 mg, 2

mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg........ 64

warfarin sodium oral tablet 6 mg.................. 65

WELCHOL................................................... 75

WELIREG.....................................................45

WELLBUTRIN SR........................................ 32

WELLBUTRIN XL.........................................32

WELLFOLA................................................ 204

wera........................................................... 142

wescaps..................................................... 113

WESNATAL DHA COMPLETE.................. 113

wes-phos 250 neutral.................................109

westab one.................................................113

WESTAB PLUS..........................................113

WIDE-SEAL DIAPHRAGM 60....................171

WIDE-SEAL DIAPHRAGM 65....................171

WIDE-SEAL DIAPHRAGM 70....................171

WIDE-SEAL DIAPHRAGM 75....................171

WIDE-SEAL DIAPHRAGM 80....................171

WIDE-SEAL DIAPHRAGM 85....................171

WIDE-SEAL DIAPHRAGM 90....................171

WIDE-SEAL DIAPHRAGM 95....................171

WINLEVI.................................................... 171

WINREVAIR...............................................171

wixela inhub............................................... 196

womans laxative.........................................171

womens gentle laxative..............................171

womens laxative.........................................171

wymzya fe.................................................. 142

XACIATO..................................................... 21

XADAGO......................................................50

XALATAN...................................................174

XALKORI ORAL CAPSULE....................... 173

XALKORI ORAL CAPSULE SPRINKLE.... 173

XANAX......................................................... 58

XANAX XR................................................... 58

XARELTO ORAL SUSPENSION

RECONSTITUTED.......................................65

XARELTO ORAL TABLET........................... 65

XARELTO STARTER PACK........................65

XATMEP.................................................... 149

XCOPRI (250 MG DAILY DOSE).................28

XCOPRI (350 MG DAILY DOSE).................28

XCOPRI ORAL TABLET 100 MG, 150 MG,

200 MG, 50 MG............................................28

XCOPRI ORAL TABLET 25 MG.................. 28

XCOPRI ORAL TABLET THERAPY PACK. 28

XDEMVY.................................................... 171

XELJANZ................................................... 147

XELJANZ XR............................................. 147

XELODA.......................................................45

XELPROS.................................................. 174

XELSTRYM................................................171

XENAZINE................................................... 79

XEOMIN INTRAMUSCULAR SOLUTION

RECONSTITUTED 200 UNIT...................... 53

XEPI............................................................. 91

XERAC AC...................................................93

XERESE.......................................................89

XGEVA.......................................................153

XHANCE.................................................... 186

XIFAXAN......................................................21

XIGDUO XR................................................. 60

XIIDRA....................................................... 175

XOFLUZA (40 MG DOSE)........................... 56

XOFLUZA (80 MG DOSE)........................... 56

XOLAIR...................................................... 147

XOPENEX HFA..........................................188

XOSPATA.................................................. 173

XPHOZAH..................................................171

XPOVIO (100 MG ONCE WEEKLY)............42

XPOVIO (40 MG ONCE WEEKLY)..............42

XPOVIO (40 MG TWICE WEEKLY).............42

XPOVIO (60 MG ONCE WEEKLY)..............42

XPOVIO (60 MG TWICE WEEKLY).............42

XPOVIO (80 MG ONCE WEEKLY)..............42

XPOVIO (80 MG TWICE WEEKLY).............42

XTAMPZA ER................................................ 7

XTANDI........................................................ 41

xulane.........................................................142

XULTOPHY..................................................60

XYBIOTIC.................................................. 122

XYLIDERM...................................................17

XYOSTED.................................................. 134

XYREM...................................................... 202

XYWAV...................................................... 200

YASMIN 28................................................ 142

YAZ............................................................ 142

YCANTH.................................................... 171

YF-VAX...................................................... 150

YONSA.......................................................171

YUFLYMA (1 PEN) SUBCUTANEOUS

AUTO-INJECTOR KIT 40 MG/0.4ML.........171

YUFLYMA (1 PEN) SUBCUTANEOUS

AUTO-INJECTOR KIT 80 MG/0.8ML.........171

YUFLYMA (2 PEN).................................... 171

YUFLYMA (2 SYRINGE)............................171

YUFLYMA-CD/UC/HS STARTER..............171

YUPELRI....................................................187

YUSIMRY...................................................171

yuvafem......................................................142

zafemy........................................................142

zafirlukast................................................... 186

zaleplon......................................................201

ZANAFLEX ORAL CAPSULE 2 MG............ 53

ZANAFLEX ORAL CAPSULE 4 MG, 6 MG. 53

ZANAFLEX ORAL TABLET......................... 53

ZARONTIN...................................................28

ZARXIO........................................................65

ZAVZPRET................................................ 171

ZEGERID................................................... 119

ZEJULA........................................................44

258

ZELAC........................................................122

ZELAPAR.....................................................50

ZELBORAF.................................................. 44

ZEMAIRA INTRAVENOUS SOLUTION

RECONSTITUTED 1000 MG.....................127

ZEMAIRA INTRAVENOUS SOLUTION

RECONSTITUTED 4000 MG, 5000 MG.... 127

ZEMBRACE SYMTOUCH............................39

ZEMPLAR ORAL....................................... 153

zenatane...................................................... 84

ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 10000-32000

UNIT, 15000-47000 UNIT, 20000-63000

UNIT, 25000-79000 UNIT, 3000-10000

UNIT, 40000-126000 UNIT, 5000-24000

UNIT...........................................................127

ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 60000-189600

UNIT...........................................................127

ZENZEDI ORAL TABLET 10 MG, 5 MG......78

ZENZEDI ORAL TABLET 15 MG, 2.5 MG,

20 MG, 30 MG, 7.5 MG................................79

ZEPOSIA......................................................81

ZEPOSIA 7-DAY STARTER PACK............. 82

ZEPOSIA STARTER KIT............................. 82

ZERUVIA......................................................17

ZERVIATE..................................................175

ZESTORETIC.............................................. 72

ZESTRIL...................................................... 68

ZETIA........................................................... 75

ZETONNA.................................................. 186

ZIAGEN........................................................55

ZIANA...........................................................84

zidovudine.................................................... 55

ZIEXTENZO................................................. 65

zileuton er tablet extended release 12 hour

600 mg oral................................................ 186

ZILRETTA.................................................. 132

ZIMHI........................................................... 18

ZIOPTAN....................................................174

ziprasidone hcl............................................. 52

ziprasidone mesylate................................... 52

ZIPSOR..........................................................6

ZIRGAN........................................................53

ZITHROMAX ORAL..................................... 24

ZITHROMAX TRI-PAK.................................24

ZITHROMAX Z-PAK.................................... 24

ZITUVIO..................................................... 171

ZOCOR........................................................ 74

zoledronic acid intravenous concentrate....153

zoledronic acid intravenous solution.......... 153

ZOLINZA...................................................... 42

zolmitriptan...................................................39

ZOLOFT....................................................... 34

zolpidem tartrate er.................................... 201

ZOLPIDEM TARTRATE ORAL CAPSULE 201

zolpidem tartrate oral tablet........................201

zolpidem tartrate sublingual....................... 201

ZOMACTON...............................................132

ZOMIG NASAL.............................................39

ZONALON....................................................88

ZONEGRAN.................................................29

ZONISADE...................................................29

zonisamide oral............................................ 29

ZONTIVITY.................................................. 65

ZORTRESS................................................149

ZORYVE.................................................... 171

zovia 1/35 (28)........................................... 142

ZOVIRAX..................................................... 54

ZTLIDO........................................................ 17

ZUBSOLV.................................................... 18

zumandimine..............................................142

ZURZUVAE................................................171

ZYCLARA.....................................................89

ZYCLARA PUMP......................................... 89

ZYDELIG......................................................44

ZYFLO........................................................186

ZYKADIA......................................................45

ZYLET........................................................ 175

ZYMFENTRA (1 PEN)............................... 149

ZYMFENTRA (2 PEN)............................... 149

ZYMFENTRA (2 SYRINGE).......................149

ZYPITAMAG................................................ 74

ZYPREXA INTRAMUSCULAR.................... 52

ZYPREXA ORAL..........................................52

ZYPREXA RELPREVV................................ 52

ZYPREXA ZYDIS.........................................52

ZYRTEC-D ALLERGY & SINUS................ 193

ZYTIGA........................................................ 41

ZYVOX ORAL SUSPENSION

RECONSTITUTED.......................................21

ZYVOX ORAL TABLET................................21

259