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2021 Drug Formulary II

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An Introduction to Independent Health’s 2021 Drug Formulary II The following information applies to plans offered through the NY State of Health: The Official Health Plan Marketplace – for individuals through the Individual Marketplace. 1-855-355-5777 https://nystateofhealth.ny.gov/ This information also applies to Independent Health plans offered to individuals directly, not through the marketplace. Check your summary of benefits to ensure this formulary (Drug Formulary II) is associated with your plan prior to using your prescription drug benefit. Note: If you are reading a printed version of this drug formulary, content may have been updated since it was last printed. For the most up-to-date information, please visit independenthealth.com. Independent Health members benefit when their health care providers use the formulary because all medications included are selected due to their effectiveness and safety. Use of a formulary also ensures that premiums are kept to a minimum. The cost of each medication on the formulary is balanced with its effectiveness, which means that medications are not included on the formulary just because they are inexpensive; effectiveness is more important that the price of the medication. If a medication is not capable of achieving the desired effect, then the price of treating an illness or condition increases because other therapies must be used. Likewise, there are expensive medications that have not been proven to be any more effective than less costly alternatives. Since 1996, all prescriptions for Independent Health members have been written from the formulary in order to qualify for coverage. When health care providers write a prescription for Independent Health members, they consult the formulary and select the medication needed. Occasionally, members need a medication that is not on the formulary. In cases when it is medically necessary for a patient to have a medication that is not included on the formulary, health care providers are encouraged to request a medical exception from Independent Health’s Medical Director. The health care provider will need to complete a medical exception form and fax it to Independent Health’s Prior Authorization Department, who will review the details of the case. Independent Health’s three-tiered formulary lets you decide among preferred generic, preferred brand-name and non-preferred brand/generic medications with three different copayment/ coinsurance levels: The lowest copayment is charged in Tier 1. This tier contains preferred generic medications, certain over-the-counter (OTC) medications and select brand-name medications. A higher copayment/coinsurance is charged for those medications in Tier 2. This tier contains non-preferred generic medications and preferred brand-name medications. The highest copayment/coinsurance is charged for those medications in Tier 3. This tier contains non-preferred brand-name medications and certain specified medications. Brand-name medications with a generic equivalent are considered non-formulary (not covered). To obtain a medication that is non- formulary your health care provider is encouraged to submit a prior authorization request for coverage through the exceptions process. If the request is approved, that particular medication will be covered at your Tier 3 copayment/coinsurance level. All medications listed on the formulary will be available to you and you will be responsible for payment of the copayment/coinsurance as referenced in this document. You will note on the
Transcript
Page 1: 2021 Drug Formulary II

An Introduction to

Independent Health’s 2021 Drug Formulary II

The following information applies to plans

offered through the NY State of Health: The

Official Health Plan Marketplace – for

individuals through the Individual Marketplace.

1-855-355-5777 https://nystateofhealth.ny.gov/

This information also applies to Independent

Health plans offered to individuals directly, not

through the marketplace. Check your summary

of benefits to ensure this formulary (Drug

Formulary II) is associated with your plan prior

to using your prescription drug benefit.

Note: If you are reading a printed version of

this drug formulary, content may have been

updated since it was last printed. For the

most up-to-date information, please visit

independenthealth.com.

Independent Health members benefit when their

health care providers use the formulary because all

medications included are selected due to their

effectiveness and safety. Use of a formulary also

ensures that premiums are kept to a minimum.

The cost of each medication on the formulary is

balanced with its effectiveness, which means that

medications are not included on the formulary just

because they are inexpensive; effectiveness is

more important that the price of the medication. If

a medication is not capable of achieving the

desired effect, then the price of treating an illness

or condition increases because other therapies

must be used. Likewise, there are expensive

medications that have not been proven to be any

more effective than less costly alternatives.

Since 1996, all prescriptions for Independent

Health members have been written from the

formulary in order to qualify for coverage. When

health care providers write a prescription for

Independent Health members, they consult the

formulary and select the medication needed.

Occasionally, members need a medication that is

not on the formulary. In cases when it is medically

necessary for a patient to have a medication that

is not included on the formulary, health care

providers are encouraged to request a medical

exception from Independent Health’s Medical

Director. The health care provider will need to

complete a medical exception form and fax it to

Independent Health’s Prior Authorization

Department, who will review the details of the

case.

Independent Health’s three-tiered formulary lets

you decide among preferred generic, preferred

brand-name and non-preferred brand/generic

medications with three different copayment/

coinsurance levels:

• The lowest copayment is charged in Tier 1. This

tier contains preferred generic medications,

certain over-the-counter (OTC) medications and

select brand-name medications.

• A higher copayment/coinsurance is charged for

those medications in Tier 2. This tier contains

non-preferred generic medications and preferred

brand-name medications.

• The highest copayment/coinsurance is charged

for those medications in Tier 3. This tier contains

non-preferred brand-name medications and

certain specified medications.

• Brand-name medications with a generic

equivalent are considered non-formulary (not

covered). To obtain a medication that is non-

formulary your health care provider is

encouraged to submit a prior authorization

request for coverage through the exceptions

process. If the request is approved, that

particular medication will be covered at your Tier

3 copayment/coinsurance level.

All medications listed on the formulary will be

available to you and you will be responsible for

payment of the copayment/coinsurance as

referenced in this document. You will note on the

Page 2: 2021 Drug Formulary II

list that a medication’s copayment/coinsurance is

assigned to a tier. How this affects your

copayment/coinsurance depends upon what

prescription plan you have. Independent Health

reserves the right to modify the copay/tier of a

particular medication as necessary. For example,

when a generic equivalent becomes available for a

covered brand-name medication, the brand-name

medication becomes non-formulary (not covered)

and will be covered only if approved through the

medical exception process. Independent Health

reserves the right to change the duration of an

approved prior authorization through the medical

exception process, including but not limited to the

termination of a previously approved authorization.

Approval of a prior authorization request does not

itself guarantee payment; payment is made based

on plan/benefit design. The generic equivalent

medication will be covered in Tier 1 or Tier 2.

Because of this, the actual copayment/coinsurance

paid may not match the copayment/coinsurance

tier levels as published in this document. To

determine which prescription plan you have, please

refer to your contract. If you have further

questions, you may contact Independent Health’s

Member Services Department.

Because there are thousands of medications in the

marketplace, not all Tier 3 non-preferred

medications can be listed here. Independent Health

makes every attempt to provide you with as

accurate a listing of medications as possible,

however the list of medications and availability of

generics can change frequently. Since this list was

created, some medications may have been added,

while others may have been deleted. For an

updated version of the formulary please visit our

website at independenthealth.com.

Prior-Authorization

Independent Health requires you to get prior

authorization for certain medications. To obtain

coverage for a medication requiring prior

authorization, a prior authorization request for

medical exception must be submitted by your

health care provider and approved by

Independent Health. Medications that require

prior authorization are listed with a “PA” in the

formulary.

Step Therapy

In some cases, Independent Health requires you to

first try certain medications to treat your medical

condition before we cover another medication for

that condition. Step therapy is a way to help you

get the best quality and value from your

prescription medication benefit. This usually means

that an equally effective generic medication is

prescribed before a more expensive brand-name

medication. Step therapy may also ensure that two

medications are used together if they are more

effective. Medications that require step therapy are

listed with a “ST” in the formulary.

Quantity Limitations

Quantity limitations may apply to certain

medications. Some medications are covered up to

a specific quantity per 30 or 90 days. Some

examples of medications with a quantity limitation

are: sumatriptan (generic Imitrex®) and zolpidem

tartrate (generic Ambien®). Medications with

quantity limitations are listed with a “QL” in the

formulary.

For some items that come pre-packaged (for

example: tube/container, inhaler device, single

dose units, or liquid container), one package size

is allowed per fill of these items. If a quantity limit

is designated on the formulary, this restriction will

take precedence over the pre-packaged

limitations, when applicable.

Specialty Medications

In order to add value and accessibility in your

pharmacy benefits, we offer a specialized

prescription medication program for certain

specialty medications through Reliance Rx®

Specialty Pharmacy. Specialty medications include

those that are either self-injectable, require special

distribution, handling and/or are at limited supply

and certain oral oncology medications. These

medications are restricted to designated

pharmacies such as Reliance Rx. Reliance Rx

specializes in providing high-quality service for

complex chronic conditions such as hepatitis,

multiple sclerosis, cancer and rheumatoid

arthritis.

Along with providing these specialized

medications, Reliance Rx also provides a

convenient way for you to receive the medication,

by arranging delivery at no charge directly to your

Page 3: 2021 Drug Formulary II

home. They can also provide you with education

on the medication you’re taking, refill reminders

and even the necessary supplies, if applicable.

Specialty medications are listed with an “SP” on

the formulary. Reliance Rx can be reached at 1-

800-809-4763.

Limited Distribution Drugs

Some specialty medications can only be

obtained through designated specialty

pharmacies due to limited distribution placed

on the medication by the manufacturer. These

medications are listed with a “LDD” on the

formulary.

Affordable Care Act (ACA)

Preventive Services

Medications covered under the Affordable

Care Act as preventive services are listed

with an “ACA” on the formulary. Certain

restrictions may apply. As drugs are added

or removed from the United States

Preventive Services Task Force

recommendations list, these drugs may not

be available to you through the ACA until

you renew your plan. There is no

copayment/coinsurance for these

medications.

Age Restriction

Some prescription medications are restricted by

age due to safety reasons or Food and Medication

Administration (FDA) recommended labeling.

Medications with an age limit are listed with an

“AL” in the formulary.

Maintenance Medications

Independent Health allows up to a 90-day supply

of certain medications to be filled. Medications

eligible to be filled for a 90-day maintenance

supply are indicated on the formulary with an

“MM.”

The first fill of new maintenance medications will

require a 30-day initial fill to ensure you do not

have any side effects. After the initial 30-day

supply has shown you can tolerate the medication,

you can receive future refills for up to a 90-day

supply as prescribed.

Over-the-Counter (OTC) Medications

Certain medications listed on the formulary

are available over the counter. A prescription

is required for coverage of the OTC products.

OTC products that we cover are listed with an

“OTC” on the formulary.

Preventive with Liability

Some medications are considered preventive

care for those with qualifying chronic

conditions. For deductible plans where this

benefit is applied, you are responsible for your

tiered copayment/coinsurance during the

deductible phase. These medications are listed

with a “PL” on the formulary.

Dental Formulary

Drugs covered on our Dental Formulary are

available when prescribed by a dental provider.

Drugs included in our Dental Formulary are listed

with a “DF” on the formulary. Drugs without a

“DF” will not be covered when written by a dental

provider.

Key

ACA – Affordable Care Act

AL – Age Limit

DF – Dental Formulary

LDD – Limited Distribution Drugs

MM – 90-day supply

OTC – Over-the-Counter

PA – Prior Authorization Required

PL – Preventive with Liability

QL – Quantity Limits Apply

SP – Specialty Pharmacy

ST – Step Therapy

Sedative/Hypnotic Medications

Sedative/hypnotic medications are limited for all

prescribers except sleep specialists to 14

tablets/capsules per month with a maximum of 3

fills per year (3 fills/365 days).

Compounded Prescription Medications

Compounded prescriptions (medications that are

not commercially manufactured) must be prepared

by a participating pharmacy and contain at least

one prescription component. The dispensing

pharmacy is required to submit for prior approval

Page 4: 2021 Drug Formulary II

and when covered the compounded prescription

will be available at a Tier 2 copayment/coinsurance.

Compounds which cost under $250 do not require

prior authorization if all other requirements are

met. Compounds which cost more than $250 will

require prior authorization.

Coverage is provided in accordance with our

Compounding Medication Products Policy. Bulk

products and powders are excluded from coverage

because they are not prescription medication

products that are approved under sections 505,

505(j) or 507 of the Federal Food, Drug, and

Cosmetic Act.

Diabetic Supplies/Medications

Products listed in this section are a covered benefit

based on your plan. Products not listed require

prior authorization. Copayments vary by plan.

BD needles and syringes are our preferred

needle/syringe products.

OneTouch glucose meters, lancets, test strips,

and supplies are our preferred diabetic supplies

and do not require prior authorization.

OneTouch will provide a glucose meter to you with

no copayment. Quantities are limited to one meter

per member. You can obtain a meter by calling

LifeScan, Inc. at 1-888-377-5227, offer code

289IHA001. Please have your ID number available

when you call.

Diabetic test strips are limited to a maximum of

100 per 30 days for non-insulin dependent

diabetics. Diabetic test strips are limited to a

maximum of 300 per 30 days for insulin

dependent diabetics.

FreeStyle Libre continuous glucose monitors

and sensors are also available at retail

pharmacies, if member is concurrently on

insulin.

Dexcom G6 continuous glucose monitoring

system covered with concurrent use of

bolus insulin.

Cost-share change for diabetic equipment,

supplies, and medications

For diabetic equipment, supplies, and

medications pay your office visit cost share.

Lost/Stolen/Damaged Medications

Replacement of any lost, stolen or damaged

medications is the responsibility of the member.

Additional Formulary Information

• Medications used for cosmetic purposes

are excluded from coverage.

• Medical devices (which may or may not require a

prescription) are excluded from coverage.

• Medical foods other than PKU supplements

(which may or may not require a

prescription) are excluded from coverage.

• Drugs used for the treatment of sexual

dysfunction (SD) may be subject to quantity

limits. Duplicate therapy with other SD

medications is not allowed.

• Prenatal vitamins classified as medical foods are

not covered. Multivitamins are NOT included in

the Formulary as various OTC products are

available.

• Contraceptives (for members with contraceptive

coverage): All tier 1 generic drugs are covered

at a $0 copayment. Brand-name drugs without

a generic equivalent are covered at a $0

copayment. Brand-name drugs with a generic

equivalent are covered at the copayment based

on your plan design. Cervical caps, diaphragms,

condoms, and spermicides are covered at a $0

copayment. Both prescription and over-the-

counter (OTC) products are covered only when

prescribed by a licensed health care provider

and require a valid prescription.

• Medications listed on the drug formulary as

covered without restriction may require prior

authorization or may not be covered if it is

determined that they are being used in

conjunction with a procedure or treatment

not covered under the member’s Health

Contract.

• Medications not recognized by the FDA without a

National Drug Code (NDC) are excluded from

coverage.

• Generic substitution is used only as required by

state pharmacy laws. Therapeutic interchange is

not utilized.

REV1120

Page 5: 2021 Drug Formulary II

TABLE OF CONTENTS

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants* .......................................................................................................................................................................... 3*Amebicides* ...................................................................................................................................................................................................................................... 3*Aminoglycosides* ..............................................................................................................................................................................................................................3*Analgesics - Anti-Inflammatory* ....................................................................................................................................................................................................... 3*Analgesics - Nonnarcotic* ................................................................................................................................................................................................................. 4*Analgesics - Opioid* .......................................................................................................................................................................................................................... 4*Androgens-Anabolic* ........................................................................................................................................................................................................................ 5*Anorectal And Related Products* ..................................................................................................................................................................................................... 5*Anthelmintics* ...................................................................................................................................................................................................................................5*Antianginal Agents* ...........................................................................................................................................................................................................................5*Antianxiety Agents* .......................................................................................................................................................................................................................... 6*Antiarrhythmics* ...............................................................................................................................................................................................................................6*Antiasthmatic And Bronchodilator Agents* ......................................................................................................................................................................................6*Anticoagulants* .................................................................................................................................................................................................................................7*Anticonvulsants* ............................................................................................................................................................................................................................... 7*Antidepressants* ...............................................................................................................................................................................................................................8*Antidiabetics* ....................................................................................................................................................................................................................................8*Antidiarrheal/Probiotic Agents* ......................................................................................................................................................................................................10*Antidotes And Specific Antagonists* ...............................................................................................................................................................................................10*Antiemetics* ....................................................................................................................................................................................................................................10*Antifungals* .....................................................................................................................................................................................................................................10*Antihistamines* ...............................................................................................................................................................................................................................10*Antihyperlipidemics* .......................................................................................................................................................................................................................10*Antihypertensives* ..........................................................................................................................................................................................................................11*Anti-Infective Agents - Misc.* ......................................................................................................................................................................................................... 11*Antimalarials* ..................................................................................................................................................................................................................................12*Antimyasthenic/Cholinergic Agents* .............................................................................................................................................................................................. 12*Antimycobacterial Agents* ............................................................................................................................................................................................................. 12*Antineoplastics And Adjunctive Therapies* .................................................................................................................................................................................... 12*Antiparkinson And Related Therapy Agents* ..................................................................................................................................................................................14*Antipsychotics/Antimanic Agents* ..................................................................................................................................................................................................14*Antivirals* ........................................................................................................................................................................................................................................15*Beta Blockers* ................................................................................................................................................................................................................................. 16*Calcium Channel Blockers* ..............................................................................................................................................................................................................16*Cardiotonics* ...................................................................................................................................................................................................................................16*Cardiovascular Agents - Misc.* ........................................................................................................................................................................................................16*Cephalosporins* .............................................................................................................................................................................................................................. 17*Chemicals* .......................................................................................................................................................................................................................................17*Contraceptives* ...............................................................................................................................................................................................................................17*Corticosteroids* .............................................................................................................................................................................................................................. 17*Cough/Cold/Allergy* ....................................................................................................................................................................................................................... 18*Dermatologicals* .............................................................................................................................................................................................................................18*Digestive Aids* ................................................................................................................................................................................................................................ 20*Diuretics* .........................................................................................................................................................................................................................................20*Endocrine And Metabolic Agents - Misc.* .......................................................................................................................................................................................21*Estrogens* ....................................................................................................................................................................................................................................... 22*Fluoroquinolones* ...........................................................................................................................................................................................................................22*Gastrointestinal Agents - Misc.* ......................................................................................................................................................................................................22*Genitourinary Agents - Miscellaneous* .......................................................................................................................................................................................... 23*Gout Agents* ...................................................................................................................................................................................................................................23*Hematological Agents - Misc.* ........................................................................................................................................................................................................ 23

1

Page 6: 2021 Drug Formulary II

*Hematopoietic Agents* ...................................................................................................................................................................................................................23*Hemostatics* ...................................................................................................................................................................................................................................23*Hypnotics/Sedatives/Sleep Disorder Agents* .................................................................................................................................................................................23*Laxatives* ........................................................................................................................................................................................................................................ 24*Macrolides* .....................................................................................................................................................................................................................................24*Medical Devices And Supplies* ....................................................................................................................................................................................................... 24*Migraine Products* ......................................................................................................................................................................................................................... 24*Minerals & Electrolytes* ................................................................................................................................................................................................................. 24*Miscellaneous Therapeutic Classes* ............................................................................................................................................................................................... 24*Mouth/Throat/Dental Agents* ....................................................................................................................................................................................................... 25*Multivitamins* .................................................................................................................................................................................................................................25*Musculoskeletal Therapy Agents* ...................................................................................................................................................................................................25*Nasal Agents - Systemic And Topical* ............................................................................................................................................................................................. 25*Neuromuscular Agents* .................................................................................................................................................................................................................. 25*Ophthalmic Agents* ........................................................................................................................................................................................................................ 25*Otic Agents* .................................................................................................................................................................................................................................... 27*Oxytocics* ....................................................................................................................................................................................................................................... 27*Passive Immunizing And Treatment Agents* .................................................................................................................................................................................. 27*Penicillins* .......................................................................................................................................................................................................................................27*Progestins* ...................................................................................................................................................................................................................................... 27*Psychotherapeutic And Neurological Agents - Misc.* .....................................................................................................................................................................27*Respiratory Agents - Misc.* .............................................................................................................................................................................................................28*Sulfonamides* ................................................................................................................................................................................................................................. 28*Tetracyclines* ..................................................................................................................................................................................................................................28*Thyroid Agents* ...............................................................................................................................................................................................................................28*Ulcer Drugs/Antispasmodics/Anticholinergics* .............................................................................................................................................................................. 28*Urinary Antispasmodics* .................................................................................................................................................................................................................29*Vaginal And Related Products* ....................................................................................................................................................................................................... 29*Vasopressors* ................................................................................................................................................................................................................................. 29*Vitamins* .........................................................................................................................................................................................................................................29

2

Page 7: 2021 Drug Formulary II

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*amphetamine sulfate oral tablet 1 ALamphetamine-dextroamphet er oral capsule extended release 24 hour

1 AL

amphetamine-dextroamphetamine oral tablet 10 mg, 15 mg

1 QL; AL

amphetamine-dextroamphetamine oral tablet 12.5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1 AL

armodafinil oral tablet 1 MMatomoxetine hcl oral capsule 2 MM; ALclonidine hcl er oral tablet extended release 12 hour

1 MM

CONTRAVE ORAL TABLET EXTENDED RELEASE 12 HOUR

3 PA

COTEMPLA XR-ODT ORAL TABLET EXTENDED RELEASE DISPERSIBLE

3 PA; AL

dexmethylphenidate hcl er oral capsule extended release 24 hour

1 MM; AL

dexmethylphenidate hcl oral tablet 1 MM; ALdextroamphetamine sulfate er oral capsule extended release 24 hour

1 AL

dextroamphetamine sulfate oral solution

1 AL

dextroamphetamine sulfate oral tablet 10 mg, 5 mg

1 AL

guanfacine hcl er oral tablet extended release 24 hour

2 MM; AL

IMCIVREE SUBCUTANEOUS SOLUTION

3 PA; SP

methylphenidate hcl er (cd) oral capsule extended release

1 MM; AL

methylphenidate hcl er (la) oral capsule extended release 24 hour

1 MM; AL

methylphenidate hcl er oral tablet extended release 10 mg, 18 mg, 20 mg, 27 mg, 36 mg, 54 mg

1 MM; AL

methylphenidate hcl oral solution 2 MM; ALmethylphenidate hcl oral tablet 1 MM; QL; ALmethylphenidate hcl oral tablet chewable

1 MM; AL

modafinil oral tablet 1 MM; ALMYDAYIS ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 ST; AL

QELBREE ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA

QSYMIA ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA

QUILLICHEW ER ORAL TABLET CHEWABLE EXTENDED RELEASE

3 AL

SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR

3 PA

SUNOSI ORAL TABLET 3 PAVYVANSE ORAL CAPSULE 2 MM; ALVYVANSE ORAL TABLET CHEWABLE 2 MM; ALWAKIX ORAL TABLET 3 PA; LDDWEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA

*Amebicides*SOLOSEC ORAL PACKET 3

*Aminoglycosides*ARIKAYCE INHALATION SUSPENSION

3 PA; SP

BETHKIS INHALATION NEBULIZATION SOLUTION

3 PA; SP; QL

KITABIS PAK INHALATION NEBULIZATION SOLUTION

3 PA; SP; QL

neomycin sulfate oral tablet 1paromomycin sulfate oral capsule 2 SPTOBI PODHALER INHALATION CAPSULE

2 PA; SP; QL

tobramycin inhalation nebulization solution 300 mg/5ml

1 PA; SP; QL

*Analgesics - Anti-Inflammatory*ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ARCALYST SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA; SP

celecoxib oral capsule 1 MMdiclofenac potassium oral tablet 50 mg

1 MM

diclofenac sodium er oral tablet extended release 24 hour

1 MM

diclofenac sodium oral tablet delayed release

1 MM

ENBREL MINI SUBCUTANEOUS SOLUTION CARTRIDGE

3 PA; SP

ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML

3 PA; SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

etodolac oral capsule 1 MMetodolac oral tablet 1 MMfenoprofen calcium oral tablet 2 MMflurbiprofen oral tablet 1 MMHUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML

3 PA; SP

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40 MG/0.8ML

3 PA; SP

HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT

3 PA; SP

HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML

3 PA; SP

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML

3 PA; SP

Drug Name Tier Notes Drug Name Tier Notes

11.01.2021

3

Page 8: 2021 Drug Formulary II

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1 DF; MM

indomethacin er oral capsule extended release

1 MM; AL

indomethacin oral capsule 25 mg, 50 mg

1 MM; AL

ketoprofen er oral capsule extended release 24 hour

2 MM

ketorolac tromethamine oral tablet 1 QL; ALKEVZARA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

KEVZARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA

leflunomide oral tablet 1 PA; PA except Rheumatology; MM

meclofenamate sodium oral capsule

2 MM

mefenamic acid oral capsule 2 MMmeloxicam oral tablet 1 MMnabumetone oral tablet 1 MMnaproxen oral tablet 1 DF; MMnaproxen sodium er oral tablet extended release 24 hour 375 mg, 500 mg

3

ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

OTEZLA ORAL TABLET 3 PA; SPOTEZLA ORAL TABLET THERAPY PACK

3 PA; SP

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 20 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML

3 PA; SP

oxaprozin oral tablet 1 MMpiroxicam oral capsule 2 MMRASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.2ML, 12.5 MG/0.25ML, 15 MG/0.3ML, 17.5 MG/0.35ML, 20 MG/0.4ML, 22.5 MG/0.45ML, 25 MG/0.5ML, 30 MG/0.6ML, 7.5 MG/0.15ML

3 PA; SP

REDITREX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

RIDAURA ORAL CAPSULE 2 MMRINVOQ ORAL TABLET EXTENDED RELEASE 24 HOUR

3 PA; SP

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

SPRIX NASAL SOLUTION 3 PA; QL; ALsulindac oral tablet 1 MMXELJANZ ORAL SOLUTION 3 PA; SP

XELJANZ ORAL TABLET 3 PA; SPXELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HOUR

3 PA; SP

*Analgesics - Nonnarcotic*butalbital-acetaminophen oral tablet 50-325 mg

1 AL

butalbital-apap-caffeine oral capsule 50-300-40 mg

1 AL

butalbital-apap-caffeine oral capsule 50-325-40 mg

3 AL

butalbital-apap-caffeine oral tablet 50-325-40 mg

1 AL

diflunisal oral tablet 2 MM

*Analgesics - Opioid*acetaminophen-codeine #2 oral tablet

1 DF; AL

acetaminophen-codeine #3 oral tablet

1 DF; AL

acetaminophen-codeine #4 oral tablet

1 DF; AL

acetaminophen-codeine oral solution

1 DF; AL

apap-caff-dihydrocodeine oral tablet 325-30-16 mg

3

benzhydrocodone-acetaminophen oral tablet

1

buprenorphine hcl sublingual tablet sublingual

1 SUD; QL

buprenorphine hcl-naloxone hcl sublingual film

1 SUD

buprenorphine hcl-naloxone hcl sublingual tablet sublingual

1 SUD

buprenorphine transdermal patch weekly

1

butalbital-apap-caff-cod oral capsule

1 AL

butalbital-asa-caff-codeine oral capsule

2 AL

butorphanol tartrate nasal solution 1 PAcodeine sulfate oral tablet 15 mg 1codeine sulfate oral tablet 30 mg, 60 mg

1 AL

fentanyl citrate buccal lozenge on a handle

2 PA; ST; PA except Oncology

fentanyl citrate buccal tablet 2 PA; ST; PA except oncology

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

2 ST

hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent

1 ST

hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml

1 DF

hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

1 DF

hydrocodone-ibuprofen oral tablet 10-200 mg

3

Drug Name Tier Notes Drug Name Tier Notes

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hydrocodone-ibuprofen oral tablet 7.5-200 mg

1 DF

hydromorphone hcl er oral tablet extended release 24 hour

2 ST

hydromorphone hcl oral liquid 1hydromorphone hcl oral tablet 1HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT

2 ST

LAZANDA NASAL SOLUTION 100 MCG/ACT, 400 MCG/ACT

3 PA; ST

methadone hcl oral concentrate 1methadone hcl oral solution 1methadone hcl oral tablet 1methadone hcl oral tablet soluble 1morphine sulfate (concentrate) oral solution 100 mg/5ml

1 ST

morphine sulfate er beads oral capsule extended release 24 hour

3 ST

morphine sulfate er oral capsule extended release 24 hour 10 mg, 20 mg, 30 mg, 50 mg, 60 mg

1

morphine sulfate er oral capsule extended release 24 hour 100 mg, 80 mg

1 ST

morphine sulfate er oral tablet extended release 100 mg, 200 mg

1 ST

morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg

1

morphine sulfate oral solution 1morphine sulfate oral tablet 1NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250 MG

2 ST

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HOUR 50 MG

2

NUCYNTA ORAL TABLET 2oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg, 15 mg, 20 mg, 30 mg, 40 mg

1

oxycodone hcl oral tablet 1oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

1

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG

2

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 60 MG, 80 MG

2 ST

oxymorphone hcl er oral tablet extended release 12 hour

2 ST

oxymorphone hcl oral tablet 2 PA; PA except Pain Medicine

tramadol hcl er (biphasic) oral tablet extended release 24 hour 100 mg, 200 mg, 300 mg

1 ST

tramadol hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg

2 ST

tramadol hcl er oral tablet extended release 24 hour

1 ST

tramadol hcl oral tablet 50 mg 1tramadol-acetaminophen oral tablet

1 PA; PA except Pain Medicine

XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-DETERRENT

3

*Androgens-Anabolic*ANDRODERM TRANSDERMAL PATCH 24 HOUR

2 PA

danazol oral capsule 2methyltestosterone oral capsule 3 PA; MMoxandrolone oral tablet 2testosterone cypionate injection solution 200 mg/ml

1 PA

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

1 PA

testosterone enanthate intramuscular solution

1 PA

testosterone transdermal gel 10 mg/act (2%), 12.5 mg/act (1%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5 mg/2.5gm (1.62%), 50 mg/5gm (1%)

2 PA

testosterone transdermal solution 2 PA

*Anorectal And Related Products*hydrocortisone rectal enema 1lidocaine-hydrocortisone ace rectal gel

1

RECTIV RECTAL OINTMENT 3

*Anthelmintics*albendazole oral tablet 2 PA; PA except

Infectious Disease or Gastroenterology

benznidazole oral tablet 3 PA; SPEMVERM ORAL TABLET CHEWABLE 3ivermectin oral tablet 1praziquantel oral tablet 2

*Antianginal Agents*ISORDIL TITRADOSE ORAL TABLET 40 MG

2 MM

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

1 MM

isosorbide mononitrate er oral tablet extended release 24 hour

1 MM

isosorbide mononitrate oral tablet 1 MMNITRO-BID TRANSDERMAL OINTMENT

2 MM

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

3 MM

nitroglycerin sublingual tablet sublingual

1

nitroglycerin transdermal patch 24 hour

1 MM

nitroglycerin translingual solution 2 MMranolazine er oral tablet extended release 12 hour

2 MM

Drug Name Tier Notes Drug Name Tier Notes

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*Antianxiety Agents*alprazolam er oral tablet extended release 24 hour

1

alprazolam oral tablet 1alprazolam oral tablet dispersible 1 PAbuspirone hcl oral tablet 1chlordiazepoxide hcl oral capsule 1 ALclorazepate dipotassium oral tablet 1diazepam oral tablet 1 ALhydroxyzine hcl oral syrup 1 ALhydroxyzine hcl oral tablet 1 ALhydroxyzine pamoate oral capsule 1 ALlorazepam oral tablet 0.5 mg 1meprobamate oral tablet 200 mg 3 ALoxazepam oral capsule 1

*Antiarrhythmics*amiodarone hcl oral tablet 1 MMdisopyramide phosphate oral capsule

1 MM; AL

dofetilide oral capsule 2 MMflecainide acetate oral tablet 2 MMmexiletine hcl oral capsule 2 MMMULTAQ ORAL TABLET 3 MMNORPACE CR ORAL CAPSULE EXTENDED RELEASE 12 HOUR

2 MM; AL

PACERONE ORAL TABLET 100 MG, 200 MG, 400 MG

1 MM

propafenone hcl er oral capsule extended release 12 hour

1 MM

propafenone hcl oral tablet 1 MMquinidine gluconate er oral tablet extended release

2 MM

quinidine sulfate oral tablet 2 MM

*Antiasthmatic And Bronchodilator Agents*ADVAIR HFA INHALATION AEROSOL 2 MMalbuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/act

1

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, (5 mg/ml) 0.5%, 0.63 mg/3ml, 1.25 mg/3ml

2 MM

albuterol sulfate oral syrup 1 MMalbuterol sulfate oral tablet 1 MMaminophylline intravenous solution 1arformoterol tartrate inhalation nebulization solution

3 PA; MM

ARNUITY ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ACT, 200 MCG/ACT

2 MM; AL

ASMANEX (120 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

ASMANEX (14 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

ASMANEX (30 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

ASMANEX (60 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

ASMANEX (7 METERED DOSES) INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

ASMANEX HFA INHALATION AEROSOL

2 MM

ATROVENT HFA INHALATION AEROSOL SOLUTION

2 MM

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH ACTIVATED

3 MM; AL

budesonide inhalation suspension 2 MM; QL; ALCOMBIVENT RESPIMAT INHALATION AEROSOL SOLUTION

2 MM

cromolyn sodium inhalation nebulization solution

1 QL

DALIRESP ORAL TABLET 2 PA; PA except Pulmonology

ELIXOPHYLLIN ORAL ELIXIR 2FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

FLOVENT HFA INHALATION AEROSOL

2 MM

fluticasone-salmeterol inhalation aerosol powder breath activated

1 MM

formoterol fumarate inhalation nebulization solution

3 PA; MM

ipratropium bromide inhalation solution

1 MM

ipratropium-albuterol inhalation solution

1 MM

levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 0.63 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

2 PA; MM

levalbuterol tartrate inhalation aerosol

1 MM

montelukast sodium oral packet 1 ALmontelukast sodium oral tablet 1 ALmontelukast sodium oral tablet chewable 4 mg, 5 mg

1 AL

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

PULMICORT FLEXHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM

QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED

2 MM

SEREVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED

2 ST; MM

SPIRIVA HANDIHALER INHALATION CAPSULE

2 MM

Drug Name Tier Notes Drug Name Tier Notes

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SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT

2 MM; AL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT

2 MM

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 2.5-2.5 MCG/ACT

2 MM

STRIVERDI RESPIMAT INHALATION AEROSOL SOLUTION

2 MM

SYMBICORT INHALATION AEROSOL 2 MMterbutaline sulfate oral tablet 1 MMTHEO-24 ORAL CAPSULE EXTENDED RELEASE 24 HOUR

2 MM

theophylline er oral tablet extended release 12 hour 300 mg, 450 mg

1

theophylline er oral tablet extended release 24 hour

1

theophylline oral solution 1WIXELA INHUB INHALATION AEROSOL POWDER BREATH ACTIVATED

1 MM

YUPELRI INHALATION SOLUTION 3 PAzafirlukast oral tablet 1 MMzileuton er oral tablet extended release 12 hour

2 PA

ZYFLO ORAL TABLET 3 PA; MM

*Anticoagulants*ELIQUIS DVT/PE STARTER PACK ORAL TABLET THERAPY PACK

2

ELIQUIS ORAL TABLET 2 MMenoxaparin sodium subcutaneous solution

2

fondaparinux sodium subcutaneous solution

2 PA; PA required for duration of greater

than 14 days except when written by

Oncology; QLFRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML, 95000 UNIT/3.8ML

3 PA; PA required for duration of greater

than 14 days except when written by

Oncology; QL

heparin sodium (porcine) injection solution 5000 unit/ml

2

JANTOVEN ORAL TABLET 1 MMPRADAXA ORAL CAPSULE 2 MMwarfarin sodium oral tablet 1 MMXARELTO ORAL TABLET 2 MMXARELTO STARTER PACK ORAL TABLET THERAPY PACK

2

*Anticonvulsants*APTIOM ORAL TABLET 3 MMBRIVIACT ORAL SOLUTION 3 PA; PA except

NeurologyBRIVIACT ORAL TABLET 3 PA; PA except

Neurology

carbamazepine er oral capsule extended release 12 hour

1 MM

carbamazepine er oral tablet extended release 12 hour

1 MM

carbamazepine oral suspension 1 MMcarbamazepine oral tablet 1 MMcarbamazepine oral tablet chewable

1 MM

CELONTIN ORAL CAPSULE 2 MMclobazam oral suspension 1 ALclobazam oral tablet 1 ALclonazepam oral tablet 1 MMclonazepam oral tablet dispersible 1 PA; MMDIACOMIT ORAL CAPSULE 3 PA; LDDDIACOMIT ORAL PACKET 3 PA; LDDdiazepam rectal gel 1 PA; ALDILANTIN ORAL CAPSULE 30 MG 2 MMdivalproex sodium er oral tablet extended release 24 hour

1 MM

divalproex sodium oral tablet delayed release

1 MM

EPIDIOLEX ORAL SOLUTION 3 PA; LDD; ALEPITOL ORAL TABLET 1 MMethosuximide oral capsule 1 MMethosuximide oral solution 1 MMfelbamate oral suspension 2 MMfelbamate oral tablet 2 MMFINTEPLA ORAL SOLUTION 3 PA; LDDFYCOMPA ORAL SUSPENSION 3 ALFYCOMPA ORAL TABLET 3 MM; ALgabapentin oral capsule 1 MMgabapentin oral solution 250 mg/5ml

1 MM

gabapentin oral tablet 1 MMlamotrigine er oral tablet extended release 24 hour

2 MM; AL

lamotrigine oral tablet 1 MMlamotrigine oral tablet chewable 1 MMlamotrigine oral tablet dispersible 2 PAlamotrigine starter kit-blue oral kit 2lamotrigine starter kit-green oral kit

2

lamotrigine starter kit-orange oral kit

2

levetiracetam er oral tablet extended release 24 hour

1 MM

levetiracetam oral solution 1 MMlevetiracetam oral tablet 1 MMNAYZILAM NASAL SOLUTION 3 PA; QLoxcarbazepine oral suspension 1oxcarbazepine oral tablet 1 MMOXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR

3 ST; MM

phenytoin oral suspension 125 mg/5ml

1 MM

phenytoin oral tablet chewable 1 MMphenytoin sodium extended oral capsule

1 MM

pregabalin oral capsule 1 MMpregabalin oral solution 1 MMprimidone oral tablet 1 MM

Drug Name Tier Notes Drug Name Tier Notes

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rufinamide oral suspension 3 ALrufinamide oral tablet 3 ALtiagabine hcl oral tablet 2 MMtopiramate er oral capsule er 24 hour sprinkle

3 PA; PA except neurology; MM

topiramate oral capsule sprinkle 2 MMtopiramate oral tablet 1 MMTROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA; MM

valproic acid oral capsule 1 MMVALTOCO 10 MG DOSE NASAL LIQUID

3 PA; QL; AL

VALTOCO 15 MG DOSE NASAL LIQUID THERAPY PACK

3 PA; QL; AL

VALTOCO 20 MG DOSE NASAL LIQUID THERAPY PACK

3 PA; QL; AL

VALTOCO 5 MG DOSE NASAL LIQUID

3 PA; QL; AL

vigabatrin oral packet 2 PA; SPvigabatrin oral tablet 2 PA; SPVIMPAT ORAL SOLUTION 3 MM; ALVIMPAT ORAL TABLET 3 MM; ALXCOPRI (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK 100 & 150 MG

3 PA; QL

XCOPRI (350 MG DAILY DOSE) ORAL TABLET THERAPY PACK

3 PA; QL

XCOPRI ORAL TABLET 3 PA; QLXCOPRI ORAL TABLET THERAPY PACK

3 PA; QL

zonisamide oral capsule 1 MM

*Antidepressants*amitriptyline hcl oral tablet 1 ALamoxapine oral tablet 1bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg

1 ACA; MM

bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg

1 ACA; PL; MM

bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg

1 MM

bupropion hcl oral tablet 1 MMcitalopram hydrobromide oral solution

1 MM

citalopram hydrobromide oral tablet

1 PL; MM

clomipramine hcl oral capsule 1 ALdesipramine hcl oral tablet 1desvenlafaxine succinate er oral tablet extended release 24 hour

2 MM

doxepin hcl oral capsule 1 ALdoxepin hcl oral concentrate 1 ALduloxetine hcl oral capsule delayed release particles

1 MM

EMSAM TRANSDERMAL PATCH 24 HOUR

3 PA; PA except Psychiatry; MM

escitalopram oxalate oral solution 1 MMescitalopram oxalate oral tablet 1 PL; MM

FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 ST

fluoxetine hcl oral capsule 1 PL; MMfluoxetine hcl oral capsule delayed release

2 MM

fluoxetine hcl oral solution 1 PL; MMfluvoxamine maleate oral tablet 1 MMimipramine hcl oral tablet 1 ALMARPLAN ORAL TABLET 3 MMmirtazapine oral tablet 1 MMmirtazapine oral tablet dispersible 1 MMnefazodone hcl oral tablet 2 PA; MMnortriptyline hcl oral capsule 1 ALnortriptyline hcl oral solution 1 ALparoxetine hcl er oral tablet extended release 24 hour

1 ST; MM

paroxetine hcl oral suspension 1paroxetine hcl oral tablet 1 PL; MMPEXEVA ORAL TABLET 3phenelzine sulfate oral tablet 1 MMprotriptyline hcl oral tablet 2sertraline hcl oral concentrate 1 PL; MMsertraline hcl oral tablet 1 PL; MMtranylcypromine sulfate oral tablet 2 MMtrazodone hcl oral tablet 1 MMtrimipramine maleate oral capsule 1 ALTRINTELLIX ORAL TABLET 3 STvenlafaxine hcl er oral capsule extended release 24 hour

1 MM

venlafaxine hcl oral tablet 1 MMVIIBRYD ORAL TABLET 3 MMVIIBRYD STARTER PACK ORAL KIT 3

*Antidiabetics*acarbose oral tablet 1 PL; MMBAQSIMI ONE PACK NASAL POWDER

1

BAQSIMI TWO PACK NASAL POWDER

1

CYCLOSET ORAL TABLET 3diazoxide oral suspension 1 PA; PA except

endocrinologyFARXIGA ORAL TABLET 2 MMglimepiride oral tablet 1 PL; MMglipizide er oral tablet extended release 24 hour

1 PL; MM

glipizide oral tablet 1 PL; MMglipizide xl oral tablet extended release 24 hour

1 MM

glipizide-metformin hcl oral tablet 1 MMGLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED

2

glucagon emergency injection kit 2glyburide micronized oral tablet 1 MM; ALglyburide oral tablet 1 MM; ALglyburide-metformin oral tablet 1 MM; ALGLYXAMBI ORAL TABLET 2 MMGVOKE HYPOPEN 1-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

1

Drug Name Tier Notes Drug Name Tier Notes

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GVOKE HYPOPEN 2-PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

1

GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

1

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML

2 MM

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 MM

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION

2 MM

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 MM

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION

2 MM

HUMALOG SUBCUTANEOUS SOLUTION

2 MM

HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE

2 MM

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 OTC; MM

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

2 OTC; MM

HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN-INJECTOR

2 OTC; MM

HUMULIN N SUBCUTANEOUS SUSPENSION

2 OTC; MM

HUMULIN R INJECTION SOLUTION 2 OTC; MMHUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

2 MM

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

JARDIANCE ORAL TABLET 2 MMJENTADUETO ORAL TABLET 2 MMJENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR

2 MM

KORLYM ORAL TABLET 3 PA; LDDLANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

LANTUS SUBCUTANEOUS SOLUTION

2 MM

LEVEMIR FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

LEVEMIR SUBCUTANEOUS SOLUTION

2 MM

LYUMJEV INJECTION SOLUTION 2 MM

LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

metformin hcl er oral tablet extended release 24 hour

1 PL; MM

metformin hcl oral solution 1 PL; MMmetformin hcl oral tablet 1 PL; MMmiglitol oral tablet 1 PA; MMnateglinide oral tablet 1 PL; MMOZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 ST; ST except endocrinology; MM

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION PEN-INJECTOR 2 MG/1.5ML

2 ST; ST except endocrinology; MM

pioglitazone hcl oral tablet 1 PL; MMpioglitazone hcl-glimepiride oral tablet

2 MM

pioglitazone hcl-metformin hcl oral tablet

2 MM

repaglinide oral tablet 1 PL; MMRIOMET ORAL SOLUTION 3 MMRYBELSUS ORAL TABLET 2 ST; ST except

endocrinology; MMSOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 ST

SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA; PA except Endocrinology; MM

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA; PA except Endocrinology; MM

SYNJARDY ORAL TABLET 2SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR

2 MM

TOUJEO MAX SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

TRADJENTA ORAL TABLET 2 MMTRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 MM

TRESIBA SUBCUTANEOUS SOLUTION

2 MM

TRIJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR

2 MM

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML

2 ST; ST except Endocrinology; MM

TRULICITY SUBCUTANEOUS SOLUTION PEN-INJECTOR 3 MG/0.5ML, 4.5 MG/0.5ML

2 ST; ST except endocrinology; MM

VICTOZA SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 ST; ST except Endocrinology; MM

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR

2 MM

ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

1

ZEGALOGUE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

1

Drug Name Tier Notes Drug Name Tier Notes

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*Antidiarrheal/Probiotic Agents*diphenoxylate-atropine oral liquid 1diphenoxylate-atropine oral tablet 2.5-0.025 mg

1

MYTESI ORAL TABLET DELAYED RELEASE

3 PA; SP

opium oral tincture 2

*Antidotes And Specific Antagonists*CHEMET ORAL CAPSULE 3deferasirox granules oral packet 3 PA; SP; ALdeferasirox oral tablet 180 mg, 360 mg

3 PA; SP; AL

deferasirox oral tablet 90 mg 2 PA; SP; ALdeferiprone oral tablet 3 PA; LDDFERRIPROX ORAL SOLUTION 3 PA; LDDFERRIPROX ORAL TABLET 3 PA; LDDFERRIPROX TWICE-A-DAY ORAL TABLET

3 PA; LDD

KLOXXADO NASAL LIQUID 2 SUDnaloxone hcl injection solution 0.4 mg/ml

1 SUD

naloxone hcl injection solution 4 mg/10ml

1

naloxone hcl injection solution cartridge

1 SUD

naloxone hcl injection solution prefilled syringe

1 SUD

naltrexone hcl oral tablet 2NARCAN NASAL LIQUID 2 SUDVISTOGARD ORAL PACKET 2 LDD; QL

*Antiemetics*AKYNZEO ORAL CAPSULE 3 ST; QLaprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg

1 ST; ST except Hematology and

Oncology; QLaprepitant oral capsule 40 mg 1 QLBONJESTA ORAL TABLET EXTENDED RELEASE

2 QL

doxylamine-pyridoxine oral tablet delayed release

2 QL

dronabinol oral capsule 2 PAEMEND ORAL SUSPENSION RECONSTITUTED

2 ST; QL

granisetron hcl oral tablet 2 ST; QLmeclizine hcl oral tablet 25 mg 1ondansetron hcl oral solution 1ondansetron hcl oral tablet 1ondansetron oral tablet dispersible 1SANCUSO TRANSDERMAL PATCH 3 ST; QLscopolamine transdermal patch 72 hour

2 QL

SYNDROS ORAL SOLUTION 3 PAtrimethobenzamide hcl oral capsule

1 AL

VARUBI (180 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

ZUPLENZ ORAL FILM 3 ST; QL

*Antifungals*fluconazole oral suspension reconstituted

1

fluconazole oral tablet 100 mg, 200 mg, 50 mg

1

fluconazole oral tablet 150 mg 1 QLflucytosine oral capsule 2griseofulvin microsize oral suspension

1

griseofulvin microsize oral tablet 1griseofulvin ultramicrosize oral tablet

1

itraconazole oral capsule 2 PA; PA except ID/Hematology or

Oncologyitraconazole oral solution 2 PA; PA except

ID/Hematology or Oncology

ketoconazole oral tablet 1 PANOXAFIL ORAL SUSPENSION 3 PA; MMnystatin oral tablet 1posaconazole oral tablet delayed release

2 PA; MM

terbinafine hcl oral tablet 2voriconazole oral suspension reconstituted

2 PA; PA except Infectious Disease

voriconazole oral tablet 2 PA; PA except Infectious Disease

*Antihistamines*carbinoxamine maleate oral solution

1 AL

carbinoxamine maleate oral tablet 4 mg

1 AL

clemastine fumarate oral tablet 2.68 mg

1

cyproheptadine hcl oral syrup 1 ALcyproheptadine hcl oral tablet 1 ALdesloratadine oral tablet 2 PAdesloratadine oral tablet dispersible

2 PA; AL

dexchlorpheniramine maleate oral solution

1 AL

diphenhydramine hcl oral capsule 50 mg

1 AL

levocetirizine dihydrochloride oral solution

2

levocetirizine dihydrochloride oral tablet

2

promethazine hcl oral solution 1 ALpromethazine hcl oral syrup 1 ALpromethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg

1 AL

promethazine hcl rectal suppository 12.5 mg, 25 mg

1 AL

*Antihyperlipidemics*atorvastatin calcium oral tablet 1 ACA; PL; MMcholestyramine light oral packet 1 MMcholestyramine light oral powder 1 MMcholestyramine oral packet 1 MMcholestyramine oral powder 1 MM

Drug Name Tier Notes Drug Name Tier Notes

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colesevelam hcl oral packet 2 MMcolesevelam hcl oral tablet 2 MMcolestipol hcl oral granules 1 MMcolestipol hcl oral packet 1 MMcolestipol hcl oral tablet 1 MMezetimibe oral tablet 2 MMezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg

2 MM

ezetimibe-simvastatin oral tablet 10-80 mg

2 PA; MM

fenofibrate micronized oral capsule 134 mg

1 MM

fenofibrate oral capsule 134 mg, 67 mg

1 MM

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

1 MM

fenofibric acid oral capsule delayed release 45 mg

1 MM

fluvastatin sodium oral capsule 1 ACA; PL; MMgemfibrozil oral tablet 1 MMJUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5 MG

3 PA; LDD

LIVALO ORAL TABLET 1 ACA; PL; MMlovastatin oral tablet 1 ACA; PL; MMNEXLETOL ORAL TABLET 3 PANEXLIZET ORAL TABLET 3 PAPRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP; PA requires attestation

pravastatin sodium oral tablet 1 ACA; MMREPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS SOLUTION CARTRIDGE

3 PA; SP; PA requires attestation

REPATHA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP; PA requires attestation

REPATHA SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP; PA requires attestation

rosuvastatin calcium oral tablet 1 ACA; PL; MMsimvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 ACA; PL; MM

simvastatin oral tablet 80 mg 1 PA; MMVASCEPA ORAL CAPSULE 2 MM

*Antihypertensives*aliskiren fumarate oral tablet 2 ST; MMamlodipine besy-benazepril hcl oral capsule

1 MM

amlodipine-olmesartan oral tablet 2 MMatenolol-chlorthalidone oral tablet 1 MMbenazepril hcl oral tablet 1 PL; MMbenazepril-hydrochlorothiazide oral tablet

1 MM

bisoprolol-hydrochlorothiazide oral tablet

1 MM

candesartan cilexetil oral tablet 1 MMcandesartan cilexetil-hctz oral tablet

1 MM

clonidine hcl oral tablet 1 MMclonidine transdermal patch weekly

1 MM

doxazosin mesylate oral tablet 1 MM

EDARBI ORAL TABLET 3 STEDARBYCLOR ORAL TABLET 3 ST; MMenalapril maleate oral solution 3 PAenalapril maleate oral tablet 1 PL; MMenalapril-hydrochlorothiazide oral tablet

1 MM

eplerenone oral tablet 1 PA; MMfosinopril sodium oral tablet 1 PL; MMguanfacine hcl oral tablet 1 MM; ALhydralazine hcl oral tablet 1 MMirbesartan oral tablet 1 MMirbesartan-hydrochlorothiazide oral tablet

1 MM

lisinopril oral tablet 1 PL; MMlisinopril-hydrochlorothiazide oral tablet

1 MM

losartan potassium oral tablet 1 MMlosartan potassium-hctz oral tablet 1 MMmethyldopa oral tablet 1 MM; ALmetoprolol-hydrochlorothiazide oral tablet

1 MM

metyrosine oral capsule 2minoxidil oral tablet 1 MMmoexipril hcl oral tablet 1 PL; MMolmesartan medoxomil oral tablet 1 MMolmesartan medoxomil-hctz oral tablet

1 MM

olmesartan-amlodipine-hctz oral tablet

2 MM

perindopril erbumine oral tablet 1 MMphenoxybenzamine hcl oral capsule

2 PA

prazosin hcl oral capsule 1 MMquinapril hcl oral tablet 1 PL; MMquinapril-hydrochlorothiazide oral tablet

1 MM

ramipril oral capsule 1 PL; MMTEKTURNA HCT ORAL TABLET 3 ST; MMtelmisartan oral tablet 1 MMtelmisartan-amlodipine oral tablet 3 MMtelmisartan-hctz oral tablet 1 MMterazosin hcl oral capsule 1 MMtrandolapril oral tablet 1 PL; MMtrandolapril-verapamil hcl er oral tablet extended release

3 MM

valsartan oral tablet 1 MMvalsartan-hydrochlorothiazide oral tablet

1 MM

VECAMYL ORAL TABLET 3 PA; LDD

*Anti-Infective Agents - Misc.*AEMCOLO ORAL TABLET DELAYED RELEASE

3 QL

ALINIA ORAL SUSPENSION RECONSTITUTED

2 PA; PA except Gastroenterology or

Infectious Disease; AL

atovaquone oral suspension 2CAYSTON INHALATION SOLUTION RECONSTITUTED

3 PA; LDD; PA except for Cystic Fibrosis

Specialists.; QL; AL

Drug Name Tier Notes Drug Name Tier Notes

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clindamycin hcl oral capsule 1 except for infectious disease specialist; QL

clindamycin palmitate hcl oral solution reconstituted

1 DF

dapsone oral tablet 2FIRVANQ ORAL SOLUTION RECONSTITUTED

3 PA; PA except Infectious Disease or

Gastroenterologyfosfomycin tromethamine oral packet

3 QL

LAMPIT ORAL TABLET 3 PAlincomycin hcl injection solution 2linezolid oral suspension reconstituted

1

linezolid oral tablet 1methenamine hippurate oral tablet 1metronidazole oral tablet 250 mg 2 QLmetronidazole oral tablet 500 mg 1nitrofurantoin macrocrystal oral capsule

1 AL

nitrofurantoin monohyd macro oral capsule

1

nitrofurantoin oral suspension 2 ALpentamidine isethionate inhalation solution reconstituted

2 PA; PA except Infectious Disease

PRIMSOL ORAL SOLUTION 2SIVEXTRO ORAL TABLET 3 PAsulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

1

sulfamethoxazole-trimethoprim oral tablet 400-80 mg

1

tinidazole oral tablet 1trimethoprim oral tablet 1vancomycin hcl oral capsule 2 PA; PA except

Infectious Disease or Gastroenterology

XIFAXAN ORAL TABLET 200 MG 3 QLXIFAXAN ORAL TABLET 550 MG 3 PA

*Antimalarials*atovaquone-proguanil hcl oral tablet

2

chloroquine phosphate oral tablet 1COARTEM ORAL TABLET 3 QLhydroxychloroquine sulfate oral tablet 200 mg

1 MM

mefloquine hcl oral tablet 2pyrimethamine oral tablet 2 PA; LDD; PA except

Infectious Diseasequinine sulfate oral capsule 1 PA; QL; AL

*Antimyasthenic/Cholinergic Agents*FIRDAPSE ORAL TABLET 3 PA; LDDpyridostigmine bromide er oral tablet extended release

2 MM

pyridostigmine bromide oral tablet 60 mg

1 MM

RUZURGI ORAL TABLET 3 PA; LDD

*Antimycobacterial Agents*cycloserine oral capsule 2ethambutol hcl oral tablet 1isoniazid oral syrup 1 MM

isoniazid oral tablet 1 MMPASER ORAL PACKET 3pretomanid oral tablet 3 PAPRIFTIN ORAL TABLET 3 QLpyrazinamide oral tablet 2rifabutin oral capsule 2 PA; PA except

Infectious Diseaserifampin oral capsule 1SIRTURO ORAL TABLET 3 PA; PA except

Infectious Disease Specialists

TRECATOR ORAL TABLET 3

*Antineoplastics And Adjunctive Therapies*abiraterone acetate oral tablet 250 mg

2 PA; SP

ACTIMMUNE SUBCUTANEOUS SOLUTION

3 PA; LDD

ALECENSA ORAL CAPSULE 3 PA; LDDALUNBRIG ORAL TABLET 3 PA; LDDALUNBRIG ORAL TABLET THERAPY PACK

3 PA; LDD

anastrozole oral tablet 1 PA; SP; PA exceptOncology,

OncologySurgery, and BreastSurgery;

ACA; PL; MMAYVAKIT ORAL TABLET 3 PA; LDDBALVERSA ORAL TABLET 3 PA; LDDbexarotene oral capsule 2 PA; SPbicalutamide oral tablet 1 SPBOSULIF ORAL TABLET 3 PA; SPBRAFTOVI ORAL CAPSULE 75 MG 3 PA; LDDBRUKINSA ORAL CAPSULE 3 PA; LDDCABOMETYX ORAL TABLET 3 PA; LDDCALQUENCE ORAL CAPSULE 3 PA; LDDcapecitabine oral tablet 2 SPCAPRELSA ORAL TABLET 3 PA; LDDCOMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20 MG

3 PA; LDD

COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20 MG & 80 MG

3 PA; LDD

COMETRIQ (60 MG DAILY DOSE) ORAL KIT

3 PA; LDD

COPIKTRA ORAL CAPSULE 3 PA; LDDCOTELLIC ORAL TABLET 3 PA; LDDcyclophosphamide oral capsule 2 SPDAURISMO ORAL TABLET 3 PA; LDDEMCYT ORAL CAPSULE 2 SPERIVEDGE ORAL CAPSULE 3 PA; LDDERLEADA ORAL TABLET 3 PA; LDDerlotinib hcl oral tablet 2 PA; SPetoposide oral capsule 2 SPeverolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg

2 PA; SP

everolimus oral tablet soluble 2 PA; SPexemestane oral tablet 1 SP; ACA; PL; MMFARYDAK ORAL CAPSULE 3 PA; LDDflutamide oral capsule 2 SPFOTIVDA ORAL CAPSULE 3 PA; LDDGAVRETO ORAL CAPSULE 3 PA; LDD

Drug Name Tier Notes Drug Name Tier Notes

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GILOTRIF ORAL TABLET 3 PA; SPGLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

3

HYCAMTIN ORAL CAPSULE 3 PA; SPhydroxyurea oral capsule 1IBRANCE ORAL CAPSULE 3 PA; LDDICLUSIG ORAL TABLET 15 MG, 45 MG

3 PA; SP; LDD

ICLUSIG ORAL TABLET 30 MG 3 PA; SPIDHIFA ORAL TABLET 3 PA; LDDimatinib mesylate oral tablet 2 PA; SPIMBRUVICA ORAL CAPSULE 3 PA; LDDIMBRUVICA ORAL TABLET 3 PA; LDDINLYTA ORAL TABLET 3 PA; SPINQOVI ORAL TABLET 3 PA; LDDINREBIC ORAL CAPSULE 3 PA; SPINTRON A INJECTION SOLUTION 2 PA; SPIRESSA ORAL TABLET 3 PA; LDDJAKAFI ORAL TABLET 3 PA; LDDKISQALI (200 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

KISQALI (400 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

KISQALI (600 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

KISQALI FEMARA (400 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

KISQALI FEMARA (600 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

KISQALI FEMARA(200 MG DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

KOSELUGO ORAL CAPSULE 3 PA; SPlapatinib ditosylate oral tablet 2 PA; SPLENVIMA (10 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

letrozole oral tablet 1 ACA; PL; MMleucovorin calcium oral tablet 1LEUKERAN ORAL TABLET 2 SPleuprolide acetate injection kit 2 PALONSURF ORAL TABLET 3 PA; SPLORBRENA ORAL TABLET 3 PA; LDDLUMAKRAS ORAL TABLET 3 PA; LDDLYNPARZA ORAL TABLET 3 PA; LDDLYSODREN ORAL TABLET 2 SPMATULANE ORAL CAPSULE 3 LDDmegestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

1 SP

megestrol acetate oral tablet 1 SPMEKINIST ORAL TABLET 3 PA; SPMEKTOVI ORAL TABLET 3 PA; LDDmelphalan oral tablet 2 SPmercaptopurine oral tablet 1MESNEX ORAL TABLET 3 PA; SP; PA except

Oncologymethotrexate oral tablet 1 MMmethotrexate sodium (pf) injection solution 50 mg/2ml

1 PA; PA except rheumatology,

dermatology and gastroenterology

methotrexate sodium injection solution 50 mg/2ml

1 PA; PA except rheumatology,

dermatology and gastroenterology

NERLYNX ORAL TABLET 3 PA; LDDNEXAVAR ORAL TABLET 3 PA; SPnilutamide oral tablet 2 PANINLARO ORAL CAPSULE 3 PA; SP; QLNUBEQA ORAL TABLET 3 PA; SPODOMZO ORAL CAPSULE 3 PA; SPONUREG ORAL TABLET 3 PA; SPORGOVYX ORAL TABLET 3 PA; SPPEMAZYRE ORAL TABLET 3 PA; SPPIQRAY (200 MG DAILY DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

PIQRAY (250 MG DAILY DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

PIQRAY (300 MG DAILY DOSE) ORAL TABLET THERAPY PACK

3 PA; SP

POMALYST ORAL CAPSULE 3 PA; LDDQINLOCK ORAL TABLET 3 PA; SPRETEVMO ORAL CAPSULE 3 PA; SPROZLYTREK ORAL CAPSULE 3 PA; SPRUBRACA ORAL TABLET 3 PA; LDDRYDAPT ORAL CAPSULE 3 PA; SPSPRYCEL ORAL TABLET 2 PA; SPSTIVARGA ORAL TABLET 3 PA; LDDsunitinib malate oral capsule 2 PA; SPSYNRIBO SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA; LDD

TABLOID ORAL TABLET 2TABRECTA ORAL TABLET 3 PA; SPTAFINLAR ORAL CAPSULE 3 PA; LDDTAGRISSO ORAL TABLET 3 PA; LDDTALZENNA ORAL CAPSULE 3 PA; LDDtamoxifen citrate oral tablet 1 ACA; PL; MMTASIGNA ORAL CAPSULE 2 PA; SPTAZVERIK ORAL TABLET 3 PA; LDDtemozolomide oral capsule 2 LDDTEPMETKO ORAL TABLET 3 PA; SPTIBSOVO ORAL TABLET 3 PA; LDDtoremifene citrate oral tablet 2 SP; MMtretinoin oral capsule 1 SPTREXALL ORAL TABLET 2TRUSELTIQ (100MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

TRUSELTIQ (125MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

Drug Name Tier Notes Drug Name Tier Notes

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TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE THERAPY PACK

3 PA; LDD

TUKYSA ORAL TABLET 3 PA; SPTURALIO ORAL CAPSULE 3 PA; LDDUKONIQ ORAL TABLET 3 PA; SPVENCLEXTA ORAL TABLET 3 PA; LDDVENCLEXTA STARTING PACK ORAL TABLET THERAPY PACK

3 PA; LDD

VERZENIO ORAL TABLET 3 PA; LDDVITRAKVI ORAL CAPSULE 3 PA; SPVITRAKVI ORAL SOLUTION 3 PA; SPVIZIMPRO ORAL TABLET 3 PA; LDDVOTRIENT ORAL TABLET 3 PA; LDDXALKORI ORAL CAPSULE 3 PA; SPXATMEP ORAL SOLUTION 3 PAXOSPATA ORAL TABLET 3 PA; LDDXTANDI ORAL CAPSULE 3 PA; LDDXTANDI ORAL TABLET 3 PA; LDDZEJULA ORAL CAPSULE 3 PA; LDDZELBORAF ORAL TABLET 3 PA; SPZOLINZA ORAL CAPSULE 3 PA; SPZYDELIG ORAL TABLET 3 PA; SPZYKADIA ORAL TABLET 3 PA; SP

*Antiparkinson And Related Therapy Agents*amantadine hcl oral capsule 1 MMamantadine hcl oral tablet 1 MMAPOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

3 PA; LDD; PA except Neurology

benztropine mesylate oral tablet 1 MM; ALbromocriptine mesylate oral capsule

2 MM

bromocriptine mesylate oral tablet 1 MMcarbidopa oral tablet 2 MMcarbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

1 MM

carbidopa-levodopa oral tablet 1 MMcarbidopa-levodopa oral tablet dispersible

1 PA; MM

carbidopa-levodopa-entacapone oral tablet

1 MM

DUOPA ENTERAL SUSPENSION 3 PA; LDD; QLentacapone oral tablet 2 ST; MMGOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA

INBRIJA INHALATION CAPSULE 3 PA; LDDKYNMOBI SUBLINGUAL FILM 3 PA; SP; PA except

neurologyKYNMOBI TITRATION KIT SUBLINGUAL KIT

3 PA; SP; PA except neurology

NEUPRO TRANSDERMAL PATCH 24 HOUR

3 PA

ONGENTYS ORAL CAPSULE 3 STOSMOLEX ER ORAL TABLET ER 24 HOUR THERAPY PACK

3 PA

OSMOLEX ER ORAL TABLET EXTENDED RELEASE 24 HOUR 129 MG, 193 MG

3 PA

pramipexole dihydrochloride er oral tablet extended release 24 hour

2 PA; MM

pramipexole dihydrochloride oral tablet

1 MM

rasagiline mesylate oral tablet 2 PA; PA except Neurology; MM

ropinirole hcl er oral tablet extended release 24 hour

1 PA except neurology; MM

ropinirole hcl oral tablet 1 MMselegiline hcl oral capsule 1 MMselegiline hcl oral tablet 1 MMtrihexyphenidyl hcl oral solution 1 MM; ALtrihexyphenidyl hcl oral tablet 1 MM; ALXADAGO ORAL TABLET 3 PA; SPZELAPAR ORAL TABLET DISPERSIBLE

3 PA; PA except Neurology; MM

*Antipsychotics/Antimanic Agents*ABILIFY MYCITE MAINTENANCE KIT ORAL TABLET

3 PA; LDD

ABILIFY MYCITE ORAL TABLET 3 PA; LDDABILIFY MYCITE STARTER KIT ORAL TABLET

3 PA; LDD

aripiprazole oral solution 2 MMaripiprazole oral tablet 1 MMasenapine maleate sublingual tablet sublingual

3

CAPLYTA ORAL CAPSULE 3 PAchlorpromazine hcl oral tablet 1 MMclozapine oral tablet 1 QL; ALclozapine oral tablet dispersible 2 PA; QL; ALFANAPT ORAL TABLET 3 PA; PA except

PsychiatryFANAPT TITRATION PACK ORAL TABLET

3 PA; PA except Psychiatry

fluphenazine decanoate injection solution

2

fluphenazine hcl oral concentrate 1 MMfluphenazine hcl oral elixir 1 MMfluphenazine hcl oral tablet 1 MMhaloperidol lactate oral concentrate

1 MM

haloperidol oral tablet 1 MMLATUDA ORAL TABLET 2 MM; ALlithium carbonate er oral tablet extended release

1 MM

lithium carbonate oral capsule 1 MMlithium carbonate oral tablet 1 MMloxapine succinate oral capsule 1 MMNUPLAZID ORAL CAPSULE 3 PA; LDDNUPLAZID ORAL TABLET 10 MG 3 PA; LDDolanzapine oral tablet 1 MMolanzapine oral tablet dispersible 1paliperidone er oral tablet extended release 24 hour

2 PA; MM

perphenazine oral tablet 1 MMprochlorperazine maleate oral tablet

1 MM; AL

prochlorperazine rectal suppository

1

Drug Name Tier Notes Drug Name Tier Notes

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quetiapine fumarate er oral tablet extended release 24 hour

1 MM

quetiapine fumarate oral tablet 1 MMREXULTI ORAL TABLET 3 PA; MMrisperidone oral solution 1 ALrisperidone oral tablet 1 MMrisperidone oral tablet dispersible 1 MMthioridazine hcl oral tablet 1 MM; ALthiothixene oral capsule 1 MMtrifluoperazine hcl oral tablet 1 MMVRAYLAR ORAL CAPSULE 3 PA; MMVRAYLAR ORAL CAPSULE THERAPY PACK

3 PA

ziprasidone hcl oral capsule 2 MM

*Antivirals*abacavir sulfate oral solution 1 MMabacavir sulfate oral tablet 1 MMabacavir sulfate-lamivudine oral tablet

2 MM

abacavir-lamivudine-zidovudine oral tablet

2 PA; MM

acyclovir oral capsule 1acyclovir oral suspension 1acyclovir oral tablet 1adefovir dipivoxil oral tablet 2 PA; PA except

Gastroenterology or Infectious Disease;

MMAPTIVUS ORAL CAPSULE 3atazanavir sulfate oral capsule 2BARACLUDE ORAL SOLUTION 3 PA; PA except

Gastroenterology and Infectious

DiseaseBIKTARVY ORAL TABLET 3CIMDUO ORAL TABLET 3COMPLERA ORAL TABLET 3CRIXIVAN ORAL CAPSULE 400 MG 2DELSTRIGO ORAL TABLET 2DESCOVY ORAL TABLET 3 PA; ACA; PLDOVATO ORAL TABLET 3 PAEDURANT ORAL TABLET 3efavirenz oral capsule 2efavirenz oral tablet 2efavirenz-emtricitab-tenofovir oral tablet

1

efavirenz-lamivudine-tenofovir oral tablet

2

emtricitabine oral capsule 1emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg, 167-250 mg

1

emtricitabine-tenofovir df oral tablet 200-300 mg

1 ACA; PL

EMTRIVA ORAL SOLUTION 2entecavir oral tablet 1 PA; PA except

Gastroenterology and Infectious

Disease; MMEPCLUSA ORAL TABLET 200-50 MG 3 PA; SP

EPIVIR HBV ORAL SOLUTION 3etravirine oral tablet 2EVOTAZ ORAL TABLET 3famciclovir oral tablet 2fosamprenavir calcium oral tablet 2FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA; SP

GENVOYA ORAL TABLET 2HARVONI ORAL TABLET 3 PA; SPINTELENCE ORAL TABLET 25 MG 2INVIRASE ORAL TABLET 3ISENTRESS HD ORAL TABLET 2ISENTRESS ORAL PACKET 2ISENTRESS ORAL TABLET 2ISENTRESS ORAL TABLET CHEWABLE

2

JULUCA ORAL TABLET 3lamivudine oral solution 1lamivudine oral tablet 1 MMlamivudine-zidovudine oral tablet 1 MMledipasvir-sofosbuvir oral tablet 2 PA; SPLEXIVA ORAL SUSPENSION 2lopinavir-ritonavir oral solution 2lopinavir-ritonavir oral tablet 2MAVYRET ORAL TABLET 3 PA; SPnevirapine er oral tablet extended release 24 hour

2

nevirapine oral suspension 2nevirapine oral tablet 1NORVIR ORAL SOLUTION 2ODEFSEY ORAL TABLET 3 ALoseltamivir phosphate oral capsule 1 QLoseltamivir phosphate oral suspension reconstituted

1 QL

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

3 PA; SP

PIFELTRO ORAL TABLET 3PREVYMIS ORAL TABLET 3 PA; SPPREZCOBIX ORAL TABLET 3PREZISTA ORAL SUSPENSION 2 STPREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG

2 ST

RELENZA DISKHALER INHALATION AEROSOL POWDER BREATH ACTIVATED

2 MM; QL; AL

REYATAZ ORAL PACKET 2ribavirin oral capsule 1 SPribavirin oral tablet 200 mg 1 SPrimantadine hcl oral tablet 2ritonavir oral tablet 2RUKOBIA ORAL TABLET EXTENDED RELEASE 12 HOUR

2

SELZENTRY ORAL SOLUTION 3 PASELZENTRY ORAL TABLET 3 PAsofosbuvir-velpatasvir oral tablet 2 PA; SPSOVALDI ORAL PACKET 3 PA; SPSOVALDI ORAL TABLET 3 PA; SPstavudine oral capsule 1STRIBILD ORAL TABLET 2SYMTUZA ORAL TABLET 2TEMIXYS ORAL TABLET 2

Drug Name Tier Notes Drug Name Tier Notes

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tenofovir disoproxil fumarate oral tablet

2

TIVICAY ORAL TABLET 2TIVICAY PD ORAL TABLET SOLUBLE 2TRIUMEQ ORAL TABLET 2 PATYBOST ORAL TABLET 2 STvalacyclovir hcl oral tablet 1valganciclovir hcl oral solution reconstituted

2 PA; PA except Infectious Disease;

MMvalganciclovir hcl oral tablet 2 PA; PA except

Infectious Disease; MM

VEMLIDY ORAL TABLET 2 PA; PA except Infectious disease

and Gastroenterology

VIRACEPT ORAL TABLET 2VIREAD ORAL POWDER 3VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

3

vocabria oral tablet 3VOSEVI ORAL TABLET 3 PA; SPXOFLUZA (40 MG DOSE) ORAL TABLET THERAPY PACK

3 QL

XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY PACK

3 QL

zidovudine oral capsule 1zidovudine oral syrup 1zidovudine oral tablet 1

*Beta Blockers*acebutolol hcl oral capsule 1 MMatenolol oral tablet 1 PL; MMbetaxolol hcl oral tablet 1 MMbisoprolol fumarate oral tablet 1 PL; MMcarvedilol oral tablet 1 PL; MMcarvedilol phosphate er oral capsule extended release 24 hour

2 MM

HEMANGEOL ORAL SOLUTION 3 PA; SPlabetalol hcl oral tablet 1 MMmetoprolol succinate er oral tablet extended release 24 hour

1 PL; MM

metoprolol tartrate oral tablet 1 PL; MMnadolol oral tablet 20 mg, 40 mg, 80 mg

1 PL; MM

nebivolol hcl oral tablet 2 MMpindolol oral tablet 3 MMpropranolol hcl er oral capsule extended release 24 hour

1 PL; MM

propranolol hcl oral solution 1 PL; MMpropranolol hcl oral tablet 1 PL; MMSORINE ORAL TABLET 1 PL; MMsotalol hcl (af) oral tablet 1 PL; MMsotalol hcl oral tablet 1 PL; MMSOTYLIZE ORAL SOLUTION 3 QLtimolol maleate oral tablet 1 PL; MM

*Calcium Channel Blockers*AFEDITAB CR ORAL TABLET EXTENDED RELEASE 24 HOUR

1 MM

amlodipine besylate oral tablet 1 MM

CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR

1 MM

diltiazem hcl er beads oral capsule extended release 24 hour

1 MM

diltiazem hcl er coated beads oral capsule extended release 24 hour

1 MM

diltiazem hcl er oral capsule extended release 12 hour

1 MM

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

1 MM

diltiazem hcl oral tablet 1 MMdilt-xr oral capsule extended release 24 hour

1 MM

felodipine er oral tablet extended release 24 hour

1 MM

isradipine oral capsule 1 MMMATZIM LA ORAL TABLET EXTENDED RELEASE 24 HOUR

2 MM

nicardipine hcl oral capsule 1 MMnifedipine er oral tablet extended release 24 hour

1 MM

nifedipine er osmotic release oral tablet extended release 24 hour

1 MM

nifedipine oral capsule 1 MM; ALnimodipine oral capsule 2 PAnisoldipine er oral tablet extended release 24 hour

2 MM

TAZTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR

1 MM

verapamil hcl er oral capsule extended release 24 hour

1 MM

verapamil hcl er oral tablet extended release 120 mg, 180 mg, 240 mg

1 MM

verapamil hcl oral tablet 1 MM

*Cardiotonics*DIGITEK ORAL TABLET 125 MCG 1 MMDIGITEK ORAL TABLET 250 MCG 1 MM; ALDIGOX ORAL TABLET 125 MCG 3 MMDIGOX ORAL TABLET 250 MCG 1 MM; ALdigoxin oral solution 1 MMdigoxin oral tablet 125 mcg 1 MMdigoxin oral tablet 250 mcg 1 MM; ALLANOXIN ORAL TABLET 62.5 MCG 3 MM

*Cardiovascular Agents - Misc.*ADEMPAS ORAL TABLET 3 PA; SPambrisentan oral tablet 2 PA; SPBIDIL ORAL TABLET 3 MMbosentan oral tablet 2 PA; SPCORLANOR ORAL SOLUTION 3 PA; ALCORLANOR ORAL TABLET 3 PA; ALENTRESTO ORAL TABLET 3OPSUMIT ORAL TABLET 3 PA; LDDORENITRAM ORAL TABLET EXTENDED RELEASE

3 PA; LDD

sildenafil citrate oral suspension reconstituted

2 PA; AL

sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg

1 QL

Drug Name Tier Notes Drug Name Tier Notes

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sildenafil citrate oral tablet 20 mg 2 PA; MM; ALtadalafil 20 mg oral tablet (pah) 2 PAtadalafil oral tablet 10 mg, 20 mg 1 QLtadalafil oral tablet 2.5 mg, 5 mg 1 MMTRACLEER ORAL TABLET SOLUBLE 3 PA; LDDUPTRAVI ORAL TABLET 3 PA; SPUPTRAVI ORAL TABLET THERAPY PACK

3 PA; SP

VENTAVIS INHALATION SOLUTION 3 PA; SPVERQUVO ORAL TABLET 3 PAVYNDAMAX ORAL CAPSULE 3 PA; LDDVYNDAQEL ORAL CAPSULE 3 PA; LDD

*Cephalosporins*cefaclor oral capsule 1cefaclor oral suspension reconstituted

1

cefadroxil oral capsule 1cefadroxil oral suspension reconstituted

1

cefadroxil oral tablet 1cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 100 gm, 300 gm, 500 mg

2

cefazolin sodium intravenous solution reconstituted

2

cefdinir oral capsule 1cefdinir oral suspension reconstituted

1

cefixime oral capsule 2cefixime oral suspension reconstituted

2

cefpodoxime proxetil oral suspension reconstituted

2

cefpodoxime proxetil oral tablet 2cefprozil oral suspension reconstituted

2

cefprozil oral tablet 2cefuroxime axetil oral tablet 2cephalexin oral capsule 250 mg, 500 mg

1 DF

cephalexin oral suspension reconstituted

1 DF

*Chemicals*vitamin d3 liquid 1000000 unit/gm 2

*Contraceptives*alyacen 7/7/7 oral tablet 1 MMANNOVERA VAGINAL RING 3BALCOLTRA ORAL TABLET 2 MMbriellyn oral tablet 1 MMCAZIANT ORAL TABLET 1 MMCESIA ORAL TABLET 1 MMdesogestrel-ethinyl estradiol oral tablet

1 MM

drospiren-eth estrad-levomefol oral tablet

1 MM

drospirenone-ethinyl estradiol oral tablet

1 MM

ELLA ORAL TABLET 2 QLELURYNG VAGINAL RING 1 MM

ethynodiol diac-eth estradiol oral tablet

1 MM

GEMMILY ORAL CAPSULE 2 MMJAIMIESS ORAL TABLET 2 MMLEENA ORAL TABLET 3 MMlevonorgest-eth est & eth est oral tablet

1 MM

levonorgest-eth estrad 91-day oral tablet 0.1-0.02 & 0.01 mg, 0.15-0.03 mg

1

levonorgest-eth estrad 91-day oral tablet 0.15-0.03 &0.01 mg

1 MM

levonorgestrel oral tablet 1.5 mg 1 OTC; QLlevonorgestrel-ethinyl estrad oral tablet

1 MM

LO LOESTRIN FE ORAL TABLET 2 MMLOJAIMIESS ORAL TABLET 2 MMMICROGESTIN FE 1.5/30 ORAL TABLET

1 MM

NATAZIA ORAL TABLET 2 MMnorethin ace-eth estrad-fe oral capsule

2 MM

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg

1 MM

norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg

1 MM

norethindrone oral tablet 1 MMnorethin-eth estradiol-fe oral tablet chewable

1 MM

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

1 MM

norgestim-eth estrad triphasic oral tablet

1 MM

SLYND ORAL TABLET 3 MMSOLIA ORAL TABLET 1 MMTILIA FE ORAL TABLET 1 MMTRI-LEGEST FE ORAL TABLET 1 MMTYDEMY ORAL TABLET 1XULANE TRANSDERMAL PATCH WEEKLY

1 MM

*Corticosteroids*budesonide er oral tablet extended release 24 hour

2 PA

budesonide oral capsule delayed release particles

2 PA; PA except Colorectal

Surgery/Gastroenterology

DEXAMETHASONE INTENSOL ORAL CONCENTRATE

2

dexamethasone oral elixir 1 DFdexamethasone oral solution 1 DFdexamethasone oral tablet 1 DFEMFLAZA ORAL SUSPENSION 3 PA; LDDEMFLAZA ORAL TABLET 3 PA; LDDfludrocortisone acetate oral tablet 1 MMhydrocortisone oral tablet 1 MMmethylprednisolone oral tablet 1 DFMILLIPRED ORAL TABLET 3prednisolone oral solution 1prednisolone oral syrup 15 mg/5ml 1

Drug Name Tier Notes Drug Name Tier Notes

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prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml

3

prednisolone sodium phosphate oral solution 15 mg/5ml

1

prednisone oral solution 1 DFprednisone oral tablet 1 DFRAYOS ORAL TABLET DELAYED RELEASE

3 PA

*Cough/Cold/Allergy*acetylcysteine inhalation solution 1benzonatate oral capsule 100 mg, 200 mg

1 QL

hydrocod polst-cpm polst er oral suspension extended release

2

promethazine vc/codeine oral syrup

1 AL

promethazine-codeine oral syrup 1 ALpromethazine-phenylephrine oral syrup

1 AL

sodium chloride inhalation nebulization solution 0.9 %

1

SSKI ORAL SOLUTION 3

*Dermatologicals*acitretin oral capsule 2 PA; PA except

dermatologyacyclovir external ointment 2adapalene external gel 0.3 % 1adapalene-benzoyl peroxide external gel

1

AKLIEF EXTERNAL CREAM 3 PA; ALalclometasone dipropionate external cream

1

alclometasone dipropionate external ointment

1

ALTABAX EXTERNAL OINTMENT 3 STamcinonide external lotion 1AMNESTEEM ORAL CAPSULE 1 PA; PA except

dermatologyARAZLO EXTERNAL LOTION 3 PAazelaic acid external gel 2AZELEX EXTERNAL CREAM 3benzoyl peroxide external gel 10 % 1benzoyl peroxide external gel 5 % 1 OTCbetamethasone dipropionate aug external cream

1

betamethasone dipropionate aug external gel

1

betamethasone dipropionate aug external lotion

1

betamethasone dipropionate aug external ointment

1

betamethasone dipropionate external cream

1

betamethasone dipropionate external lotion

1

betamethasone dipropionate external ointment

1

betamethasone valerate external cream

1

betamethasone valerate external lotion

1

betamethasone valerate external ointment

1

BRYHALI EXTERNAL LOTION 3calcipotriene external cream 2 PA; PA except

Dermatologycalcipotriene external ointment 2 PA; PA except

Dermatologycalcipotriene external solution 2 PA; PA except

Dermatologycalcipotriene-betameth diprop external ointment

3 PA; PA except Dermatology

calcipotriene-betameth diprop external suspension

3 PA; PA except dermatology

calcitriol external ointment 3 PAciclopirox external gel 1ciclopirox external shampoo 1ciclopirox external solution 1 ALciclopirox olamine external cream 1ciclopirox olamine external suspension

1

CLARAVIS ORAL CAPSULE 2 PA; PA except Dermatology

clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 %

1

clindamycin phosphate external gel 1clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

clobetasol propionate e external cream

1

clobetasol propionate external cream

1

clobetasol propionate external ointment

1

clobetasol propionate external shampoo

1

clobetasol propionate external solution

1

clotrimazole external cream 1clotrimazole-betamethasone external cream

1 QL

clotrimazole-betamethasone external lotion

1 QL

CONDYLOX EXTERNAL GEL 3COSENTYX (300 MG DOSE) SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MG/ML

3 PA; SP

Drug Name Tier Notes Drug Name Tier Notes

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COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML

3 PA; SP

CROTAN EXTERNAL LOTION 1dapsone external gel 5 % 2dapsone external gel 7.5 % 2 STDENAVIR EXTERNAL CREAM 3desonide external cream 1desonide external ointment 1 STdesoximetasone external cream 1desoximetasone external gel 1desoximetasone external ointment 0.25 %

1

diclofenac sodium external gel 1 % 1diclofenac sodium external gel 3 % 1 PA; PA except

dermatologydiflorasone diacetate external cream

2

diflorasone diacetate external ointment

2

doxycycline oral capsule delayed release

2 PA

DRYSOL EXTERNAL SOLUTION 2DUOBRII EXTERNAL LOTION 3 PADUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 200 MG/1.14ML

2 PA; SP

DUPIXENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 300 MG/2ML

3 PA; SP

DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

econazole nitrate external cream 1EPIDUO FORTE EXTERNAL GEL 3 PAerythromycin external gel 1erythromycin external solution 1EUCRISA EXTERNAL OINTMENT 3 PA; ST; ALFABIOR EXTERNAL FOAM 3 ST; ST except

dermatology; QLFINACEA EXTERNAL FOAM 3fluocinolone acetonide body external oil

1

fluocinolone acetonide external cream

1

fluocinolone acetonide external ointment

1

fluocinolone acetonide external solution

1

fluocinolone acetonide scalp external oil

1

fluocinonide external cream 0.05 % 1fluocinonide external gel 1fluocinonide external ointment 1fluocinonide external solution 1FLUOROPLEX EXTERNAL CREAM 3fluorouracil external cream 0.5 % 3 STfluorouracil external cream 5 % 1fluorouracil external solution 1flurandrenolide external cream 2flurandrenolide external lotion 2

fluticasone propionate external cream

1

fluticasone propionate external lotion

1

fluticasone propionate external ointment

1

gentamicin sulfate external cream 1gentamicin sulfate external ointment

1

halobetasol propionate external cream

1

halobetasol propionate external ointment

1

hydrocortisone butyr lipo base external cream

1

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 2.5 %

1

hydrocortisone external lotion 2.5 %

1

hydrocortisone external ointment 2.5 %

1

hydrocortisone valerate external cream

1

hydrocortisone valerate external ointment

1

imiquimod external cream 5 % 1 PA except Dermatology,

Urology, OBGYN, and Colorectal Surgery

iodoquinol-hydrocortisone-aloe external cream

2

isotretinoin capsule 10 mg oral 3 PA; generic for Absorica

isotretinoin capsule 20 mg oral 3 PA; generic for Absorica

isotretinoin capsule 30 mg oral 3 PA; generic for Absorica

isotretinoin capsule 40 mg oral 3 PA; generic for Absorica

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg

1 PA; PA except dermatology

isotretinoin oral capsule 25 mg, 35 mg

3 PA; generic for Absorica

ivermectin external cream 2 PA; PA except dermatology

ivermectin external lotion 2 QLJUBLIA EXTERNAL SOLUTION 3 PAketoconazole external cream 1ketoconazole external foam 3ketoconazole external shampoo 2 %

1

lidocaine external ointment 5 % 1lidocaine external patch 5 % 2lidocaine hcl external solution 1lidocaine-prilocaine external cream 1LIDOCARE ARM/NECK/LEG EXTERNAL PATCH

2 OTC

Drug Name Tier Notes Drug Name Tier Notes

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LIDOCARE BACK/SHOULDER EXTERNAL PATCH

2 OTC

lindane external shampoo 1malathion external lotion 1MENTAX EXTERNAL CREAM 3methoxsalen rapid oral capsule 2metronidazole external cream 1metronidazole external gel 1metronidazole external lotion 1mometasone furoate external cream

1

mometasone furoate external ointment

1

mupirocin calcium external cream 1mupirocin external ointment 1MYORISAN ORAL CAPSULE 2 PA; PA except

Dermatologynaftifine hcl external cream 2NEO-SYNALAR EXTERNAL CREAM 3nystatin external cream 1nystatin external ointment 1nystatin external powder 1nystatin-triamcinolone external cream

1

nystatin-triamcinolone external ointment

1

oxiconazole nitrate external cream 2OXISTAT EXTERNAL LOTION 3PANRETIN EXTERNAL GEL 3 PApermethrin external cream 1pimecrolimus external cream 1 ALpodofilox external solution 1prednicarbate external ointment 1QBREXZA EXTERNAL PAD 3 PAREGRANEX EXTERNAL GEL 3 PASANTYL EXTERNAL OINTMENT 3selenium sulfide external lotion 1SILIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

silver sulfadiazine external cream 1SKYRIZI (150 MG DOSE) SUBCUTANEOUS PREFILLED SYRINGE KIT

3 PA; SP

SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

SOOLANTRA EXTERNAL CREAM 3 PA; PA except dermatology

spinosad external suspension 2 QLsulconazole nitrate external cream 3sulconazole nitrate external solution

3

sulfacetamide sodium (acne) external lotion

1

sulfacetamide sodium external liquid

1

sulfacetamide sodium-sulfur external liquid 10-2 %, 9-4 %, 9-4.5 %

1

SULFAMYLON EXTERNAL CREAM 3

SYNERA EXTERNAL PATCH 3 PAtacrolimus external ointment 0.03 %, 0.1 %

2 AL

TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

TARGRETIN EXTERNAL GEL 3 PA; SPtavaborole external solution 3 PAtazarotene external cream 1 ST; ST except

DermatologyTAZORAC EXTERNAL CREAM 0.05 % 3 ST; ST except

dermatologyTAZORAC EXTERNAL GEL 3 ST; ST except

DermatologyTEXACORT EXTERNAL SOLUTION 3THERMAZENE EXTERNAL CREAM 1TREMFYA SUBCUTANEOUS SOLUTION PEN-INJECTOR

3 PA; SP

TREMFYA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

tretinoin external cream 1tretinoin external gel 0.01 %, 0.025 %

1

triamcinolone acetonide external aerosol solution

2

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 %

1

TRIANEX EXTERNAL OINTMENT 3VALCHLOR EXTERNAL GEL 3 PA; SPVERDESO EXTERNAL FOAM 3VEREGEN EXTERNAL OINTMENT 3WINLEVI EXTERNAL CREAM 3 PAZITHRANOL EXTERNAL SHAMPOO 3 PA

*Digestive Aids*CREON ORAL CAPSULE DELAYED RELEASE PARTICLES

2 MM

SUCRAID ORAL SOLUTION 3 PA; LDDZENPEP 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

2 MM

*Diuretics*acetazolamide er oral capsule extended release 12 hour

1 MM

acetazolamide oral tablet 1 MMALDACTAZIDE ORAL TABLET 50-50 MG

2 MM

amiloride hcl oral tablet 1 MMamiloride-hydrochlorothiazide oral tablet

1 MM

bumetanide oral tablet 1 MMchlorthalidone oral tablet 25 mg, 50 mg

1 MM

Drug Name Tier Notes Drug Name Tier Notes

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DIURIL ORAL SUSPENSION 2 MMDYRENIUM ORAL CAPSULE 3 MMethacrynic acid oral tablet 2furosemide oral solution 10 mg/ml, 8 mg/ml

1 MM

furosemide oral tablet 1 MMhydrochlorothiazide oral capsule 1 MMhydrochlorothiazide oral tablet 1 MMindapamide oral tablet 1 MMKEVEYIS ORAL TABLET 3 PA; LDDmethazolamide oral tablet 1 MMmetolazone oral tablet 1 MMspironolactone oral tablet 1 MMspironolactone-hctz oral tablet 1 MMtorsemide oral tablet 1 MMtriamterene-hctz oral capsule 37.5-25 mg

1 MM

triamterene-hctz oral tablet 1 MM

*Endocrine And Metabolic Agents - Misc.*alendronate sodium oral solution 1 PL; MMalendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg

1 PL; MM

cabergoline oral tablet 1calcitonin (salmon) nasal solution 1 MMcalcitriol oral capsule 1 MMcalcitriol oral solution 1 MMCARBAGLU ORAL TABLET 3 PA; LDDchorionic gonadotropin intramuscular solution reconstituted

2 PA; ST

cinacalcet hcl oral tablet 2 MMclomiphene citrate oral tablet 2 PA; PA except

OB/GYN; QLCYSTADANE ORAL POWDER 3 PA; LDDdesmopressin ace spray refrig nasal solution

2 MM

desmopressin acetate oral tablet 2 MMdesmopressin acetate spray nasal solution

2 MM

doxercalciferol oral capsule 1 ST; MMFOLLISTIM AQ SUBCUTANEOUS SOLUTION

2 PA

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG/2.48ML

2 PA; SP

GALAFOLD ORAL CAPSULE 3 PA; LDD; ALganirelix acetate subcutaneous solution prefilled syringe

3 PA

GENOTROPIN MINIQUICK SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA; SP

GENOTROPIN SUBCUTANEOUS SOLUTION RECONSTITUTED

2 PA; SP

ibandronate sodium oral tablet 1 MM; QLINCRELEX SUBCUTANEOUS SOLUTION

3 PA; LDD; MM

ISTURISA ORAL TABLET 3 PA; SPJYNARQUE ORAL TABLET THERAPY PACK

3 PA; LDD

KERENDIA ORAL TABLET 3 PA

MENOPUR SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA

mifepristone oral tablet 2MYALEPT SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA; LDD

MYCAPSSA ORAL CAPSULE DELAYED RELEASE

3 PA; LDD

NATPARA SUBCUTANEOUS CARTRIDGE

3 PA; LDD

nitisinone oral capsule 2 PA; LDDNITYR ORAL TABLET 2 PA; LDDoctreotide acetate injection solution 100 mcg/ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

2 PA; PA except hematology,

oncology, endocrinology; MM

ORFADIN ORAL CAPSULE 20 MG 2 PA; LDDORFADIN ORAL SUSPENSION 2 PA; LDDORILISSA ORAL TABLET 2 PAOSPHENA ORAL TABLET 3OVIDREL SUBCUTANEOUS INJECTABLE

3 PA; ST

PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; LDD

paricalcitol oral capsule 1 mcg 1 ST; MMparicalcitol oral capsule 2 mcg, 4 mcg

3 ST; MM

raloxifene hcl oral tablet 1 ACA; PL; MMRAVICTI ORAL LIQUID 3 PA; LDDRAYALDEE ORAL CAPSULE EXTENDED RELEASE

3 ST

risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg

1 PL; MM

risedronate sodium oral tablet delayed release

1 PL; MM

SAIZEN INJECTION SOLUTION RECONSTITUTED

3 PA; SP

sapropterin dihydrochloride oral packet

2 PA; SP

sapropterin dihydrochloride oral tablet

2 PA; SP

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG, 5 MG, 6 MG

3 PA; SP

SIGNIFOR SUBCUTANEOUS SOLUTION

3 PA; LDD

sodium phenylbutyrate oral powder 3 gm/tsp

1 PA; LDD

sodium phenylbutyrate oral tablet 2 PA; LDDSOMATULINE DEPOT SUBCUTANEOUS SOLUTION

3 PA

SOMAVERT SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA; LDD

STIMATE NASAL SOLUTION 3 MMSTRENSIQ SUBCUTANEOUS SOLUTION

2 PA; LDD

SYNAREL NASAL SOLUTION 3 PAteriparatide (recombinant) subcutaneous solution pen-injector

3 PA; SP

tolvaptan oral tablet 3 PATYMLOS SUBCUTANEOUS SOLUTION PEN-INJECTOR

3 PA; LDD

Drug Name Tier Notes Drug Name Tier Notes

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XGEVA SUBCUTANEOUS SOLUTION 3 PA; LDDXURIDEN ORAL PACKET 3 PA; LDDZORBTIVE SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA; SP

*Estrogens*ANGELIQ ORAL TABLET 3 MM; ALCOMBIPATCH TRANSDERMAL PATCH TWICE WEEKLY

3 MM; AL

COVARYX HS ORAL TABLET 1 MM; ALCOVARYX ORAL TABLET 1 MM; ALDUAVEE ORAL TABLET 3 MM; ALELESTRIN TRANSDERMAL GEL 3 ALest estrogens-methyltest ds oral tablet

1 MM; AL

est estrogens-methyltest hs oral tablet

1 MM; AL

est estrogens-methyltest oral tablet 1.25-2.5 mg

1 MM; AL

estradiol oral tablet 1 MM; ALestradiol transdermal patch twice weekly

1 MM; AL

estradiol transdermal patch weekly 1 ALestradiol-norethindrone acet oral tablet

1 MM; AL

ESTROGEL TRANSDERMAL GEL 3EVAMIST TRANSDERMAL SOLUTION

3 MM; AL

JINTELI ORAL TABLET 1 MM; ALMENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

2 AL

MENOSTAR TRANSDERMAL PATCH WEEKLY

3 AL

MYFEMBREE ORAL TABLET 2 PAnorethindrone-eth estradiol oral tablet 1-5 mg-mcg

1 MM; AL

ORIAHNN ORAL CAPSULE THERAPY PACK

2 PA

PREMARIN ORAL TABLET 2 MM; ALPREMPHASE ORAL TABLET 2 MM; ALPREMPRO ORAL TABLET 2 MM; AL

*Fluoroquinolones*CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)

3

ciprofloxacin hcl oral tablet 100 mg 2ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

1

levofloxacin oral solution 2levofloxacin oral tablet 2moxifloxacin hcl oral tablet 1ofloxacin oral tablet 300 mg, 400 mg

2

*Gastrointestinal Agents - Misc.*alosetron hcl oral tablet 2 PAAURYXIA ORAL TABLET 3balsalazide disodium oral capsule 1 ALBYLVAY (PELLETS) ORAL CAPSULE SPRINKLE

3 PA; LDD

BYLVAY ORAL CAPSULE 3 PA; LDDCHENODAL ORAL TABLET 3 PA; LDD

CHOLBAM ORAL CAPSULE 3 PA; LDDCIMZIA PREFILLED SUBCUTANEOUS KIT

3 PA; SP

CIMZIA STARTER KIT SUBCUTANEOUS KIT

3 PA; SP

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG

3 PA; SP

cromolyn sodium oral concentrate 1 MMDIPENTUM ORAL CAPSULE 3enulose oral solution 1generlac oral solution 1lactulose encephalopathy oral solution

1

lanthanum carbonate oral tablet chewable

2 MM

LINZESS ORAL CAPSULE 2 ST except Gastroenterology and Colon-Rectal

surgery; MMlubiprostone oral capsule 3 ST; ST except

gastroenterology and colorectal surgery

mesalamine er oral capsule extended release 24 hour

3 ST; MM

mesalamine oral capsule delayed release

1 MM

mesalamine oral tablet delayed release

1 MM

mesalamine rectal enema 1mesalamine rectal suppository 2mesalamine-cleanser rectal kit 2metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

1

metoclopramide hcl oral tablet 1metoclopramide hcl oral tablet dispersible 5 mg

2 PA

MOVANTIK ORAL TABLET 3 PAOCALIVA ORAL TABLET 3 PA; LDDPENTASA ORAL CAPSULE EXTENDED RELEASE

2 MM

PHOSLYRA ORAL SOLUTION 2 MMRELISTOR ORAL TABLET 3 PARELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML, 8 MG/0.4ML

3 PA

sevelamer carbonate oral packet 2 MMsevelamer carbonate oral tablet 2 MMsevelamer hcl oral tablet 2 MMSFROWASA RECTAL ENEMA 2sulfasalazine oral tablet 1 MMsulfasalazine oral tablet delayed release

1 MM

SYMPROIC ORAL TABLET 3 PAursodiol oral capsule 300 mg 1 MMursodiol oral tablet 1 MMVELPHORO ORAL TABLET CHEWABLE

3

VIBERZI ORAL TABLET 3 PAXERMELO ORAL TABLET 3 PA; LDD

Drug Name Tier Notes Drug Name Tier Notes

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*Genitourinary Agents - Miscellaneous*alfuzosin hcl er oral tablet extended release 24 hour

1 MM

CARDURA XL ORAL TABLET EXTENDED RELEASE 24 HOUR

3 MM

CYSTAGON ORAL CAPSULE 2 PA; LDDdutasteride oral capsule 1 MMdutasteride-tamsulosin hcl oral capsule

1

ELMIRON ORAL CAPSULE 2 PA; PA except urology

finasteride oral tablet 5 mg 1 MMphenazopyridine hcl oral tablet 100 mg, 200 mg

1

potassium citrate er oral tablet extended release

1

PROCYSBI ORAL CAPSULE DELAYED RELEASE

3 PA; LDD

PROCYSBI ORAL PACKET 3 PA; LDDsilodosin oral capsule 1 MMsodium chloride irrigation solution 0.9 %

1

tamsulosin hcl oral capsule 1 MMTHIOLA EC ORAL TABLET DELAYED RELEASE

3 PA; LDD

tiopronin oral tablet 3 PA; SP

*Gout Agents*allopurinol oral tablet 1 MMcolchicine oral capsule 2colchicine oral tablet 2colchicine-probenecid oral tablet 1 MMfebuxostat oral tablet 2 ST; MMprobenecid oral tablet 1 MM

*Hematological Agents - Misc.*anagrelide hcl oral capsule 1 PA; PA except

oncology and hematology; MM

aspirin-dipyridamole er oral capsule extended release 12 hour

2 PA; MM; AL

BRILINTA ORAL TABLET 2 MMcilostazol oral tablet 1 MMclopidogrel bisulfate oral tablet 1 MMdipyridamole oral tablet 1 MM; ALHAEGARDA SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA; LDD

icatibant acetate subcutaneous solution

2 PA; SP

ORLADEYO ORAL CAPSULE 3 PA; SPpentoxifylline er oral tablet extended release

1 DF; MM

prasugrel hcl oral tablet 1 MM; ALTAKHZYRO SUBCUTANEOUS SOLUTION

3 PA; LDD; QL; AL

TAVALISSE ORAL TABLET 3 PA; LDDZONTIVITY ORAL TABLET 3 PA; MM

*Hematopoietic Agents*ACCRUFER ORAL CAPSULE 3 PA

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML, 60 MCG/ML

3 PA; SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

3 PA; SP

CERDELGA ORAL CAPSULE 3 PA; SPcyanocobalamin injection solution 1000 mcg/ml

1

DOPTELET ORAL TABLET 20 MG 3 PA; LDDDROXIA ORAL CAPSULE 1folic acid oral tablet 1 mg 1 MMmiglustat oral capsule 2 PA; LDDMOZOBIL SUBCUTANEOUS SOLUTION

3 PA

MULPLETA ORAL TABLET 3 PA; SPMULTIGEN PLUS ORAL TABLET 3NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

NIVESTYM INJECTION SOLUTION PREFILLED SYRINGE

2 SP

OXBRYTA ORAL TABLET 3 PA; SPPROMACTA ORAL PACKET 3 PA; SPPROMACTA ORAL TABLET 3 PA; SPRETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML

2 PA; SP

SIKLOS ORAL TABLET 3 PAUDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ZARXIO INJECTION SOLUTION PREFILLED SYRINGE

2 SP

*Hemostatics*aminocaproic acid oral tablet 2tranexamic acid oral tablet 1 AL

*Hypnotics/Sedatives/Sleep Disorder Agents*BELSOMRA ORAL TABLET 2 ST; QLDAYVIGO ORAL TABLET 3 PAdoxepin hcl oral tablet 3 QLestazolam oral tablet 1 QL; ALeszopiclone oral tablet 1 QL; ALflurazepam hcl oral capsule 1 QL; ALHETLIOZ LQ ORAL SUSPENSION 3 PA; LDDHETLIOZ ORAL CAPSULE 3 PA; LDDmidazolam hcl oral syrup 1phenobarbital oral elixir 1phenobarbital oral tablet 1 ALquazepam oral tablet 1 QL; ALramelteon oral tablet 2 QLtemazepam oral capsule 1 QL; ALtriazolam oral tablet 1 QL; ALzaleplon oral capsule 2 QL; ALzolpidem tartrate er oral tablet extended release

1 QL; AL

zolpidem tartrate oral tablet 1 QL; ALzolpidem tartrate sublingual tablet sublingual

2 ST; QL; AL

Drug Name Tier Notes Drug Name Tier Notes

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*Laxatives*CLENPIQ ORAL SOLUTION 2 ACA; PL; QLconstulose oral solution 1KRISTALOSE ORAL PACKET 20 GM 3lactulose oral packet 1lactulose oral solution 1OSMOPREP ORAL TABLET 3peg 3350-kcl-na bicarb-nacl oral solution reconstituted

1 ACA

SUPREP BOWEL PREP KIT ORAL SOLUTION

2 ACA; PL; QL

SUTAB ORAL TABLET 2 QL

*Macrolides*azithromycin oral packet 1azithromycin oral suspension reconstituted

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

1

clarithromycin er oral tablet extended release 24 hour

1

clarithromycin oral suspension reconstituted

1

clarithromycin oral tablet 250 mg 1clarithromycin oral tablet 500 mg 1 DFDIFICID ORAL SUSPENSION RECONSTITUTED

3 PA

DIFICID ORAL TABLET 3 PAERYTHROCIN STEARATE ORAL TABLET 250 MG

2

erythromycin base oral capsule delayed release particles

1

erythromycin base oral tablet 2 DFerythromycin ethylsuccinate oral suspension reconstituted

2

erythromycin ethylsuccinate oral tablet

2 DF

*Medical Devices And Supplies*FEMCAP VAGINAL DEVICE 2OMNIPOD DASH 5 PACK PODS 2V-GO 20 KIT 2V-GO 30 KIT 2V-GO 40 KIT 2

*Migraine Products*AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA

AJOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA

AJOVY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA

almotriptan malate oral tablet 2 QLdihydroergotamine mesylate injection solution

2 PA; QL

dihydroergotamine mesylate nasal solution

2 PA; QL

eletriptan hydrobromide oral tablet

1 QL

ERGOMAR SUBLINGUAL TABLET SUBLINGUAL

2 LDD

ergotamine-caffeine oral tablet 2

frovatriptan succinate oral tablet 2 QLnaratriptan hcl oral tablet 1 QLNURTEC ORAL TABLET DISPERSIBLE 2 PAREYVOW ORAL TABLET 2 PArizatriptan benzoate oral tablet 1 QLrizatriptan benzoate oral tablet dispersible

1 QL

sumatriptan nasal solution 1 QLsumatriptan succinate oral tablet 1 QLsumatriptan succinate refill subcutaneous solution cartridge

1 QL

sumatriptan succinate subcutaneous solution 6 mg/0.5ml

1 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml

1 QL

UBRELVY ORAL TABLET 2 PAzolmitriptan oral tablet 2 QLZOMIG NASAL SOLUTION 3 QL

*Minerals & Electrolytes*KLOR-CON 10 ORAL TABLET EXTENDED RELEASE

1 MM

KLOR-CON M10 ORAL TABLET EXTENDED RELEASE

1 MM

KLOR-CON M15 ORAL TABLET EXTENDED RELEASE

1 MM

KLOR-CON M20 ORAL TABLET EXTENDED RELEASE

1 MM

KLOR-CON ORAL TABLET EXTENDED RELEASE

1 MM

potassium chloride crys er oral tablet extended release 10 meq, 20 meq

1 MM

potassium chloride er oral capsule extended release

1 MM

potassium chloride er oral tablet extended release

1 MM

potassium chloride oral packet 1

*Miscellaneous Therapeutic Classes*ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA; MM

azathioprine oral tablet 100 mg, 75 mg

2 MM

azathioprine oral tablet 50 mg 1 MMBENLYSTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

cyclosporine modified oral capsule 1 MMcyclosporine modified oral solution 1 MMcyclosporine oral capsule 1 MMENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

ENVARSUS XR ORAL TABLET EXTENDED RELEASE 24 HOUR

3 PA

everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg

1 PA; PA except RenalTransplant

Surgeonsand Nephrology; MM

Drug Name Tier Notes Drug Name Tier Notes

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GENGRAF ORAL CAPSULE 100 MG, 25 MG

1 MM

GENGRAF ORAL SOLUTION 1 MMLOKELMA ORAL PACKET 2LUPKYNIS ORAL CAPSULE 3 PA; SPmycophenolate mofetil oral capsule

1 MM

mycophenolate mofetil oral suspension reconstituted

1

mycophenolate mofetil oral tablet 1 MMmycophenolate sodium oral tablet delayed release

1 PA; PA except renal transplant surgeon

and nephrology; MMpenicillamine oral capsule 2 PA; SPPHYSIOLYTE IRRIGATION SOLUTION 2PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

1

REVLIMID ORAL CAPSULE 2 PA; LDDREZUROCK ORAL TABLET 3 PA; LDDSANDIMMUNE ORAL SOLUTION 3 MMsirolimus oral solution 2 PA; PA except Renal

Transplant Surgeons and Nephrology; MM

sirolimus oral tablet 2 PA; PA except Renal Transplant Surgeons

and Nephrology; MMsodium polystyrene sulfonate oral powder

1

SPS ORAL SUSPENSION 1tacrolimus oral capsule 1 MMTHALOMID ORAL CAPSULE 3 LDDtrientine hcl oral capsule 2 PA; SPVELTASSA ORAL PACKET 2ZOKINVY ORAL CAPSULE 3 PA; SP; LDDZORTRESS ORAL TABLET 1 MG 2 PA; PA except Renal

Transplant Surgeons and Nephrology; MM

*Mouth/Throat/Dental Agents*cevimeline hcl oral capsule 2 MMchlorhexidine gluconate mouth/throat solution

1

clotrimazole mouth/throat troche 1 DFDEBACTEROL MOUTH/THROAT SOLUTION

3 PA

lidocaine hcl mouth/throat solution

1

nystatin mouth/throat suspension 1 DFORAVIG BUCCAL TABLET 3 PA; ALpilocarpine hcl oral tablet 1 MMsf 5000 plus dental cream 1 DFtriamcinolone acetonide mouth/throat paste

1 DF

*Multivitamins*CITRANATAL BLOOM ORAL TABLET 3 MMDIALYVITE ORAL TABLET 1 PA; PA except

NephrologyNEPHRONEX ORAL TABLET 1 PA; PA except

Nephrologyprenatal 19 oral tablet 29-1 mg 2 MMprenatal 19 oral tablet chewable 2 MM

prenatal oral tablet 27-1 mg 2 MMprenatal plus iron oral tablet 2 MMprenatal plus oral tablet 2 MMprenatal vitamin oral tablet 1 OTCprenatal vitamins oral tablet 28-0.8 mg

1 OTC

PRENATAL-U ORAL CAPSULE 2 MMtri-vite/fluoride oral solution 0.5 mg/ml

1

*Musculoskeletal Therapy Agents*baclofen oral tablet 1 MMcarisoprodol oral tablet 1 ALcarisoprodol-aspirin-codeine oral tablet

1 AL

chlorzoxazone oral tablet 500 mg 1 ALcyclobenzaprine hcl oral tablet 1 ALdantrolene sodium oral capsule 1metaxalone oral tablet 2 ALmethocarbamol oral tablet 1 ALorphenadrine citrate er oral tablet extended release 12 hour

1 AL

tizanidine hcl oral capsule 1 MMtizanidine hcl oral tablet 1 MM

*Nasal Agents - Systemic And Topical*azelastine hcl nasal solution 0.1 %, 0.15 %

1

budesonide nasal suspension 1 OTCflunisolide nasal solution 25 mcg/act (0.025%)

1

fluticasone propionate nasal suspension

1

ipratropium bromide nasal solution 0.03 %

1 MM

ipratropium bromide nasal solution 0.06 %

1

olopatadine hcl nasal solution 2triamcinolone acetonide nasal aerosol

1

ZETONNA NASAL AEROSOL SOLUTION

3 ST

*Neuromuscular Agents*EVRYSDI ORAL SOLUTION RECONSTITUTED

3 PA; LDD

EXSERVAN ORAL FILM 3 PAriluzole oral tablet 2 MMTIGLUTIK ORAL SUSPENSION 3 SP

*Ophthalmic Agents*ALAWAY CHILDRENS ALLERGY OPHTHALMIC SOLUTION

1 OTC

ALAWAY OPHTHALMIC SOLUTION 1 OTCALOCRIL OPHTHALMIC SOLUTION 3 STALOMIDE OPHTHALMIC SOLUTION 3 STapraclonidine hcl ophthalmic solution

2

AZASITE OPHTHALMIC SOLUTION 3 PAazelastine hcl ophthalmic solution 1bacitracin ophthalmic ointment 2bacitra-neomycin-polymyxin-hc ophthalmic ointment

1

Drug Name Tier Notes Drug Name Tier Notes

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bepotastine besilate ophthalmic solution

3 ST

BESIVANCE OPHTHALMIC SUSPENSION

3

betaxolol hcl ophthalmic solution 1bimatoprost ophthalmic solution (glaucoma)

2

BLEPHAMIDE OPHTHALMIC SUSPENSION

2

brimonidine tartrate ophthalmic solution

1

brinzolamide ophthalmic suspension

2

bromfenac sodium (once-daily) ophthalmic solution

2

carteolol hcl ophthalmic solution 1ciprofloxacin hcl ophthalmic solution

1

COMBIGAN OPHTHALMIC SOLUTION

3

cromolyn sodium ophthalmic solution

1 MM

CYSTADROPS OPHTHALMIC SOLUTION

3 PA; SP

CYSTARAN OPHTHALMIC SOLUTION

3 PA; LDD

dexamethasone sodium phosphate ophthalmic solution

1

diclofenac sodium ophthalmic solution

1

dorzolamide hcl ophthalmic solution

1

dorzolamide hcl-timolol mal ophthalmic solution

1

epinastine hcl ophthalmic solution 1erythromycin ophthalmic ointment 1 ACAFLAREX OPHTHALMIC SUSPENSION 2fluorometholone ophthalmic suspension

1

flurbiprofen sodium ophthalmic solution

1

FML FORTE OPHTHALMIC SUSPENSION

2

FML OPHTHALMIC OINTMENT 2gatifloxacin ophthalmic solution 2gentamicin sulfate ophthalmic solution

1

ILEVRO OPHTHALMIC SUSPENSION 3INVELTYS OPHTHALMIC SUSPENSION

3

ketorolac tromethamine ophthalmic solution

1

ketotifen fumarate ophthalmic solution

1

LASTACAFT OPHTHALMIC SOLUTION

3 ST

latanoprost ophthalmic solution 2levobunolol hcl ophthalmic solution 0.5 %

1

levofloxacin ophthalmic solution 2

loteprednol etabonate ophthalmic suspension

2

MAXIDEX OPHTHALMIC SUSPENSION

3

moxifloxacin hcl ophthalmic solution

1

NATACYN OPHTHALMIC SUSPENSION

2 PA

neomycin-bacitracin zn-polymyx ophthalmic ointment 3.5-400-10000

1

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

1

ofloxacin ophthalmic solution 1 QLolopatadine hcl ophthalmic solution

1

OXERVATE OPHTHALMIC SOLUTION

3 PA; SP

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

1 MM

polymyxin b-trimethoprim ophthalmic solution

1

PRED MILD OPHTHALMIC SUSPENSION

2

PRED-G OPHTHALMIC SUSPENSION 3prednisolone acetate ophthalmic suspension

1

prednisolone sodium phosphate ophthalmic solution

1

PROLENSA OPHTHALMIC SOLUTION

3 ST; Maximum of 2 fills per year

proparacaine hcl ophthalmic solution

1

RESTASIS OPHTHALMIC EMULSION 2 PA; PA except ophthalmologist and

optometrist; QLRHOPRESSA OPHTHALMIC SOLUTION

3 ST

ROCKLATAN OPHTHALMIC SOLUTION

3 ST

SIMBRINZA OPHTHALMIC SUSPENSION

2

sulfacetamide sodium ophthalmic solution

1

timolol maleate ophthalmic gel forming solution

1

timolol maleate ophthalmic solution 0.25 %, 0.5 %

1 PL

tobramycin ophthalmic solution 1tobramycin-dexamethasone ophthalmic suspension

1

travoprost (bak free) ophthalmic solution

2

trifluridine ophthalmic solution 1tropicamide ophthalmic solution 1UPNEEQ OPHTHALMIC SOLUTION 3 PAVYZULTA OPHTHALMIC SOLUTION 3 ST

Drug Name Tier Notes Drug Name Tier Notes

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XIIDRA OPHTHALMIC SOLUTION 2 PA; PA except ophthalmology; QL

ZIOPTAN OPHTHALMIC SOLUTION 3ZIRGAN OPHTHALMIC GEL 3ZYLET OPHTHALMIC SUSPENSION 3

*Otic Agents*ACETASOL HC OTIC SOLUTION 1acetic acid otic solution 1CIPRO HC OTIC SUSPENSION 3 PA; PA except

otolaryngologyciprofloxacin hcl otic solution 1ciprofloxacin-dexamethasone otic suspension

2 PA; PA except otolaryngology

CORTISPORIN-TC OTIC SUSPENSION

3

fluocinolone acetonide otic oil 1hydrocortisone-acetic acid otic solution

1

neomycin-polymyxin-hc otic solution 3.5-10000-1

1

neomycin-polymyxin-hc otic suspension

1

ofloxacin otic solution 1

*Oxytocics*methylergonovine maleate oral tablet

1 QL

*Passive Immunizing And Treatment Agents*GAMASTAN INTRAMUSCULAR INJECTABLE

3 PA

*Penicillins*amoxicillin oral capsule 1 DFamoxicillin oral suspension reconstituted

1 DF

amoxicillin oral tablet 1 DFamoxicillin oral tablet chewable 125 mg, 250 mg

1 DF

amoxicillin-pot clavulanate er oral tablet extended release 12 hour

1 DF

amoxicillin-pot clavulanate oral suspension reconstituted

1 DF

amoxicillin-pot clavulanate oral tablet

1 DF

amoxicillin-pot clavulanate oral tablet chewable

1 DF

ampicillin oral capsule 500 mg 1dicloxacillin sodium oral capsule 1penicillin v potassium oral solution reconstituted

1

penicillin v potassium oral tablet 1 DF

*Progestins*medroxyprogesterone acetate oral tablet

1 MM

megestrol acetate oral suspension 625 mg/5ml

1 SP

norethindrone acetate oral tablet 2 MMprogesterone oral capsule 1 MM

*Psychotherapeutic And Neurological Agents - Misc.*acamprosate calcium oral tablet delayed release

1

AUBAGIO ORAL TABLET 2 PA; SP; PA except Neurology

AUSTEDO ORAL TABLET 3 PA; SPAVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT

3 PA; SP; PA except Neurology

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

3 PA; SP; PA except Neurology

BAFIERTAM ORAL CAPSULE DELAYED RELEASE

3 PA; SP

bupropion hcl er (smoking det) oral tablet extended release 12 hour

1 ACA; MM

chlordiazepoxide-amitriptyline oral tablet

1 MM; AL

dalfampridine er oral tablet extended release 12 hour

2 PA; SP

dimethyl fumarate oral capsule delayed release

1 PA; SP; PA except neurology

dimethyl fumarate starter pack oral

1 PA; SP; PA except neurology

disulfiram oral tablet 1 MMdonepezil hcl oral tablet 10 mg, 5 mg

2 MM

donepezil hcl oral tablet dispersible 2 MMergoloid mesylates oral tablet 2EXTAVIA SUBCUTANEOUS KIT 3 PA; SPfluoxetine hcl (pmdd) oral tablet 2galantamine hydrobromide er oral capsule extended release 24 hour

2 MM

galantamine hydrobromide oral solution

2 MM

galantamine hydrobromide oral tablet

2 MM

GILENYA ORAL CAPSULE 3 PA; SP; PA except Neurology

glatiramer acetate subcutaneous solution prefilled syringe

2 PA; SP; PA except Neurology

GLATOPA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

GRALISE ORAL TABLET 3 STINGREZZA ORAL CAPSULE 3 PA; LDDINGREZZA ORAL CAPSULE THERAPY PACK

3 PA; LDD

KESIMPTA SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

LUCEMYRA ORAL TABLET 3 PA; QLMAVENCLAD (10 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

MAVENCLAD (4 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

MAVENCLAD (5 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

MAVENCLAD (6 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

MAVENCLAD (7 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

MAVENCLAD (8 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

MAVENCLAD (9 TABS) ORAL TABLET THERAPY PACK

3 PA; LDD; QL

Drug Name Tier Notes Drug Name Tier Notes

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MAYZENT ORAL TABLET 3 PA; SP; PA except Neurology

MAYZENT STARTER PACK ORAL TABLET THERAPY PACK 12 X 0.25 MG

3 PA; SP; PA except neurology

memantine hcl er oral capsule extended release 24 hour

2 MM

memantine hcl oral solution 2 mg/ml

2 MM

memantine hcl oral tablet 10 mg, 5 mg

2 MM

memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg

2

NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK

3 ST

NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 ST

NICOTROL INHALATION INHALER 2 ACA; QLNICOTROL NS NASAL SOLUTION 2 ACA; QLNUEDEXTA ORAL CAPSULE 2 PA; SPolanzapine-fluoxetine hcl oral capsule

2 PA; PA except psychiatry; MM

paroxetine mesylate oral capsule 2perphenazine-amitriptyline oral tablet

1 MM; AL

pimozide oral tablet 2 MM; ALPLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PEN-INJECTOR

3 PA; SP; PA except Neurology

PLEGRIDY STARTER PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP; PA except Neurology

PLEGRIDY SUBCUTANEOUS SOLUTION PEN-INJECTOR

3 PA; SP; PA except Neurology

PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP; PA except Neurology

PONVORY ORAL TABLET 2 PA; SP; PA except neurology

PONVORY STARTER PACK ORAL TABLET THERAPY PACK

2 PA; SP; PA except neurology

pregabalin er oral tablet extended release 24 hour

3 MM

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP; PA except neurology

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA; SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; LDD

rivastigmine tartrate oral capsule 2 MMrivastigmine transdermal patch 24 hour

2 MM

SAVELLA ORAL TABLET 2 MMSAVELLA TITRATION PACK ORAL 2 MMTEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA; LDD

tetrabenazine oral tablet 2 PA; LDD; QLvarenicline tartrate oral tablet 1 ACA; AL

VUMERITY ORAL CAPSULE DELAYED RELEASE

3 PA; SP

XYREM ORAL SOLUTION 3 PA; LDDZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE THERAPY PACK

3 PA; SP

ZEPOSIA ORAL CAPSULE 3 PA; SPZEPOSIA STARTER KIT ORAL CAPSULE THERAPY PACK

3 PA; SP

*Respiratory Agents - Misc.*BRONCHITOL INHALATION CAPSULE

3 PA

ESBRIET ORAL CAPSULE 3 PA; SP; QLESBRIET ORAL TABLET 3 PA; SP; QLKALYDECO ORAL PACKET 3 PA; LDDKALYDECO ORAL TABLET 3 PA; LDDOFEV ORAL CAPSULE 3 PA; LDDORKAMBI ORAL PACKET 3 PA; LDD; ALORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

3 PA; LDD; AL

SYMDEKO ORAL TABLET THERAPY PACK

3 PA; LDD; AL

TRIKAFTA ORAL TABLET THERAPY PACK

3 PA; SP

*Sulfonamides*sulfadiazine oral tablet 2

*Tetracyclines*demeclocycline hcl oral tablet 2doxycycline hyclate oral capsule 100 mg

1

doxycycline hyclate oral capsule 50 mg

1 DF

doxycycline hyclate oral tablet 100 mg, 50 mg

1

doxycycline hyclate oral tablet 20 mg

1 DF

doxycycline monohydrate oral capsule 100 mg, 50 mg

1

doxycycline monohydrate oral suspension reconstituted

2 PA

minocycline hcl oral capsule 2tetracycline hcl oral capsule 2

*Thyroid Agents*ARMOUR THYROID ORAL TABLET 2 MMEUTHYROX ORAL TABLET 1 MMlevothyroxine sodium oral tablet 1 MMliothyronine sodium oral tablet 1 MMmethimazole oral tablet 1 MMNATURE-THROID ORAL TABLET 3 MMnp thyroid oral tablet 1 MMpropylthiouracil oral tablet 1 MMSYNTHROID ORAL TABLET 2 MMUNITHROID ORAL TABLET 1 MMWP THYROID ORAL TABLET 3 MM

*Ulcer Drugs/Antispasmodics/Anticholinergics*amoxicill-clarithro-lansopraz oral 1chlordiazepoxide-clidinium oral capsule

1 AL

cimetidine hcl oral solution 300 mg/5ml

1 MM

Drug Name Tier Notes Drug Name Tier Notes

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cimetidine oral tablet 300 mg, 400 mg, 800 mg

1 MM

CUVPOSA ORAL SOLUTION 3 ST; MMdicyclomine hcl oral capsule 1 MMdicyclomine hcl oral solution 2 MMdicyclomine hcl oral tablet 1 MMesomeprazole magnesium oral capsule delayed release

1 MM

famotidine oral suspension reconstituted

1 MM

famotidine oral tablet 20 mg, 40 mg

1 MM

glycopyrrolate oral tablet 1 mg, 2 mg

1 MM

HELIDAC THERAPY ORAL 3 PAhyoscyamine sulfate oral tablet 1 ALlansoprazole oral capsule delayed release 30 mg

1

methscopolamine bromide oral tablet

2

misoprostol oral tablet 1 MMnizatidine oral capsule 1 MMnizatidine oral solution 1 MMomeprazole oral capsule delayed release

1 MM

omeprazole-sodium bicarbonate oral capsule

3 ST

pantoprazole sodium oral tablet delayed release

1

pb-hyoscy-atropine-scopolamine oral tablet

1

phenobarbital-belladonna alk oral elixir

1

rabeprazole sodium oral tablet delayed release

1

sucralfate oral tablet 1 MM

*Urinary Antispasmodics*bethanechol chloride oral tablet 1darifenacin hydrobromide er oral tablet extended release 24 hour

2 MM; AL

flavoxate hcl oral tablet 1 MMGELNIQUE TRANSDERMAL GEL 10 %

3 MM; AL

MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER

3 AL

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR

3 MM

oxybutynin chloride er oral tablet extended release 24 hour

1 MM; AL

oxybutynin chloride oral syrup 1 MM; ALoxybutynin chloride oral tablet 1 MM; ALsolifenacin succinate oral tablet 1 MM; ALtolterodine tartrate er oral capsule extended release 24 hour

1 MM; AL

tolterodine tartrate oral tablet 1 MM; ALtrospium chloride er oral capsule extended release 24 hour

1 MM; AL

trospium chloride oral tablet 1 MM; ALVESICARE LS ORAL SUSPENSION 3 PA

*Vaginal And Related Products*CLEOCIN VAGINAL SUPPOSITORY 3clindamycin phosphate vaginal cream

1

ENDOMETRIN VAGINAL INSERT 3 QLestradiol vaginal cream 2estradiol vaginal tablet 1 MMESTRING VAGINAL RING 2 MMFEMRING VAGINAL RING 2GYNAZOLE-1 VAGINAL CREAM 3metronidazole vaginal gel 1NUVESSA VAGINAL GEL 3PREMARIN VAGINAL CREAM 2terconazole vaginal cream 1terconazole vaginal suppository 1YUVAFEM VAGINAL TABLET 1 MM

*Vasopressors*droxidopa oral capsule 3 PA; SP; LDDepinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml

1 QL

midodrine hcl oral tablet 2SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE

2 QL

*Vitamins*ergocalciferol oral capsule 1 MMphytonadione oral tablet 2vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)

1 MM

vitamin d3 oral capsule 1.25 mg (50000 ut)

2 OTC

Drug Name Tier Notes Drug Name Tier Notes

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INDEX

Index

abacavir sulfate ..................................................15abacavir sulfate-lamivudine ...............................15abacavir-lamivudine-zidovudine ........................15ABILIFY MYCITE ..................................................14ABILIFY MYCITE MAINTENANCE KIT ...................14ABILIFY MYCITE STARTER KIT .............................14abiraterone acetate ........................................... 12acamprosate calcium.........................................27acarbose .............................................................. 8ACCRUFER..........................................................23acebutolol hcl .................................................... 16acetaminophen-codeine ......................................4acetaminophen-codeine #2 .................................4acetaminophen-codeine #3 .................................4acetaminophen-codeine #4 .................................4ACETASOL HC.....................................................27acetazolamide ....................................................20acetazolamide er ............................................... 20acetic acid .......................................................... 27acetylcysteine .................................................... 18acitretin ............................................................. 18ACTEMRA.............................................................3ACTEMRA ACTPEN............................................... 3ACTIMMUNE......................................................12acyclovir .......................................................15, 18adapalene.......................................................... 18adapalene-benzoyl peroxide ............................. 18adefovir dipivoxil ............................................... 15ADEMPAS...........................................................16ADVAIR HFA......................................................... 6AEMCOLO.......................................................... 11AFEDITAB CR......................................................16AIMOVIG............................................................24AJOVY.................................................................24AKLIEF ................................................................ 18AKYNZEO............................................................10ALAWAY............................................................. 25ALAWAY CHILDRENS ALLERGY...........................25albendazole ..........................................................5albuterol sulfate .................................................. 6albuterol sulfate hfa ............................................ 6alclometasone dipropionate ..............................18ALDACTAZIDE.....................................................20ALECENSA.......................................................... 12alendronate sodium.......................................... 21alfuzosin hcl er ...................................................23ALINIA ................................................................ 11aliskiren fumarate ..............................................11allopurinol ..........................................................23almotriptan malate ............................................24ALOCRIL ............................................................. 25ALOMIDE............................................................25alosetron hcl ...................................................... 22alprazolam........................................................... 6alprazolam er .......................................................6ALTABAX............................................................ 18ALUNBRIG.......................................................... 12alyacen 7/7/7 .....................................................17amantadine hcl .................................................. 14ambrisentan .......................................................16amcinonide ........................................................ 18amiloride hcl ...................................................... 20

Index

amiloride-hydrochlorothiazide .......................... 20aminocaproic acid ..............................................23aminophylline ...................................................... 6amiodarone hcl ....................................................6amitriptyline hcl ...................................................8amlodipine besy-benazepril hcl .........................11amlodipine besylate .......................................... 16amlodipine-olmesartan ..................................... 11AMNESTEEM......................................................18amoxapine ........................................................... 8amoxicill-clarithro-lansopraz ............................. 28amoxicillin ..........................................................27amoxicillin-pot clavulanate ................................27amoxicillin-pot clavulanate er ........................... 27amphetamine sulfate ...........................................3amphetamine-dextroamphet er ..........................3amphetamine-dextroamphetamine.................... 3ampicillin ............................................................27anagrelide hcl .................................................... 23anastrozole ........................................................ 12ANDRODERM....................................................... 5ANGELIQ............................................................ 22ANNOVERA........................................................ 17apap-caff-dihydrocodeine ................................... 4APOKYN............................................................. 14apraclonidine hcl ............................................... 25aprepitant .......................................................... 10APTIOM................................................................7APTIVUS............................................................. 15ARANESP (ALBUMIN FREE) ................................ 23ARAZLO.............................................................. 18ARCALYST .............................................................3arformoterol tartrate ...........................................6ARIKAYCE............................................................. 3aripiprazole ........................................................14armodafinil .......................................................... 3ARMOUR THYROID............................................ 28ARNUITY ELLIPTA................................................. 6asenapine maleate ............................................ 14ASMANEX (120 METERED DOSES) ....................... 6ASMANEX (14 METERED DOSES) ......................... 6ASMANEX (30 METERED DOSES) ......................... 6ASMANEX (60 METERED DOSES) ......................... 6ASMANEX (7 METERED DOSES) ........................... 6ASMANEX HFA..................................................... 6aspirin-dipyridamole er ..................................... 23ASTAGRAF XL ..................................................... 24atazanavir sulfate .............................................. 15atenolol ..............................................................16atenolol-chlorthalidone..................................... 11atomoxetine hcl ...................................................3atorvastatin calcium.......................................... 10atovaquone........................................................11atovaquone-proguanil hcl ..................................12ATROVENT HFA....................................................6AUBAGIO............................................................27AURYXIA .............................................................22AUSTEDO........................................................... 27AVONEX PEN......................................................27AVONEX PREFILLED............................................27AYVAKIT ............................................................. 12AZASITE ..............................................................25

Index

azathioprine .......................................................24azelaic acid .........................................................18azelastine hcl ..................................................... 25AZELEX............................................................... 18azithromycin ...................................................... 24bacitracin ........................................................... 25bacitra-neomycin-polymyxin-hc ........................ 25baclofen ............................................................. 25BAFIERTAM........................................................ 27BALCOLTRA........................................................ 17balsalazide disodium..........................................22BALVERSA.......................................................... 12BAQSIMI ONE PACK............................................. 8BAQSIMI TWO PACK............................................ 8BARACLUDE....................................................... 15BELSOMRA.........................................................23benazepril hcl .....................................................11benazepril-hydrochlorothiazide ........................ 11BENLYSTA...........................................................24benzhydrocodone-acetaminophen..................... 4benznidazole ........................................................5benzonatate .......................................................18benzoyl peroxide ............................................... 18benztropine mesylate ........................................14bepotastine besilate .......................................... 26BESIVANCE.........................................................26betamethasone dipropionate ............................18betamethasone dipropionate aug ..................... 18betamethasone valerate ................................... 18betaxolol hcl ................................................ 16, 26bethanechol chloride .........................................29BETHKIS ................................................................3bexarotene ........................................................ 12bicalutamide ...................................................... 12BIDIL ...................................................................16BIKTARVY........................................................... 15bimatoprost ....................................................... 26bisoprolol fumarate ........................................... 16bisoprolol-hydrochlorothiazide ......................... 11BLEPHAMIDE......................................................26BONJESTA.......................................................... 10bosentan ............................................................16BOSULIF ............................................................. 12BRAFTOVI ...........................................................12BREO ELLIPTA.......................................................6briellyn ...............................................................17BRILINTA............................................................ 23brimonidine tartrate ..........................................26brinzolamide ......................................................26BRIVIACT.............................................................. 7bromfenac sodium (once-daily) .........................26bromocriptine mesylate .................................... 14BRONCHITOL ......................................................28BRUKINSA.......................................................... 12BRYHALI ............................................................. 18budesonide .............................................. 6, 17, 25budesonide er ....................................................17bumetanide ....................................................... 20buprenorphine .....................................................4buprenorphine hcl ............................................... 4buprenorphine hcl-naloxone hcl ......................... 4bupropion hcl .......................................................8

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Index

bupropion hcl er (smoking det) ......................... 27bupropion hcl er (sr) ............................................ 8bupropion hcl er (xl) ............................................ 8buspirone hcl ....................................................... 6butalbital-acetaminophen................................... 4butalbital-apap-caff-cod...................................... 4butalbital-apap-caffeine ...................................... 4butalbital-asa-caff-codeine ..................................4butorphanol tartrate ........................................... 4BYLVAY...............................................................22BYLVAY (PELLETS) .............................................. 22cabergoline ........................................................ 21CABOMETYX.......................................................12calcipotriene ...................................................... 18calcipotriene-betameth diprop......................... 18calcitonin (salmon) ............................................ 21calcitriol ....................................................... 18, 21CALQUENCE....................................................... 12candesartan cilexetil ..........................................11candesartan cilexetil-hctz .................................. 11capecitabine ...................................................... 12CAPLYTA.............................................................14CAPRELSA...........................................................12CARBAGLU......................................................... 21carbamazepine .................................................... 7carbamazepine er ................................................ 7carbidopa...........................................................14carbidopa-levodopa...........................................14carbidopa-levodopa er ...................................... 14carbidopa-levodopa-entacapone...................... 14carbinoxamine maleate ..................................... 10CARDURA XL ...................................................... 23carisoprodol .......................................................25carisoprodol-aspirin-codeine .............................25carteolol hcl ....................................................... 26CARTIA XT .......................................................... 16carvedilol ........................................................... 16carvedilol phosphate er ..................................... 16CAYSTON............................................................11CAZIANT.............................................................17cefaclor .............................................................. 17cefadroxil ........................................................... 17cefazolin sodium................................................17cefdinir ...............................................................17cefixime............................................................. 17cefpodoxime proxetil .........................................17cefprozil ............................................................. 17cefuroxime axetil ............................................... 17celecoxib .............................................................. 3CELONTIN.............................................................7cephalexin ..........................................................17CERDELGA..........................................................23CESIA ..................................................................17cevimeline hcl .................................................... 25CHEMET............................................................. 10CHENODAL.........................................................22chlordiazepoxide hcl ............................................ 6chlordiazepoxide-amitriptyline ..........................27chlordiazepoxide-clidinium................................28chlorhexidine gluconate .................................... 25chloroquine phosphate ......................................12chlorpromazine hcl ............................................ 14chlorthalidone................................................... 20chlorzoxazone....................................................25

Index

CHOLBAM.......................................................... 22cholestyramine .................................................. 10cholestyramine light .......................................... 10chorionic gonadotropin ..................................... 21ciclopirox ............................................................18ciclopirox olamine ..............................................18cilostazol ............................................................ 23CIMDUO.............................................................15cimetidine .......................................................... 29cimetidine hcl .................................................... 28CIMZIA ............................................................... 22CIMZIA PREFILLED..............................................22CIMZIA STARTER KIT .......................................... 22cinacalcet hcl ..................................................... 21CIPRO................................................................. 22CIPRO HC............................................................27ciprofloxacin hcl .....................................22, 26, 27ciprofloxacin-dexamethasone........................... 27citalopram hydrobromide ....................................8CITRANATAL BLOOM......................................... 25CLARAVIS ........................................................... 18clarithromycin ....................................................24clarithromycin er ............................................... 24clemastine fumarate ..........................................10CLENPIQ............................................................. 24CLEOCIN............................................................. 29clindamycin hcl .................................................. 12clindamycin palmitate hcl ..................................12clindamycin phos-benzoyl perox ....................... 18clindamycin phosphate ................................18, 29clobazam..............................................................7clobetasol propionate ........................................18clobetasol propionate e .....................................18clomiphene citrate .............................................21clomipramine hcl ................................................. 8clonazepam..........................................................7clonidine ............................................................ 11clonidine hcl .......................................................11clonidine hcl er .................................................... 3clopidogrel bisulfate .......................................... 23clorazepate dipotassium......................................6clotrimazole ................................................. 18, 25clotrimazole-betamethasone............................ 18clozapine ............................................................14COARTEM...........................................................12codeine sulfate .................................................... 4colchicine ........................................................... 23colchicine-probenecid ....................................... 23colesevelam hcl ................................................. 11colestipol hcl ......................................................11COMBIGAN........................................................ 26COMBIPATCH.....................................................22COMBIVENT RESPIMAT........................................6COMETRIQ (100 MG DAILY DOSE) ..................... 12COMETRIQ (140 MG DAILY DOSE) ..................... 12COMETRIQ (60 MG DAILY DOSE) ....................... 12COMPLERA.........................................................15CONDYLOX......................................................... 18constulose ..........................................................24CONTRAVE........................................................... 3COPIKTRA...........................................................12CORLANOR.........................................................16CORTISPORIN-TC................................................27COSENTYX.......................................................... 19

Index

COSENTYX (300 MG DOSE) ................................ 18COSENTYX SENSOREADY (300 MG) ................... 18COSENTYX SENSOREADY PEN............................ 18COTELLIC ............................................................12COTEMPLA XR-ODT..............................................3COVARYX............................................................22COVARYX HS ...................................................... 22CREON................................................................20CRIXIVAN............................................................15cromolyn sodium..................................... 6, 22, 26CROTAN............................................................. 19CUVPOSA........................................................... 29cyanocobalamin .................................................23cyclobenzaprine hcl ........................................... 25cyclophosphamide .............................................12cycloserine ......................................................... 12CYCLOSET.............................................................8cyclosporine .......................................................24cyclosporine modified ....................................... 24cyproheptadine hcl ............................................ 10CYSTADANE........................................................21CYSTADROPS......................................................26CYSTAGON......................................................... 23CYSTARAN..........................................................26dalfampridine er ................................................ 27DALIRESP..............................................................6danazol ................................................................ 5dantrolene sodium............................................ 25dapsone....................................................... 12, 19darifenacin hydrobromide er .............................29DAURISMO.........................................................12DAYVIGO............................................................23DEBACTEROL......................................................25deferasirox .........................................................10deferasirox granules .......................................... 10deferiprone........................................................10DELSTRIGO.........................................................15demeclocycline hcl .............................................28DENAVIR ............................................................ 19DESCOVY............................................................15desipramine hcl ................................................... 8desloratadine .....................................................10desmopressin ace spray refrig ...........................21desmopressin acetate ........................................21desmopressin acetate spray .............................. 21desogestrel-ethinyl estradiol ............................. 17desonide ............................................................ 19desoximetasone.................................................19desvenlafaxine succinate er .................................8dexamethasone................................................. 17DEXAMETHASONE INTENSOL............................ 17dexamethasone sodium phosphate .................. 26dexchlorpheniramine maleate .......................... 10dexmethylphenidate hcl ...................................... 3dexmethylphenidate hcl er ..................................3dextroamphetamine sulfate ................................ 3dextroamphetamine sulfate er ............................3DIACOMIT ............................................................ 7DIALYVITE ...........................................................25diazepam..........................................................6, 7diazoxide ..............................................................8diclofenac potassium...........................................3diclofenac sodium....................................3, 19, 26diclofenac sodium er ........................................... 3

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Index

dicloxacillin sodium............................................27dicyclomine hcl .................................................. 29DIFICID ............................................................... 24diflorasone diacetate .........................................19diflunisal .............................................................. 4DIGITEK.............................................................. 16DIGOX................................................................ 16digoxin ............................................................... 16dihydroergotamine mesylate ............................ 24DILANTIN..............................................................7diltiazem hcl .......................................................16diltiazem hcl er .................................................. 16diltiazem hcl er beads ........................................16diltiazem hcl er coated beads ............................ 16dilt-xr ................................................................. 16dimethyl fumarate .............................................27dimethyl fumarate starter pack .........................27DIPENTUM......................................................... 22diphenhydramine hcl .........................................10diphenoxylate-atropine ..................................... 10dipyridamole ......................................................23disopyramide phosphate ..................................... 6disulfiram...........................................................27DIURIL ................................................................ 21divalproex sodium............................................... 7divalproex sodium er ........................................... 7dofetilide ..............................................................6donepezil hcl ......................................................27DOPTELET .......................................................... 23dorzolamide hcl ................................................. 26dorzolamide hcl-timolol mal ..............................26DOVATO.............................................................15doxazosin mesylate ........................................... 11doxepin hcl .....................................................8, 23doxercalciferol ................................................... 21doxycycline ........................................................ 19doxycycline hyclate ............................................28doxycycline monohydrate ................................. 28doxylamine-pyridoxine ...................................... 10dronabinol ......................................................... 10drospiren-eth estrad-levomefol ........................ 17drospirenone-ethinyl estradiol .......................... 17DROXIA.............................................................. 23droxidopa...........................................................29DRYSOL.............................................................. 19DUAVEE..............................................................22duloxetine hcl ...................................................... 8DUOBRII ............................................................. 19DUOPA............................................................... 14DUPIXENT.......................................................... 19dutasteride ........................................................ 23dutasteride-tamsulosin hcl ................................ 23DYRENIUM......................................................... 21econazole nitrate ...............................................19EDARBI ............................................................... 11EDARBYCLOR......................................................11EDURANT........................................................... 15efavirenz ............................................................ 15efavirenz-emtricitab-tenofovir .......................... 15efavirenz-lamivudine-tenofovir ......................... 15ELESTRIN............................................................ 22eletriptan hydrobromide................................... 24ELIQUIS ................................................................ 7ELIQUIS DVT/PE STARTER PACK...........................7

Index

ELIXOPHYLLIN...................................................... 6ELLA................................................................... 17ELMIRON............................................................23ELURYNG............................................................17EMCYT................................................................12EMEND...............................................................10EMFLAZA............................................................17EMSAM................................................................ 8emtricitabine ..................................................... 15emtricitabine-tenofovir df ................................. 15EMTRIVA............................................................ 15EMVERM..............................................................5enalapril maleate ...............................................11enalapril-hydrochlorothiazide ........................... 11ENBREL .................................................................3ENBREL MINI ........................................................3ENBREL SURECLICK .............................................. 3ENDOMETRIN.................................................... 29enoxaparin sodium.............................................. 7ENSPRYNG......................................................... 24entacapone........................................................14entecavir ............................................................ 15ENTRESTO.......................................................... 16enulose .............................................................. 22ENVARSUS XR.................................................... 24EPCLUSA.............................................................15EPIDIOLEX............................................................ 7EPIDUO FORTE................................................... 19epinastine hcl .....................................................26epinephrine ....................................................... 29EPITOL ..................................................................7EPIVIR HBV.........................................................15eplerenone........................................................ 11ergocalciferol ..................................................... 29ergoloid mesylates .............................................27ERGOMAR..........................................................24ergotamine-caffeine .......................................... 24ERIVEDGE...........................................................12ERLEADA............................................................ 12erlotinib hcl ........................................................12ERYTHROCIN STEARATE.....................................24erythromycin ............................................... 19, 26erythromycin base .............................................24erythromycin ethylsuccinate ............................. 24ESBRIET .............................................................. 28escitalopram oxalate ........................................... 8esomeprazole magnesium.................................29est estrogens-methyltest ...................................22est estrogens-methyltest ds .............................. 22est estrogens-methyltest hs .............................. 22estazolam...........................................................23estradiol .......................................................22, 29estradiol-norethindrone acet ............................ 22ESTRING............................................................. 29ESTROGEL .......................................................... 22eszopiclone ........................................................ 23ethacrynic acid ...................................................21ethambutol hcl .................................................. 12ethosuximide ....................................................... 7ethynodiol diac-eth estradiol .............................17etodolac ...............................................................3etoposide ...........................................................12etravirine ........................................................... 15EUCRISA............................................................. 19

Index

EUTHYROX......................................................... 28EVAMIST ............................................................ 22everolimus ................................................... 12, 24EVOTAZ.............................................................. 15EVRYSDI ............................................................. 25exemestane ....................................................... 12EXSERVAN.......................................................... 25EXTAVIA............................................................. 27ezetimibe ........................................................... 11ezetimibe-simvastatin ....................................... 11FABIOR...............................................................19famciclovir ......................................................... 15famotidine ......................................................... 29FANAPT.............................................................. 14FANAPT TITRATION PACK.................................. 14FARXIGA...............................................................8FARYDAK............................................................ 12FASENRA PEN.......................................................6febuxostat ..........................................................23felbamate .............................................................7felodipine er ...................................................... 16FEMCAP............................................................. 24FEMRING............................................................29fenofibrate .........................................................11fenofibrate micronized ...................................... 11fenofibric acid .................................................... 11fenoprofen calcium..............................................3fentanyl ................................................................4fentanyl citrate .................................................... 4FERRIPROX......................................................... 10FERRIPROX TWICE-A-DAY.................................. 10FETZIMA...............................................................8FINACEA............................................................. 19finasteride ..........................................................23FINTEPLA..............................................................7FIRDAPSE........................................................... 12FIRVANQ............................................................ 12FLAREX............................................................... 26flavoxate hcl .......................................................29flecainide acetate ................................................ 6FLOVENT DISKUS..................................................6FLOVENT HFA.......................................................6fluconazole ........................................................ 10flucytosine ......................................................... 10fludrocortisone acetate ..................................... 17flunisolide .......................................................... 25fluocinolone acetonide ................................ 19, 27fluocinolone acetonide body ............................. 19fluocinolone acetonide scalp .............................19fluocinonide .......................................................19fluorometholone ................................................26FLUOROPLEX......................................................19fluorouracil ........................................................ 19fluoxetine hcl ....................................................... 8fluoxetine hcl (pmdd) ........................................ 27fluphenazine decanoate .................................... 14fluphenazine hcl .................................................14flurandrenolide ..................................................19flurazepam hcl ................................................... 23flurbiprofen ..........................................................3flurbiprofen sodium...........................................26flutamide ........................................................... 12fluticasone propionate .................................19, 25fluticasone-salmeterol .........................................6

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Index

fluvastatin sodium............................................. 11fluvoxamine maleate ........................................... 8FML.................................................................... 26FML FORTE.........................................................26folic acid .............................................................23FOLLISTIM AQ.................................................... 21fondaparinux sodium...........................................7formoterol fumarate ............................................6FORTEO..............................................................21fosamprenavir calcium...................................... 15fosfomycin tromethamine.................................12fosinopril sodium............................................... 11FOTIVDA.............................................................12FRAGMIN............................................................. 7frovatriptan succinate ....................................... 24furosemide.........................................................21FUZEON..............................................................15FYCOMPA.............................................................7gabapentin ...........................................................7GALAFOLD..........................................................21galantamine hydrobromide...............................27galantamine hydrobromide er ...........................27GAMASTAN........................................................27ganirelix acetate ................................................ 21gatifloxacin ........................................................ 26GAVRETO........................................................... 12GELNIQUE.......................................................... 29gemfibrozil .........................................................11GEMMILY ........................................................... 17generlac ............................................................. 22GENGRAF........................................................... 25GENOTROPIN..................................................... 21GENOTROPIN MINIQUICK..................................21gentamicin sulfate ....................................... 19, 26GENVOYA...........................................................15GILENYA............................................................. 27GILOTRIF ............................................................ 13glatiramer acetate ............................................. 27GLATOPA............................................................27GLEOSTINE......................................................... 13glimepiride ...........................................................8glipizide ................................................................8glipizide er ............................................................8glipizide xl ............................................................ 8glipizide-metformin hcl ........................................8GLUCAGEN HYPOKIT ............................................8glucagon emergency ............................................8glyburide ..............................................................8glyburide micronized ........................................... 8glyburide-metformin ........................................... 8glycopyrrolate ....................................................29GLYXAMBI ............................................................ 8GOCOVRI ............................................................14GRALISE ..............................................................27granisetron hcl ...................................................10griseofulvin microsize ........................................ 10griseofulvin ultramicrosize ................................ 10guanfacine hcl ....................................................11guanfacine hcl er ................................................. 3GVOKE HYPOPEN 1-PACK.................................... 8GVOKE HYPOPEN 2-PACK.................................... 9GVOKE PFS ........................................................... 9GYNAZOLE-1 ...................................................... 29HAEGARDA.........................................................23

Index

halobetasol propionate ..................................... 19haloperidol .........................................................14haloperidol lactate .............................................14HARVONI ............................................................15HELIDAC THERAPY............................................. 29HEMANGEOL......................................................16heparin sodium (porcine) .................................... 7HETLIOZ ............................................................. 23HETLIOZ LQ........................................................ 23HUMALOG........................................................... 9HUMALOG JUNIOR KWIKPEN.............................. 9HUMALOG KWIKPEN........................................... 9HUMALOG MIX 50/50 ..........................................9HUMALOG MIX 50/50 KWIKPEN..........................9HUMALOG MIX 75/25 ..........................................9HUMALOG MIX 75/25 KWIKPEN..........................9HUMIRA............................................................... 3HUMIRA PEDIATRIC CROHNS START....................3HUMIRA PEN........................................................3HUMIRA PEN-CD/UC/HS STARTER.......................3HUMIRA PEN-PS/UV/ADOL HS START................. 3HUMULIN 70/30 .................................................. 9HUMULIN 70/30 KWIKPEN.................................. 9HUMULIN N......................................................... 9HUMULIN N KWIKPEN......................................... 9HUMULIN R ..........................................................9HUMULIN R U-500 (CONCENTRATED) ................. 9HUMULIN R U-500 KWIKPEN............................... 9HYCAMTIN......................................................... 13hydralazine hcl ...................................................11hydrochlorothiazide ...........................................21hydrocod polst-cpm polst er ..............................18hydrocodone bitartrate er ...................................4hydrocodone-acetaminophen............................. 4hydrocodone-ibuprofen ...................................4, 5hydrocortisone .........................................5, 17, 19hydrocortisone butyr lipo base ..........................19hydrocortisone butyrate ....................................19hydrocortisone valerate .................................... 19hydrocortisone-acetic acid ................................ 27hydromorphone hcl ............................................. 5hydromorphone hcl er .........................................5hydroxychloroquine sulfate ...............................12hydroxyurea .......................................................13hydroxyzine hcl ....................................................6hydroxyzine pamoate .......................................... 6hyoscyamine sulfate .......................................... 29HYSINGLA ER ........................................................5ibandronate sodium.......................................... 21IBRANCE.............................................................13ibuprofen ............................................................. 4icatibant acetate ................................................23ICLUSIG.............................................................. 13IDHIFA................................................................ 13ILEVRO............................................................... 26imatinib mesylate .............................................. 13IMBRUVICA........................................................ 13IMCIVREE............................................................. 3imipramine hcl .....................................................8imiquimod..........................................................19INBRIJA ...............................................................14INCRELEX............................................................21indapamide ........................................................21indomethacin .......................................................4

Index

indomethacin er .................................................. 4INGREZZA...........................................................27INLYTA................................................................13INQOVI ...............................................................13INREBIC .............................................................. 13INTELENCE......................................................... 15INTRON A........................................................... 13INVELTYS ............................................................26INVIRASE ............................................................ 15iodoquinol-hydrocortisone-aloe ........................19ipratropium bromide..................................... 6, 25ipratropium-albuterol ..........................................6irbesartan .......................................................... 11irbesartan-hydrochlorothiazide .........................11IRESSA................................................................ 13ISENTRESS .......................................................... 15ISENTRESS HD.................................................... 15isoniazid ............................................................. 12ISORDIL TITRADOSE............................................. 5isosorbide dinitrate ..............................................5isosorbide mononitrate ....................................... 5isosorbide mononitrate er ...................................5isotretinoin ........................................................ 19isradipine ........................................................... 16ISTURISA............................................................ 21itraconazole ....................................................... 10ivermectin ......................................................5, 19JAIMIESS ............................................................ 17JAKAFI ................................................................ 13JANTOVEN............................................................7JARDIANCE...........................................................9JENTADUETO........................................................9JENTADUETO XR.................................................. 9JINTELI ................................................................22JUBLIA ................................................................ 19JULUCA...............................................................15JUXTAPID........................................................... 11JYNARQUE..........................................................21KALYDECO..........................................................28KERENDIA...........................................................21KESIMPTA.......................................................... 27ketoconazole ................................................10, 19ketoprofen er .......................................................4ketorolac tromethamine ................................4, 26ketotifen fumarate ............................................ 26KEVEYIS .............................................................. 21KEVZARA.............................................................. 4KINERET............................................................... 4KISQALI (200 MG DOSE) .....................................13KISQALI (400 MG DOSE) .....................................13KISQALI (600 MG DOSE) .....................................13KISQALI FEMARA (400 MG DOSE) ......................13KISQALI FEMARA (600 MG DOSE) ......................13KISQALI FEMARA(200 MG DOSE) .......................13KITABIS PAK......................................................... 3KLOR-CON.......................................................... 24KLOR-CON 10 ..................................................... 24KLOR-CON M10..................................................24KLOR-CON M15..................................................24KLOR-CON M20..................................................24KLOXXADO......................................................... 10KORLYM............................................................... 9KOSELUGO......................................................... 13KRISTALOSE........................................................24

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Index

KYNMOBI ........................................................... 14KYNMOBI TITRATION KIT ................................... 14labetalol hcl ....................................................... 16lactulose .............................................................24lactulose encephalopathy ..................................22lamivudine ......................................................... 15lamivudine-zidovudine ...................................... 15lamotrigine .......................................................... 7lamotrigine er ...................................................... 7lamotrigine starter kit-blue ..................................7lamotrigine starter kit-green............................... 7lamotrigine starter kit-orange............................. 7LAMPIT ...............................................................12LANOXIN............................................................ 16lansoprazole .......................................................29lanthanum carbonate ........................................ 22LANTUS................................................................ 9LANTUS SOLOSTAR.............................................. 9lapatinib ditosylate ............................................ 13LASTACAFT.........................................................26latanoprost ........................................................ 26LATUDA..............................................................14LAZANDA..............................................................5ledipasvir-sofosbuvir ..........................................15LEENA.................................................................17leflunomide..........................................................4LENVIMA (10 MG DAILY DOSE) ..........................13LENVIMA (12 MG DAILY DOSE) ..........................13LENVIMA (14 MG DAILY DOSE) ..........................13LENVIMA (18 MG DAILY DOSE) ..........................13LENVIMA (20 MG DAILY DOSE) ..........................13LENVIMA (24 MG DAILY DOSE) ..........................13LENVIMA (4 MG DAILY DOSE) ............................13LENVIMA (8 MG DAILY DOSE) ............................13letrozole .............................................................13leucovorin calcium.............................................13LEUKERAN..........................................................13leuprolide acetate ..............................................13levalbuterol hcl .................................................... 6levalbuterol tartrate ............................................ 6LEVEMIR...............................................................9LEVEMIR FLEXTOUCH...........................................9levetiracetam.......................................................7levetiracetam er ...................................................7levobunolol hcl .................................................. 26levocetirizine dihydrochloride ........................... 10levofloxacin ..................................................22, 26levonorgest-eth est & eth est ............................17levonorgest-eth estrad 91-day .......................... 17levonorgestrel ....................................................17levonorgestrel-ethinyl estrad ............................ 17levothyroxine sodium........................................ 28LEXIVA................................................................15lidocaine ............................................................ 19lidocaine hcl ................................................. 19, 25lidocaine-hydrocortisone ace .............................. 5lidocaine-prilocaine ........................................... 19LIDOCARE ARM/NECK/LEG................................ 19LIDOCARE BACK/SHOULDER.............................. 20lincomycin hcl .................................................... 12lindane............................................................... 20linezolid ..............................................................12LINZESS .............................................................. 22liothyronine sodium...........................................28

Index

lisinopril ............................................................. 11lisinopril-hydrochlorothiazide ............................11lithium carbonate .............................................. 14lithium carbonate er .......................................... 14LIVALO............................................................... 11LO LOESTRIN FE ................................................. 17LOJAIMIESS ........................................................ 17LOKELMA........................................................... 25LONSURF............................................................13lopinavir-ritonavir ..............................................15lorazepam............................................................ 6LORBRENA......................................................... 13losartan potassium............................................ 11losartan potassium-hctz .................................... 11loteprednol etabonate .......................................26lovastatin ........................................................... 11loxapine succinate ............................................. 14lubiprostone...................................................... 22LUCEMYRA.........................................................27LUMAKRAS.........................................................13LUPKYNIS ........................................................... 25LYNPARZA.......................................................... 13LYSODREN..........................................................13LYUMJEV.............................................................. 9LYUMJEV KWIKPEN..............................................9malathion ...........................................................20MARPLAN.............................................................8MATULANE........................................................ 13MATZIM LA........................................................ 16MAVENCLAD (10 TABS) ......................................27MAVENCLAD (4 TABS) ........................................27MAVENCLAD (5 TABS) ........................................27MAVENCLAD (6 TABS) ........................................27MAVENCLAD (7 TABS) ........................................27MAVENCLAD (8 TABS) ........................................27MAVENCLAD (9 TABS) ........................................27MAVYRET........................................................... 15MAXIDEX............................................................26MAYZENT........................................................... 28MAYZENT STARTER PACK...................................28meclizine hcl ...................................................... 10meclofenamate sodium.......................................4medroxyprogesterone acetate .......................... 27mefenamic acid ................................................... 4mefloquine hcl ...................................................12megestrol acetate ........................................13, 27MEKINIST ........................................................... 13MEKTOVI ............................................................13meloxicam........................................................... 4melphalan .......................................................... 13memantine hcl ...................................................28memantine hcl er ...............................................28MENEST............................................................. 22MENOPUR..........................................................21MENOSTAR........................................................ 22MENTAX.............................................................20meprobamate ......................................................6mercaptopurine .................................................13mesalamine ....................................................... 22mesalamine er ................................................... 22mesalamine-cleanser .........................................22MESNEX............................................................. 13metaxalone ........................................................25metformin hcl ...................................................... 9

Index

metformin hcl er ..................................................9methadone hcl .....................................................5methazolamide ..................................................21methenamine hippurate ....................................12methimazole ......................................................28methocarbamol ................................................. 25methotrexate .....................................................13methotrexate sodium........................................13methotrexate sodium (pf) ................................. 13methoxsalen rapid .............................................20methscopolamine bromide ............................... 29methyldopa ........................................................11methylergonovine maleate ............................... 27methylphenidate hcl ............................................3methylphenidate hcl er ....................................... 3methylphenidate hcl er (cd) ................................ 3methylphenidate hcl er (la) ................................. 3methylprednisolone .......................................... 17methyltestosterone............................................. 5metoclopramide hcl ...........................................22metolazone........................................................21metoprolol succinate er .....................................16metoprolol tartrate ............................................16metoprolol-hydrochlorothiazide ....................... 11metronidazole ........................................12, 20, 29metyrosine .........................................................11mexiletine hcl ...................................................... 6MICROGESTIN FE 1.5/30 ....................................17midazolam hcl ....................................................23midodrine hcl .....................................................29mifepristone...................................................... 21miglitol .................................................................9miglustat ............................................................23MILLIPRED..........................................................17minocycline hcl .................................................. 28minoxidil ............................................................ 11mirtazapine ..........................................................8misoprostol ........................................................29modafinil ..............................................................3moexipril hcl ...................................................... 11mometasone furoate .........................................20montelukast sodium............................................ 6morphine sulfate ................................................. 5morphine sulfate (concentrate) ...........................5morphine sulfate er ............................................. 5morphine sulfate er beads ...................................5MOVANTIK .........................................................22moxifloxacin hcl ........................................... 22, 26MOZOBIL ............................................................23MULPLETA......................................................... 23MULTAQ.............................................................. 6MULTIGEN PLUS................................................ 23mupirocin ...........................................................20mupirocin calcium............................................. 20MYALEPT............................................................21MYCAPSSA......................................................... 21mycophenolate mofetil ..................................... 25mycophenolate sodium..................................... 25MYDAYIS .............................................................. 3MYFEMBREE...................................................... 22MYORISAN......................................................... 20MYRBETRIQ........................................................29MYTESI ............................................................... 10nabumetone........................................................ 4

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Index

nadolol ...............................................................16naftifine hcl ........................................................20naloxone hcl .......................................................10naltrexone hcl .................................................... 10NAMZARIC ......................................................... 28naproxen..............................................................4naproxen sodium er .............................................4naratriptan hcl ................................................... 24NARCAN............................................................. 10NATACYN........................................................... 26NATAZIA .............................................................17nateglinide ........................................................... 9NATPARA........................................................... 21NATURE-THROID................................................28NAYZILAM............................................................ 7nebivolol hcl .......................................................16nefazodone hcl .................................................... 8neomycin sulfate ................................................. 3neomycin-bacitracin zn-polymyx .......................26neomycin-polymyxin-dexameth........................ 26neomycin-polymyxin-hc .................................... 27NEO-SYNALAR....................................................20NEPHRONEX.......................................................25NERLYNX............................................................ 13NEULASTA..........................................................23NEUPRO............................................................. 14nevirapine ..........................................................15nevirapine er ......................................................15NEXAVAR........................................................... 13NEXLETOL...........................................................11NEXLIZET ............................................................ 11nicardipine hcl ................................................... 16NICOTROL.......................................................... 28NICOTROL NS ..................................................... 28nifedipine ...........................................................16nifedipine er .......................................................16nifedipine er osmotic release ............................ 16nilutamide..........................................................13nimodipine .........................................................16NINLARO............................................................ 13nisoldipine er ..................................................... 16nitisinone........................................................... 21NITRO-BID............................................................5NITRO-DUR.......................................................... 5nitrofurantoin .................................................... 12nitrofurantoin macrocrystal .............................. 12nitrofurantoin monohyd macro .........................12nitroglycerin .........................................................5NITYR................................................................. 21NIVESTYM.......................................................... 23nizatidine ........................................................... 29norethin ace-eth estrad-fe ................................ 17norethindrone................................................... 17norethindrone acetate ...................................... 27norethindrone acet-ethinyl est ..........................17norethindrone-eth estradiol ..............................22norethin-eth estradiol-fe ................................... 17norgestimate-eth estradiol ................................17norgestim-eth estrad triphasic .......................... 17NORPACE CR........................................................ 6nortriptyline hcl ................................................... 8NORVIR .............................................................. 15NOXAFIL ............................................................. 10np thyroid .......................................................... 28

Index

NUBEQA.............................................................13NUCALA................................................................6NUCYNTA............................................................. 5NUCYNTA ER........................................................ 5NUEDEXTA......................................................... 28NUPLAZID...........................................................14NURTEC..............................................................24NUVESSA............................................................29nystatin .................................................. 10, 20, 25nystatin-triamcinolone...................................... 20OCALIVA.............................................................22octreotide acetate ............................................. 21ODEFSEY ............................................................ 15ODOMZO........................................................... 13OFEV.................................................................. 28ofloxacin .................................................22, 26, 27olanzapine ......................................................... 14olanzapine-fluoxetine hcl .................................. 28olmesartan medoxomil ......................................11olmesartan medoxomil-hctz ..............................11olmesartan-amlodipine-hctz ............................. 11olopatadine hcl ............................................ 25, 26omeprazole ........................................................29omeprazole-sodium bicarbonate ...................... 29OMNIPOD DASH 5 PACK PODS.......................... 24ondansetron...................................................... 10ondansetron hcl .................................................10ONGENTYS......................................................... 14ONUREG.............................................................13opium.................................................................10OPSUMIT ............................................................16ORAVIG.............................................................. 25ORENCIA.............................................................. 4ORENCIA CLICKJECT ............................................. 4ORENITRAM.......................................................16ORFADIN............................................................ 21ORGOVYX...........................................................13ORIAHNN........................................................... 22ORILISSA.............................................................21ORKAMBI ........................................................... 28ORLADEYO......................................................... 23orphenadrine citrate er ..................................... 25oseltamivir phosphate ....................................... 15OSMOLEX ER ......................................................14OSMOPREP........................................................ 24OSPHENA........................................................... 21OTEZLA.................................................................4OTREXUP..............................................................4OVIDREL .............................................................21oxandrolone .........................................................5oxaprozin ............................................................. 4oxazepam.............................................................6OXBRYTA............................................................23oxcarbazepine ......................................................7OXERVATE..........................................................26oxiconazole nitrate ............................................ 20OXISTAT............................................................. 20OXTELLAR XR........................................................7oxybutynin chloride ........................................... 29oxybutynin chloride er .......................................29oxycodone hcl ......................................................5oxycodone hcl er ..................................................5oxycodone-acetaminophen.................................5OXYCONTIN..........................................................5

Index

oxymorphone hcl .................................................5oxymorphone hcl er .............................................5OZEMPIC (0.25 OR 0.5 MG/DOSE) .......................9OZEMPIC (1 MG/DOSE) ........................................9PACERONE........................................................... 6paliperidone er .................................................. 14PALYNZIQ........................................................... 21PANRETIN.......................................................... 20pantoprazole sodium.........................................29paricalcitol ......................................................... 21paromomycin sulfate ...........................................3paroxetine hcl ...................................................... 8paroxetine hcl er ..................................................8paroxetine mesylate .......................................... 28PASER.................................................................12pb-hyoscy-atropine-scopolamine ...................... 29peg 3350-kcl-na bicarb-nacl ...............................24PEGASYS .............................................................15PEMAZYRE......................................................... 13penicillamine ..................................................... 25penicillin v potassium........................................ 27pentamidine isethionate ................................... 12PENTASA............................................................ 22pentoxifylline er .................................................23perindopril erbumine .........................................11permethrin .........................................................20perphenazine .....................................................14perphenazine-amitriptyline ............................... 28PEXEVA................................................................ 8phenazopyridine hcl .......................................... 23phenelzine sulfate ............................................... 8phenobarbital .................................................... 23phenobarbital-belladonna alk ........................... 29phenoxybenzamine hcl ......................................11phenytoin .............................................................7phenytoin sodium extended................................7PHOSLYRA.......................................................... 22PHYSIOLYTE ........................................................25PHYSIOSOL IRRIGATION.....................................25phytonadione.................................................... 29PIFELTRO............................................................15pilocarpine hcl ............................................. 25, 26pimecrolimus ..................................................... 20pimozide ............................................................ 28pindolol ..............................................................16pioglitazone hcl ....................................................9pioglitazone hcl-glimepiride ................................ 9pioglitazone hcl-metformin hcl ............................9PIQRAY (200 MG DAILY DOSE) ...........................13PIQRAY (250 MG DAILY DOSE) ...........................13PIQRAY (300 MG DAILY DOSE) ...........................13piroxicam............................................................. 4PLEGRIDY........................................................... 28PLEGRIDY STARTER PACK...................................28podofilox ............................................................20polymyxin b-trimethoprim................................ 26POMALYST ......................................................... 13PONVORY...........................................................28PONVORY STARTER PACK.................................. 28posaconazole ..................................................... 10potassium chloride ............................................ 24potassium chloride crys er .................................24potassium chloride er ........................................ 24potassium citrate er ...........................................23

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Index

PRADAXA............................................................. 7PRALUENT..........................................................11pramipexole dihydrochloride ............................ 14pramipexole dihydrochloride er ........................ 14prasugrel hcl ...................................................... 23pravastatin sodium............................................ 11praziquantel .........................................................5prazosin hcl ........................................................11PRED MILD......................................................... 26PRED-G...............................................................26prednicarbate .................................................... 20prednisolone......................................................17prednisolone acetate .........................................26prednisolone sodium phosphate ................. 18, 26prednisone.........................................................18pregabalin ............................................................7pregabalin er ......................................................28PREMARIN....................................................22, 29PREMPHASE.......................................................22PREMPRO...........................................................22prenatal ............................................................. 25prenatal 19 ........................................................ 25prenatal plus ......................................................25prenatal plus iron ...............................................25prenatal vitamin ................................................ 25prenatal vitamins ...............................................25PRENATAL-U...................................................... 25pretomanid ........................................................ 12PREVYMIS .......................................................... 15PREZCOBIX ......................................................... 15PREZISTA............................................................15PRIFTIN.............................................................. 12primidone............................................................ 7PRIMSOL............................................................ 12probenecid .........................................................23prochlorperazine ............................................... 14prochlorperazine maleate ................................. 14PROCYSBI ........................................................... 23progesterone..................................................... 27PROLENSA..........................................................26PROMACTA........................................................ 23promethazine hcl ...............................................10promethazine vc/codeine ..................................18promethazine-codeine ...................................... 18promethazine-phenylephrine ............................18propafenone hcl .................................................. 6propafenone hcl er .............................................. 6proparacaine hcl ................................................ 26propranolol hcl .................................................. 16propranolol hcl er .............................................. 16propylthiouracil ................................................. 28protriptyline hcl ................................................... 8PULMICORT FLEXHALER.......................................6pyrazinamide..................................................... 12pyridostigmine bromide.................................... 12pyridostigmine bromide er ................................ 12pyrimethamine.................................................. 12QBREXZA............................................................20QELBREE...............................................................3QINLOCK............................................................ 13QSYMIA................................................................3quazepam.......................................................... 23quetiapine fumarate ..........................................15quetiapine fumarate er ......................................15

Index

QUILLICHEW ER................................................... 3quinapril hcl ....................................................... 11quinapril-hydrochlorothiazide ........................... 11quinidine gluconate er .........................................6quinidine sulfate .................................................. 6quinine sulfate ................................................... 12QVAR REDIHALER.................................................6rabeprazole sodium...........................................29raloxifene hcl ..................................................... 21ramelteon.......................................................... 23ramipril .............................................................. 11ranolazine er ........................................................5rasagiline mesylate ............................................ 14RASUVO............................................................... 4RAVICTI .............................................................. 21RAYALDEE.......................................................... 21RAYOS................................................................ 18REBIF ..................................................................28REBIF REBIDOSE.................................................28REBIF REBIDOSE TITRATION PACK..................... 28REBIF TITRATION PACK...................................... 28RECTIV ..................................................................5REDITREX............................................................. 4REGRANEX......................................................... 20RELENZA DISKHALER..........................................15RELISTOR............................................................22repaglinide ...........................................................9REPATHA............................................................11REPATHA PUSHTRONEX SYSTEM....................... 11REPATHA SURECLICK ..........................................11RESTASIS ............................................................ 26RETACRIT ........................................................... 23RETEVMO...........................................................13REVLIMID........................................................... 25REXULTI ..............................................................15REYATAZ.............................................................15REYVOW.............................................................24REZUROCK..........................................................25RHOPRESSA........................................................26ribavirin ..............................................................15RIDAURA.............................................................. 4rifabutin ............................................................. 12rifampin ............................................................. 12riluzole ............................................................... 25rimantadine hcl ..................................................15RINVOQ................................................................4RIOMET................................................................ 9risedronate sodium............................................21risperidone.........................................................15ritonavir ............................................................. 15rivastigmine ....................................................... 28rivastigmine tartrate ..........................................28rizatriptan benzoate .......................................... 24ROCKLATAN....................................................... 26ropinirole hcl ......................................................14ropinirole hcl er ................................................. 14rosuvastatin calcium..........................................11ROZLYTREK.........................................................13RUBRACA........................................................... 13rufinamide ........................................................... 8RUKOBIA............................................................ 15RUZURGI ............................................................ 12RYBELSUS............................................................. 9RYDAPT.............................................................. 13

Index

SAIZEN................................................................21SANCUSO........................................................... 10SANDIMMUNE................................................... 25SANTYL ...............................................................20sapropterin dihydrochloride ..............................21SAVELLA............................................................. 28SAVELLA TITRATION PACK................................. 28SAXENDA..............................................................3scopolamine .......................................................10selegiline hcl ...................................................... 14selenium sulfide .................................................20SELZENTRY......................................................... 15SEREVENT DISKUS................................................6SEROSTIM.......................................................... 21sertraline hcl ........................................................ 8sevelamer carbonate ......................................... 22sevelamer hcl .....................................................22sf 5000 plus ........................................................25SFROWASA.........................................................22SIGNIFOR........................................................... 21SIKLOS................................................................ 23sildenafil citrate ........................................... 16, 17SILIQ...................................................................20silodosin .............................................................23silver sulfadiazine .............................................. 20SIMBRINZA.........................................................26SIMPONI ...............................................................4simvastatin .........................................................11sirolimus ............................................................ 25SIRTURO.............................................................12SIVEXTRO........................................................... 12SKYRIZI ............................................................... 20SKYRIZI (150 MG DOSE) ..................................... 20SKYRIZI PEN........................................................20SLYND.................................................................17sodium chloride ........................................... 18, 23sodium phenylbutyrate ..................................... 21sodium polystyrene sulfonate ........................... 25sofosbuvir-velpatasvir ....................................... 15SOLIA ..................................................................17solifenacin succinate ..........................................29SOLIQUA.............................................................. 9SOLOSEC.............................................................. 3SOMATULINE DEPOT......................................... 21SOMAVERT.........................................................21SOOLANTRA....................................................... 20SORINE...............................................................16sotalol hcl ...........................................................16sotalol hcl (af) .................................................... 16SOTYLIZE ............................................................ 16SOVALDI .............................................................15spinosad.............................................................20SPIRIVA HANDIHALER.......................................... 6SPIRIVA RESPIMAT...............................................7spironolactone...................................................21spironolactone-hctz ........................................... 21SPRIX ....................................................................4SPRYCEL ............................................................. 13SPS ..................................................................... 25SSKI .................................................................... 18stavudine ........................................................... 15STIMATE.............................................................21STIOLTO RESPIMAT..............................................7STIVARGA...........................................................13

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Index

STRENSIQ........................................................... 21STRIBILD.............................................................15STRIVERDI RESPIMAT...........................................7SUCRAID.............................................................20sucralfate ........................................................... 29sulconazole nitrate ............................................ 20sulfacetamide sodium..................................20, 26sulfacetamide sodium (acne) .............................20sulfacetamide sodium-sulfur ............................. 20sulfadiazine ........................................................28sulfamethoxazole-trimethoprim....................... 12SULFAMYLON.....................................................20sulfasalazine .......................................................22sulindac ................................................................4sumatriptan ....................................................... 24sumatriptan succinate ....................................... 24sumatriptan succinate refill ............................... 24sunitinib malate ................................................. 13SUNOSI .................................................................3SUPREP BOWEL PREP KIT ...................................24SUTAB................................................................ 24SYMBICORT..........................................................7SYMDEKO...........................................................28SYMJEPI ..............................................................29SYMLINPEN 120................................................... 9SYMLINPEN 60 ..................................................... 9SYMPROIC ..........................................................22SYMTUZA........................................................... 15SYNAREL .............................................................21SYNDROS............................................................10SYNERA.............................................................. 20SYNJARDY.............................................................9SYNJARDY XR....................................................... 9SYNRIBO.............................................................13SYNTHROID........................................................ 28TABLOID.............................................................13TABRECTA.......................................................... 13tacrolimus .................................................... 20, 25tadalafil ..............................................................17tadalafil 20 mg oral tablet (pah) ........................ 17TAFINLAR........................................................... 13TAGRISSO...........................................................13TAKHZYRO..........................................................23TALTZ ................................................................. 20TALZENNA..........................................................13tamoxifen citrate ............................................... 13tamsulosin hcl ....................................................23TARGRETIN.........................................................20TASIGNA.............................................................13tavaborole ..........................................................20TAVALISSE .......................................................... 23tazarotene......................................................... 20TAZORAC............................................................20TAZTIA XT ...........................................................16TAZVERIK ........................................................... 13TEGSEDI ............................................................. 28TEKTURNA HCT.................................................. 11telmisartan .........................................................11telmisartan-amlodipine ..................................... 11telmisartan-hctz .................................................11temazepam........................................................23TEMIXYS .............................................................15temozolomide ....................................................13tenofovir disoproxil fumarate ............................16

Index

TEPMETKO......................................................... 13terazosin hcl .......................................................11terbinafine hcl ....................................................10terbutaline sulfate ............................................... 7terconazole ........................................................ 29teriparatide (recombinant) ................................21testosterone........................................................ 5testosterone cypionate ........................................5testosterone enanthate .......................................5tetrabenazine .................................................... 28tetracycline hcl .................................................. 28TEXACORT..........................................................20THALOMID......................................................... 25THEO-24...............................................................7theophylline .........................................................7theophylline er .....................................................7THERMAZENE.....................................................20THIOLA EC .......................................................... 23thioridazine hcl .................................................. 15thiothixene........................................................ 15tiagabine hcl ........................................................ 8TIBSOVO.............................................................13TIGLUTIK ............................................................ 25TILIA FE .............................................................. 17timolol maleate ............................................16, 26tinidazole ........................................................... 12tiopronin ............................................................ 23TIVICAY.............................................................. 16TIVICAY PD......................................................... 16tizanidine hcl ......................................................25TOBI PODHALER...................................................3tobramycin .....................................................3, 26tobramycin-dexamethasone..............................26tolterodine tartrate ........................................... 29tolterodine tartrate er ....................................... 29tolvaptan ............................................................21topiramate ...........................................................8topiramate er .......................................................8toremifene citrate ............................................. 13torsemide ...........................................................21TOUJEO MAX SOLOSTAR......................................9TOUJEO SOLOSTAR.............................................. 9TRACLEER...........................................................17TRADJENTA.......................................................... 9tramadol hcl .........................................................5tramadol hcl er .................................................... 5tramadol hcl er (biphasic) ....................................5tramadol-acetaminophen....................................5trandolapril ........................................................ 11trandolapril-verapamil hcl er ............................. 11tranexamic acid ................................................. 23tranylcypromine sulfate .......................................8travoprost (bak free) ..........................................26trazodone hcl .......................................................8TRECATOR..........................................................12TREMFYA............................................................20TRESIBA................................................................9TRESIBA FLEXTOUCH............................................9tretinoin ....................................................... 13, 20TREXALL ............................................................. 13triamcinolone acetonide ..............................20, 25triamterene-hctz ................................................21TRIANEX............................................................. 20triazolam............................................................23

Index

trientine hcl ....................................................... 25trifluoperazine hcl ..............................................15trifluridine ..........................................................26trihexyphenidyl hcl ............................................ 14TRIJARDY XR.........................................................9TRIKAFTA........................................................... 28TRI-LEGEST FE .................................................... 17trimethobenzamide hcl ..................................... 10trimethoprim..................................................... 12trimipramine maleate ..........................................8TRINTELLIX ........................................................... 8TRIUMEQ........................................................... 16tri-vite/fluoride .................................................. 25TROKENDI XR ....................................................... 8tropicamide ....................................................... 26trospium chloride .............................................. 29trospium chloride er .......................................... 29TRULICITY .............................................................9TRUSELTIQ (100MG DAILY DOSE) ...................... 13TRUSELTIQ (125MG DAILY DOSE) ...................... 13TRUSELTIQ (50MG DAILY DOSE) ........................ 14TRUSELTIQ (75MG DAILY DOSE) ........................ 14TUKYSA.............................................................. 14TURALIO.............................................................14TYBOST...............................................................16TYDEMY............................................................. 17TYMLOS..............................................................21UBRELVY............................................................ 24UDENYCA........................................................... 23UKONIQ..............................................................14UNITHROID........................................................ 28UPNEEQ............................................................. 26UPTRAVI .............................................................17ursodiol ..............................................................22valacyclovir hcl ...................................................16VALCHLOR..........................................................20valganciclovir hcl ................................................16valproic acid .........................................................8valsartan ............................................................ 11valsartan-hydrochlorothiazide ...........................11VALTOCO 10 MG DOSE........................................ 8VALTOCO 15 MG DOSE........................................ 8VALTOCO 20 MG DOSE........................................ 8VALTOCO 5 MG DOSE.......................................... 8vancomycin hcl .................................................. 12varenicline tartrate ............................................ 28VARUBI (180 MG DOSE) .....................................10VASCEPA............................................................ 11VECAMYL........................................................... 11VELPHORO......................................................... 22VELTASSA........................................................... 25VEMLIDY............................................................ 16VENCLEXTA........................................................ 14VENCLEXTA STARTING PACK..............................14venlafaxine hcl ..................................................... 8venlafaxine hcl er .................................................8VENTAVIS ...........................................................17verapamil hcl ..................................................... 16verapamil hcl er ................................................. 16VERDESO............................................................20VEREGEN............................................................20VERQUVO...........................................................17VERZENIO...........................................................14VESICARE LS ....................................................... 29

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Index

V-GO 20 ............................................................. 24V-GO 30 ............................................................. 24V-GO 40 ............................................................. 24VIBERZI ...............................................................22VICTOZA...............................................................9vigabatrin .............................................................8VIIBRYD................................................................ 8VIIBRYD STARTER PACK........................................8VIMPAT................................................................ 8VIRACEPT........................................................... 16VIREAD...............................................................16VISTOGARD........................................................ 10vitamin d (ergocalciferol) ...................................29vitamin d3 .................................................... 17, 29VITRAKVI ............................................................ 14VIZIMPRO...........................................................14vocabria ............................................................. 16voriconazole .......................................................10VOSEVI ............................................................... 16VOTRIENT...........................................................14VRAYLAR............................................................ 15VUMERITY ..........................................................28VYNDAMAX........................................................17VYNDAQEL......................................................... 17VYVANSE..............................................................3VYZULTA.............................................................26WAKIX .................................................................. 3warfarin sodium...................................................7WEGOVY.............................................................. 3WINLEVI ............................................................. 20WIXELA INHUB.....................................................7WP THYROID...................................................... 28XADAGO.............................................................14XALKORI ............................................................. 14XARELTO.............................................................. 7XARELTO STARTER PACK......................................7XATMEP............................................................. 14XCOPRI ................................................................. 8XCOPRI (250 MG DAILY DOSE) .............................8XCOPRI (350 MG DAILY DOSE) .............................8XELJANZ............................................................... 4XELJANZ XR.......................................................... 4XERMELO........................................................... 22XGEVA................................................................22XIFAXAN.............................................................12XIGDUO XR...........................................................9XIIDRA................................................................ 27XOFLUZA (40 MG DOSE) .................................... 16XOFLUZA (80 MG DOSE) .................................... 16XOSPATA............................................................14XTAMPZA ER........................................................ 5XTANDI ...............................................................14XULANE..............................................................17XURIDEN............................................................ 22XYREM................................................................28YUPELRI ................................................................7YUVAFEM...........................................................29zafirlukast ............................................................ 7zaleplon ............................................................. 23ZARXIO............................................................... 23ZEGALOGUE......................................................... 9ZEJULA............................................................... 14ZELAPAR.............................................................14ZELBORAF.......................................................... 14

Index

ZENPEP...............................................................20ZEPOSIA ............................................................. 28ZEPOSIA 7-DAY STARTER PACK.......................... 28ZEPOSIA STARTER KIT ........................................ 28ZETONNA........................................................... 25zidovudine ......................................................... 16zileuton er ............................................................7ZIOPTAN.............................................................27ziprasidone hcl ...................................................15ZIRGAN...............................................................27ZITHRANOL........................................................ 20ZOKINVY.............................................................25ZOLINZA............................................................. 14zolmitriptan ....................................................... 24zolpidem tartrate ...............................................23zolpidem tartrate er ...........................................23ZOMIG................................................................24zonisamide ...........................................................8ZONTIVITY ..........................................................23ZORBTIVE ........................................................... 22ZORTRESS ...........................................................25ZUPLENZ.............................................................10ZYDELIG..............................................................14ZYFLO................................................................... 7ZYKADIA............................................................. 14ZYLET ..................................................................27

39

Page 44: 2021 Drug Formulary II
Page 45: 2021 Drug Formulary II

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