2022 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

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

HPMS Approved Formulary File Submission ID 22234 Version Number 5This formulary was updated on 10012021 For more recent information or other questions please contact Cigna Customer Service at 1-800-668-3813 (TTY users should call 711) October 1 ndash March 31 8 am ndash 8 pm local time 7 days a week From April 1 ndash September 30 Monday ndash Friday 8 am ndash 8 pm local time Messaging service used weekends after hours and on federal holidays or visit CignaMedicarecom The Formulary pharmacy network andor provider network may change at any time 22_F_01_MAPD_01_V01October 2021 INT_22_98644_C_Final_1a

1October 2021

What is the Cigna Comprehensive Drug ListA drug list is a list of covered drugs sele

team of health care pcription therapies bel

atment program Cigned in our drug list as lary the prescription i and other plan rules

cted by Cigna in consultation with a roviders which represents the pres ieved to be a necessary part of a quality tre a will generally cover the drugs list ong as the drug is medically necess s filled at a Cigna network pharmacy are followed For more information on how to fill your prescriptions please review your Evidence of Coverage

Can the Drug List (formulary) changeMost changes in drug coverage happen on January 1 but we may add or remove drugs on the drug list during the year move them to different cost-sharing tiers or add new restrictions We must follow Medicare rules in making these changesChanges that can affect you this year In the below cases you will be affected by coverage changes during the yearbull New generic drugs We may immediately remove a brand

name drug on our drug list if we are replacing it with a new generic drug that will appear on the same or lower cost-sharing tier and with the same or fewer restrictions Also when adding the new generic drug we may decide to keep the brand name drug on our drug list but immediately move it to a different cost-sharing tier or add new restrictions If you are currently taking that brand name drug we may not tell you in advance before we make that change but we will later provide you with information about the specific change(s) we have made ndash If we make such a change you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and

you can also find information in the section entitled ldquoHow do I request an exception to the Cigna Drug Listrdquo

bull Drugs removed from the market If the Food and Drug Administration (FDA) deems a drug on our drug list to be unsafe or the drugrsquos manufacturer removes the drug from the market we will immediately remove the drug from our drug list and provide notice to customers who take the drug

bull Other changes We may make other changes that affect customers currently taking a drug For instance we may add a generic drug that is not new to the market to replace a brand name drug currently on the drug list or add new restrictions to the brand name drug or move it to a different cost-sharing tier or both Or we may make changes based on new clinical guidelines andor studies If we remove drugs from our drug list add prior authorization quantity limits andor step therapy restrictions on a drug or move a drug to a higher cost-sharing tier we must notify affected customers of the change at least 30 days before the change becomes effective or at the time the customer requests a refill of the drug at which time the customer will receive a 30-day supply of the drug ndash If we make these other changes you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you The notice we provide you will also include information on how to request an exception and you can find information in the section below titled ldquoHow do I request an exception to the Cigna Drug Listrdquo

Changes that will not affect you if you are currently taking the drug Generally if you are taking a drug on our 2022 drug list that was covered at the beginning of the year we will not discontinue or reduce coverage of the drug during the 2022 coverage year except as described above This means these

Note to existing customers This formulary has changed since last year Please review this document to make sure that it still contains the drugs you take When this drug list (formulary) refers to ldquowerdquo ldquousrdquo or ldquoourrdquo it means Cigna When it refers to ldquoplanrdquo or ldquoour planrdquo it means Cigna Alliance Medicare (HMO) Cigna Preferred GA Medicare (HMO) Cigna Preferred Medicare (HMO) Cigna Preferred Plus Medicare (HMO) Cigna Preferred Savings Medicare (HMO) Cigna Premier Medicare (HMO-POS) Cigna Primary Medicare (HMO) Cigna TotalCare Plus (HMO D-SNP) Cigna True Choice Medicare (PPO) and Cigna True Choice Plus Medicare (PPO) This document includes a list of the drugs (formulary) for our plans which is current as of October 2021 For an updated formulary please contact us Our contact information along with the date we last updated the formulary appears on the front and back cover pages You must generally use network pharmacies to use your prescription drug benefit Benefits formulary pharmacy network andor copaymentscoinsurance may change on January 1 2023 and from time to time during the year

2October 2021

drugs will remain available at the same cost-sharing and with no new restrictions for those customers taking them for the remainder of the coverage year You will not get direct notice this year about changes that do not affect you However on January 1 of the next year such changes would affect you and it is important to check the drug list for the new benefit year for any changes to drugs

nclosed drug list is current as of October 2021 To ed information about the drugs covered by Cigna ct us Our contact information appears on the frontover pages If there are significant changes made

d drug list within the covered year you may be notentifying the changes Drug lists located on our wviewed and updated on a monthly basis

o I use the Drug List are two ways to find your drug within the drug listal Conditionrug list begins on page 29 The drugs in this drug louped into categories depending on the type of mions that they are used to treat For example drugto treat a heart condition are listed under the categ

The e get updat please conta and back c to the printe ified by mail id ebsite are re

How dThereMedicThe d ist are gr edical condit s used ory ldquoCARDIOVASCULAR HYPERTENSION LIPIDSrdquo If you know what your drug is used for look for the category name in the list that begins on page 29 Then look under the category name for your drug Covered Drug IndexIf you are not sure what category to look under you should look for your drug in the Covered Drugs Index that begins on page 77 The Covered Drugs Index provides an alphabetical list of all of the drugs included in this document Both brand name drugs and generic drugs are listed in the Index Look in the Index and find your drug Next to your drug you will see the page number where you can find coverage information Turn to the page listed in the Covered Drug Index and find the name of your drug in the drug name column of the list

What are generic drugsCigna covers both brand name drugs and generic drugs A generic drug is approved by the FDA as having the same active ingredient as the brand name drug Generally generic drugs cost less than brand name drugs

Are there any restrictions on my coverageSome covered drugs may have additional requirements or limits on coverage These requirements and limits may include

bull Prior Authorization Cigna requires you or your doctor to get prior authorization for certain drugs This means that you

will need to get approval from Cigna before you fill these prescriptions If you donrsquot get approval Cigna may not cover the drug

bull Quantity Limits For certain drugs Cigna limits the amount of the drug that Cigna will cover For example Cigna allows for 1 tablet per day for atorvastatin 40mg This applies to a standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days)

bull Step Therapy In some cases Cigna requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition For example if Drug A and Drug B both treat your medical condition Cigna may not cover Drug B unless you try Drug A first If Drug A does not work for you Cigna will then cover Drug B

bull Non-Extended Days Supply For certain drugs Cigna limits the amount of the drug that Cigna will cover to only a 30-day supply or less at one time For example customers who have not had any recent fill of opioid pain medications within the past 108 days (referred to as ldquoopioid naiumlverdquo) are limited to a maximum of 7 daysrsquo supply of opioid pain medication Customers who have received a recent fill of an opioid pain medication (not opioid naiumlve) are limited to up to a monthrsquos supply of that medication at one time Other high cost drugs may be subject to a non-extended day supply restriction as well

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 29 You can also get more information about the restrictions applied to specific covered drugs by visiting our website We have posted online documents that explain our prior authorization and step therapy restrictions You may also ask us to send you a copy Our contact information along with the date we last updated the drug list appears on the front and back cover pagesYou can ask Cigna to make an exception to these restrictions or limits or for a list of other similar drugs that may treat your health condition See the section ldquoHow do I request an exception to the Cigna drug listrdquo on page 3 for information about how to request an exception

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health We are committed to helping you control your chronic conditions by making it easy for you to receive your maintenance medications There are several ways we can work together to accomplish this goal

3October 2021

bull Talk with your doctor about whether a 90-day supply of your ongoing stable medications may be appropriate Taking these medications every day as prescribed is important for your overall health and getting 90-day prescriptions of these medications can help ensure that you do not miss a dose

bull You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies

bull Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications

How can I use my prescription drug coverage to save money on my medications

ay be opportunities for youtions using your Cigna coveour doctor (or other prescri

r-cost generic alternatives ant medicationse plans may offer a $0 copas filled at a preferred retail a

There m to save money on your medica ragebull Ask y ber) if there are any

lowe vailable for any of your curre

bull Som y for Tier 1 and 2 generic drug ndor mail-order pharmacies Check the Drug Tier and Cost-share Tables on page 5 to see if your plan offers these savings

bull Explore whether the lsquoCMS Extra Helprsquo program may offer additional financial support for your medications

bull If your medication is not covered in the Cigna drug list talk with your doctor about alternative medications which are covered on the drug list

What if my drug is not on the Drug ListIf your drug is not included in this drug list you should first contact Customer Service and ask if your drug is covered If you learn that Cigna does not cover your drug you have two optionsbull You can ask Customer Service for a list of similar drugs that

are covered by Cigna When you receive the list show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna

bull You can ask Cigna to make an exception and cover your drug See the next section for information about how to request an exception

How do I request an exception to the Cigna Drug ListYou can ask Cigna to make an exception to our coverage rules There are several types of exceptions that you can ask us to make

bull You can ask us to cover a drug even if it is not on our drug list If approved this drug will be covered at a pre-determined cost-sharing level and you would not be able to ask us to provide the drug at a lower cost-sharing level

bull You can ask us to waive coverage restrictions or limits on your drug For example for certain drugs Cigna limits the amount of the drug that we will cover If your drug has a quantity limit you can ask us to waive the limit and cover a greater amount

bull You can ask us to cover a formulary drug at a lower cost-sharing level unless the drug is on the specialty tier If approved this would lower the amount you must pay for your drug This applies to the following circumstances ndash If the drug yoursquore taking is a brand name drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains brand name alternatives for treating your condition

ndash If the drug yoursquore taking is a generic drug you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains either brand or generic alternatives for treating your condition

ndash If the drug yoursquore taking is a biological product you can ask us to cover your drug at the cost-sharing amount that applies to the lowest tier that contains biological product alternatives for treating your condition

Please note if we grant your request to cover a drug that is not on our drug list you may not ask us to provide this drug at a lower cost-sharing level

Generally Cigna will only approve your request for an exception if the alternative drug is included in our drug list the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition andor would cause you to have adverse medical effects You should contact us to ask us for an initial coverage decision for a drug list tiering or utilization restriction exception When you request a drug list tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request Generally we must make our decision within 72 hours of getting your prescriberrsquos supporting statement You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision If your request to expedite is granted we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber

4October 2021

What do I do before I can talk to my doctor about changing my drugs or requesting an exceptionAs a new or existing customer in our plan you may be taking drugs that are not on our drug list Or you may be taking a drug that is on our drug list but your ability to get it is limited For example you may need a prior authorization from us before you can fill your prescription You should talk to your doctor to decide if you should switch

st a drug list e While you talk

to an appropriate drug that we cover or reque xception so that we will cover the drug you take to your doctor to determine the right course of action for you we may cover your drug up to a 30-day supply in certain cases during the first 90 days you are a customer of our planFor each of your drugs that is not on our drug list or if your ability to get your drugs is limited we will cover a temporary 30-day supply If your prescription is written for fewer days wersquoll allow refills to provide up to a maximum 30-day supply of medication After your first 30-day supply we will not pay for these drugs without a drug list exception even if you have been a customer of the plan less than 90 days If you are a resident of a long-term care facility and you need a drug that is not on our drug list or if your ability to get your drugs is limited but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug while you pursue a drug list exception In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days)

Cignarsquos Drug ListThe comprehensive drug list that begins on page 29 provides coverage information about all of the drugs covered by Cigna If you have trouble finding your drug in the list turn to the Covered Drug Index that begins on page 77 The first column of the chart lists the drug name Brand name drugs are capitalized (eg TRELEGY ELLIPTA) and generic drugs are listed in lower-case italics (eg atorvastatin)The information in the RequirementsLimits column tells you if Cigna has any special requirements for coverage of your drug Some Cigna plans offer additional prescription drug coverage in the coverage gap Please refer to your Evidence of Coverage to see if your plan has this coverage and for more informationWe provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 29 along with the amount dispensed per the days supplied (For example atorvastatin 40mg QL 3030 this means the drug atorvastatin 40mg is limited to 30 tablets per 30 days For 90-day supplies this quantity limit would be expanded to 90 tablets per 90 days)

What is a preferred network pharmacyIf your plan has preferred network pharmacies you will typically save money by using these pharmacies Your prescription drug costs (like a copay or coinsurance) will typically be less at a preferred network pharmacy because it has a preferred agreement with your plan or you can visit CignaMedicarecom for the most current Pharmacy Directory

For more information

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

5October 2021

Drug Tier and Cost-Share TableThe following table represents the plan name plan service area the drug tier number as it appears on the drug list and the cost-share amount for that tier number Tier 1 is for Preferred Ge

is for Generic drugs Tier 3 is for Preferred Brais for Non-Preferred drugs Tier 5 is for Speciaase refer to the following chart You may also

nce of Coverage document for additional detailways able to keep all generic medications in t

neric and Generic drug tiers and some generi

neric drugs Tier 2 nd drugs Tier 4 lty tier drugs Ple refer to your Evide lsCigna is not a he Preferred Ge c medications may be in Tier 3 Tier 4 or Tier 5 Keep in mind that

the name ldquoTier 3 Preferred Brand Drugsrdquo is just a description of the majority of the drugs in the tier It does not mean that there are only brand drugs in that tierFor customers receiving Extra Help Your Low Income Subsidy (LIS) copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs Due to this a generic drug may receive a preferred brand copay or a preferred brand drug may receive a generic drug copay Please see your LIS Rider for additional information on these copay levels Or call Customer Service for further clarification regarding a specific drug

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

Service Area Alabama H7849-012 ndash Cigna True Choice Medicare (PPO) Blount Cherokee Colbert DeKalb Etowah Jackson Lawrence Limestone Madison Marshall Morgan St Clair and Tuscaloosa AlabamaH7849-013 ndash Cigna True Choice Medicare (PPO) Autauga Bibb Chilton Coosa Cullman Dallas Elmore Jefferson Lowndes Mobile Montgomery Perry Shelby Talladega and Walker Alabama

Drug Tier

Preferred Retail Cost-Sharing

Standard Retail Cost-Sharing

Preferred Mail-Order Cost-Sharing

Standard Mail-Order Cost-Sharing

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $2 $4 $5 $7 $14 $21 $2 $4 $0 $7 $14 $21Tier 2 Generic Drugs $4 $8 $10 $9 $18 $27 $4 $8 $0 $9 $18 $27Tier 3 Preferred Brand Drugs $40 $80 $120 $45 $90 $135 $40 $80 $120 $45 $90 $135Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area Arkansas H4513-038 ndash Cigna Preferred Medicare (HMO) Clay Craighead Crittenden Cross Greene Independence Jackson Lawrence Lee Mississippi Poinsett Randolph St Francis White and Woodruff Arkansas

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 $0 $0 $10 $20 $30 $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs $15 $30 $30 $20 $40 $60 $15 $30 $0 $20 $40 $60Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs 47 47 47 47Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

6October 2021

Service Area Arkansas H4513-050 ndash Cigna Preferred Medicare (HMO) Arkansas Calhoun Clark Cleburne Conway Faulkner Garland Grant Hot Spring Lonoke Perry Pope Prairie Pulaski Saline Stone and Van Buren ArkansasH4513-051 ndash Cigna Preferred Medicare (H

kansas ndash Cigna Preferred Medicare (H

3erred Generic Drugs

MO) Crawford Franklin Johnson Logan Montgomery Scott Sebastian and Yell ArH4513-052 MO) Benton Carroll Madison Newton and Washington Arkansas

Drug Tier

0 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Pref $0 $0 $0 $10 $20 $30 $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs $15 $30 $30 $20 $40 $60 $15 $30 $0 $20 $40 $60Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs 50 50 50 50Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area Connecticut H7849-052 ndash Cigna True Choice Medicare (PPO) H7849-054 ndash Cigna True Choice Plus Medicare (PPO) New Haven Connecticut

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) $0 $0 $0 $10 $20 $20 $0 $0 $0 $10 $20 $20Tier 2 Generic Drugs $0 $0 $0 $20 $40 $40 $0 $0 $0 $20 $40 $40Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area Florida H5410-018 ndash Cigna Preferred Medicare (HMO) Bay Escambia Okaloosa Santa Rosa and Walton Florida

Drug Tier

GC We provide additional coverage of the prescription drugs in this tier in the coverage gap Please refer to our Evidence of Coverage for more information about this coverage

7October 2021

Service Area Florida H5410-037 ndash Cigna Preferred Medicare (HMO) Indian River Martin and St Lucie FloridaH5410-039 ndash Cigna Preferred Medicare (HMO) Collier and Lee Florida

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) $0 $0 $0 $10 $20 $30 $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs (GC)

er 3 Preferred Brand Drugser 4 Non-Preferred Drugser 5 Specialty Tier

rvice Area Florida 5410-040 ndash Cigna Preferred S

$0 $0 $0 $20 $40 $60 $0 $0 $0 $20 $40 $60Ti $35 $70 $105 $47 $94 $141 $35 $70 $105 $47 $94 $141Ti $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Ti 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

SeH avings Medicare (HMO) Indian River Martin and St Lucie FloridaH5410-041 ndash Cigna Preferred Savings Medicare (HMO) Collier and Lee Florida

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) $0 $0 $0 $7 $14 $21 $0 $0 $0 $7 $14 $21Tier 2 Generic Drugs (GC) $4 $8 $8 $9 $18 $27 $4 $8 $0 $9 $18 $27Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

8October 2021

Service Area Florida H5410-025 ndash Cigna TotalCare Plus (HMO D-SNP) Lake Marion Orange Osceola Polk and Seminole Florida

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $2 $4 $4 $18 $36 $54 $0 $0 $0 $18 $36 $54Tier 2 Generic Drugs

ferred Brand Drugs-Preferred Drugscialty Tier

$13 $26 $26 $20 $40 $60 $13 $26 $0 $20 $40 $60Tier 3 Pre 18 19 18 19Tier 4 Non 44 44 44 44Tier 5 Spe 25 (30 days) 25 (30 days) 25 (30 days) 25 (30 days)

If you receive ldquoExtra Helprdquo your cost-shares may be Standard Retail and Mail-Order Cost-Sharing

$0 $135 $395 (generics)$0 $400 $985 (all other drugs)

Service Area Florida H5410-031 ndash Cigna TotalCare Plus (HMO D-SNP) Brevard Flagler and Volusia FloridaH5410-032 ndash Cigna TotalCare Plus (HMO D-SNP) Hernando Hillsborough Manatee Pasco Pinellas and Sarasota Florida

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $1 $2 $2 $18 $36 $54 $0 $0 $0 $18 $36 $54Tier 2 Generic Drugs $12 $24 $24 $20 $40 $60 $12 $24 $0 $20 $40 $60Tier 3 Preferred Brand Drugs 18 19 18 19Tier 4 Non-Preferred Drugs 41 41 41 41Tier 5 Specialty Tier 25 (30 days) 25 (30 days) 25 (30 days) 25 (30 days)

Cost-sharing is based on your level of ldquoExtra HelprdquoSome additional drugs that are not covered by Medicare may be covered through your Medicaid benefits To find out about Medicaid drug coverage call Customer Service at 1-800-668-3813

9October 2021

Service Area Florida H5410-033 ndash Cigna Primary Medicare (HMO) Lake Marion Orange Osceola Polk Seminole and Sumter FloridaH5410-035 ndash Cigna Primary Medicare (HMO) Hernando Hillsborough Manatee Pasco Pinellas and Sarasota Florida

Drug Tier

referred Brand Drugson-Preferred Drugspecialty Tier

Area Florida 34 ndash Cigna Primary Medicare (HMO

$12 $24 $24 $20 $40 $60 $12 $24 $0 $20 $40 $60Tier 3 P 18 19 18 19Tier 4 N 41 41 41 41Tier 5 S 25 (30 days) 25 (30 days) 25 (30 days) 25 (30 days)

Service H5410-0 ) Brevard Flagler and Volusia Florida

Drug Tier

Service Area Florida H7849-017 ndash Cigna True Choice Medicare (PPO) Lake Marion Orange Osceola Polk Seminole and Sumter FloridaH7849-047 ndash Cigna True Choice Medicare (PPO) Brevard Flagler and Volusia FloridaH7849-048 ndash Cigna True Choice Medicare (PPO) Hernando Hillsborough Manatee Pasco Pinellas and Sarasota Florida

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $2 $4 $4 $7 $14 $21 $2 $4 $0 $7 $14 $21Tier 2 Generic Drugs $4 $8 $8 $9 18 $27 $4 $8 $0 $9 18 $27Tier 3 Preferred Brand Drugs $40 $80 $120 $45 $90 $135 $40 $80 $120 $45 $90 $135Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

10October 2021

Service Area Florida H7849-044 ndash Cigna True Choice Medicare (PPO) Escambia and Santa Rosa Florida

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $2 $4 $5 $7 $14 $21 $2 $4 $0 $7 $14 $21Tier 2 Generic Drugs $4 $8 $10 $9 $18 $27 $4 $8 $0 $9 $18 $27Tier 3 Preferred Brand Drugs $40 $80

ier 4 Non-Preferred Drugs $95 $190 ier 5 Specialty Tier 31 (30 d

$120 $45 $90 $135 $40 $80 $120 $45 $90 $135T $285 $100 $200 $300 $95 $190 $285 $100 $200 $300T ays) 31 (30 days) 31 (30 days) 31 (30 days)

Service Area Florida H7849-056 ndash Cigna True Choice Medicare (PPO) Collier and Lee Florida

Drug Tier

Service Area GeorgiaH0439-003-001 ndash Cigna Preferred GA Medicare (HMO) Barrow Butts Clarke Clayton DeKalb Douglas Franklin Fulton Greene Gwinnett Henry Madison Morgan Newton Oconee Oglethorpe Rockdale Spalding and Walton GeorgiaH0439-003-002 ndash Cigna Preferred GA Medicare (HMO) Banks Bartow Chattooga Cherokee Cobb Coweta Dawson Fayette Floyd Forsyth Gordon Habersham Hall Jackson Lumpkin Paulding Pickens Polk Stephens and White Georgia

Drug Tier

11October 2021

Service Area GeorgiaH0439-006 ndash Cigna Preferred Plus Medicare (HMO) Banks

Coweta Dawson DeKalb Douglas Fayette Floyd Fron Lumpkin Madison Morgan Newton Oconee Oglet

Barrow Bartow Butts Chattooga Cherokee Clarke Clayton Cobb anklin Fulton Gordon Greene Gwinnett Habersham Hall Henry Jacks horpe Paulding Pickens Polk Rockdale Spalding Stephens Walton and White Georgia

Drug Tier

Service Area GeorgiaH0439-007 ndash Cigna Preferred Medicare (HMO) Barrow Butts Cherokee Clayton Coweta DeKalb Fayette Forsyth Fulton Gwinnett Henry Newton Pickens Rockdale and Spalding GeorgiaH0439-009 ndash Cigna Preferred Medicare (HMO) Clarke Franklin Greene Madison Morgan Oconee Oglethorpe and Walton Georgia

Drug Tier

Service Area GeorgiaH0439-008 ndash Cigna Preferred Medicare (HMO) Cobb Douglas and Paulding Georgia

Drug Tier

12October 2021

Service Area GeorgiaH0439-010 ndash Cigna Preferred Medicare (HMO) Banks Dawso

ite Georgia Preferred Retail

Cost-Sharingier

30 60 90 DaysPreferred Generic Drugs $0 $0 $0Generic Drugs $4 $8 $8Preferred Brand Drugs $42 $84 $126Non-Preferred Drugs $95 $190 $285Specialty Tier 31 (30 days)

n Habersham Hall Jackson Lumpkin Stephens and Wh

Drug T

30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 $7 $14 $21 $0 $0 $0 $7 $14 $21Tier 2 $9 $18 $27 $4 $8 $0 $9 $18 $27Tier 3 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 31 (30 days) 31 (30 days) 31 (30 days)

Service Area GeorgiaH0439-011 ndash Cigna Preferred Medicare (HMO) Bartow Chattooga Floyd Gordon and Polk Georgia

Drug Tier

Service Area GeorgiaH7849-003 ndash Cigna True Choice Medicare (PPO) Barrow Butts Cherokee Clayton Coweta DeKalb Fayette Forsyth Fulton Gwinnett Henry Newton Pickens Rockdale and Spalding Georgia

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 $0 $0 $10 $20 $30 $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs $12 24 $30 $20 $40 $60 $12 24 $0 $20 $40 $60Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

13October 2021

Service Area GeorgiaH7849-020 ndash Cigna True Choice Medicare (PPO) Cobb Douglas and Paulding Georgia H7849-022 ndash Cigna True Choice Medicare (PPO) Banks Dawson Habersham Hall Jackson Lumpkin Stephens and White Georgia

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generi

2 Generic Drugs 3 Preferred Brand 4 Non-Preferred D 5 Specialty Tier

c Drugs $3 $6 $750 $8 $16 $24 $3 $6 $0 $8 $16 $24Tier $12 $24 $30 $17 $34 $51 $12 $24 $0 $17 $34 $51Tier Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier rugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 29 (30 days) 29 (30 days) 29 (30 days) 29 (30 days)

Service Area GeorgiaH7849-021 ndash Cigna True Choice Medicare (PPO) Franklin Greene Madison Morgan Oconee Oglethorpe and Walton Georgia

Drug Tier

Service Area GeorgiaH7849-023 ndash Cigna True Choice Medicare (PPO) Bartow Chattooga Floyd Gordon and Polk Georgia

Drug Tier

14October 2021

Service Area GeorgiaH4513-030 ndash Cigna Preferred Medicare (HMO) Catoosa Dade and Walker Georgia

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC)

eneric Drugs (GC) $referred Brand Drugs $on-Preferred Drugspecialty Tier

Area Georgia35 ndash Cigna True Choice Medicare (

P

er3

referred Generic Drugseneric Drugsreferred Brand Drugs $on-Preferred Drugs $8pecialty Tier

$3 $6 $6 $10 $20 $20 $3 $6 $0 $10 $20 $20Tier 2 G 12 $24 $24 $20 $40 $40 $12 $24 $0 $20 $40 $40Tier 3 P 42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 N 38 38 38 38Tier 5 S 29 (30 days) 29 (30 days) 29 (30 days) 29 (30 days)

ServiceH7849-0 PPO) Catoosa Dade and Walker Georgia

Drug Ti

referred Retail Cost-Sharing

0 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 P $0 $0 $0 $5 $10 $1250 $0 $0 $0 $5 $10 $1250Tier 2 G $4 $8 $10 $9 $18 $2250 $0 $0 $0 $9 $18 $2250Tier 3 P 40 $80 $120 $45 $90 $135 $40 $80 $120 $45 $90 $135Tier 4 N 0 $160 $240 $85 $170 $255 $80 $160 $240 $85 $170 $255Tier 5 S 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area Illinois H1415-021 ndash Cigna Premier Medicare (HMO-POS) H1415-024 ndash Cigna Preferred Medicare (HMO) Cook DuPage Kane Kankakee Lake and Will IllinoisH7389-004 ndash Cigna Preferred Medicare (HMO) H7849-058 ndash Cigna True Choice Medicare (PPO) Bond Clinton Jersey Macoupin and Washington IllinoisH7849-059 ndash Cigna True Choice Medicare (PPO) Christian Jackson Logan Mason Menard Montgomery Morgan Moultrie Perry Sangamon Shelby and Williamson Illinois

Drug Tier

GC We provide additional coverage of the prescription drugs in this tier in the coverage gap Please refer to our Evidence of Coverage for more information about this coverageCignarsquos pharmacy network includes limited lower-cost preferred pharmacies in the county of Clinton in Illinois The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use For up-to-date information about our network pharmacies including whether there are any lower-cost preferred pharmacies in your area please call 1-800-668-3813 (TTY 711) or consult the online pharmacy directory at CignaMedicarecom

15October 2021

Service Area Illinois H7849-002 ndash Cigna True Choice Medicare (PPO) Cook DuPage Kane Kankakee Lake and Will Illinois

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 $0 $0 $9 $18 $18 $0 $0 $0 $9 $18 $18Tier 2 Generic Drugs $4 $8 $8 $12 $24 $24 $4 $8 $0 $12 $24 $24Tier 3 Preferred Brand Drugs

er 4 Non-Preferred Drugser 5 Specialty Tier

rvice Area Illinois 389-005 ndash Cigna Preferred Plus Mediultrie Perry Sangamon Shelby and W

ug Tier

er 1 Preferred Generic Drugser 2 Generic Drugser 3 Preferred Brand Drugser 4 Non-Preferred Drugser 5 Specialty Tier

rvice Area Kansas Missouri

$42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Ti 45 45 45 45Ti 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

SeH7 care (HMO) Christian Jackson Logan Mason Menard Montgomery Morgan Mo illiamson Illinois

Dr

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTi $0 $0 $0 $9 $18 $18 $0 $0 $0 $9 $18 $18Ti $4 $8 $8 $12 $24 $24 $4 $8 $0 $12 $24 $24Ti $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Ti 48 48 48 48Ti 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

SeH9460-001 ndash Cigna Preferred Medicare (HMO) Franklin Jefferson Johnson Leavenworth Miami and Wyandotte Kansas Andrew Bates Caldwell Carroll Cass Clay Clinton DeKalb Henry Holt Jackson Johnson Lafayette Platte and Ray Missouri

Drug Tier

16October 2021

Service Area Kansas MissouriH7849-024 ndash Cigna True Choice Medicare (PPO) Franklin Jefferson Johnson Leavenworth Miami and Wyandotte Kansas Andrew Bates Caldwell Carroll Cass Clay Clinton DeKalb Henry Holt Jackson Johnson Lafayette Platte and Ray Missouri

Drug Tier

Non-Preferred Drugs Specialty Tier

e Area Mid-Atlantic -008 ndash Cigna True Choict of Columbia New Castle-028 ndash Cigna Preferred

$42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 50 50 50 50Tier 5 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

ServicH7849 e Medicare (PPO) H7849-009 ndash Cigna True Choice Plus Medicare (PPO) Distric DelawareH2108 Medicare (HMO) District of Columbia Kent New Castle and Sussex Delaware

Drug Tier

Service Area Mid-Atlantic H2108-022 ndash Cigna Preferred Plus Medicare (HMO) Anne Arundel Baltimore Baltimore City and Harford MarylandH2108-036 ndash Cigna Alliance Medicare (HMO) Anne Arundel Baltimore and Baltimore City Maryland

Drug Tier

17October 2021

Service Area Mid-Atlantic H2108-034 ndash Cigna Preferred Medicare (HMO) Montgomery and Prince Georgersquos Maryland

Drug Tier

ier 3 Preferred Brand Drugsier 4 Non-Preferred Drugs $ier 5 Specialty Tier

ervice Area Mississippi7849-016 ndash Cigna True Choice Medicare (d Rankin Mississippi

rug Tier3

$5 $10 $5 $20 $40 $40 $0 $0 $0 $20 $40 $40T $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141T 95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300T 28 (30 days) 28 (30 days) 28 (30 days) 28 (30 days)

SH PPO) Hancock Harrison Hinds Jackson Jones Madison an

D

Service Area MississippiH4407-026 ndash Cigna Preferred Medicare (HMO) Covington Forrest George Hancock Harrison Hinds Jackson Jones Lamar Madison Marion Pearl River Perry Rankin and Stone Mississippi

Drug Tier

18October 2021

Service Area MississippiH4407-027 ndash Cigna Preferred Plus Medicare (HMO) Covington Forrest George Hancock Harrison Hinds Jackson Jones Lamar Madison Marion Pearl River Perry Rankin and Stone Mississippi

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs

Generic Drugs Preferred Brand Drugs Non-Preferred Drugs Specialty Tier

ce Area Mississippi7-028 ndash Cigna Preferred Medicare (H

Tier

$0 $0 $0 $5 $10 $15 $0 $0 $0 $5 $10 $15Tier 2 $4 $8 $8 $9 $18 $27 $4 $8 $0 $9 $18 $27Tier 3 $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

ServiH440 MO) Desoto Marshall Tate and Tunica Mississippi

Drug

Service Area MississippiH7849-060 ndash Cigna True Choice Medicare (PPO) Desoto Marshall Tate and Tunica Mississippi

Drug Tier

19October 2021

Service Area Missouri IllinoisH7389-003 ndash Cigna Preferred Medicare (HMO) Crawford Franklin Jefferson St Charles St Francois St Louis St Louis City Warren and Washington Missouri Madison Monroe and St Clair Illinois

Drug Tier

Preferred Retail Cost-Sharing Cost-Sh 60 90 Days 30 60 90$0 $0 $0 $9 $18

Standard Retail aring

30 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) $18 $0 $0 $0 $9 $18 $18Tier 2 Generic Drugs $4 $8 $8 $12 $24 $24 $4 $8 $0 $12 $24 $24Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs 50 50 50 50Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area Missouri IllinoisH7849-057 ndash Cigna True Choice Medicare (PPO) Crawford Franklin Jefferson St Charles St Francois St Louis St Louis City Warren and Washington Missouri Madison Monroe and St Clair Illinois

Drug Tier

Service Area New JerseyH3949-032 ndash Cigna Preferred Medicare (HMO) H3949-033 ndash Cigna Preferred Plus Medicare (HMO) H7849-033 ndash Cigna True Choice Plus Medicare (PPO) Atlantic Burlington Camden Cumberland Gloucester Mercer and Salem New JerseyH3949-034 ndash Cigna Preferred Medicare (HMO) H7849-030 ndash Cigna True Choice Plus Medicare (PPO) Monmouth and Ocean New Jersey

Drug Tier

20October 2021

Service Area New MexicoH0672-005 ndash Cigna Preferred Medicare (HMO) H7849-028 ndash Cigna True Choice Medicare (PPO) Bernalillo Rio Arriba Sandoval San Juan San Miguel Sante Fe Taos Torrance and Valencia New Mexico

Drug Tier

Preferred Retail Cost-Sharing Cost-Shari

0 90 Days 30 60 90 D $0 $0 $10 $20 $$10 $10 $20 $40 $

Standard Retail ng

30 6 ays 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 30 $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs $5 60 $0 $0 $0 $20 $40 $60Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area North CarolinaH7849-019 ndash Cigna True Choice Medicare (PPO) Alexander Anson Cabarrus Catawba Cleveland Gaston Iredell Lincoln Mecklenburg Polk Rowan Stokes Union and Yadkin North CarolinaH7849-046 ndash Cigna True Choice Medicare (PPO) Chatham Durham and Orange North Carolina

Drug Tier

Service Area North CarolinaH7849-011 ndash Cigna True Choice Medicare (PPO) Davidson Davie Forsyth and Guilford North Carolina

Drug Tier

21October 2021

Service Area OhioH0672-006 ndash Cigna Preferred Medicare (HMO) H7849-015 ndash Cigna True Choice Medicare (PPO) Cuyahoga Geauga Lake Lorain Medina and Summit Ohio

Drug Tier

Preferred Retail Cost-Sharing Cost-Sharing C

60 90 Days 30 60 90 Days 30 0 $0 $0 $9 $18 $18 $ $10 $10 $20 $40 $40 $

Standard Retail Preferred Mail-Order ost-Sharing

30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) $ 0 $0 $0 $9 $18 $18Tier 2 Generic Drugs $5 5 $10 $0 $20 $40 $40Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area Oregon WashingtonH7389-002 ndash Cigna Preferred Medicare (HMO) Clackamas Multnomah and Washington Oregon Clark Washington

Drug Tier

Service Area Oregon WashingtonH7849-055 ndash Cigna True Choice Medicare (PPO) Clackamas Multnomah and Washington Oregon Clark Washington

Drug Tier

22October 2021

Service Area Pennsylvania H3949-013 ndash Cigna Preferred Plus Medicare (HMO) H3949-030 ndash Cigna Preferred Medicare (HMO) H3949-031 ndash Cigna Alliance Medicare (HMO) H7849-006 ndash Cigna True Choice Medicare (PPO) H7849-007 ndash Cigna True Choice Plus Medicare (PPO) Bucks Chester Delaware Montgomery and Philadelphia PennsylvaniaH3949-035 ndash Cigna Preferred Medicare (HMO) H7849-031 ndash Cigna True Choice Medicare (PPO) H7849-032 ndash Cigna True Choice Plus Medicare (PPO) Adams Berks Cumberland Dauphin Lancaster Lebanon and York Pennsylvania

Drug Tier

30 60 90 Days 30 60 90 D$0 $0 $0 $9 $18 $

$5 $10 $10 $15 $30 $42 $84 $126 $47 $94 $

ays 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) 18 $0 $0 $0 $9 $18 $18Tier 2 Generic Drugs 30 $5 $10 $0 $15 $30 $30Tier 3 Preferred Brand Drugs $ 141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area South CarolinaH7020-004 ndash Cigna Preferred Medicare (HMO) Anderson Cherokee Chester Greenville Lancaster Pickens Spartanburg Union and York South CarolinaH7020-008 ndash Cigna Preferred Medicare (HMO) Berkeley Charleston and Dorchester South Carolina

Drug Tier

23October 2021

Service Area South CarolinaH7020-006 ndash Cigna Preferred Plus Medicare (HMO) Anderson Cherokee Chester Greenville Lancaster Pickens Spartanburg Union and York South Carolina

Drug Tier

30 60 90 Days 30 60 90 $0 $0 $5 $10 $ $8 $8 $15 $30

Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 15 $0 $0 $0 $5 $10 $15Tier 2 Generic Drugs $4 $45 $4 $8 $0 $15 $30 $45Tier 3 Preferred Brand Drugs $47 $94 $141 $47 $94 $141 $47 $94 $141 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area South CarolinaH7849-018 ndash Cigna True Choice Medicare (PPO) Anderson Cherokee Chester Greenville Lancaster Pickens Spartanburg Union and York South Carolina

Drug Tier

Service Area South CarolinaH7849-045 ndash Cigna True Choice Medicare (PPO) Charleston Berkeley and Dorchester South Carolina

Drug Tier

24October 2021

Service Area Tennessee H4513-049-001 ndash Cigna Preferred Medicare (HMO) Bedford Benton Bledsoe Bradley Cannon Carroll Chester Clay Coffee Crockett Cumberland Davidson Decatur DeKalb Fayette Fentress Franklin Gibson Giles Grundy Hamilton Hardeman Hardin Haywood Henderson Henry Houston Humphreys Jackson Lake Lauderdale Lawrence Lewis Lincoln Macon Madison Marion Marshall Maury McNairy Moore Obion Overton Perry Pickett Polk Putnam Rutherford Sequatchie Shelby Smith Stewart Sumner Tipton Trousdale Van Buren Warren Wayne Weakley White Williamson and Wilson TennesseeH4513-049-002 ndash Cigna Preferred Medicare (HMO) Cheatham Dickson Hickman Montgomery and Robertson Tennessee

Drug Tier

30 60 90 Days 30 60 90 Day0 $0 $0 $10 $20 $30

s 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $ $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs $5 $10 $10 $20 $40 $60 $5 $10 $0 $20 $40 $60Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs 50 50 50 50Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area TennesseeH4513-036 ndash Cigna Premier Medicare (HMO-POS) Bedford Benton Bledsoe Bradley Cannon Carroll Cheatham Chester Clay Coffee Crockett Cumberland Davidson Decatur DeKalb Dickson Fayette Fentress Gibson Giles Grundy Hamilton Hardeman Hardin Haywood Henderson Hickman Houston Humphreys Jackson Lauderdale Lawrence Lewis Lincoln Macon Madison Marion Marshall Maury McNairy Montgomery Moore Overton Perry Pickett Polk Putnam Robertson Rutherford Sequatchie Shelby Smith Stewart Sumner Tipton Trousdale Van Buren Warren Wayne White Williamson and Wilson Tennessee

Drug Tier

Service Area TennesseeH4513-037 ndash Cigna Preferred Medicare (HMO) Anderson Blount Campbell Claiborne Cocke Grainger Hamblen Hancock Jefferson Knox Loudon Meigs Monroe Morgan Rhea Scott Sevier and Union Tennessee

Drug Tier

25October 2021

Service Area TennesseeH4513-059 ndash Cigna Preferred Medicare (HMO) Carter Greene Hawkins Johnson Sullivan Unicoi and Washington Tennessee

Drug Tier

30 60 90 Days 30 60 90 Days$0 $0 $0 $10 $20 $20

$10 $20 $20 $20 $40 $40

30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 $0 $0 $10 $20 $20Tier 2 Generic Drugs $10 $20 $0 $20 $40 $40Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs 49 49 49 49Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

Service Area TennesseeH7849-010 ndash Cigna True Choice Medicare (PPO) Bedford Cannon Cheatham Clay Coffee Davidson DeKalb Dickson Giles Hickman Houston Humphreys Lawrence Lewis Lincoln Macon Marshall Maury Moore Overton Perry Pickett Putnam Robertson Rutherford Smith Stewart Sumner Trousdale Warren Wayne Williamson and Wilson TennesseeH7849-036 ndash Cigna True Choice Medicare (PPO) Bledsoe Bradley Cumberland Grundy Hamilton Marion Polk Sequatchie Van Buren and White TennesseeH7849-037 ndash Cigna True Choice Medicare (PPO) Benton Carroll Decatur Fayette Hardeman Hardin Haywood Henderson Henry Lake Lauderdale McNairy Madison Obion Shelby Tipton and Weakley TennesseeH7849-043 ndash Cigna True Choice Medicare (PPO) Anderson Blount Campbell Claiborne Cocke Fentress Grainger Hamblen Hancock Jackson Jefferson Knox Loudon Meigs Monroe Morgan Rhea Scott Sevier and Union TennesseeService Area Tennessee (Tri-cities)H7849-034 ndash Cigna True Choice Medicare (PPO) Carter Greene Hawkins Johnson Sullivan Unicoi and Washington Tennessee Russell Scott Washington and Wise Virginia

Drug Tier

26October 2021

Service Area TexasH4513-026 ndash Cigna Preferred Medicare (HMO) Henderson Rusk Smith Upshur and Van Zandt TexasH4513-028 ndash Cigna Preferred Medicare (HMO) Bexar Collin Dallas Denton Hood Johnson Parker Tarrant and Wise TexasH4513-061-001 ndash Cigna Preferred Medicare (HMO) H4513-066 ndash Cigna Preferred Savings Medicare (HMO) Angelina Atascosa Bandera Bexar Brazoria Chambers Comal Fort Bend Galveston Guadalupe Hardin Harris Jasper Jefferson Kendall Liberty Medina Montgomery Nacogdoches Newton Orange Polk San Jacinto Tyler Walker Waller and Wilson TexasH4513-061-002 ndash Cigna Preferred Medicare (HMO) Cameron Hidalgo Webb and Willacy TexasH4513-061-003 ndash Cigna Preferred Medicare (HMO) El PasoTexasH4513-064 ndash Cigna Alliance Medicare (HMO) Brazoria Chambers Fort Bend Galveston Hardin Harris Jefferson Liberty Montgomery Orange Walker and Waller TexasH7849-062 ndash Cigna True Choice Plus Medicare (PPO) Angelina Atascosa Bandera Brazoria Fort Bend Galveston Harris Jasper Kendall Medina Liberty Montgomery Nacogdoches Polk San Jacinto Walker Waller and Wilson Texas

Drug Tier

30 60 90 Days 30 60 90 D $0 $0 $10 $20 $

ays 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs (GC) $0 30 $0 $0 $0 $10 $20 $30Tier 2 Generic Drugs $4 $8 $8 $20 $40 $60 $4 $8 $0 $20 $40 $60Tier 3 Preferred Brand Drugs $42 $84 $126 $47 $94 $141 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs $95 $190 $285 $100 $200 $300 $95 $190 $285 $100 $200 $300Tier 5 Specialty Tier 29 (30 days) 29 (30 days) 29 (30 days) 29 (30 days)

Service Area UtahH7389-001 ndash Cigna Preferred Medicare (HMO) H7849-029 ndash Cigna True Choice Medicare (PPO) Box Elder Davis Salt Lake Tooele Utah and Weber Utah

Drug Tier

27October 2021

Service Area Virginia (Tri-Cities)H9725-008 ndash Cigna Preferred Medicare (HMO) Russell Scott Washington and Wise Virginia

Drug Tier

30 60 90 Days 30 60 90 Days 30 60 90 Days 30 60 90 DaysTier 1 Preferred Generic Drugs $0 $0 $0 $10 $20 $20

20 $20 $20 $40 $404 $126 $47 $94 $141

$0 $0 $0 $10 $20 $20Tier 2 Generic Drugs $10 $ $10 $20 $0 $20 $40 $40Tier 3 Preferred Brand Drugs $42 $8 $42 $84 $126 $47 $94 $141Tier 4 Non-Preferred Drugs 50 50 50 50Tier 5 Specialty Tier 33 (30 days) 33 (30 days) 33 (30 days) 33 (30 days)

My MedicationsIn this section you can write down all of the medications you are currently taking You can then find your drug on the following drug list pages Look and see what tier your drug is on Once you find out what tier your drug is on you can look at the charts before this page and locate your cost-share for that drug If you need help locating your drugs and cost-share please call Customer Service at 1-800-668-3813 October 1 ndash March 31 8 am ndash 8 pm local time 7 days a week From April 1 ndash September 30 Monday ndash Friday 8 am ndash 8 pm local time Messaging service used weekends after hours and on federal holidays TTY users can call 711

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

28October 2021

Drug List Table of ContentsThe drugs on the drug list are grouped into categories depending on the type of medical conditions that they are used to treat If you know what your drug is used for look for the category name in the list below Then look under the category name within the drug list for your drug Page

ANTI - INFECTIVES 29

ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS 35

AUTONOMIC CNS DRUGS NEU

IOVASCULAR HYPERTENS

ATOLOGICALSTOPICAL T

ROLOGY PSYCH 42

CARD ION LIPIDS 51

DERM HERAPY 55

DIAGNOSTICS MISCELLANEOUS AGENTS 58

EAR NOSE THROAT MEDICATIONS 59

ENDOCRINEDIABETES 59

GASTROENTEROLOGY 63

IMMUNOLOGY VACCINES BIOTECHNOLOGY 65

MUSCULOSKELETAL RHEUMATOLOGY 66

OBSTETRICS GYNECOLOGY 67

OPHTHALMOLOGY 70

RESPIRATORY AND ALLERGY 72

UROLOGICALS 74

VITAMINS HEMATINICS ELECTROLYTES 74

Drug List KeyBD ndash This prescription drug has a Part B versus D administrative prior authorization requirement This drug may be covered under Medicare Part B or D depending on circumstancesGC ndash We provide additional coverage of the prescription drugs in this tier in the coverage gap Please refer to our Evidence of Coverage for more information about this coverageLA ndash Limited Availability This prescription may be available only at certain pharmacies For more information consult your Pharmacy Directory or call Customer Service at 1-800-668-3813 (TTY users should call 711) October 1 ndash March 31 8 am ndash 8 pm local time 7 days a week From

April 1 ndash September 30 Monday ndash Friday 8 am ndash 8 pm local time Messaging service used weekends after hours and on federal holidays or visit CignaMedicarecom NDS ndash Non-extended day supply medication This drug is only available as a 30-day supply or lessPA ndash This drug requires prior authorizationQL ndash This drug has quantity limitsST ndash This drug has step therapy requirementsGenerally all medications on the drug list are available through mail-order except when special circumstances or situations prohibit mailing a particular medication to your home

October 2021 29

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugYou can find information on what the symbols and abbreviations on this table mean by going to page 28

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTSABELCET 4 PAAMBISOME 5 PA NDSamphotericin b

intravenous recon

4 PAcaspofunginsoln 50 mg

5 PA NDS

caspofunginsoln 70 mg

4 PA

clotrimazole mucous membrane

2

CRESEMBA ORAL 5 NDSfluconazole 2fluconazole in nacl (iso-osm) intravenous piggyback 200 mg100 ml 400 mg200 ml

4 PA

flucytosine 5 NDSgriseofulvin microsize 4griseofulvin ultramicrosize 4itraconazole oral capsule 4 QL (12030)itraconazole oral solution 4ketoconazole oral 2micafungin 5 NDSnystatin oral suspension 2nystatin oral tablet 3posaconazole oral tablet delayed release (drec)

5 QL (9630) NDS

terbinafine hcl oral 2voriconazole intravenous 5 PA NDSvoriconazole oral suspension for reconstitution

5 NDS

voriconazole oral tablet 4ANTIVIRALSabacavir oral solution 3 QL (96030)abacavir oral tablet 4 QL (6030)abacavir-lamivudine 3 QL (3030)abacavir-lamivudine-zidovudine 5 QL (6030) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

acyclovir oral capsule 2acyclovir oral suspension 200 mg5 ml

4

acyclovir oral tablet 2acyclovir sodium intravenous solution

4 BD PA

adefovir 4amantadine hcl 3APTIVUS 5 QL (12030) NDSatazanavir oral capsule 150 mg 300 mg

4 QL (3030)

atazanavir oral capsule 200 mg 4 QL (6030)BARACLUDE ORAL SOLUTION

4 QL (63030)

BIKTARVY 5 NDSCIMDUO 5 NDSCOMPLERA 5 QL (3030) NDSDELSTRIGO 5 NDSDESCOVY 5 QL (3030) NDSDOVATO 5 NDSEDURANT 5 QL (3030) NDSefavirenz oral capsule 200 mg 4 QL (12030)efavirenz oral capsule 50 mg 3 QL (18030)efavirenz oral tablet 4 QL (3030)efavirenz-emtricitabin-tenofov 5 QL (3030) NDSefavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg

5 QL (3030) NDS

efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg

5 NDS

emtricitabine 3 QL (3030)EMTRICITABINE-TENOFOVIR (TDF) ORAL TABLET 100-150 MG 133-200 MG 167-250 MG

5 QL (3030) NDS

emtricitabine-tenofovir (tdf) oral tablet 200-300 mg

5 QL (3030) NDS

EMTRIVA ORAL SOLUTION 4 QL (68028)entecavir 4 QL (3030)

October 2021 30

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

lamivudine oral tablet 100 mg 300 mg

3 QL (3030)

lamivudine oral tablet 150 mg 3 QL (6030)lamivudine-zidovudine 3 QL (6030)LEXIVA ORAL SUSPENSION 4 QL (157528)lopinavir-ritonavir oral

avir-ritonavir oral t25 mgavir-ritonavir oral t50 mgYRET

solution 3lopin ablet 100-

4 QL (30030)

lopin ablet 200-

4 QL (12030)

MAV 5 PA QL (8428) NDS

nevirapine oral suspension 4 QL (120030)nevirapine oral tablet 3 QL (6030)nevirapine oral tablet extended release 24 hr 100 mg

4 QL (9030)

nevirapine oral tablet extended release 24 hr 400 mg

4 QL (3030)

NORVIR ORAL POWDER IN PACKET

4

NORVIR ORAL SOLUTION 3 QL (48030)ODEFSEY 5 QL (3030) NDSoseltamivir 3PIFELTRO 5 NDSPREVYMIS ORAL 5 QL (3030) NDSPREZCOBIX 5 QL (3030) NDSPREZISTA ORAL SUSPENSION

5 QL (40030) NDS

PREZISTA ORAL TABLET 150 MG

4 QL (24030)

5 QL (6030) NDS

3 QL (48030)

5 QL (3030) NDS

RETROVIR INTRAVENOUS 4REYATAZ ORAL POWDER IN PACKET

5 QL (24030) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

EPCLUSA ORAL TABLET 200-50 MG

5 PA QL (5628) NDS

5 PA QL (2828) NDS

EPIVIR HBV ORAL SOLUTION 4etravirine 5 QL (6030) NDSEVOTAZ 5 QL (3030) NDSfamciclovir 3 QL (6030)fosamprenavir 5 QL (12030) NDSFUZEON SUBCUTANEOUS RECON SOLN

5 QL (6030) NDS

GENVOYA 5 QL (3030) NDSHARVONI ORAL PELLETS IN PACKET 3375-150 MG

5 PA QL (2828) NDS

HARVONI ORAL PELLETS IN PACKET 45-200 MG

5 PA QL (5628) NDS

HARVONI ORAL TABLET 45-200 MG

5 PA QL (5628) NDS

5 PA QL (2828) NDS

INTELENCE ORAL TABLET 100 MG 200 MG

5 QL (6030) NDS

INTELENCE ORAL TABLET 25 MG

4 QL (12030)

INVIRASE ORAL TABLET 5 QL (12030) NDSISENTRESS HD 5 NDSISENTRESS ORAL POWDER IN PACKET

4 QL (6030)

ISENTRESS ORAL TABLET 5 QL (12030) NDSISENTRESS ORAL TABLET CHEWABLE 100 MG

5 QL (18030) NDS

ISENTRESS ORAL TABLET CHEWABLE 25 MG

3 QL (18030)

JULUCA 5 NDSKALETRA ORAL TABLET 100-25 MG

4 QL (30030)

KALETRA ORAL TABLET 200-50 MG

5 QL (12030) NDS

lamivudine oral solution 3 QL (90030)

October 2021 31

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

VOSEVI 5 PA QL (2828) NDS

XOFLUZA ORAL TABLET 20 MG 40 MG

4

XOFLUZA ORAL TABLET 80 MG

4

zidovudine oral capsule 4 QL (18030)zidovudine oral syrup 3 QL (168028)zidovudine oral tablet 3 QL (6030)CEPHALOSPORINScefaclor oral capsule 2cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml

3

cefaclor oral tablet extended release 12 hr

3

cefadroxil oral capsule 3cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml

3

cefadroxil oral tablet 3cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml 2 gram100 ml 2 gram50 ml

4

cefazolin injection recon soln 1 gram 10 gram 100 gram 300 g 500 mg

4

cefazolin intravenous 4cefdinir oral capsule 2cefdinir oral suspension for reconstitution

3

cefepime in dextrose 5 4cefepime in dextroseiso-osm 4cefepime injection 4cefepime intravenous 4 PAcefixime 4cefotaxime injection recon soln 1 gram

4 PA

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ribavirin oral capsule 3ribavirin oral tablet 200 mg 3rimantadine 2ritonavir

OBIAZENTRY ORAL UTIONZENTRY ORAL TAMG 75 MGZENTRY ORAL TAG

3 QL (36030)RUK 5 NDSSELSOL

5 NDS

SEL BLET 150

5 QL (6030) NDS

SEL BLET 25 M

3 QL (12030)

SELZENTRY ORAL TABLET 300 MG

5 QL (12030) NDS

stavudine oral capsule 3 QL (6030)STRIBILD 5 QL (3030) NDSSYMTUZA 5 NDSTEMIXYS 5 NDStenofovir disoproxil fumarate 4 QL (3030)TIVICAY ORAL TABLET 10 MG 4 QL (6030)TIVICAY ORAL TABLET 25 MG 50 MG

5 QL (6030) NDS

TIVICAY PD 5 QL (18030) NDSTRIUMEQ 5 QL (3030) NDSTROGARZO 5 NDSTYBOST 3valacyclovir oral tablet 1 gram 2 QL (12030)valacyclovir oral tablet 500 mg 2 QL (6030)valganciclovir oral recon soln 5 NDSvalganciclovir oral tablet 3VEMLIDY 5 NDSVIRACEPT ORAL TABLET 250 MG

5 QL (27030) NDS

VIRACEPT ORAL TABLET 625 MG

5 QL (12030) NDS

VIREAD ORAL POWDER 5 QL (24030) NDSVIREAD ORAL TABLET 150 MG 200 MG 250 MG

5 QL (3030) NDS

October 2021 32

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ery-tab oral tabletdelayed release (drec) 250 mg

3

ERY-TAB ORAL TABLET DELAYED RELEASE (DREC) 333 MG

3

erythrocin (as stearate) oral tablet 250 mg

4

ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG

4 PA

erythromycin ethylsuccinate oral suspension for reconstitution 200 mg5 ml

3

5 NDS

erythromycin ethylsuccinate oral tablet

3

erythromycin oral tablet 4erythromycin oral tablet delayed release (drec)

3

MISCELLANEOUS ANTIINFECTIVESalbendazole 5 NDSALINIA ORAL SUSPENSION FOR RECONSTITUTION

5 QL (36030) NDS

ALINIA ORAL TABLET 5 QL (2010) NDSamikacin injection solution 1000 mg4 ml 500 mg2 ml

4 PA

ARIKAYCE 5 PA LA NDSatovaquone 5 NDSatovaquone-proguanil 2aztreonam injection recon soln 1 gram

3 PA

aztreonam injection recon soln 2 gram

4 PA

bacitracin intramuscular 4CAPASTAT 4CAYSTON 5 PA LA QL (8428)

NDSchloramphenicol sod succinate 4chloroquine phosphate 2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

cefotetan in dextrose iso-osm 4 PAcefotetan injection 4 PAcefoxitin 4 PAcefoxitin in dextrose iso-osm 4 PAcefpodoxime 2cefprozileftazidimeeftazidime eftriaxoneeftriaxone iefuroxime

2c 4 PAc in d5w 4 PAc 4c n dextroseiso-os 4c axetil oral tablet 2cefuroxime sodium injection recon soln 750 mg

4 PA

cefuroxime sodium intravenous 4 PAcephalexin oral capsule 250 mg 500 mg

1

cephalexin oral suspension for reconstitution

2

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML

4

tazicef 4 PATEFLARO 5 PA NDSERYTHROMYCINS OTHER MACROLIDESazithromycin intravenous 4 PAazithromycin oral packet 3azithromycin oral suspension for reconstitution

2

azithromycin oral tablet 2clarithromycin oral suspension for reconstitution

3

clarithromycin oral tablet 2clarithromycin oral tablet extended release 24 hr

2

DIFICID ORAL SUSPENSION FOR RECONSTITUTION

5 QL (13610) NDS

DIFICID ORAL TABLET 5 QL (2010) NDS

October 2021 33

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

linezolid oral suspension for reconstitution

5 QL (180030) NDS

linezolid oral tablet 4 QL (6030)linezolid-09 sodium chloride 4 PAmefloquine 2meropenem 4meropenem-09 sodium chloride

4

metronidazole in nacl (iso-os) 4 PAmetronidazole oral tablet 2neomycin 2NITAZOXANIDE 5 QL (2010) NDSORBACTIV 5 PA QL (330) NDSparomomycin 4PASER 4pentamidine inhalation 3 BD PA QL (128)pentamidine injection 3polymyxin b sulfate 4 PApraziquantel 4PRIFTIN 4PRIMAQUINE 3pyrazinamide 4pyrimethamine 5 PA NDSquinine sulfate 4 PA QL (427)rifabutin 4rifampin intravenous 4rifampin oral 2SIRTURO 4 PA LASIVEXTRO INTRAVENOUS 5 PA QL (628) NDSSIVEXTRO ORAL 5 QL (628) NDSstreptomycin 5 PA NDSSYNERCID 5 PA NDStigecycline 5 PA NDSTOBI PODHALER INHALATION CAPSULE WINHALATION DEVICE

5 QL (22428) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

clindamycin hcl 2clindamycin in 09 sod chlor 4 PAclindamycin in 5 dextrose 4 PAclindamycin pediatric

phosphate injection phosphate solution 600 mg4

4clindamycin 4 PAclindamycinintravenousml

4 PA

COARTEM 4 QL (2430)colistin (colistimethate na) 5 PA NDScycloserine 2dapsone oral 3DAPTOMYCIN INTRAVENOUS RECON SOLN 350 MG

5 NDS

daptomycin intravenous recon soln 500 mg

5 NDS

EMVERM 5 NDSertapenem 4ethambutol 3FIRVANQ ORAL RECON SOLN 25 MGML

4 QL (40010)

FIRVANQ ORAL RECON SOLN 50 MGML

4 QL (45010)

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg100 ml 100 mg50 ml 120 mg100 ml 60 mg50 ml 80 mg100 ml 80 mg50 ml

4 PA

gentamicin injection solution 40 mgml

4 PA

gentamicin sulfate (ped) (pf) 4 PAhydroxychloroquine oral tablet 200 mg

2

imipenem-cilastatin 4isoniazid oral solution 4isoniazid oral tablet 2ivermectin oral 3lincomycin 4 PAlinezolid in dextrose 5 4 PA

October 2021 34

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

amoxicillin-pot clavulanate oral tablet extended release 12 hr

4

amoxicillin-pot clavulanate oral tabletchewable

2

ampicillin oral capsule 2ampicillin sodium 4 PAampicillin-sulbactam 4 PAAUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-3125 MG5 ML

5 NDS

BICILLIN L-A 4 PAdicloxacillin 2nafcillin 4 PAnafcillin in dextrose iso-osm 4 PAoxacillin injection 4 PApenicillin g potassium injection recon soln 20 million unit

4 PA

penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet 250 mg

1

2

pfizerpen-g 4 PApiperacillin-tazobactam 4ZOSYN IN DEXTROSE (ISO-OSM)

4

QUINOLONESCIPRO ORAL SUSPENSION MICROCAPSULE RECON

4

ciprofloxacin hcl oral tablet 100 mg

3

ciprofloxacin hcl oral tablet 250 mg 500 mg 750 mg

2

ciprofloxacin in 5 dextrose 4 PAlevofloxacin in d5w 4 PAlevofloxacin intravenous 4 PAlevofloxacin oral solution 4

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

tobramycin in 0225 nacl 5 BD PA QL (28028) NDS

tobramycin sulfate 4 PATRECATOR 3VANCOMYCIN IN 09

UM CHL INTRAVENYBACKOMYCIN IN DEXTRTRAVENOUS YBACK 1 GRAM200G150 MLmycin in dextrose 5enous piggyback 500 0 mlmycin injectionmycin intravenous re

SODI OUS PIGG

4

VANC OSE 5 INPIGG ML 750 M

4

vanco intravmg10

4

vanco 4vanco con soln 1000 mg 10 gram 250 mg 5 gram 500 mg 750 mg

4

VANCOMYCIN INTRAVENOUS RECON SOLN 125 GRAM 15 GRAM

4

vancomycin oral capsule 125 mg

3 PA QL (4010)

3 PA QL (8010)

VANCOMYCIN-WATER INJECT (PEG)

4

XIFAXAN ORAL TABLET 550 MG

5 PA QL (9030) NDS

PENICILLINSamoxicillin oral capsule 1amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet 2amoxicillin oral tabletchewable 125 mg 250 mg

2

amoxicillin-pot clavulanate oral suspension for reconstitution

2

amoxicillin-pot clavulanate oral tablet

2

October 2021 35

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

URINARY TRACT AGENTSfosfomycin tromethamine 4methenamine hippurate 2nitrofurantoin 4nitrofurantoin macrocrystal 2nitrofurantoin monohydm-cryst 3trimethoprim 2

ANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTSleucovorin calcium injection 4leucovorin calcium oral 3mesna 4 BD PAMESNEX ORAL 5 NDSXGEVA 5 PA QL (1728)

NDSANTINEOPLASTIC IMMUNOSUPPRESSANT DRUGSabiraterone oral tablet 250 mg 5 PA QL (12030)

NDSABIRATERONE ORAL TABLET 500 MG

5 PA QL (6030) NDS

ABRAXANE 5 PA NDSADCETRIS 5 PA NDSadriamycin intravenous recon soln 10 mg

4 BD PA

adriamycin intravenous solution 4 BD PAAFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG

5 PA QL (15030) NDS

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG 5 MG

5 PA QL (5628) NDS

AFINITOR ORAL TABLET 10 MG

5 PA QL (3030) NDS

ALECENSA 5 PA QL (24030) NDS

ALIMTA 5 PA NDSALIQOPA 5 PA NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

levofloxacin oral tablet 2moxifloxacin oral 4moxifloxacin-sodacesul-water 4 PAmoxifloxacin-sodchloride(iso) 4 PASULFAS RELATED AGENTSsulfadiazine 4sulfamethoxazole-trimethoprim intravenous

xazole-trimetho

4 PA

sulfametho prim oral suspension

4

sulfamethoxazole-trimethoprim oral tablet

1

TETRACYCLINESdemeclocycline 4doxy-100 4 PAdoxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg

1

2

doxycycline monohydrate oral capsule 100 mg 50 mg

2

doxycycline monohydrate oral capsuleir - delay relbiphase

4

doxycycline monohydrate oral suspension for reconstitution

2

doxycycline monohydrate oral tablet

3

minocycline oral capsule 2minocycline oral tablet 2mondoxyne nl oral capsule 100 mg

2

mondoxyne nl oral capsule 75 mg

3

morgidox oral capsule 100 mg 1NUZYRA INTRAVENOUS 5 PA NDSNUZYRA ORAL 5 NDStetracycline 2

October 2021 36

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

CALQUENCE 5 PA LA QL (6030) NDS

CAPRELSA ORAL TABLET 100 MG

5 PA LA QL (6030) NDS

carboplatin intravenous solution 4 BD PAcarmustine 4 BD PAcisplatin intravenous solution 4 BD PAcladribine 4 BD PAclofarabine 4 BD PACOMETRIQ ORAL CAPSULE 100 MGDAY(80 MG X1-20 MG X1)

5 PA QL (5628) NDS

COMETRIQ ORAL CAPSULE 140 MGDAY(80 MG X1-20 MG X3)

5 PA QL (11228) NDS

COMETRIQ ORAL CAPSULE 60 MGDAY (20 MG X 3DAY)

5 PA QL (8428) NDS

COPIKTRA 5 PA LA QL (6030) NDS

COSMEGEN 5 BD PA NDSCOTELLIC 5 PA LA QL (6328)

NDScyclophosphamide intravenous 5 BD PA NDScyclophosphamide oral 3 BD PAcyclosporine intravenous 4 BD PAcyclosporine modified 4 BD PAcyclosporine oral capsule 4 BD PACYRAMZA 5 PA NDScytarabine 4 BD PAcytarabine (pf) 4 BD PAdacarbazine 4 BD PAdactinomycin 4 BD PADARZALEX 5 PA NDSDARZALEX FASPRO 5 PA NDSdaunorubicin intravenous solution

4 BD PA

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ALUNBRIG ORAL TABLET 180 MG 90 MG

5 PA QL (3030) NDS

ALUNBRIG ORAL TABLET 30 MG

5 PA QL (6030) NDS

ALUNBRIG ORAL TABLETS DOSE PACK

5 PA QL (60365) NDS

anastrozole 2ARRANON 4 BD PAarsenic trioxide 5 BD PA NDSARZERRA 5 BD PA NDSAYVAKIT 5 PA LA QL (3030)

NDSazacitidine 5 BD PA NDS

BD PABD PA

AZASAN 3azathioprine 2azathioprine sodium 4 BD PABALVERSA 5 PA LA NDSBAVENCIO 5 PA NDSBELEODAQ 5 BD PA NDSBENDEKA 5 BD PA NDSBESPONSA 5 PA NDSbexarotene 5 PA NDSbicalutamide 2BLENREP 5 PA NDSbleomycin 4 BD PABLINCYTO INTRAVENOUS KIT

5 BD PA NDS

bortezomib 5 PA NDSBOSULIF ORAL TABLET 100 MG

5 PA QL (9030) NDS

BOSULIF ORAL TABLET 400 MG 500 MG

5 PA QL (3030) NDS

BRAFTOVI ORAL CAPSULE 75 MG

BRUKINSA 5 PA LA NDSBUSULFAN 5 BD PA NDSCABOMETYX 5 PA LA QL (3030)

NDS

October 2021 37

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

everolimus (antineoplastic) 5 PA QL (3030) NDS

everolimus (immunosuppressive) oral tablet 025 mg 075 mg

5 BD PA QL (6030) NDS

everolimus (immunosuppressive) oral tablet 05 mg

EVOMELA 5 PA NDSexemestane 2FARYDAK 5 PA QL (621) NDSFIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG

5 BD PA NDS

FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG

4 BD PA

floxuridine 4 BD PAfludarabine 4 BD PAfluorouracil intravenous 4 BD PAflutamide 2FOLOTYN 5 BD PA NDSFOTIVDA 5 PA LA QL (2128)

NDSfulvestrant 5 BD PA NDSGAVRETO 5 PA LA QL

(12030) NDSGAZYVA 5 PA NDSgemcitabine intravenous recon soln

4 BD PA

gemcitabine intravenous solution 1 gram263 ml (38 mgml) 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml)

4 BD PA

gemcitabine intravenous solution 100 mgml

5 BD PA NDS

gengraf 4 BD PAGILOTRIF 5 PA QL (3030)

NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

DAURISMO ORAL TABLET 100 MG

5 PA QL (3030) NDS

5 PA QL (6030) NDS

decitabine 5 BD PA NDSdocetaxel intravenous solution 160 mg16 ml (10 mgml) 160 mg8 ml (20 mgml) 20 mg2 ml (10 mgml) 20 mgml (1 ml) 80

l (20 mgml) 80 mg8 gml)icin intravenous recon

mgicin intravenous

mg4 mml (10 m

4 BD PA

doxorubsoln 50

4 BD PA

doxorubsolution

4 BD PA

doxorubicin peg-liposomal 5 BD PA NDSDROXIA 3ELIGARD 4 PAELIGARD (3 MONTH) 4 PAELIGARD (4 MONTH) 4 PAELIGARD (6 MONTH) 4 PAELZONRIS 5 PA NDSEMCYT 5 NDSEMPLICITI 4 PAENHERTU 5 PA NDSENVARSUS XR 4 BD PAepirubicin intravenous solution 4 BD PAERBITUX 5 BD PA NDSERIVEDGE 5 PA QL (3030)

NDSERLEADA 5 PA QL (12030)

NDSerlotinib oral tablet 100 mg 150 mg

5 PA QL (3030) NDS

erlotinib oral tablet 25 mg 5 PA QL (6030) NDS

ERWINAZE 5 BD PA NDSETOPOPHOS 4 BD PAetoposide intravenous 3 BD PA

October 2021 38

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

JEVTANA 4 BD PAKADCYLA 5 PA NDSKEYTRUDA 5 PA NDSKISQALI 5 PA QL (6328)

NDSKISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY(200 MG X 1)-25 MG

5 PA QL (4928) NDS

KISQALI FEMARA CO-PACK ORAL TABLET 400 MGDAY(200 MG X 2)-25 MG

5 PA QL (7028) NDS

5 PA QL (9128) NDS

KYPROLIS 5 BD PA NDSlapatinib 5 PA QL (18030)

NDSLENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 4 MG

5 PA QL (3030) NDS

LENVIMA ORAL CAPSULE 12 MGDAY (4 MG X 3) 18 MGDAY (10 MG X 1-4 MG X2) 24 MGDAY(10 MG X 2-4 MG X 1)

5 PA QL (9030) NDS

LENVIMA ORAL CAPSULE 14 MGDAY(10 MG X 1-4 MG X 1) 20 MGDAY (10 MG X 2) 8 MGDAY (4 MG X 2)

5 PA QL (6030) NDS

letrozole 2LEUKERAN 4leuprolide subcutaneous kit 5 PA NDSLIBTAYO 5 PA NDSLONSURF ORAL TABLET 15-614 MG

5 PA QL (10028) NDS

LONSURF ORAL TABLET 20-819 MG

5 PA QL (8028) NDS

LORBRENA ORAL TABLET 100 MG

5 PA QL (3030) NDS

5 PA QL (9030) NDS

LUMAKRAS 5 PA QL (24030) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

gleostine oral capsule 10 mg 40 mg

3

gleostine oral capsule 100 mg 5 NDSHALAVEN 5 P

urea 2E 5 P

A NDShydroxyIBRANC A QL (2128)

NDSICLUSIG 5 PA QL (3030)

NDSidarubicin 4 BD PAIDHIFA 5 PA LA QL (3030)

NDSifosfamide 4 BD PAimatinib oral tablet 100 mg 5 PA QL (18030)

NDSimatinib oral tablet 400 mg 5 PA QL (6030)

NDSIMBRUVICA ORAL CAPSULE 140 MG

5 PA QL (12030) NDS

IMBRUVICA ORAL CAPSULE 70 MG

5 PA QL (3030) NDS

IMBRUVICA ORAL TABLET 5 PA QL (3030) NDS

IMFINZI 5 PA NDSINFUGEM 5 BD PA NDSINLYTA ORAL TABLET 1 MG 5 PA QL (18030)

NDSINLYTA ORAL TABLET 5 MG 5 PA QL (12030)

NDSINQOVI 5 PA QL (528) NDSINREBIC 5 PA LA QL

(12030) NDSIRESSA 5 PA QL (3030)

NDSirinotecan 4 BD PAIXEMPRA 5 BD PA NDSJAKAFI 5 PA QL (6030)

NDSJEMPERLI 5 PA NDS

October 2021 39

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

mycophenolate mofetil oral tablet

2 BD PA

mycophenolate sodium 2 BD PAMYLOTARG 5 PA NDSNERLYNX 5 PA LA NDSNEXAVAR 5 PA LA QL

(12030) NDSnilutamide 5 NDSNINLARO 5 PA QL (328) NDSNIPENT 4 BD PANUBEQA 5 PA LA QL

(12030) NDSNULOJIX 5 BD PA QL (2628)

NDSoctreotide acetate injection solution 1000 mcgml 100 mcgml 200 mcgml 50 mcgml

4 PA

octreotide acetate injection solution 500 mcgml

5 PA NDS

octreotide acetate injection syringe

4 PA

ODOMZO 5 PA LA QL (3030) NDS

ONIVYDE 5 PA NDSONUREG 5 PA QL (1428)

NDSOPDIVO INTRAVENOUS SOLUTION 100 MG10 ML 240 MG24 ML 40 MG4 ML

5 PA QL (8028) NDS

ORGOVYX 5 PA LA QL (3030) NDS

oxaliplatin 4 BD PApaclitaxel 4 BD PAPADCEV 5 PA NDSPEMAZYRE 5 PA LA QL (1421)

NDSPEPAXTO 5 PA NDSPERJETA 5 PA NDSPHESGO 5 PA NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

LUMOXITI 5 PA NDSLUPRON DEPOT 5 PA NDS

POT (3 MONTH) 4 PAPOT (4 MONTH) 4 PAPOT (6 MONTH) 4 PAPOT-PED 5 PA NDSPOT-PED (3 5 PA NDS

5 PA QL (12030) NDS

5 NDS5 BD PA NDS5 NDS

al suspension 400 3 PA

LUPRON DELUPRON DELUPRON DELUPRON DELUPRON DEMONTH)LYNPARZA

LYSODRENMARQIBOMATULANEmegestrol ormg10 ml (10 ml) 400 mg10 ml (40 mgml)megestrol oral tablet 3 PAMEKINIST ORAL TABLET 05 MG

5 PA QL (9030) NDS

MEKINIST ORAL TABLET 2 MG

5 PA QL (3030) NDS

MEKTOVI 5 PA LA QL (18030) NDS

melphalan 4 BD PAmelphalan hcl 5 BD PA NDSmercaptopurine 2methotrexate sodium (pf) 4 BD PAmethotrexate sodium injection 4 BD PAmethotrexate sodium oral 2mitomycin intravenous 4 BD PAmitoxantrone 4 BD PAMONJUVI 5 PA NDSmycophenolate mofetil (hcl) 4 BD PAmycophenolate mofetil oral capsule

2 BD PA

mycophenolate mofetil oral suspension for reconstitution

5 BD PA NDS

October 2021 40

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

sirolimus oral solution 5 BD PA NDSsirolimus oral tablet 4 BD PASOLTAMOX 5 NDSSOMATULINE DEPOT 5 PA NDSSPRYCEL ORAL TABLET 100 MG 140 MG 50 MG 80 MG

5 PA QL (3030) NDS

PRYCEL ORAL TABLET 20 MG 70 MG

5 PA QL (6030) NDS

TIVARGA 5 PA QL (8428) NDS

unitinib 5 PA QL (3030) NDS

UTENT 5 PA QL (3030) NDS

YNRIBO 5 PA NDSABLOID 4ABRECTA 5 PA NDSacrolimus oral 2 BD PAAFINLAR 5 PA QL (12030)

NDSAGRISSO 5 PA LA QL (3030)

NDSALZENNA ORAL CAPSULE 25 MG

5 PA QL (9030) NDS

ALZENNA ORAL CAPSULE MG

5 PA QL (3030) NDS

tamoxifen 2TARGRETIN TOPICAL 5 PA NDSTASIGNA ORAL CAPSULE 150 MG 200 MG

5 PA QL (11228) NDS

TASIGNA ORAL CAPSULE 50 MG

5 PA QL (12030) NDS

TAZVERIK 5 PA LA NDSTECENTRIQ 5 PA NDSTEMODAR INTRAVENOUS 5 BD PA NDStemsirolimus 5 BD PA NDSTEPMETKO 5 PA LA QL (6030)

NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

PIQRAY 5 PA NDSPOLIVY 5 PA NDSPOMALYST 5 PA LA QL (2128)

NDSPORTRAZZA 4 BD PAPOTELIGEO 5 PA NDS

TRAVENOUS 4 BD PA SRAL GRANULES 4 BD PA

S5 NDS5 PA LA QL (9030) s

NDSRAL CAPSULE 5 PA LA QL S

(18030) NDSRAL CAPSULE 5 PA LA QL S

(12030) NDS T5 PA LA QL (2828) T

NDS t INTRAVENOUS 5 PA NDS T

ORAL CAPSULE 5 PA QL (15030) TNDS

ORAL CAPSULE 5 PA QL (9030) TNDS 0

5 PA LA QL T(12030) NDS 1

PROGRAF INPROGRAF OIN PACKETPURIXANQINLOCK

RETEVMO O40 MGRETEVMO O80 MGREVLIMID

ROMIDEPSINSOLUTIONROZLYTREK 100 MGROZLYTREK 200 MGRUBRACA

RUXIENCE 5 PA NDSRYBREVANT 5 PA NDSRYDAPT 5 PA QL (24030)

NDSSANDIMMUNE ORAL SOLUTION

4 BD PA

SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON

5 PA NDS

SARCLISA 5 PA NDSSIGNIFOR 5 PA NDSSIMULECT 5 BD PA NDS

October 2021 41

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

UKONIQ 5 PA LA QL (12030) NDS

UNITUXIN 5 PA NDSvalrubicin 4 BD PAVECTIBIX 5 PA NDSVELCADE 5 PA NDSVENCLEXTA ORAL TABLET 10 MG

4 PA LA QL (6030)

VEN solution 4 BD PA 100

VEN5 NDS 50 5 PA NDS VEN5 BD PA NDS

SCULAR 4 PA VER

25 MG vinblvinc

SCULAR 5 PA NDS vincrvino5 MG

CLEXTA ORAL TABLET MG

CLEXTA STARTING PACK 5 PA LA QL (84365) NDS

ZENIO 5 PA LA QL (6030) NDS

astine 4 BD PAasar pfs 4 BD PAistine 4 BD PArelbine 4 BD PA

VITRAKVI ORAL CAPSULE 100 MG

VITRAKVI ORAL SOLUTION 5 PA LA QL (30030) NDS

VIZIMPRO 5 PA QL (3030) NDS

VOTRIENT 5 PA QL (12030) NDS

VYXEOS 5 BD PA NDSXALKORI 5 PA QL (6030)

NDSXATMEP 4 PAXOSPATA 5 PA LA NDSXPOVIO 5 PA LA NDSXTANDI ORAL CAPSULE 5 PA QL (12030)

NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

THALOMID ORAL CAPSULE 100 MG 150 MG 50 MG

5 PA QL (2828) NDS

THALOMID ORAL CAPSULE 200 MG

5 PA QL (5628) NDS

thiotepa 4 PATIBSOVO 5 PA NDStoposar 3 BD PAtopotecan intravenous recon soln

5 BD PA NDS

topotecan intravenous4 mg4 ml (1 mgml)toremifeneTRAZIMERATREANDATRELSTAR INTRAMUSUSPENSION FOR RECONSTITUTION 11375 MGTRELSTAR INTRAMUSUSPENSION FOR RECONSTITUTION 22tretinoin (antineoplastic) 5 NDSTRIPTODUR 5 PA QL (1168)

NDSTRODELVY 5 PA NDSTRUSELTIQ ORAL CAPSULE 100 MGDAY (100 MG X 1)

5 PA QL (2128) NDS

TRUSELTIQ ORAL CAPSULE 125 MGDAY(100 MG X1-25MG X1) 50 MGDAY (25 MG X 2)

5 PA QL (4228) NDS

TRUSELTIQ ORAL CAPSULE 75 MGDAY (25 MG X 3)

5 PA QL (6328) NDS

TUKYSA ORAL TABLET 150 MG

TURALIO 5 PA LA QL (12030) NDS

October 2021 42

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

carbamazepine oral suspension 100 mg5 ml 200 mg10 ml

2

carbamazepine oral tablet 2carbamazepine oral tablet extended release 12 hr

2

carbamazepine oral tablet chewable

2

CELONTIN ORAL CAPSULE 300 MG

3

clobazam oral suspension 4 PA QL (48030)clobazam oral tablet 10 mg 4 PA QL (12030)clobazam oral tablet 20 mg 4 PA QL (6030)clonazepam oral tablet 05 mg 1 mg

2 QL (12030)

clonazepam oral tablet 2 mg 2 QL (30030)clonazepam oral tablet disintegrating 0125 mg 025 mg

2 QL (9030)

clonazepam oral tablet disintegrating 05 mg 1 mg

2 QL (12030)

clonazepam oral tablet disintegrating 2 mg

2 QL (30030)

DIACOMIT 3 LAdiazepam rectal 4DILANTIN 30 MG 3divalproex 2EPIDIOLEX 5 PA LA NDSepitol 2ethosuximide 3felbamate 4FINTEPLA 5 PA LA QL

(36030) NDSfosphenytoin 3FYCOMPA ORAL SUSPENSION

4 QL (72030)

FYCOMPA ORAL TABLET 10 MG 12 MG 8 MG

5 QL (3030) NDS

FYCOMPA ORAL TABLET 2 MG

4 QL (6030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

XTANDI ORAL TABLET 40 MG 5 PA QL (12030) NDS

YERVOY 5 PA NDSYONDELIS 5 PA NDSZALTRAP 4 BD PAZANOSAR 4 BD PAZEJULA 5 PA LA QL (9030)

NDS5 PA QL (24030)

NDS5 PA NDS5 PA NDS4 BD PA5 PA QL (12030)

NDS5 BD PA NDS

ZELBORAF

ZEPZELCAZIRABEVZOLADEXZOLINZA

ZORTRESS ORAL TABLET 1 MGZYDELIG 5 PA QL (6030)

NDSZYKADIA ORAL TABLET 5 PA QL (9030)

NDSZYNLONTA 5 PA NDS

AUTONOMIC CNS DRUGS NEUROLOGY PSYCH

ANTICONVULSANTSAPTIOM ORAL TABLET 200 MG

5 QL (18030) NDS

APTIOM ORAL TABLET 400 MG

5 QL (9030) NDS

APTIOM ORAL TABLET 600 MG 800 MG

5 QL (6030) NDS

BANZEL ORAL SUSPENSION 5 PA NDSBRIVIACT INTRAVENOUS 5 NDSBRIVIACT ORAL SOLUTION 5 QL (60030) NDSBRIVIACT ORAL TABLET 5 QL (6030) NDScarbamazepine oral capsule er multiphase 12 hr

2

October 2021 43

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

pregabalin oral tablet extended release 24 hr 165 mg 825 mg

3 QL (3030)

pregabalin oral tablet extended release 24 hr 330 mg

3 QL (6030)

primidone 2roweepra oral tablet 500 mg 2RUFINAMIDE ORAL SUSPENSION

5 PA NDS

rufinamide oral tablet 5 PA NDSSPRITAM 4subvenite 2subvenite starter (blue) kit 2subvenite starter (green) kit 2subvenite starter (orange) kit 2SYMPAZAN 5 PA QL (6030)

NDStiagabine 4topiramate oral capsule sprinkle

2 PA

topiramate oral tablet 2 PATROKENDI XR ORAL CAPSULEEXTENDED RELEASE 24HR 100 MG 25 MG 50 MG

4 PA

TROKENDI XR ORAL CAPSULEEXTENDED RELEASE 24HR 200 MG

5 PA NDS

valproate sodium 3valproic acid 2valproic acid (as sodium salt) 2VALTOCO 5 PA QL (1030)

NDSvigabatrin 5 PA LA QL

(18030) NDSvigadrone 5 PA LA QL

(18030) NDSVIMPAT INTRAVENOUS 5 QL (120030) NDSVIMPAT ORAL SOLUTION 5 QL (120030) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

FYCOMPA ORAL TABLET 4 MG 6 MG

5 QL (6030) NDS

gabapentin oral capsule 100 mg 300 mg

2 QL (36030)

gabapentin oral capsule 400

ral solutionral tablet 600 mgral tablet 800 mgral tabletral tablet extende

mg2 QL (27030)

gabapentin o 4 QL (216030)gabapentin o 2 QL (18030)gabapentin o 2 QL (12030)lamotrigine o 2lamotrigine o d release 24hr

2

lamotrigine oral tablet chewable dispersible

2

lamotrigine oral tablet disintegrating

2

levetiracetam in nacl (iso-os) 4levetiracetam intravenous 3levetiracetam oral 2NAYZILAM 5 PA QL (1030)

NDSoxcarbazepine 2phenobarbital oral elixir 3 PA QL (150030)phenobarbital oral tablet 3 PA QL (12030)phenobarbital sodium injection solution

3

phenytoin oral suspension 2phenytoin oral tabletchewable 2phenytoin sodium extended 2phenytoin sodium intravenous solution

3

pregabalin oral capsule 100 mg 150 mg 25 mg 50 mg 75 mg

2 QL (12030)

pregabalin oral capsule 200 mg 2 QL (9030)pregabalin oral capsule 225 mg 300 mg

2 QL (6030)

pregabalin oral solution 3 QL (90030)

October 2021 44

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

pramipexole oral tablet 2pramipexole oral tablet extended release 24 hr

4

rasagiline 3ropinirole oral tablet 2RYTARY 4 STselegiline hcl 3tolcapone 5 NDStrihexyphenidyl 2 PAMIGRAINE CLUSTER HEADACHE THERAPYAIMOVIG AUTOINJECTOR 3 PA QL (128)AJOVY AUTOINJECTOR 3 PA QL (1530)AJOVY SYRINGE 3 PA QL (1530)dihydroergotamine nasal 5 PA QL (828) NDSergotamine-caffeine 3migergot 5 NDSnaratriptan 3 QL (1828)rizatriptan 3 QL (3628)sumatriptan nasal spraynon-aerosol 20 mgactuation

4 QL (1828)

sumatriptan nasal spraynon-aerosol 5 mgactuation

4 QL (3628)

sumatriptan succinate oral 2 QL (1828)sumatriptan succinate subcutaneous cartridge

4 QL (828)

sumatriptan succinate subcutaneous pen injector

4 QL (828)

sumatriptan succinate subcutaneous solution

4 QL (828)

MISCELLANEOUS NEUROLOGICAL THERAPYAUSTEDO ORAL TABLET 12 MG 9 MG

AUSTEDO ORAL TABLET 6 MG

COPAXONE SUBCUTANEOUS SYRINGE 20 MGML

5 PA QL (3030) NDS

5 PA QL (1228) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

VIMPAT ORAL TABLET 100 MG 150 MG 200 MG

5 QL (6030) NDS

VIMPAT ORAL TABLET 50 MG 4 QL (12030)XCOPRI MAINTENANCE PACK ORAL TABLET 250MGDAY(150 MG X1-100MG X1)

5 PA NDS

XCOPRI MAINTENANAL TABLET MG X1-150

RAL TABL

CE PACK OR 350 MGDAY (200 MG X1)

5 PA QL (5628) NDS

XCOPRI O ET 100 MG

5 PA NDS

XCOPRI ORAL TABLET 150 MG 200 MG

5 PA QL (6030) NDS

XCOPRI ORAL TABLET 50 MG 5 PA QL (24030) NDS

XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 125 MG (14)- 25 MG (14) 150 MG (14)- 200 MG (14)

4 PA QL (5628)

XCOPRI TITRATION PACK ORAL TABLETSDOSE PACK 50 MG (14)- 100 MG (14)

4 PA QL (56365)

zonisamide 2 PAANTIPARKINSONISM AGENTSbenztropine injection 4benztropine oral 2 PAbromocriptine 4carbidopa 4carbidopa-levodopa oral tablet 2carbidopa-levodopa oral tablet extended release

3

carbidopa-levodopa oral tablet disintegrating

2

carbidopa-levodopa-entacapone

3

entacapone 4KYNMOBI SUBLINGUAL FILM 10 MG 15 MG 20 MG 25 MG 30 MG

5 PA QL (15030) NDS

NEUPRO 4

October 2021 45

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

MUSCLE RELAXANTS ANTISPASMODIC THERAPYbaclofen oral tablet 10 mg 5 mg

1

baclofen oral tablet 20 mg 2cyclobenzaprine oral tablet 10 mg 5 mg

3 PA

dantrolene oral 4methocarbamol oral 2 PApyridostigmine bromide oral syrup

5 NDS

pyridostigmine bromide oral tablet 60 mg

3

pyridostigmine bromide oral tablet extended release

4

regonol 4tizanidine oral capsule 4tizanidine oral tablet 2NARCOTIC ANALGESICSacetaminophen-codeine oral solution 120 mg-12 mg 5 ml (5 ml) 120-12 mg5 ml 300 mg-30 mg 125 ml

2 QL (450030) NDS

acetaminophen-codeine oral tablet 300-15 mg 300-30 mg

2 QL (36030) NDS

acetaminophen-codeine oral tablet 300-60 mg

2 QL (18030) NDS

buprenorphine hcl injection 4 NDSbuprenorphine hcl sublingual 4 PABUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCGHOUR 15 MCGHOUR 20 MCGHOUR 5 MCGHOUR

4 QL (428) NDS

buprenorphine transdermal patch weekly 75 mcghour

4 QL (428) NDS

endocet 3 QL (36030) NDSfentanyl 4 QL (1030) NDSfentanyl citrate (pf) injection solution

4 NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

dalfampridine 3 PA QL (6030)dimethyl fumarate oral capsule delayed release(drec) 120 mg

mg (46)umarate oral capsule lease(drec) 120 mg

oral tablet 10 mg oral tablet 5 mg

(14)- 240

5 PA QL (120365) NDS

dimethyl fdelayed re240 mg

5 PA QL (6030) NDS

donepezil 2 QL (6030)donepezil 2 QL (3030)donepezil oral tablet disintegrating 10 mg

2 QL (6030)

donepezil oral tablet disintegrating 5 mg

2 QL (3030)

FIRDAPSE 5 PA LA NDSgalantamine oral capsuleext rel pellets 24 hr

4 QL (3030)

galantamine oral solution 4 QL (20030)galantamine oral tablet 4 QL (6030)GILENYA ORAL CAPSULE 05 MG

5 PA QL (3030) NDS

memantine oral capsule sprinkleer 24hr

4 PA

memantine oral solution 3 PA QL (30030)memantine oral tablet 10 mg 3 PA QL (6030)memantine oral tablet 5 mg 3 PA QL (9030)memantine oral tabletsdose pack

3 PA QL (98365)

NAMZARIC 3 PANUEDEXTA 5 PA NDSOCREVUS 5 PA NDSrivastigmine 4rivastigmine tartrate 4 QL (6030)tetrabenazine oral tablet 125 mg

5 PA QL (24030) NDS

tetrabenazine oral tablet 25 mg 5 PA QL (12030) NDS

TYSABRI 5 PA NDS

October 2021 46

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

morphine intravenous solution 10 mgml 4 mgml 8 mgml

4 NDS

morphine oral solution 3 QL (90030) NDSMORPHINE ORAL TABLET 3 QL (18030) NDSmorphine oral tablet extended release

3 QL (12030) NDS

oxycodone oral concentrate 4 QL (18030) NDSoxycodone oral solution 4 QL (120030) NDSoxycodone oral tablet 10 mg 15 mg 20 mg 30 mg

3 QL (18030) NDS

oxycodone oral tablet 5 mg 3 QL (36030) NDSoxycodone-acetaminophen oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

3 QL (36030) NDS

oxymorphone oral tablet extended release 12 hr

3 QL (9030) NDS

XTAMPZA ER 3 QL (9030) NDSNON-NARCOTIC ANALGESICSbuprenorphine-naloxone sublingual film 12-3 mg

4 QL (6030)

buprenorphine-naloxone sublingual film 2-05 mg

4 QL (36030)

buprenorphine-naloxone sublingual film 4-1 mg 8-2 mg

4 QL (9030)

buprenorphine-naloxone sublingual tablet 2-05 mg

2 QL (36030)

2 QL (9030)

butorphanol nasal 4 QL (1028) NDScelecoxib 3 QL (6030)diclofenac potassium 2diclofenac sodium oral 2diclofenac sodium topical drops 4 QL (30028)diclofenac sodium topical gel 1

3 QL (100028)

diflunisal 2etodolac 4flurbiprofen oral tablet 100 mg 2ibu 1

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 400 mcg 600 mcg 800 mcg

5 PA QL (12030) NDS

fentanyl citrate buccal lozenge 4andle 200 mcg

codone-acetaminophen 3olution 10-325 mg15 ml)codone-acetaminophen 4olution 75-325 mg15 mlOCODONE- 3

on a hPA QL (12030) NDS

hydrooral sml(15

NDS

hydrooral s

QL (555030) NDS

HYDRACETAMINOPHEN ORAL TABLET 10-300 MG 75-300 MG

QL (39030) NDS

hydrocodone-acetaminophen oral tablet 10-325 mg 5-325 mg 75-325 mg

3 QL (36030) NDS

hydrocodone-ibuprofen 3 QL (5030) NDShydromorphone oral liquid 4 QL (240030) NDShydromorphone oral tablet 3 QL (18030) NDSINFUMORPH PF 5 BD PA NDSmethadone injection solution 4 NDSmethadone oral concentrate 4 QL (9030) NDSmethadone oral solution 10 mg5 ml

4 QL (60030) NDS

methadone oral solution 5 mg5 ml

4 QL (120030) NDS

methadone oral tablet 10 mg 3 QL (12030) NDSmethadone oral tablet 5 mg 3 QL (24030) NDSmorphine (pf) injection solution 05 mgml 1 mgml

4 NDS

morphine concentrate oral solution

3 QL (90030) NDS

MORPHINE INJECTION SOLUTION 10 MGML 2 MGML 4 MGML 5 MGML

4 NDS

morphine injection solution 8 mgml

4 NDS

MORPHINE INJECTION SYRINGE 2 MGML 4 MGML

4 NDS

October 2021 47

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

alprazolam oral tablet disintegrating 2 mg

3 QL (15030)

amitriptyline 3amoxapine 3aripiprazole oral solution 4aripiprazole oral tablet 10 mg 15 mg 2 mg 5 mg

3 QL (6030)

aripiprazole oral tablet 20 mg 30 mg

3 QL (3030)

aripiprazole oral tablet disintegrating

4 QL (6030)

ARISTADA INITIO 5 QL (48365) NDSARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 1064 MG39 ML

5 QL (3956) NDS

ARISTADA INTRAMUSCULAR SUSPENSIONEXTENDED REL SYRING 441 MG16 ML

5 QL (1628) NDS

5 QL (2428) NDS

5 QL (3228) NDS

armodafinil 3 PA QL (3030)asenapine maleate sublingual tablet 10 mg 25 mg

4 QL (6030)

asenapine maleate sublingual tablet 5 mg

4 QL (9030)

atomoxetine oral capsule 10 mg 18 mg 25 mg 40 mg

4 QL (6030)

atomoxetine oral capsule 100 mg 60 mg 80 mg

4 QL (3030)

bupropion hcl oral tablet 100 mg

3 QL (12030)

bupropion hcl oral tablet 75 mg 3 QL (18030)bupropion hcl oral tablet extended release 24 hr 150 mg

3 QL (9030)

bupropion hcl oral tablet extended release 24 hr 300 mg

3 QL (3030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ibuprofen oral suspension 2ibuprofen oral tablet 400 mg 600 mg 800 mg

1

KLOXXADO 3meloxicam oral tablet 15 mg 1

ral tablet 75 mg 1 QL (6030)2

ection solution 2ection syringe 1 2

2al suspension 3al tablet 1al tabletdelayed 2

meloxicam onabumetonenaloxone injnaloxone injmgmlnaltrexonenaproxen ornaproxen ornaproxen orrelease (drec)naproxen sodium oral tablet 275 mg 550 mg

4

NARCAN 3oxaprozin 4salsalate 2sulindac 2tramadol oral tablet 50 mg 2 QL (24030) NDStramadol-acetaminophen 3 QL (24030) NDSVIVITROL 5 NDSZUBSOLV SUBLINGUAL TABLET 07-018 MG 14-036 MG 114-29 MG 29-071 MG 57-14 MG

3 QL (3030)

ZUBSOLV SUBLINGUAL TABLET 86-21 MG

3 QL (6030)

PSYCHOTHERAPEUTIC DRUGSABILIFY MAINTENA 5 QL (128) NDSalprazolam oral tablet 025 mg 05 mg 1 mg

2 QL (12030)

alprazolam oral tablet 2 mg 2 QL (15030)alprazolam oral tablet disintegrating 025 mg 05 mg 1 mg

3 QL (9030)

October 2021 48

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

dextroamphetamine oral tablet 10 mg 5 mg

4

dextroamphetamine-amphetamine oral capsule extended release 24hr

4 QL (6030)

dextroamphetamine-amphetamine oral tablet 10 mg

3 QL (18030)

dextroamphetamine-amphetamine oral tablet 125 mg 30 mg 75 mg

3 QL (6030)

3 QL (12030)

3 QL (9030)

3 QL (36030)

diazepam injection 2diazepam oral concentrate 2 QL (36030)diazepam oral solution 5 mg5 ml (1 mgml)

2 QL (180030)

diazepam oral tablet 2 QL (18030)doxepin oral capsule 3doxepin oral concentrate 3DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 20 MG 60 MG

4 QL (6030)

DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 30 MG

4 QL (12030)

4 QL (9030)

duloxetine oral capsuledelayed release(drec) 20 mg 60 mg

2 QL (6030)

duloxetine oral capsuledelayed release(drec) 30 mg

2 QL (12030)

EMSAM 5 QL (3030) NDSescitalopram oxalate oral solution

3 QL (60030)

escitalopram oxalate oral tablet 10 mg 5 mg

2 QL (6030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

bupropion hcl oral tablet sustained-release 12 hr 100 mg

3 QL (12030)

bupropion hcl oral tablet 3 QL (6030)stained-release 12 hr 150 200 mgspirone 2PLYTA 5 PA QL (3030)

NDSlorpromazine injection 4lorpromazine oral 2alopram oral solution 3alopram oral tablet 10 mg 1 QL (6030) mgalopram oral tablet 40 mg 1 QL (3030)mipramine 4razepate dipotassium oral 3 QL (18030)let 15 mgrazepate dipotassium oral 3 QL (9030)let 375 mg

sumgbuCA

chchcitcit20citcloclotabclotabclorazepate dipotassium oral tablet 75 mg

3 QL (36030)

clozapine oral tablet 3clozapine oral tablet disintegrating

4

desipramine 3desvenlafaxine succinate oral tablet extended release 24 hr 100 mg

4 QL (12030)

desvenlafaxine succinate oral tablet extended release 24 hr 25 mg

4 QL (6030)

4 QL (9030)

dexmethylphenidate oral tablet 3dextroamphetamine oral capsule extended release

4

dextroamphetamine oral solution

4 QL (180030)

October 2021 49

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

haloperidol lactate oral 2haloperidol oral tablet 05 mg 1 mg 2 mg 5 mg

1

haloperidol oral tablet 10 mg 20 mg

2

HETLIOZ 5 PA QL (3030) NDS

imipramine hcl 3INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG075 ML

5 QL (07528) NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MGML

5 QL (128) NDS

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG15 ML

5 QL (1528) NDS

4 QL (02528)

5 QL (0528) NDS

INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG0875 ML

4 QL (08890)

4 QL (13290)

4 QL (17590)

4 QL (26390)

LATUDA ORAL TABLET 120 MG 20 MG 40 MG 60 MG

5 QL (3030) NDS

LATUDA ORAL TABLET 80 MG 5 QL (6030) NDSlithium carbonate 2lorazepam injection 4lorazepam intensol 3 QL (15030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

escitalopram oxalate oral tablet 20 mg

2 QL (3030)

FANAPT ORAL TABLET 1 MG 2 MG 4 MG

4 PA QL (6030)

FANAPT ORAL TABLET 10 5G 12 MG 6 MGANAPT ORAL TABLET 8 MG 5

ANAPT ORAL TABLETS 4OSE PACKETZIMA ORAL CAPSULE 4XT REL 24HR DOSE PACKETZIMA ORAL CAPSULE 4XTENDED RELEASE 24 HRuoxetine (pmdd) oral tablet 10 3

MPA QL (6030) NDS

F PA QL (9030) NDS

FD

PA QL (16365)

FE

ST QL (56365)

FE

ST QL (3030)

flmg

QL (12030)

fluoxetine (pmdd) oral tablet 20 mg

3

fluoxetine oral capsule 10 mg 2 QL (12030)fluoxetine oral capsule 20 mg 2fluoxetine oral capsule 40 mg 2 QL (9030)fluoxetine oral capsuledelayed release(drec)

3 QL (428)

fluoxetine oral solution 2fluoxetine oral tablet 10 mg 3 QL (12030)fluoxetine oral tablet 20 mg 3fluphenazine decanoate 4fluphenazine hcl injection 4fluphenazine hcl oral concentrate

4

fluphenazine hcl oral elixir 4fluphenazine hcl oral tablet 2fluvoxamine oral tablet 100 mg 25 mg

2 QL (9030)

fluvoxamine oral tablet 50 mg 2 QL (12030)guanfacine oral tablet extended release 24 hr

4 QL (3030)

haloperidol decanoate 4haloperidol lactate injection 4

October 2021 50

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

paliperidone oral tablet extended release 24hr 15 mg 9 mg

4 PA QL (3030)

paliperidone oral tablet elease 24hr 3 mg

4 PA QL (6030)

hcl oral tablet 10 mg 2 QL (18030) hcl oral tablet 20 2 QL (3030)

hcl oral tablet 30 mg 2 QL (6030) hcl oral tablet elease 24 hr

3 QL (6030)

AL SUSPENSION 4 ST QL (90030)ine 4ine-amitriptyline 4

S 5 QL (128) NDSe 3

4e 4 oral tablet 100 mg mg

2 QL (12030)

oral tablet 200 mg 2 QL (9030) oral tablet 300 mg 2 QL (6030)

oral tablet extended hr 150 mg 200 mg

3 QL (3030)

quetiapine oral tablet extended release 24 hr 300 mg 400 mg 50 mg

3 QL (6030)

ramelteon 3 QL (3030)REXULTI 5 QL (3030) NDSRISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 125 MG2 ML

4 QL (228)

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 25 MG2 ML 375 MG2 ML 50 MG2 ML

5 QL (228) NDS

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

lorazepam oral tablet 05 mg 1 mg

2 QL (9030)

lorazepam oral tablet 2 mg 2 QL (15030)loxapine succinate 2

extended rotiline 4 6 mgLAN 4 QL (18030) paroxetineate er 3 paroxetinelphenidate hcl oral tablet 3 QL (9030) mg 40 mglphenidate hcl oral tablet 3 paroxetineded release paroxetinelphenidate hcl oral tablet 3 extended rded release 24hr 18 mg PAXIL OR (bx rating) 27 mg 27 x rating) 36 mg 36 mg perphenazting) 54 mg 54 mg (bx perphenaz) PERSERIapine oral tablet 2 phenelzinapine oral tablet 3 QL (3030) pimozide

egrating protriptylindone 2 quetiapineodone 4 25 mg 50 ptyline oral capsule 2 quetiapineptyline oral solution 3 quetiapineAZID ORAL CAPSULE 5 PA QL (3030) 400 mg

NDS quetiapineAZID ORAL TABLET 10 5 PA QL (3030) release 24

NDS

maprMARPmetadmethymethyextenmethyexten18 mgmg (b(bx raratingmirtazmirtazdisintmolinnefaznortrinortriNUPL

NUPLMGolanzapine intramuscular 4 QL (3030)olanzapine oral tablet 10 mg 25 mg 5 mg 75 mg

2 QL (6030)

olanzapine oral tablet 15 mg 20 mg

2 QL (3030)

olanzapine oral tablet disintegrating 10 mg 5 mg

4 QL (6030)

4 QL (3030)

olanzapine-fluoxetine 4oxazepam 2 QL (12030)

October 2021 51

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

VIIBRYD ORAL TABLETS DOSE PACK 10 MG (7)- 20 MG (23)

4 ST QL (60365)

VRAYLAR ORAL CAPSULE 5 PA QL (3030) NDS

VRAYLAR ORAL CAPSULE DOSE PACK

4 PA QL (14365)

XYREM 5 PA LA QL (54030) NDS

zaleplon oral capsule 10 mg 3 QL (6030)zaleplon oral capsule 5 mg 3 QL (3030)ziprasidone hcl oral capsule 20 mg

3 QL (18030)

ziprasidone hcl oral capsule 40 mg

3 QL (12030)

ziprasidone hcl oral capsule 60 mg 80 mg

3 QL (6030)

ziprasidone mesylate 4 QL (630)zolpidem oral tablet 2 QL (3030)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG

4 PA QL (228)

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG

5 PA QL (228) NDS

5 PA QL (128) NDS

CARDIOVASCULAR HYPERTENSION LIPIDS

ANTIARRHYTHMIC AGENTSamiodarone intravenous solution

4 BD PA

amiodarone oral 2dofetilide 3flecainide 3lidocaine (pf) intravenous 4mexiletine 2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

risperidone oral solution 2risperidone oral syringe 2risperidone oral tablet 025 mg 05 mg 4 mg

2 QL (12030)

risperidone oral tablet 1 mg 2 QL (18030)risperidone oral tablet 2 mg 2 QL (9030)risperidone oral tablet 3 mg 2 QL (6030)

done oral tablet 4 QL (12030)grating 025 mg 05 mg

done oral tablet 4 QL (18030)grating 1 mgdone oral tablet 4 QL (9030)grating 2 mgdone oral tablet 4 QL (6030)grating 3 mgADO 5 QL (3030) Nline oral concentrate 4line oral tablet 1 QL (6030)epam oral capsule 15 4 QL (60365) mg

azine 3

risperidisinte4 mgrisperidisinterisperidisinterisperidisinteSECU DSsertrasertratemazmg 30thioridthiothixene 4tranylcypromine 4trazodone 2trifluoperazine 3trimipramine 4TRINTELLIX 4 ST QL (3030)venlafaxine oral capsule extended release 24hr 150 mg 375 mg

2 QL (6030)

venlafaxine oral capsule extended release 24hr 75 mg

2 QL (9030)

venlafaxine oral tablet 100 mg 25 mg 375 mg

2 QL (9030)

venlafaxine oral tablet 50 mg 75 mg

2 QL (12030)

VERSACLOZ 5 NDSVIIBRYD ORAL TABLET 4 ST QL (3030)

October 2021 52

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

chlorthalidone oral tablet 25 mg 50 mg

2

clonidine 4 QL (428)clonidine hcl oral tablet 01 mg 02 mg

1

clonidine hcl oral tablet 03 mg 2diltiazem hcl intravenous 4diltiazem hcl oral capsule extended release 12 hr

2

diltiazem hcl oral capsule extended release 24 hr 420 mg

2

diltiazem hcl oral capsule extended release 24hr 120 mg 180 mg 240 mg 300 mg

2

diltiazem hcl oral tablet 2diltiazem hcl oral tablet extended release 24 hr

2

dilt-xr 2doxazosin oral tablet 1 mg 2 mg 4 mg

2 QL (3030)

doxazosin oral tablet 8 mg 2 QL (6030)EDARBI 4EDARBYCLOR 4enalapril maleate oral tablet 1enalapril-hydrochlorothiazide 1ethacrynate sodium 4felodipine 2fosinopril 1fosinopril-hydrochlorothiazide 1furosemide injection 4furosemide oral solution 10 mgml 40 mg5 ml (8 mgml)

2

furosemide oral tablet 1hydralazine injection 4hydralazine oral 2hydrochlorothiazide 1indapamide 1irbesartan 1 QL (3030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

pacerone oral tablet 100 mg 200 mg 400 mg

2

propafenone oral capsule extended release 12 hr

4

propafenone oral tablet 2ine sulfate oral tablet 2

2l af 2l oral 2LIZE 4

HYPERTENSIVE THERAPYtolol 2en 4ride 2ride-hydrochlorothiazide 2ipine 1ipine-benazepril 1ipine-valsartan 1ipine-valsartan-hcthiazid 1

quinidsorinesotalosotaloSOTYANTIacebualiskiramiloamiloamlodamlodamlodamlodatenolol 1atenolol-chlorthalidone 1benazepril 1benazepril-hydrochlorothiazide 1betaxolol oral 2BIDIL 3 QL (18030)bisoprolol fumarate 2bisoprolol-hydrochlorothiazide 1bumetanide injection 4bumetanide oral 3candesartan oral tablet 16 mg 4 mg 8 mg

1 QL (6030)

candesartan oral tablet 32 mg 1 QL (3030)candesartan-hydrochlorothiazid 1cartia xt 2carvedilol 1carvedilol phosphate 3chlorothiazide sodium 4

October 2021 53

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

propranolol oral capsule extended release 24 hr

3

propranolol oral solution 2propranolol oral tablet 1propranolol-hydrochlorothiazid 2quinapril 1quinapril-hydrochlorothiazide 1ramipril 1spironolactone 1spironolacton-hydrochlorothiaz 2taztia xt oral capsuleextended release 24 hr 120 mg 180 mg 240 mg 300 mg

2

TEKTURNA HCT 3telmisartan 1telmisartan-amlodipine 1telmisartan-hydrochlorothiazid 1terazosin oral capsule 1 mg 2 mg 5 mg

1 QL (3030)

terazosin oral capsule 10 mg 1 QL (6030)tiadylt er 2timolol maleate oral 4torsemide oral 2trandolapril 1triamterene-hydrochlorothiazid oral capsule 375-25 mg

1

triamterene-hydrochlorothiazid oral tablet

1

UPTRAVI ORAL 5 PA LA NDSvalsartan oral tablet 160 mg 40 mg 80 mg

1 QL (6030)

valsartan oral tablet 320 mg 1 QL (3030)valsartan-hydrochlorothiazide 1 QL (3030)verapamil intravenous solution 4verapamil oral capsule 24 hr er pellet ct

2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

irbesartan-hydrochlorothiazide 1 QL (3030)isradipine 3labetalol oral 3lisinopril 1lisinopril-hydrochlorothiazide 1losartan 1 QL (6030)losartan-hydrochlorothiazide 1 QL (3030)

100-125 mg 100-25

drochlorothiazide 1 QL (6030)50-125 mg

2a 4e 3 succinate 1 ta-hydrochlorothiaz 2 tartrate oral 1

5 PA NDSral 2

1

oral tablet mglosartan-hyoral tablet matzim lamethyldopmetolazonmetoprololmetoprololmetoprololmetyrosineminoxidil omoexiprilnadolol 3nadolol-bendroflumethiazide oral tablet 80-5 mg

3

nicardipine intravenous solution 4nicardipine oral 2nifedipine oral tablet extended release

3

nifedipine oral tablet extended release 24hr

3

nimodipine 4nisoldipine 4olmesartan 1olmesartan-hydrochlorothiazide 1perindopril erbumine 1phenoxybenzamine 5 NDSpindolol 1prazosin 3

October 2021 54

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

jantoven 1pentoxifylline 2PRADAXA 4PRASUGREL 3PROMACTA ORAL POWDER IN PACKET 125 MG

PROMACTA ORAL POWDER IN PACKET 25 MG

PROMACTA ORAL TABLET 125 MG 25 MG 50 MG

PROMACTA ORAL TABLET 75 MG

warfarin 1XARELTO 3XARELTO DVT-PE TREAT 30D START

3

LIPIDCHOLESTEROL LOWERING AGENTSatorvastatin 1 QL (3030)cholestyramine (with sugar) 3cholestyramine light oral powder in packet

3

colesevelam 3colestipol oral granules 4colestipol oral packet 4colestipol oral tablet 3ezetimibe 2 QL (3030)ezetimibe-simvastatin 4 QL (3030)fenofibrate micronized oral capsule 134 mg 200 mg 67 mg

3

fenofibrate nanocrystallized oral tablet 145 mg 48 mg

3

fenofibrate oral tablet 160 mg 54 mg

2

fenofibric acid (choline) 4gemfibrozil 1LIVALO 3 QL (3030)lovastatin oral tablet 10 mg 1 QL (3030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

verapamil oral capsuleext rel pellets 24 hr 120 mg 180 mg 240 mg

2

VERAPAMIL ORAL CAPSULE 3EL PELLETS 24 HR Gmil oral tablet 1mil oral tablet extended 2

eULATION THERAPY

caproic acid oral 4-dipyridamole 4TA 4 QL (6030)

zol 2ogrel oral tablet 300 mg 4ogrel oral tablet 75 mg 1 QL (3030)amole oral 3IS 3IS DVT-PE TREAT 30D 3

Tparin 3arinux subcutaneous 5 NDS

e 10 mg08 ml 5 mg04 mg06 mlarinux subcutaneous 4

EXT R360 MverapaverapareleasCOAGaminoaspirinBRILINcilostaclopidclopiddipyridELIQUELIQUSTARenoxafondapsyringml 75fondapsyringe 25 mg05 mlheparin (porcine) in 5 dex intravenous parenteral solution 20000 unit500 ml (40 unitml) 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml)

4

heparin (porcine) in nacl (pf) 4heparin (porcine) injection solution

3

heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml

4

heparin porcine (pf) injection syringe

4

October 2021 55

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

nitroglycerin translingual 4

DERMATOLOGICALSTOPICAL THERAPY

ANTIPSORIATIC ANTISEBORRHEICacitretin 4 PAcalcipotriene scalp 3 QL (12030)calcipotriene topical cream 4 QL (12030)calcipotriene topical ointment 4 QL (12030)calcitriol topical 4selenium sulfide topical lotion 2SKYRIZI SUBCUTANEOUS PEN INJECTOR

5 PA QL (128) NDS

SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML

5 PA QL (128) NDS

SKYRIZI SUBCUTANEOUS SYRINGE KIT

5 PA QL (228) NDS

STELARA SUBCUTANEOUS SOLUTION

5 PA QL (0528) NDS

STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML

5 PA QL (0528) NDS

STELARA SUBCUTANEOUS SYRINGE 90 MGML

5 PA QL (128) NDS

TALTZ SYRINGE 5 PA QL (428) NDSMISCELLANEOUS DERMATOLOGICALSammonium lactate 3DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG114 ML

5 PA QL (45628) NDS

DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG2 ML

5 PA QL (828) NDS

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG114 ML

5 PA QL (45628) NDS

5 PA QL (828) NDS

fluorouracil topical cream 05 5 NDSfluorouracil topical cream 5 3fluorouracil topical solution 2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

lovastatin oral tablet 20 mg 40 mg

1 QL (6030)

niacin oral tablet 500 mg 2niacin oral tablet extended release 24 hr

2

niacor 2 ethyl esters 4

1 QL (30powder in packet 3

3 PA QL SHTRONEX 3 PA QL RECLICK 3 PA QL

1 QL (30al tablet 1 QL (30

3OUS CARDIOVASCULAR AGEN

ORAL TABLET 4 PA QL 2

omega-3 acidpravastatin 30)prevalite oral REPATHA (328)REPATHA PU (3528)REPATHA SU (328)rosuvastatin 30)simvastatin or 30)VASCEPAMISCELLANE TSCORLANOR (6030)digitekdigox 2digoxin injection solution 4digoxin oral solution 3digoxin oral tablet 2ENTRESTO 3 QL (6030)LANOXIN ORAL TABLET 625 MCG (00625 MG)

4

LANOXIN PEDIATRIC 4ranolazine 4 QL (6030)VYNDAMAX 5 PA NDSVYNDAQEL 5 PA NDSNITRATESisosorbide dinitrate oral tablet 3isosorbide mononitrate 2minitran 2nitroglycerin intravenous 4 BD PAnitroglycerin sublingual 2nitroglycerin transdermal patch 24 hour

2

October 2021 56

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

clindamycin phosphate topical lotion

4 QL (12030)

clindamycin phosphate topical solution

3 QL (12030)

clindamycin phosphate topical swab

2 QL (6030)

ery pads 3ERYTHROMYCIN WITH ETHANOL TOPICAL GEL

4

erythromycin with ethanol topical solution

2

erythromycin-benzoyl peroxide 4isotretinoin oral capsule 10 mg 20 mg 30 mg 40 mg

4

metronidazole topical cream 4metronidazole topical gel 4metronidazole topical lotion 4myorisan 4rosadan topical cream 4rosadan topical gel 4tazarotene topical cream 4 PATAZORAC TOPICAL CREAM 005

4 PA

TAZORAC TOPICAL GEL 4 PAtretinoin microspheres 4 PAtretinoin topical cream 0025 005 01

4 PA

tretinoin topical topical gel 001

3 PA

tretinoin topical topical gel 0025 005

4 PA

zenatane 4TOPICAL ANTIBACTERIALSgentamicin topical cream 3 QL (6030)gentamicin topical ointment 3mupirocin 2 QL (4430)mupirocin calcium 4 QL (3030)sulfacetamide sodium (acne) 3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

glydo 3 QL (6030)imiquimod topical cream in metered-dose pump

ical cream in 5 NDS

ical cream in 3

injection solution 4njection solution 4aryngotracheal 4

ucous 3 QL (6030)lyucous 2

lution 4 (40 mg

5 NDS

imiquimod toppacket 375imiquimod toppacket 5lidocaine (pf) lidocaine hcl ilidocaine hcl llidocaine hcl mmembrane jellidocaine hcl mmembrane soml)lidocaine topical adhesive patchmedicated 5

4 PA QL (9030)

lidocaine topical ointment 4 QL (5030)lidocaine viscous 1lidocaine-prilocaine topical cream

4 QL (3030)

methoxsalen 4pimecrolimus 4 PA QL (10030)podofilox 2REGRANEX 5 PA NDSSANTYL 4silver sulfadiazine 3ssd 3tacrolimus topical 3 PA QL (10030)VALCHLOR 5 PA NDSZTLIDO 4 PA QL (9030)THERAPY FOR ACNEamnesteem 4avita 4 PAclaravis 4clindacin p 2 QL (6930)clindamycin phosphate topical gel

3 QL (12030)

October 2021 57

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

betamethasone valerate topical ointment

2

betamethasone augmented 3clobetasol scalp 2 QL (10028)clobetasol topical cream 2 QL (12028)clobetasol topical foam 4 QL (10028)clobetasol topical gel 2 QL (12028)clobetasol topical ointment 2 QL (12028)clobetasol topical shampoo 4 QL (23628)clobetasol-emollient topical cream

2 QL (12028)

clobetasol-emollient topical foam

4 QL (10028)

CLOCORTOLONE PIVALATE 4clodan 4 QL (23628)desonide topical cream 3desonide topical lotion 3desonide topical ointment 3desoximetasone topical cream 4desoximetasone topical gel 4desoximetasone topical ointment

4

fluocinolone and shower cap 3fluocinolone topical cream 2fluocinolone topical oil 3fluocinolone topical ointment 2fluocinolone topical solution 2fluocinonide topical cream 005

2 QL (12030)

fluocinonide topical cream 01 4 QL (12030)fluocinonide topical gel 2 QL (12030)fluocinonide topical ointment 3 QL (12030)fluocinonide topical solution 3 QL (12030)fluticasone propionate topical cream

2

fluticasone propionate topical ointment

2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

TOPICAL ANTIFUNGALSciclodan topical solution 3ciclopirox topical cream 3 QL (9

topical shampoo 3 QL (1 topical solution 3 topical suspension 3 QL (6ole topical cream 3 QL (4ole topical solution 3 QL (3ole-betamethasone 2 QL (4eamole-betamethasone 2 QL (6tionle 3 QL (8zole topical cream 2 QL (6

028)ciclopirox 2028)ciclopiroxciclopirox 028)clotrimaz 528)clotrimaz 028)clotrimaztopical cr

528)

clotrimaztopical lo

028)

econazo 528)ketocona 028)ketoconazole topical shampoo 2 QL (12028)naftifine topical cream 3 QL (6028)NAFTIN TOPICAL GEL 2 3 QL (6028)nyamyc 3 QL (18030)nystatin topical cream 2 QL (3028)nystatin topical ointment 2 QL (3028)nystatin topical powder 3 QL (18030)nystatin-triamcinolone 4 QL (6028)nystop 3 QL (18030)TOPICAL ANTIVIRALSacyclovir topical ointment 4 QL (3030)DENAVIR 5 QL (530) NDSTOPICAL CORTICOSTEROIDSala-cort topical cream 1 1alclometasone 2betamethasone dipropionate 3betamethasone valerate topical cream

2

betamethasone valerate topical foam

3

betamethasone valerate topical lotion

2

October 2021 58

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

MISCELLANEOUS AGENTSacamprosate 2anagrelide 2ARALAST NP INTRAVENOUS RECON SOLN 1000 MG

5 PA LA NDS

ARALAST NP INTRAVENOUS RECON SOLN 500 MG

5 PA NDS

CARBAGLU 5 PA LA NDSCHEMET 4 PACLINIMIX 425D5W SULFIT FREE

4 BD PA

d10-045 sodium chloride 4d25-045 sodium chloride 4d5 and 09 sodium chloride 4d5-045 sodium chloride 4deferasirox oral granules in packet

5 PA NDS

deferasirox oral tablet 5 PA NDSdeferiprone 5 PA NDSdextrose 10 and 02 nacl 4DEXTROSE 10 IN WATER (D10W)

4

dextrose 20 in water (d20w) 4dextrose 25 in water (d25w) 4DEXTROSE 5 IN WATER (D5W) INTRAVENOUS PARENTERAL SOLUTION

4

dextrose 5 in water (d5w) intravenous piggyback

4

dextrose 5-lactated ringers 4dextrose 5-02 sod chloride 4dextrose 5-03 sodchloride 4dextrose 50 in water (d50w) 4dextrose 70 in water (d70w) 4disulfiram 2droxidopa oral capsule 100 mg 4 PA QL (9030)droxidopa oral capsule 200 mg 300 mg

4 PA QL (18030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

halobetasol propionate topical cream

3

halobetasol propionate topical ointment

3

hydrocortisone butyrate topical 4 QL (12030)

sone butyrate topical 3 QL (12030)

sone topical cream 1

sone topical lotion 2

sone topical ointment 2

sone valerate 3ne topical 2ate topical ointment 2ne acetonide topical 2

25 05ne acetonide topical 1

ne acetonide topical 2

creamhydrocortiointmenthydrocortisolutionhydrocorti1hydrocorti25hydrocorti1 25hydrocortimometasoprednicarbtriamcinolocream 00triamcinolocream 01triamcinololotiontriamcinoloointmenttriderm topical cream 01 1TOPICAL SCABICIDES PEDICULICIDESlindane topical shampoo 3malathion 4permethrin 3

DIAGNOSTICS MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONSlactated ringers irrigation 4neomycin-polymyxin b gu 4ringerrsquos irrigation 4tis-u-sol pentalyte 4

October 2021 59

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

SMOKING DETERRENTSbupropion hcl (smoking deter) 3 QL (6030)CHANTIX 4CHANTIX CONTINUING MONTH BOX

4

CHANTIX STARTING MONTH BOX

4

NICOTROL 4NICOTROL NS 4

EAR NOSE THROAT MEDICATIONS

MISCELLANEOUS AGENTSazelastine nasal 3 QL (6030)chlorhexidine gluconate mucous membrane

1

fluoride (sodium) dental paste 4ipratropium bromide nasal 2 QL (3030)oralone 3sodium fluoride-pot nitrate 4triamcinolone acetonide dental 3MISCELLANEOUS OTIC PREPARATIONSacetic acid otic (ear) 2flac otic oil 4fluocinolone acetonide oil 4hydrocortisone-acetic acid 2ofloxacin otic (ear) 2OTIC STEROID ANTIBIOTICCIPRO HC 3ciprofloxacin-dexamethasone 3cortisporin-tc 4neomycin-polymyxin-hc otic (ear)

3

ENDOCRINEDIABETES

ADRENAL HORMONESDEPO-MEDROL 4dexamethasone intensol 4dexamethasone oral elixir 2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

FERRIPROX 5 PA NDSINCRELEX 4 PA LAlevocarnitine (with sugar) 4levocarnitine oral solution 100 4

larnitine oral tablet 3

ELMA 3drine 3none 5 NDSTHERA ORAL CAPSULE 5 PA QL (9030)

G NDSTHERA ORAL CAPSULE 5 PA QL (18030)

G 300 MG NDSarpine hcl oral 4LASTIN-C INTRAVENOUS 5 PA LA NDSON SOLNLASTIN-C INTRAVENOUS 5 PA NDSUTIONle 3ronate oral tablet 30 mg 3 QL (3030)ELAMER CARBONATE 4

mgmlevocLOKmidonitisiNOR100 MNOR200 MpilocPRORECPROSOLriluzorisedSEVsodium chloride 09 intravenous

4

sodium chloride irrigation 4sodium phenylbutyrate 5 PA NDSsodium polystyrene sulfonate oral powder

3

sps (with sorbitol) oral 3trientine 5 PA QL (24030)

NDSVELPHORO 5 NDSVELTASSA 3water for irrigation sterile 4XIAFLEX 5 PA NDSZEMAIRA 5 PA LA NDSZOLEDRONIC ACID-MANNITOL-WATER INTRAVENOUS PIGGYBACK 5 MG100 ML

4 BD PA

October 2021 60

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

DIABETES THERAPYacarbose oral tablet 100 mg 2 QL (9030)acarbose oral tablet 25 mg 2 QL (36030)acarbose oral tablet 50 mg 2 QL (18030)ALCOHOL PADS 2BAQSIMI 3bd safetyglide insulin syringe syringe 1 ml 31 gauge x 1564rdquo

2 QL (20030)

bd ultra-fine nano pen needle 2 QL (20030)bd ultra-fine short pen needle 2 QL (20030)BYDUREON BCISE 3 QL (428)CYCLOSET 4 QL (18030)diazoxide 4GAUZE PADS 2 X 2 2glimepiride oral tablet 1 mg 1 QL (24030)glimepiride oral tablet 2 mg 1 QL (12030)glimepiride oral tablet 4 mg 1 QL (6030)glipizide oral tablet 10 mg 1 QL (12030)glipizide oral tablet 5 mg 1 QL (24030)glipizide oral tablet extended release 24hr 10 mg

1 QL (6030)

glipizide oral tablet extended release 24hr 25 mg

1 QL (24030)

1 QL (12030)

glipizide-metformin oral tablet 25-250 mg

1 QL (24030)

glipizide-metformin oral tablet 25-500 mg 5-500 mg

1 QL (12030)

GLUCAGEN HYPOKIT 3GLUCAGON EMERGENCY KIT (HUMAN)

3

GLYXAMBI 3 QL (3030)GVOKE HYPOPEN 2-PACK 3GVOKE PFS 1-PACK SYRINGE

3

GVOKE PFS 2-PACK SYRINGE

3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

dexamethasone oral solution 2dexamethasone oral tablet 2dexamethasone sodium phos 4(pf) injection solutiondexamethasone sodium 4phosphate injection solutionfludrocortisone 2hydrocortisone oral 3MEDROL ORAL TABLET 2 MG 3methylprednisolone acetate 4methylprednisolone oral tablet 2methylprednisolone oral tablets 2dose packmethylprednisolone sodium 4succ injection recon soln 125

BD PA

mg 40 mgmethylprednisolone sodium succ intravenous

4

prednisolone oral solution 3prednisolone sodium phosphate oral solution 15 mg5 ml (3 mgml) 15 mg5 ml (5 ml) 25 mg5 ml (5 mgml) 5 mg base5 ml (67 mg5 ml)

3

prednisone intensol 4prednisone oral solution 2prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg

1

prednisone oral tablet 50 mg 2prednisone oral tabletsdose pack

1

SOLU-CORTEF ACT-O-VIAL (PF)

4

triamcinolone acetonide injection suspension 40 mgml

2

ANTITHYROID AGENTSmethimazole oral tablet 10 mg 5 mg

2

propylthiouracil 3

October 2021 61

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 50-1000 MG 50-500 MG

3 QL (6030)

JANUVIA 3 QL (3030)JARDIANCE 3 QL (3030)JENTADUETO 3 QL (6030)JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG

3 QL (6030)

JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 5-1000 MG

3 QL (3030)

LANTUS SOLOSTAR U-100 INSULIN

3

LANTUS U-100 INSULIN 3LEVEMIR FLEXTOUCH U-100 INSULN

3

LEVEMIR U-100 INSULIN 3LYUMJEV KWIKPEN U-100 INSULIN

3

LYUMJEV KWIKPEN U-200 INSULIN

3

LYUMJEV U-100 INSULIN 3METFORMIN ORAL SOLUTION

3 QL (76530)

metformin oral tablet 1000 mg 1 QL (7530)metformin oral tablet 500 mg 1 QL (15030)metformin oral tablet 850 mg 1 QL (9030)metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr)

1 QL (12030)

metformin oral tablet extended release 24 hr 750 mg (generic for glucophage xr)

1 QL (6030)

metformin oral tablet extended release 24hr 1000 mg

1 QL (6030)

1 QL (15030)

miglitol oral tablet 100 mg 4 QL (9030)miglitol oral tablet 25 mg 4 QL (36030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

HUMALOG JUNIOR KWIKPEN U-100

3

HUMALOG KWIKPEN 3SULINUMALOG MIX 50-50 INSULN 3-100UMALOG MIX 50-50 3WIKPENUMALOG MIX 75-25 3WIKPENUMALOG MIX 75-25(U-100) 3SULNUMALOG U-100 INSULIN 3UMULIN 7030 U-100 3SULINUMULIN 7030 U-100 3WIKPENUMULIN N NPH INSULIN 3WIKPEN

INHUHKHKHINHHINHKHKHUMULIN N NPH U-100 INSULIN

3

HUMULIN R REGULAR U-100 INSULN

3

HUMULIN R U-500 (CONC) INSULIN

5 BD PA NDS

HUMULIN R U-500 (CONC) KWIKPEN

5 NDS

INSULIN LISPRO 3INSULIN LISPRO PROTAMIN-LISPRO

3

INSULIN PEN NEEDLE 2 QL (20030)INSULIN SYRINGE (DISP) U-100 03 ML 1 ML 12 ML

2 QL (20030)

INVOKAMET 3 QL (6030)INVOKAMET XR 3 QL (6030)INVOKANA 3 QL (3030)JANUMET 3 QL (6030)JANUMET XR ORAL TABLET ER MULTIPHASE 24 HR 100-1000 MG

3 QL (3030)

October 2021 62

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

TECHLITE INSULN SYR(HALF UNIT)

2 QL (20030)

TECHLITE PEN NEEDLE 2 QL (20030)TOUJEO MAX U-300 SOLOSTAR

3

TOUJEO SOLOSTAR U-300 INSULIN

3

TRADJENTA 3 QL (3030)TRESIBA FLEXTOUCH U-100 3TRESIBA FLEXTOUCH U-200 3TRESIBA U-100 INSULIN 3TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 25-5-1000 MG

3 QL (3030)

TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 125-25-1000 MG 5-25-1000 MG

3 QL (6030)

TRULICITY 3 QL (228)V-GO 20 3V-GO 30 3V-GO 40 3VICTOZA 3-PAK 3 QL (930)XULTOPHY 10036 3 QL (1530)MISCELLANEOUS HORMONESALDURAZYME 5 PA NDScabergoline 3calcitonin (salmon) nasal 3calcitriol intravenous solution 1 mcgml

4

calcitriol oral capsule 3calcitriol oral solution 4CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

5 PA NDS

CHORIONIC GONADOTROPIN HUMAN INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg 60 mg

4 QL (6030)

cinacalcet oral tablet 90 mg 4 QL (12030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

miglitol oral tablet 50 mg 4 QL (18030)nateglinide oral tablet 120 mg 1 QL (9030)nateglinide oral tablet 60 NEEDLES INSULIN DISPSAFETYNOVOFINE PEN NEEDLNOVOTWIST PEN NEEDOMNIPOD DASH 5 PACKOMNIPOD DASH PDM KIOMNIPOD INSULIN MANAGEMENTOMNIPOD INSULIN REFIOZEMPIC SUBCUTANEPEN INJECTOR 025 MG

mg 1 QL (18030)2 QL (20030)

E 2 QL(20030)LE 2 QL(20030) POD 3 QL (3030)T 3 QL (3030)

3 QL (1365)

LL 3 QL (3030)OUS OR

05 MG(2 MG15 ML)

3 QL (1528)

OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML)

3 QL (328)

pioglitazone 1 QL (3030)pioglitazone-metformin 1 QL (9030)repaglinide oral tablet 05 mg 1 QL (96030)repaglinide oral tablet 1 mg 1 QL (48030)repaglinide oral tablet 2 mg 1 QL (24030)RYBELSUS 3 QL (3030)SOLIQUA 10033 3 QL (1525)SYMLINPEN 120 5 PA QL (10830)

NDSSYMLINPEN 60 5 PA QL (630) NDSSYNJARDY 3 QL (6030)SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-1000 MG 125-1000 MG 5-1000 MG

3 QL (6030)

SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG

3 QL (3030)

TECHLITE INSULIN SYRINGE 2 QL (20030)

October 2021 63

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

testosterone transdermal gel in packet 1 (25 mg25gram) 1 (50 mg5 gram)

4 PA QL (30030)

tolvaptan oral tablet 30 mg 5 PA QL (6030) NDS

zoledronic acid ioxercalciferol 4 solutionLAPRASE 5 PA NDS zoledronic acid-ABRAZYME 5 NDS water intravenoORLYM 5 PA QL (12030) mg100 ml

NDS zoledronic ac-mUVAN 5 PA NDS THYROID HORUMIZYME 5 PA NDS EUTHYROXIACALCIN INJECTION 5 NDS LEVO-Tiglustat 5 LA NDS levothyroxine orAGLAZYME 5 PA NDS levoxyl oral tablATPARA 5 PA LA QL (228) mcg 175 mcg

NDS LEVOXYL ORAxandrolone oral tablet 10 mg 4 PA QL (6030) MCG 137 MCG

200 MCG 25 Mxandrolone oral tablet 25 mg 3 PA QL (12030) 75 MCG 88 MCamidronate 4

ntravenous 4 BD PA

mannitol-us piggyback 4

4 BD PA

annitol-09nacl 4 BD PAMONES

33

al tablet 1et 100 mcg 112 3

L TABLET 125 150 MCG CG 50 MCG G

3

liothyronine oral 2SYNTHROID 3UNITHROID ORAL TABLET 100 MCG 112 MCG 125 MCG 150 MCG 175 MCG 200 MCG 25 MCG 300 MCG 50 MCG 75 MCG 88 MCG

3

unithroid oral tablet 137 mcg 3

GASTROENTEROLOGY

ANTIDIARRHEALS ANTISPASMODICSatropine injection solution 04 mgml

4

atropine injection syringe 005 mgml 01 mgml

4

dicyclomine oral capsule 1dicyclomine oral solution 3dicyclomine oral tablet 1diphenoxylate-atropine 3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

danazol 4desmopressin injection 5 NDSdesmopressin nasal spray with pump

4

desmopressin oral 3dEFK

KLMmNN

oopparicalcitol oral 4SAMSCA ORAL TABLET 15 MG

5 PA QL (12030) NDS

sapropterin 5 PA NDSSOMAVERT 5 PA QL (3030)

NDSSYNAREL 5 NDStestosterone cypionate intramuscular oil 100 mgml 200 mgml (1 ml)

3

TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MGML

3

testosterone enanthate 4testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1)

4 PA QL (30030)

October 2021 64

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

hydrocortisone topical cream with perineal applicator 25

1

INFLECTRA 5 PA QL (2030) NDS

lactulose oral solution 2LINZESS 3 QL (3030)

tablet 125 mg 2

ral capsule ase 24hr

3

ectal enema 4ith cleansing 4

de hcl oral 2

de hcl oral tablet 24 QL (3030)5 PA LA QL (3030)

NDS3 BD PA

cl (pf) 4cl intravenous 4cl oral solution 4 BD PA QL

(45030)cl oral tablet 2 BD PA

palonosetron intravenous solution 025 mg5 ml

4

peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram

2

peg-electrolyte 2PENTASA 4prochlorperazine 2prochlorperazine edisylate 4prochlorperazine maleate oral 2procto-med hc 2procto-pak 2proctosol hc topical 2proctozone-hc 2

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

glycopyrrolate (pf) in water injection

4

glycopyrrolate (pf) in water intravenous syringe 04 mg2 ml (02 mgml)

4

glycopyrrolate injection 4glycopyrrolate oral tablet 1 mg 2 meclizine oral

25 mgamide oral capsule 2 mesalamine oELLANEOUS GASTROINTESTINAL AGENTS extended reletron oral tablet 05 mg 4 PA mesalamine rtron oral tablet 1 mg 5 PA NDS mesalamine w

pitant 4 BD PA wipe

lazide 4 metoclopramisolutionsonide oral capsule 4

edextendrelease metocloprami

sonide oral tabletdelayed 5 NDS MOVANTIKxtrelease OCALIVAro 2

tulose 2 ondansetron

TIFOAM 4 ondansetron h

ON 3 ondansetron h

olyn oral 3 ondansetron h

TADANE 5 NDSondansetron h

2 mgloperMISCalosealoseaprebalsabudedelaybudeand ecompconsCORCREcromCYSdronabinol 4 BD PA QL (6030)EMEND ORAL SUSPENSION FOR RECONSTITUTION

4 BD PA

enulose 2GATTEX 30-VIAL 5 PA NDSgavilyte-c 2gavilyte-n 2generlac 2granisetron (pf) intravenous solution 1 mgml (1 ml)

4 BD PA

granisetron hcl intravenous 4granisetron hcl oral 4 BD PA QL (6030)hydrocortisone rectal 3

October 2021 65

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ARCALYST 5 PA NDSAVONEX INTRAMUSCULAR PEN INJECTOR KIT

5 PA QL (128) NDS

AVONEX INTRAMUSCULAR SYRINGE KIT

5 PA QL (128) NDS

BETASERON SUBCUTANEOUS KIT

5 PA QL (1428) NDS

GENOTROPIN 5 PA NDSGENOTROPIN MINIQUICK 5 PA NDSINTRON A INJECTION 5 BD PA NDSLEUKINE INJECTION RECON SOLN

5 PA NDS

MOZOBIL 5 BD PA NDSNIVESTYM 5 PA NDSNYVEPRIA 5 PA NDSPEGASYS SUBCUTANEOUS SOLUTION

5 PA QL (428) NDS

PEGASYS SUBCUTANEOUS SYRINGE

5 PA QL (228) NDS

PROLEUKIN 4 BD PAREBIF (WITH ALBUMIN) 5 PA QL (628) NDSREBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG05 ML 44 MCG05 ML

5 PA QL (628) NDS

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 88MCG02ML-22 MCG05ML (6)

5 PA QL (84365) NDS

REBIF TITRATION PACK 5 PA QL (84365) NDS

RETACRIT 3 PAVACCINES MISCELLANEOUS IMMUNOLOGICALSACTHIB (PF) 3ADACEL(TDAP ADOLESNADULT)(PF)

3

ATGAM 4 BD PABCG VACCINE LIVE (PF) 3BEXSERO 3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

RECTIV 4SANCUSO 5 NDSscopolamine base 4 QL (1030)sulfasalazine 2

REP BOWEL PREP KIT 3AB 4e with flavor packets 2diol oral capsule 300 mg 3diol oral tablet 4KACE 4PEP ORAL CAPSULE 3AYED RELEASE(DREC) 00-32000 -42000 UNIT 00-47000 -63000 UNIT 00-63000- 84000 UNIT 00-79000- 105000 UNIT 0-10000 -14000-UNIT 00-126000- 168000 UNIT 0-17000- 24000 UNITER THERAPY

SUPSUTtrilytursoursoVIOZENDEL100150200250300400500ULCesomeprazole magnesium oral capsuledelayed release(drec)

3 QL (6030)

famotidine oral suspension 4famotidine oral tablet 20 mg 40 mg

2

lansoprazole oral capsule delayed release(drec)

3 QL (6030)

misoprostol 3nizatidine oral capsule 3omeprazole oral capsule delayed release(drec)

2 QL (6030)

pantoprazole oral tablet delayed release (drec)

1 QL (6030)

sucralfate oral suspension 4sucralfate oral tablet 2

IMMUNOLOGY VACCINES BIOTECHNOLOGY

BIOTECHNOLOGY DRUGSACTIMMUNE 5 PA NDS

October 2021 66

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

RABAVERT (PF) 3RECOMBIVAX HB (PF) 3 BD PAROTARIX 3ROTATEQ VACCINE 3SHINGRIX (PF) 3 QL (2999)STAMARIL (PF) 3TDVAX 3TENIVAC (PF) 3TETANUSDIPHTHERIA TOX PED(PF)

3

TICE BCG 4 BD PATRUMENBA 3TWINRIX (PF) 3TYPHIM VI 3VAQTA (PF) 3VARIVAX (PF) 3VARIZIG 4YF-VAX (PF) 3ZOSTAVAX (PF) 3

MUSCULOSKELETAL RHEUMATOLOGY

GOUT THERAPYallopurinol 1colchicine oral tablet 4 QL (12030)FEBUXOSTAT 3 STMITIGARE 3probenecid 2probenecid-colchicine 2OSTEOPOROSIS THERAPYalendronate oral tablet 10 mg 5 mg

1 QL (3030)

alendronate oral tablet 35 mg 70 mg

1 QL (428)

BINOSTO 4 QL (428)ibandronate oral 2 QL (128)PROLIA 4 QL (1168)raloxifene 2 QL (3030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

BOOSTRIX TDAP 3BOTOX 4 PADAPTACEL (DTAP 3

IATRIC) (PF)ERIX-B (PF) 3 BERIX-B PEDIATRIC (PF) 3 B

epizole 5 NDMMAGARD LIQUID 5 BMMAGARD S-D (IGA lt 1 5 BGML)MMAKED INJECTION 5 BLUTION 1 GRAM10 ML ) 10 GRAM100 ML ) 20 GRAM200 ML ) 5 GRAM50 ML (10)MUNEX-C 5 BRDASIL 9 (PF) 3RIX (PF) 3

RAMUSCULAR SYRINGEERIX (PF) 3

PEDENG D PAENG D PAfom SGA D PA NDSGAMC

D PA NDS

GASO(10(10(10

D PA NDS

GA D PA NDSGAHAVINTHIBHIZENTRA 5 BD PA NDSIMOVAX RABIES VACCINE (PF)

3

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

3

IPOL 3IXIARO (PF) 3KINRIX (PF) 3MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

MENQUADFI (PF) 3MENVEO A-C-Y-W-135-DIP (PF)

3

M-M-R II (PF) 3PEDIARIX (PF) 3PEDVAX HIB (PF) 3PENTACEL (PF) 3PROQUAD (PF) 3QUADRACEL (PF) 3

October 2021 67

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

HUMIRA(CF) PEN SUBCUTANEOUS INJECTOR KIT 40 MG04 ML

5 PA QL (428) NDS

HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML

5 PA QL (228) NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML

5 PA QL (228) NDS

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 40 MG04 ML

5 PA QL (428) NDS

leflunomide 2 QL (3030)penicillamine 5 NDSRIDAURA 5 NDSRINVOQ 5 PA QL (3030)

NDSXELJANZ ORAL SOLUTION 5 PA QL (30030)

NDSXELJANZ ORAL TABLET 5 PA QL (6030)

NDSXELJANZ XR 5 PA QL (3030)

NDS

OBSTETRICS GYNECOLOGY

ESTROGENS PROGESTINSALORA 3 QL (828)camila 3deblitane 3DELESTROGEN INTRAMUSCULAR OIL 10 MGML

4

DEPO-ESTRADIOL 4dotti 2 QL (828)DUAVEE 4 PAerrin 3estradiol oral 2estradiol transdermal patch semiweekly

2 QL (828)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

risedronate oral tablet 150 mg 3 QL (128)risedronate oral tablet 35 mg 35 mg (12 pack) 35 mg (4 pack)

3 QL (428)

risedronate oral tablet 5 mg 3 QL (3030)TERIPARATIDE 5 PA QL (24828)

NDSTYMLOS 5 PA QL (15630)

NDSER RHEUMATOLOGICALSLYSTA 5 PA NDSREL MINI 5 PA QL (8REL SUBCUTANEOUS 5 PA QL (16ON SOLN NDSREL SUBCUTANEOUS 5 PA QL (8UTIONREL SUBCUTANEOUS 5 PA QL (8INGEREL SURECLICK 5 PA QL (8IRA PEN 5 PA QL (4IRA PEN CROHNS- 5 PA QL (12S START NDSIRA PEN PSOR-UVEITS- 5 PA QL (8L HS NDS

OTHBENENB 28) NDSENBREC

28)

ENBSOL

28) NDS

ENBSYR

28) NDS

ENB 28) NDSHUM 28) NDSHUMUC-H

365)

HUMADO

365)

HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML

5 PA QL (428) NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML

5 PA QL (6365) NDS

HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML-40 MG04 ML

5 PA QL (4365) NDS

HUMIRA(CF) PEN CROHNS-UC-HS

5 PA QL (6365) NDS

HUMIRA(CF) PEN PEDIATRIC UC

5 PA QL (4180) NDS

HUMIRA(CF) PEN PSOR-UV-ADOL HS

5 PA QL (6365) NDS

October 2021 68

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

alyacen 777 (28) 3amethia 3amethyst (28) 3apri 3

333333333333

blisovi 24 fe 3blisovi fe 1530 (28) 3blisovi fe 120 (28) 3briellyn 3camrese 3camrese lo 3caziant (28) 3charlotte 24 fe 3chateal (28) 3chateal eq (28) 3cryselle (28) 3cyclafem 135 (28) 3cyclafem 777 (28) 3cyred eq 3dasetta 135 (28) 3dasetta 777 (28) 3daysee 3desog-eestradioleestradiol 3desogestrel-ethinyl estradiol 3dolishale 3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

estradiol transdermal patch weekly

2 QL (428)

estradiol vaginal 4estradiol valerate intramuscular oil 20 mgml 40 mgml aranelle (28)ESTRING 4 ashlynafyavolv 3 aubra eqheather 3 aurovela 1530 (21)hydroxyprogesterone caproate 5 NDS aurovela 120 (21)incassia 3 aurovela 24 feJENCYCLA 3 aurovela fe 1530 (28)lyza 3 aurovela fe 1-20 (28)medroxyprogesterone 4 avianeintramuscular

ayunamedroxyprogesterone oral 2azurette (28)MENOSTAR 3 QL (428)balziva (28)nora-be 3

4

norethindrone (contraceptive) 3norethindrone acetate 3norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg

3

PREMARIN INJECTION 4PREMARIN ORAL 3PREMARIN VAGINAL 3progesterone micronized 3sharobel 3yuvafem 4MISCELLANEOUS OBGYNclindamycin phosphate vaginal 3metronidazole vaginal 3terconazole 3tranexamic acid oral 3vandazole 3ORAL CONTRACEPTIVES RELATED AGENTSafirmelle 3altavera (28) 3alyacen 135 (28) 3

October 2021 69

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

larin 1530 (21) 3larin 120 (21) 3larin 24 fe 3

30 (28) 3 (28) 3

3333

8) 3rel-ethinyl estrad 3h estrad triphasic 3

3lillow (28) 3lojaimiess 3loryna (28) 3low-ogestrel (28) 3lo-zumandimine (28) 3lutera (28) 3marlissa (28) 3merzee 3mibelas 24 fe 3microgestin 1530 (21) 3microgestin 120 (21) 3microgestin fe 1530 (28) 3microgestin fe 120 (28) 3mili 3mono-linyah 3necon 0535 (28) 3nikki (28) 3noreth-ethinyl estradiol-iron 3norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg

3

norethindrone-eestradiol-iron oral capsule

3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

drospirenone-eestradiol-lmfa 3drospirenone-ethinyl estradiol 3elinest 3ELLA 3 larin fe 15

oquette 3 larin fe 120resse 3 larissiakyce 3 layolis fe

arylla 3 leena 28ynodiol diac-eth estradiol 3 lessinaina (28) 3 levonest (2

osim 3 levonorgestynor 3 levonorg-etmily 3 levora-28

emenpensestethfalmfayfemgemhailey 3hailey 24 fe 3hailey fe 1530 (28) 3hailey fe 120 (28) 3ICLEVIA 3introvale 3isibloom 3jaimiess 3jasmiel (28) 3jolessa 3juleber 3junel 1530 (21) 3junel 120 (21) 3junel fe 1530 (28) 3junel fe 120 (28) 3junel fe 24 3kaitlib fe 3kalliga 3kariva (28) 3kelnor 135 (28) 3kelnor 1-50 (28) 3kurvelo (28) 3l norgesteestradiol-eestrad 3

October 2021 70

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

tri-lo-estarylla 3tri-lo-marzia 3tri-lo-mili 3tri-lo-sprintec 3tri-mili 3tri-nymyo 3tri-previfem (28)tri-sprintec (28)trivora (28)tri-vylibratri-vylibra lotyblumetydemyvelivet triphasic regimevestura (28)vienvaviorele (28)volnea (28)vyfemla (28)

3333333

n (28) 333333

vylibra 3wera (28) 3wymzya fe 3zarah 3zovia 135e (28) 3zovia 1-35 (28) 3zumandimine (28) 3

OPHTHALMOLOGY

ANTIBIOTICSAZASITE 3bacitracin ophthalmic (eye) 2bacitracin-polymyxin b ophthalmic (eye)

2

BESIVANCE 4CILOXAN OPHTHALMIC (EYE) OINTMENT

3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

norethindrone-eestradiol-iron oral tablet 15 mg-30 mcg (21)75 mg (7)

3

norethindrone-eestradiol-iron oral tabletchewable

3

norgestimate-ethinyl estradiol 3nortrel 0535 (28) 3nortrel 135 (21) 3nortrel 135 (28) 3nortrel 777 (28) 3NYLIA 777 (28) 3nymyo 3ocella 3orsythia 3philith 3pimtrea (28) 3PIRMELLA ORAL TABLET 050751 MG- 35 MCG

3

pirmella oral tablet 1-35 mg-mcg

3

portia 28 3previfem 3reclipsen (28) 3rivelsa 3setlakin 3simliya (28) 3simpesse 3sprintec (28) 3sronyx 3syeda 3tarina 24 fe 3tarina fe 1-20 eq (28) 3tilia fe 3tri femynor 3tri-estarylla 3tri-legest fe 3tri-linyah 3

October 2021 71

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

olopatadine ophthalmic (eye) 3OXERVATE 5 PA QL (11256)

NDSpilocarpine hcl ophthalmic (eye) drops 1 2 4

3

RESTASIS 3 QL (6030)RESTASIS MULTIDOSE 3 QL (5530)sulfacetamide sodium ophthalmic (eye) drops

2

sulfacetamide-prednisolone 2NON-STEROIDAL ANTI-INFLAMMATORY AGENTSbromfenac 4diclofenac sodium ophthalmic (eye)

2

flurbiprofen sodium 2ketorolac ophthalmic (eye) 2PROLENSA 3ORAL DRUGS FOR GLAUCOMAacetazolamide 3acetazolamide sodium 4methazolamide 4OTHER GLAUCOMA DRUGSbimatoprost ophthalmic (eye) 2brinzolamide 4COMBIGAN 3dorzolamide 2dorzolamide-timolol 2latanoprost 1LUMIGAN OPHTHALMIC (EYE) DROPS 001

3

RHOPRESSA 4 STROCKLATAN 4 STSIMBRINZA 4travoprost 3STEROID-ANTIBIOTIC COMBINATIONSneomycin-bacitracin-poly-hc 3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

ciprofloxacin hcl ophthalmic (eye)

hromycin ophthalmic (eye) 2tak ophthalmic (eye) 2menttamicin ophthalmic (eye) 2psifloxacin ophthalmic (eye) 3ACYN 3mycin-bacitracin-polymyxin 2mycin-polymyxin-gramicidin 2-polycin 2xacin ophthalmic (eye) 2

2

erytgenointgendromoxNATneoneoneooflopolycin 2polymyxin b sulf-trimethoprim 2tobramycin ophthalmic (eye) 2TOBREX OPHTHALMIC (EYE) OINTMENT

4

ANTIVIRALStrifluridine 3ZIRGAN 3BETA-BLOCKERScarteolol 2levobunolol ophthalmic (eye) drops 05

1

timolol maleate ophthalmic (eye) drops

1

TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION

4

MISCELLANEOUS OPHTHALMOLOGICSatropine ophthalmic (eye) drops 3azelastine ophthalmic (eye) 2cromolyn ophthalmic (eye) 2CYSTARAN 5 PA NDSepinastine 3EYLEA 5 PA NDSLACRISERT 4

October 2021 72

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

epinephrine injection solution 1 mgml

4

hydroxyzine hcl oral tablet 3 PAlevocetirizine oral solution 4levocetirizine oral tablet 2 QL (3030)promethazine oral 2 PApromethazine rectal suppository 125 mg 25 mg

4

promethegan rectal suppository 25 mg 50 mg

4

PULMONARY AGENTSacetylcysteine 3 BD PAADEMPAS 5 PA LA QL (9030)

NDSADVAIR HFA 3 QL (1230)albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (generic for proair)

4 QL (1730)

ALBUTEROL SULFATE INHALATION HFA AEROSOL INHALER 90 MCGACTUATION (GENERIC FOR PROVENTIL)

4 QL (13430)

albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (generic for ventolin)

4 QL (3630)

albuterol sulfate inhalation solution for nebulization

2 BD PA

albuterol sulfate oral syrup 2albuterol sulfate oral tablet 4albuterol sulfate oral tablet extended release 12 hr

4

alyq 4 PA QL (6030)ambrisentan 5 PA LA QL (3030)

NDSANORO ELLIPTA 3 QL (6030)arformoterol 4 BD PAARNUITY ELLIPTA 3 QL (3030)ATROVENT HFA 4 QL (25830)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

neomycin-polymyxin b-dexameth

eomycin-polymyxin-hc 2phthalmic (eye)eo-polycin hc 3bramycin-dexamethasone 3YLET 3TEROIDSexamethasone sodium 2hosphate ophthalmic (eye)UREZOL 3uorometholone 3VELTYS 4

OTEMAX 4OTEMAX SM 4rednisolone acetate 3rednisolone sodium 2hosphate ophthalmic (eye)

2

nontoZSdpDflINLLpppSYMPATHOMIMETICSALPHAGAN P OPHTHALMIC (EYE) DROPS 01

3

apraclonidine 3brimonidine ophthalmic (eye) drops 015

3

brimonidine ophthalmic (eye) drops 02

2

RESPIRATORY AND ALLERGY

ANTIHISTAMINE ANTIALLERGENIC AGENTSdesloratadine oral tablet 2 QL (3030)diphenhydramine hcl injection solution 50 mgml

4

epinephrine injection auto-injector 015 mg015 ml 03 mg03 ml

3 QL (230)

2 QL (230)

October 2021 73

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

formoterol fumarate 3 BD PA QL (12030)

HAEGARDA 5 PA LA NDSicatibant 5 PA QL (1830)

NDS3 QL (3030)2 BD PA2 BD PA5 PA QL (5628)

NDS5 PA QL (6030)

NDS4 BD PA33 QL (3430)3 QL (3030)

2 QL (3030)2 QL (3030)

5 PA QL (6030) NDS

5 PA LA NDS

IN PACKET5 PA QL (5628)

NDSORKAMBI ORAL TABLET 5 PA QL (11228)

NDSPERFOROMIST 3 BD PA QL

(12030)PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 025 MG2 ML 05 MG2 ML

4 BD PA QL (12030)

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG2 ML

4 BD PA QL (6030)

PULMOZYME 5 BD PA QL (15030) NDS

SEREVENT DISKUS 3 QL (6030)

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

bosentan 5 PA LA NDSBREO ELLIPTA 3 QL (6030)BROVANA 4 BD PAbudesonide inhalation suspension for nebulization (12030)

25 mg2 ml 05 mg2 ml INCRUSE ELLIPTAudesonide inhalation 4 BD PA QL (6030) ipratropium bromide inhalationuspension for nebulization 1 ipratropium-albuterolg2 ml KALYDECO ORAL GRANULES OMBIVENT RESPIMAT 3 QL (830) IN PACKETromolyn inhalation 2 BD PA KALYDECO ORAL TABLETALIRESP 4 PA QL (3030)SBRIET ORAL CAPSULE 5 PA QL (27030) levalbuterol hcl

NDS metaproterenol oral syrupSBRIET ORAL TABLET 267 5 PA QL (27030) mometasone nasalG NDS montelukast oral granules in SBRIET ORAL TABLET 801 5 PA QL (9030) packetG NDS montelukast oral tabletLOVENT DISKUS 3 QL (6030) montelukast oral tablet NHALATION BLISTER chewableITH DEVICE 100 MCGCTUATION 50 MCG OFEVCTUATIONLOVENT DISKUS 3 QL (24030) OPSUMIT

NHALATION BLISTER ORKAMBI ORAL GRANULES

0

4 BD PA QL

bsmCcDE

EMEMFIWAAFIWITH DEVICE 250 MCGACTUATIONFLOVENT HFA AEROSOL INHALER 110 MCGACTUATION

3 QL (1230)

FLOVENT HFA AEROSOL INHALER 220 MCGACTUATION

3 QL (2430)

3 QL (10630)

flunisolide 3 QL (5030)fluticasone propionate nasal 2 QL (1630)fluticasone propion-salmeterol inhalation blister with device

2 QL (6030)

October 2021 74

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

MYRBETRIQ ORAL TABLET 3

223 QL (6030)

243 QL (3030)

LASIA(BPH) THERAPY2242 QL (3030)2 QL (6030)

ALSbethanechol chloride 2CYSTAGON 4 LAELMIRON 4K-PHOS ORIGINAL 4potassium citrate 4RENACIDIN 4

VITAMINS HEMATINICS ELECTROLYTES

ELECTROLYTEScalcium acetate(phosphat bind) 3klor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 2klor-con m20 2lactated ringers intravenous 4magnesium sulfate in d5w intravenous piggyback 1 gram100 ml

4

magnesium sulfate in water 4magnesium sulfate injection 4

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

sildenafil (pulmonary arterial hypertension) oral tablet EXTENDED RELEASE 24 HR

MDEKO 5 PA QL (5628) oxybutynin chloride oral syrupNDS oxybutynin chloride oral tablet

alafil (pulmonary arterial 4 PA QL (6030tension) oral tablet 20 mgaline 4-24 4hylline oral tablet 3ded release 12 hr 300 50 mghylline oral tablet 3ded release 24 hrEGY ELLIPTA 3 QL (6030)FTA ORAL TABLETS 5 PA QL (8428ENTIAL 100-50-75 NDS) 150 MG (N)FTA ORAL TABLETS 5 PA NDSENTIAL 50-25-375 MG MG (N)AVIS 5 PA NDSOLIN HFA 3 QL (3630) inhub 2 QL (6030)CE 4 ST QL (3230

) oxybutynin chloride oral tablet er extended release 24hrut solifenacin

EO tolterodineop TOVIAZen BENIGN PROSTATIC HYPERP 4

alfuzosinopen dutasterideEL dutasteride-tamsulosinIKA ) finasteride oral tablet 5 mgQU tamsulosin(D MISCELLANEOUS UROLOGICIKA

3 PA QL (9030)

SY

tadhypterbTHtheextmgtheextTRTRSEMGTRSEQU(D)75VENTVENTwixelaXHAN )XOLAIR SUBCUTANEOUS RECON SOLN

XOLAIR SUBCUTANEOUS SYRINGE 150 MGML

XOLAIR SUBCUTANEOUS SYRINGE 75 MG05 ML

XOPENEX 4 BD PAXOPENEX CONCENTRATE 4 BD PAYUPELRI 4 BD PA QL (9030)zafirlukast 3 QL (6030)

UROLOGICALS

ANTICHOLINERGICS ANTISPASMODICSdarifenacin 4flavoxate 2

October 2021 75

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

POTASSIUM CHLORIDE-D5-09NACL

4

ringerrsquos intravenous 4sodium bicarbonate intravenous syringe 10 meq10 ml (84) 75 (09 meqml) 84 (1 meqml)

4

sodium chloride 045 arenteral solution

4

de 3 4de 5 4de intravenous 4OLYTES 4 BD PA

EOUS NUTRITION PRODUCTS 15 4 BD PA

PF 10 4 BD PAPF 7 (SULFITE- 4 BD PA

D15W SULFITE 4 BD PA

5D10W SULF 4 BD PA

-D20W(SULFITE- 4 BD PA

-D5W (SULFITE- 4 BD PA

-D14W(SULFITE-FREE)

4 BD PA

CLINIMIX E 425D10W SUL FREE

4 BD PA

CLINISOL SF 15 4 BD PAelectrolyte-48 in d5w 4FREAMINE III 10 4 BD PAHEPATAMINE 8 4 BD PAINTRALIPID INTRAVENOUS EMULSION 20 30

4 BD PA

KABIVEN 4 BD PA

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

NORMOSOL-R 4NORMOSOL-R IN 5 DEXTROSE

4

POTASSIUM CHLORID-D5-045NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQL 20 MEQL 40 MEQL

4

potassium chlorid-d5- 4045nacl intravenous intravenous p

eral solution 30 meql sodium chloriium chloride in 09nacl 4 sodium chlorinous parenteral solution sodium chloril 40 meql

TPN ELECTRium chloride in 5 dex 4nous parenteral solution MISCELLANl AMINOSYN II

ium chloride in lr-d5 4 AMINOSYN-nous parenteral solution AMINOSYN-l FREE)ium chloride in water 4 CLINIMIX 5nous piggyback 10 FREE0 ml 10 meq50 ml 20 0 ml 20 meq50 ml 40 CLINIMIX 420 ml FREE

ium chloride intravenous 4 CLINIMIX 5FREE)ium chloride oral 2

e extended release CLINIMIX 6FREE)ium chloride oral liquid 4CLINIMIX 8ium chloride oral packet 2 FREE)

ium chloride oral tablet 2 CLINIMIX 8ed release

parentpotassintrave20 meqpotassintrave20 meqpotassintrave20 meqpotassintravemeq10meq10meq10potasspotasscapsulpotasspotasspotassextendpotassium chloride oral tablet er particlescrystals 10 meq 20 meq

2

potassium chloride-045 nacl 4POTASSIUM CHLORIDE-D5-02NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQL

4

potassium chloride-d5-03nacl intravenous parenteral solution 20 meql

4

October 2021 76

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

TRINATAL RX 1 3TRIVEEN-DUO DHA 3VIRT-C DHA 3VIRT-NATE DHA 3VIRT-PN DHA 3VIRT-PN PLUS 3VP-PNV-DHA 3ZATEAN-PN DHA 3ZATEAN-PN PLUS 3

DRUG NAME DRUG TIER

REQUIREMENTSLIMITS

NORMOSOL-M IN 5 DEXTROSE

4

NUTRILIPID 4 BD PAPERIKABIVEN 4 BD PAPLENAMINE 4 BD PAPREMASOL 10 4 BD PAPROCALAMINE 3 4 BD PAPROSOL 20 4 BD PATRAVASOL 10 4 BD PATROPHAMINE 10 4 BD PAVITAMINS HEMATINICSBAL-CARE DHA 3C-NATE DHA 3COMPLETE NATAL DHA 3ELITE-OB 3fluoride (sodium) oral tablet 1FOLIVANE-OB 3ludent fluoride oral tablet 1chewable 1 mg (22 mg sod fluoride)M-NATAL PLUS 3PNV 29-1 3PNV-DHA 3PNV-OMEGA 3PNV-SELECT 3PR NATAL 400 3PR NATAL 400 EC 3PR NATAL 430 3PR NATAL 430 EC 3PRENATAL PLUS 3PRENATAL VITAMIN ORAL TABLET

3

PREPLUS 3PRETAB 3SE-NATAL 19 CHEWABLE 3SE-NATAL-19 3TARON-C DHA 3

October 2021 77

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

Aabacavir-lamivudine adriamycin inabacavir-lamivudine-zidovudine 29 recon soln 10abacavir oral solution 29 adriamycin inabacavir oral tablet 29 ADVAIR HFA ABELCET 29 AFINITOR DIABILIFY MAINTENA 47 FOR SUSPEabiraterone oral tablet 250 mg 35 AFINITOR DI

FOR SUSPEABIRATERONE ORAL TABLET 500 MG 35 AFINITOR OABRAXANE 35 afirmelle

acamprosate 58 AIMOVIG AUacarbose oral tablet 25 mg 60 AJOVY AUTacarbose oral tablet 50 mg 60 AJOVY SYRIacarbose oral tablet 100 mg 60 ala-cort topicacebutolol 52 albendazole

acetaminophen-codeine oral albuterol sulfsolution 120 mg-12 mg 5 ml aerosol inhal(5 ml) 120-12 mg5 ml (generic for p

29

TOINJECTOR

OINJECTOR NGE al cream 1

ate inhalation hfa er 90 mcgactuationroair)

g-30 mg 125 ml 45 ALBUTEROL SULFATE inophen-codeine oral INHALATION HFA AEROSOL

300-15 mg 300-30 mg 45 INHALER 90 MCGACTUATION (GENERIC FOR PROVENTIL) inophen-codeine oral

300-60 mg 45 albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuationolamide 71 (generic for ventolin)

olamide sodium 71 albuterol sulfate inhalation acid otic (ear) 59 solution for nebulization ysteine 72 albuterol sulfate oral syrup

in 55 albuterol sulfate oral tablet IB (PF) 65 albuterol sulfate oral tablet

300 macetamtablet acetamtablet acetazacetazacetic acetylcacitretACTHACTIMMUNE 65acyclovir oral capsule 29acyclovir oral suspension 200 mg5 ml 29acyclovir oral tablet 29acyclovir sodium intravenous solution 29acyclovir topical ointment 57ADACEL (TDAP ADOLESNADULT)(PF) 65ADCETRIS 35

adefovir 29ADEMPAS 72

travenous mg 35travenous solution 35 72

SPERZ ORAL TABLET NSION 2 MG 35SPERZ ORAL TABLET NSION 3 MG 5 MG 35RAL TABLET 10 MG 35

68

44

57

32

72

extended release 12 hr 72alclometasone 57ALCOHOL PADS 60ALDURAZYME 62ALECENSA 35alendronate oral tablet 10 mg 5 mg 66alendronate oral tablet 35 mg 70 mg 66alfuzosin 74ALIMTA 35

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 32ALINIA ORAL TABLET 32ALIQOPA 35aliskiren 52allopurinol 66ALORA 67alosetron oral tablet 05 mg 64alosetron oral tablet 1 mg 64ALPHAGAN P OPHTHALMIC (EYE) DROPS 01 72alprazolam oral ta025 mg 05 mg alprazolam oral taalprazolam oral tadisintegrating 0205 mg 1 mg alprazolam oral tadisintegrating 2 maltavera (28) ALUNBRIG ORAALUNBRIG ORA180 MG 90 MG ALUNBRIG ORADOSE PACK alyacen 135 (28) alyacen 777 (28)alyq

blet 1 mg 47blet 2 mg 47blet

5 mg 47blet g 47 68

L TABLET 30 MG 36L TABLET 36

L TABLETS 36 68 68

72amantadine hcl 29AMBISOME 29ambrisentan 72amethia 68amethyst (28) 68amikacin injection solution 1000 mg4 ml 500 mg2 ml 32amiloride 52amiloride-hydrochlorothiazide 52aminocaproic acid oral 54AMINOSYN II 15 75AMINOSYN-PF 7 (SULFITE-FREE) 75AMINOSYN-PF 10 75

October 2021 78

Covered Drugs Index

atomoxetine oral capsule 10 mg 18 mg 25 mg 40 mg 47atomoxetine oral capsule 100 mg 60 mg 80 mg 47

n 54e 32e-proguanil 32jection solution 63jection syringe l 01 mgml 63phthalmic (eye) drops 71T HFA 72 68TIN ORAL SUSPENSION ONSTITUTION MG5 ML 34530 (21) 6820 (21) 684 fe 68

e 1530 (28) 68e 1-20 (28) 68

O ORAL TABLET 6 MG 44O ORAL TABLET MG 44 68 56NTRAMUSCULAR

PEN INJECTOR KIT 65AVONEX INTRAMUSCULAR SYRINGE KIT 65ayuna 68AYVAKIT 36azacitidine 36AZASAN 36AZASITE 70azathioprine 36azathioprine sodium 36azelastine nasal 59azelastine ophthalmic (eye) 71azithromycin intravenous 32azithromycin oral packet 32

ARALAST NP INTRAVENOUS RECON SOLN 500 MG 58

68

65

36 36

asenapine maleate sublingual tablet 5 mg 47asenapine maleate sublingual tablet 10 mg 25 mg 47ashlyna 68aspirin-dipyridamole 54atazanavir oral capsule 150 mg 300 mg 29atazanavir oral capsule 200 mg 29atenolol 52atenolol-chlorthalidone 52ATGAM 65

amiodarone intravenous solution 51amiodarone oral 51amitriptyline 47 aranelle (28)

dipine 52 ARCALYST

arsenic trioxiderelide 58ARZERRAtrozole 36

amloamlodipine-benazepril arformoterol atorvastati

52 72atovaquonlodipine-valsartan YCE 52 ARIKA 32atovaquonlodipine-valsartan-hcthiazid al solution 52 aripiprazole or 47

monium lactate 55 aripiprazole oral tablet atropine in10 mg 15 mg 2 mg 5 mg 47 04 mgml

nesteem 56aripiprazole oral tablet atropine in

oxapine 47 20 mg 30 mg 47 005 mgmoxicillin oral capsule 34 aripiprazole oral tablet atropine ooxicillin oral suspension disintegrating 47 ATROVEN reconstitution 34 ARISTADA INITIO 47 aubra eq oxicillin oral tablet 34 ARISTADA INTRAMUSCULAR AUGMENoxicillin oral tablet SUSPENSIONEXTENDED REL FOR RECwable 125 mg 250 mg 34 SYRING 1064 MG39 ML 47 125-3125oxicillin-pot clavulanate oral ARISTADA INTRAMUSCULAR aurovela 1pension for reconstitution 34 SUSPENSIONEXTENDED REL aurovela 1oxicillin-pot clavulanate SYRING 441 MG16 ML 47 aurovela 2l tablet 34 ARISTADA INTRAMUSCULAR aurovela foxicillin-pot clavulanate SUSPENSIONEXTENDED REL l tabletchewable 34 SYRING 662 MG24 ML 47 aurovela foxicillin-pot clavulanate oral ARISTADA INTRAMUSCULAR AUSTEDlet extended release 12 hr 34 SUSPENSIONEXTENDED REL AUSTED

SYRING 882 MG32 ML 47photericin b 29 12 MG 9 armodafinilicillin oral capsule 47p aviane 34ARNUITY ELLIPTA 72picillin sodium 34 avita ARRANONp 36icillin-sulbactam 34 AVONEX I

amamamamamamamforamamcheamsusamoraamoraamtabamamamamanaganasANORO ELLIPTA 72apraclonidine 72aprepitant 64apri 68APTIOM ORAL TABLET 200 MG 42APTIOM ORAL TABLET 400 MG 42APTIOM ORAL TABLET 600 MG 800 MG 42APTIVUS 29ARALAST NP INTRAVENOUS RECON SOLN 1000 MG 58

October 2021 79

Covered Drugs Index

brimonidine ophthalmic (eye) drops 015 72brinzolamide 71BRIVIACT INTRAVENOUS 42BRIVIACT ORAL SOLUTION 42BRIVIACT ORAL TABLET 42bromfenac 71bromocriptine 44BROVANA 73BRUKINSA 36budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml 73budesonide inhalation suspension for nebulization 1 mg2 ml 73budesonide oral capsule delayedextendrelease 64budesonide oral tablet delayed and extrelease 64bumetanide injection 52bumetanide oral 52buprenorphine hcl injection 45buprenorphine hcl sublingual 45buprenorphine-naloxone sublingual film 2-05 mg 46buprenorphine-naloxone sublingual film 4-1 mg 8-2 mg 46buprenorphine-naloxone sublingual film 12-3 mg 46buprenorphine-naloxone sublingual tablet 2-05 mg 46buprenorphine-naloxone sublingual tablet 8-2 mg 46buprenorphine transdermal patch weekly 75 mcghour 45BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 10 MCGHOUR 15 MCGHOUR 20 MCGHOUR 5 MCGHOUR 45bupropion hcl oral tablet 75 mg 47bupropion hcl oral tablet 100 mg 47bupropion hcl oral tablet extended release 24 hr 150 mg 47

betamethasone valerate topical cream 57betamethasone

57

65

52

74

36

65

36

34

52

29ye) 71 66 52

bisoprolol-hydrochlorothiazide 52BLENREP 36bleomycin 36BLINCYTO INTRAVENOUS KIT 36blisovi 24 fe 68blisovi fe 1530 (28) 68blisovi fe 120 (28) 68BOOSTRIX TDAP 66bortezomib 36bosentan 73BOSULIF ORAL TABLET 100 MG 36BOSULIF ORAL TABLET 400 MG 500 MG 36BOTOX 66BRAFTOVI ORAL CAPSULE 75 MG 36BREO ELLIPTA 73briellyn 68BRILINTA 54brimonidine ophthalmic (eye) drops 02 72

azithromycin oral suspension for reconstitution 32azithromycin oral tablet 32aztreonam injection valerate topical foam

soln 1 gram 32 betamethasone nam injection valerate topical lotion soln 2 gram 32 betamethasone te (28) valerate topical ointment 68

BETASERON SUBCUTANEOUS KIT betaxolol oral

cin intramuscular 32 bethanechol chloride cin ophthalmic (eye) 70 bexarotene cin-polymyxin b BEXSERO lmic (eye) 70 bicalutamide n oral tablet 10 mg 5 mg 45 BICILLIN L-A n oral tablet 20 mg 45 BIDIL

ARE DHA 76 BIKTARVY zide 64 bimatoprost ophthalmic (eRSA 36 BINOSTO (28) 68 bisoprolol fumarate

recon aztreorecon azuret

BbacitrabacitrabacitraophthabaclofebaclofeBAL-CbalsalaBALVEbalzivaBANZEL ORAL SUSPENSION 42BAQSIMI 60BARACLUDE ORAL SOLUTION 29BAVENCIO 36BCG VACCINE LIVE (PF) 65bd safetyglide insulin syringe syringe 1 ml 31 gauge x 1564rdquo 60bd ultra-fine nano pen needle 60bd ultra-fine short pen needle 60BELEODAQ 36benazepril 52benazepril-hydrochlorothiazide 52BENDEKA 36BENLYSTA 67benztropine injection 44benztropine oral 44BESIVANCE 70BESPONSA 36betamethasone augmented 57betamethasone dipropionate 57

October 2021 80

Covered Drugs Index

cefazolin intravenous 31cefdinir oral capsule 31cefdinir oral suspension for reconstitution 31cefepime in dextrose 5 31cefepime in dextroseiso-osm 31cefepime injection 31cefepime intravenous 31cefixime 31cefotaxime injection recon soln 1 gram 31cefotetan in dextrose iso-osm 32cefotetan injection 32cefoxitin 32cefoxitin in dextrose iso-osm 32cefpodoxime 32cefprozil 32ceftazidime 32ceftazidime in d5w 32ceftriaxone 32ceftriaxone in dextroseiso-os 32cefuroxime axetil oral tablet 32cefuroxime sodium injection recon soln 750 mg 32cefuroxime sodium intravenous 32celecoxib 46CELONTIN ORAL CAPSULE 300 MG 42cephalexin oral capsule 250 mg 500 mg 32cephalexin oral suspension for reconstitution 32CEREZYME INTRAVENOUS RECON SOLN 400 UNIT 62CHANTIX 59CHANTIX CONTINUING MONTH BOX 59CHANTIX STARTING MONTH BOX 59charlotte 24 fe 68chateal (28) 68chateal eq (28) 68CHEMET 58

carbamazepine oral suspension 100 mg5 ml 200 mg10 ml 42carbamazepine oral tablet 42carbamazepine oral tablet

42

44one 44et 44et 44et 44on 36

36

71

52

29

32caziant (28) 68cefaclor oral capsule 31cefaclor oral suspension for reconstitution 125 mg5 ml 250 mg5 ml 375 mg5 ml 31cefaclor oral tablet extended release 12 hr 31cefadroxil oral capsule 31cefadroxil oral suspension for reconstitution 250 mg5 ml 500 mg5 ml 31cefadroxil oral tablet 31cefazolin in dextrose (iso-os) intravenous piggyback 1 gram50 ml 2 gram100 ml 2 gram50 ml 31cefazolin injection recon soln 1 gram 10 gram 100 gram 300 g 500 mg 31

bupropion hcl oral tablet extended release 24 hr 300 mg 47bupropion hcl oral tablet sustained-release 12 hr 100 mg 48bupropion hcl oral tablet sustained- chewable

hr 150 mg 200 mg 48 carbamazepine oral tablet hcl (smoking deter) 59 extended release 12 hr 48 carbidopa 36 carbidopa-levodopa-entacapl nasal 46 carbidopa-levodopa oral tablN BCISE 60 carbidopa-levodopa oral tabl

disintegrating carbidopa-levodopa oral tablextended release

62 carboplatin intravenous solutiYX 36 carmustine e scalp 55 carteolol e topical cream 55 cartia xt e topical ointment 55 carvedilol salmon) nasal 62 carvedilol phosphate ravenous caspofungin intravenous cgml 62 recon soln 50 mg

al capsule 62 caspofungin intravenous al solution 62 recon soln 70 mg pical 55 CAYSTON

release 12 bupropion buspirone BUSULFANbutorphanoBYDUREO

CcabergolineCABOMETcalcipotriencalcipotriencalcipotriencalcitonin (calcitriol intsolution 1 mcalcitriol orcalcitriol orcalcitriol tocalcium acetate(phosphat bind) 74CALQUENCE 36camila 67camrese 68camrese lo 68candesartan-hydrochlorothiazid 52candesartan oral tablet 16 mg 4 mg 8 mg 52candesartan oral tablet 32 mg 52CAPASTAT 32CAPLYTA 48CAPRELSA ORAL TABLET 100 MG 36CAPRELSA ORAL TABLET 300 MG 36CARBAGLU 58carbamazepine oral capsule er multiphase 12 hr 42

October 2021 81

Covered Drugs Index

clobetasol topical foam 57clobetasol topical gel 57clobetasol topical ointment 57clobetasol topical shampoo 57CLOCORTOLONE PIVALATE 57clodan 57clofarabine 36clomipramine 48clonazepam oral tablet 05 mg 1 mg 42clonazepam oral tablet 2 mg 42clonazepam oral tablet disintegrating 05 mg 1 mg 42clonazepam oral tablet disintegrating 0125 mg 025 mg 42clonazepam oral tablet disintegrating 2 mg 42clonidine 52clonidine hcl oral tablet 01 mg 02 mg 52clonidine hcl oral tablet 03 mg 52clopidogrel oral tablet 75 mg 54clopidogrel oral tablet 300 mg 54clorazepate dipotassium oral tablet 375 mg 48clorazepate dipotassium oral tablet 75 mg 48clorazepate dipotassium oral tablet 15 mg 48clotrimazole-betamethasone topical cream 57clotrimazole-betamethasone topical lotion 57clotrimazole mucous membrane 29clotrimazole topical cream 57clotrimazole topical solution 57clozapine oral tablet 48clozapine oral tablet disintegrating 48C-NATE DHA 76COARTEM 33colchicine oral tablet 66colesevelam 54

clarithromycin oral tablet 32

clobazam oral suspension 42clobazam oral tablet 10 mg 42clobazam oral tablet 20 mg 42clobetasol-emollient topical cream 57clobetasol-emollient topical foam 57clobetasol scalp 57clobetasol topical cream 57

chloramphenicol sod succinate 32chlorhexidine gluconate clarithromycin oral tablet

s membrane 59 extended release 24 hr 32quine phosphate 32 clindacin p 56thiazide sodium 52 clindamycin hcl 33romazine injection 48 clindamycin in 09 sod chlor 33romazine oral 48 clindamycin in 5 dextrose 33alidone oral tablet clindamycin pediatric 33 50 mg 52 clindamycin phosphate injection 33tyramine light clindamycin phosphate wder in packet 54 intravenous solution 600 mg4 ml 33tyramine (with sugar) 54 clindamycin phosphate topical gel 56IONIC GONADOTROPIN clindamycin phosphate N INTRAMUSCULAR 62 topical lotion 56n topical solution 57 clindamycin phosphate

rox topical cream 57 topical solution 56rox topical shampoo 57 clindamycin phosphate rox topical solution 57 topical swab 56rox topical suspension 57 clindamycin phosphate vaginal 68zol 54 CLINIMIX 425D5W

SULFIT FREE 58AN OPHTHALMIC OINTMENT 70 CLINIMIX 425D10W

SULF FREE 75O 29CLINIMIX 5D15W lcet oral tablet 30 mg 60 mg 62 SULFITE FREE 75

lcet oral tablet 90 mg 62 CLINIMIX 5-D20W oxacin-dexamethasone 59 (SULFITE-FREE) 75oxacin hcl ophthalmic (eye) 71 CLINIMIX 6-D5W oxacin hcl oral tablet 100 mg 34 (SULFITE-FREE) 75oxacin hcl oral tablet CLINIMIX 8-D10W g 500 mg 750 mg 34 (SULFITE-FREE) 75oxacin in 5 dextrose 34 CLINIMIX 8-D14W

(SULFITE-FREE) 75 HC 59CLINIMIX E 425D10W ORAL SUSPENSION SUL FREECAPSULE RECON 75 34CLINISOL SF 15 75in intravenous solution 36

mucouchlorochlorochlorpchlorpchlorth25 mgcholesoral pocholesCHORHUMAciclodaciclopiciclopiciclopiciclopicilostaCILOX(EYE)CIMDUcinacacinacaciproflciproflciproflciprofl250 mciproflCIPROCIPROMICROcisplatcitalopram oral solution 48citalopram oral tablet 10 mg 20 mg 48citalopram oral tablet 40 mg 48cladribine 36claravis 56clarithromycin oral suspension for reconstitution 32

October 2021 82

Covered Drugs Index

deferasirox oral tablet 58deferiprone 58DELESTROGEN INTRAMUSCULAR OIL 10 MGML 67DELSTRIGO 29demeclocycline 35DENAVIR 57DEPO-ESTRADIOL 67DEPO-MEDROL 59DESCOVY 29desipramine 48desloratadine oral tablet 72desmopressin injection 63desmopressin nasal spray with pump 63desmopressin oral 63desog-eestradioleestradiol 68desogestrel-ethinyl estradiol 68desonide topical cream 57desonide topical lotion 57desonide topical ointment 57desoximetasone topical cream 57desoximetasone topical gel 57desoximetasone topical ointment 57desvenlafaxine succinate oral tablet extended release 24 hr 25 mg 48desvenlafaxine succinate oral tablet extended release 24 hr 50 mg 48desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 48dexamethasone intensol 59dexamethasone oral elixir 59dexamethasone oral solution 60dexamethasone oral tablet 60dexamethasone sodium phos (pf) injection solution 60dexamethasone sodium phosphate injection solution 60dexamethasone sodium phosphate ophthalmic (eye) 72dexmethylphenidate oral tablet 48

cyclosporine modified 36cyclosporine oral capsule 36CYRAMZA 36cyred eq 68

DARZALEX FASPRO 36dasetta 135 (28) 68dasetta 777 (28) 68daunorubicin intravenous solution 36DAURISMO ORAL TABLET 25 MG 37DAURISMO ORAL TABLET 100 MG 37daysee 68deblitane 67decitabine 37deferasirox oral granules in packet 58

colestipol oral granules 54colestipol oral packet 54colestipol oral tablet 54colistin (colistimethate na) 33COMBIGAN 71 CYSTADANE 64

MBIVENT RESPIMAT 73 CYSTAGON 74METRIQ ORAL CAPSULE CYSTARAN 71

MGDAY (20 MG X 3DAY) 36 cytarabine 36METRIQ ORAL CAPSULE cytarabine (pf) 36

0 MGDAY(80 MG X1-20 MG X1) 36METRIQ ORAL CAPSULE

0 MGDAY(80 MG X1-20 MG X3) 36 DMPLERA 29 d25-045 sodium chloride 58MPLETE NATAL DHA 76 d5-045 sodium chloride 58

mpro 64 d5 and 09 sodium chloride 58nstulose 64 d10-045 sodium chloride 58PAXONE SUBCUTANEOUS dacarbazine 36RINGE 20 MGML 44 dactinomycin 36PAXONE SUBCUTANEOUS dalfampridine 45RINGE 40 MGML 44 DALIRESP 73PIKTRA 36 danazol 63RLANOR ORAL TABLET 55 dantrolene oral 45RTIFOAM 64 dapsone oral 33

rtisporin-tc 59 DAPTACEL SMEGEN 36 (DTAP PEDIATRIC) (PF) 66TELLIC 36 DAPTOMYCIN INTRAVENOUS EON 64 RECON SOLN 350 MG 33ESEMBA ORAL 29 daptomycin intravenous

olyn inhalation 73 recon soln 500 mg 33olyn ophthalmic (eye) darifenacin 71 74olyn oral DARZALEX 64 36

COCO60CO10CO14COCOcocoCOSYCOSYCOCOCOcoCOCOCRCRcromcromcromcryselle (28) 68cyclafem 135 (28) 68cyclafem 777 (28) 68cyclobenzaprine oral tablet 10 mg 5 mg 45cyclophosphamide intravenous 36cyclophosphamide oral 36cycloserine 33CYCLOSET 60cyclosporine intravenous 36

October 2021 83

Covered Drugs Index

divalproex 42docetaxel intravenous solution 160 mg16 ml (10 mgml) 160 mg 8 ml (20 mgml) 20 mg2 ml (10 mgml) 20 mgml (1 ml) 80 mg4 ml (20 mgml) 80 mg8 ml (10 mgml) 37dofetilide 51dolishale 68donepezil oral tablet 5 mg 45donepezil oral tablet 10 mg 45donepezil oral tablet disintegrating 5 mg 45donepezil oral tablet disintegrating 10 mg 45dorzolamide 71dorzolamide-timolol 71dotti 67DOVATO 29doxazosin oral tablet 1 mg 2 mg 4 mg 52doxazosin oral tablet 8 mg 52doxepin oral capsule 48doxepin oral concentrate 48doxercalciferol 63doxorubicin intravenous recon soln 50 mg 37doxorubicin intravenous solution 37doxorubicin peg-liposomal 37doxy-100 35doxycycline hyclate oral capsule 35doxycycline hyclate oral tablet 20 mg 35doxycycline hyclate oral tablet 100 mg 35doxycycline monohydrate oral capsule 100 mg 50 mg 35doxycycline monohydrate oral capsuleir - delay relbiphase 35doxycycline monohydrate oral suspension for reconstitution 35doxycycline monohydrate oral tablet 35

diclofenac sodium ophthalmic (eye) 71diclofenac sodium oral 46diclofenac sodium topical drops 46diclofenac sodium topical gel 1 46dicloxacillin extroamphetamine-

mphetamine oral tablet 10 mg 48 dicyclomine oral capsule

extroamphetamine- dicyclomine oral solution mphetamine oral tablet dicyclomine oral tablet 25 mg 30 mg 75 mg 48 DIFICID ORAL SUSPENSION extroamphetamine- FOR RECONSTITUTION mphetamine oral tablet 15 mg 48 DIFICID ORAL TABLET extroamphetamine- diflunisal mphetamine oral tablet 20 mg 48

digitek extroamphetamine oral digoxapsule extended release 48

digoxin injection solutionextroamphetamine oral solution 48digoxin oral solutionextroamphetamine

ral tablet 10 mg 5 mg 48 digoxin oral tablet extrose 5-02 sod chloride 58 dihydroergotamine nasal extrose 5-03 sodchloride 58 DILANTIN 30 MG EXTROSE 5 IN diltiazem hcl intravenous ATER (D5W) INTRAVENOUS diltiazem hcl oral capsule

ARENTERAL SOLUTION 58 extended release 12 hr extrose 5 in water (d5w) diltiazem hcl oral capsule

ntravenous piggyback 58 extended release 24hr 120 mg extrose 5-lactated ringers 58 180 mg 240 mg 300 mg extrose 10 and 02 nacl 58 diltiazem hcl oral capsule EXTROSE 10 extended release 24 hr 420 mg

N WATER (D10W) 58 diltiazem hcl oral tablet extrose 20 in water (d20w) 58 diltiazem hcl oral tablet

extended release 24 hr

34636363

3232465555555555444252

52

5252

52dilt-xr 52dimethyl fumarate oral capsule delayed release(drec) 120 mg (14)- 240 mg (46) 45dimethyl fumarate oral capsule delayed release(drec) 120 mg 240 mg 45diphenhydramine hcl injection solution 50 mgml 72diphenoxylate-atropine 63dipyridamole oral 54disulfiram 58

dextroamphetamine- amphetamine oral capsule extended release 24hr 48dextroamphetamine- amphetamine oral tablet 5 mg 48dada1dadadcddoddDWPdiddDIddextrose 25 in water (d25w) 58dextrose 50 in water (d50w) 58dextrose 70 in water (d70w) 58DIACOMIT 42diazepam injection 48diazepam oral concentrate 48diazepam oral solution 5 mg5 ml (1 mgml) 48diazepam oral tablet 48diazepam rectal 42diazoxide 60diclofenac potassium 46

October 2021 84

Covered Drugs Index

ENBREL SURECLICK 67endocet 45

IX-B PEDIATRIC (PF) 66IX-B (PF) 66TU 37arin 54e 69 69one 44r 29

STO 55 64

SUS XR 37SA ORAL 200-50 MG 30

SA ORAL 400-100 MG 30

LEX 42ne 71rine injection auto-injector 03 ml 03 mg03 ml 72rine injection auto-injector 015 ml 03 mg03 ml 72rine injection 1 mgml 72

epirubicin intravenous solution 37epitol 42EPIVIR HBV ORAL SOLUTION 30ERBITUX 37ergotamine-caffeine 44ERIVEDGE 37ERLEADA 37erlotinib oral tablet 25 mg 37erlotinib oral tablet 100 mg 150 mg 37errin 67ertapenem 33ERWINAZE 37ery pads 56ery-tab oral tabletdelayed release (drec) 250 mg 32

efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg 29

emtricitabine 29EMTRICITABINE-TENOFOVIR (TDF) ORAL TABLET 100-150 MG 133-200 MG 167-250 MG 29emtricitabine-tenofovir (tdf) oral tablet 200-300 mg 29EMTRIVA ORAL SOLUTION 29EMVERM 33enalapril-hydrochlorothiazide 52enalapril maleate oral tablet 52ENBREL MINI 67ENBREL SUBCUTANEOUS RECON SOLN 67ENBREL SUBCUTANEOUS SOLUTION 67ENBREL SUBCUTANEOUS SYRINGE 67

DRIZALMA SPRINKLE ORAL CAPSULE DELAYED REL SPRINKLE 20 MG 60 MG 48 efavirenz oral capsule 50 mg 29 ENGER

RIZALMA SPRINKLE ORAL efavirenz oral capsule 200 mg 29 ENGERAPSULE DELAYED REL efavirenz oral tabletRINKLE 30 MG 48 29 ENHERELAPRASERIZALMA SPRINKLE ORAL 63 enoxap

APSULE DELAYED REL electrolyte-48 in d5w 75 enpressRINKLE 40 MG 48 ELIGARD 37 enskyce

onabinol 64 ELIGARD (3 MONTH) 37 entacapospirenone-eestradiol-lmfa 69 ELIGARD (4 MONTH) 37 entecaviospirenone-ethinyl estradiol 69 ELIGARD (6 MONTH) 37 ENTREROXIA 37 elinest 69 enulose oxidopa oral capsule 100 mg 58 ELIQUIS 54 ENVARoxidopa oral capsule ELIQUIS DVT-PE EPCLU0 mg 300 mg 58 TREAT 30D START 54 TABLETUAVEE 67 ELITE-OB 76 EPCLUloxetine oral capsuledelayed ELLA 69 TABLETlease(drec) 20 mg 60 mg 48 ELMIRON 74 EPIDIOloxetine oral capsuledelayed ELZONRIS 37 epinastilease(drec) 30 mg 48

EMCYT 37 epinephUPIXENT PEN SUBCUTANEOUS OR 200 MG114 ML EMEND ORAL SUSPENSION 015 mgN INJECT 55

FOR RECONSTITUTION 64 epinephUPIXENT PEN SUBCUTANEOUS emoquette 69 015 mgN INJECTOR 300 MG2 ML 55EMPLICITI 37 epinephUPIXENT SYRINGE solution BCUTANEOUS SYRINGE EMSAM 48

DCSPDCSPdrdrdrDdrdr20DduredureDPEDPEDSU200 MG114 ML 55DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG2 ML 55DUREZOL 72dutasteride 74dutasteride-tamsulosin 74

Eeconazole 57EDARBI 52EDARBYCLOR 52EDURANT 29efavirenz-emtricitabin-tenofov 29efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg 29

October 2021 85

Covered Drugs Index

fenofibrate nanocrystallized oral tablet 145 mg 48 mg 54fenofibrate oral tablet 160 mg 54 mg 54fenofibric acid (choline) 54fentanyl 45fentanyl citrate buccal lozenge on a handle 1200 mcg 1600 mcg 400 mcg 600 mcg 800 mcg 46fentanyl citrate buccal lozenge on a handle 200 mcg 46fentanyl citrate (pf) injection solution 45FERRIPROX 59FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HR 49FETZIMA ORAL CAPSULE EXT REL 24HR DOSE PACK 49finasteride oral tablet 5 mg 74FINTEPLA 42FIRDAPSE 45FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 80 MG 37FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS RECON SOLN 120 MG 37FIRVANQ ORAL RECON SOLN 25 MGML 33FIRVANQ ORAL RECON SOLN 50 MGML 33flac otic oil 59flavoxate 74flecainide 51FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION 73FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION 73FLOVENT HFA AEROSOL INHALER 44 MCGACTUATION 73

ethambutol 33ethosuximide 42ethynodiol diac-eth estradiol 69

46

37

30

63stic) 37ppressive) 37ppressive) 5 mg 37 37 30 37 71 54 54

FFABRAZYME 63falmina (28) 69famciclovir 30famotidine oral suspension 65famotidine oral tablet 20 mg 40 mg 65FANAPT ORAL TABLET 1 MG 2 MG 4 MG 49FANAPT ORAL TABLET 8 MG 49FANAPT ORAL TABLET 10 MG 12 MG 6 MG 49FANAPT ORAL TABLETS DOSE PACK 49FARYDAK 37fayosim 69FEBUXOSTAT 66felbamate 42felodipine 52femynor 69fenofibrate micronized oral capsule 134 mg 200 mg 67 mg 54

ERY-TAB ORAL TABLET DELAYED RELEASE (DREC) 333 MG 32erythrocin (as stearate) oral tablet 250 mg 32 etodolac

RYTHROCIN INTRAVENOUS ETOPOPHOSECON SOLN 500 MG 32etoposide intravenous56 rythromycin-benzoyl peroxide etravirine rythromycin ethylsuccinate oral

uspension for reconstitution EUTHYROX 00 mg5 ml 32 everolimus (antineoplarythromycin ethylsuccinate oral everolimus (immunosuuspension for reconstitution oral tablet 05 mg 00 mg5 ml 32 everolimus (immunosurythromycin ethylsuccinate oral tablet 025 mg 07ral tablet 32 EVOMELA rythromycin ophthalmic (eye) 71 EVOTAZ rythromycin oral tablet 32 exemestane rythromycin oral tablet EYLEA elayed release (drec) 32

ezetimibe RYTHROMYCIN WITH THANOL TOPICAL GEL ezetimibe-simvastatin 56rythromycin with ethanol

ERees2es4eoeeedEEetopical solution 56ESBRIET ORAL CAPSULE 73ESBRIET ORAL TABLET 267 MG 73ESBRIET ORAL TABLET 801 MG 73escitalopram oxalate oral solution 48escitalopram oxalate oral tablet 10 mg 5 mg 48escitalopram oxalate oral tablet 20 mg 49esomeprazole magnesium oral capsuledelayed release(drec) 65estarylla 69estradiol oral 67estradiol transdermal patch semiweekly 67estradiol transdermal patch weekly 68estradiol vaginal 68estradiol valerate intramuscular oil 20 mgml 40 mgml 68ESTRING 68ethacrynate sodium 52

October 2021 86

Covered Drugs Index

FYCOMPA ORAL SUSPENSION 42FYCOMPA ORAL TABLET 2 MG 42FYCOMPA ORAL TABLET 4 MG 6 MG 43FYCOMPA ORAL TABLET 10 MG 12 MG 8 MG 42

Ggabapentin oral capsule 100 mg 300 mg 43gabapentin oral capsule 400 mg 43gabapentin oral solution 43gabapentin oral tablet 600 mg 43gabapentin oral tablet 800 mg 43galantamine oral capsule ext rel pellets 24 hr 45galantamine oral solution 45galantamine oral tablet 45GAMMAGARD LIQUID 66GAMMAGARD S-D (IGA lt 1 MCGML) 66GAMMAKED INJECTION SOLUTION 1 GRAM10 ML (10) 10 GRAM 100 ML (10) 20 GRAM200 ML (10) 5 GRAM50 ML (10) 66GAMUNEX-C 66GARDASIL 9 (PF) 66GATTEX 30-VIAL 64GAUZE PADS 2 X 2 60gavilyte-c 64gavilyte-n 64GAVRETO 37GAZYVA 37gemcitabine intravenous recon soln 37gemcitabine intravenous solution 1 gram263 ml (38 mgml) 2 gram526 ml (38 mgml) 200 mg526 ml (38 mgml) 37gemcitabine intravenous solution 100 mgml 37gemfibrozil 54gemmily 69

fluphenazine decanoate 49fluphenazine hcl injection 49fluphenazine hcl oral concentrate 49fluphenazine hcl oral elixir 49fluphenazine hcl oral tablet 49flurbiprofen oral tablet 100 mg

nazole in nacl (iso-osm) flurbiprofen sodium venous piggyback mg100 ml 400 mg200 ml 29 flutamide

tosine 29 fluticasone propionate nasal

rabine 37 fluticasone propionate topical cream ocortisone 60fluticasone propionate olide 73 topical ointment

inolone acetonide oil 59 fluticasone propion-salmeterol inolone and shower cap 57 inhalation blister with device inolone topical cream 57 fluvoxamine oral tablet 50 mg inolone topical oil 57 fluvoxamine oral tablet inolone topical ointment 57 100 mg 25 mg inolone topical solution 57 FOLIVANE-OB inonide topical cream 01 57 FOLOTYN inonide topical cream 005 57 fomepizole inonide topical gel 57 fondaparinux subcutaneous inonide topical ointment 57 syringe 25 mg05 ml

inonide topical solution 57 fondaparinux subcutaneous syringe 10 mg08 ml ide (sodium) dental paste 59 5 mg04 ml 75 mg06 ml

ide (sodium) oral tablet 76 formoterol fumarate ometholone 72 fosamprenavir ouracil intravenous 37 fosfomycin tromethamine ouracil topical cream 05 55 fosinopril

46

71

37

73

57

73

49

76

37

66

54

73

30

35

52fosinopril-hydrochlorothiazide 52fosphenytoin 42FOTIVDA 37FREAMINE III 10 75fulvestrant 37furosemide injection 52furosemide oral solution 10 mgml 40 mg5 ml (8 mgml) 52furosemide oral tablet 52FUZEON SUBCUTANEOUS RECON SOLN 30fyavolv 68

FLOVENT HFA AEROSOL INHALER 110 MCGACTUATION 73FLOVENT HFA AEROSOL INHALER 220 MCGACTUATION 73floxuridine 37fluconazole 29flucointra200 flucyfludafludrflunisfluocfluocfluocfluocfluocfluocfluocfluocfluocfluocfluocfluorfluorfluorfluorfluorfluorouracil topical cream 5 55fluorouracil topical solution 55fluoxetine oral capsule 10 mg 49fluoxetine oral capsule 20 mg 49fluoxetine oral capsule 40 mg 49fluoxetine oral capsuledelayed release(drec) 49fluoxetine oral solution 49fluoxetine oral tablet 10 mg 49fluoxetine oral tablet 20 mg 49fluoxetine (pmdd) oral tablet 10 mg 49fluoxetine (pmdd) oral tablet 20 mg 49

October 2021 87

Covered Drugs Index

HARVONI ORAL TABLET 45-200 MG 30HARVONI ORAL TABLET 90-400 MG 30HAVRIX (PF) INTRAMUSCULAR SYRINGE 66heather 68heparin(porcine) in 045 nacl intravenous parenteral solution 25000 unit250 ml 25000 unit500 ml 54heparin (porcine) in 5 dex intravenous parenteral solution 20000 unit500 ml (40 unitml) 25000 unit250 ml(100 unitml) 25000 unit500 ml (50 unitml) 54heparin (porcine) injection solution 54heparin (porcine) in nacl (pf) 54heparin porcine (pf) injection syringe 54HEPATAMINE 8 75HETLIOZ 49HIBERIX (PF) 66HIZENTRA 66HUMALOG JUNIOR KWIKPEN U-100 61HUMALOG KWIKPEN INSULIN 61HUMALOG MIX 50-50 INSULN U-100 61HUMALOG MIX 50-50 KWIKPEN 61HUMALOG MIX 75-25 KWIKPEN 61HUMALOG MIX 75-25 (U-100)INSULN 61HUMALOG U-100 INSULIN 61HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 67HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML- 40 MG04 ML 67HUMIRA(CF) PEN CROHNS-UC-HS 67HUMIRA(CF) PEN PEDIATRIC UC 67

glycopyrrolate (pf) in water injection 64glycopyrrolate (pf) in water intravenous syringe 04 mg2 ml (02 mgml) 64glydo 56GLYXAMBI ution 40 mgml 33granisetron hcl intravenous tamicin in nacl (iso-osm)

avenous piggyback granisetron hcl oral mg100 ml 100 mg50 ml granisetron (pf) intravenous mg100 ml 60 mg50 ml solution 1 mgml (1 ml)

mg100 ml 80 mg50 ml 33 griseofulvin microsize tamicin ophthalmic (eye) drops 71 griseofulvin ultramicrosize tamicin sulfate (ped) (pf) 33 guanfacine oral tablet tamicin topical cream 56 extended release 24 hr tamicin topical ointment 56 GVOKE HYPOPEN 2-PACNVOYA 30 GVOKE PFS 1-PACK SYRIENYA ORAL CAPSULE 05 MG 45 GVOKE PFS 2-PACK SYRIOTRIF 37ostine oral capsule Hmg 40 mg 38

HAEGARDA ostine oral capsule 100 mg 38hailey epiride oral tablet 1 mg 60hailey 24 fe epiride oral tablet 2 mg 60hailey fe 1530 (28) epiride oral tablet 4 mg 60hailey fe 120 (28) izide-metformin oral

let 25-250 mg HALAVEN 60izide-metformin oral halobetasol propionate let 25-500 mg 5-500 mg topical cream 60izide oral tablet 5 mg 60 halobetasol propionate

topical ointment izide oral tablet 10 mg 60

60

64

64 64 29 29

49K 60NGE 60NGE 60

73

69

38

58

58haloperidol decanoate 49haloperidol lactate injection 49haloperidol lactate oral 49haloperidol oral tablet 05 mg 1 mg 2 mg 5 mg 49haloperidol oral tablet 10 mg 20 mg 49HARVONI ORAL PELLETS IN PACKET 3375-150 MG 30HARVONI ORAL PELLETS IN PACKET 45-200 MG 30

generlac 64gengraf 37GENOTROPIN 65GENOTROPIN MINIQUICK 65gentak ophthalmic (eye) ointment 71gentamicin injection solgenintr10012080 gengengengenGEGILGILgle10 gleglimglimglimgliptabgliptabglipglipglipizide oral tablet extended release 24hr 25 mg 60glipizide oral tablet extended release 24hr 5 mg 60glipizide oral tablet extended release 24hr 10 mg 60GLUCAGEN HYPOKIT 60GLUCAGON EMERGENCY KIT (HUMAN) 60glycopyrrolate injection 64glycopyrrolate oral tablet 1 mg 2 mg 64

October 2021 88

Covered Drugs Index

IMBRUVICA ORAL CAPSULE 70 MG 38IMBRUVICA ORAL CAPSULE 140 MG 38IMBRUVICA ORAL TABLET 38IMFINZI 38imipenem-cilastatin 33imipramine hcl 49imiquimod topical cream in metered-dose pump 56imiquimod topical cream in packet 375 56imiquimod topical cream in packet 5 56IMOVAX RABIES VACCINE (PF) 66incassia 68INCRELEX 59INCRUSE ELLIPTA 73indapamide 52INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 66INFLECTRA 64INFUGEM 38INFUMORPH PF 46INLYTA ORAL TABLET 1 MG 38INLYTA ORAL TABLET 5 MG 38INQOVI 38INREBIC 38INSULIN LISPRO 61INSULIN LISPRO PROTAMIN-LISPRO 61INSULIN PEN NEEDLE 61INSULIN SYRINGE (DISP) U-100 03 ML 1 ML 12 ML 61INTELENCE ORAL TABLET 25 MG 30INTELENCE ORAL TABLET 100 MG 200 MG 30INTRALIPID INTRAVENOUS EMULSION 20 30 75INTRON A INJECTION 65introvale 69

hydrocodone-ibuprofen 46hydrocortisone-acetic acid 59hydrocortisone butyrate

SUBCUTANEOUS INJECTOR topical cream KIT 40 MG04 ML 67 hydrocortisone butyrate HUMIRA(CF) PEN topical ointment SUBCUTANEOUS PEN hydrocortisone butyrate INJECTOR KIT 80 MG08 ML 67 topical solution HUMIRA(CF) SUBCUTANEOUS hydrocortisone oralSYRINGE KIT 10 MG01 ML

20 MG02 ML 67 hydrocortisone rectal

HUMIRA(CF) SUBCUTANEOUS hydrocortisone topical cream SYRINGE KIT 40 MG04 ML 67 hydrocortisone topical cream HUMIRA PEN 67 with perineal applicator 25

HUMIRA PEN CROHNS- hydrocortisone topical lotion 2UC-HS START 67 hydrocortisone topical HUMIRA PEN PSOR- ointment 1 25 UVEITS-ADOL HS 67 hydrocortisone valerate HUMIRA SUBCUTANEOUS hydromorphone oral liquid SYRINGE KIT 40 MG08 ML 67 hydromorphone oral tablet HUMULIN 7030 U-100 INSULIN 61 hydroxychloroquine HUMULIN 7030 U-100 KWIKPEN 61 oral tablet 200 mg HUMULIN N NPH hydroxyprogesterone caproatINSULIN KWIKPEN 61 hydroxyurea HUMULIN N NPH U-100 INSULIN 61 hydroxyzine hcl oral tablet HUMULIN R REGULAR U-100 INSULN 61HUMULIN R U-500

I

58

60

641 58

645 58

58

46

33e 68 38 72

ibandronate oral 66IBRANCE 38ibu 46ibuprofen oral suspension 47ibuprofen oral tablet 400 mg 600 mg 800 mg 47icatibant 73ICLEVIA 69ICLUSIG 38idarubicin 38IDHIFA 38ifosfamide 38imatinib oral tablet 100 mg 38imatinib oral tablet 400 mg 38

HUMIRA(CF) PEN PSOR-UV-ADOL HS 67HUMIRA(CF) PEN

(CONC) INSULIN 61HUMULIN R U-500 (CONC) KWIKPEN 61hydralazine injection 52hydralazine oral 52hydrochlorothiazide 52hydrocodone-acetaminophen oral solution 75-325 mg15 ml 46hydrocodone-acetaminophen oral solution 10-325 mg15 ml(15 ml) 46HYDROCODONE- ACETAMINOPHEN ORAL TABLET 10-300 MG 75-300 MG 46hydrocodone-acetaminophen oral tablet 10-325 mg 5-325 mg 75-325 mg 46

October 2021 89

Covered Drugs Index

junel 1530 (21) 69junel 120 (21) 69junel fe 1530 (28) 69junel fe 120 (28) 69junel fe 24 69

KKABIVEN 75KADCYLA 38kaitlib fe 69KALETRA ORAL TABLET 100-25 MG 30KALETRA ORAL TABLET 200-50 MG 30kalliga 69KALYDECO ORAL GRANULES IN PACKET 73KALYDECO ORAL TABLET 73kariva (28) 69kelnor 135 (28) 69kelnor 1-50 (28) 69ketoconazole oral 29ketoconazole topical cream 57ketoconazole topical shampoo 57ketorolac ophthalmic (eye) 71KEYTRUDA 38KINRIX (PF) 66KISQALI 38KISQALI FEMARA CO-PACK ORAL TABLET 200 MGDAY (200 MG X 1)-25 MG 38KISQALI FEMARA CO-PACK ORAL TABLET 400 MGDAY (200 MG X 2)-25 MG 38KISQALI FEMARA CO-PACK ORAL TABLET 600 MGDAY (200 MG X 3)-25 MG 38klor-con 74KLOR-CON 8 74KLOR-CON 10 74klor-con m10 74

isibloom 69isoniazid oral solution 33isoniazid oral tablet 33isosorbide dinitrate oral tablet 55isosorbide mononitrate 55

mg 56 53 29 29 33 38 66

69

38

54

61LET 61LET

61

61jasmiel (28) 69JEMPERLI 38JENCYCLA 68JENTADUETO 61JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 61JENTADUETO XR ORAL TABLET IR - ER BIPHASIC 24HR 5-1000 MG 61JEVTANA 38jolessa 69juleber 69JULUCA 30

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG025 ML 49INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG05 ML 49

EGA SUSTENNA isotretinoin oral capsule RAMUSCULAR SYRINGE 10 mg 20 mg 30 mg 40 MG075 ML 49 isradipine EGA SUSTENNA itraconazole oral capsule RAMUSCULAR SYRINGE itraconazole oral solution MGML 49

ivermectin oral EGA SUSTENNA IXEMPRARAMUSCULAR SYRINGE

MG15 ML 49 IXIARO (PF) EGA TRINZA INTRAMUSCULAR INGE 273 MG0875 ML 49 J

EGA TRINZA INTRAMUSCULAR INGE 410 MG1315 ML 49 jaimiess

JAKAFIEGA TRINZA INTRAMUSCULAR INGE 546 MG175 ML 49 jantoven

EGA TRINZA INTRAMUSCULAR JANUMET INGE 819 MG2625 ML 49 JANUMET XR ORAL TAB

ELTYS 72 ER MULTIPHASE 24 HR IRASE ORAL TABLET 50-1000 MG 50-500 MG30

JANUMET XR ORAL TABOKAMET 61ER MULTIPHASE 24 HR OKAMET XR 61 100-1000 MG

OKANA 61 JANUVIA L 66 JARDIANCE

INVINT117INVINT156INVINT234INVSYRINVSYRINVSYRINVSYRINVINVINVINVINVIPOipratropium-albuterol 73ipratropium bromide inhalation 73ipratropium bromide nasal 59irbesartan 52irbesartan-hydrochlorothiazide 53IRESSA 38irinotecan 38ISENTRESS HD 30ISENTRESS ORAL POWDER IN PACKET 30ISENTRESS ORAL TABLET 30ISENTRESS ORAL TABLET CHEWABLE 25 MG 30ISENTRESS ORAL TABLET CHEWABLE 100 MG 30

October 2021 90

Covered Drugs Index

levocetirizine oral tablet 72levofloxacin in d5w 34levofloxacin intravenous 34levofloxacin oral solution 34levofloxacin oral tablet 35levonest (28) 69levonorgestrel-ethinyl estrad 69levonorg-eth estrad triphasic 69levora-28 69LEVO-T 63levothyroxine oral tablet 63levoxyl oral tablet 100 mcg 112 mcg 175 mcg 63LEVOXYL ORAL TABLET 125 MCG 137 MCG 150 MCG 200 MCG 25 MCG 50 MCG 75 MCG 88 MCG 63LEXIVA ORAL SUSPENSION 30LIBTAYO 38lidocaine hcl injection solution 56lidocaine hcl laryngotracheal 56lidocaine hcl mucous membrane jelly 56lidocaine hcl mucous membrane solution 4 (40 mgml) 56lidocaine (pf) injection solution 56lidocaine (pf) intravenous 51lidocaine-prilocaine topical cream 56lidocaine topical adhesive patchmedicated 5 56lidocaine topical ointment 56lidocaine viscous 56lillow (28) 69lincomycin 33lindane topical shampoo 58linezolid-09 sodium chloride 33linezolid in dextrose 5 33linezolid oral suspension for reconstitution 33linezolid oral tablet 33LINZESS 64liothyronine oral 63

larin fe 1530 (28) 69larin fe 120 (28) 69larissia 69latanoprost 71

U-100 INSULN 61LEVEMIR U-100 INSULIN 61levetiracetam in nacl (iso-os) 43levetiracetam intravenous 43levetiracetam oral 43levobunolol ophthalmic (eye) drops 05 71levocarnitine oral solution 100 mgml 59levocarnitine oral tablet 59levocarnitine (with sugar) 59levocetirizine oral solution 72

klor-con m20 74KLOXXADO 47KORLYM 63K-PHOS ORIGINAL 74kurvelo (28) 69 LATUDA ORAL TABLET 80 MG 49

VAN 63 LATUDA ORAL TABLET NMOBI SUBLINGUAL 120 MG 20 MG 40 MG 60 MG 49

LM 10 MG 15 MG layolis fe 69 MG 25 MG 30 MG 44 leena 28 69PROLIS 38 leflunomide 67

LENVIMA ORAL CAPSULE 10 MGDAY (10 MG X 1) 4 MG 38LENVIMA ORAL CAPSULE betalol oral 53 12 MGDAY (4 MG X 3) 18 MGDAY

CRISERT 71 (10 MG X 1-4 MG X2) 24 MGDAY ctated ringers intravenous 74 (10 MG X 2-4 MG X 1) 38ctated ringers irrigation 58 LENVIMA ORAL CAPSULE ctulose oral solution 64 14 MGDAY(10 MG X 1-4 MG X 1)

20 MGDAY (10 MG X 2) mivudine oral solution 30 8 MGDAY (4 MG X 2) 38mivudine oral tablet lessina 690 mg 300 mg 30

letrozole 38mivudine oral tablet 150 mg 30leucovorin calcium injection 35mivudine-zidovudine 30leucovorin calcium oral 35motrigine oral tablet 43LEUKERAN 38motrigine oral tablet

ewable dispersible 43 LEUKINE INJECTION RECON SOLN 65motrigine oral tablet

sintegrating leuprolide subcutaneous kit 43 38motrigine oral tablet levalbuterol hcl 73tended release 24hr 43 LEVEMIR FLEXTOUCH

KUKYFI20KY

LlaLAlalalalala10lalalalachladilaexLANOXIN ORAL TABLET 625 MCG (00625 MG) 55LANOXIN PEDIATRIC 55lansoprazole oral capsule delayed release(drec) 65LANTUS SOLOSTAR U-100 INSULIN 61LANTUS U-100 INSULIN 61lapatinib 38larin 1530 (21) 69larin 120 (21) 69larin 24 fe 69

October 2021 91

Covered Drugs Index

megestrol oral suspension 400 mg10 ml (10 ml) 400 mg10 ml (40 mgml) 39megestrol oral tablet 39MEKINIST ORAL TABLET 05 MG 39MEKINIST ORAL TABLET 2 MG 39MEKTOVI 39meloxicam oral tablet 75 mg 47meloxicam oral tablet 15 mg 47melphalan 39melphalan hcl 39memantine oral capsule sprinkleer 24hr 45memantine oral solution 45memantine oral tablet 5 mg 45memantine oral tablet 10 mg 45memantine oral tabletsdose pack 45MENACTRA (PF) INTRAMUSCULAR SOLUTION 66MENOSTAR 68MENQUADFI (PF) 66MENVEO A-C-Y-W-135-DIP (PF) 66mercaptopurine 39meropenem 33meropenem-09 sodium chloride 33merzee 69mesalamine oral capsule extended release 24hr 64mesalamine rectal enema 64mesalamine with cleansing wipe 64mesna 35MESNEX ORAL 35metadate er 50metaproterenol oral syrup 73METFORMIN ORAL SOLUTION 61metformin oral tablet 1000 mg 61metformin oral tablet 500 mg 61metformin oral tablet 850 mg 61metformin oral tablet extended release 24hr 1000 mg 61

LUMIZYME 63LUMOXITI 39

39ONTH) 39ONTH) 39ONTH) 39

39

69

39

61

61IN 61 68

w

74tion 74ater 74

malathion 58maprotiline 50marlissa (28) 69MARPLAN 50MARQIBO 39MATULANE 39matzim la 53MAVYRET 30meclizine oral tablet 125 mg 25 mg 64MEDROL ORAL TABLET 2 MG 60medroxyprogesterone intramuscular 68medroxyprogesterone oral 68mefloquine 33

lisinopril 53lisinopril-hydrochlorothiazide 53lithium carbonate 49 LUPRON DEPOT

ALO 54 LUPRON DEPOT (3 Morgesteestradiol-eestrad 69 LUPRON DEPOT (4 Maimiess 69 LUPRON DEPOT (6 MKELMA 59 LUPRON DEPOT-PED NSURF ORAL LUPRON DEPOT-PED BLET 15-614 MG 38 (3 MONTH) NSURF ORAL lutera (28) BLET 20-819 MG 38 LYNPARZA eramide oral capsule 64 LYSODREN inavir-ritonavir oral solution 30 LYUMJEV KWIKPEN inavir-ritonavir U-100 INSULIN l tablet 100-25 mg 30 LYUMJEV KWIKPEN inavir-ritonavir U-200 INSULIN l tablet 200-50 mg 30 LYUMJEV U-100 INSUL

azepam injection 49 lyza azepam intensol 49azepam oral tablet 05 mg 1 mg 50 Mazepam oral tablet 2 mg 50

magnesium sulfate in d5RBRENA ORAL TABLET 25 MG 38 intravenous piggyback RBRENA ORAL TABLET 100 MG 38 1 gram100 ml yna (28) 69 magnesium sulfate injecartan 53 magnesium sulfate in wartan-hydrochlorothiazide

LIVl nlojLOLOTALOTAloploploporaloporalorlorlorlorLOLOlorloslosoral tablet 50-125 mg 53losartan-hydrochlorothiazide oral tablet 100-125 mg 100-25 mg 53LOTEMAX 72LOTEMAX SM 72lovastatin oral tablet 10 mg 54lovastatin oral tablet 20 mg 40 mg 55low-ogestrel (28) 69loxapine succinate 50lo-zumandimine (28) 69ludent fluoride oral tablet chewable 1 mg (22 mg sod fluoride) 76LUMAKRAS 38LUMIGAN OPHTHALMIC (EYE) DROPS 001 71

October 2021 92

Covered Drugs Index

mometasone nasal 73mometasone topical 58mondoxyne nl oral capsule 75 mg 35mondoxyne nl oral capsule 100 mg 35MONJUVI 39mono-linyah 69montelukast oral granules in packet 73montelukast oral tablet 73montelukast oral tablet chewable 73morgidox oral capsule 100 mg 35morphine concentrate oral solution 46morphine injection solution 8 mgml 46MORPHINE INJECTION SOLUTION 10 MGML 2 MGML 4 MGML 5 MGML 46MORPHINE INJECTION SYRINGE 2 MGML 4 MGML 46morphine intravenous solution 10 mgml 4 mgml 8 mgml 46morphine oral solution 46MORPHINE ORAL TABLET 46morphine oral tablet extended release 46morphine (pf) injection solution 05 mgml 1 mgml 46MOVANTIK 64moxifloxacin ophthalmic (eye) 71moxifloxacin oral 35moxifloxacin-sodacesul-water 35moxifloxacin-sodchloride(iso) 35MOZOBIL 65mupirocin 56mupirocin calcium 56mycophenolate mofetil (hcl) 39mycophenolate mofetil oral capsule 39mycophenolate mofetil oral suspension for reconstitution 39mycophenolate mofetil oral tablet 39mycophenolate sodium 39MYLOTARG 39myorisan 56

metoprolol succinate 53metoprolol ta-hydrochlorothiaz 53metoprolol tartrate oral 53metronidazole in nacl (iso-os) 33metronidazole oral tablet etformin oral tablet

xtended release 24 hr 750 mg metronidazole topical cream 56generic for glucophage xr) 61 metronidazole topical gel 56ethadone injection solution 46 metronidazole topical lotion 56ethadone oral concentrate 46 metronidazole vaginal 68ethadone oral solution 5 mg5 ml 46 metyrosine 53ethadone oral solution 10 mg5 ml 46 mexiletine 51ethadone oral tablet 5 mg 46 MIACALCIN INJECTION 63ethadone oral tablet 10 mg 46 mibelas 24 fe 69ethazolamide 71 micafungin 29ethenamine hippurate 35 microgestin 1530 (21) 69ethimazole oral tablet microgestin 120 (21) 690 mg 5 mg 60 microgestin fe 1530 (28) 69ethocarbamol oral 45 microgestin fe 120 (28) 69ethotrexate sodium injection 39 midodrine 59ethotrexate sodium oral 39 migergot 44ethotrexate sodium (pf) 39 miglitol oral tablet 25 mg 61ethoxsalen 56 miglitol oral tablet 50 mg 62ethyldopa 53 miglitol oral tablet 100 mg 61ethylphenidate hcl oral tablet 50 miglustat 63ethylphenidate hcl oral tablet mili 69xtended release 50

minitran 55ethylphenidate hcl oral tablet minocycline oral capsule 35xtended release 24hr 18 mg

8 mg (bx rating) 27 mg 27 mg minocycline oral tablet 35bx rating) 36 mg 36 mg (bx rating) minoxidil oral 53

33

mirtazapine oral tablet 50mirtazapine oral tablet disintegrating 50misoprostol 65MITIGARE 66mitomycin intravenous 39mitoxantrone 39M-M-R II (PF) 66M-NATAL PLUS 76moexipril 53molindone 50

metformin oral tablet extended release 24hr 500 mg 61metformin oral tablet extended release 24 hr 500 mg (generic for glucophage xr) 61me(mmmmmmmmm1mmmmmmmmeme1(54 mg 54 mg (bx rating) 50methylprednisolone acetate 60methylprednisolone oral tablet 60methylprednisolone oral tablets dose pack 60methylprednisolone sodium succ injection recon soln 125 mg 40 mg 60methylprednisolone sodium succ intravenous 60metoclopramide hcl oral solution 64metoclopramide hcl oral tablet 64metolazone 53

October 2021 93

Covered Drugs Index

nizatidine oral capsule 65nora-be 68noreth-ethinyl estradiol-iron 69norethindrone acetate 68norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 68norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg 15-30 mg-mcg 69norethindrone (contraceptive) 68norethindrone-eestradiol-iron oral capsule 69norethindrone-eestradiol-iron oral tablet 15 mg-30 mcg (21)75 mg (7) 70norethindrone-eestradiol-iron oral tabletchewable 70norgestimate-ethinyl estradiol 70NORMOSOL-M IN 5 DEXTROSE 76NORMOSOL-R 75NORMOSOL-R IN 5 DEXTROSE 75NORTHERA ORAL CAPSULE 100 MG 59NORTHERA ORAL CAPSULE 200 MG 300 MG 59nortrel 0535 (28) 70nortrel 135 (21) 70nortrel 135 (28) 70nortrel 777 (28) 70nortriptyline oral capsule 50nortriptyline oral solution 50NORVIR ORAL POWDER IN PACKET 30NORVIR ORAL SOLUTION 30NOVOFINE PEN NEEDLE 62NOVOTWIST PEN NEEDLE 62NUBEQA 39NUEDEXTA 45NULOJIX 39NUPLAZID ORAL CAPSULE 50NUPLAZID ORAL TABLET 10 MG 50NUTRILIPID 76

neomycin-polymyxin-hc otic (ear) 59neo-polycin 71neo-polycin hc 72NERLYNX 39NEUPRO 44nevirapine oral suspension 30nevirapine oral tablet 30nevirapine oral tablet extended release 24 hr 100 mg 30

30

39

55

53

59

53

69

39

53

39

53

33

59

35

35nitroglycerin intravenous 55nitroglycerin sublingual 55nitroglycerin transdermal patch 24 hour 55nitroglycerin translingual 55NIVESTYM 65

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 74

Nnabumetone 47nadolol 53nadolol-bendroflumethiazide oral tablet 80-5 mg 53nafcillin 34nafcillin in dextrose iso-osm 34 nevirapine oral tablet extended

release 24 hr 400 mg57 topical cream NEXAVAR TOPICAL GEL 2 57 niacin oral tablet 500 mgYME 63 niacin oral tablet extended e injection solution 47 release 24 hr

e injection syringe 1 mgml 47 niacor ne 47 nicardipine intravenous solution RIC 45 nicardipine oral n oral suspension 47 NICOTROL n oral tablet 47 NICOTROL NS n oral tablet nifedipine oral tablet release (drec) 47 extended release n sodium nifedipine oral tablet et 275 mg 550 mg 47 extended release 24hr an 44 nikki (28) N 47 nilutamide N 71 nimodipine

ide oral tablet 60 mg 62 NINLARO ide oral tablet 120 mg 62 NIPENT A 63 nisoldipine M 43 NITAZOXANIDE

535 (28) 69 nitisinone S INSULIN DISPSAFETY 62 nitrofurantoin

one 50 nitrofurantoin macrocrystal in 33 nitrofurantoin monohydm-cryst

naftifineNAFTINNAGLAZnaloxonnaloxonnaltrexoNAMZAnaproxenaproxenaproxedelayednaproxeoral tablnaratriptNARCANATACYnateglinnateglinNATPARNAYZILAnecon 0NEEDLEnefazodneomycneomycin-bacitracin-poly-hc 71neomycin-bacitracin-polymyxin 71neomycin-polymyxin b-dexameth 72neomycin-polymyxin b gu 58neomycin-polymyxin-gramicidin 71neomycin-polymyxin-hc ophthalmic (eye) 72

October 2021 94

Covered Drugs Index

oxycodone oral concentrate 46oxycodone oral solution 46oxycodone oral tablet 5 mg 46oxycodone oral tablet 10 mg 15 mg 20 mg 30 mg 46oxymorphone oral tablet extended release 12 hr 46OZEMPIC SUBCUTANEOUS PEN INJECTOR 025 MG OR 05 MG(2 MG15 ML) 62OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MGDOSE (2 MG15 ML) 1 MGDOSE (4 MG3 ML) 62

Ppacerone oral tablet 100 mg 200 mg 400 mg 52paclitaxel 39PADCEV 39paliperidone oral tablet extended release 24hr 15 mg 9 mg 50paliperidone oral tablet extended release 24hr 3 mg 6 mg 50palonosetron intravenous solution 025 mg5 ml 64pamidronate 63pantoprazole oral tablet delayed release (drec) 65paricalcitol oral 63paromomycin 33paroxetine hcl oral tablet 10 mg 50paroxetine hcl oral tablet 20 mg 40 mg 50paroxetine hcl oral tablet 30 mg 50paroxetine hcl oral tablet extended release 24 hr 50PASER 33PAXIL ORAL SUSPENSION 50PEDIARIX (PF) 66PEDVAX HIB (PF) 66peg 3350-electrolytes oral recon soln 236-2274-674 -586 gram 64

55

65D 62 62

62

64

39

73

59

33

39

73

70

30oxacillin injection 34oxaliplatin 39oxandrolone oral tablet 25 mg 63oxandrolone oral tablet 10 mg 63oxaprozin 47oxazepam 50oxcarbazepine 43OXERVATE 71oxybutynin chloride oral syrup 74oxybutynin chloride oral tablet 74oxybutynin chloride oral tablet extended release 24hr 74oxycodone-acetaminophen oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg 46

NUZYRA INTRAVENOUS 35 omega-3 acid ethyl esters NUZYRA ORAL 35 omeprazole oral capsule nyamyc 57 delayed release(drec) NYLIA 777 (28) 70 OMNIPOD DASH 5 PACK POnymyo 70 OMNIPOD DASH PDM KIT nystatin oral suspension 29 OMNIPOD INSULIN

MANAGEMENT nystatin oral tablet 29OMNIPOD INSULIN REFILL nystatin topical cream 57ondansetron nystatin topical ointment 57ondansetron hcl intravenous nystatin topical powder 57ondansetron hcl oral solution nystatin-triamcinolone 57ondansetron hcl oral tablet nystop 57ondansetron hcl (pf) NYVEPRIA 65ONIVYDE

O ONUREG OPDIVO INTRAVENOUS

OCALIVA 64 SOLUTION 100 MG10 ML ocella 70 240 MG24 ML 40 MG4 ML OCREVUS 45 OPSUMIT octreotide acetate injection oralone solution 1000 mcgml 100 mcgml ORBACTIV 200 mcgml 50 mcgml 39 ORGOVYX octreotide acetate injection ORKAMBI ORAL solution 500 mcgml 39 GRANULES IN PACKET octreotide acetate injection syringe 39 ORKAMBI ORAL TABLET ODEFSEY 30 orsythia ODOMZO 39 oseltamivir OFEV 73ofloxacin ophthalmic (eye) 71ofloxacin otic (ear) 59olanzapine-fluoxetine 50olanzapine intramuscular 50olanzapine oral tablet 10 mg 25 mg 5 mg 75 mg 50olanzapine oral tablet 15 mg 20 mg 50olanzapine oral tablet disintegrating 10 mg 5 mg 50olanzapine oral tablet disintegrating 15 mg 20 mg 50olmesartan 53olmesartan-hydrochlorothiazide 53olopatadine ophthalmic (eye) 71

October 2021 95

Covered Drugs Index

POTASSIUM CHLORIDE-D5- 02NACL INTRAVENOUS PARENTERAL SOLUTION 20 MEQL 75potassium chloride-d5-03nacl intravenous parenteral solution 20 meql 75POTASSIUM CHLORIDE- D5-09NACL 75potassium chloride in 09nacl intravenous parenteral solution 20 meql 40 meql 75potassium chloride in 5 dex intravenous parenteral solution 20 meql 75potassium chloride in lr-d5 intravenous parenteral solution 20 meql 75potassium chloride intravenous 75potassium chloride in water intravenous piggyback 10 meq100 ml 10 meq50 ml 20 meq100 ml 20 meq50 ml 40 meq100 ml 75potassium chloride oral capsule extended release 75potassium chloride oral liquid 75potassium chloride oral packet 75potassium chloride oral tablet er particlescrystals 10 meq 20 meq 75potassium chloride oral tablet extended release 75potassium citrate 74POTELIGEO 40PRADAXA 54pramipexole oral tablet 44pramipexole oral tablet extended release 24 hr 44PRASUGREL 54pravastatin 55praziquantel 33prazosin 53prednicarbate topical ointment 58prednisolone acetate 72

PHESGO 39philith 70

0

1960032240

006666660131

POMALYST 40portia 28 70PORTRAZZA 40posaconazole oral tablet delayed release (drec) 29POTASSIUM CHLORID-D5- 045NACL INTRAVENOUS PARENTERAL SOLUTION 10 MEQL 20 MEQL 40 MEQL 75potassium chlorid-d5-045nacl intravenous parenteral solution 30 meql 75potassium chloride-045 nacl 75

PEGASYS SUBCUTANEOUS SOLUTION 65PEGASYS SUBCUTANEOUS PIFELTRO 3

INGE 65 pilocarpine hcl ophthalmic -electrolyte 64 (eye) drops 1 2 4 7AZYRE 39 pilocarpine hcl oral 5

icillamine 67 pimecrolimus 5icillin g potassium injection pimozide 5n soln 20 million unit 34 pimtrea (28) 7icillin v potassium pindolol 5l recon soln 34

pioglitazone 6icillin v potassium l tablet 250 mg 34 pioglitazone-metformin 6icillin v potassium piperacillin-tazobactam 3l tablet 500 mg 34 PIQRAY 4

TACEL (PF) 66 PIRMELLA ORAL TABLET tamidine inhalation 33 050751 MG- 35 MCG 7tamidine injection 33 pirmella oral tablet 1-35 mg-mcg 7TASA 64 PLENAMINE 7

toxifylline 54 PNV 29-1 7AXTO 39 PNV-DHA 7FOROMIST 73 PNV-OMEGA 7IKABIVEN 76 PNV-SELECT 7

indopril erbumine 53 podofilox 5JETA 39 POLIVY 4

methrin 58 polycin 7phenazine 50 polymyxin b sulfate 3phenazine-amitriptyline 50 polymyxin b sulf-trimethoprim 7

SYRpegPEMpenpenrecopenorapenorapenoraPENpenpenPENpenPEPPERPERperPERperperperPERSERIS 50pfizerpen-g 34phenelzine 50phenobarbital oral elixir 43phenobarbital oral tablet 43phenobarbital sodium injection solution 43phenoxybenzamine 53phenytoin oral suspension 43phenytoin oral tabletchewable 43phenytoin sodium extended 43phenytoin sodium intravenous solution 43

October 2021 96

Covered Drugs Index

propafenone oral tablet 52propranolol-hydrochlorothiazid 53propranolol oral capsule extended release 24 hr 53propranolol oral solution 53propranolol oral tablet 53propylthiouracil 60PROQUAD (PF) 66PROSOL 20 76protriptyline 50PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 025 MG 2 ML 05 MG2 ML 73PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG2 ML 73PULMOZYME 73PURIXAN 40pyrazinamide 33pyridostigmine bromide oral syrup 45pyridostigmine bromide oral tablet 60 mg 45pyridostigmine bromide oral tablet extended release 45pyrimethamine 33

QQINLOCK 40QUADRACEL (PF) 66quetiapine oral tablet 100 mg 25 mg 50 mg 50quetiapine oral tablet 200 mg 50quetiapine oral tablet 300 mg 400 mg 50quetiapine oral tablet extended release 24 hr 150 mg 200 mg 50quetiapine oral tablet extended release 24 hr 300 mg 400 mg 50 mg 50quinapril 53quinapril-hydrochlorothiazide 53

PRIFTIN 33 33 43 76 76 76 76 66 66 76 64 64 64 64 64 64 64 68 40

40S 59

PROLASTIN-C INTRAVENOUS SOLUTION 59PROLENSA 71PROLEUKIN 65PROLIA 66PROMACTA ORAL POWDER IN PACKET 125 MG 54PROMACTA ORAL POWDER IN PACKET 25 MG 54PROMACTA ORAL TABLET 125 MG 25 MG 50 MG 54PROMACTA ORAL TABLET 75 MG 54promethazine oral 72promethazine rectal suppository 125 mg 25 mg 72promethegan rectal suppository 25 mg 50 mg 72propafenone oral capsule extended release 12 hr 52

prednisolone oral solution 60prednisolone sodium phosphate PRIMAQUINE ophthalmic (eye) 72 primidone prednisolone sodium phosphate PR NATAL 400 oral solution 15 mg5 ml PR NATAL 400 EC (3 mgml) 15 mg5 ml (5 ml) 25 mg5 ml (5 mgml) PR NATAL 430 5 mg base5 ml (67 mg5 ml) 60 PR NATAL 430 EC prednisone intensol 60 probenecid prednisone oral solution 60 probenecid-colchicine prednisone oral tablet 1 mg PROCALAMINE 3 10 mg 25 mg 20 mg 5 mg 60 prochlorperazine prednisone oral tablet 50 mg 60 prochlorperazine edisylate prednisone oral tabletsdose pack 60 prochlorperazine maleate oral pregabalin oral capsule 100 mg procto-med hc 150 mg 25 mg 50 mg 75 mg 43

procto-pak pregabalin oral capsule 200 mg 43proctosol hc topical pregabalin oral capsule

43 proctozone-hc225 mg 300 mg progesterone micronizedpregabalin oral solution 43PROGRAF INTRAVENOUSpregabalin oral tablet extended

release 24 hr 165 mg 825 mg 43 PROGRAF ORAL GRANULES IN PACKETpregabalin oral tablet extended

release 24 hr 330 mg 43 PROLASTIN-C INTRAVENOURECON SOLN PREMARIN INJECTION 68

PREMARIN ORAL 68PREMARIN VAGINAL 68PREMASOL 10 76PRENATAL PLUS 76PRENATAL VITAMIN ORAL TABLET 76PREPLUS 76PRETAB 76prevalite oral powder in packet 55previfem 70PREVYMIS ORAL 30PREZCOBIX 30PREZISTA ORAL SUSPENSION 30PREZISTA ORAL TABLET 75 MG 30PREZISTA ORAL TABLET 150 MG 30PREZISTA ORAL TABLET 600 MG 30PREZISTA ORAL TABLET 800 MG 30

October 2021 97

Covered Drugs Index

risperidone oral tablet disintegrating 3 mg 51ritonavir 31rivastigmine 45

ne tartrate 45 70 44

TAN 71PSIN NOUS SOLUTION 40oral tablet 44opical cream 56opical gel 56tin 55 66

Q VACCINE 66oral tablet 500 mg 43

REK ORAL E 100 MG 40REK ORAL E 200 MG 40A 40

MIDE ORAL SION 43e oral tablet 43

A 31CE 40

RYBELSUS 62RYBREVANT 40RYDAPT 40RYTARY 44

Ssalsalate 47SAMSCA ORAL TABLET 15 MG 63SANCUSO 65SANDIMMUNE ORAL SOLUTION 40SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 40

REYATAZ ORAL POWDER IN PACKET 30RHOPRESSA 71ribavirin oral capsule 31ribavirin oral tablet 200 mg rivastigmi

AVERT (PF) 66 RIDAURA 67 rivelsa ifene 66 rifabutin 33 rizatriptanlteon 50 rifampin intravenous 33 ROCKLA

pril 53 rifampin oral 33 ROMIDElazine 55 riluzole 59 INTRAVEgiline 44 rimantadine 31 ropinirole IF REBIDOSE ringerrsquos intravenous rosadan t

ANEOUS PEN INJECTOR 75CUT rosadan tCG02ML-22 MCG05ML (6) 65 ringerrsquos irrigation 58IF REBIDOSE RINVOQ 67 rosuvastaCUTANEOUS PEN INJECTOR risedronate oral tablet 5 mg 67 ROTARIXCG05 ML 44 MCG05 ML 65 risedronate oral tablet 30 mg 59 ROTATEIF TITRATION PACK 65 risedronate oral tablet 35 mg roweepra IF (WITH ALBUMIN) 65 35 mg (12 pack) 35 mg (4 pack) 67 ROZLYTpsen (28) 70 risedronate oral tablet 150 mg 67 CAPSULOMBIVAX HB (PF) 66 RISPERDAL CONSTA ROZLYT

INTRAMUSCULAR CAPSULTIV 65SUSPENSIONEXTENDED RUBRACnol 45 REL RECON 125 MG2 ML 50 RUFINARANEX 56 RISPERDAL CONSTA SUSPEN

ACIDIN 74 INTRAMUSCULAR rufinamidglinide oral tablet 05 mg 62 SUSPENSIONEXTENDED RUKOBIglinide oral tablet 1 mg 62 REL RECON 25 MG2 ML

375 MG2 ML 50 MG2 ML 50 RUXIEN

31

risperidone oral solution 51risperidone oral syringe 51risperidone oral tablet 025 mg 05 mg 4 mg 51risperidone oral tablet 1 mg 51risperidone oral tablet 2 mg 51risperidone oral tablet 3 mg 51risperidone oral tablet disintegrating 025 mg 05 mg 4 mg 51risperidone oral tablet disintegrating 1 mg 51risperidone oral tablet disintegrating 2 mg 51

quinidine sulfate oral tablet 52quinine sulfate 33

RRABraloxrameramiranorasaREBSUB88MREBSUB22 MREBREBrecliRECRECregoREGRENrepareparepaglinide oral tablet 2 mg 62REPATHA 55REPATHA PUSHTRONEX 55REPATHA SURECLICK 55RESTASIS 71RESTASIS MULTIDOSE 71RETACRIT 65RETEVMO ORAL CAPSULE 40 MG 40RETEVMO ORAL CAPSULE 80 MG 40RETROVIR INTRAVENOUS 30REVLIMID 40REXULTI 50

October 2021 98

Covered Drugs Index

STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 55STELARA SUBCUTANEOUS SYRINGE 90 MGML 55STIVARGA 40streptomycin 33STRIBILD 31subvenite 43subvenite starter (blue) kit 43subvenite starter (green) kit 43subvenite starter (orange) kit 43sucralfate oral suspension 65sucralfate oral tablet 65sulfacetamide-prednisolone 71sulfacetamide sodium (acne) 56sulfacetamide sodium ophthalmic (eye) drops 71sulfadiazine 35sulfamethoxazole-trimethoprim intravenous 35sulfamethoxazole-trimethoprim oral suspension 35sulfamethoxazole-trimethoprim oral tablet 35sulfasalazine 65sulindac 47sumatriptan nasal spray non-aerosol 5 mgactuation 44sumatriptan nasal spray non-aerosol 20 mgactuation 44sumatriptan succinate oral 44sumatriptan succinate subcutaneous cartridge 44sumatriptan succinate subcutaneous pen injector 44sumatriptan succinate subcutaneous solution 44sunitinib 40SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG5 ML 32SUPREP BOWEL PREP KIT 65SUTAB 65

SKYRIZI SUBCUTANEOUS SYRINGE KIT 55sodium bicarbonate intravenous syringe 10 meq10 ml (84) 75 (09 meqml) 84 (1 meqml) 75sodium chloride 09 intravenous 59sodium chlori

selenium sulfide topical lotion 55 intravenous pSELZENTRY ORAL SOLUTION 31 sodium chloriSELZENTRY ORAL sodium chloriTABLET 25 MG 31 sodium chloriSELZENTRY ORAL sodium chloriTABLET 150 MG 75 MG 31

sodium fluoriSELZENTRY ORAL TABLET 300 MG 31 sodium phenSE-NATAL-19 76 sodium polys

oral powder SE-NATAL 19 CHEWABLE 76solifenacin SEREVENT DISKUS 73SOLIQUA 10sertraline oral concentrate 51SOLTAMOX sertraline oral tablet 51SOLU-CORTsetlakin 70SOMATULINSEVELAMER CARBONATE 59SOMAVERT sharobel 68sorine SHINGRIX (PF) 66sotalol af SIGNIFOR 40sotalol oral sildenafil (pulmonary arterial SOTYLIZE

de 045 arenteral solution 75de 3 75de 5 75de intravenous 75de irrigation 59de-pot nitrate 59ylbutyrate 59tyrene sulfonate

59

74033 62 40EF ACT-O-VIAL (PF) 60E DEPOT 40 63 52 52 52 52

spironolactone 53spironolacton-hydrochlorothiaz 53sprintec (28) 70SPRITAM 43SPRYCEL ORAL TABLET 20 MG 70 MG 40SPRYCEL ORAL TABLET 100 MG 140 MG 50 MG 80 MG 40sps (with sorbitol) oral 59sronyx 70ssd 56STAMARIL (PF) 66stavudine oral capsule 31STELARA SUBCUTANEOUS SOLUTION 55

SANTYL 56sapropterin 63SARCLISA 40scopolamine base 65SECUADO 51selegiline hcl 44

hypertension) oral tablet 74silver sulfadiazine 56SIMBRINZA 71simliya (28) 70simpesse 70SIMULECT 40simvastatin oral tablet 55sirolimus oral solution 40sirolimus oral tablet 40SIRTURO 33SIVEXTRO INTRAVENOUS 33SIVEXTRO ORAL 33SKYRIZI SUBCUTANEOUS PEN INJECTOR 55SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML 55

October 2021 99

Covered Drugs Index

testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1) 63testosterone transdermal gel in packet 1 (25 mg25gram) 1 (50 mg5 gram) 63TETANUSDIPHTHERIA TOX PED(PF) 66tetrabenazine oral tablet 125 mg 45tetrabenazine oral tablet 25 mg 45tetracycline 35THALOMID ORAL CAPSULE 100 MG 150 MG 50 MG 41THALOMID ORAL CAPSULE 200 MG 41THEO-24 74theophylline oral tablet extended release 12 hr 300 mg 450 mg 74theophylline oral tablet extended release 24 hr 74thioridazine 51thiotepa 41thiothixene 51tiadylt er 53tiagabine 43TIBSOVO 41TICE BCG 66tigecycline 33tilia fe 70timolol maleate ophthalmic (eye) drops 71TIMOLOL MALEATE OPHTHALMIC (EYE) GEL FORMING SOLUTION 71timolol maleate oral 53tis-u-sol pentalyte 58TIVICAY ORAL TABLET 10 MG 31TIVICAY ORAL TABLET 25 MG 50 MG 31TIVICAY PD 31tizanidine oral capsule 45tizanidine oral tablet 45

tazicef 32TAZORAC TOPICAL CREAM 005

AC TOPICAL GEL oral capsuleextende 24 hr 120 mg 180 m 300 mg RIK

56

56d g 53 40 66

TRIQ 40ITE INSULIN SYRINGE 62ITE INSULN SYR

(HALF UNIT) 62TECHLITE PEN NEEDLE 62TEFLARO 32TEKTURNA HCT 53telmisartan 53telmisartan-amlodipine 53telmisartan-hydrochlorothiazid 53temazepam oral capsule 15 mg 30 mg 51TEMIXYS 31TEMODAR INTRAVENOUS 40temsirolimus 40TENIVAC (PF) 66tenofovir disoproxil fumarate 31TEPMETKO 40terazosin oral capsule 1 mg 2 mg 5 mg 53terazosin oral capsule 10 mg 53terbinafine hcl oral 29terbutaline 74terconazole 68TERIPARATIDE 67testosterone cypionate intramuscular oil 100 mgml 200 mgml (1 ml) 63TESTOSTERONE CYPIONATE INTRAMUSCULAR OIL 200 MGML 63testosterone enanthate 63

SUTENT 40syeda 70SYMDEKO 74SYMLINPEN 60 62 TAZOR

PEN 120 62 taztia xtreleaseZAN 43 240 mg

ZA 31 TAZVEEL 63 TDVAXCID 33 TECENRDY 62 TECHLRDY XR ORAL TABLET IR - TECHL

SYMLINSYMPASYMTUSYNARSYNERSYNJASYNJAER BIPHASIC 24HR 10-1000 MG 125-1000 MG 5-1000 MG 62SYNJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 25-1000 MG 62SYNRIBO 40SYNTHROID 63

TTABLOID 40TABRECTA 40tacrolimus oral 40tacrolimus topical 56tadalafil (pulmonary arterial hypertension) oral tablet 20 mg 74TAFINLAR 40TAGRISSO 40TALTZ SYRINGE 55TALZENNA ORAL CAPSULE 025 MG 40TALZENNA ORAL CAPSULE 1 MG 40tamoxifen 40tamsulosin 74TARGRETIN TOPICAL 40tarina 24 fe 70tarina fe 1-20 eq (28) 70TARON-C DHA 76TASIGNA ORAL CAPSULE 50 MG 40TASIGNA ORAL CAPSULE 150 MG 200 MG 40tazarotene topical cream 56

October 2021 100

Covered Drugs Index

TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG (D) 150 MG (N) 74tri-legest fe 70tri-linyah 70tri-lo-estarylla 70tri-lo-marzia 70tri-lo-mili 70tri-lo-sprintec 70trilyte with flavor packets 65trimethoprim 35tri-mili 70trimipramine 51TRINATAL RX 1 76TRINTELLIX 51tri-nymyo 70tri-previfem (28) 70TRIPTODUR 41tri-sprintec (28) 70TRIUMEQ 31TRIVEEN-DUO DHA 76trivora (28) 70tri-vylibra 70tri-vylibra lo 70TRODELVY 41TROGARZO 31TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24HR 100 MG 25 MG 50 MG 43TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24HR 200 MG 43TROPHAMINE 10 76TRULICITY 62TRUMENBA 66TRUSELTIQ ORAL CAPSULE 75 MGDAY (25 MG X 3) 41TRUSELTIQ ORAL CAPSULE 100 MGDAY (100 MG X 1) 41TRUSELTIQ ORAL CAPSULE 125 MGDAY(100 MG X1-25MG X1) 50 MGDAY (25 MG X 2) 41

TRELSTAR INTRAMUSCULAR 225 MG 41CH U-100 62CH U-200 62ULIN 62tic) 41s 56

m 56al gel 001 56al gel 56ide dental 59ide 40 mgml 60ide 58ide

05 58ide 58

triamcinolone acetonide topical ointment 58triamterene-hydrochlorothiazid oral capsule 375-25 mg 53triamterene-hydrochlorothiazid oral tablet 53triderm topical cream 01 58trientine 59tri-estarylla 70tri femynor 70trifluoperazine 51trifluridine 71trihexyphenidyl 44TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 10-5-1000 MG 25-5-1000 MG 62TRIJARDY XR ORAL TABLET IR - ER BIPHASIC 24HR 125- 25-1000 MG 5-25-1000 MG 62TRIKAFTA ORAL TABLETS SEQUENTIAL 50-25-375 MG (D)75 MG (N) 74

TOBI PODHALER INHALATION CAPSULE SUSPENSION FOR

ALATION DEVICE 33 RECONSTITUTION ycin-dexamethasone 72 TRESIBA FLEXTOUycin in 0225 nacl 34 TRESIBA FLEXTOUycin ophthalmic (eye) 71 TRESIBA U-100 INSycin sulfate 34 tretinoin (antineoplas

EX OPHTHALMIC tretinoin microsphere OINTMENT 71 tretinoin topical creaone 44 0025 005 01dine 74 tretinoin topical topictan oral tablet 30 mg 63 tretinoin topical topicmate oral capsule sprinkle 43 0025 005 mate oral tablet 43 triamcinolone acetonr 41 triamcinolone aceton

injection suspension can intravenous recon soln 41triamcinolone acetoncan intravenous topical cream 01 n 4 mg4 ml (1 mgml) 41triamcinolone acetonifene 41 topical cream 0025

ide oral 53 triamcinolone acetonEO MAX U-300 SOLOSTAR 62 topical lotion

WINHtobramtobramtobramtobramTOBR(EYE)tolcaptolterotolvaptopiratopiratoposatopotetopotesolutiotoremtorsemTOUJTOUJEO SOLOSTAR U-300 INSULIN 62TOVIAZ 74TPN ELECTROLYTES 75TRADJENTA 62tramadol-acetaminophen 47tramadol oral tablet 50 mg 47trandolapril 53tranexamic acid oral 68tranylcypromine 51TRAVASOL 10 76travoprost 71TRAZIMERA 41trazodone 51TREANDA 41TRECATOR 34TRELEGY ELLIPTA 74TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 1125 MG 375 MG 41

October 2021 101

Covered Drugs Index

venlafaxine oral tablet 50 mg 75 mg 51venlafaxine oral tablet 100 mg 25 mg 375 mg 51VENTAVIS 74VENTOLIN HFA 74verapamil intravenous solution 53verapamil oral capsule 24 hr er pellet ct 53verapamil oral capsule ext rel pellets 24 hr 120 mg 180 mg 240 mg 54VERAPAMIL ORAL CAPSULE EXT REL PELLETS 24 HR 360 MG 54verapamil oral tablet 54verapamil oral tablet extended release 54VERSACLOZ 51VERZENIO 41vestura (28) 70V-GO 20 62V-GO 30 62V-GO 40 62VICTOZA 3-PAK 62vienva 70vigabatrin 43vigadrone 43VIIBRYD ORAL TABLET 51VIIBRYD ORAL TABLETS DOSE PACK 10 MG (7)- 20 MG (23) 51VIMPAT INTRAVENOUS 43VIMPAT ORAL SOLUTION 43VIMPAT ORAL TABLET 50 MG 44VIMPAT ORAL TABLET 100 MG 150 MG 200 MG 44vinblastine 41vincasar pfs 41vincristine 41vinorelbine 41VIOKACE 65viorele (28) 70

34

34vandazole 68VAQTA (PF) 66VARIVAX (PF) 66VARIZIG 66VASCEPA 55VECTIBIX 41VELCADE 41velivet triphasic regimen (28) 70VELPHORO 59VELTASSA 59VEMLIDY 31VENCLEXTA ORAL TABLET 10 MG 41VENCLEXTA ORAL TABLET 50 MG 41VENCLEXTA ORAL TABLET 100 MG 41VENCLEXTA STARTING PACK 41venlafaxine oral capsule extended release 24hr 75 mg 51venlafaxine oral capsule extended release 24hr 150 mg 375 mg 51

TUKYSA ORAL TABLET 50 MG 41 VANCOMYCIN IN 09 YSA ORAL TABLET 150 MG 41 SODIUM CHL INTRAVENOUS

PIGGYBACK ALIO 41VANCOMYCIN IN DEXTROSE RIX (PF) 66 5 INTRAVENOUS PIGGYBAC

70 1 GRAM200 ML 750 MG150

31 vancomycin in dextrose 5

70 intravenous piggyback 500 mg100 ml 67vancomycin injection66 vancomycin intravenous recon 45 soln 1000 mg 10 gram 250 mg5 gram 500 mg 750 mg VANCOMYCIN INTRAVENOUS RECON SOLN 125 GRAM 41 15 GRAM

AL TABLET vancomycin oral capsule 125 mgCG 125 MCG CG 200 MCG vancomycin oral capsule 250 mg

K me ML OST

y LOS HIM VI ABRI

NIQ

HROID ORMCG 112 M

MCG 175 M CG 300 MCG 50 MCG VANCOMYCIN-WATER CG 88 MCG 63 INJECT (PEG)

TUKTURTWINtybluTYBtydemTYMTYPTYS

UUKOUNIT100 150 25 M75 Munithroid oral tablet 137 mcg 63UNITUXIN 41UPTRAVI ORAL 53ursodiol oral capsule 300 mg 65ursodiol oral tablet 65

Vvalacyclovir oral tablet 1 gram 31valacyclovir oral tablet 500 mg 31VALCHLOR 56valganciclovir oral recon soln 31valganciclovir oral tablet 31valproate sodium 43valproic acid 43valproic acid (as sodium salt) 43valrubicin 41valsartan-hydrochlorothiazide 53valsartan oral tablet 160 mg 40 mg 80 mg 53valsartan oral tablet 320 mg 53VALTOCO 43

October 2021 102

Covered Drugs Index

XPOVIO 41XTAMPZA ER 46XTANDI ORAL CAPSULE 41XTANDI ORAL TABLET 40 MG 42XTANDI ORAL TABLET 80 MG 42XULTOPHY 10036 62XYREM 51

YYERVOY 42YF-VAX (PF) 66YONDELIS 42YUPELRI 74yuvafem 68

Zzafirlukast 74zaleplon oral capsule 5 mg 51zaleplon oral capsule 10 mg 51ZALTRAP 42ZANOSAR 42zarah 70ZATEAN-PN DHA 76ZATEAN-PN PLUS 76ZEJULA 42ZELBORAF 42ZEMAIRA 59zenatane 56ZENPEP ORAL CAPSULE DELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 25000-79000- 105000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT 65ZEPZELCA 42zidovudine oral capsule 31zidovudine oral syrup 31zidovudine oral tablet 31

X 41 54

44

44XELJANZ ORAL SOLUTION 67XELJANZ ORAL TABLET 67XELJANZ XR 67XGEVA 35XHANCE 74XIAFLEX 59XIFAXAN ORAL TABLET 550 MG 34XOFLUZA ORAL TABLET 20 MG 40 MG 31XOFLUZA ORAL TABLET 80 MG 31XOLAIR SUBCUTANEOUS RECON SOLN 74XOLAIR SUBCUTANEOUS SYRINGE 75 MG05 ML 74XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 74XOPENEX 74XOPENEX CONCENTRATE 74XOSPATA 41

VIRACEPT ORAL TABLET 250 MG 31VIRACEPT ORAL XALKORI TABLET 625 MG 31 XARELTO VIREAD ORAL POWDER 31 XARELTO DVT-PE

D ORAL TABLET TREAT 30D START 54G 200 MG 250 MG 31 XATMEP 41C DHA 76 XCOPRI MAINTENANCE PACK NATE DHA 76 ORAL TABLET 250MGDAY PN DHA 76 (150 MG X1-100MG X1) 44PN PLUS 76 XCOPRI MAINTENANCE PACK

ORAL TABLET 350 MGDAY KVI ORAL (200 MG X1-150MG X1) 44ULE 25 MG 41XCOPRI ORAL TABLET 50 MG 44KVI ORAL

ULE 100 MG 41 XCOPRI ORAL TABLET 100 MG 44KVI ORAL SOLUTION 41 XCOPRI ORAL TABLET

150 MG 200 MG 44ROL 47XCOPRI TITRATION PACK PRO 41 ORAL TABLETSDOSE PACK

VIREA150 MVIRT-VIRT-VIRT-VIRT-VITRACAPSVITRACAPSVITRAVIVITVIZIMvolnea (28) 70 125 MG (14)- 25 MG (14) voriconazole intravenous 29 150 MG (14)- 200 MG (14)

voriconazole oral suspension XCOPRI TITRATION PACK for reconstitution 29 ORAL TABLETSDOSE PACK

50 MG (14)- 100 MG (14)voriconazole oral tablet 29VOSEVI 31VOTRIENT 41VP-PNV-DHA 76VRAYLAR ORAL CAPSULE 51VRAYLAR ORAL CAPSULE DOSE PACK 51vyfemla (28) 70vylibra 70VYNDAMAX 55VYNDAQEL 55VYXEOS 41

Wwarfarin 54water for irrigation sterile 59wera (28) 70wixela inhub 74wymzya fe 70

October 2021 103

Covered Drugs Index

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG 51ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG 51

ziprasidone hcl oral capsule 20 mg 51ziprasidone hcl oral capsule 40 mg 51ziprasidone hcl oral capsule

g 80 mg 51sidone mesylate 51BEV 42AN 71

ADEX 42dronic acid venous solution 63dronic acid-mannitol-water venous piggyback 100 ml 63EDRONIC ACID-MANNITOL-ER INTRAVENOUS YBACK 5 MG100 ML 59

dronic ac-mannitol-09nacl 63INZA 42idem oral tablet 51samide 44

60 mzipraZIRAZIRGZOLzoleintrazoleintra4 mgZOLWATPIGGzoleZOLzolpzoniZORTRESS ORAL TABLET 1 MG 42ZOSTAVAX (PF) 66ZOSYN IN DEXTROSE (ISO-OSM) 34zovia 1-35 (28) 70zovia 135e (28) 70ZTLIDO 56ZUBSOLV SUBLINGUAL TABLET 07-018 MG 14-036 MG 114-29 MG 29-071 MG 57-14 MG 47ZUBSOLV SUBLINGUAL TABLET 86-21 MG 47zumandimine (28) 70ZYDELIG 42ZYKADIA ORAL TABLET 42ZYLET 72ZYNLONTA 42ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG 51

104

Notes

105

Notes

106

Notes

Notice of Nondiscrimination Discrimi

Cigna complies with applicable Federal cage disability or sex Cigna does not exdisability or sex Cigna bull Provides free aids and services to peominus Qualified sign language interpreters minus Written information in other formats (

bull Provides free language services to peominus Qualified interpreters minus Information written in other language

If you need these services contact CustIf you believe that Cigna has failed to pronational origin age disability or sex you

nation is Against the Law

ivil rights laws and does not discriminate on the basis of race color national origin clude people or treat them differently because of race color national origin age

ple with disabilities to communicate effectively with us such as

large print audio accessible electronic formats other formats) ple whose primary language is not English such as

s omer Service at 1-800-668-3813 (TTY 711) 8 am to 8 pm 7 days a week vide these services or discriminated in another way on the basis of race color can file a grievance with

Cigna Attn Grievance Department PO Box 188080 Chattanooga TN 37422 Phone 1-800-668-3813 (TTY 711) Fax 1-888-586-9946

You can file a grievance in writing by mail or fax If you need help filing a grievance Customer Service is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at

US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD) Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc ATTENTION If you speak languages other than English language assistance services free of charge are available to you Call 1-800-668-3813 (TTY 711) 8 am to 8 pm 7 days a week ATENCIOacuteN si usted habla un idioma que no sea ingleacutes tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al 1-800-668-3813 (TTY 711) 8 am a 8 pm 7 diacuteas de la semana Cigna is contracted with Medicare for PDP plans HMO and PPO plans in select states and with select State Medicaid programs Enrollment in Cigna depends on contract renewal copy 2017 Cigna

INT_17_49135 v05012020 20_NDMLI_MAPD

0XOWLODQJXDJHQWHUSUHWHU6HUYLFHV English ndash ATTENTION If you speak English language assistance services free of charge are available to you Call (TTY 711)

Spanish ndash ATENCIOacuteN si habla espantildeol tiene a su disposicioacuten servicios gratuitos de asistencia linguumliacutestica Llame al (TTY 711)

Chinese ndash 㲐シ烉⤪㝄ぐἧ䓐橼㔯炻ぐẍ屣䌚婆妨≑㚵⊁ˤ婳农暣 (TTY 711)ˤ

Vietnamese ndash CHUacute Yacute NӃu bҥn noacutei TiӃng ViӋt coacute caacutec dӏch vө hӛ trӧ ngocircn ngӳ miӉn phiacute dagravenh cho bҥn Gӑi sӕ (TTY 711)

French Creole ndash ATANSYON Si w pale Kreyogravel Ayisyen gen segravevis egraved pou lang ki disponib gratis pou ou Rele (TTY 711)

Korean ndash 㨰㢌aG䚐ạ㛨⪰G㟝䚌㐐G㟤SG㛬㛨G㫴㠄G⪰Gⱨ⨀⦐G㢨㟝䚌㐘GG㢼UGG (TTY 711)ⶼ㡰⦐G㤸䞈䚨G㨰㐡㐐㝘U

Polish ndash UWAGA JeĪeli moacutewisz po polsku moĪesz skorzystauuml z bezpaacuteatnej pomocy jĊzykowej ZadzwoĔ pod numer (TTY 711)

French ndash ATTENTION Si vous parlez franccedilais des services daide linguistique vous sont proposeacutes gratuitement Appelez le (ATS 711)

Arabic ndash ϡϗέΑϝλΗϥΎΟϣϟΎΑϙϟέϓϭΗΗΔϳϭϐϠϟΓΩϋΎγϣϟΕΎϣΩΧϥΈϓˬΔϳΑέόϟΔϐϠϟΙΩΣΗΗΕϧϛΫΔυϭΣϠϣ 711TTY

Russian ndash ȼɇɂɆȺɇɂȿ ȿɫɥɢ ɜɵ ɝɨɜɨɪɢɬɟ ɧɚ ɪɭɫɫɤɨɦ ɹɡɵɤɟ ɬɨ ɜɚɦ ɞɨɫɬɭɩɧɵ ɛɟɫɩɥɚɬɧɵɟ ɭɫɥɭɝɢ ɩɟɪɟɜɨɞɚ Ɂɜɨɧɢɬɟ (ɬɟɥɟɬɚɣɩ 711)

Tagalog ndash PAUNAWA Kung nagsasalita ka ng Tagalog maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad Tumawag sa (TTY 711)

FarsiPersian ndash ΩηΎΑϣϡϫέϓΎϣηέΑϥΎϳέΕέϭλΑϧΎΑίΕϼϳϬγΗˬΩϳϧϣϭΗϔγέΎϓϥΎΑίϪΑέϪΟϭΗ ΩϳέϳΑαΎϣΗ(711 TTY) ΎΑ

German ndash ACHTUNG Wenn Sie Deutsch sprechen stehen Ihnen kostenlos sprachliche

deg

Hilfsdienstleistungen zur Verfuumlgung Rufnummer (TTY 711)

Portuguese ndash ATENCcedilAtildeO Se fala portuguecircs encontram-se disponiacuteveis serviccedilos linguiacutesticos graacutetis Ligue para (TTY 711)

Italian ndash ATTENZIONE In caso la lingua parlata sia litaliano sono disponibili servizi di assistenza linguistica gratuiti Chiamare il numero (TTY 711)

Japanese ndash ὀព㡯㸸ᮏㄒヰࡉሙࠊdarrᩱࡢゝㄒᨭࡈ⏝ࠋࡍࡅࡔࡓ (TTY 711)ࠊ㟁ヰࡈ㐃⤡ࠋࡉࡔࡃ

Navajo ndashMLLLVYYeTY^LLOMPPdYF_TRZTYl-TeLLO^LLOMPPVYOLbZO _UTTVPSYSW(VZUSOWYTS (TTY 711)

Gujarati ndash ƚ]hW8XsKsSpȤK^hSjZs_ShesSsiWɃƣD[hchdeh]d X_ƞVJk k pahBSh^hhN p

YsWD^s (TTY 711)

ΑϥΎΑίϭΩέέϳΩΟϭΗΗϟϭΑίفϟفϭΗϳفΕΎϣΩΧϥϭΎόϣϥΎϳέϝΎلϳΏΎϳΗγΩϳϣΕϔϣ Urdu (TTY 711)

Y0036_17_50169 ACCEPTED B0$3B10

This formulary w ation or other questions please contact Cigna Customer Service at 1-800-668-3 h 31 8 am ndash 8 pm local time 7 days a week From April 1 ndash September 30 ing service used weekends after hours and on federal holidays or visit CignaM rovided exclusively by or through operating subsidiaries of Cigna Corporation Th wned by Cigna Intellectual Property Inc copy 2021 CignaOctober 2021 952846 a

CignaMedicarecom

1-800-668-3813 (TTY 711) October 1 ndash March 31 800 am ndash 80time 7 days a week From April 1 ndash SeMonday ndash Friday 800 am ndash 800 pmMessaging service used weekends aftand on federal holidays

0 pm lptembe local tier hour

as updated on 10012021 For more recent inform813 (TTY users should call 711) October 1 ndash MarcMonday ndash Friday 8 am ndash 8 pm local time Messagedicarecom All Cigna products and services are pe Cigna name logos and other Cigna marks are o

ocal r 30 me s

Structure Bookmarks
- Cigna Alliance MedicaCigna Preferred GA MCigna Preferred MedicCigna Preferred Plus
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- 73
- 74
- 75
- 76
- 77
- 78
- 79
- 80
- 81
- 82
- 83
- 84
- 85
- 86
- 87
- 88
- 89
- 90
- 91
- 92
- 93
- 94
- 95
- 96
- 97
- 98
- 99
- 100
- 101
- 102
- 103
- 104
- 105
- 106
- Notice of Nondiscrimination DiscrimiCigna complies with applicable Federal cage disability or sex Cigna does not exdisability or sex Cigna bull Provides free aids and services to peominus Qualified sign language interpreters minus Written information in other formats (bull Provides free language services to peominus Qualified interpreters minus Information written in other languageIf you need these services contact CustIf you believe that Cigna has failed to pronational origin age disability or sex you
- 711)
- 1-800-668-3813 (TTY 711) October 1 ndash March 31 800 am ndash 80time 7 days a week From April 1 ndash SeMonday ndash Friday 800 am ndash 800 pmMessaging service used weekends aftand on federal holidays

Page 2: 2022 CIGNA COMPREHENSIVE DRUG LIST (Formulary)