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Your Prescription Drug List/Formulary

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1 2021 Your Prescription Drug List/Formulary Effective July 1, 2021 For a complete list of covered drugs or if you have questions: Call a customer care representative toll-free at (855) 828-9834 (TTY 711). Visit www.HealthSelectRx.com Locate an OptumRx in-network pharmacy Look up possible lower-cost medication alternatives Compare medication pricing and options Please read: This document contains information about the drugs covered under your pharmacy benefit plan. HealthSelect SM of Texas
Transcript
Page 1: Your Prescription Drug List/Formulary

1

2021

Your Prescription Drug ListFormulary

Effective July 1 2021

For a complete list of covered drugs or if you have questions

bull Call a customer care representative toll-free at (855) 828-9834 (TTY 711)

bull Visit wwwHealthSelectRxcom

mdash Locate an OptumRx in-network pharmacy

mdash Look up possible lower-cost medication alternatives

mdash Compare medication pricing and options

Please read This document contains information about the drugs covered under your pharmacy benefit plan

HealthSelectSM

of Te

xas

2

Your Prescription Drug List Formulary

This formulary outlines the most commonly prescribed medications covered under your planrsquos prescription drug benefits The formulary is also known as the Prescription Drug List (PDL) A formulary identifies the drugs available for certain conditions and organizes them into cost levels also known as tiers An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you

Go to wwwHealthSelectRxcom for complete and up-to-date drug information

Since the formulary may change we encourage you to visit our website wwwHealthSelectRxcom and click on Prescription Drug List This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers possible lower-cost options and cost comparisons

3

Understanding your Prescription Drug ListformularyWhat is a formulary

This document is a list of prescription medications covered by your plan for their safety cost and effectiveness Medications are listed by categories or class and are placed into cost levels known as tiers It includes both brand and generic prescription medications approved by the US Food and Drug Administration (FDA)

Where differences exist between this formulary and your benefit plan documents the benefit plan documents will rule This may not be a complete list of medications and not all medications listed may be covered under your plan Please look at the Master Benefit Plan Document (MBPD) provided by your plan for full details

How do I use my formulary

You and your doctor can consult the formulary to help you select the most cost-effective prescription medications This guide tells you if a medication is generic or brand and if special rules apply Bring this list with you when you see your doctor It is organized by common medical conditions Medications are then listed alphabetically

If your medication is not listed on this document it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program Please visit wwwHealthSelectRxcom and click on Prescription Drug List for the most up to date list of medications covered under your plan If you have any questions call a customer care representative toll-free at (855) 828-9834 (TTY 711)

What are tiers

Tiers are the different cost levels you pay for a medication Each tier is assigned a cost which is determined by your plan This is how much you will pay when you fill a prescription The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met Tier 1 medications are your lowest-cost options If your medication is placed in Tier 2 or 3 look to see if there is a Tier 1 option available Discuss these options with your doctor

4

When does the formulary change

bull Medications may move to a lower tier at any time

bull Medications may move to a higher tier when its generic becomes available

bull Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year

When a medication changes tiers you may have to pay a different amount for that medication

For the most up-to-date list call a customer care representative 24 hours a day 7 days a week toll-free at (855) 828-9834 (TTY 711)

Why are some medications excluded from coverage

A medication may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective

What if I donrsquot agree with a decision about an excluded medication

You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711)

5

Medication Tips What is the difference between brand-name and generic medications

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications but they often cost less Once the patent of a brand-name medication ends the FDA can approve a generic version with the same active ingredients

What if my doctor writes a brand-name prescription

If your doctor gives you a prescription for a brand-name medication ask if a generic equivalent or lower-cost option is available and if it might be right for you Generic medications are usually your lowest-cost option but not always

An OTC medication may be the right treatment option for some conditions Talk to your doctor about available OTC options Even though these medications may not be covered under your pharmacy benefit they may cost less than prescription medications covered under your prescription drug plan

What if I am taking a specialty medication

Specialty medications treat rare or complex conditions and are typically higher cost medications Please note not all specialty medications are listed in the Formulary Optum Specialty Pharmacy can provide most of your specialty medications along with helpful programs and services Call Optum Specialty Pharmacy at (855) 427-4682 and have your prescriptions delivered right to your home or doctorrsquos office

6

Reading your formularyThe formulary give your choices so you and your doctor can determine your best course of treatment In this formulary brand-name medications are shown in UPPERCASE (for example CLOBEX) and generic medications in lowercase (for example clobetasol)

Tier information

Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost Your prescription drug plan has multiple tiers Please note If you have a high deductible plan the tier cost levels will apply once you hit your deductible

Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost commonly used generic drugs Some low-cost brands may be included

Use Tier 1 drugs for the lowest out-of-pocket costs

Tier 2 Mid-range Cost

Many common brand-name drugs called preferred brands

Use Tier 2 drugs instead of Tier 3 to help reduce your out-of-pocket costs

Tier 3 Highest Cost

Mostly higher-cost brand drugs also known as non-preferred brands

Many Tier 3 drugs have lower-cost options in Tier 1 or 2 Ask your doctor if they could work for you

Tier E Excluded May be excluded from coverage or subject to prior authorization Lower-cost options are available and covered

Drug list information

In this drug list some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits Your benefit plan determines how these medications may be covered for you

PA Prior Authorization ndash Your doctor is required to provide additional information before the drug will be covered by your prescription drug plan

ST Step Therapy ndash Requires you to first try a cost-effective medication before the more expensive medication will be covered

QL Quantity Limit ndash Limits the amount of a medication that will be covered under your prescription drug plan

SP Specialty Medication ndash Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused are high cost have special delivery and storage requirements or require close monitoring or care coordination with your doctor

E Excluded ndash Drugs that are not covered by your health plan Lower-cost options are available and covered

Table of Contents

Analgesics - Drugs for Pain9Analgesics - Drugs for Pain and Inflammation 14Anesthetics17Anti-Addiction Substance Abuse Treatment Agents 20Antibacterials21Anticoagulants26Anticonvulsants - Drugs for Seizures 27Antidementia Agents - Drugs for Alzheimers Disease and Dementia 29Antidepressants29Antiemetics - Drugs for Nausea and Vomiting 30Antifungals31Antigout Agents 34Anti-inflammatory Agents 34Antimigraine Agents 34Antimyasthenic Agents35Antimycobacterials 35Antineoplastics - Drugs for Cancer35Antiparasitics 41Antiparkinson Agents 42Antiplatelets43Antipsychotics - Drugs for Mood Disorders 43Antivirals44Anxiolytics - Drugs for Anxiety47Bipolar Agents - Drugs for Mood Disorders47Blood Products and Modifiers - Drugs for Blood Disorders48Cardiovascular Agents - Drugs for Heart and Circulation Conditions 50Central Nervous System Agents - Drugs for Attention Deficit Disorder 56Central Nervous System Agents - Drugs for Multiple Sclerosis 57Central Nervous System Agents - Miscellaneous 58Dental and Oral Agents - Drugs for Mouth and Throat Conditions59Dermatological Agents - Drugs for Skin Conditions 60Diabetes - Antidiabetic Agents 72Diabetes - Glucose Monitoring 73Diabetes - Glycemic Agents 75Diabetes - Insulins75Electrolytes Minerals Metals Vitamins77Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer85Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions86Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment 91Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions92Genitourinary Agents - Drugs for Prostate Conditions 94Hormonal Agents - Adrenal 94Hormonal Agents - Mens Health96Hormonal Agents - Osteoporosis 97Hormonal Agents - Pituitary 97Hormonal Agents - Prostaglandins99Hormonal Agents - Sex Hormones and Birth Control99Hormonal Agents - Thyroid 104Immunological Agents - Drugs for Immune System Stimulation or Suppression 105Immunological Agents - Drugs for Vaccination 108Inflammatory Bowel Disease Agents110

7

Metabolic Bone Disease Agents - Drugs for Osteoporosis 111Metabolic Bone Disease Agents - Other 112Miscellaneous Therapeutic Agents 112Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation120Ophthalmic Agents - Drugs for Glaucoma122Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions 123Otic Agents - Drugs for Ear Conditions 126Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold126Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions 130Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis 133Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension 133Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm 134Sleep Disorder Agents 134

8

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

8 hour pain reliever E

8 hr arthritis pain relief E

acetaminophen 8 hour oral tablet extended release

E

acetaminophen childrens oral solution

E

acetaminophen childrens oral suspension 160 mg5ml

E

acetaminophen childrens oral tablet chewable 160 mg

E

acetaminophen er E

acetaminophen extra strength oral tablet

E

acetaminophen oral solution 160 mg5ml 325 mg1015ml 650 mg203ml

E

acetaminophen oral suspension 160 mg5ml

E

acetaminophen oral tablet

E

acetaminophen oral tablet chewable 160 mg

E

acetaminophen rectal suppository 120 mg 650 mg

E

acetaminophen-codeine

1 QL

acetaminophen-codeine 2

1 QL

acetaminophen-codeine 3

1 QL

acetaminophen-codeine 4

1 QL

ACTIQ 3 PA QL

ALLZITAL E

APADAZ E

Drug Name Drug Tier Notes

apap-caff-dihydrocodeine oral capsule

1 QL

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

1 QL

arthritis pain reliever oral

E

ascomp-codeine 1

aurophen childrens E

bac 1

BELBUCA 2 PA QL

BENZHYDROCODONE-ACETAMINOPHEN

E

BUPAP ORAL TABLET 50-300 MG

3

BUPRENEX E

buprenorphine hcl injection solution 03 mgml

E

buprenorphine transdermal

1 PA QL

butalbital-acetaminophen capsule 50-300 mg oral

1

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

E

butalbital-acetaminophen oral tablet

1

butalbital-apap-caff-cod 1

butalbital-apap-caffeine oral capsule

1

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

1

butalbital-asa-caff-codeine

1

butalbital-aspirin-caffeine

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

9

Drug Name Drug Tier Notes

butorphanol tartrate injection

E

butorphanol tartrate nasal

1 QL

BUTRANS 3 PA QL

carisoprodol-aspirin-codeine

1

codeine sulfate oral tablet

1 QL

CONZIP E

cvs acetaminophen ex st oral tablet

E

DEMEROL INJECTION SOLUTION 50 MGML

E

DILAUDID ORAL E

DSUVIA E

DURAGESIC-100 E

DURAGESIC-12 E

DURAGESIC-25 E

DURAGESIC-50 E

DURAGESIC-75 E

duramorph E

endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 QL

ESGIC 3

fentanyl 1 PA QL

fentanyl citrate (pf) E

fentanyl citrate buccal lozenge on a handle

1 PA QL

FENTANYL CITRATE BUCCAL TABLET

E

FENTANYL CITRATE SOLUTION PREFILLED SYRINGE 100 MCG2ML INTRAVENOUS

E

FENTANYL CITRATE-NACL INJECTION

E

Drug Name Drug Tier Notes

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 125-09 MG250ML-

E

FENTANYL CITRATE-NACL SOLUTION 1-09 MG100ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION 25-09 MG250ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION 2-09 MG100ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION PREFILLED SYRINGE 500-09 MCG50ML- INTRAVENOUS

E

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 08-01667-09 MG200ML-

E

FENTANYL-BUPIVACAINE-NACL INJECTION

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 02-01-09 MG100ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 02-0125-09 MG100ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-00625-09 MG250ML- EPIDURAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

10

Drug Name Drug Tier Notes

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-01-09 MG250ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-0125-09 MG250ML- EPIDURAL

E

FENTORA BUCCAL TABLET 100 MCG 200 MCG 400 MCG 600 MCG 800 MCG

E

FIORICET ORAL CAPSULE

3

FIORICETCODEINE ORAL CAPSULE 50-300-40-30 MG

3

goodsense pain relief oral tablet

E

headache relief oral E

hydrocodone bitartrate er oral capsule extended release 12 hour

1 PA ST QL

hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent

1 PA QL

hydrocodone-acetaminophen oral solution 10-325 mg15ml 75-325 mg15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg

1 QL

hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg

1 QL

Drug Name Drug Tier Notes

hydromorphone hcl er oral tablet extended release 24 hour

1 PA QL

hydromorphone hcl injection solution 2 mgml

E

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal

E

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 25-09 MG50ML- 50-09 MG50ML-

E

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-09 MG50ML- 15-09 MG30ML-

E

HYSINGLA ER 2 PA QL

INFUMORPH 200 E

INFUMORPH 500 E

LAZANDA NASAL SOLUTION 100 MCGACT 400 MCGACT

E

levorphanol tartrate oral E

liquid acetaminophen E

LORTAB ORAL ELIXIR 10-300 MG15ML

3 QL

meperidine hcl injection solution 50 mgml

E

meperidine hcl oral solution

1 QL

meperidine hcl oral tablet 50 mg

1 QL

methadone hcl injection E

methadone hcl intensol 1

methadone hcl oral concentrate

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

11

Drug Name Drug Tier Notes

methadone hcl oral solution

1

methadone hcl oral tablet

1 PA

methadone hcl oral tablet soluble

1

methadose oral concentrate 10 mgml

1

methadose oral tablet soluble

1

methadose sugar-free 1

migraine relief E

mitigo E

morphine sulfate (concentrate) oral solution 100 mg5ml 20 mgml

1 QL

morphine sulfate (pf) injection

E

morphine sulfate (pf) intravenous solution 10 mgml 2 mgml 4 mgml 8 mgml

E

morphine sulfate er beads

1 PA QL

morphine sulfate er oral capsule extended release 24 hour

1 PA QL

morphine sulfate er oral tablet extended release

1 PA QL

MORPHINE SULFATE INJECTION SOLUTION 1 MGML

E

morphine sulfate injection solution 2 mgml 4 mgml

E

MORPHINE SULFATE INTRAVENOUS SOLUTION 05 MGML

E

morphine sulfate intravenous solution 50 mgml

E

morphine sulfate oral 1 QL

Drug Name Drug Tier Notes

morphine sulfate rectal E

MORPHINE SULFATE SOLUTION 1 MGML INTRAVENOUS

E

morphine sulfate solution 1 mgml intravenous

E

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-09 MG50ML-

E

m-pap E

MS CONTIN ORAL TABLET EXTENDED RELEASE

E

nalbuphine hcl injection solution 20 mgml

1

NALOCET E

NUCYNTA E

NUCYNTA ER E

OXAYDO ORAL TABLET

E

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG 30 MG 60 MG 80 MG

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG ORAL

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20 MG ORAL

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 40 MG ORAL

E

oxycodone hcl oral capsule

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

12

Drug Name Drug Tier Notes

oxycodone hcl oral concentrate 100 mg5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet

1 QL

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 10-300 MG5ML

E

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG 25-300 MG 5-300 MG

E

oxycodone-acetaminophen oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 QL

oxycodone-aspirin oral tablet 48355-325 mg

1 QL

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT

2 PA QL

oxymorphone hcl 1 QL

oxymorphone hcl er 1 PA QL

pain amp fever childrens oral suspension

E

pain amp fever infants E

pain relief childrens oral elixir

E

pain relief extra strength oral capsule 500 mg

E

pain relief extra strength oral tablet 500 mg

E

pain relief oral liquid E

pain relief regular strength

E

Drug Name Drug Tier Notes

pain reliever extra strength oral tablet 250-250-65 mg

E

PANADOL CHILDRENS

E

PANADOL EXTRA E

PANADOL EXTRA STRENGTH

E

PANADOL INFANTS E

pentazocine-naloxone hcl

1 QL

PERCOCET ORAL TABLET 10-325 MG 25-325 MG 5-325 MG 75-325 MG

E

PRIALT 2 SP

PROBUPHINE IMPLANT KIT

E

PROLATE E

QDOLO E

ROXICODONE ORAL TABLET

E

SUBSYS E

SYNAPRYN FUSEPAQ E

TENCON ORAL TABLET 50-325 MG

E

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

1 PA ST QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG 200 MG 300 MG

E

tramadol hcl er oral tablet extended release 24 hour

1 PA QL

tramadol hcl ir 1 QL

tramadol-acetaminophen

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

13

Drug Name Drug Tier Notes

TREZIX ORAL CAPSULE 3205-30-16 MG

3 QL

TYLENOL 8 HOUR E

TYLENOL EXTRA STRENGTH ORAL TABLET

E

TYLENOL INFANTS PAIN+FEVER

E

TYLENOL ORAL TABLET

E

ULTRACET E

ULTRAM E

VTOL LQ E

XTAMPZA ER 2 PA QL

ZEBUTAL ORAL CAPSULE 50-325-40 MG

3

ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR

E

Analgesics - Drugs for Pain and Inflammation

adult aspirin regimen $0

ADVIL E

ADVIL JUNIOR STRENGTH

E

ADVIL LIQUI-GELS MINIS

E

ADVIL MIGRAINE E

aif 2 drug preparation kit

E

AIF 3 DRUG PREPARATION KIT

E

ALEVE ORAL TABLET E

ARTHROTEC ORAL TABLET DELAYED RELEASE

E

aspirin adult low strength oral tablet delayed release

$0

Drug Name Drug Tier Notes

aspirin childrens $0

aspirin ec low dose $0

aspirin ec low strength $0

aspirin ec oral tablet delayed release 325 mg

$0

aspirin low dose oral tablet chewable

$0

aspirin low dose oral tablet delayed release

$0

aspirin oral tablet 325 mg

$0

aspirin oral tablet delayed release 325 mg 81 mg

$0

aspirin rectal suppository 300 mg 600 mg

E

BAYER ASPIRIN EC LOW DOSE

$0

BAYER ASPIRIN ORAL TABLET

$0

BAYER ASPIRIN ORAL TABLET DELAYED RELEASE

$0

BIIFENAC 1000 E

BIIFENAC 500 E

CALDOLOR INTRAVENOUS SOLUTION 800 MG200ML 800 MG8ML

E

CAMBIA E

CAPSFENAC PAK E

CAPSINAC E

CATAFLAM 3

CELEBREX E

celecoxib oral 1 QL

DAYPRO 3

DERMACINRX LEXITRAL PHARMAPAK

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

14

Drug Name Drug Tier Notes

DFS DRMSMENTHCAP PAK

E

DFSMSMENTHCAP PAK

E

DICLOFENAC CAP 35MG

E

DICLOFENAC PATCH EXTERNAL

E

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium external gel 1

1 QL

diclofenac sodium external solution

1 PA

diclofenac sodium oral 1

diclofenac-misoprostol oral tablet delayed release

1

DICLOFONO GEL 16 EXTERNAL

3

DICLOFONO GEL 16 EXTERNAL

E

DICLOPR E

DICLOSTREAM E

DICLOTREX E

DICLOVIX E

DICLOVIX M E

DICLOZOR EXTERNAL

E

diflunisal oral 1

DIMENTHO E

DUAL COMPLEX FORMULA 1 KIT

E

DUEXIS E

EC-NAPROSYN 3

ec-naproxen 1

ENOVARX-DICLOFENAC SODIUM EXTERNAL

E

enovarx-ibuprofen E

Drug Name Drug Tier Notes

enovarx-naproxen external

E

etodolac er 1

etodolac oral 1

FBL KIT E

FELDENE 3

fenoprofen calcium oral E

fenortho oral capsule 200 mg

E

FLECTOR EXTERNAL E

FLEXIPAK E

flurbiprofen oral 1

FROTEK E

GABAPENTIN-NAPROXEN CMPD KIT

E

goodsense aspirin low dose

$0

goodsense ibuprofen oral capsule

E

IBUPAK E

ibuprofen 1

ibuprofen infants E

ibuprofen oral capsule E

ibuprofen oral suspension

1

ibuprofen oral tablet 200 mg

E

inavix E

INDOCIN ORAL 3 ST

INDOCIN RECTAL E

indomethacin er 1

INDOMETHACIN ORAL CAPSULE 20 MG

E

indomethacin oral capsule 25 mg 50 mg

1 ST

INFLAMMACIN E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

15

Drug Name Drug Tier Notes

INFLATHERM COMBINATION THERAPY PACK

E

KBGL IN TERODERM

E

kapzin dc E

KETOPHENE RAPIDPAQ

E

ketoprofen er 1

ketoprofen oral 1

KETOROLAC TROMETHAMINE EXTERNAL

E

ketorolac tromethamine injection solution 15 mgml

1

ketorolac tromethamine intramuscular solution 60 mg2ml

1

KETOROLAC TROMETHAMINE NASAL

3 PA QL

ketorolac tromethamine oral

1 QL

ketorolac tromethamine solution 30 mgml injection

1

KETOROLAC TROMETHAMINE SOLUTION 30 MGML INJECTION

3

LICART EXTERNAL E

LODINE 3

meclofenamate sodium oral

1

mefenamic acid oral E

meloxicam oral capsule 1

meloxicam oral tablet 1

MOBIC ORAL TABLET E

MOTRIN IB ORAL CAPSULE

E

Drug Name Drug Tier Notes

MOTRIN INFANTS DROPS

E

nabumetone oral 1

NALFON ORAL CAPSULE 400 MG

3

NALFON ORAL TABLET

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG 500 MG

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

NAPROSYN ORAL SUSPENSION

3

NAPROSYN ORAL TABLET 500 MG

3

naproxen oral suspension

E

naproxen oral tablet 1

naproxen oral tablet delayed release

1

naproxen sodium er oral tablet extended release 24 hour 375 mg 500 mg

E

NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

naproxen sodium oral tablet 220 mg

E

naproxen sodium oral tablet 275 mg 550 mg

1

naproxen-esomeprazole

1 PA QL

NP 2 DRUG PREPARATION KIT

E

NUDICLO SOLUPAK E

NUDICLO TABPAK E

NUDROXIPAK E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

16

Drug Name Drug Tier Notes

NUDROXIPAK DSDR-50

E

NUDROXIPAK DSDR-75

E

NUDROXIPAK E-400 E

NUDROXIPAK I-800 E

NUDROXIPAK M-15 E

NUDROXIPAK N-500 E

ORMECA E

oxaprozin 1

PENNSAID EXTERNAL

E

piroxicam oral 1

PRASTERA E

PREVIDOLRX ANALGESIC

E

previdolrx plus analgesic

E

QMIIZ ODT E

RELAFEN E

RELAFEN DS E

salsalate oral E

SPRIX 3 PA QL

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE

$0

sulindac oral 1

sure result dss premium pack

E

TIVORBEX ORAL CAPSULE 20 MG

E

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet 600 mg

1

TORONOVA II SUIK E

TORONOVA SUIK E

tri-buffered aspirin oral tablet 325 mg

E

Drug Name Drug Tier Notes

TRIPLE COMPLEX FORMULA 3 KIT

E

VAROPHEN E

VENNGEL ONE E

VIMOVO E

VIVLODEX 3 ST

VOLTAREN EXTERNAL

E

VP FC KIT E

VP GKL KIT E

XRYLIX EXTERNAL E

ZIPSOR E

ZORVOLEX E

Anesthetics

1ST MEDX-PATCH LIDOCAINE EXTERNAL PATCH 4-00375-5-20

E

7T LIDO E

ACCUCAINE E

ACTIVE INJECTION LM-2

E

AGONEAZE E

ANODYNE LPT E

APRIZIO PAK E

APRIZIO PAK II E

ASTERO E

BENZO-LIDOCAINE-TETRACAINE

E

blue tube aloe E

bupivacaine fisiopharma

E

bupivacaine hcl (pf) E

BUPIVACAINE HCL INJECTION SOLUTION 0125

E

bupivacaine hcl injection solution 025 05

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

17

Drug Name Drug Tier Notes

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0125 (50 ML)

E

CADIRAMD E

CAPSAICIN-MENTHOL

E

CETACAINE EXTERNAL AEROSOL

E

COCAINE HCL NASAL E

DERMACINRX EMPRICAINE

E

DERMACINRX PHN E

DERMACINRX PRIZOPAK

E

DERMACINRX ZRM E

DERMALID E

EHA E

EMPRICAINE-II E

enovarx-lidocaine hcl E

ENZNONUTY E

ethyl chloride 1

EXPAREL E

FLEXIN E

GEBAUERS PAIN EASE

3

GEBAUERS SPRAY AND STRETCH

3

GEN7T E

GEN7T PLUS E

glydo external prefilled syringe

1

GOPRELTO E

LDO PLUS E

lets E

LEVATIO E

LIDO BDK E

lidocaine external cream 4

E

Drug Name Drug Tier Notes

lidocaine external patch 5

1

lidocaine hcl (pf) injection solution

1

lidocaine hcl external cream 3

E

LIDOCAINE HCL EXTERNAL CREAM 412

E

lidocaine hcl external lotion

E

lidocaine hcl external solution

1

lidocaine hcl injection solution 05

1

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MGML 100 MG10ML 100 MG5ML 200 MG10ML 60 MG3ML

E

LIDOCAINE HCL INTRADERMAL

E

LIDOCAINE HCL SOLUTION 1 INJECTION

3

lidocaine hcl solution 1 injection

1

LIDOCAINE HCL SOLUTION 2 INJECTION

3

lidocaine hcl solution 2 injection

1

lidocaine hcl urethralmucosal

1

lidocaine ointment 5 external

1 QL

lidocaine ointment 5 external

E

lidocaine-prilocaine external cream

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

18

Drug Name Drug Tier Notes

lidocaine-prilocaine external kit

E

LIDOCAINE-TETRACAINE

E

LIDOCANNA E

LIDODERM E

LIDO-EPINEPHRINE-TETRACAINE SOLUTION 4-005-05 EXTERNAL

3

LIDO-EPINEPHRINE-TETRACAINE SOLUTION 4-005-05 EXTERNAL

E

LIDOMARK 25 E

LIDOPAC E

lidopin external cream 3

E

LIDOPIN EXTERNAL CREAM 325

E

LIDOPRIL EXTERNAL KIT

E

LIDOPRIL XR E

LIDO-PRILO CAINE PACK

E

LIDOPURE PATCH E

LIDORX E

LIDO-SORB E

LIDOSTREAM E

LIDOTHOL E

LIDOTRAL E

LIDOVIX L E

LIDTOPIC MAX E

LIVIXIL PAK E

LMR PLUS E

LYDEXA E

MARCAINE E

MARCAINE PRESERVATIVE FREE

E

Drug Name Drug Tier Notes

marlido E

MARLIDO-25 E

MARVONA SUIK E

NUMBRINO E

NUVAKAAN E

NUVAKAAN-II E

pain relieving + lidocaine

E

PAINGO KFT E

PLIAGLIS E

POINT OF CARE LM-22

E

POINT OF CARE LM-25

E

premium lidocaine E

PREMIUM SCAR E

PREPIV SUPPLY 3

PRILO PATCH E

PRILO PATCH II E

PRILOLID E

PRILOVIX E

PRILOVIX LITE E

PRILOVIX LITE PLUS E

PRILOVIX PLUS E

PRILOVIX ULTRALITE E

PRILOVIX ULTRALITE PLUS

E

PRILOVIXIL E

PRIZOPAK II E

PRIZOTRAL E

PRIZOTRAL-II E

READYSHARP-A E

RELADOR PAK EXTERNAL KIT

E

RELADOR PAK PLUS E

SENSORCAINE E

SENSORCAINE-MPF INJECTION SOLUTION 075

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

19

Drug Name Drug Tier Notes

sensorcaine-mpf solution 025 injection

E

SENSORCAINE-MPF SOLUTION 025 INJECTION

E

sensorcaine-mpf solution 05 injection

E

SENSORCAINE-MPF SOLUTION 05 INJECTION

E

SKYADERM-LP E

SOOTHEE EXTERNAL PATCH 05-00375-5-2

E

STERILE TOPICAL LET GEL

3

SX1 MEDICATED POST-OPERATIVE

E

SYNERA E

VENIPUNCTURE PX1 PHLEBOTOMY

3

VEXATROL E

WPR PLUS WOUND HEALING SYSTEM

E

XARACOLL E

XYLOCAINE INJECTION

3

XYLOCAINE-MPF INJECTION SOLUTION 05 1 15 2

3

ZERUVIA E

ZILACAINE PATCH E

ZINGO INTRADERMAL JET-INJECTOR

E

ZIONODIL E

ZIONODIL 100 E

ZTLIDO E

Drug Name Drug Tier Notes

Anti-Addiction Substance Abuse Treatment Agents

acamprosate calcium 1

BUNAVAIL BUCCAL FILM 42-07 MG 63-1 MG

3 QL

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl

1 QL

bupropion hcl er (smoking det)

$0 QL

CHANTIX $0 QL

CHANTIX CONTINUING MONTH PAK

$0 QL

CHANTIX STARTING MONTH PAK

$0 QL

disulfiram oral 1

goodsense nicotine mouththroat lozenge 4 mg

$0 QL

habitrol $0 QL

LIFEMS NALOXONE E

LUCEMYRA 3 ST QL

naloxone hcl injection solution 04 mgml 4 mg10ml

E

naloxone hcl injection solution cartridge

E

naloxone hcl injection solution prefilled syringe

E

naltrexone hcl oral 1

NALTREXONE SUBCUTANEOUS

E

NARCAN 2

NICORETTE MOUTHTHROAT GUM 2 MG

$0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

20

Drug Name Drug Tier Notes

nicotine polacrilex mouththroat

$0 QL

nicotine step 1 $0 QL

nicotine step 2 $0 QL

nicotine step 3 $0 QL

NICOTROL $0 QL

NICOTROL NS $0 QL

SUBLOCADE 3 SP

SUBOXONE SUBLINGUAL FILM

2 QL

VIVITROL 3 SP

ZUBSOLV 2 QL

Antibacterials

ACTICLATE E

AEMCOLO 3 PA

ALTABAX 3

amikacin sulfate injection solution 500 mg2ml

E

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1

amoxicillin oral tablet chewable 125 mg 250 mg

1

amoxicillin-potassium clavulanate er

1

amoxicillin-potassium clavulanate oral

1

ampicillin oral capsule 500 mg

1

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

E

ARIKAYCE 3 PA SP

AUGMENTIN ES-600 3

Drug Name Drug Tier Notes

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-3125 MG5ML 250-625 MG5ML

3

AUGMENTIN ORAL TABLET 500-125 MG

3

avidoxy 1 ST

AVIDOXY DK E

azithromycin oral packet

1

azithromycin oral suspension reconstituted

1

azithromycin oral tablet 250 mg 500 mg 600 mg

1

bacitracin external E

bacitracin zinc external E

BACTRIM 3

BACTRIM DS 3

BAXDELA INTRAVENOUS

E

BAXDELA ORAL 3

BENZALKONIUM CHLORIDE EXTERNAL SOLUTION

3

benzalkonium chloride external solution 50

1

BENZODOX E

BICILLIN L-A E

cefaclor 1

cefaclor er 1

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm 10 gm

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

21

Drug Name Drug Tier Notes

cefazolin sodium-dextrose intravenous solution 2-4 gm100ml-

E

cefdinir 1

cefepime hcl injection solution reconstituted 2 gm

E

cefixime 1

CEFOTAN E

cefotaxime sodium injection solution reconstituted 1 gm 2 gm

E

cefotetan disodium injection solution reconstituted 1 gm 2 gm

E

cefoxitin sodium injection

E

cefpodoxime proxetil 1

cefprozil 1

ceftazidime injection solution reconstituted 1 gm 2 gm 6 gm

E

ceftriaxone sodium injection solution reconstituted 1 gm 2 gm 250 mg 500 mg

1

cefuroxime axetil oral tablet

1

CENTANY 3

CENTANY AT E

cephalexin 1

chloramphenicol sod succinate

E

CIPRO ORAL SUSPENSION RECONSTITUTED

3

CIPRO ORAL TABLET 250 MG 500 MG

3

ciprofloxacin hcl oral 1

Drug Name Drug Tier Notes

clarithromycin er 1

clarithromycin oral 1

CLEOCIN ORAL 3

CLEOCIN VAGINAL CREAM

3

CLEOCIN VAGINAL SUPPOSITORY

2

clindamycin hcl oral 1

clindamycin palmitate hcl

1

clindamycin phosphate vaginal

1

CLINDESSE 3

colistimethate sodium (cba)

E

COLY-MYCIN M E

coremino E

CUBICIN E

CUBICIN RF E

daptomycin E

demeclocycline hcl oral 1

dicloxacillin sodium 1

DIFICID 3

DORYX MPC E

DORYX ORAL TABLET DELAYED RELEASE 200 MG 50 MG

3 ST

DORYX ORAL TABLET DELAYED RELEASE 80 MG

E

doxy 100 E

doxycycline hyclate intravenous

E

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg 50 mg

1

doxycycline hyclate oral tablet 150 mg 75 mg

1 ST

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

22

Drug Name Drug Tier Notes

doxycycline hyclate oral tablet 20 mg

E

doxycycline hyclate oral tablet delayed release 100 mg 75 mg

1

doxycycline hyclate oral tablet delayed release 150 mg 200 mg 50 mg

1 ST

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

E

doxycycline monohydrate oral capsule 100 mg 150 mg 75 mg

1 ST

doxycycline monohydrate oral capsule 50 mg

1

doxycycline monohydrate oral suspension reconstituted

1

doxycycline monohydrate oral tablet

1 ST

EES GRANULES 3

ertapenem sodium E

ERYPED 200 3

ERYPED 400 3

ERY-TAB 3

ERYTHROCIN STEARATE ORAL TABLET 250 MG

3

erythromycin base oral 1

erythromycin ethylsuccinate oral

1

erythromycin oral 1

FETROJA E

FIRST-METRONIDAZOLE ORAL SUSPENSION RECONSTITUTED 50 MGML

E

Drug Name Drug Tier Notes

FIRVANQ 3

FLAGYL ORAL CAPSULE

3

FLAGYL ORAL TABLET 500 MG

3

FORTAZ INJECTION SOLUTION RECONSTITUTED 1 GM

E

fosfomycin tromethamine

1

gentamicin sulfate external

1

HIPREX 3

imipenem-cilastatin intravenous solution reconstituted 250 mg

E

INVANZ INJECTION E

iodine tincture external tincture 2

1

KEFLEX ORAL CAPSULE 750 MG

3

levofloxacin oral 1

LINCOCIN E

lincomycin hcl injection E

linezolid in sodium chloride

E

linezolid intravenous solution 600 mg300ml

E

linezolid oral 1 QL

LUGOLS STRONG IODINE

3

MACROBID 3

MACRODANTIN 3

mafenide acetate external

1

meropenem intravenous solution reconstituted 500 mg

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

23

Drug Name Drug Tier Notes

MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM50ML 500 MG50ML

E

methenamine hippurate 1

methenamine mandelate oral

E

METRONIDAZOLE BENZO+SYRSPEND

E

metronidazole oral 1

metronidazole vaginal 1

MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3

minocycline hcl er oral tablet extended release 24 hour

E

minocycline hcl oral 1

MINOLIRA E

mondoxyne nl oral capsule 100 mg 75 mg

1 ST

MONUROL 3

MORGIDOX COMBINATION KIT 1 X 100 MG 2 X 100 MG

E

morgidox oral capsule 100 mg

1

moxifloxacin hcl in nacl E

moxifloxacin hcl oral 1

mupirocin calcium E

mupirocin external 1

nafcillin sodium injection solution reconstituted 1 gm

E

nafcillin sodium intravenous solution reconstituted 10 gm

E

neomycin sulfate oral 1

Drug Name Drug Tier Notes

neomycin-polymyxin b gu

E

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

nitrofurantoin oral suspension

1

NUTRIDOX E

NUVESSA E

NUZYRA ORAL TABLET 150 MG

3

ofloxacin oral tablet 300 mg 400 mg

1

oxacillin sodium injection solution reconstituted 1 gm

E

oxacillin sodium intravenous

E

paromomycin sulfate oral

1

penicillin g potassium injection solution reconstituted 5000000 unit

E

penicillin g procaine E

penicillin g sodium E

penicillin v potassium 1

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 5000000 UNIT

E

piperacillin sod-tazobactam so intravenous solution reconstituted 45 (4-05) gm

E

polymyxin b sulfate injection

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

24

Drug Name Drug Tier Notes

POLYSPORIN EXTERNAL OINTMENT 500-10000 UNITGM

E

PRIMSOL 3

RECARBRIO E

SCRUB CARE POVIDONE-IODINE

E

SEYSARA 3 ST

SILVADENE 3

silver nitrate external solution

E

silver sulfadiazine external

1

SIVEXTRO E

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG 115 MG 55 MG 65 MG 80 MG

3

SOLOSEC 3

ssd 1

streptomycin sulfate intramuscular

E

sulfadiazine oral 1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5ml

1

sulfamethoxazole-trimethoprim oral tablet

1

SULFAMYLON EXTERNAL CREAM

E

SULFAMYLON EXTERNAL PACKET

3

sulfatrim pediatric 1

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION RECONSTITUTED

3

Drug Name Drug Tier Notes

SUPRAX ORAL TABLET CHEWABLE

3

TARGADOX E

tazicef injection E

tazicef intravenous solution reconstituted 1 gm

E

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

E

tetracycline hcl oral 1

tigecycline E

tinidazole oral 1

trimethoprim oral 1

TYGACIL E

UNASYN INJECTION SOLUTION RECONSTITUTED 3 (2-1) GM

E

VANCOCIN 3

VANCOCIN HCL ORAL CAPSULE 125 MG

3

vancomycin hcl in nacl intravenous solution 1-09 gm200ml-

E

vancomycin hcl intravenous solution 1000 mg200ml 1250 mg250ml 1500 mg300ml 1750 mg350ml 2000 mg400ml 500 mg100ml 750 mg150ml

E

vancomycin hcl oral 1

VANCOMYCIN+SYRSPEND SF

E

vandazole 1

VIBRAMYCIN 3 ST

XENLETA INTRAVENOUS

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

25

Drug Name Drug Tier Notes

XENLETA ORAL 3

XEPI 3

XIFAXAN 3 PA

XIMINO 3

ZEMDRI E

ZITHROMAX ORAL PACKET

3

ZITHROMAX ORAL SUSPENSION RECONSTITUTED

3

ZITHROMAX ORAL TABLET 250 MG 500 MG

3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZYVOX INTRAVENOUS SOLUTION 200 MG100ML 600 MG300ML

E

ZYVOX ORAL 3 QL

Anticoagulants

ACD-A NOCLOT-50 3

ACTIVASE E

ANTICOAGULANT SODIUM CITRATE

3

ARIXTRA 3 SP QL

CATHFLO ACTIVASE E

ELIQUIS 2 QL

ELIQUIS DVTPE STARTER PACK ORAL TABLET THERAPY PACK

2 QL

enoxaparin sodium 1 SP QL

fondaparinux sodium 1 SP QL

Drug Name Drug Tier Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNITML 12500 UNIT05ML 15000 UNIT06ML 18000 UNT072ML 2500 UNIT02ML 5000 UNIT02ML 7500 UNIT03ML 95000 UNIT38ML

3 SP QL

heparin (porcine) in nacl intravenous solution 1000-09 ut500ml- 2000-09 unitl-

E

heparin sodium (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml

1

heparin sodium (porcine) injection solution prefilled syringe

E

heparin sodium (porcine) pf injection solution 5000 unit05ml

1

heparin sodium (porcine) pf injection solution 5000 unitml

E

jantoven 1

LOVENOX 3 SP QL

PRADAXA 2 QL

REGIOCIT E

SAVAYSA 3 QL

THROMBATE III 3 SP

TRICITRASOL 3

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

26

Drug Name Drug Tier Notes

Anticonvulsants - Drugs for Seizures

APTIOM 3

BANZEL 3 PA

BRIVIACT INTRAVENOUS

E

BRIVIACT ORAL 3 ST

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

CELONTIN 3

CEREBYX INJECTION SOLUTION 500 MG PE10ML

E

clobazam 1 PA

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE

3

DIACOMIT 3 PA SP

DIASTAT ACUDIAL 3 QL

DIASTAT PEDIATRIC 3 QL

diazepam rectal 1 QL

DILANTIN INFATABS E

DILANTIN ORAL CAPSULE 100 MG

E

DILANTIN ORAL CAPSULE 30 MG

3

DILANTIN ORAL SUSPENSION

E

divalproex sodium er oral tablet extended release 24 hour

1

divalproex sodium oral capsule delayed release sprinkle

1

divalproex sodium oral tablet delayed release

1

ELEPSIA XR E

Drug Name Drug Tier Notes

EPIDIOLEX 3 PA SP

epitol 1

ethosuximide oral 1

FANATREX FUSEPAQ E

felbamate 1

FELBATOL 3

FINTEPLA 3 PA SP

fosphenytoin sodium injection solution 500 mg pe10ml

E

FYCOMPA 3

gabapentin oral capsule

1

gabapentin oral solution 250 mg5ml

1

gabapentin oral tablet 1

GABITRIL 3

KEPPRA INTRAVENOUS

E

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL ODT ORAL KIT 21 X 25 MG amp 7 X 50 MG 42 X 50 MG amp 14X100 MG

2

LAMICTAL ODT ORAL KIT 25 amp 50 amp 100 MG

E

LAMICTAL ODT ORAL TABLET DISPERSIBLE

3

LAMICTAL ORAL TABLET

3

LAMICTAL ORAL TABLET CHEWABLE 25 MG 5 MG

3

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine er 1

lamotrigine oral kit 25 amp 50 amp 100 mg

1

lamotrigine oral tablet 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

27

Drug Name Drug Tier Notes

lamotrigine oral tablet chewable

1

lamotrigine oral tablet dispersible

1

lamotrigine starter kit-blue

1

lamotrigine starter kit-green

1

lamotrigine starter kit-orange

1

levetiracetam er 1

levetiracetam intravenous

E

levetiracetam oral 1

MYSOLINE 3

NAYZILAM 3 QL

NEURONTIN 3

ONFI ORAL SUSPENSION

3 PA

ONFI ORAL TABLET 10 MG 20 MG

3 PA

oxcarbazepine 1

OXTELLAR XR E

phenobarbital oral elixir 1

phenobarbital oral tablet

1

PHENYTEK 3

phenytoin infatabs 1

phenytoin oral suspension 125 mg5ml

1

phenytoin oral tablet chewable

1

phenytoin sodium extended

1

primidone oral 1

QUDEXY XR 3

roweepra oral tablet 500 mg

1

rufinamide 1 PA

Drug Name Drug Tier Notes

SABRIL ORAL PACKET

E SP

SABRIL ORAL TABLET

3 PA SP

SPRITAM E

subvenite 1

subvenite starter kit-blue

1

subvenite starter kit-green

1

subvenite starter kit-orange

1

SYMPAZAN 3 PA

TEGRETOL ORAL SUSPENSION

3

TEGRETOL ORAL TABLET

3

TEGRETOL-XR 3

tiagabine hcl 1

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 1

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3 ST

valproic acid oral capsule

1

valproic acid oral solution

1

VALTOCO 3 QL

vigabatrin 1 PA SP

vigadrone 1 PA SP

VIMPAT INTRAVENOUS

E

VIMPAT ORAL 3

XCOPRI 3 ST

ZARONTIN 3

ZONEGRAN 3

zonisamide oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

28

Drug Name Drug Tier Notes

Antidementia Agents - Drugs for Alzheimers Disease and Dementia

ARICEPT 3

donepezil hcl 1

EXELON TRANSDERMAL

3

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl er 1 QL

memantine hcl oral solution 2 mgml

1

memantine hcl oral tablet

1

NAMENDA ORAL TABLET

3

NAMENDA TITRATION PAK

3

NAMENDA XR 3 QL

NAMENDA XR TITRATION PACK

3 QL

NAMZARIC 2 QL

RAZADYNE ER 3

rivastigmine 1

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL 3

APLENZIN E

BRISDELLE 3 ST QL

bupropion hcl er (sr) 1 QL

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

1 QL

Drug Name Drug Tier Notes

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

E

bupropion hcl oral 1

CELEXA ORAL TABLET

3

chlordiazepoxide-amitriptyline

1

citalopram hydrobromide

1

clomipramine hcl oral 1

CYMBALTA E

desipramine hcl oral 1

DESVENLAFAXINE ER

3 ST QL

desvenlafaxine succinate er

1 QL

doxepin hcl oral capsule

1

doxepin hcl oral concentrate

1

DRIZALMA SPRINKLE 3 ST QL

duloxetine hcl oral 1 QL

EFFEXOR XR E

EMSAM 3 QL

escitalopram oxalate 1

FETZIMA 3 ST QL

FETZIMA TITRATION 3 ST QL

fluoxetine hcl (pmdd) oral tablet

1

fluoxetine hcl oral capsule

1

fluoxetine hcl oral capsule delayed release

1 QL

fluoxetine hcl oral solution

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

fluvoxamine maleate er 1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

29

Drug Name Drug Tier Notes

FORFIVO XL E

imipramine hcl oral 1

imipramine pamoate 1

LEXAPRO ORAL TABLET

E

maprotiline hcl 1

MARPLAN 3

mirtazapine oral 1

NARDIL 3

nefazodone hcl 1

NORPRAMIN ORAL TABLET 10 MG 25 MG

3

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl

1 QL

PAMELOR ORAL CAPSULE

3

PARNATE 3

paroxetine hcl er 1

paroxetine hcl oral tablet

1

paroxetine mesylate 1 QL

PAXIL CR 3

PAXIL ORAL SUSPENSION

2 ST

PAXIL ORAL TABLET 3

perphenazine-amitriptyline

1

PEXEVA E

phenelzine sulfate oral 1

PRISTIQ E

protriptyline hcl 1

PROZAC ORAL CAPSULE

E

REMERON ORAL TABLET 15 MG 30 MG

3

REMERON SOLTAB 3

sertraline hcl oral 1

Drug Name Drug Tier Notes

SPRAVATO (56 MG DOSE)

3 PA SP

SPRAVATO (84 MG DOSE)

3 PA SP

SYMBYAX ORAL CAPSULE 12-50 MG 3-25 MG 6-25 MG 6-50 MG

3 QL

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral

1

TRINTELLIX 3 ST QL

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD ORAL TABLET

3 QL

VIIBRYD STARTER PACK

3 QL

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

ZULRESSO 3 PA SP

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS

E

AKYNZEO ORAL 3 QL

ALOXI INTRAVENOUS SOLUTION 025 MG5ML

E

ANZEMET ORAL 3 QL

aprepitant 1 QL

BONJESTA 3 PA QL

compro 1

cvs motion sickness E

DICLEGIS 3 PA QL

doxylamine-pyridoxine 1 PA QL

dronabinol 1 PA QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

30

Drug Name Drug Tier Notes

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

E

EMEND ORAL CAPSULE 80 MG

3 QL

EMEND ORAL SUSPENSION RECONSTITUTED

3

EMEND TRI-PACK 3 QL

fosaprepitant dimeglumine

E

GIMOTI E

goodsense motion sickness

E

granisetron hcl intravenous solution 1 mgml 4 mg4ml

E

granisetron hcl oral 1 QL

MARINOL 3 PA QL

meclizine hcl oral tablet 1

meclizine hcl tablet chewable 25 mg oral (otc)

E

meclizine hcl tablet chewable 25 mg oral (rx)

1

metoclopramide hcl oral solution 10 mg10ml 5 mg5ml

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet dispersible

1

motion sickness relief E

ondansetron hcl injection solution 4 mg2ml 40 mg20ml

E

ondansetron hcl oral solution

1 QL

ondansetron hcl oral tablet 24 mg

1 QL

Drug Name Drug Tier Notes

ondansetron hcl oral tablet 4 mg 8 mg

1

ondansetron odt 1

palonosetron hcl E

perphenazine oral 1

prochlorperazine 1

prochlorperazine maleate oral

1

REGLAN ORAL 3

SANCUSO 3 QL

scopolamine 1

SUSTOL E

SYNDROS 3 PA QL

TIGAN INTRAMUSCULAR

E

TIGAN ORAL 3

TRANSDERM SCOP (15 MG)

3

TRANSDERM-SCOP (15 MG)

3

trimethobenzamide hcl oral

1

VARUBI (180 MG DOSE)

3 QL

ZOFRAN ORAL TABLET 4 MG

3

ZUPLENZ E

Antifungals

ALA-QUIN E

ALCORTIN A E

ALOE VESTA CLEAR ANTIFUNGAL

E

ANCOBON 3

athletes foot (terbinafine)

E

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 70 MG

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

31

Drug Name Drug Tier Notes

caspofungin acetate intravenous solution reconstituted 70 mg

E

ciclodan external solution

1

ciclopirox external 1

ciclopirox olamine external

1

ciclopirox treatment E

clotrimazole external cream

1

clotrimazole external solution

1

clotrimazole mouththroat troche

1

clotrimazole vaginal cream 1

E

clotrimazole-betamethasone

1

CRESEMBA ORAL 3

cvs clotrimazole 3 E

DERMACINRX THERAZOLE PAK

E

DESENEX EXTERNAL POWDER

E

DIFLUCAN 3

DIFMETIOXRIME E

ECONASIL E

econazole nitrate external

1

ECONAZOLE NITRATE-NIACINAMIDE

E

ECOZA E

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

E

ERTACZO E

EXELDERM E

Drug Name Drug Tier Notes

EXODERM EXTERNAL LOTION

3

EXTINA 3

fluconazole oral 1

FLUCON-IBUPROF-ITRACON-TERBINA

E

flucytosine oral 1

FUNGIMEZ E

griseofulvin microsize oral

1

griseofulvin ultramicrosize

1

GYNAZOLE-1 3

HIXDEFRIMA E

hydrocortisone-iodoquinol external cream 1-1

E

IMIOXIA E

IODOQUIMEZ-HC E

iodoquinol-hc-aloe polysacch

E

IODOQUINOL-HC-KETOCONAZOLE

E

iodoquinol-hydrocortisone-aloe

E

itraconazole oral 1 PA

JUBLIA E

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external foam

E

ketoconazole external shampoo 2

1

ketoconazole oral 1

KETOCONAZOLE-HYDROCORTISONE

E

ketodan external foam E

KETODAN EXTERNAL KIT

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

32

Drug Name Drug Tier Notes

LOPROX EXTERNAL CREAM

3

LOPROX EXTERNAL KIT

E

LOPROX EXTERNAL SHAMPOO

3

LOPROX EXTERNAL SUSPENSION

3

LOTRIMIN AF EXTERNAL POWDER

E

LULICONAZOLE E

LUZU E

MENTAX E

micaderm E

micafungin sodium intravenous solution reconstituted 100 mg

E

miconazole 1 E

miconazole 3 vaginal suppository

1

miconazole 7 E

miconazole nitrate external cream

E

MICONAZOLE-ZINC OXIDE-PETROLAT

E

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

E

MYCOZYL AP E

naftifine hcl 1

NAFTIN EXTERNAL GEL

3

NOXAFIL ORAL 3 PA

nyamyc 1

nystatin external 1

nystatin mouththroat 1

nystatin oral tablet 1

nystatin-triamcinolone 1

nystop 1

Drug Name Drug Tier Notes

ONYCHO-MED E

ORAVIG E

oxiconazole nitrate E

OXISTAT EXTERNAL CREAM

3

OXISTAT EXTERNAL LOTION

E

PEDIZOLPAK E

PHEODOYO E

PHEYO E

posaconazole 1 PA

QUINJA E

RECURA E

SPORANOX 3 PA

SPORANOX PULSEPAK

3 PA

SULCONAZOLE NITRATE

E

tavaborole 1 PA

terbinafine hcl oral 1 QL

terconazole 1

tolnaftate antifungal E

tolnaftate external powder

E

TOLSURA E

VFEND 3

voriconazole oral 1

VUSION E

VYTONE E

XOLEGEL E

XOLEGEL COREPAK E

XOLEGEL DUOHEAD amp SHOULDERS

E

XOLEGEL DUOXOLEX

E

ZEASORB-AF EXTERNAL POWDER

E

ZOLPAK E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

33

Drug Name Drug Tier Notes

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

E

colchicine oral tablet 1

colchicine-probenecid 1

COLCRYS E

febuxostat 1 ST

GLOPERBA E

KRYSTEXXA 3 PA SP

MITIGARE E

probenecid oral 1

ULORIC 3 ST

ZYLOPRIM 3

Anti-inflammatory Agents

EMFLAZA 3 PA SP

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MGML 70 MGML

2 PA QL

AJOVY E

almotriptan malate 1 QL

AMERGE 3 QL

CAFERGOT 3

DHE 45 3 PA QL

dihydroergotamine mesylate injection

1 PA QL

dihydroergotamine mesylate nasal

1 PA QL

eletriptan hydrobromide 1 QL

EMGALITY 2 PA QL

EMGALITY (300 MG DOSE)

2 PA QL

ERGOMAR 3

ergotamine-caffeine 1

FROVA 3 QL

Drug Name Drug Tier Notes

frovatriptan succinate 1 QL

IMITREX 3 QL

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE

3 QL

IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 QL

MAXALT ORAL TABLET 10 MG

3 QL

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG

3 QL

MIGERGOT 3

MIGRAINE PACK E

MIGRANAL 3 PA QL

MIGRANOW E

naratriptan hcl 1 QL

NURTEC 2 PA QL

ONZETRA XSAIL 3 ST QL

RELPAX 3 QL

REYVOW E

rizatriptan benzoate 1 QL

SUMANSETRON E

sumatriptan nasal 1 QL

sumatriptan succinate oral

1 QL

sumatriptan succinate refill subcutaneous solution cartridge

1 QL

sumatriptan succinate subcutaneous solution 6 mg05ml

1 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg05ml 6 mg05ml

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

34

Drug Name Drug Tier Notes

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg05ml

1 QL

sumatriptan-naproxen sodium

1 QL

TOSYMRA E

TREXIMET ORAL TABLET 85-500 MG

3 ST QL

UBRELVY 2 PA QL

VYEPTI E

ZEMBRACE SYMTOUCH

E

ZOLMITRIPTAN NASAL

3 ST QL

zolmitriptan oral 1 QL

ZOMIG NASAL 3 ST QL

ZOMIG ORAL E

ZOMIG ZMT E

Antimyasthenic Agents

GUANIDINE HCL ORAL

3

MESTINON ORAL SOLUTION

3

MESTINON ORAL TABLET

3

MESTINON ORAL TABLET EXTENDED RELEASE

3

NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 5 MG5ML INTRAVENOUS

E

pyridostigmine bromide er

1

pyridostigmine bromide oral solution

1

pyridostigmine bromide oral tablet

1

Drug Name Drug Tier Notes

Antimycobacterials

CAPASTAT SULFATE E

cycloserine oral 1

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL ORAL TABLET 400 MG

3

MYCOBUTIN 3

PASER 3

PRETOMANID 3

PRIFTIN 3

pyrazinamide oral 1

rifabutin 1

rifampin oral 1

RIFAMPIN+SYRSPEND SF

E

SIRTURO 3

TRECATOR 3

Antineoplastics - Drugs for Cancer

abiraterone acetate 1 PA SP

ABRAXANE 2 SP

ADCETRIS 2 PA SP

adriamycin intravenous solution

1 SP

adriamycin intravenous solution reconstituted 10 mg 50 mg

1 SP

AFINITOR DISPERZ 3 PA SP

AFINITOR ORAL TABLET 10 MG

2 PA SP QL

AFINITOR ORAL TABLET 25 MG 5 MG 75 MG

E SP

ALECENSA 2 PA SP

ALIMTA 2 SP

ALIQOPA 3 PA SP

ALKERAN 3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

35

Drug Name Drug Tier Notes

ALUNBRIG 2 PA SP QL

anastrozole oral $0

ARIMIDEX E

AROMASIN 3

ARRANON 2 SP

arsenic trioxide intravenous

1 SP

ARZERRA 2 PA SP

ASPARLAS 3 SP

AVASTIN 3 PA SP

AYVAKIT 3 PA SP QL

azacitidine 1 PA SP

BALVERSA 3 PA SP

BAVENCIO 3 PA SP

BELEODAQ 3 PA SP

BELRAPZO E SP

BENDEKA 3 PA SP

BESPONSA 3 PA SP

bexarotene 1 PA SP

bicalutamide 1

BICNU 3 SP

BLENREP 3 PA SP

bleomycin sulfate 1 SP

BLINCYTO 3 PA SP

BORTEZOMIB 3 PA SP

BOSULIF 3 PA SP

BRAFTOVI ORAL CAPSULE 75 MG

3 PA SP

BREYANZI E SP

BRUKINSA 3 PA SP

busulfan 1 SP

BUSULFEX 3 SP

CABOMETYX 2 PA SP

CALQUENCE 3 PA SP

CAMPATH 2 SP

CAMPTOSAR 3 SP

capecitabine 1 PA SP

Drug Name Drug Tier Notes

CAPRELSA ORAL TABLET 100 MG

2 PA SP QL

CAPRELSA ORAL TABLET 300 MG

2 PA SP

carboplatin intravenous solution

1 SP

carmustine 1 SP

CASODEX 3

cisplatin intravenous solution 100 mg100ml 200 mg200ml 50 mg50ml

1 SP

CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED

3 SP

cladribine intravenous solution 10 mg10ml

1 SP

clofarabine 1 SP

CLOLAR 3 SP

COMETRIQ ORAL KIT 20 MG 3 X 20 MG amp 80 MG 80 amp 20 MG

3 PA SP

COPIKTRA 3 PA SP

COSELA E SP

COSMEGEN 3 SP

COTELLIC 3 PA SP

cyclophosphamide injection

1 SP

CYCLOPHOSPHAMIDE INTRAVENOUS

3 SP

cyclophosphamide oral capsule

1

CYCLOPHOSPHAMIDE ORAL TABLET

2

CYRAMZA 3 PA SP

cytarabine (pf) 1 SP

cytarabine injection solution

1 SP

dacarbazine intravenous

1 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

36

Drug Name Drug Tier Notes

DACOGEN 3 PA SP

dactinomycin 1 SP

DANYELZA 3 PA SP

DARZALEX 3 PA SP

DARZALEX FASPRO E SP

daunorubicin hcl intravenous solution

1 SP

DAURISMO 3 PA SP

decitabine 1 PA SP

dexrazoxane hcl 1 SP

docetaxel intravenous concentrate 160 mg8ml 20 mgml 80 mg4ml

1 SP

docetaxel intravenous solution 160 mg16ml 20 mg2ml 80 mg8ml

1 SP

DOXIL 3 SP

doxorubicin hcl intravenous solution

1 SP

doxorubicin hcl liposomal

1 SP

DROXIA 3

ELITEK 3 SP

ELLENCE 3 SP

ELZONRIS 3 PA SP

EMCYT 2

EMPLICITI 3 PA SP

ENHERTU 3 PA SP

epirubicin hcl intravenous solution 200 mg100ml 50 mg25ml

1 SP

ERBITUX 2 PA SP

ERIVEDGE 2 PA SP

ERLEADA E SP

erlotinib hcl oral tablet 100 mg 150 mg

1 PA SP

erlotinib hcl oral tablet 25 mg

1 PA SP QL

Drug Name Drug Tier Notes

ERWINAZE INJECTION

3 SP

ETHYOL 3 SP

ETOPOPHOS 3 SP

etoposide intravenous solution 1 gm50ml 100 mg5ml 500 mg25ml

1 SP

etoposide oral 1 SP

everolimus oral tablet 25 mg 5 mg 75 mg

1 PA SP QL

EVOMELA 3 SP

exemestane $0

FARESTON 3

FARYDAK 3 PA SP

FASLODEX INTRAMUSCULAR SOLUTION 250 MG5ML

3 SP

FEMARA 3

floxuridine injection 1 SP

fludarabine phosphate 1 SP

fluorouracil intravenous 1 SP

flutamide 1

FOLOTYN 2 PA SP

FOTIVDA E SP

fulvestrant 1 SP

GAVRETO E SP

GAZYVA 3 PA SP

gemcitabine hcl 1 SP

GILOTRIF 3 PA SP QL

GLEEVEC 3 PA SP

GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG

3 SP

HALAVEN 2 PA SP

HERCEPTIN HYLECTA

3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

37

Drug Name Drug Tier Notes

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

3 PA SP

HERZUMA E SP

HYCAMTIN 3 SP

HYDREA 3

hydroxyurea oral 1

IBRANCE 3 PA SP

ICLUSIG ORAL TABLET 10 MG 15 MG

3 PA SP QL

ICLUSIG ORAL TABLET 30 MG 45 MG

3 PA SP

IDAMYCIN PFS 3 SP

idarubicin hcl 1 SP

IDHIFA 3 PA SP QL

IFEX 3 SP

ifosfamide 1 SP

imatinib mesylate 1 PA SP

IMBRUVICA 3 PA SP

IMFINZI 3 PA SP

IMLYGIC 3 SP

INFUGEM 3 SP

INLYTA 3 PA SP

INQOVI E SP

INREBIC 3 PA SP

IRESSA 3 PA SP

irinotecan hcl 1 SP

ISTODAX (OVERFILL) 3 PA SP

IXEMPRA KIT 2 SP

JAKAFI ORAL TABLET 10 MG

2 PA SP QL

JAKAFI ORAL TABLET 15 MG 20 MG 25 MG 5 MG

2 PA SP

JELMYTO E SP

JEVTANA 2 PA SP

Drug Name Drug Tier Notes

KADCYLA 3 PA SP

KANJINTI 2 PA SP

KEYTRUDA INTRAVENOUS SOLUTION

3 PA SP

KHAPZORY 3 ST SP

KISQALI FEMARA 3 PA SP

KISQALI ORAL TABLET THERAPY PACK 200 MG

3 PA SP

KOSELUGO 3 PA SP

KYPROLIS 2 PA SP

lapatinib ditosylate 1 PA SP

LENVIMA ORAL CAPSULE THERAPY PACK 10 amp 4 MG 10 MG 10 MG amp 2 X 4 MG 2 X 10 MG 2 X 10 MG amp 4 MG 2 X 4 MG 3 X 4 MG 4 MG

3 PA SP

letrozole oral 1

leucovorin calcium injection

E

leucovorin calcium oral 1

LEUKERAN 2

levoleucovorin calcium intravenous solution reconstituted 50 mg

1 SP

levoleucovorin calcium pf

1 SP

LIBTAYO 3 PA SP

LONSURF 3 PA SP

LORBRENA 3 PA SP

LUMOXITI 3 PA SP

LUTATHERA E

LYNPARZA ORAL TABLET

2 PA SP

LYSODREN 2

MARQIBO 3 SP

MATULANE 2 SP

MEKINIST 2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

38

Drug Name Drug Tier Notes

MEKTOVI 3 PA SP

melphalan 1 SP

melphalan hcl 1 SP

mercaptopurine oral 1

mesna 1 SP

MESNEX 3 SP

mitomycin intravenous 1 SP

MITOMYCIN INTRAVESICAL

E SP

mitoxantrone hcl 1 PA SP

MONJUVI 3 PA SP

mutamycin 1 SP

MVASI 2 PA SP

MYLERAN 2

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 45 MG

3 PA SP

NAVELBINE 3 SP

NERLYNX 3 PA SP QL

NEXAVAR 2 PA SP

NILANDRON 3 SP

nilutamide 1 SP

NINLARO 3 PA SP

NIPENT 3 SP

NUBEQA 3 PA SP

ODOMZO 3 PA SP

OGIVRI E SP

ONCASPAR INJECTION

2 SP

ONIVYDE 3 SP

ONTRUZANT E SP

ONUREG 3 PA SP

OPDIVO 3 PA SP

ORGOVYX 3 PA SP

oxaliplatin intravenous solution 100 mg20ml 50 mg10ml

1 SP

Drug Name Drug Tier Notes

oxaliplatin intravenous solution 200 mg40ml

E

oxaliplatin intravenous solution reconstituted

1 SP

paclitaxel 1 SP

PADCEV 3 PA SP

PANRETIN 3

paraplatin 1 SP

PEMAZYRE 3 PA SP QL

PERJETA 2 PA SP

PHESGO 2 PA SP

PHOTOFRIN 3 SP

PIQRAY 3 PA SP

POLIVY 3 PA SP

POMALYST 3 PA SP

PORTRAZZA 3 PA SP

POTELIGEO 3 PA SP

PROLEUKIN 2 SP

PURIXAN 3 SP

QINLOCK 3 PA SP

RETEVMO 3 PA SP

REVLIMID 2 PA SP

RIABNI 3 PA SP

RITUXAN HYCELA 3 PA SP

RITUXAN INTRAVENOUS SOLUTION

3 PA SP

ROMIDEPSIN INTRAVENOUS SOLUTION

3 PA SP

ROZLYTREK 3 PA SP

RUBRACA 2 PA SP

RUXIENCE 2 PA SP

RYDAPT 3 PA SP

SARCLISA 3 PA SP

SIKLOS 3 PA

SOLTAMOX $0

SPRYCEL 2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

39

Drug Name Drug Tier Notes

STIVARGA 3 PA SP

SUTENT 2 PA SP

SYLVANT 3 PA SP

SYNRIBO 3 PA SP

TABLOID 2 SP

TABRECTA E SP

TAFINLAR 2 PA SP

TAGRISSO ORAL TABLET 40 MG

3 PA SP QL

TAGRISSO ORAL TABLET 80 MG

3 PA SP

TALZENNA 3 PA SP

tamoxifen citrate oral 1

TARCEVA ORAL TABLET 100 MG 150 MG

3 PA SP

TARCEVA ORAL TABLET 25 MG

3 PA SP QL

TARGRETIN EXTERNAL

3 PA SP

TARGRETIN ORAL E SP

TASIGNA 3 PA SP

TAZVERIK E SP

TECARTUS 3 PA SP

TECENTRIQ 3 PA SP

TEMODAR INTRAVENOUS

2 SP

TEMODAR ORAL CAPSULE 100 MG 140 MG 180 MG 250 MG

3 PA SP

temozolomide 1 PA SP

teniposide 1 SP

TEPADINA 3 SP

TEPMETKO E SP

THALOMID 2 PA SP

thiotepa injection 1 SP

TIBSOVO 3 PA SP

Drug Name Drug Tier Notes

toposar intravenous solution 1 gm50ml 100 mg5ml 500 mg25ml

1 SP

topotecan hcl 1 SP

toremifene citrate 1

TOTECT 3 SP

TRAZIMERA 2 PA SP

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

E SP

tretinoin oral 1 SP

TRISENOX INTRAVENOUS SOLUTION 12 MG6ML

3 SP

TRODELVY 3 PA SP

TRUXIMA E SP

TUKYSA 3 PA SP

TURALIO 3 PA SP

TYKERB 3 PA SP

UKONIQ E SP

UNITUXIN 3 PA SP

VALCHLOR 3 PA SP

valrubicin E

VALSTAR E

VECTIBIX INTRAVENOUS SOLUTION 100 MG5ML 400 MG20ML

3 SP

VELCADE INJECTION 2 PA SP

VENCLEXTA 3 PA SP

VENCLEXTA STARTING PACK

3 PA SP

VERZENIO 3 PA SP

VIDAZA 3 PA SP

vinblastine sulfate intravenous solution

1 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

40

Drug Name Drug Tier Notes

vincristine sulfate intravenous

1 SP

vinorelbine tartrate 1 SP

VITRAKVI 3 PA SP

VIZIMPRO 3 PA SP

VORAXAZE E

VOTRIENT 3 PA SP

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

3 PA SP

XALKORI 3 PA SP

XELODA 3 PA SP

XOFIGO INTRAVENOUS SOLUTION 30 MCCIML

E

XOSPATA 3 PA SP

XPOVIO (100 MG ONCE WEEKLY)

3 PA SP

XPOVIO (40 MG ONCE WEEKLY)

3 PA SP

XPOVIO (40 MG TWICE WEEKLY)

3 PA SP

XPOVIO (60 MG ONCE WEEKLY)

3 PA SP

XPOVIO (60 MG TWICE WEEKLY)

3 PA SP

XPOVIO (80 MG ONCE WEEKLY)

3 PA SP

XPOVIO (80 MG TWICE WEEKLY)

3 PA SP

XTANDI 3 PA SP

YERVOY 2 PA SP

YESCARTA 3 PA SP

YONDELIS 3 SP

YONSA E SP

ZALTRAP 2 PA SP

ZANOSAR 2 SP

ZEJULA 2 PA SP

Drug Name Drug Tier Notes

ZELBORAF 3 PA SP

ZEPZELCA 3 PA SP

ZEVALIN Y-90 3 SP

ZIRABEV 2 PA SP

ZOLINZA 2 PA SP

ZYDELIG 3 PA SP

ZYKADIA ORAL TABLET

3 PA SP

ZYTIGA E SP

Antiparasitics

albendazole oral 1 PA

ALBENZA 3 PA

ALINIA ORAL SUSPENSION RECONSTITUTED

2

ALINIA ORAL TABLET 3

ARAKODA 3

atovaquone oral 1

atovaquone-proguanil hcl

1

BENZNIDAZOLE 3

BILTRICIDE 3

chloroquine phosphate oral

1

COARTEM 3

crotan 1

DARAPRIM 3 PA SP

EGATEN 3

ELIMITE 3

EMVERM 2

hydroxychloroquine sulfate oral

1

IMPAVIDO 3

ivermectin external lotion

1

ivermectin oral 1

KRINTAFEL 3

LAMPIT 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

41

Drug Name Drug Tier Notes

lice killing external shampoo 4-033

E

lice treatment external liquid 1

E

lindane external shampoo

1

MALARONE 3

malathion external 1

mefloquine hcl 1

MEPRON 3

NATROBA 3

NEBUPENT 3

nitazoxanide 1

OVIDE 3

PENTAM E

pentamidine isethionate inhalation

1

pentamidine isethionate injection

E

permethrin external cream

1

PLAQUENIL 3

praziquantel oral 1

primaquine phosphate oral

1

pyrimethamine oral 1 PA SP

PYRIMETHAMINE-LEUCOVORIN

3

QUALAQUIN 3 PA

quinine sulfate oral 1 PA

spinosad 1

stop lice complete treatment

E

STROMECTOL 3

SULFURATED LIME 3

Antiparkinson Agents

amantadine hcl oral 1

Drug Name Drug Tier Notes

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

3 PA SP QL

AZILECT 3

benztropine mesylate oral

1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa 1

carbidopa-levodopa er oral tablet extended release 25-100 mg 50-200 mg

1

carbidopa-levodopa-entacapone

1

COMTAN 3

DUOPA ENTERAL 3 PA

entacapone 1

GOCOVRI E

INBRIJA 3 PA SP

KYNMOBI 3 PA SP QL

KYNMOBI TITRATION KIT

3 PA SP QL

LODOSYN 3

MIRAPEX ER 3

MIRAPEX ORAL TABLET 0125 MG 05 MG 075 MG 1 MG

3

NEUPRO 3 ST

NOURIANZ 3 PA

ONGENTYS 3 ST

OSMOLEX ER E

PARLODEL 3

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

1

rasagiline mesylate oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

42

Drug Name Drug Tier Notes

ropinirole hcl 1

ropinirole hcl er 1

RYTARY 3 ST

selegiline hcl oral 1

SINEMET ORAL TABLET 10-100 MG 25-100 MG

3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR ORAL TABLET 100 MG

3

tolcapone 1

trihexyphenidyl hcl 1

XADAGO 3 ST QL

ZELAPAR 3

Antiplatelets

aspirin-dipyridamole er 1

ASPIRIN-OMEPRAZOLE

E

BRILINTA 2

CABLIVI 3 PA SP QL

cilostazol 1

clopidogrel bisulfate oral

1

dipyridamole oral 1

DURLAZA E

EFFIENT 3

PLAVIX ORAL TABLET 75 MG

3

prasugrel hcl 1

YOSPRALA E

ZONTIVITY 3

Drug Name Drug Tier Notes

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

3

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

ABILIFY MYCITE E

ABILIFY MYCITE MAINTENANCE KIT

E

ABILIFY MYCITE STARTER KIT

E

ABILIFY ORAL TABLET

3 QL

ADASUVE 3 PA

aripiprazole 1 QL

ARISTADA E

ARISTADA INITIO E

asenapine maleate 1 QL

CAPLYTA 3 ST QL

chlorpromazine hcl injection

E

chlorpromazine hcl oral 1

clozapine 1 QL

CLOZARIL 3 QL

FANAPT 3 ST QL

FANAPT TITRATION PACK

3 ST QL

fluphenazine decanoate injection

E

fluphenazine hcl injection

E

fluphenazine hcl oral 1

GEODON INTRAMUSCULAR

E

GEODON ORAL 3 QL

HALDOL DECANOATE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

43

Drug Name Drug Tier Notes

haloperidol decanoate intramuscular solution 100 mgml 50 mgml

E

haloperidol lactate oral 1

haloperidol oral 1

INVEGA 3 QL

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

LATUDA 3 QL

loxapine succinate oral 1

molindone hcl 1

NUPLAZID ORAL CAPSULE

3 PA

NUPLAZID ORAL TABLET 10 MG

3 PA

olanzapine intramuscular

E

olanzapine oral 1 QL

paliperidone er 1 QL

PERSERIS E

pimozide 1

quetiapine fumarate 1 QL

quetiapine fumarate er 1 QL

REXULTI 3 QL

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

RISPERDAL ORAL SOLUTION

E

RISPERDAL ORAL TABLET 05 MG 1 MG 2 MG 3 MG 4 MG

E

risperidone 1 QL

Drug Name Drug Tier Notes

SAPHRIS E

SECUADO E

SEROQUEL 3 QL

SEROQUEL XR 3 QL

thioridazine hcl oral 1

thiothixene oral 1

trifluoperazine hcl oral 1

VERSACLOZ 3 QL

VRAYLAR 3 ST QL

ziprasidone hcl 1 QL

ziprasidone mesylate E

ZYPREXA INTRAMUSCULAR

3

ZYPREXA ORAL 3 QL

ZYPREXA RELPREVV E

ZYPREXA ZYDIS 3 QL

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1

abacavir-lamivudine-zidovudine

1

acyclovir external 1

acyclovir oral 1

ACYCLOVIX E

adefovir dipivoxil 1 SP

APTIVUS 2

atazanavir sulfate 1

ATRIPLA E

BARACLUDE 3 SP QL

BIKTARVY 3

CABENUVA E

cidofovir intravenous E

CIMDUO 2

COMBIVIR 3

COMPLERA 2

CRIXIVAN ORAL CAPSULE 400 MG

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

44

Drug Name Drug Tier Notes

DELSTRIGO 3

DENAVIR E

DESCOVY E

DOVATO 2

EDURANT 2

efavirenz 1

efavirenz-emtricitab-tenofovir

1

efavirenz-lamivudine-tenofovir

1

emtricitabine 1

emtricitabine-tenofovir df

1

EMTRIVA ORAL CAPSULE

3

EMTRIVA ORAL SOLUTION

2

entecavir 1 SP QL

EPCLUSA 2 PA SP QL

EPIVIR 3

EPIVIR HBV ORAL SOLUTION

2 SP

EPIVIR HBV ORAL TABLET

3 SP

EPZICOM 3

EVOTAZ 2

famciclovir oral 1

FAVIPIRAVIR 3

fosamprenavir calcium 1

foscarnet sodium intravenous solution 6000 mg250ml

E

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG250ML

E

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

E

GENVOYA 3

Drug Name Drug Tier Notes

HARVONI 2 PA SP QL

HEPSERA 3 SP

INTELENCE 2

INTRON A 3 PA SP

INVIRASE ORAL TABLET

2

ISENTRESS 2

ISENTRESS HD 2

JULUCA 2

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET

2

lamivudine oral solution 1

lamivudine oral tablet 100 mg

1 SP

lamivudine oral tablet 150 mg 300 mg

1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

E SP

LEXIVA ORAL SUSPENSION

2

LEXIVA ORAL TABLET 3

lopinavir-ritonavir 1

MAVYRET 2 PA SP QL

nevirapine 1

nevirapine er 1

NORVIR ORAL PACKET

2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET

3

ODEFSEY 3

oseltamivir phosphate oral

1 QL

PEGASYS SUBCUTANEOUS SOLUTION

2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

45

Drug Name Drug Tier Notes

PEGINTRON SUBCUTANEOUS KIT 50 MCG05ML

3 PA SP

PIFELTRO 3

PREVYMIS 3 SP

PREZCOBIX 2

PREZISTA ORAL SUSPENSION

2

PREZISTA ORAL TABLET 150 MG 600 MG 75 MG 800 MG

2

RAPIVAB E

RELENZA DISKHALER 3 QL

RETROVIR INTRAVENOUS

E

RETROVIR ORAL CAPSULE

3

RETROVIR ORAL SYRUP

3

REYATAZ ORAL CAPSULE 150 MG 200 MG 300 MG

3

REYATAZ ORAL PACKET

2

ribavirin inhalation 1

ribavirin oral capsule 1 SP

ribavirin oral tablet 200 mg

1 SP

rimantadine hcl 1

ritonavir 1

RUKOBIA 3

SELZENTRY 2 PA

SITAVIG E

SOFOSBUVIR-VELPATASVIR

E SP

SOVALDI 3 PA SP QL

stavudine oral capsule 1

STRIBILD 3

SUSTIVA 3

SYMFI 2

Drug Name Drug Tier Notes

SYMFI LO 2

SYMTUZA 3

TAMIFLU ORAL CAPSULE

E

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MGML

E

TEMIXYS E

tenofovir disoproxil fumarate

1

TIVICAY 2

TIVICAY PD 2

TRIUMEQ 2

TRIZIVIR 3

TROGARZO 3 PA

TRUVADA E

TYBOST 2

valacyclovir hcl oral 1 QL

VALCYTE 3

valganciclovir hcl 1

VALTREX 3 QL

VEMLIDY 3 SP

VIEKIRA PAK 3 PA SP QL

VIRACEPT ORAL TABLET

2

VIRAMUNE ORAL SUSPENSION

3

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG

3

VIRAZOLE 3

VIREAD ORAL POWDER

2

VIREAD ORAL TABLET 150 MG 200 MG 250 MG

2

VIREAD ORAL TABLET 300 MG

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

46

Drug Name Drug Tier Notes

VOCABRIA E

VOSEVI 2 PA SP QL

XERESE E

XOFLUZA (40 MG DOSE)

3 QL

XOFLUZA (80 MG DOSE)

3 QL

ZEPATIER 3 PA SP QL

ZIAGEN 3

zidovudine 1

ZOVIRAX EXTERNAL CREAM

3

ZOVIRAX EXTERNAL OINTMENT

E

ZOVIRAX ORAL SUSPENSION

E

Anxiolytics - Drugs for Anxiety

alprazolam er 1 QL

alprazolam intensol 1 QL

alprazolam oral 1 QL

alprazolam xr 1 QL

ATIVAN E

buspirone hcl oral 1

chlordiazepoxide hcl 1 QL

clonazepam oral 1 QL

clorazepate dipotassium

1 QL

diazepam intensol 1

diazepam oral concentrate

1

diazepam oral solution 5 mg5ml

1

diazepam oral tablet 1

DORAL 3 QL

estazolam 1 QL

HALCION 3 QL

hydroxyzine hcl oral syrup

1

Drug Name Drug Tier Notes

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral

1

KLONOPIN 3 QL

lorazepam injection E

lorazepam intensol 1 QL

lorazepam oral concentrate 2 mgml

1 QL

lorazepam oral tablet 1 QL

meprobamate 1

midazolam hcl oral 1

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-08 MG100ML- 50-08 MG50ML- 50-09 MG50ML-

E

MIDAZOLAM HCL-SODIUM CHLORIDE SOLUTION 100-09 MG100ML- INTRAVENOUS

E

MIDAZOLAM+SYRSPEND SF

E

oxazepam 1 QL

quazepam 1 QL

TRANXENE-T ORAL TABLET 75 MG

3 QL

triazolam 1 QL

VALIUM E

VISTARIL 3

XANAX E

XANAX XR E

Bipolar Agents - Drugs for Mood Disorders

EQUETRO 3

lithium 1

lithium carbonate er 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

47

Drug Name Drug Tier Notes

lithium carbonate oral 1

LITHOBID 3

Blood Products and Modifiers - Drugs for Blood Disorders

ADVATE 2 SP

ADYNOVATE 3 SP

AFSTYLA 3 SP

AGRYLIN 3

ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 500 UNIT

2 SP

ALPHANINE SD 2 SP

ALPROLIX 3 SP

AMICAR ORAL SOLUTION

3

AMICAR ORAL TABLET

3

aminocaproic acid oral solution

1

aminocaproic acid oral tablet

1

anagrelide hcl 1

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML

2 PA SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

2 PA SP

ASTRINGYN SOLUTION 259 MGGM EXTERNAL

3

Drug Name Drug Tier Notes

ASTRINGYN SOLUTION 259 MGGM EXTERNAL

E

BENEFIX INTRAVENOUS KIT

2 SP

CEPROTIN 3 SP

COAGADEX 3 SP

CORIFACT 2 SP

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG10ML

E

DOPTELET ORAL TABLET 20 MG

3 PA SP

ELOCTATE 3 SP

EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML

E SP

ESPEROCT E SP

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 2500 UNIT 500 UNIT

2 SP

FIBRYGA 2 SP

FULPHILA E SP

GRANIX E SP

HEMLIBRA 3 SP

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 1700 UNIT 250 UNIT 500 UNIT

3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

48

Drug Name Drug Tier Notes

HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT

2 SP

IDELVION 3 SP

IXINITY 3 SP

JIVI 3 SP

KOATE 2 SP

KOATE-DVI 2 SP

KOGENATE FS 3 SP

KOVALTRY 3 SP

LEUKINE INJECTION SOLUTION RECONSTITUTED

3 PA SP

LYSTEDA 3

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE

3 PA SP

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

2 SP

monsels ferric subsulfate external

E

MOZOBIL 2 PA SP QL

MULPLETA 2 PA SP

NEULASTA ONPRO 3 PA SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16ML

E SP

Drug Name Drug Tier Notes

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE

E SP

NIVESTYM 2 PA SP

NOVOEIGHT 2 SP

NOVOSEVEN RT 2 SP

NPLATE 3 PA SP

NUWIQ 2 SP

NYVEPRIA 3 PA SP

OBIZUR 3 SP

PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

3 SP

PROCRIT E SP

PROFILNINE 2 SP

PROMACTA 3 PA SP

REBINYN 3 SP

REBLOZYL 3 PA SP

RECOMBINATE 2 SP

RECOTHROM 3

RECOTHROM SPRAY KIT

3

RETACRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML

2 PA SP

RIASTAP 2 SP

RIXUBIS 3 SP

SEVENFACT E SP

SOLIRIS INTRAVENOUS SOLUTION 300 MG30ML

3 PA SP

TAVALISSE 3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

49

Drug Name Drug Tier Notes

THROMBIN-JMI EPISTAXIS

3

THROMBIN-JMI EXTERNAL KIT

3

THROMBOGEN 3

tranexamic acid intravenous solution 1000 mg10ml

E

tranexamic acid oral 1

TRANEXAMIC ACID-NACL

E

TRETTEN 3 SP

UDENYCA E SP

ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG11ML 300 MG3ML

3 PA SP

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG30ML

2 PA SP

VONVENDI 3 SP

WILATE INTRAVENOUS KIT

2 SP

XYNTHA INTRAVENOUS KIT 1000 UNIT 2000 UNIT 250 UNIT 500 UNIT

2 SP

XYNTHA SOLOFUSE 2 SP

ZARXIO 2 PA SP

ZIEXTENZO 3 PA SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL 3

ACCURETIC 3

acebutolol hcl oral 1

AKOVAZ SOLUTION 50 MGML INTRAVENOUS

E

Drug Name Drug Tier Notes

ALDACTAZIDE 3

ALDACTONE 3

aliskiren fumarate 1 ST

ALTACE ORAL CAPSULE

E

ALTOPREV E

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral 1

AMLODIPINE BES+SYRSPEND SF

E

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-atorvastatin 1

amlodipine-olmesartan 1

amlodipine-valsartan-hctz

1

ANTARA ORAL CAPSULE 30 MG 90 MG

E

ATACAND E

ATACAND HCT 3

atenolol oral 1

ATENOLOL+SYRSPEND SF

E

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

AVALIDE ORAL TABLET 150-125 MG 300-125 MG

3

AVAPRO 3

AZOR E

benazepril hcl oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

50

Drug Name Drug Tier Notes

benazepril-hydrochlorothiazide

1

BENICAR E

BENICAR HCT E

BETAPACE AF 3

BETAPACE ORAL TABLET 120 MG 160 MG 80 MG

3

betaxolol hcl oral 1

BIDIL 3

bisoprolol fumarate oral 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

BUMEX ORAL TABLET 05 MG

3

BYSTOLIC 2

CADUET ORAL TABLET 10-10 MG 10-20 MG 10-40 MG 10-80 MG 5-10 MG 5-20 MG 5-40 MG 5-80 MG

3

CALAN SR 3

candesartan cilexetil 1

candesartan cilexetil-hctz

1

captopril oral 1

captopril-hydrochlorothiazide

1

CARDIZEM CD 3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG 240 MG 300 MG 360 MG 420 MG

E

CARDIZEM ORAL TABLET 120 MG 30 MG 60 MG

3

Drug Name Drug Tier Notes

CARDURA 3

CAROSPIR 3

cartia xt 1

carvedilol 1

carvedilol phosphate er 1

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

chlorthalidone oral tablet 25 mg 50 mg

1

cholestyramine light 1

cholestyramine oral 1

clonidine 1

clonidine hcl oral 1

colesevelam hcl 1

COLESTID E

COLESTID FLAVORED

E

colestipol hcl 1

CONJUPRI E

CONSENSI E

COREG 3

COREG CR 3

CORGARD 3

CORLANOR 3 PA QL

COZAAR 3

CRESTOR E

DEMSER 3

DIBENZYLINE 3

digitek 1

digox 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er beads 1

diltiazem hcl er coated beads

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

51

Drug Name Drug Tier Notes

diltiazem hcl er oral capsule extended release 12 hour

1

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

1

diltiazem hcl oral 1

DILTIAZEM HCL-DEXTROSE SOLUTION 125-5 MG125ML- INTRAVENOUS

E

dilt-xr 1

DIOVAN E

DIOVAN HCT E

disopyramide phosphate oral

1

DIURIL 3

dofetilide 1

doxazosin mesylate oral

1

droxidopa 1 PA SP

DUTOPROL E

DYRENIUM 3

EDARBI 3 ST

EDARBYCLOR 3 ST

EDECRIN 3

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 QL

EPANED ORAL SOLUTION

E

ephedrine sulfate intravenous solution

E

EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-09 MG10ML- INTRAVENOUS

E

Drug Name Drug Tier Notes

EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-09 MG5ML- INTRAVENOUS

E

eplerenone 1

ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE

E

ethacrynic acid oral 1

EVKEEZA E SP

EXFORGE 3

EXFORGE HCT 3

EZALLOR SPRINKLE 3 ST

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized oral capsule 130 mg 43 mg

1

fenofibrate micronized oral capsule 134 mg 200 mg 67 mg

1 ST

fenofibrate oral capsule 134 mg 200 mg 67 mg

1 ST

fenofibrate oral capsule 150 mg 50 mg

1

fenofibrate oral tablet 120 mg 40 mg

E

fenofibrate oral tablet 145 mg 48 mg

1

fenofibrate oral tablet 160 mg 54 mg

1 ST

fenofibric acid oral capsule delayed release

1

fenofibric acid oral tablet

1 ST

FENOGLIDE 3 ST

FIBRICOR E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

52

Drug Name Drug Tier Notes

flecainide acetate 1

FLOLIPID 3 ST

fluvastatin sodium 1

fluvastatin sodium er 1

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide oral solution 10 mgml 8 mgml

1

furosemide oral tablet 1

gemfibrozil oral 1

GONITRO 3

guanfacine hcl oral 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral

1

HYZAAR 3

icosapent ethyl 1 PA

indapamide oral 1

INDERAL LA E

INDERAL XL E

INNOPRAN XL E

INSPRA 3

irbesartan 1

irbesartan-hydrochlorothiazide

1

ISORDIL TITRADOSE 3

isosorbide dinitrate oral 1

isosorbide mononitrate 1

isosorbide mononitrate er

1

ISOXSUPRINE HCL ORAL TABLET 10 MG

E

isoxsuprine hcl oral tablet 20 mg

E

isradipine 1

Drug Name Drug Tier Notes

JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 5 MG

3 PA SP QL

KAPSPARGO SPRINKLE

E

KATERZIA E

labetalol hcl oral 1

LANOXIN ORAL TABLET 125 MCG 250 MCG 625 MCG

2

LASIX 3

LESCOL XL E

LIPITOR E

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO E

LOPID 3

LOPRESSOR ORAL 3

losartan potassium oral 1

losartan potassium-hctz 1

LOTENSIN HCT ORAL TABLET 10-125 MG 20-125 MG 20-25 MG

3

LOTENSIN ORAL TABLET 10 MG 20 MG 40 MG

3

LOTREL ORAL CAPSULE 10-20 MG 10-40 MG 5-10 MG 5-20 MG

3

lovastatin oral 1

LOVAZA E

matzim la 1

MAXZIDE 3

MAXZIDE-25 3

methyldopa oral 1

methyldopa-hydrochlorothiazide

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

53

Drug Name Drug Tier Notes

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

metyrosine 1

mexiletine hcl oral 1

MICARDIS 3

MICARDIS HCT 3

midodrine hcl 1

milrinone lactate in dextrose

E

milrinone lactate intravenous solution 10 mg10ml 20 mg20ml 50 mg50ml

E

MINIPRESS 3

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 3

nadolol oral tablet 20 mg 40 mg 80 mg

1

NEXLETOL 2 PA QL

NEXLIZET 2 PA QL

niacin (antihyperlipidemic)

1

niacin er (antihyperlipidemic)

1

niacor 1

NIASPAN 3

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 1

NITRO-BID 3

Drug Name Drug Tier Notes

NITRO-DUR 3

nitroglycerin sublingual 1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual solution

1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT E

NITRO-TIME E

NORPACE 3

NORPACE CR 2

NORTHERA 3 PA SP

NORVASC E

NYMALIZE ORAL SOLUTION 6 MGML

3

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

1

OMEGA-3 RX COMPLETE

3

omega-3-acid ethyl esters

1 PA

PACERONE ORAL TABLET 100 MG 200 MG 400 MG

3

papaverine hcl injection E

pentoxifylline er 1

perindopril erbumine 1

phenoxybenzamine hcl oral

1

phentolamine mesylate injection solution reconstituted

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

54

Drug Name Drug Tier Notes

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-09 MG10ML- 100-09 MCG10ML- 20-09 MG50ML-

E

pindolol 1

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA QL

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA 3 ST

prevalite 1

PRINIVIL ORAL TABLET 20 MG

3

procainamide hcl injection

E

PROCARDIA 3

PROCARDIA XL 3

propafenone hcl 1

propafenone hcl er 1

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

QBRELIS E

QUESTRAN E

QUESTRAN LIGHT ORAL POWDER

E

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate oral 1

ramipril 1

RANEXA 3 ST

ranolazine er 1 ST

Drug Name Drug Tier Notes

RECTIV 3

REPATHA 2 PA QL

REPATHA PUSHTRONEX SYSTEM

2 PA QL

REPATHA SURECLICK

2 PA QL

rosuvastatin calcium 1

ROSZET TABLET 10-10 MG ORAL

3

ROSZET TABLET 10-20 MG ORAL

3

ROSZET TABLET 10-40 MG ORAL

3

ROSZET TABLET 10-5 MG ORAL

3

RYTHMOL SR 3

simvastatin oral tablet 1

sotalol hcl (af) 1

sotalol hcl oral 1

SOTYLIZE 3

spironolactone oral 1

spironolactone-hctz 1

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG 34 MG 85 MG

3

SURE RESULT O3D3 SYSTEM

E

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG 2-240 MG 4-240 MG

3

taztia xt 1

TEKTURNA 2 ST

TEKTURNA HCT 2 ST

telmisartan 1

telmisartan-amlodipine 1

telmisartan-hctz 1

TENORETIC 100 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

55

Drug Name Drug Tier Notes

TENORETIC 50 3

TENORMIN E

tiadylt er 1

TIAZAC 3

TIKOSYN E

timolol maleate oral 1

TOPROL XL E

torsemide oral 1

trandolapril 1

trandolapril-verapamil hcl er

1

triamterene oral 1

triamterene-hctz oral capsule 375-25 mg

1

triamterene-hctz oral tablet

1

TRIBENZOR E

TRICOR 3

TRILIPIX 3

TWYNSTA 3

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 2 PA

VASERETIC 3

VASOTEC 3

VECAMYL 3

verapamil hcl er oral capsule extended release 24 hour

1

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

1

verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VERQUVO E

VYNDAMAX 3 PA SP QL

Drug Name Drug Tier Notes

VYNDAQEL 3 PA SP QL

VYTORIN E

WELCHOL 3

ZESTORETIC 3

ZESTRIL ORAL TABLET 10 MG 20 MG 5 MG

3

ZESTRIL ORAL TABLET 25 MG 30 MG 40 MG

E

ZETIA E

ZIAC 3

ZOCOR ORAL TABLET 10 MG 20 MG 40 MG 80 MG

3

ZYPITAMAG ORAL TABLET 2 MG 4 MG

E

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL 3 PA QL

ADDERALL XR E

ADHANSIA XR E

ADZENYS ER 3 PA ST QL

ADZENYS XR-ODT 3 PA ST QL

AMPHETAMINE ER 3 PA ST QL

amphetamine sulfate 1 PA ST QL

amphetamine-dextroamphetamine

1 PA QL

amphetamine-dextroamphetamine er

1 PA QL

APTENSIO XR 3 PA ST QL

atomoxetine hcl 1 QL

clonidine hcl er 1 ST

CONCERTA E

COTEMPLA XR-ODT 3 PA ST QL

DAYTRANA 3 PA ST QL

DESOXYN 3 PA ST QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

56

Drug Name Drug Tier Notes

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA QL

dexmethylphenidate hcl 1 PA QL

dexmethylphenidate hcl er

1 PA ST QL

dextroamphetamine sulfate er

1 PA QL

dextroamphetamine sulfate oral

1 PA ST QL

DYANAVEL XR 3 PA ST QL

EVEKEO 3 PA ST QL

EVEKEO ODT 3 PA QL

FOCALIN 3 PA QL

FOCALIN XR 3 PA ST QL

guanfacine hcl er 1

INTUNIV 3

JORNAY PM 3 PA ST QL

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR

3 ST

methamphetamine hcl 1 PA ST QL

METHYLIN ORAL SOLUTION

3 PA ST QL

methylphenidate hcl er (cd)

1 PA ST QL

methylphenidate hcl er (la)

1 PA ST QL

methylphenidate hcl er (xr)

1 PA ST QL

methylphenidate hcl er oral tablet extended release

1 PA ST QL

methylphenidate hcl er oral tablet extended release 24 hour

1 PA QL

methylphenidate hcl oral solution

1 PA ST QL

methylphenidate hcl oral tablet

1 PA QL

Drug Name Drug Tier Notes

methylphenidate hcl oral tablet chewable

1 PA ST QL

MYDAYIS 3 PA ST QL

PROCENTRA 3 PA ST QL

QUILLICHEW ER 3 PA ST QL

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER

3 PA ST QL

relexxii 1 PA ST QL

RITALIN 3 PA QL

RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG 20 MG 30 MG 40 MG

3 PA ST QL

STRATTERA 3 QL

VYVANSE 2 PA QL

ZENZEDI 3 PA ST QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA SP QL

AUBAGIO 3 PA SP QL

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT

2 PA SP QL

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

2 PA SP QL

BAFIERTAM 2 PA SP QL

BETASERON SUBCUTANEOUS KIT

2 PA SP QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

dalfampridine er 1 PA SP QL

dimethyl fumarate oral 1 PA SP QL

dimethyl fumarate starter pack

1 PA SP QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

57

Drug Name Drug Tier Notes

EXTAVIA SUBCUTANEOUS KIT

E SP

GILENYA 3 PA SP QL

glatiramer acetate 1 PA SP QL

glatopa 1 PA SP QL

KESIMPTA 2 PA SP QL

LEMTRADA 3 PA SP

MAVENCLAD 3 PA SP

MAYZENT 3 PA SP QL

OCREVUS 3 PA SP QL

PLEGRIDY E SP

PLEGRIDY STARTER PACK

E SP

PONVORY E SP

PONVORY STARTER PACK

E SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

E SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

E SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E SP

TECFIDERA E SP

TYSABRI 3 PA SP QL

VUMERITY 2 PA SP QL

ZEPOSIA 3 PA SP QL

ZEPOSIA 7-DAY STARTER PACK

3 PA SP QL

ZEPOSIA STARTER KIT

3 PA SP QL

Drug Name Drug Tier Notes

Central Nervous System Agents - Miscellaneous

ADDYI 3 PA QL

ADIPEX-P E

AUSTEDO 3 PA SP QL

benzphetamine hcl E

caffeine citrate oral 1

CONTRAVE E

CONVENIENCE PAK E

diethylpropion hcl er E

diethylpropion hcl oral E

GRALISE 3 ST QL

HORIZANT ORAL TABLET EXTENDED RELEASE

3 PA QL

IMCIVREE 3 PA SP QL

INGREZZA 3 PA SP QL

LIPRITIN II COMBINATION THERAPY PACK 100 MG

E

LOMAIRA E

LYRICA CR 3 ST QL

LYRICA ORAL CAPSULE

2 QL

LYRICA ORAL SOLUTION

3 QL

NEURAPTINE E

NUEDEXTA 3 PA

ONPATTRO 3 PA SP

phendimetrazine tartrate

E

phendimetrazine tartrate er

E

phentermine hcl oral E

pregabalin oral 1 QL

QSYMIA E

RADICAVA 3 PA SP

RILUTEK 3 PA QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

58

Drug Name Drug Tier Notes

riluzole 1 PA QL

SAVELLA 3 ST QL

SAVELLA TITRATION PACK

3 ST QL

SAXENDA E

SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 140 MG7ML

E

TEGSEDI 3 PA SP

tetrabenazine 1 PA SP

TIGLUTIK 3 PA SP QL

VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE

E

VYLEESI 3 PA QL

XENAZINE 3 PA SP

XENICAL E

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN E

cavarest E

cevimeline hcl 1

chlorhexidine gluconate mouththroat

E

CLINPRO 5000 E

DEBACTEROL SOLUTION 30-50 MOUTHTHROAT

E

DENTA 5000 PLUS E

DENTAGEL E

DERMACINRX CLORHEXACIN

E

easygel dental E

EVOXAC 3

Drug Name Drug Tier Notes

FIRST-MOUTHWASH BLM

E

FLUORIDEX E

fluoridex daily renewal E

FLUORIDEX ENHANCED WHITENING DENTAL PASTE

E

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE

E

HURRICAINE MOUTHTHROAT GEL

E

instant oral pain relief max

E

KEPIVANCE 2 SP

lidocaine hcl mouththroat

1

lidocaine viscous hcl 1

MOUTH KOTE REMINT

E

MUCOSITISRX E

NAFRINSE DAILY ACIDULATED

E

NAFRINSE DAILYNEUTRAL

E

NAFRINSE WEEKLY E

NUSURGEPAK SURGICAL PREPCARE

E

oralone 1

PERIDEX E

periogard E

pilocarpine hcl oral 1

PREVIDENT E

PREVIDENT 5000 BOOSTER PLUS

E

PREVIDENT 5000 DRY MOUTH DENTAL GEL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

59

Drug Name Drug Tier Notes

PREVIDENT 5000 ENAMEL PROTECT

E

PREVIDENT 5000 ORTHO DEFENSE

E

PREVIDENT 5000 PLUS

E

PREVIDENT 5000 SENSITIVE

E

SALAGEN 3

SALIVAMAX E

sf E

sf 5000 plus E

sodium fluoride 5000 enamel

E

sodium fluoride 5000 plus

E

sodium fluoride 5000 ppm

E

sodium fluoride 5000 sensitive

E

sodium fluoride dental cream

E

sodium fluoride dental gel 11

E

triamcinolone acetonide mouththroat

1

XEROSTOMIA RELIEF SPRAY

E

Dermatological Agents - Drugs for Skin Conditions

AAGC KIT IN TERODERM

E

ABREVA E

ABSORICA E

ABSORICA LD 3 PA

ACANYA E

accutane oral capsule 20 mg 30 mg 40 mg

1 PA

ACESO AG E

ACIOXIAY E

Drug Name Drug Tier Notes

acitretin 1

ACZONE EXTERNAL GEL 5

E

ACZONE EXTERNAL GEL 75

2

ADAINZDE E

ADAINZOXIA E

adapalene external cream

1 PA

adapalene external gel 1 PA

ADAPALENE EXTERNAL PAD

E

ADAPALENE EXTERNAL SOLUTION

3 PA

ADAPALENE-BENZOYL PER-CLINDAMY

E

ADAPALENE-BENZOYL PER-NIACINAM

E

adapalene-benzoyl peroxide external gel

1

ADAPALENE-BENZOYL PEROXIDE EXTERNAL PAD

E

ADVANCED ALLERGY COLLECTION

E

AKLIEF E

ALA SCALP E

ala-cort external cream 1

alclometasone dipropionate

1

ALDARA E

ALEVAMAX E

ALTRENO 3 PA

amcinonide external cream

E

amcinonide external lotion

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

60

Drug Name Drug Tier Notes

amcinonide external ointment

1

AMELUZ E

ammonium lactate external

1

amnesteem 1 PA

AMZEEQ 3

ANACAINE E

APEXICON E E

AQUAPHILIC E

ARAZLO E

ARIDA E

ARZOL SILVER NIT APPLICATORS

E

ATOPADERM E

ATOPICLAIR E

ATRALIN 3 PA

AVAR CLEANSER E

AVAR LS CLEANSER E

AVAR-E EMOLLIENT E

AVAR-E GREEN E

AVAR-E LS E

AVEIDAOXIA E

AVITA E

AZADROX E

azelaic acid external 1 ST

AZELAIC ACID-NIACINAMIDE

E

AZELEX 3

balsam peru-castor oil 1

BEAU RX E

BENSAL HP EXTERNAL OINTMENT 3

E

BENZ PER-CLIND-NIACIN-TRETIN

E

BENZAC AC WASH EXTERNAL LIQUID

E

BENZACLIN E

Drug Name Drug Tier Notes

BENZACLIN WITH PUMP

E

BENZAMYCIN E

BENZEPRO CREAMY WASH

E

BENZEPRO EXTERNAL

E

BENZEPRO EXTERNAL FOAM 52 97

E

benzepro external foam 53

E

BENZEPRO EXTERNAL LIQUID

E

BENZEPRO FOAMING CLOTHS

E

BENZEPRO SHORT CONTACT

E

benzoin compound E

BENZOIN EXTERNAL TINCTURE

E

BENZOYL PEROX-HYDROCORTISONE

E

benzoyl peroxide external foam 98

E

BENZOYL PEROXIDE EXTERNAL GEL 65 8

E

BENZOYL PEROXIDE FORTE- HC

E

benzoyl peroxide-erythromycin

1 ST

BESER EXTERNAL KIT

E

beser external lotion 1

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

BETAMETHASONE DIPROP-MINOXIDIL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

61

Drug Name Drug Tier Notes

betamethasone valerate external

1

BIAFINE E

BIONECT EXTERNAL CREAM

E

blanche E

BOTOX COSMETIC 3 PA SP

bp 10-1 E

bp cleansing wash E

bp wash external liquid 25 7

E

BPCO 3

BRYHALI E

calamine external lotion 8-8

E

calcipotriene external cream

1 QL

CALCIPOTRIENE EXTERNAL FOAM

E

calcipotriene external ointment

1

calcipotriene external solution

1

calcipotriene-betameth diprop external ointment

E

calcipotriene-betameth diprop external suspension

1 QL

CALCIPOTRIENE-CLOBETASOL PROP

E

CALCITRENE 3

calcitriol external 1

CANTHARIDIN EXTERNAL

E

CAPEX E

capsaicin external cream 0025

E

capzix E

CARAC 3

CEM-UREA E

Drug Name Drug Tier Notes

CERACADE E

cerovel external lotion E

CHLOOXIA E

CICLOPIROX-CLOBETASOL

E

CICLOPIROX-CLOBETASOL-SAL ACID

E

CICLOPIROX-SALICYLIC ACID

E

CIMETIDINE-LIDO-SALICYLIC ACID

E

claravis 1 PA

CLENIA PLUS E

CLEOCIN-T EXTERNAL LOTION

3

CLINDACIN ETZ EXTERNAL KIT

E

clindacin etz external swab

1

CLINDACIN PAC E

clindacin-p 1

CLINDAGEL E

CLINDAMY-BENZOYL PER-NIACINAM

E

clindamycin phos-benzoyl perox external gel 1-5 12-25 12-5

1 ST

CLINDAMYCIN PHOS-NIACINAMIDE

E

clindamycin phosphate external foam

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 EXTERNAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

62

Drug Name Drug Tier Notes

clindamycin phosphate gel 1 external

1

CLINDAMYCIN-NIACIN-TRETINOIN

E

clindamycin-tretinoin 1 ST

CLIND-NIACIN-SPIRONOLAC-TRETIN

E

CLINOIN E

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate emulsion

1

clobetasol propionate external

1

CLOBETASOL PROP-LEVOCETIRIZINE

E

CLOBETASOL PROP-NIACINAMIDE

E

CLOBETAVIX E

CLOBEX 3

CLOBEX SPRAY 3

clocortolone pivalate 1

CLODAN EXTERNAL KIT

E

clodan external shampoo

1

CLODERM E

COAL TAR EXTERNAL SOLUTION

3

COLLATYL E

CONDYLOX EXTERNAL GEL

3

COPADERM E

COPASIL EXTERNAL E

CORDRAN EXTERNAL CREAM 0025

E

CORDRAN EXTERNAL CREAM 005

3

Drug Name Drug Tier Notes

CORDRAN EXTERNAL LOTION

3

CORDRAN EXTERNAL OINTMENT

3

CORDRAN EXTERNAL TAPE

E

corn amp callus remover E

CORTANE-B EXTERNAL

E

CUTIVATE EXTERNAL LOTION

3

dapsone external gel 5

1

dapsone gel 75 external

1

DAPSONE GEL 75 EXTERNAL

E

DAPSONE-NIACINAMIDE

E

DAPSONE-NIACINAMIDE-SPIRONOLAC

E

DELUO E

DEOXIA E

DERMACINRX PENETRAL

E

DERMACINRX SURGICAL COMBOPAK

E

DERMA-SMOOTHEFS BODY

3

DERMA-SMOOTHEFS SCALP

3

DERMELLE E

DERMULCERA 3

DERPIXA E

DESONATE E

desonide external 1

DESOWEN EXTERNAL CREAM

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

63

Drug Name Drug Tier Notes

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external liquid

E

desoximetasone external ointment 005

E

desoximetasone external ointment 025

1

DEXERYL E

DIADIMAXIA E

DIAOXIA E

diaper rash external ointment

E

DIASDIMAXIA E

DIASOXIA E

dibucaine (perianal) E

diclofenac sodium gel 3 external

1 ST QL

diclofenac sodium gel 3 external

1 PA QL

diclofenac sodium gel 3 external

E

DICLOFENAC-NA HYALURON-NIACIN

E

DIFFERIN EXTERNAL CREAM

E

DIFFERIN EXTERNAL GEL 03

E

DIFFERIN EXTERNAL LOTION

E

diflorasone diacetate external

E

DIMOXIA E

DIOCHLOY E

DIPROLENE AF 3

Drug Name Drug Tier Notes

DIPROLENE EXTERNAL OINTMENT

3

docosanol external E

DOVONEX EXTERNAL CREAM

3

doxepin hcl external 1 PA

doxycycline 1

DR SMITHS ADULT BARRIER EXTERNAL OINTMENT

E

DRAXACE E

DRAXACE LOTION CLEANSER

E

DRITHO-CREME HP E

DRIXECE E

DRYSOL 3

DUOBRII E

DUPIXENT 2 PA SP QL

ECEOXIA E

EFUDEX EXTERNAL CREAM

3

ELETONE E

ELIDEL 3 ST

EMULSION SB E

enovarx-tramadol E

ENSTILAR E

ENTTY SPRAY E

ENZOCLEAR E

EPICERAM E

EPIDUO 3

EPIDUO FORTE 3

EPIFOAM 3

ery 1

ERYGEL 3

erythromycin external gel

1

erythromycin external solution

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

64

Drug Name Drug Tier Notes

ESKATA E

ETHOXIA E

EUCRISA 2 ST

EVOCLIN 3

FABIOR E

FINACEA 3 ST

FINAPOD E

finasteride oral tablet 1 mg

E

FINASTERIDE-MINOXIDIL

E

FLUOCINOLONE ACET-NIACINAMIDE

E

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide cream 01 external

E

fluocinonide emulsified base

1

fluocinonide external cream 005

1

fluocinonide external gel

1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOPAR E

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 05

2

fluorouracil external cream 5

1

fluorouracil external solution

1

FLUOVIX E

Drug Name Drug Tier Notes

FLUOVIX PLUS E

flurandrenolide E

fluticasone propionate external

1

FORAXA E

GEAMETDRAY E

GENADUR E

GORDOFILM 3

GUANENDRUX E

halcinonide E

halobetasol propionate external cream

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

E

halobetasol propionate external ointment

1

HALOG E

HALUCORT E

HAXCHLO E

HPR PLUS EXTERNAL CREAM

E

hpr plus external foam E

HPR PLUS HYDROGEL

E

HYALURONATE-NIACINAM-TRETINOIN

E

HYALURONATE-NIACIN-TACROLIMUS

E

HYALURONIC ACID-HYDROQUINONE

E

HYDRO 40 E

hydrocortisone ace-pramoxine external cream 25-1

E

hydrocortisone acetate external cream

E

hydrocortisone acetate external ointment 1

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

65

Drug Name Drug Tier Notes

hydrocortisone butyr lipo base

E

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external lotion

E

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 05

E

hydrocortisone external cream 1 25

1

hydrocortisone external lotion 25

1

hydrocortisone external ointment 1 25

1

hydrocortisone valerate 1

hydroquinone external cream

E

HYDROQUINONE EXTERNAL EMULSION

E

HYDROQUINONE-HC-TRETINOIN

E

HYDROQUINONE-HYDROCORTISONE

E

HYLATOPIC PLUS EXTERNAL CREAM

E

HYLATOPIC PLUS EXTERNAL LOTION

E

imiquimod external E

IMIQUIMOD PUMP E

IMIQUIMOD-LEVOCETIRIZIN-NIACIN

E

IMIQUIMOD-LEVOCET-TRETINOIN

E

IMPEKLO E

IMPOYZ E

INOVA E

Drug Name Drug Tier Notes

INOVA 41 ACNE CONTROL THERAPY

E

INOVA 82 ACNE CONTROL THERAPY

E

isotretinoin oral 1 PA

ITHOXIA E

IVERMECTIN-METRONIDAZOL-NIACIN

E

KAMDOY E

KATARYA E

KATARYAXN E

KAXM E

KEIDO E

KELARX E

KENALOG EXTERNAL 3

KERAGEL E

KERALAC EXTERNAL CREAM 47

E

KERALYT EXTERNAL GEL 6

E

KERALYT EXTERNAL SHAMPOO

3

KERALYT SCALP E

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

3

KETARYA E

KEVARYA E

KEXM E

KEYA E

KIVIK E

KLARON 3

KLISYRI E

KUTARYAXM E

KUTARYAXMPA E

KUTEA E

KUVARYA E

KUVARYE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

66

Drug Name Drug Tier Notes

KUXM E

lactic acid e 1

lactic acid external lotion

1

LACTIC ACID-NIACINAMIDE

E

lavare wound wash E

LEVULAN KERASTICK 3

LEXETTE E

LIDOCAINE (ANORECTAL) RECTAL

E

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL CREAM 1-1

E

LIDOTREX (ALOE VERA)

E

LOCOID EXTERNAL LOTION

3

LOCOID LIPOCREAM E

LUXIQ 3

MEDERMA E

MEDERMA FOR KIDS E

MEDERMA SPF 30 E

MEDPURA ALCOHOL PADS

E

medpura hand sanitizer external gel 70

E

methoxsalen rapid 1

methyl salicylate external liquid

E

METROCREAM 3

METROGEL EXTERNAL GEL

E

METROLOTION 3

metronidazole external 1

MIMYX E

MINOXIDIL-PROGEST-TRETINOIN

E

Drug Name Drug Tier Notes

MIRVASO 3

moisturel external lotion 3

E

mometasone furoate external

1

myorisan 1 PA

NEOSALUS E

NEOSPORIN ORIGINAL EXTERNAL OINTMENT

E

NEO-SYNALAR EXTERNAL CREAM

3

NEO-SYNALAR EXTERNAL KIT

E

neuac external gel 1 ST

NEUAC EXTERNAL KIT

E

NIACINAMIDE-SPIRONOLACTONE

E

NIACINAMIDE-SULFACETAMIDE

E

NIACINAMIDE-TACROLIMUS

E

NIACINAMIDE-TAZAROTENE

E

NIACINAMIDE-TRETINOIN

E

NIACINAMIDE-TRIAMCINOLONE ACET

E

NIACIN-SPIRONOLACTON-TRETINOIN

E

nolix E

NORITATE E

NOVACORT EXTERNAL GEL 1-2

E

NUCARACLINPAK E

NUCARARXPAK E

NUCORT E

NUDERMRXPAK 120 E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

67

Drug Name Drug Tier Notes

NUDERMRXPAK 60 E

NUTRASEB E

NUTRIARX CREAMPAK

E

NUVAIL E

OLUX 3

OLUX-E 3

ONEXTON 3

ONZDEOXIA E

ORACEA 3

OVACE PLUS E

OVACE PLUS WASH E

OVACE WASH E

OXIANUJO E

OXIATAR E

OXIAVARRY E

OXIAZAR E

OXOPOD E

OXSORALEN ULTRA 3

PANDEL E

PENLEN E

PHLAG SPRAY E

pimecrolimus 1 ST

PLEXION E

PLEXION CLEANSER EXTERNAL LIQUID

E

PLEXION CLEANSING CLOTH EXTERNAL PAD

E

podocon E

podofilox external 1

PODPROG E

PR BENZOYL PEROXIDE

E

PR BENZOYL PEROXIDE WASH

E

PR CREAM E

pramosone external cream 1-1

1

Drug Name Drug Tier Notes

PRAMOSONE EXTERNAL CREAM 1-25

E

PRAMOSONE EXTERNAL LOTION

3

PRAMOSONE EXTERNAL OINTMENT

E

pramox E

PRE amp POST SX POUCH

E

prednicarbate 1

PRESERA E

PROGESTERONE-MINOXIDIL

E

PROMISEB CREAM EXTERNAL

3

PROMISEB EXTERNAL CREAM

E

PROPECIA E

PROSILK EXTERNAL E

PROTEXA E

PROTOPIC 3

PROTYL AG E

PRUCLAIR E

PRUDOXIN 3 PA

PRUMYX E

PSORCON E

PYROGALLIC ACID 3

QBREXZA 3 QL

QUIHOXVAR E

QUINIXIL E

QUTENZA E

QUTENZA (2 PATCH) E

QUTENZA (4 PATCH) E

RADIAGEL E

RADIAPLEXRX GEL EXTERNAL

3

RADIAPLEXRX GEL EXTERNAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

68

Drug Name Drug Tier Notes

RECEDO E

REFISSA E

REGENECARE 3

REGRANEX 3 PA

remergent hq E

REMIGEN E

RENOVA E

RENOVA PUMP E

RESORCINOL-SULFUR

E

RETIN-A 3 PA

RETIN-A MICRO GEL 004 01

E

RETIN-A MICRO PUMP EXTERNAL GEL 004 01

E

RETIN-A MICRO PUMP EXTERNAL GEL 006 008

2 PA

REXASIL PATCH amp VITAMIN E LIQ

E

RHOFADE 3

RIAX E

ROAOXIA E

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL KIT

E

SALEX EXTERNAL SHAMPOO

E

salicylic acid er E

salicylic acid external foam

E

salicylic acid external gel

E

salicylic acid external shampoo

E

salicylic acid external solution 26

E

Drug Name Drug Tier Notes

salicylic acid wart remover

E

salicylic acid-cleanser external kit 6 (cream)

E

SALICYLIC ACID-SULFACETAMIDE

E

salimez E

SALIMEZ FORTE E

SALVAX E

SALVAX DUO PLUS E

SANADERMRX SKIN REPAIR

E

SANTYL 3

SCALACORT DK E

SCARCARE GEL-PAD KITLARGE

E

SCARCIN E

SCARSILK EXTERNAL E

SCARZEN SKIN REPAIR

E

SCENESSE 3 PA SP

selenium sulfide external lotion

1

selenium sulfide external shampoo

E

SELRX E

SERNIVO 3

SILA III E

SILIPAC E

SILVERSEAL HYDROGEL DRESSING EXTERNAL PAD 2X3

E

skarjel E

sodium sulfacetamide external shampoo

E

sodium sulfacetamide wash

E

SODIUM SULFACETAMIDE-BAKUCHIOL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

69

Drug Name Drug Tier Notes

SOLARAVIX EXTERNAL

E

SOLOX E

SOOLANTRA 3

SORIATANE ORAL CAPSULE 10 MG 25 MG

3

SORILUX E

sss 10-5 E

STRATA CTX E

STRATA GRT E

STRATA MARK E

STRATA TRIZ E

STRATA XRT E

sulfacetamide sodium (acne)

1

sulfacetamide sodium external gel

E

sulfacetamide sodium external liquid

E

sulfacetamide sodium-sulfur emulsion 10-5 external

1

sulfacetamide sodium-sulfur emulsion 10-5 external

E

sulfacetamide sodium-sulfur external cream

E

sulfacetamide sodium-sulfur external liquid

E

sulfacetamide sodium-sulfur external lotion

E

sulfacetamide sodium-sulfur external pad 10-4

E

sulfacetamide sodium-sulfur external suspension

E

sulfacetamide sod-sulfur wash external kit

E

Drug Name Drug Tier Notes

sulfacetamide sod-sulfur wash external liquid

E

sulfacetamide-sulfur in urea external emulsion

E

SULFACLEANSE 84 E

sulfamez wash E

SUMADAN E

SUMADAN WASH E

SUMADAN XLT E

SUMAXIN E

SUMAXIN CP E

SUMAXIN WASH E

SUVICORT E

SYNALAR 3

SYNALAR (CREAM) E

SYNALAR (OINTMENT)

E

SYNALAR TS E

SYNERDERM E

TACLONEX EXTERNAL OINTMENT

E

TACLONEX EXTERNAL SUSPENSION

3 QL

TACROLIMUS EXTERNAL CREAM

E

tacrolimus external ointment

1

TARDEOXIA E

TARDIMAXIA E

TAROXIA E

TASOPROL E

tazarotene external cream

1 PA

TAZAROTENE EXTERNAL FOAM

E

TAZORAC EXTERNAL CREAM 005

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

70

Drug Name Drug Tier Notes

TAZORAC EXTERNAL CREAM 01

3 PA

TAZORAC EXTERNAL GEL

E

TEMOVATE EXTERNAL CREAM

3

TEMOVATE EXTERNAL OINTMENT

3

TETRIX EXTERNAL CREAM

E

TEXACORT 3

TOPICORT EXTERNAL CREAM

3

TOPICORT EXTERNAL GEL

3

TOPICORT EXTERNAL OINTMENT

3

TOPICORT SPRAY E

tovet external foam 1

TOVET EXTERNAL KIT

E

tretinoin (emollient) E

tretinoin external 1 PA

tretinoin microsphere 1 PA

tretinoin microsphere pump

1 PA

triamcinolone acetonide external aerosol solution

E

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment

1

TRIANEX E

TRI-CHLOR 3

triderm external cream 1

TRIDESILON 3

Drug Name Drug Tier Notes

TRILOCICLO E

TRI-LUMA E

triple antibiotic external ointment 35-400-5000 5-400-5000

E

triple antibiotic+pain relief

E

TRIVIX E

TURPENTINE EXTERNAL

E

ULTRASAL-ER E

ULTRAVATE EXTERNAL LOTION

E

UMECTA MOUSSE E

URAMAXIN EXTERNAL GEL

E

urea external cream 39 40 41 45 47

E

UREA EXTERNAL FOAM

E

urea external lotion 40

E

urea hydrating E

urea nail external gel 45

E

ureacin-10 E

ureacin-20 E

uredeb E

UREMEZ-40 E

URESOL E

UTOPIC E

VANICREAM EXTERNAL OINTMENT

E

VANIQA E

VANOS 3

VANOXIDE-HC E

VARDIMAXIA E

VAROXIA E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

71

Drug Name Drug Tier Notes

VECTICAL E

VELTIN E

VENELEX 3

VERDESO E

VEREGEN E

VEXASYN E

VIRASAL E

WINLEVI 3 PA

WYNZORA E

XALIX E

XERAC AC 3

XERALUX E

xurea E

ZACARE E

zaclir cleansing external lotion 8

E

zenatane 1 PA

ZIANA E

ZILXI 3 ST

ZITHRANOL E

ZONALON 3 PA

ZYCLARA E

ZYCLARA PUMP E

Diabetes - Antidiabetic Agents

acarbose oral 1

ACTOPLUS MET 3

ACTOS 3

ADLYXIN E

ADLYXIN STARTER PACK

E

ALOGLIPTIN BENZOATE

E

ALOGLIPTIN-METFORMIN HCL

E

ALOGLIPTIN-PIOGLITAZONE

E

AMARYL 3

Drug Name Drug Tier Notes

BYDUREON BCISE AUTOINJECTOR

2 ST QL

BYETTA 10 MCG PEN 2 ST QL

BYETTA 5 MCG PEN 2 ST QL

CYCLOSET 3 ST

DUETACT 3

FARXIGA 2 ST

FORTAMET E

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glipizide-metformin hcl 1 ST

GLUCOTROL ORAL TABLET 10 MG

3

GLUCOTROL XL 3

GLUMETZA E

glyburide micronized 1

glyburide oral 1

glyburide-metformin 1

GLYNASE 3

GLYXAMBI 2 ST

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2 ST

JENTADUETO 2 ST

JENTADUETO XR 2 ST

KAZANO E

KOMBIGLYZE XR E

metformin hcl er 1

metformin hcl er (mod) E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

72

Drug Name Drug Tier Notes

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg 500 mg

E

metformin hcl ir 1

miglitol 1

nateglinide 1

NESINA E

ONGLYZA E

OSENI E

OZEMPIC 2 ST QL

pioglitazone hcl 1

pioglitazone hcl-glimepiride

1

pioglitazone hcl-metformin hcl

1

PRECOSE 3

QTERN E

repaglinide 1

RIOMET 3 ST

RYBELSUS 2 ST QL

SEGLUROMET E

SOLIQUA 2 ST QL

STARLIX ORAL TABLET 120 MG

3

STEGLATRO E

STEGLUJAN E

SYMLINPEN 120 3 PA

SYMLINPEN 60 3 PA

SYNJARDY 2 ST

SYNJARDY XR 2 ST

tolbutamide 1 ST

TRADJENTA 2 ST

TRIJARDY XR 2 ST

TRULICITY 2 ST QL

VICTOZA 2 ST QL

XIGDUO XR 2 ST

XULTOPHY 3 ST QL

Drug Name Drug Tier Notes

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO SOLUTION

E

ACCU-CHEK AVIVA PLUS TEST STRIPS

E

ACCU-CHEK COMPACT PLUS CONTROL

E

ACCU-CHEK COMPACT PLUS TEST STRIPS

E

ACCU-CHEK FASTCLIX LANCET KIT

$0

ACCU-CHEK GUIDE TEST STRIPS

E

ACCU-CHEK GUIDE CONTROL

E

ACCU-CHEK SMARTVIEW CONTROL

E

ACCU-CHEK SMARTVIEW TEST STRIPS

E

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

$0

AUTOLET LANCING DEVICE

$0

BLUESTAR E

CARETOUCH CONTROL SOL LEVEL 2

E

CARETOUCH LANCINGEJECTOR

$0

CARETOUCH TEST E

CEQUR SIMPLICITY 2U

3

CONTOUR CONTROL SOLUTION

E

CONTOUR MONITOR DEVICE DEVICE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

73

Drug Name Drug Tier Notes

CONTOUR MONITOR KIT WDEVICE KIT

E

CONTOUR NEXT CONTROL SOLUTION

E

CONTOUR NEXT EZ KIT WDEVICE

E

CONTOUR NEXT LINK KIT WDEVICE

E

CONTOUR NEXT MONITOR KIT WDEVICE

E

CONTOUR NEXT ONE KIT

E

CONTOUR NEXT TEST STRIPS

E

CONTOUR TEST STRIPS

E

EASYMAX 15 LEVEL 2-3 CONTROL

E

EASYMAX CONTROL IN VITRO SOLUTION NORMAL

E

GLUCOSE CONTROL SOLUTIONS

E

ENLITE GLUCOSE SENSOR

E

FORTISCARE CONTROL

E

FORTISCARE GLUCOSE SYSTEM DEVICE

E

FORTISCARE T1 GLUCOSE SYSTEM

E

FREESTYLE LIBRE 14 DAY READER

E

FREESTYLE LIBRE 14 DAY SENSOR

E

FREESTYLE LIBRE 2 READER

E

FREESTYLE LIBRE 2 SENSOR

E

FREESTYLE LIBRE READER

E

Drug Name Drug Tier Notes

FREESTYLE LIBRE SENSOR SYSTEM

E

FREESTYLE PRECISION NEO TEST

E

GUARDIAN CONNECT TRANSMITTER

E

GUARDIAN LINK 3 TRANSMITTER

E

GUARDIAN SENSOR (3)

E

KETONE TEST 3

KETOSTIX 3

MICRODOT TEST E

MICROLET NEXT LANCING DEVICE

$0

NOVOPEN ECHO 3

ONETOUCH DELICA LANCING DEV

$0

ONETOUCH DELICA PLUS LANCING

$0

ONETOUCH ULTRA $0 QL

ONETOUCH ULTRA 2 KIT WDEVICE

2

ONETOUCH ULTRA MINI KIT WDEVICE

2

ONETOUCH VERIO KIT WDEVICE

2

ONETOUCH VERIO FLEX SYSTEM KIT WDEVICE

2

ONETOUCH VERIO IN VITRO SOLUTION HIGH

3

ONETOUCH VERIO TEST STRIPS

$0 QL

ONETOUCH VERIO IQ SYSTEM

2

ONETOUCH VERIO REFLECT

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

74

Drug Name Drug Tier Notes

ONETOUCH VERIO SYNC SYSTEM KIT WDEVICE

2

PRECISION LINK E

PRECISION PCX PLUS TEST

E

PRECISION QID MONITOR

E

PRECISION QID TEST E

PRECISION SOF-TACT MONITOR

E

PRECISION SOF-TACT TEST

E

PRECISION XTRA BLOOD GLUCOSE

E

PRECISION XTRA DEVICE

E

PRECISION XTRA KIT E

PRECISION XTRA MONITOR

E

RELION BLOOD GLUCOSE TEST

E

SURESTEP PRO HIGH GLUCOSE

3

SURESTEP PRO LOW GLUCOSE

3

SURESTEP PRO NORMAL GLUCOSE

3

TRUE METRIX BLOOD GLUCOSE TEST

E

TRUE METRIX LEVEL 1

E

TRUE METRIX LEVEL 2

E

TRUE METRIX LEVEL 3

E

TRUE METRIX PRO BLOOD GLUCOSE

E

TRUETRACK TEST E

UNISTRIP CONTROL IN VITRO SOLUTION LOW

E

Drug Name Drug Tier Notes

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

diazoxide oral 1

GLUCAGEN HYPOKIT 3 ST

glucagon emergency kit 1 mg injection 1 mg

1

GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG

3 Made by Lilly

GLUCAGON EMERGENCY KIT

2Made by Fresenius

GVOKE HYPOPEN 1-PACK

2

GVOKE HYPOPEN 2-PACK

2

GVOKE PFS 2

PROGLYCEM 3

Diabetes - Insulins

ADMELOG E

ADMELOG SOLOSTAR

E

AFREZZA INHALATION POWDER 12 UNIT 4 amp 8 amp 12 UNIT 4 UNIT 8 UNIT 90 X 4 UNIT amp 90X8 UNIT 90 X 8 UNIT amp 90X12 UNIT

3 PA

APIDRA SOLOSTAR E

APIDRA VIAL E

BASAGLAR KWIKPEN E

FIASP E

FIASP FLEXTOUCH E

FIASP PENFILL E

HUMALOG U-100 AND U-200 KWIKPEN

2

HUMALOG MIX 5050 KWIKPEN

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

75

Drug Name Drug Tier Notes

HUMALOG MIX 5050 VIAL

2

HUMALOG MIX 7525 KWIKPEN

2

HUMALOG MIX 7525 VIAL

2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMALOG VIAL 2

HUMULIN 7030 KWIKPEN

2

HUMULIN 7030 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN

2

HUMULIN R U-500 VIAL

2

HUMULIN R VIAL 2

INSULIN ASP PROT amp ASP FLEXPEN

E

INSULIN ASPART E

INSULIN ASPART FLEXPEN

E

INSULIN ASPART PENFILL

E

INSULIN ASPART PROT amp ASPART

E

INSULIN LISPRO (1 UNIT DIAL)

E

INSULIN LISPRO JUNIOR KWIKPEN

E

INSULIN LISPRO PROT amp LISPRO

E

INSULIN LISPRO SUBCUTANEOUS SOLUTION

E

Drug Name Drug Tier Notes

INSULIN PEN NEEDLES 29G X 127MM 29G X 12MM 29G X 5MM 29G X 8MM 31G X 5 MM 31G X 6 MM 31G X 8 MM 32G X 4 MM 33G X 4 MM 33G X 5 MM 33G X 6 MM

$0

INSULIN SYRINGES $0

LANTUS U-100 SOLOSTAR

2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

E

LEVEMIR U-100 VIAL E

LYUMJEV KWIKPEN 2

LYUMJEV VIAL 2

MAXICOMFORT SYR 27G X 12

$0

MYXREDLIN 3

NOVOFINE AUTOCOVER PEN NEEDLE

$0

NOVOFINE PEN NEEDLE 32G X 6 MM

$0

NOVOFINE PLUS PEN NEEDLE

$0

NOVOLIN 7030 FLEXPEN

E

NOVOLIN 7030 FLEXPEN RELION

E

NOVOLIN 7030 RELION

E

NOVOLIN 7030 VIAL E

NOVOLIN N FLEXPEN E

NOVOLIN N FLEXPEN RELION

E

NOVOLIN N RELION E

NOVOLIN N VIAL E

NOVOLIN R FLEXPEN E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

76

Drug Name Drug Tier Notes

NOVOLIN R FLEXPEN RELION

E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG U-100 FLEXPEN

E

NOVOLOG MIX 7030 FLEXPEN

E

NOVOLOG MIX 7030 VIAL

E

NOVOLOG U-100 PENFILL

E

NOVOLOG U-100 VIAL E

NOVOTWIST PEN NEEDLE 32G X 5 MM

$0

SEMGLEE E

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA E

TRESIBA FLEXTOUCH

E

Electrolytes Minerals Metals Vitamins

ABANEU-SL E

ACTITROM-D E

ACTIVE FE E

ACTIVITE E

adcf (05mgml) 1

ADRENAL C FORMULA

E

airavite E

aminoamrms E

aminoreliefrms E

ANIMI-3 E

ANIMI-3VITAMIN D E

AQUASOL A INTRAMUSCULAR SOLUTION 15 MGML 50000 UNITML

E

Drug Name Drug Tier Notes

ASCOR E

ASCORBIC ACID SOLUTION 500 MGML INJECTION

E

ascorbic acid solution 500 mgml injection

E

ATABEX OB 2

AZESCHEW PRENATALPOSTNATAL

E

AZESCO E

B-12 COMPLIANCE INJECTION

E

b-6 folic acid oral capsule 8333-100-1 mg

E

BACMIN E

b-complexb-12 oral E

biocel E

biopetit E

biotin oral tablet 1000 mcg

E

bp vit 3 E

b-plex E

b-plex plus E

calcidol oral solution 200 mcgml

E

CALCIFOL 3

calcium-folic acid plus d E

CARBAGLU 2 SP

CARDIOPLEGIA DEL NIDO FORMULA

E

CARDIOPLEGIA IND PLASMA HIGH K

E

CARDIOPLEGIA IND PLASMA-TROMET

E

CARDIOPLEGIA INDUCTION HIGH K

E

CARDIOPLEGIA INDUCTION LOW DEX

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

77

Drug Name Drug Tier Notes

CARDIOPLEGIA INDUCTION NON-ENR

E

CARDIOPLEGIA MAIN LOW DEXTROSE

E

CARDIOPLEGIA MAIN LOW TROMETHA

E

CARDIOPLEGIA MAIN PLASMA-TROME

E

CARDIOPLEGIA MAINTENANCE

E

CARDIOPLEGIA REPERFUSATE 41

E

CARNITOR INTRAVENOUS

E

CARNITOR ORAL 3

CARNITOR SF 3

CENFOL E

CENTRATEX E

CEREFOLIN E

cerefolin nac oral tablet 6-90314-2-600 mg

E

CHEMET 3

CHOLECAL DF E

CHROMAGEN ORAL CAPSULE

E

CIFEREX E

CITRANATAL BLOOM E

CITRANATAL MEDLEY

E

clovique 1 PA SP

COD LIVER OIL ORAL OIL

E

CORVITE 150 E

corvite fe E

cyanocobalamin injection solution 1000 mcgml

1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCGML

3

Drug Name Drug Tier Notes

cytra k crystals E

d3 high potency oral capsule 25 mcg (1000 ut)

E

d3 super strength E

daflonex-xl oral capsule E

DECARA E

deferasirox 1 PA

deferasirox granules 1 PA

deferiprone 1 PA

DEPLIN 15 E

DEPLIN 75 E

DERMACINRX PUREFOLIX

E

DEXIFOL E

DIALYVITE E

DIALYVITE 3000 E

DIALYVITE 5000 E

DIALYVITE SUPREME D

E

DIALYVITEZINC E

DRISDOL ORAL CAPSULE

3

d-vite pediatric E

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ 20 MEQ

3

effer-k tablet effervescent 25 meq oral

1

effer-k tablet effervescent 25 meq oral

E

ELFOLATE E

ELFOLATE PLUS ORAL TABLET 3-35-2 MG

E

ENBRACE HR E

ERGOCAL E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

78

Drug Name Drug Tier Notes

ergocalciferol oral capsule

1

ergocalciferol oral solution 200 mcgml

E

EXJADE 3 PA

fabb E

fa-vitamin b-6-vitamin b-12

E

FEONYX E

FERAHEME E

FERIVA 217 E

FERIVAFA E

ferocon E

ferotrinsic E

FERRALET 90 E

ferraplus 90 E

FERRIPROX 3 PA

FERRIPROX TWICE-A-DAY

3 PA

FERRLECIT E

ferrocite plus oral tablet E

FERRO-PLEX HEMATINIC

E

ferrous sulfate oral solution 75 (15 fe) mgml

E

ferrous sulfate oral syrup

E

ferrous sulfate oral tablet 325 (65 fe) mg

E

ferrous sulfate oral tablet delayed release 324 (65 fe) mg 325 (65 fe) mg

E

FLORIVA E

FLORIVA PLUS E

fluoritab oral solution $0

folbee E

folbee plus E

FOLBEE PLUS CZ E

Drug Name Drug Tier Notes

FOLBIC RF E

FOLGARD OS E

FOLGARD RX E

folic acid injection E

folic acid oral tablet 1 mg

1

FOLIC D3 E

FOLIC-K E

FOLI-D E

FOLITE E

FOLITIN-Z E

FOLIXAPURE E

folplex 22 E

foltanx E

FOLTANX RF E

FOLTRATE E

FOLTREXYL E

foltrin E

FOLTX ORAL TABLET 113-25-2 MG

E

FOLVITE-D E

FOSTEUM E

FUSION PLUS E

GALZIN 3

GENICIN VITA-D E

GENICIN VITA-Q E

GENICIN VITA-S E

hematinic plus vitminerals

E

hematinicfolic acid E

HEMATOGEN E

HEMATOGEN FA E

HEMATRON-AF E

HEMETAB E

HEMOCYTE PLUS E

hemocyte-f oral tablet E

HYLAVITE E

HYLAZINC E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

79

Drug Name Drug Tier Notes

ICAR-C PLUS E

iferex 150 forte E

INFED E

INFUVITE ADULT E

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

E

INTEGRA F E

INTEGRA PLUS E

IODINE STRONG ORAL

3

IROSPAN 246 E

ISOLYTE-S E

JADENU 3 PA

JADENU SPRINKLE 3 PA

JENLIVA PRENATALPOSTNATAL

E

JYNARQUE 3 SP QL

KCL-LIDOCAINE-NACL SOLUTION 10-10 MEQ-MG 100ML INTRAVENOUS

E

klor-con 10 1

klor-con m10 1

KLOR-CON M15 3

klor-con m20 1

klor-con oral packet 20 meq

1

klor-con oral tablet extended release

1

klor-conef 1

K-PHOS NO 2 E

K-PHOS TABLET 500 MG ORAL

3

K-PHOS TABLET 500 MG ORAL

E

K-PHOS-NEUTRAL E

k-prime 1

K-TAB 3

Drug Name Drug Tier Notes

k-tan plus E

L-CYSTINE E

levocarnitine oral solution

1

levocarnitine oral tablet 1

levocarnitine sf 1

L-ISOLEUCINE E

l-methylfolate E

l-methylfolate ca me-cbl nac

E

l-methylfolate calcium oral

E

l-methylfolate forte E

l-methylfolate-algae oral capsule 15-90314 mg

E

l-methylfolate-algae-b12-b6

E

l-methylfolate-b6-b12 oral tablet 3-35-2 mg

E

l-methyl-mc E

l-methyl-mc nac E

LOKELMA 3

LORID E

lysiplex plus oral tablet E

MVI ADULT E

MVI PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

E

MAGNEBIND 400 3

magnesium oxide oral tablet 400 (2413 mg) mg

E

magnesium sulfate intravenous solution 2 gm50ml 20 gm500ml 4 gm100ml 4 gm50ml 40 gm1000ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

80

Drug Name Drug Tier Notes

MAGNESIUM SULFATE SOLUTION 50 INJECTION

E

magnesium sulfate solution 50 injection

E

magnesium-oxide E

mag-oxide oral tablet 200 mg

E

MEPHYTON 3

metafolbic E

metafolbic plus E

METAFOLBIC PLUS RF

E

METANX ORAL CAPSULE

E

methylfol-algae-b12-acetylcyst

E

MICROPLEGIA MSA-MSG

E

MIFEPREX 3

mifepristone 1

M-NATAL PLUS 2

MONOFERRIC E

MULTIGEN E

MULTIGEN FOLIC E

MULTIGEN PLUS E

MULTIPRO E

multi-vitironfluoride 1

multivitaminfluoride oral solution

1

multi-vitaminfluoride oral solution

1

multivitaminfluoride oral tablet chewable 025 mg 05 mg 1 mg

1

MULTIVITAMINFLUORIDE ORAL TABLET CHEWABLE 025-03 MG 05-03 MG 1-03 MG

E

Drug Name Drug Tier Notes

multi-vitaminfluorideiron

1

myferon 150 forte E

mynephrocaps capsule 1 mg oral

E

MYNEPHRON E

na ferric gluc cplx in sucrose

E

n-acetyl-l-cysteine oral 1

nafrinse $0

nafrinse drops $0

NASCOBAL 3

NEONATAL + DHA E

NEONATAL 19 2

NEONATAL COMPLETE

E

NEONATAL FE E

NEONATAL PLUS 2

NEOVITE E

NEPHPLEX RX E

nephronex oral tablet E

NEPHRO-VITE RX E

NESTABS 2

NESTABS ONE E

NEURIN-SL E

NICADAN E

NICAZEL E

NICAZEL FORTE E

NICOMIDE ORAL TABLET 750-27-2-05 MG

E

NIFEREX ORAL TABLET

E

NOVAMV PEDIATRIC MULTI-VITAMIN

E

NUFERA E

nufol E

NUTRICAP E

nutrifac zx E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

81

Drug Name Drug Tier Notes

NUTRIVIT E

OCUVEL ORAL CAPSULE 05 MG

E

ONE VITE WOMENS $0

ONE VITE WOMENS PLUS

2

ONEVITE E

ORACIT 3

ORTHO DF E

OVEEZA E

oyster shell calciumd oral tablet 250-250 mg-unit 500-200 mg-unit 500-400 mg-unit

E

oyster shell calciumvitamin d oral tablet 500-200 mg-unit

E

pediatric electrolyte oral solution

E

pediavit E

PHOSPHA 250 NEUTRAL

3

phosphorous 1

phosphorus supplement

E

phosphorus wsod amp potassium

E

phospho-trin 250 neutral

1

PHOXILLUM B22K40 E

PHOXILLUM BK425 E

PHYSICIANS EZ USE B-12

E

PHYSIOLYTE E

PHYSIOSOL IRRIGATION

E

phytonadione injection solution 1 mg05ml 10 mgml

E

phytonadione oral 1

PLASMA-LYTE 148 E

Drug Name Drug Tier Notes

PLASMA-LYTE A E

PNV TABS 20-1 E

PODIAPN ORAL CAPSULE

E

poly-iron 150 forte E

polysaccharide iron forte

E

POLY-VI-FLOR ORAL SUSPENSION

3

POLY-VI-FLOR ORAL TABLET CHEWABLE

E

POLY-VI-FLORIRON ORAL SUSPENSION

2

POLY-VI-FLORIRON ORAL TABLET CHEWABLE

E

POLY-VITE PEDIATRIC ORAL SOLUTION

E

POTABA ORAL CAPSULE

E

potassium chloride crys er

1

potassium chloride er 1

potassium chloride in nacl intravenous solution 20-045 meql- 20-09 meql- 40-09 meql-

E

potassium chloride oral packet

1

potassium chloride oral solution 20 meq15ml (10) 40 meq15ml (20)

1

potassium citrate er 1

potassium citrate-citric acid oral solution

E

PREGEN DHA E

PREGENNA E

PREMESISRX E

PRENAISSANCE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

82

Drug Name Drug Tier Notes

PRENARA E

prenatal oral tablet 27-08 mg

$0

prenatal plus iron 1

prenatal tablet 27-1 mg oral

1

prenatal tablet 27-1 mg oral

E

prenatal vitamin plus low iron

1

PRENATE E

PRENATE DHA ORAL CAPSULE 18-06-04-300 MG

E

PRENATE ELITE ORAL TABLET 20-06-04 MG

E

PRENATE ENHANCE E

PRENATE ESSENTIAL ORAL CAPSULE 18-06-04-300 MG

E

PRENATE MINI ORAL CAPSULE 18-06-04-350 MG

E

PRENATE PIXIE E

PRENATE RESTORE E

PRENATRIX E

PRENATRYL E

PRENATVITE COMPLETE

E

PRENATVITE PLUS 2

PRENATVITE RX 2

preplus 1

PRETAB 2

PRIMACARE ORAL CAPSULE

E

PRO HERS RX E

PRO HIS RX E

PRO PCOS RX E

PROTEINEX P18 E

Drug Name Drug Tier Notes

purevit dualfe plus E

pyridoxine hcl injection E

QUFLORA FE E

QUFLORA FE PEDIATRIC

E

QUFLORA GUMMIES E

QUFLORA PEDIATRIC E

RELNATE DHA 2

REMEDIENT E

RENAL MULTIVITAMIN FORMULA

E

RENAL ORAL CAPSULE

E

RENATABS E

RENATABS WITH IRON

E

rena-vite E

reno caps capsule 1 mg oral (rx)

E

REQ 49+ E

REVESTA E

ringers irrigation E

SAMSCA 3 SP QL

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

E

se-tan plus E

SIDEROL ORAL TABLET

E

SLOWMAG MG MUSCLEHEART

E

sod citrate-citric acid 1

sodium bicarbonate intravenous solution 75

E

sodium bicarbonate solution 42 intravenous

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

83

Drug Name Drug Tier Notes

sodium bicarbonate solution 84 intravenous

E

SODIUM BICARBONATE SOLUTION 84 INTRAVENOUS

E

sodium chloride (pf) solution 09 injection

E

sodium chloride injection solution 25 meqml

E

sodium chloride intravenous solution 045 09 3 5

E

sodium chloride solution 4 meqml intravenous

E

sodium fluoride oral $0

sodium polystyrene sulfonate oral powder

1

soluvita e E

sps 1

STROVITE FORTE E

STROVITE ONE E

SUPERVITE E

support E

SUPPORT-500 E

SYPRINE 3 PA SP

SYSTANE ICAPS AREDS2 ORAL TABLET CHEWABLE

E

TALIVA E

thiamine hcl injection E

tis-u-sol E

tl-hem 150 E

TOLVAPTAN ORAL TABLET 15 MG

3 SP QL

tolvaptan oral tablet 30 mg

1 SP QL

Drug Name Drug Tier Notes

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

2

tricitrates E

TRICON E

trientine hcl 1 PA SP

TRIFERIC HEMODIALYSIS PACKET

E

TRINATE 2

TRINAZ E

TRISTART DHA E

TRISTART FREE E

TRISTART ONE E

TRI-VI-FLOR 3

TRI-VI-FLORO 3

tri-vite pediatric E

tri-vitefluoride 1

TRONVITE E

UDAMIN SP E

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

urosex E

v-c forte E

VELTASSA 3

VENEXA E

VENOFER E

vic-forte E

VINATE ONE 2

virt-caps E

VIRT-FEFA PLUS E

virt-gard E

virt-phos 250 neutral 1

vita s forte E

vitacel E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

84

Drug Name Drug Tier Notes

VITAFOL FE+ ORAL CAPSULE

E

VITAFOL STRIPS 2

VITAFOL-NANO E

VITAFOL-OB+DHA E

VITAL-D RX E

VITAMEZ E

vitamin b complex 100 E

vitamin b-complex 100 E

vitamin d (ergocalciferol) oral capsule 125 mg (50000 ut)

1

VITAMIN DEFICIENCY SYSTEM-B12

E

vitamin k1 injection solution 1 mg05ml 10 mgml

E

vitamins acd-fluoride 1

VITAROCA PLUS E

VITA-RX DIABETIC VITAMIN

E

VITASURE E

VITATHELY WITH GINGER

E

VITRANOL FE E

VITREXATE E

VITREXATE FE E

VITREXYL E

VITREXYL + IRON E

vp-pnv-dha 1

vp-vite rx E

weekly-d E

westab mini E

westab one E

WESTAB PLUS 2

WESTGEL DHA E

WHEAT GERM OIL ORAL OIL

E

Drug Name Drug Tier Notes

WILZIN 3

XAQUIL XR E

XVITE E

ZALVIT E

zinc sulfate oral tablet 220 (50 zn) mg

E

ZYVANA E

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

acid reducer oral tablet 10 mg

E

acid reducer oral tablet delayed release

E

ACIPHEX E

ACIPHEX SPRINKLE E

CARAFATE ORAL SUSPENSION

3

CARAFATE ORAL TABLET

E

cimetidine hcl oral 1

cimetidine oral 1

CYTOTEC 3

DEXILANT 2 QL

ESOMEP-EZS E

esomeprazole magnesium oral capsule delayed release

1 QL

esomeprazole magnesium oral packet

1 QL

ESOMEPRAZOLE STRONTIUM ORAL CAPSULE DELAYED RELEASE 493 MG

E

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg 40 mg

1

famotidine orig st E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

85

Drug Name Drug Tier Notes

FIRST-LANSOPRAZOLE

3 ST

FIRST-OMEPRAZOLE 3 ST

lansoprazole oral capsule delayed release

1 ST QL

lansoprazole oral tablet delayed release dispersible

1 QL

misoprostol oral 1

NEXIUM ORAL CAPSULE DELAYED RELEASE

E

NEXIUM ORAL PACKET

3 QL

nizatidine 1

omeprazole magnesium oral tablet delayed release

E

omeprazole oral capsule delayed release

1 ST QL

omeprazole oral tablet delayed release

E

OMEPRAZOLE+SYRSPEND SF ALKA

3 ST

omeprazole-sodium bicarbonate

E

pantoprazole sodium oral

1 ST QL

PEPCID ORAL TABLET

3

PREVACID E

PREVACID 24HR E

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE

3 ST QL

PRILOSEC ORAL PACKET

3 ST QL

PROTONIX ORAL 3 ST QL

Drug Name Drug Tier Notes

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

E

rabeprazole sodium oral tablet delayed release

1 ST QL

sucralfate oral 1

ZEGERID E

Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions

ACTIPHLORA E

alosetron hcl 1 PA

alum amp mag hydroxide-simeth

E

alumina-magnesia-simethicone

E

alvimopan 1

AMITIZA E

amoxicill-clarithro-lansopraz

1 ST

ANASPAZ 3

antacid anti-gas max strength

E

antacid calcium E

antacid calcium rich E

antacid extra strength oral tablet chewable 160-105 mg 750 mg

E

antacid maximum E

antacid oral tablet chewable 500 mg 750 mg

E

antacid regular strength E

antacid ultra strength oral tablet chewable 1000 mg

E

antacidantigas E

antacidanti-gas E

anti-diarrheal oral liquid E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

86

Drug Name Drug Tier Notes

anti-diarrheal oral tablet E

ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR

E

atropine sulfate injection solution 04 mgml 1 mgml

E

atropine sulfate injection solution prefilled syringe 025 mg5ml

E

atropine sulfate intravenous solution

E

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 08 MG2ML 1 MG25ML 12 MG3ML

E

atropine sulfate solution 8 mg20ml injection

E

atropine sulfate solution prefilled syringe 05 mg5ml injection

E

atropine sulfate solution prefilled syringe 1 mg10ml injection

E

BACICAP E

belladonna alkaloids-opium

E

bisacodyl ec $0 QL

bisacodyl rectal E

bismuth subsalicylate oral suspension 525 mg30ml

E

cascara sagrada oral fluid extract

1

CHENODAL 3 PA SP

chlordiazepoxide-clidinium

E

chocolated laxative E

Drug Name Drug Tier Notes

citroma $0 QL

clearlax oral powder $0 QL

CLENPIQ 3

constulose 1

cromolyn sodium oral 1

CUVPOSA 3

cvs antacid extra strength oral tablet chewable 750 mg

E

cvs gentle laxative rectal

E

dicyclomine hcl oral 1

diotame instydose E

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet 25-0025 mg

1

docusate calcium E

docusate mini E

docusate sodium oral capsule

E

docusate sodium oral syrup

E

docuzen E

dok oral tablet E

DONNATAL E

ED-SPAZ 3

ENTEREG 3

enulose 1

EX-LAX ULTRA E

fiber laxative oral tablet E

fiber oral powder 283

E

FOLIKA PROBIOTIC E

gas relief extra strength oral capsule

E

gas relief infants oral suspension

E

gas relief oral tablet chewable

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

87

Drug Name Drug Tier Notes

GASTROCROM 3

GATTEX 3 PA SP

gavilax oral powder $0 QL

gavilyte-c $0 QL

gavilyte-g $0 QL

gavilyte-h 1

gavilyte-n with flavor pack

$0 QL

GELUSIL E

generlac 1

gentle laxative oral $0 QL

gentle laxative rectal E

geri-kot E

GIALAX E

GLYCATE E

glycolax $0 QL

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE 06 MG3ML

E

glycopyrrolate oral tablet 1 mg 2 mg

1

GLYCOPYRROLATE ORAL TABLET 15 MG

E

glycopyrrolate pf E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 06 MG3ML INTRAVENOUS

E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 1 MG5ML INJECTION

E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 1 MG5ML INTRAVENOUS

E

Drug Name Drug Tier Notes

GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE

E

gnp senna lax E

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

goodsense antacid amp gas relief

E

goodsense antacid oral tablet chewable 500 mg 750 mg

E

goodsense anti-diarrheal

E

HELIDAC THERAPY 3

high potency probiotic E

hm stomach relief oral suspension 525 mg30ml

E

hm stool softener oral capsule 100 mg

E

hyoscyamine sulfate er oral tablet extended release 12 hour

E

hyoscyamine sulfate oral elixir

1

hyoscyamine sulfate oral tablet

1

hyoscyamine sulfate oral tablet dispersible

1

hyoscyamine sulfate sl 1

hyoscyamine sulfate solution 0125 mgml oral

E

hyoscyamine sulfate solution 0125 mgml oral

1

hyoscyamine sulfate tablet sublingual 0125 mg sublingual

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

88

Drug Name Drug Tier Notes

hyoscyamine sulfate tablet sublingual 0125 mg sublingual

E

hyosyne 1

IMODIUM A-D ORAL TABLET

E

IMODIUM MULTI-SYMPTOM RELIEF ORAL TABLET

E

infants gas relief oral suspension 20 mg03ml

E

KRISTALOSE E

LACTEROL E

lactobacillus oral tablet E

LACTOJEN E

lactulose encephalopathy

1

lactulose oral 1

laxative max str E

laxative regular strength

E

LEVBID E

LEVSIN ORAL TABLET

E

LEVSINSL E

LIBRAX 3

LINZESS 2 ST QL

LOMOTIL ORAL TABLET

3

loperamide hcl oral capsule

1

loperamide hcl oral solution

E

loperamide hcl oral suspension

E

LOTRONEX 3 PA

LUBIPROSTONE E

MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION

E

Drug Name Drug Tier Notes

magnesium citrate oral solution 1745 gm30ml

$0 QL

magnesium oxide oral tablet 400 mg 420 mg

E

methscopolamine bromide oral

1

milk of magnesia oral suspension 1200 mg15ml 400 mg5ml

E

mineral oil heavy oral 1

mm clearlax $0 QL

mm stool softener laxative

E

MOTEGRITY 3 ST QL

MOTOFEN E

MOVANTIK E

MOVIPREP E

MYTESI 3 QL

natural senna laxative oral tablet 86 mg

E

NULEV 3

NULYTELY LEMON-LIME

3

OMECLAMOX-PAK 2

opium E

oscimin oral tablet 1

oscimin sr E

oscimin sublingual 1

OSMOPREP E

pb-hyoscy-atropine-scopolamine

E

PCP 100 E

peg 3350-kcl-na bicarb-nacl

$0 QL

peg-3350electrolytes $0 QL

peg-3350electrolytesascorbat

1

peg-kcl-nacl-nasulf-na asc-c

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

89

Drug Name Drug Tier Notes

peg-prep 1

PERDIEM OVERNIGHT RELIEF

E

phenobarbital-belladonna alk oral elixir

E

phenobarbital-belladonna alk oral tablet

1

PHENOHYTRO E

pink bismuth maximum strength

E

PLENVU E

PROBICHEW E

PROBITROL E

PRODIGEN E

PROMELLA IN PREBIOTIC

E

PROMEROL E

PYLERA 2

qc magnesium citrate $0 QL

quad-probiotic E

RELISTOR ORAL E

RELISTOR SUBCUTANEOUS SOLUTION 12 MG06ML 8 MG04ML

E

RELTONE E

RESTORA RX 3

saccharomyces boulardii

E

senexon-s E

senna oral liquid E

senna oral syrup 88 mg5ml

E

senna oral tablet 86 mg

E

senna plus oral tablet E

senna s E

Drug Name Drug Tier Notes

senna smooth E

senna-docusate sodium

E

senna-plus E

SENOKOT EXTRA STRENGTH

E

SENOKOT S E

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG 5 MG 6 MG

3 PA SP

simethicone oral capsule 125 mg

E

simethicone oral suspension 40 mg06ml

E

simethicone oral tablet chewable 80 mg

E

simethicone ultra strength

E

SODIUM BICARBONATE ORAL POWDER

3

sodium bicarbonate oral tablet 325 mg 650 mg

E

soothe oral tablet E

stimulant laxative oral tablet

E

stomach relief oral tablet chewable

E

stool softener laxative oral capsule 100 mg

E

stool softener oral capsule 100 mg 250 mg

E

stool softener plus laxative

E

stool softenerlaxative oral tablet

E

SUPREP BOWEL PREP KIT

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

90

Drug Name Drug Tier Notes

SUTAB 3

SYMAX DUOTAB E

SYMAX-SL E

SYMAX-SR E

SYMPROIC 2 ST QL

TALICIA 3

TRULANCE E

TUMS CHEWY BITES E

URSO 250 3

URSO FORTE 3

ursodiol oral 1

URSODIOL+SYRSPEND SF

E

vegetable lax+stool softener

E

VIBERZI 3 PA QL

VISBIOME E

womens 50 billion E

XERMELO TABLET 250 MG ORAL

3 PA SP QL

ZELAC E

ZELNORM 3 PA QL

ZORBTIVE 3 PA SP

Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment

ALDURAZYME 2 PA SP

AMONDYS 45 E SP

BRINEURA KIT 3 PA SP

BUPHENYL ORAL POWDER 3 GMTSP

3 SP

BUPHENYL ORAL TABLET

3 SP

CERDELGA 3 PA SP

Drug Name Drug Tier Notes

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

2 PA SP

CHOLBAM 3 PA SP

CITRULLINE EASY E

CREON 2

CRYSVITA 3 PA SP

CYSTADANE 3 SP

CYSTAGON 3 SP

ELAPRASE 2 PA SP

ELELYSO 3 PA SP

ENZADYNE E

EVRYSDI 3 PA SP QL

EXONDYS 51 E SP

FABRAZYME 2 PA SP

GALAFOLD 3 PA SP QL

KANUMA 3 PA SP

KUVAN ORAL PACKET

E SP

KUVAN ORAL TABLET E SP

LUMIZYME 2 PA SP

MEPSEVII 3 PA SP

miglustat 1 PA SP

MYALEPT 3 PA SP

NAGLAZYME 2 PA SP

nitisinone 1 PA SP

NITYR 3 PA SP

OCALIVA 3 PA SP QL

ORFADIN 3 PA SP

PALYNZIQ 3 PA SP QL

PANCREAZE E

PERTZYE E

PROCYSBI 3 PA SP

RAVICTI 3 PA SP

REVCOVI 3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

91

Drug Name Drug Tier Notes

sapropterin dihydrochloride oral packet

1 PA SP

sapropterin dihydrochloride oral tablet

1 PA SP

sodium phenylbutyrate oral powder 3 gmtsp

1 SP

sodium phenylbutyrate oral tablet

1 SP

STRENSIQ 2 PA SP

SUCRAID 3 SP

VIMIZIM 3 PA SP

VIOKACE E

VPRIV 3 PA SP

VYONDYS 53 E SP

XURIDEN 3 PA SP QL

ZAVESCA 3 PA SP

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT 15000-47000 UNIT 20000-63000 UNIT 25000-79000 UNIT 3000-14000 UNIT 40000-126000 UNIT 5000-24000 UNIT

2

ZOLGENSMA 3 PA SP

Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions

aminoacetic acid E

AURYXIA 3

azo tabs E

bethanechol chloride oral

1

BI-MIX 3

calcium acetate (phos binder)

1

Drug Name Drug Tier Notes

calcium acetate oral tablet 667 mg

1

CAVERJECT IMPULSE

3 QL

CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 40 MCG

3 QL

CERVIDIL 3

CIALIS 3 QL

CUPRIMINE ORAL CAPSULE 250 MG

3 PA SP

darifenacin hydrobromide er

1

DEPEN TITRATABS 2 SP

DETROL 3

DETROL LA 3

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG 5 MG

3

EDEX 3 QL

ELMIRON E

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 75 MG

3

FEM PH E

flavoxate hcl 1

FOSRENOL ORAL PACKET

3

FOSRENOL ORAL TABLET CHEWABLE 1000 MG 500 MG 750 MG

3

GELNIQUE TRANSDERMAL GEL 10

3 ST

GEMTESA E

glycine irrigation E

glycine urologic E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

92

Drug Name Drug Tier Notes

HYOPHEN E

INTRAROSA 3 ST

lanthanum carbonate 1

LEVITRA ORAL TABLET 10 MG 20 MG

E

LITHOSTAT 3

menaphosmbhyo1 E

MUSE 3 QL

MYRBETRIQ 2

OXLUMO 3 PA SP

oxybutynin chloride er 1

oxybutynin chloride oral 1

OXYTROL 3 ST QL

OXYTROL FOR WOMEN

E

penicillamine oral capsule

1 PA SP

penicillamine oral tablet 1 SP

PENTOSAN POLYSULFATE SODIUM ORAL

E

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg 200 mg

1

PHENYLEPHRINE HCL INTRACAVERNOSAL

E

PHOSLYRA 3

PHOSPHASAL E

PREPIDIL 3

PROSTIN E2 3

PYRIDIUM E

QUAD-MIX 3

RENACIDIN E

RENAGEL ORAL TABLET 800 MG

E

RENVELA 3

Drug Name Drug Tier Notes

RIMSO-50 E

sevelamer carbonate 1

sevelamer hcl 1

sildenafil citrate oral tablet 100 mg 25 mg 50 mg

1 QL

solifenacin succinate 1

STAXYN E

STENDRA E

SUPER BI-MIX 3

SUPER QUAD-MIX 3

SUPER TRI-MIX E

tadalafil oral 1 QL

THIOLA EC 3 SP

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 3

TRI-MIX E

trospium chloride 1 ST

trospium chloride er 1

URELLE E

uretron ds oral tablet 816 mg

1

URIBEL E

URIMAR-T E

urin ds oral tablet 816 mg

1

urinary pain relief oral tablet 95 mg

E

URO-458 E

UROGESIC-BLUE E

uro-mp E

USTELL E

UTIRA-C E

vardenafil hcl oral 1 QL

VELPHORO 3

VESICARE 3

VESICARE LS E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

93

Drug Name Drug Tier Notes

VIAGRA E

VILAMIT MB E

VILEVEV MB E

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART 3

CARDURA XL 3 ST

dutasteride oral 1

dutasteride-tamsulosin hcl

1

finasteride oral tablet 5 mg

1

FLOMAX E

JALYN 3

PROSCAR 3

RAPAFLO 3

silodosin 1

tamsulosin hcl 1

terazosin hcl oral 1

UROXATRAL 3

Hormonal Agents - Adrenal

ACTIVE INJECTION D E

ACTIVE INJECTION KIT L

E

ACTIVE INJECTION KL-3

E

ACTIVE INJECTION LM-DEP-2

E

ALKINDI SPRINKLE E

BETA 1 KIT E

BETALOAN SUIK E

BETAMETHASONE COMBO

E

Drug Name Drug Tier Notes

BETAMETHASONE SOD PHOS amp ACET INJECTION SUSPENSION 7 (4-3) MGML

E

BETAMETHASONE SOD PHOS amp ACET SUSPENSION 6 (3-3) MGML INJECTION

E

betamethasone sod phos amp acet suspension 6 (3-3) mgml injection

E

BSP 0820 E

CELESTONE SOLUSPAN

E

CONTRAST ALLERGY PREMED PACK

E

CORTEF 3

DECADRON ORAL TABLET

E

DEPO-MEDROL E

DEXABLISS E

dexamethasone intensol

1

dexamethasone oral 1

dexamethasone sod phosphate pf

E

dexamethasone sodium phosphate injection solution 100 mg10ml 120 mg30ml 20 mg5ml

E

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MGML INJECTION

E

dexamethasone sodium phosphate solution 10 mgml injection

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

94

Drug Name Drug Tier Notes

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 MGML INJECTION

E

dexamethasone sodium phosphate solution 4 mgml injection

E

DEXONTO 04 3

DMT SUIK E

DOUBLEDEX E

DXEVO 11-DAY E

DYURAL-40 E

DYURAL-80 E

DYURAL-L E

DYURAL-LM E

fludrocortisone acetate oral

1

HEMADY E

HIDEX 6-DAY E

hydrocortisone oral 1

KENALOG INJECTION 3

KENALOG-80 3

MAS CARE-PAK E

MEDROL ORAL TABLET 16 MG 32 MG 4 MG 8 MG

3

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK

3

MEDROLOAN II SUIK E

MEDROLOAN SUIK E

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MGML

E

Drug Name Drug Tier Notes

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MGML INJECTION

E

methylprednisolone acetate suspension 40 mgml injection

E

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MGML INJECTION

E

methylprednisolone acetate suspension 80 mgml injection

E

methylprednisolone oral

1

MILLIPRED ORAL TABLET

E

MULTI-SPECIALTY E

ORAPRED ODT 3

P-CARE K40 E

P-CARE K40G E

P-CARE K40MX E

P-CARE K80 E

P-CARE K80G E

P-CARE K80MX E

PEDIAPRED 3

physicians ez use jointtunnel

E

PHYSICIANS EZ USE M-PRED

E

POD-CARE 100K E

POINT OF CARE L2 E

POINT OF CARE L5 E

POINT OF CARE LM DEP 2

E

prednisolone oral solution

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

95

Drug Name Drug Tier Notes

prednisolone sodium phosphate oral solution 10 mg5ml 15 mg5ml 20 mg5ml 25 mg5ml 67 (5 base) mg5ml

1

prednisolone sodium phosphate oral tablet dispersible

1

prednisone intensol 1

prednisone oral 1

PRO-C-DURE 5 E

PRO-C-DURE 6 E

RAYOS E

READYSHARP ANESTH + METHYLPRED

E

READYSHARP BETAMETHASONE

E

READYSHARP DEXAMETHASONE

E

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG

3

TAPERDEX 12-DAY E

TAPERDEX 6-DAY E

TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 15 MG (27)

E

TOPIDEX E

TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 MGML

E

triamcinolone acetonide suspension 40 mgml injection

1

Drug Name Drug Tier Notes

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MGML INJECTION

3

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MGML INJECTION

E

TRILOAN II SUIK E

TRILOAN SUIK E

ZCORT 7-DAY E

ZILRETTA E

Hormonal Agents - Mens Health

ANDRODERM TRANSDERMAL PATCH 24 HOUR

2 PA

ANDROGEL PUMP TRANSDERMAL GEL 2025 MGACT (162)

3 PA

ANDROGEL TRANSDERMAL GEL 2025 MG125GM (162) 405 MG25GM (162)

3 PA

ANDROGEL TRANSDERMAL GEL 25 MG25GM (1) 50 MG5GM (1)

E

AVEED E

danazol oral 1

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION

E

EC-RX TESTOSTERONE

E

FORTESTA E

JATENZO E

METHITEST 3 PA

methyltestosterone oral 1 PA

NATESTO E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

96

Drug Name Drug Tier Notes

oxandrolone oral 1 PA QL

TESTIM E

TESTONE CIK E

TESTOPEL E

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MGML

E

testosterone cypionate intramuscular solution 100 mgml 200 mgml

1 PA

testosterone enanthate intramuscular solution

1 PA

TESTOSTERONE IMPLANT PELLET 100 MG 200 MG 25 MG 50 MG

E

testosterone transdermal gel 162 10 mgact (2) 125 mgact (1) 2025 mg125gm (162) 2025 mgact (162) 25 mg25gm (1) 405 mg25gm (162) 50 mg5gm (1)

1 PA

testosterone transdermal solution

1 PA

VOGELXO PUMP E

VOGELXO TRANSDERMAL GEL 50 MG5GM (1)

E

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

EVISTA 3

OSPHENA 3

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 2 PA SP

Drug Name Drug Tier Notes

BYNFEZIA PEN E SP

cabergoline 1

CETROTIDE SUBCUTANEOUS KIT 025 MG

E SP

chorionic gonadotropin intramuscular

1 PA SP

clomiphene citrate oral 1 PA

DDAVP INJECTION SOLUTION 4 MCGML

3

DDAVP ORAL 3

DDAVP PF 3

DDAVP RHINAL TUBE 2

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate pf

1

desmopressin acetate spray

1

EGRIFTA SV 3 PA SP QL

ELIGARD 3 PA SP QL

FENSOLVI (6 MONTH) 3 PA SP QL

FIRMAGON (240 MG DOSE)

3 PA SP QL

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

3 PA SP QL

FOLLISTIM AQ SUBCUTANEOUS

2 PA SP

ganirelix acetate solution prefilled syringe 250 mcg05ml subcutaneous

1 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

97

Drug Name Drug Tier Notes

ganirelix acetate solution prefilled syringe 250 mcg05ml subcutaneous

1PA Made by Organon SP

GENOTROPIN E SP

GENOTROPIN MINIQUICK

E SP

GONAL-F E SP

GONAL-F RFF E SP

GONAL-F RFF REDIJECT

E SP

HUMATROPE E SP

INCRELEX 2 PA SP

ISTURISA E SP

leuprolide acetate injection

1 PA SP

LUPANETA PACK 3 PA SP QL

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 375 MG

3 PA SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 75 MG

2 PA SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 1125 MG

3 PA SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 225 MG

2 PA SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 PA SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 PA SP

Drug Name Drug Tier Notes

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 1125 MG

3 PA SP

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG 75 MG

2 PA SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 1125 MG (PED)

3 PA SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED)

2 PA SP

MENOPUR 3 PA SP

MYCAPSSA E SP

NOCDURNA 3

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

novarel intramuscular solution reconstituted 10000 unit

1 PA SP

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

3 PA SP

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

98

Drug Name Drug Tier Notes

NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

octreotide acetate injection solution 100 mcgml 1000 mcgml 200 mcgml 50 mcgml 500 mcgml

1 PA SP

OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE

E SP

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

E SP

ORILISSA 2 PA QL

OVIDREL 3 PA SP

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 30 UNIT500ML

E

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 20-09 UNITL- 20-09 UNTL-

E

pregnyl 1 PA SP

SAIZEN E SP

SAIZENPREP E SP

SANDOSTATIN INJECTION SOLUTION 100 MCGML 50 MCGML 500 MCGML

E SP

SANDOSTATIN LAR DEPOT

E SP

SIGNIFOR E SP

Drug Name Drug Tier Notes

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3 PA SP QL

SOMATULINE DEPOT 3 PA SP

SOMAVERT 3 PA SP

STIMATE 3

SUPPRELIN LA 2 PA SP QL

SYNAREL 2

TEPEZZA 3 PA SP

TRELSTAR MIXJECT 3 PA SP QL

TRIPTODUR 3 PA SP QL

VANTAS 3 PA SP QL

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG

3 SP QL

ZOLADEX SUBCUTANEOUS IMPLANT 36 MG

2 SP QL

ZOMACTON E SP

ZOMACTON (FOR ZOMA-JET 10)

E SP

Hormonal Agents - Prostaglandins

KORLYM 3 PA SP QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 1-05 MG

3

afirmelle $0 QL

ALORA 3 ST

altavera $0 QL

alyacen 135 $0 QL

alyacen 777 $0 QL

amabelz 1

amethia $0 QL

amethyst $0 QL

ANGELIQ 3

ANNOVERA E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

99

Drug Name Drug Tier Notes

apri $0 QL

aranelle $0 QL

ashlyna $0 QL

aubra $0 QL

aubra eq $0 QL

aurovela 1530 $0 QL

aurovela 120 $0 QL

aurovela 24 fe $0 QL

aurovela fe 1530 $0 QL

aurovela fe 120 $0 QL

aviane $0 QL

AYGESTIN 3

ayuna $0 QL

azurette $0 QL

BALCOLTRA E

balziva $0 QL

bekyree $0 QL

BEYAZ E

BIESTPROGESTERONE

E

BIJUVA 3

blisovi 24 fe $0 QL

blisovi fe 1530 $0 QL

blisovi fe 120 $0 QL

briellyn $0 QL

camila $0 QL

camrese $0 QL

camrese lo $0 QL

caziant $0 QL

charlotte 24 fe $0 QL

chateal $0 QL

chateal eq $0 QL

CLIMARA 3

CLIMARA PRO 2

COMBIPATCH 3

COVARYX E

COVARYX HS E

Drug Name Drug Tier Notes

CRINONE VAGINAL GEL 4

3 QL

CRINONE VAGINAL GEL 8

3 PA QL

cryselle-28 $0 QL

cyclafem 135 $0 QL

cyclafem 777 $0 QL

cyred $0 QL

cyred eq $0 QL

dasetta 135 $0 QL

dasetta 777 $0 QL

daysee $0 QL

deblitane $0 QL

DELESTROGEN 3

delyla $0 QL

DEPO-ESTRADIOL 3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML

3 QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3 QL

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE

$0 QL

desogestrel-ethinyl estradiol

$0 QL

DIVIGEL 3

dotti 1

drospiren-eth estrad-levomefol

$0 QL

drospirenone-ethinyl estradiol

$0 QL

DUAVEE 2

EC-RX ESTRADIOL E

EC-RX PROGESTERONE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

100

Drug Name Drug Tier Notes

EEMT E

EEMT HS E

ELESTRIN 3

elinest $0 QL

ELLA $0 QL

eluryng $0 QL

emoquette $0 QL

ENDOMETRIN 2 PA

enpresse-28 $0 QL

enskyce oral tablet 015-30 mg-mcg

$0 QL

errin $0 QL

est estrogens-methyltest

E

est estrogens-methyltest ds

E

est estrogens-methyltest hs

E

estarylla $0 QL

ESTRACE 3

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

estradiol valerate intramuscular oil 20 mgml 40 mgml

1

estradiol-norethindrone acet

1

ESTRING 3 QL

ESTROGEL 3

ESTROSTEP FE 3 QL

ethynodiol diac-eth estradiol

$0 QL

etonogestrel-ethinyl estradiol

$0 QL

EVAMIST 3

FALESSA ORAL KIT 20-1-01 MCG-MG

E

falmina $0 QL

Drug Name Drug Tier Notes

fayosim $0 QL

FEMHRT LOW DOSE 3

FEMRING 3 ST QL

femynor $0 QL

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG 200 MG

E

fyavolv 1

gemmily $0 QL

GENERESS FE 3 QL

hailey 1530 $0 QL

hailey 24 fe $0 QL

hailey fe 1530 $0 QL

hailey fe 120 $0 QL

heather $0 QL

hydroxyprogesterone caproate intramuscular

1 PA SP

iclevia $0 QL

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

incassia $0 QL

introvale $0 QL

isibloom $0 QL

jaimiess $0 QL

jasmiel $0 QL

jencycla $0 QL

jinteli 1

jolessa $0 QL

juleber $0 QL

junel 1530 $0 QL

junel 120 $0 QL

junel fe 1530 $0 QL

junel fe 120 $0 QL

junel fe 24 $0 QL

kaitlib fe $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

101

Drug Name Drug Tier Notes

kalliga $0 QL

kariva $0 QL

kelnor 135 $0 QL

kelnor 150 $0 QL

kurvelo $0 QL

KYLEENA E

larin 1530 $0 QL

larin 120 $0 QL

larin 24 fe $0 QL

larin fe 1530 $0 QL

larin fe 120 $0 QL

larissia $0 QL

layolis fe $0 QL

leena $0 QL

lessina $0 QL

levonest $0 QL

levonorgest-eth est amp eth est

$0 QL

levonorgest-eth estrad 91-day

$0 QL

levonorgestrel oral tablet 15 mg

$0 QL

levonorgestrel-ethinyl estrad

$0 QL

levonorg-eth estrad triphasic oral tablet 50-3075-40 125-30 mcg

$0 QL

levora 01530 (28) $0 QL

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 195 MCGDAY

E

lillow $0 QL

LO LOESTRIN FE $0 QL

LOESTRIN 1530 (21) 3 QL

LOESTRIN 120 (21) 3 QL

LOESTRIN FE 1530 3 QL

LOESTRIN FE 120 3 QL

Drug Name Drug Tier Notes

lojaimiess $0 QL

loryna $0 QL

LOSEASONIQUE 3 QL

low-ogestrel $0 QL

lo-zumandimine $0 QL

lutera $0 QL

lyleq $0 QL

lyllana 1

lyza $0 QL

MAKENA 2 PA SP

marlissa $0 QL

medroxyprogesterone acetate intramuscular

$0 QL

medroxyprogesterone acetate oral

1

megestrol acetate oral suspension 40 mgml 625 mg5ml

1

megestrol acetate oral tablet

1

MENEST ORAL TABLET 03 MG 0625 MG 125 MG

2

MENOSTAR 3 ST

merzee $0 QL

mibelas 24 fe $0 QL

microgestin 1530 $0 QL

microgestin 120 $0 QL

microgestin 24 fe $0 QL

microgestin fe 1530 $0 QL

microgestin fe 120 $0 QL

mili $0 QL

mimvey 1

MINASTRIN 24 FE E

MINIVELLE 3 ST

MIRCETTE 3 QL

MIRENA (52 MG) E

mono-linyah $0 QL

NATAZIA $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

102

Drug Name Drug Tier Notes

necon 0535 (28) $0 QL

NEXPLANON E

nikki $0 QL

nora-be $0 QL

norethin ace-eth estrad-fe oral capsule

$0 QL

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg 15-30 mg-mcg

$0 QL

norethin ace-eth estrad-fe oral tablet chewable

$0 QL

norethindrone acetate oral

1

norethindrone acet-ethinyl est oral tablet

$0 QL

norethindrone oral $0 QL

norethindrone-eth estradiol

1

norethin-eth estradiol-fe $0 QL

norgestimate-eth estradiol oral tablet 025-35 mg-mcg

$0 QL

norgestimate-ethinyl estradiol triphasic

$0 QL

norlyda $0 QL

norlyroc $0 QL

nortrel 0535 (28) $0 QL

nortrel 135 (21) $0 QL

nortrel 135 (28) $0 QL

nortrel 777 $0 QL

NUVARING 3 QL

nylia 777 $0 QL

nymyo $0 QL

ocella $0 QL

ORIAHNN 2 PA QL

orsythia $0 QL

ORTHO MICRONOR E

Drug Name Drug Tier Notes

PARAGARD INTRAUTERINE COPPER

E

philith $0 QL

pimtrea $0 QL

pirmella 135 $0 QL

pirmella 777 $0 QL

PLAN B ONE-STEP $0 QL

portia-28 $0 QL

PREFEST 3

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

previfem $0 QL

progesterone intramuscular

1

PROGESTERONE MICRONIZED TRANSDERMAL

E

progesterone oral 1

PROMETRIUM 3

PROVERA 3

QUARTETTE 3 QL

reclipsen $0 QL

rivelsa $0 QL

SAFYRAL 3 QL

SEASONIQUE 3 QL

setlakin $0 QL

sharobel $0 QL

simliya $0 QL

simpesse $0 QL

SKYLA E

SLYND E

sprintec 28 $0 QL

sronyx $0 QL

syeda $0 QL

tarina 24 fe $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

103

Drug Name Drug Tier Notes

tarina fe 120 $0 QL

tarina fe 120 eq $0 QL

TAYTULLA E

tilia fe $0 QL

tri femynor $0 QL

tri-estarylla $0 QL

tri-legest fe $0 QL

tri-linyah $0 QL

tri-lo-estarylla $0 QL

tri-lo-marzia $0 QL

tri-lo-mili $0 QL

tri-lo-sprintec $0 QL

tri-mili $0 QL

tri-nymyo $0 QL

tri-previfem $0 QL

tri-sprintec $0 QL

trivora (28) $0 QL

tri-vylibra $0 QL

tri-vylibra lo $0 QL

tulana $0 QL

TWIRLA E

tyblume oral tablet chewable

$0 QL

tydemy $0 QL

VAGIFEM VAGINAL TABLET 10 MCG

E

velivet $0 QL

vestura $0 QL

vienva $0 QL

viorele $0 QL

VIVELLE-DOT E

volnea $0 QL

vyfemla $0 QL

vylibra $0 QL

wera $0 QL

wymzya fe $0 QL

xulane $0 QL

Drug Name Drug Tier Notes

YASMIN 28 3 QL

YAZ E

yuvafem 1

zafemy $0 QL

zarah $0 QL

zovia 135 (28) $0 QL

zovia 135e (28) $0 QL

zumandimine $0 QL

Hormonal Agents - Thyroid

ARMOUR THYROID 3 ST

CYTOMEL E

euthyrox 1

levo-t 1

LEVOTHYROXINE SODIUM ORAL CAPSULE

E

levothyroxine sodium oral tablet

1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3 ST

np thyroid 1

propylthiouracil oral 1

SYNTHROID 3

TAPAZOLE 3

THYQUIDITY 3

TIROSINT E

TIROSINT-SOL 3

unithroid 1

WESTHROID ORAL TABLET 130 MG 195 MG 325 MG 65 MG 975 MG

3 ST

WP THYROID 3 ST

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

104

Drug Name Drug Tier Notes

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA 3 PA SP

ACTEMRA ACTPEN 3 PA SP

ACTIMMUNE 2 PA SP

ALFERON N 2 SP

ARAVA 3

ARCALYST 3 PA SP

ASCENIV E SP

ASTAGRAF XL 3 SP

ATGAM 2 SP

AVSOLA 2 PA SP

AZASAN 3

azathioprine oral 1

azathioprine sodium E

BAMLANIVIMAB E

BENLYSTA 3 PA SP

BERINERT 3 PA SP QL

BIVIGAM INTRAVENOUS SOLUTION 5 GM50ML

3 PA SP

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM 6 GM

3 PA SP

CASIRIVIMAB E

CELLCEPT 3 SP

CELLCEPT INTRAVENOUS

3 SP

CIMZIA PREFILLED KIT

2 PA SP

CIMZIA STARTER KIT 2 PA SP

CIMZIA VIAL KIT 2 PA SP

CINRYZE 2 PA SP

Drug Name Drug Tier Notes

COSENTYX (300 MG DOSE)

E SP

COSENTYX 150 MGML

E SP

COSENTYX SENSOREADY (300 MG)

E SP

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MGML

E SP

CUTAQUIG E SP

CUVITRU 3 PA SP

cyclosporine intravenous

1 SP

cyclosporine modified 1 SP

cyclosporine oral capsule

1 SP

CYTOGAM 2 PA SP

ENBREL MINI 3 PA SP

ENBREL SUBCUTANEOUS SOLUTION 25 MG05ML

3 PA SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA SP

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA SP

ENSPRYNG 3 PA SP

ENTYVIO 3 PA SP

ENVARSUS XR 3 SP

ETESEVIMAB E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

105

Drug Name Drug Tier Notes

everolimus oral tablet 025 mg 05 mg 075 mg

1 SP

FIRAZYR 3 PA SP QL

FLEBOGAMMA DIF 3 PA SP

GAMASTAN 2 PA SP

GAMIFANT 3 PA SP

GAMMAGARD 3 PA SP

GAMMAGARD SD LESS IGA

3 PA SP

GAMMAKED INJECTION SOLUTION 1 GM10ML 10 GM100ML 20 GM200ML 5 GM50ML

3 PA SP

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM100ML 10 GM200ML 20 GM200ML 20 GM400ML 5 GM100ML 5 GM50ML

3 PA SP

GAMUNEX-C 3 PA SP

gengraf oral capsule 100 mg 25 mg

1 SP

gengraf oral solution 1 SP

HAEGARDA 3 PA SP

HEPAGAM B E

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM5ML 10 GM50ML 2 GM10ML 4 GM20ML

3 PA SP

HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

Drug Name Drug Tier Notes

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG08ML 80 MG08ML amp 40MG04ML

2 PA SP

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

2 PA SP

HUMIRA PEN-CDUCHS STARTER

2 PA SP

HUMIRA PEN-PEDIATRIC UC START

2 PA SP

HUMIRA PEN-PSUVADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG08ML

2 PA SP

HUMIRA PEN-PSORUVEIT STARTER

2 PA SP

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG01ML 20 MG02ML 40 MG04ML 40 MG08ML

2 PA SP

HYPERHEP B E

HYPERRAB E

HYPERRAB SD INJECTION

E

HYPERRHO SD INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

HYPERTET SD E

HYQVIA 3 PA SP

icatibant acetate 1 PA SP QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

106

Drug Name Drug Tier Notes

ILARIS SUBCUTANEOUS SOLUTION

2 PA SP QL

ILUMYA 3 PA SP

IMDEVIMAB E

IMOGAM RABIES-HT INJECTION

E

IMURAN 3

INFLECTRA 2 PA SP

KALBITOR 3 PA SP QL

KEDRAB INJECTION E

KEVZARA 3 PA SP

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

KYMRIAH 3 PA SP

leflunomide oral 1

LUPKYNIS E SP

methotrexate oral 1

methotrexate sodium (pf) injection solution 1 gm40ml 250 mg10ml 50 mg2ml

1

methotrexate sodium injection solution 250 mg10ml 50 mg2ml

1

methotrexate sodium injection solution reconstituted

1

methotrexate sodium oral

1

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

mycophenolate mofetil hcl

1 SP

mycophenolate mofetil intravenous

1 SP

Drug Name Drug Tier Notes

mycophenolate mofetil oral

1 SP

mycophenolate sodium 1 SP

MYFORTIC 3 SP

NABI-HB E

NEORAL 3 SP

NULOJIX 3 SP

OCTAGAM 3 PA SP

OLUMIANT E SP

ORENCIA CLICKJECT 3 PA SP

ORENCIA INTRAVENOUS

3 PA SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

ORLADEYO 3 PA SP QL

OTEZLA ORAL TABLET

2 PA SP

OTEZLA ORAL TABLET THERAPY PACK

2 PA SP

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG04ML 15 MG04ML 20 MG04ML 25 MG04ML

3 PA QL

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG04ML 175 MG04ML 225 MG04ML

E

PANZYGA E SP

PRIVIGEN 3 PA SP

PROGRAF 3 SP

PROVENGE 2 PA SP

RAPAMUNE 3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

107

Drug Name Drug Tier Notes

RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG02ML 125 MG025ML 15 MG03ML 175 MG035ML 20 MG04ML 225 MG045ML 25 MG05ML 30 MG06ML 75 MG015ML

2 PA QL

REDITREX E

REMICADE E SP

RENFLEXIS E SP

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE

E

RIDAURA 3 SP

RINVOQ 2 PA SP

RUCONEST 3 PA SP QL

SANDIMMUNE INTRAVENOUS

2 SP

SANDIMMUNE ORAL CAPSULE

3 SP

SANDIMMUNE ORAL SOLUTION

2 SP

SILIQ 3 PA SP

SIMPONI ARIA 2 PA SP

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA SP

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP

Drug Name Drug Tier Notes

SIMULECT E

sirolimus oral 1 SP

SKYRIZI (150 MG DOSE)

2 PA SP QL

STELARA INTRAVENOUS

2 PA SP

STELARA SUBCUTANEOUS SOLUTION 45 MG05ML

2 PA SP QL

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

SYNAGIS 2 PA SP

tacrolimus oral 1 SP

TAKHZYRO 3 PA SP

TALTZ 3 PA SP

temsirolimus 1 SP

THYMOGLOBULIN E

TICE BCG 2 SP

TORISEL 3 SP

TREMFYA 2 PA SP

TREXALL 3

UPLIZNA 3 PA SP

VARIZIG INTRAMUSCULAR SOLUTION

E

WINRHO SDF 2 SP

XATMEP 3

XELJANZ 2 PA SP

XELJANZ XR 2 PA SP

XEMBIFY 3 PA SP

ZINPLAVA E

ZORTRESS 3 SP

Immunological Agents - Drugs for Vaccination

ACTHIB $0

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

108

Drug Name Drug Tier Notes

ADACEL INTRAMUSCULAR SUSPENSION 5-2-155 LF-MCG05

$0

AFLURIA QUADRIVALENT

$0

ASTRAZENECA COVID-19 VACCINE

3

BCG VACCINE E

BEXSERO $0

BIOTHRAX E

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-25-185 LF-MCG05

$0

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

$0

DIPHTHERIA-TETANUS TOXOIDS DT

$0

ENGERIX-B INJECTION SUSPENSION 10 MCG05ML 20 MCGML

$0

FLUAD $0

FLUAD QUADRIVALENT

$0

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

FLUCELVAX QUADRIVALENT

$0

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

FLUMIST QUADRIVALENT

$0

Drug Name Drug Tier Notes

FLUZONE HIGH-DOSE QUADRIVALENT

$0

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 05 ML

$0

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 05 ML

$0

GARDASIL 9 $0

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL UML 720 EL U05ML

$0

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

$0

HIBERIX INJECTION $0

IMOVAX RABIES E

INFANRIX $0

IPOL INJECTION INJECTABLE

$0

IXIARO E

JANSSEN COVID-19 VACCINE

$0

MENACTRA $0

MENQUADFI $0

MENVEO $0

M-M-R II INJECTION $0

MODERNA COVID-19 VACCINE

$0

PEDVAX HIB INTRAMUSCULAR SUSPENSION

$0

PFIZER-BIONTECH COVID-19 VACC

$0

PNEUMOVAX 23 $0

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

109

Drug Name Drug Tier Notes

PREVNAR 13 $0

RABAVERT E

RECOMBIVAX HB INJECTION SUSPENSION 10 MCGML 40 MCGML 5 MCG05ML

$0

ROTARIX $0

ROTATEQ ORAL SOLUTION

$0

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG05ML

$0

STAMARIL E

TDVAX $0

TENIVAC $0

TETANUS-DIPHTHERIA TOXOIDS TD

$0

TRUMENBA $0

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05ML

E

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT05ML 50 UNITML

$0

VARIVAX $0

VAXCHORA E

VIVOTIF E

YF-VAX E

Inflammatory Bowel Disease Agents

ana-lex E

Drug Name Drug Tier Notes

ANALPRAM HC EXTERNAL

E

ANALPRAM HC SINGLES EXTERNAL

E

ANALPRAM-HC EXTERNAL CREAM

3

ANALPRAM-HC EXTERNAL LOTION

E

anucort-hc E

ANUSOL-HC EXTERNAL

3

ANUSOL-HC RECTAL SUPPOSITORY

E

APRISO 2

ASACOL HD E

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

budesonide er oral tablet extended release 24 hour

1

budesonide oral 1

CANASA E

COLAZAL 3

CORTENEMA 3

CORTIFOAM EXTERNAL

3

DELZICOL E

DIPENTUM E

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES

3

HEMMOREX-HC RECTAL SUPPOSITORY 25 MG

E

hydrocortisone (perianal)

1

hydrocortisone ace-pramoxine external cream 1-1

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

110

Drug Name Drug Tier Notes

hydrocortisone acetate rectal

E

hydrocortisone rectal enema

1

hydrocort-pramoxine (perianal)

E

LIALDA E

lidocaine-hydrocort (perianal)

E

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

E

lidocaine-hydrocortisone ace rectal kit

E

LIDOCORT EXTERNAL

E

mesalamine er oral capsule 0375 gm

1

mesalamine oral 1

mesalamine rectal 1

mesalamine-cleanser 1

ORTIKOS E

PENTASA 3

PROCORT EXTERNAL E

PROCTOCORT EXTERNAL

3

PROCTOCORT RECTAL SUPPOSITORY

E

PROCTOFOAM HC EXTERNAL

2

procto-med hc external 1

procto-pak external 1

proctozone-hc external 1

ROWASA RECTAL 3

SFROWASA 2

sulfasalazine oral 1

UCERIS 3

Drug Name Drug Tier Notes

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG 35 MG

3 QL

alendronate sodium oral solution

1

alendronate sodium oral tablet 10 mg 5 mg

1

alendronate sodium oral tablet 35 mg 70 mg

1 QL

ATELVIA 3 QL

BINOSTO 3 QL

BONIVA INTRAVENOUS

E

BONIVA ORAL TABLET 150 MG

3 QL

calcitonin (salmon) 1 QL

EVENITY 3 PA SP QL

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG248ML

E SP

FOSAMAX ORAL TABLET 70 MG

3 QL

FOSAMAX PLUS D E

ibandronate sodium intravenous solution 3 mg3ml

E

ibandronate sodium oral

1 QL

MIACALCIN INJECTION

3

pamidronate disodium 1 SP

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

RAYALDEE 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

111

Drug Name Drug Tier Notes

RECLAST 3 SP

risedronate sodium oral tablet 150 mg 35 mg

1 QL

risedronate sodium oral tablet 30 mg 5 mg

1

risedronate sodium oral tablet delayed release

1 QL

TERIPARATIDE (RECOMBINANT)

2 PA SP

TYMLOS 2 PA SP

XGEVA 2 PA SP

zoledronic acid intravenous concentrate

1 SP

zoledronic acid intravenous solution

1 SP

Metabolic Bone Disease Agents - Other

calcitriol intravenous solution 1 mcgml

E

calcitriol oral 1

cinacalcet hcl 1 PA

doxercalciferol oral 1

NATPARA 3 PA SP QL

paricalcitol intravenous E

paricalcitol oral 1

PARSABIV 3 SP

ROCALTROL 3

SENSIPAR 3 PA

ZEMPLAR INTRAVENOUS

E

ZEMPLAR ORAL CAPSULE 1 MCG 2 MCG

3

Miscellaneous Therapeutic Agents

3232a infant formula E

ACACIA SUBCUTANEOUS

E

Drug Name Drug Tier Notes

ACCU-CHEK TENDER 1 INFUSION

E

ACCU-CHEK ULTRAFLEX INF SET

E

ACREMONIUM E

ACST KIT E

ACTIFOAM COLLAGEN SPONGE

E

ACUNOL E

ADAKVEO 3 PA SP

ADULT AEROSOL MASK

E

AERIVA CONCENTRATOR NEBULIZER

E

ALCOHOL PREP PADS PAD

3

ALCOHOL PREP PADS PAD 70

3

ALCOHOL PREP PADS SHEET 70

3

ALDER E

ALTERNARIA E

AMERICAN BEECH E

AMERICAN COCKROACH

E

AMERICAN ELM E

AMINOPMRMS E

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

E

ANTIVENIN LATRODECTUS MACTANS

E

ANTIVENIN MICRURUS FULVIUS INTRAVENOUS

E

APP SLIM RMS E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

112

Drug Name Drug Tier Notes

ARIDOL INHALATION KIT 0 amp 5 amp 10 amp 20 amp 40 MG

E

ARIZONA CYPRESS E

ARTISS EXTERNAL SOLUTION

3

asilnasalrms E

ASPARTAME E

ASPARTAME (NUTRASWEET)

E

AUREOBASIDIUM E

AUSTRALIAN PINE E

AUTOSOFT 30 INFUSION SET

E

AUTOSOFT 90 INFUSION SET

E

AUTOSOFT XC INFUSION SET

E

AVAILNEX E

AVITENE E

AVITENE FLOUR E

AXONA E

AZALGIA E

BAHIA E

BALD CYPRESS E

BAYBERRY (WAX MYRTLE)

E

BERMUDA GRASS SUBCUTANEOUS

E

BHI URI-CONTROL E

BLACK WILLOW E

BOTOX 2PA Non-Cosmetic SP

BOTRYTIS SUBCUTANEOUS

E

BREATHE EASE HUMIDIFIER

E

BREATHE EASE NEB MASKCHILD

E

Drug Name Drug Tier Notes

BREATHE EASE NEB MASKINFANT

E

BRIDION INTRAVENOUS SOLUTION 500 MG5ML

E

BRIDION SOLUTION 200 MG2ML INTRAVENOUS

E

BROME E

CALIFORNIA PEPPER TREE

E

CAMINO PRO COMPLETEGLYTACTIN

E

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNUML

E

CARDIOVID PLUS E

CARETOUCH 2 CPAP HOSE HANGER

E

CARETOUCH CPAP amp BIPAP HOSE

E

CARETOUCH CPAP MASK WIPES

E

CARETOUCH CPAP PRE-WASH SOLN

E

CARETOUCH CPAP TUBE BRUSH

E

CARETOUCH UNIVERSL CPAP FILTER

E

CARTICEL E

CAT HAIR EXTRACT SUBCUTANEOUS

E

CATTLE EPITHELIUM E

CAYA $0 QL

CEDAR ELM E

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

113

Drug Name Drug Tier Notes

CLADOSPORIUM SPHAEROSPERMUM

E

COCKLEBUR E

coenzyme q10 oral capsule 100 mg 50 mg

E

COLCIGEL E

COLD-EEZE NATURAL MULTI-SYMP MOUTHTHROAT

E

COLD-EEZE PLUS DEFENSE MOUTHTHROAT

E

COLD-EEZE SUGAR FREE MOUTHTHROAT LOZENGE

E

COMFORT TOUCH ALCOHOL PREP

3

COMPRESSOR NEBULIZER

E

CONDOMS E

CORN POLLEN E

CORTROSYN E

cosyntropin injection E

COVID-19 SPECIMEN COLLECTION

E

CROFAB E

CURVULARIA E

DANDELION E

deferoxamine mesylate E

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

E

desflurane 1

dexmedetomidine hcl in nacl intravenous solution 200-09 mcg50ml-

E

Drug Name Drug Tier Notes

dexmedetomidine hcl in nacl solution 200 mcg50ml intravenous

E

dexmedetomidine hcl in nacl solution 400 mcg100ml intravenous

E

dexmedetomidine hcl in nacl solution 80 mcg20ml intravenous

E

dexmedetomidine hcl intravenous solution 200 mcg2ml

E

DIGIFAB E

DOG EPITHELIUM E

DOG FENNEL E

DOJOLVI E

DRECHSLERA E

DUROLANE INTRA-ARTICULAR

2 PA SP

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS

E

DYSPORT 3 PA SP

EASIVENT 2

EASTERN COTTONWOOD

E

EC-RX DHEA E

ECZEMOL E

ENDARI 3 PA

ENDO AVITENE E

ENFAGROW NEUROPRO TODDLER

E

ENFAMIL GENTLEASE ORAL POWDER

E

ENFAMIL INFANT ORAL POWDER

E

ENFAMIL NEUROPRO INFANT ORAL POWDER

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

114

Drug Name Drug Tier Notes

ENFAMIL NEUROPRO SENSITIVE

E

ENFAMIL NUTRAMIGEN LIPIL ORAL LIQUID

E

ENFAMIL NUTRAMIGEN LIPIL ORAL POWDER

E

ENFAMIL NUTRAMIGEN ORAL LIQUID

E

ENLYTE E

enovarx-amitriptyline E

ENTERAGAM E

enteric fish oil E

ENU PRO3 PLUS E

EPICOCCUM E

EPISIL E

EQUACARE JR E

ergoloid mesylates oral 1

ESSENTIAL CARE JR E

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

2 PA SP

FIRDAPSE E SP

FIRE ANT E

FLEXICHAMBER ADULT MASKSMALL

2

FLEXICHAMBER CHILD MASKLARGE

2

FLEXICHAMBER CHILD MASKSMALL

2

FORANE 3

formaldehyde external solution 10

E

FORMALDEHYDE SOLUTION 37 EXTERNAL (RX)

3

Drug Name Drug Tier Notes

FORMALDEHYDE SOLUTION 37 EXTERNAL (RX)

E

FOSTEUM PLUS E

FUSARIUM E

GELCLAIR E

GELFILM EXTERNAL E

GEL-FLOW E

GEL-FLOW NT E

GELFOAM E

GELFOAM COMPRESSED SIZE 100

E

GELFOAM DENTAL PACK SIZE 4

E

GELFOAM SPONGE E

GELFOAM SPONGE SIZE 100

E

GELFOAM SPONGE SIZE 200

E

GELFOAM SPONGE SIZE 50

E

GELFOAM-JMI POWDER

E

GELFOAM-JMI SPONGE

E

GELSYN-3 2 PA SP

GELX E

GERMAN COCKROACH

E

GIVLAARI 3 PA SP

GLEOLAN E

GLUTARALDEHYDE EXTERNAL

3

GLYTACTIN BETTERMILK 15

E

GLYTACTIN BETTERMILK DE-LITE

E

GLYTACTIN BUILD 10PE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

115

Drug Name Drug Tier Notes

GLYTACTIN BUILD 2020

E

GLYTACTIN BUILD 2020 PKU

E

GLYTACTIN BURST E

GLYTACTIN COMPLETE 10PE

E

GLYTACTIN RESTORE 10

E

GLYTACTIN RESTORE 5

E

GLYTACTIN RESTORE LITE 10

E

GLYTACTIN RESTORE LITE 10PE

E

GLYTACTIN RTD 10 LIQUID ORAL

E

GLYTACTIN RTD 15 E

GLYTACTIN RTD LITE 15 LIQUID ORAL

E

GLYTACTIN SWIRL 15PE

E

GOLDENROD E

GRASTEK 3 PA QL

HACKBERRY E

HCU EASY E

heparin lock flush intravenous solution 10 unitml

1

heparin sodium lock flush intravenous solution 100 unitml

1

HEPMED E

HIBICLENS E

HOMACTIN AA PLUS E

HOME PAP KIT E

HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

Drug Name Drug Tier Notes

HORSE EPITHELIUM E

HUMATROPEN FOR 12MG

E

HUMATROPEN FOR 24MG

E

HUMATROPEN FOR 6MG

E

HYALGAN E SP

HYLAFEM E

HYMOVIS E SP

INSPIREASE RESERVOIR BAGS

2

INTERCEED E

IOSAT E

isoflurane 1

JOHNSON GRASS E

JUNE GRASS POLLEN STANDARDIZED

E

KAPOK E

KETAMINE HCL SUBLINGUAL

3

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-09 MG5ML-

E

KETOVIE LIQUID ORAL

E

KETOVIE PEPTIDE E

KOCHIA E

LENSCALE E

LIMBREL E

LIMBREL250 E

LIMBREL500 E

LORMATE E

MACRILEN E

MEADOW FESCUE GRASS POLLEN

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

116

Drug Name Drug Tier Notes

MELALEUCA E

MESQUITE E

METHACHOLINE CHLORIDE INHALATION

E

METHAVER E

methergine oral 1 QL

METHOHEXITAL SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG10ML

E

methylergonovine maleate oral

1 QL

METOPIRONE E

MINIMED PUMP RESERVOIR 3ML

E

MITE (D FARINAE) SUBCUTANEOUS

E

MITE (D PTERONYSSINUS) SUBCUTANEOUS

E

MIXED ASPERGILLUS E

MIXED FEATHERS E

MIXED RAGWEED E

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100-1100-1100 MCG

E

MKO MELT DOSE PACK

E

mlk f1 E

mlk f2 E

mlk f3 E

mlk f4 E

MONOVISC E SP

MORCIN E

MOUNTAIN CEDAR E

Drug Name Drug Tier Notes

MOUSE EPITHELIUM E

MSUD EASY E

MUCOR SUBCUTANEOUS

E

MUCOTROL E

MUGARD E

MUGWORT E

MYOBLOC 3 PA SP

NEODOT THERMOMETER

E

NICAPRIN E

NICAZYME E

NORDIPEN 5 INJECTION DEVICE

E

ODACTRA 3 PA QL

odorless coated fish oil E

OLIVE TREE E

OMNIVEX E

ORALAIR 3 PA QL

ORALAIR ADULT STARTER PACK

3 PA QL

ORALAIR CHILDRENS STARTER PACK

3 PA QL

ORAMAGICRX E

ORCHARD GRASS POLLEN

E

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

OXBRYTA E SP

PALFORZIA E SP

PARI ALTERA NEBULIZER HANDSET

E

PARI TREK S COMBO PACK

E

PARI VORTEX ADULT MASK

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

117

Drug Name Drug Tier Notes

PEDIATRIC COMPRESSOR NEBULIZER

E

PENICILLIUM NOTATUM SUBCUTANEOUS

E

PH STRIPS E

PHEXXI E

PHOMA EXIGUA E

PHOTREXA-PHOTREXA VISCOUS KIT

3

PKU EASY E

PKU EASY MICROTABS

E

PKU GO E

PRAXBIND E

PRECEDEX INTRAVENOUS SOLUTION 1000 MCG250ML 200 MCG2ML 200 MCG50ML 400 MCG100ML 80 MCG20ML

E

PREMIUM CONDOMS LUBRICATED

E

PRID E

PRIVET E

PRO-CRITIC E

PROFESSIONAL DNA COLLECTION

E

PROLEVA E

PRONEB ULTRA FILTER SET

E

PSORIZIDE FORTE E

PSORIZIDE ULTRA E

PURAMINO DHAARA E

QUEEN PALM E

RABBIT EPITHELIUM E

RADIOGARDASE 3

Drug Name Drug Tier Notes

RAGWITEK 3 PA QL

RAPID GEL RX E

RED MAPLE E

RED MULBERRY E

RED TOP GRASS POLLEN

E

RESECTISOL E

RESOURCE THICKENUP JUICE

E

RHEUMATE E

RHIZOPUS E

RIBOZEL E

ROUGH MARSH ELDER

E

RUSSIAN THISTLE E

RUZURGI 3 PA SP

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS

E

SALICEPT MOUTHTHROAT SUSPENSION RECONSTITUTED

E

sevoflurane 1

SHAGBARK HICKORY E

SHARPS CONTAINER E

SHEEP SORREL E

SHORT RAGWEED POLLEN EXT

E

SILTREX E

SORBITOL IRRIGATION

E

sorbitol-mannitol E

SORRELDOCK MIX E

SPEEDGEL RX E

SPINRAZA 3 PA SP

SPINY PIGWEED E

STEMPHYLIUM E

SUPARTZ FX E SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

118

Drug Name Drug Tier Notes

SUPRANE 3

SWEET GUM E

SWEET VERNAL GRASS POLLEN

E

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

SYRINGE AVITENE E

TACHOSIL 3

TALL RAGWEED E

terrell 1

THROMBI-GEL 10 E

THROMBI-GEL 100 E

THROMBI-GEL 40 E

THROMBI-PAD E

THYROGEN 2 PA SP

TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS

E

TISSEEL EXTERNAL KIT

3

TOBAKIENT E

TRANZGEL E

TRAUMEEL EXTERNAL OINTMENT

E

TRAUMEEL ORAL TABLET

E

TRICHOPHYTON MENTAGROPHYTES

E

TRICHOPHYTON SUBCUTANEOUS

E

TRILURON E SP

TRUSTEEL INFUSION SET

E

T-SUPPORT MAX E

Drug Name Drug Tier Notes

TYLACTIN BUILD 20PE TYR

E

TYLACTIN COMPLETE 15 PE

E

TYLACTIN RESTORE 10

E

TYLACTIN RESTORE 5PE

E

TYLACTIN RTD 15 E

TYR EASY E

TYROS 2 E

ULTANE 3

ULTRA HERS RX E

ULTRA HIS E

ULTRA PCOS E

ULTRAFOAM SPONGE 2X625X7CM

E

ULTRAFOAM SPONGE 8X125X1CM

E

ULTRAFOAM SPONGE 8X125X3CM

E

ULTRAFOAM SPONGE 8X25X1CM

E

ULTRAFOAM SPONGE 8X625X1CM

E

VARISOFT INFUSION SET

E

VASCULERA E

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

$0 QL

vcf vaginal contraceptive vaginal gel

$0 QL

VILACTIN AA PLUS E

VILTEPSO E SP

VISTOGARD 3

VITRASE INJECTION SOLUTION

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

119

Drug Name Drug Tier Notes

WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

WELLMIND VERTIGO E

westab max E

WESTERN JUNIPER E

WHITE BIRCH E

WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

WHITE MULBERRY E

WHITE OAK E

WHITE PINE E

WIDE-SEAL DIAPHRAGM 60

$0 QL

WIDE-SEAL DIAPHRAGM 65

$0 QL

WIDE-SEAL DIAPHRAGM 70

$0 QL

WIDE-SEAL DIAPHRAGM 75

$0 QL

WIDE-SEAL DIAPHRAGM 80

$0 QL

WIDE-SEAL DIAPHRAGM 85

$0 QL

WIDE-SEAL DIAPHRAGM 90

$0 QL

WIDE-SEAL DIAPHRAGM 95

$0 QL

XEOMIN 3 PA SP

XIAFLEX 2 PA SP

XYZBAC E

XYZMUNE E

YELLOW DOCK E

Drug Name Drug Tier Notes

YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS

E

ZOKINVY 3 PA SP QL

ZYVEXOL E

ZYVIT E

Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation

ACULAR 3

ACULAR LS 3

ACUVAIL E

ALAWAY E

ALOCRIL E

ALOMIDE 3

ALREX E

AZASITE 3

azelastine hcl ophthalmic

1

bacitracin ophthalmic 1

BEPREVE E

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

BLEPH-10 3

bromfenac sodium (once-daily)

1 QL

BROMSITE E

CILOXAN 3

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

120

Drug Name Drug Tier Notes

dexamethasone sodium phosphate ophthalmic

1

DEXTENZA E SP

DEXYCU E

diclofenac sodium ophthalmic

1

DUREZOL E

epinastine hcl 1

erythromycin ophthalmic

1

eye itch relief E

EYSUVIS 3 PA

FLAREX 3

fluorometholone ophthalmic

1

flurbiprofen sodium 1

FML 2

FML FORTE 3

FML LIQUIFILM 3

gatifloxacin ophthalmic 1

gentak ophthalmic ointment

1

gentamicin sulfate ophthalmic solution

1

ILEVRO E

ILUVIEN INTRAVITREAL

E SP

INVELTYS 3

ketorolac tromethamine ophthalmic

1

KLARITY-A E

KLARITY-L E

levofloxacin ophthalmic 1

LOTEMAX OPHTHALMIC GEL

E

LOTEMAX OPHTHALMIC OINTMENT

E

Drug Name Drug Tier Notes

LOTEMAX OPHTHALMIC SUSPENSION

3

LOTEMAX SM 3

loteprednol etabonate ophthalmic gel

1 QL

loteprednol etabonate ophthalmic suspension

1

MAXIDEX 3

MITOSOL 3

MOXEZA 2

moxifloxacin hcl (2x day)

1

moxifloxacin hcl ophthalmic solution

1

MOXIFLOXACIN HCL OPHTHALMIC SOLUTION PREFILLED SYRINGE

E

NATACYN 2

NEVANAC E

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl solution 01 ophthalmic (otc)

E

olopatadine hcl solution 01 ophthalmic (rx)

1

olopatadine hcl solution 02 ophthalmic (otc)

E

olopatadine hcl solution 02 ophthalmic (rx)

1

OZURDEX INTRAVITREAL

E SP

PATADAY OPHTHALMIC SOLUTION 01 02

E

POVIDONE-IODINE OPHTHALMIC

3

PRED FORTE 3

PRED MILD 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

121

Drug Name Drug Tier Notes

PREDNISOL ACE-MOXIFLOX-BROMFEN

E

prednisolone acetate ophthalmic

1

prednisolone acetate p-f

E

prednisolone sodium phosphate ophthalmic

1

PREDNISOLON-MOXIFLOX-NEPAFENAC

E

PROLENSA 2 QL

RETISERT INTRAVITREAL

E SP

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX 3

trifluridine ophthalmic 1

TRIPLE PMB E

TRIPLE PMK E

UPNEEQ 3 PA

VANCOMYCIN HCL OPHTHALMIC

3

VIGAMOX 3

YUTIQ E SP

ZADITOR E

ZERVIATE E

ZIRGAN 3

ZYMAXID 3

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

ALPHAGAN P OPHTHALMIC SOLUTION 01

2

ALPHAGAN P OPHTHALMIC SOLUTION 015

E

Drug Name Drug Tier Notes

apraclonidine hcl 1

AZOPT 3

betaxolol hcl ophthalmic

1

BETIMOL 3

BETOPTIC-S 3

bimatoprost ophthalmic 1 QL

brimonidine tartrate ophthalmic

1

BRIMONIDINE-DORZOLAMIDE

E

brinzolamide 1

carteolol hcl 1

COMBIGAN 2

COSOPT 3

COSOPT PF OPHTHALMIC SOLUTION 2-05

3

DORZOLAMIDE HCL SOLUTION 2 OPHTHALMIC

3

dorzolamide hcl solution 2 ophthalmic

1

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

1

DURYSTA E

IOPIDINE OPHTHALMIC SOLUTION 1

3

ISOPTO CARPINE 3

ISTALOL 3

KEVEYIS 3 PA SP QL

latanoprost ophthalmic 1

LATANOPROST-TIMOLOL MALEATE

E

levobunolol hcl ophthalmic solution 05

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

122

Drug Name Drug Tier Notes

LUMIGAN OPHTHALMIC SOLUTION 001

2 QL

methazolamide oral 1

PHOSPHOLINE IODIDE

2

pilocarpine hcl ophthalmic solution 1 2 4

1

RHOPRESSA 3 QL

ROCKLATAN 3 QL

SIMBRINZA 2

timolol maleate ophthalmic

1

timolol maleate pf 1

TIMOLOL-BRIMON-DORZOL-LATANOPR

E

TIMOLOL-BRIMONIDINE-DORZOLAMID

E

TIMOLOL-DORZOLAMID-LATANOPROST

E

TIMOPTIC E

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 025

3

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 05

E

TIMOPTIC-XE E

TRAVATAN Z 3 QL

travoprost (bak free) 1 QL

TRUSOPT 3

VYZULTA E

XALATAN 3

XELPROS 3 ST QL

ZIOPTAN E

Drug Name Drug Tier Notes

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac 1

AKTEN 3

ALCAINE 3

ALTACAINE 3

altachlore E

ALTAFLUOR BENOX E

altafrin ophthalmic solution 10 25

1

artificial eye E

artificial tears ophthalmic solution 05-06 14

E

atropine sulfate ophthalmic ointment

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 001

E

atropine sulfate ophthalmic solution 1

1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unitgm

1

bacitra-neomycin-polymyxin-hc

1

BEOVU E SP

BEVACIZUMAB 3 SP

bimatoprost external E

BIO GLO E

BLEPHAMIDE 3

BLEPHAMIDE SOP 3

carboxymethylcellulose sodium ophthalmic solution 05

E

CEQUA E

CHONDROITIN SULFATE OPHTHALMIC

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

123

Drug Name Drug Tier Notes

cvs lubricant eye drops ophthalmic solution 04-03

E

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

E

CYSTADROPS 3 PA SP QL

CYSTARAN 3 PA SP QL

DOUBLE PM E

EYLEA INTRAVITREAL

3 PA SP

FLUCAINE E

FLUORESCEIN SODIUMBENOXINATE

E

fluorescein-benoxinate E

fluor-i-strips at E

FLURA-SAFE E

FUL-GLO E

GELFILM OPHTHALMIC

E

GENTEAL TEARS NIGHT-TIME

E

GENTEAL TEARS OPHTHALMIC SOLUTION 01-03

E

GENTEAL TEARS SEVERE DAYNIGHT

E

GLOSTRIPS OPHTHALMIC STRIP 1 MG

E

GREEN GLO LISSAMINE GREEN

E

homatropaire 1

HYPOCYN EXTERNAL SOLUTION

E

ISOPTO ATROPINE 3

LACRISERT 3

Drug Name Drug Tier Notes

LASTACAFT E

LATISSE E

lubricant eye drops ophthalmic solution 04-03

E

lubricant eye drops pf E

lubricant eye pm E

lubricant pm E

lubricating eye drops E

lubricating plus eye drops

E

LUCENTIS INTRAVITREAL

2 PA SP

LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 VGML

3 PA SP

MAXITROL 3

MURO 128 OPHTHALMIC OINTMENT

E

MURO 128 OPHTHALMIC SOLUTION 5

E

MYDRIACYL E

neomycin-bacitracin zn-polymyx

1

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 35-10000-01

1

neomycin-polymyxin-gramicidin ophthalmic solution 175-10000-025

1

neomycin-polymyxin-hc ophthalmic suspension 35-10000-1

1

neo-polycin 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

124

Drug Name Drug Tier Notes

neo-polycin hc 1

OXERVATE 3 PA SP QL

PAREMYD E

phenylephrine hcl ophthalmic solution 10 25

1

polycin 1

polymyxin b-trimethoprim

1

POLYTRIM 3

PRED-G 3

PRED-G SOP 3

PREDNISOLONE ACETATE-NEPAFENAC

E

PREDNISOLONE ACET-MOXIFLOXACIN

E

PREDNISOLONE-BROMFENAC

E

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION

E

PREDNISOLONE-MOXIFLOXACIN

E

PREDNISOLON-GATIFLOX-BROMFENAC

E

PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-05-0075

E

proparacaine hcl ophthalmic

1

proparacaine-fluorescein

E

REFRESH RELIEVA E

REFRESH RELIEVA PF OPHTHALMIC SOLUTION 05-09

E

Drug Name Drug Tier Notes

RESTASIS 2 PA

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 005

2 PA

sodium chloride (hypertonic)

E

sulfacetamide-prednisolone ophthalmic solution

1

SYSTANE COMPLETE E

SYSTANE HYDRATION PF

E

SYSTANE ULTRA PF E

tetracaine hcl ophthalmic

1

TOBRADEX OPHTHALMIC OINTMENT

3

TOBRADEX OPHTHALMIC SUSPENSION

E

TOBRADEX ST 3

tobramycin-dexamethasone

1

tropicamide ophthalmic E

TROPICAMIDE-CYCLOPENTOLATE-PE

E

TROPICAMIDE-PHENYLEPHRINE

E

TROPIC-CYCLOPENT-PE-KETOROLAC

E

TROPIC-CYCLOP-PE-KETO-PROPAR

E

TROPIC-PROPARACA-PE-KETOROLAC

E

ultra fresh pm E

ultra lubricating eye drops

E

VISIONBLUE 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

125

Drug Name Drug Tier Notes

VISTA GEL DRY EYE RELIEF

E

VISTA MEIBO TEARS E

VISTA TEARS E

VISUDYNE 3 SP

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CETRAXAL 3 ST

CIPRO HC 3

CIPRODEX E

ciprofloxacin hcl otic 1 ST

ciprofloxacin-dexamethasone

1

CIPROFLOXACIN-FLUOCINOLONE PF

E

cortic-nd 1

CORTISPORIN-TC 3

DERMOTIC 3

exotic-hc 1

flac 1

fluocinolone acetonide otic

1

hydrocortisone-acetic acid

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTIPRIO E

OTOVEL E

PRAMOTIC 3

Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold

12 hour allergy-d E

12 hour nasal decongestant nasal

E

Drug Name Drug Tier Notes

12hr allergy amp congestion

E

24hr allergy relief E

ADRENALIN NASAL E

all day allergy d E

all day allergy d-12 E

allergy 24hour indooroutdoor

E

allergy 24-hr E

allergy childrens E

allergy rel child (loratadine)

E

allergy relief cetirizine E

allergy relief d-12 E

allergy relief oral capsule 10 mg

E

allergy relief oral tablet 10 mg 180 mg 25 mg 4 mg

E

allergy relief oral tablet dispersible

E

allergy reliefindooroutdoor

E

allergy reliefnasal decongest oral tablet extended release 12 hour

E

allergy relief-d oral tablet extended release 12 hour

E

antihistamine amp nasal deconges

E

aurodryl allergy childrens

E

azelastine hcl nasal 1 QL

azelastine-fluticasone 1 QL

banophen oral capsule 25 mg

E

banophen oral tablet E

BECONASE AQ 3 QL

benzonatate 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

126

Drug Name Drug Tier Notes

carbinoxamine maleate oral solution

1

carbinoxamine maleate oral tablet 4 mg

1

carbinoxamine maleate oral tablet 6 mg

E

cetirizine hcl childrens oral tablet chewable 5 mg

E

cetirizine hcl oral solution

1

cetirizine hcl oral tablet E

cetirizine hcl oral tablet chewable 10 mg

E

cetirizine-pseudoephedrine er

E

chest congestion relief dm oral syrup

E

chest congestion relief oral syrup

E

chlorpheniramine maleate er

E

CHLOR-TRIMETON ORAL TABLET

E

CINQAIR 3 PA SP

CLARINEX ORAL TABLET

E

CLARINEX-D 12 HOUR

E

CLARITIN CHILDRENS TABLET CHEWABLE 5 MG ORAL

E

CLARITIN ORAL TABLET

E

CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG

E

CLARITIN-D 12 HOUR E

clemastine fumarate oral tablet 268 mg

1

cold amp flu relief daytime E

Drug Name Drug Tier Notes

coldflu daytime relief E

cough dm oral suspension extended release

E

coughchest congestion dm

E

CUROSURF INTRATRACHEAL SUSPENSION 120 MG15ML

3

cyproheptadine hcl oral 1

DAYHIST ALLERGY 12 HOUR RELIEF

E

daytime cold amp flu relief oral capsule

E

daytime coldflu relief oral capsule

E

DERMACINRX AZENASE PAK

E

desloratadine oral tablet

1

desloratadine oral tablet dispersible 5 mg

1

dexchlorpheniramine maleate oral solution

E

DICOPANOL FUSEPAQ

E

DICOPANOL RAPIDPAQ

E

dimaphen dm coldcough oral liquid

E

DI-PHEN E

diphen oral elixir 1

diphenhydramine hcl injection

E

diphenhydramine hcl oral capsule

E

diphenhydramine hcl oral elixir

1

diphenhydramine hcl oral liquid 125 mg5ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

127

Drug Name Drug Tier Notes

diphenhydramine hcl oral tablet 25 mg

E

DYMISTA 2 QL

FASENRA 2 PA SP

FASENRA PEN 2 PA SP

fexofenadine hcl oral tablet 180 mg 60 mg

E

fexofenadine-pseudoephed er oral tablet extended release 12 hour

E

flunisolide nasal solution 25 mcgact (0025)

1 QL

fluticasone propionate nasal

1

geri-dryl oral liquid E

geri-dryl oral tablet E

GILPHEX TR E

giltuss severe sinus E

goodsense tussin dm max

E

guaiatussin ac 1 PA QL

guaifenesin ac 1 PA QL

guaifenesin oral tablet 400 mg

E

guaifenesin-dm oral syrup

E

hm adult tussin cough amp chest

E

HYCODAN 3 PA QL

hydrocodone polst-chlorphen polst er susp oral suspension extended release

1 PA QL

hydrocodone-homatropine

1 PA QL

hydromet 1 PA QL

HYPERSAL 3

INFASURF INTRATRACHEAL

3

Drug Name Drug Tier Notes

ipratropium bromide nasal

1

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE

E

levocetirizine dihydrochloride oral

1

liquid allergy relief E

loratadine childrens oral tablet chewable

E

loratadine oral syrup E

loratadine oral tablet E

loratadine-d 12hr E

loratadine-d 24hr E

maxi-tuss ac 1 PA QL

maxi-tuss gmx E

maxi-tuss pe max E

m-dryl E

MICLARA LQ E

mometasone furoate nasal

1 QL

MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG5ML

E

MUCINEX CHILDRENS STUFFY NOSE

E

MUCINEX DM E

MUCINEX FAST-MAX DM MAX

E

mucus dm E

mucus relief d oral tablet extended release 12 hour 60-600 mg

E

mucus relief dm oral liquid

E

mucus relief max st E

mucus-d E

NASACORT ALLERGY 24HR

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

128

Drug Name Drug Tier Notes

nasal decongestant oral tablet 30 mg

E

nasal decongestant pe E

nasal moisturizing spray

E

nasal spray 12 hour E

nasal spray no drip E

NASONEX E

NEO-SYNEPHRINE COLDALLRG MILD

E

NEO-SYNEPHRINE COLDALLRGY EXT

E

NEO-SYNEPHRINE COLDALLRGY REG

E

NEOTUSS PLUS E

NUCALA 2 PA SP QL

olopatadine hcl nasal 1 QL

OMNARIS 3 QL

PATANASE 3 QL

pediaclear pd childrens E

PHENERGAN INJECTION

E

promethazine hcl injection

E

promethazine hcl oral 1

promethazine hcl rectal suppository 125 mg 25 mg

1

promethazine vc 1

promethazine vccodeine

1 PA QL

promethazine-codeine 1 PA QL

promethazine-dm oral syrup

1

promethazine-phenyleph-codeine

1 PA QL

promethazine-phenylephrine

1

promethegan 1

PROPEL E

Drug Name Drug Tier Notes

PROPEL MINI E

pseudoephedrine hcl er E

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg5ml

1

pseudoephedrine-guaifenesin er

E

QNASL 3 QL

QNASL CHILDRENS 3 QL

ROBITUSSIN 12 HOUR COUGH CHILD

E

ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG20ML

E

RYCLORA ORAL SOLUTION

3

ryvent E

sinus 12 hour E

SINUVA E

sodium chloride inhalation nebulization solution 09 10 3 7

1

SSKI E

SUDAFED CONGESTION

E

sudogest 12 hour E

sudogest maximum strength

E

sudogest oral tablet 30 mg

E

SURVANTA INTRATRACHEAL

3

TESSALON PERLES 3

triprolidine hcl oral liquid 0313 mgml 0625 mgml 0938 mgml 25 mg5ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

129

Drug Name Drug Tier Notes

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG

E

tussin cf multi-symptom cold

E

tussin dm max adult oral liquid 5-100 mg5ml

E

tussin dm max oral liquid 20-400 mg20ml

E

tussin dm oral syrup 100-10 mg5ml

E

TUXARIN ER E

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE

E

virtussin ac walc 1 PA QL

wal-tap coldallergy oral elixir

E

XHANCE E

XOLAIR 2 PA SP

ZETONNA 3 QL

ZYRTEC ALLERGY ORAL TABLET

E

Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE 3

acetylcysteine inhalation

1

ADRENALIN INJECTION SOLUTION 1 MGML

3

ADVAIR DISKUS 1 QL

ADVAIR HFA 2 QL

ADYPHREN E

ADYPHREN AMP E

ADYPHREN AMP II E

ADYPHREN II E

Drug Name Drug Tier Notes

AIRDUO DIGIHALER E

AIRDUO RESPICLICK 11314

E

AIRDUO RESPICLICK 23214

E

AIRDUO RESPICLICK 5514

E

albuterol sulfate er 1

albuterol sulfate hfa aerosol solution 108 (90 base) mcgact inhalation

1 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCGACT INHALATION

E

albuterol sulfate inhalation nebulization solution (25 mg3ml) 0083 063 mg3ml 125 mg3ml 25 mg05ml

1 QL

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MGML) 05 INHALATION

E

albuterol sulfate nebulization solution (5 mgml) 05 inhalation

1 QL

albuterol sulfate oral 1

ALVESCO E

ANORO ELLIPTA 2 QL

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG

3 PA SP

ARMONAIR DIGIHALER

E

ARNUITY ELLIPTA 2 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

130

Drug Name Drug Tier Notes

ASMANEX (120 METERED DOSES)

E

ASMANEX (14 METERED DOSES)

E

ASMANEX (30 METERED DOSES)

E

ASMANEX (60 METERED DOSES)

E

ASMANEX (7 METERED DOSES)

E

ASMANEX HFA E

ATROVENT HFA 3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 01 MG01ML

3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 015 MG015ML 03 MG03ML

E

BEVESPI AEROSPHERE

E

BREO ELLIPTA 2 QL

BREZTRI AEROSPHERE

2 QL

BROVANA 3 QL

budesonide inhalation 1 QL

BUDESONIDE-FORMOTEROL FUMARATE

E

COMBIVENT RESPIMAT

2 QL

cromolyn sodium inhalation

1

DALIRESP 3 PA

DUAKLIR PRESSAIR E

DULERA E

ELIXOPHYLLIN 2

epinephrine injection solution auto-injector 015 mg015ml

1 ST

Drug Name Drug Tier Notes

epinephrine injection solution auto-injector 015 mg03ml

1

EPINEPHRINE PROFESSIONAL

E

epinephrine solution auto-injector 03 mg03ml injection

1 ST

epinephrine solution auto-injector 03 mg03ml injection

1

EPINEPHRINESNAP-EMS

E

EPINEPHRINESNAP-V E

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR

3 ST

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR

E

EPISNAP E

ESBRIET 3 PA SP

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcgdose inhalation

1 QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcgdose inhalation

E

fluticasone-salmeterol aerosol powder breath activated 250-50 mcgdose inhalation

1 QL

fluticasone-salmeterol aerosol powder breath activated 250-50 mcgdose inhalation

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

131

Drug Name Drug Tier Notes

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCGACT 232-14 MCGACT 55-14 MCGACT

1 ST QL

fluticasone-salmeterol inhalation aerosol powder breath activated 500-50 mcgdose

E

GLASSIA 3 PA SP

INCRUSE ELLIPTA E

ipratropium bromide inhalation

1 QL

ipratropium-albuterol 1 QL

levalbuterol hcl inhalation nebulization solution 031 mg3ml 063 mg3ml 125 mg05ml 125 mg3ml

1 QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCGACT

E

LONHALA MAGNAIR REFILL KIT

3 QL

LONHALA MAGNAIR STARTER KIT

3 QL

montelukast sodium oral

1

OFEV 3 PA SP

PERFOROMIST 3 QL

PROAIR DIGIHALER E

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROLASTIN-C INTRAVENOUS SOLUTION

3 PA SP

Drug Name Drug Tier Notes

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

3 PA SP

PROVENTIL HFA E

PULMICORT FLEXHALER

2 QL

PULMICORT SUSPENSION

E

QVAR REDIHALER E

SEEBRI NEOHALER E

SEREVENT DISKUS 2 QL

SINGULAIR E

SPIRIVA HANDIHALER

2 QL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 125 MCGACT 25 MCGACT

2 QL

STERITALC 3

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 25-25 MCGACT

2 QL

STRIVERDI RESPIMAT

2 ST QL

SYMBICORT 2 QL

SYMJEPI 3

terbutaline sulfate injection

E

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

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

1

theophylline er oral tablet extended release 24 hour

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

132

INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCGACT

E

UTIBRON NEOHALER E

VENTOLIN HFA 2 QL

wixela inhub E

XOPENEX NEB 3 QL

XOPENEX CONCENTRATE

3 QL

XOPENEX HFA E

YUPELRI 3 QL

zafirlukast 1

ZEMAIRA 3 PA SP

zileuton er 1 ST

ZYFLO E

Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS E SP

BRONCHITOL E

BRONCHITOL TOLERANCE TEST

E

CAYSTON E SP

KALYDECO 3 PA SP

KITABIS PAK E SP

ORKAMBI 3 PA SP QL

PULMOZYME 2 PA SP

SYMDEKO 3 PA SP QL

TOBI NEBULIZER E SP

TOBI PODHALER 3 ST SP QL

tobramycin inhalation nebulization solution 300 mg4ml

1 SP

tobramycin nebulization solution 300 mg5ml inhalation

E SP

Drug Name Drug Tier Notes

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG5ML INHALATION

E SP

TRIKAFTA 3 PA SP QL

Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA 3 PA SP QL

ADEMPAS 2 PA SP QL

alyq 1 PA SP QL

ambrisentan 1 PA SP QL

bosentan 1 PA SP QL

epoprostenol sodium 1 PA SP

FLOLAN 3 PA SP

LETAIRIS 3 PA SP QL

OPSUMIT 2 PA SP QL

ORENITRAM 3 PA SP

REMODULIN INJECTION SOLUTION 100 MG20ML 20 MG20ML 200 MG20ML 50 MG20ML

E SP

REVATIO INTRAVENOUS

3 PA SP

REVATIO ORAL 3 PA SP QL

sildenafil citrate intravenous

1 PA SP

sildenafil citrate oral suspension reconstituted

1 PA SP QL

sildenafil citrate oral tablet 20 mg

1 PA SP QL

tadalafil (pah) 1 PA SP QL

TRACLEER 625 MG 125 MG

E SP

TRACLEER 32 MG 3 PA SP QL

treprostinil 1 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

133

Drug Name Drug Tier Notes

TRELEGY ELLIPTA 2 QL

TUDORZA PRESSAIR

Drug Name Drug Tier Notes

TYVASO 3 PA SP QL

TYVASO REFILL 3 PA SP QL

TYVASO STARTER 3 PA SP QL

UPTRAVI 3 PA SP QL

VELETRI 3 PA SP

VENTAVIS 3 PA SP QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX E

BACLOFEN EXTERNAL

E

baclofen intrathecal E

baclofen oral 1

carisoprodol oral 1

chlorzoxazone oral tablet 250 mg

1 QL

chlorzoxazone oral tablet 375 mg 500 mg 750 mg

1

CYCLOGABA 10300 E

cyclobenzaprine hcl er 1

cyclobenzaprine hcl oral tablet 5 mg 75 mg

1

cyclobenzaprine hcl tablet 10 mg oral

1

cyclobenzaprine hcl tablet 10 mg oral

E

CYCLOPAK E

CYCLOPHENE RAPIDPAQ

E

DANTRIUM ORAL CAPSULE 25 MG 50 MG

3

dantrolene sodium oral 1

enovarx-baclofen E

enovarx-cyclobenzaprine hcl

E

FEXMID 3

Drug Name Drug Tier Notes

FIRST-BACLOFEN E

GABLOFEN INTRATHECAL SOLUTION 10000 MCG20ML 20000 MCG20ML 40000 MCG20ML

E

GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 10000 MCG20ML 20000 MCG20ML 40000 MCG20ML 50 MCGML

E

LIORESAL E

LORZONE 3

METAXALL CP E

metaxalone 1

methocarbamol oral 1

NOPIOID-LMC KIT E

NORGESIC FORTE E

orphenadrine citrate er 1

orphenadrine-asa-caffeine

1

ORPHENGESIC FORTE ORAL TABLET 50-770-60 MG

E

OZOBAX E

SKELAXIN E

SOMA 3

TABRADOL FUSEPAQ E

TABRADOL RAPIDPAQ

E

tizanidine hcl oral 1

VANADOM 3

ZANAFLEX E

Sleep Disorder Agents

AMBIEN E

AMBIEN CR E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

134

Drug Name Drug Tier Notes

armodafinil 1 PA QL

BELSOMRA 3 ST QL

DAYVIGO 3 ST QL

doxepin hcl oral tablet 1 QL

EDLUAR E

eszopiclone 1 QL

flurazepam hcl 1 PA QL

HETLIOZ 3 PA SP QL

HETLIOZ LQ E SP

LUNESTA E

modafinil 1 PA QL

NUVIGIL E

PROVIGIL E

ramelteon 1 QL

RESTORIL E

ROZEREM 3 QL

SILENOR 3 QL

sleep aid (diphenhydramine)

E

sleep-aid oral capsule E

SUNOSI 2 PA QL

temazepam 1 QL

WAKIX 3 PA SP QL

XYREM 3 PA SP QL

XYWAV 3 PA SP QL

zaleplon 1 QL

zolpidem tartrate 1 QL

zolpidem tartrate er 1 QL

ZOLPIMIST 3 ST QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

135

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

136

Index of Drugs

12 hour allergy-d 12612 hour nasal decongestant12612hr allergy amp congestion 1261ST MEDX-PATCH LIDOCAINE1724hr allergy relief 1263232a infant formula 1127T LIDO 178 hour pain reliever 98 hr arthritis pain relief 9AAGC KIT IN TERODERM 60abacavir sulfate44abacavir sulfate-lamivudine 44abacavir-lamivudine-zidovudine44ABANEU-SL77ABILIFY43ABILIFY MAINTENA 43ABILIFY MYCITE 43ABILIFY MYCITE MAINTENANCE KIT 43ABILIFY MYCITE STARTER KIT 43abiraterone acetate 35ABRAXANE 35ABREVA 60ABSORICA 60ABSORICA LD60ACACIA112acamprosate calcium 20ACANYA 60acarbose 72ACCOLATE130ACCUCAINE17ACCU-CHEK AVIVA DEVICE73ACCU-CHEK AVIVA PLUS KIT WDEVICE73ACCU-CHEK COMPACT PLUS CONTROL 73ACCU-CHEK COMPACT PLUS TEST STRIPS 73ACCU-CHEK FASTCLIX LANCET KIT 73ACCU-CHEK GUIDE CONTROL 73ACCU-CHEK GUIDE TEST STRIPS 73ACCU-CHEK SMARTVIEW CONTROL 73ACCU-CHEK SMARTVIEW TEST STRIPS73ACCU-CHEK SOFTCLIX LANCET DEVICE KIT73

ACCU-CHEK TENDER 1 INFUSION112ACCU-CHEK ULTRAFLEX INF SET 112ACCUPRIL50ACCURETIC 50accutane 60ACD-A NOCLOT-5026acebutolol hcl 50ACESO AG 60acetaminophen 9acetaminophen 8 hour 9acetaminophen childrens 9acetaminophen er 9acetaminophen extra strength 9acetaminophen-codeine9acetaminophen-codeine 29acetaminophen-codeine 39acetaminophen-codeine 49acetazolamide122acetazolamide er122acetic acid 126acetylcysteine 130acid reducer 85ACIOXIAY 60ACIPHEX 85ACIPHEX SPRINKLE 85acitretin 60ACREMONIUM 112ACST KIT112ACTEMRA 105ACTEMRA ACTPEN105ACTHAR 97ACTHIB108ACTICLATE 21ACTIFOAM COLLAGEN SPONGE112ACTIMMUNE 105ACTIPHLORA 86ACTIQ 9ACTITROM-D 77ACTIVASE 26ACTIVE FE 77ACTIVE INJECTION D 94ACTIVE INJECTION KIT L 94ACTIVE INJECTION KL-3 94ACTIVE INJECTION LM-217ACTIVE INJECTION LM-DEP-2 94ACTIVELLA99ACTIVITE77ACTONEL 111ACTOPLUS MET 72

ACTOS72ACULAR 120ACULAR LS 120ACUNOL 112ACUVAIL120acyclovir 44ACYCLOVIX 44ACZONE 60ADACEL109ADAINZDE60ADAINZOXIA 60ADAKVEO112adapalene 60ADAPALENE 60ADAPALENE-BENZOYL PER-CLINDAMY 60ADAPALENE-BENZOYL PER-NIACINAM 60adapalene-benzoyl peroxide60ADAPALENE-BENZOYL PEROXIDE 60ADASUVE43adcf (05mgml) 77ADCETRIS35ADCIRCA133ADDERALL 56ADDERALL XR 56ADDYI 58adefovir dipivoxil 44ADEMPAS 133ADHANSIA XR56ADIPEX-P 58ADLYXIN72ADLYXIN STARTER PACK 72ADMELOG 75ADMELOG SOLOSTAR 75ADRENAL C FORMULA77ADRENALIN 126 130adriamycin35ADULT AEROSOL MASK112adult aspirin regimen14ADVAIR DISKUS 130ADVAIR HFA 130ADVANCED ALLERGY COLLECTION 60ADVATE48ADVIL14ADVIL JUNIOR STRENGTH 14ADVIL LIQUI-GELS MINIS 14ADVIL MIGRAINE14ADYNOVATE48ADYPHREN 130ADYPHREN AMP 130

137

ADYPHREN AMP II 130ADYPHREN II 130ADZENYS ER 56ADZENYS XR-ODT 56AEMCOLO 21AERIVA CONCENTRATOR NEBULIZER112AFINITOR 35AFINITOR DISPERZ35afirmelle 99AFLURIA QUADRIVALENT109AFREZZA75AFSTYLA 48AGONEAZE 17AGRYLIN 48aif 2 drug preparation kit 14AIF 3 DRUG PREPARATION KIT 14AIMOVIG34airavite 77AIRDUO DIGIHALER130AIRDUO RESPICLICK 11314130AIRDUO RESPICLICK 23214130AIRDUO RESPICLICK 5514130AJOVY 34AKLIEF60AKOVAZ 50ak-poly-bac 123AKTEN 123AKYNZEO30ALA SCALP 60ala-cort 60ALA-QUIN 31ALAWAY 120albendazole41ALBENZA41albuterol sulfate130ALBUTEROL SULFATE 130albuterol sulfate er 130albuterol sulfate hfa130ALBUTEROL SULFATE HFA 130ALCAINE123alclometasone dipropionate 60ALCOHOL PREP PADS 112ALCORTIN A 31ALDACTAZIDE 50ALDACTONE 50ALDARA60ALDER 112ALDURAZYME 91ALECENSA35alendronate sodium 111ALEVAMAX60

ALEVE 14ALFERON N 105alfuzosin hcl er 94ALIMTA 35ALINIA41ALIQOPA 35aliskiren fumarate50ALKERAN 35ALKINDI SPRINKLE 94all day allergy d 126all day allergy d-12126allergy 24hour indooroutdoor 126allergy 24-hr 126allergy childrens 126allergy rel child (loratadine)126allergy relief126allergy relief cetirizine 126allergy relief d-12 126allergy reliefindooroutdoor 126allergy reliefnasal decongest 126allergy relief-d 126allopurinol34ALLZITAL9almotriptan malate 34ALOCRIL120ALOE VESTA CLEAR ANTIFUNGAL 31ALOGLIPTIN BENZOATE 72ALOGLIPTIN-METFORMIN HCL72ALOGLIPTIN-PIOGLITAZONE 72ALOMIDE120ALORA99alosetron hcl86ALOXI 30ALPHAGAN P 122ALPHANATE48ALPHANINE SD48alprazolam 47alprazolam er 47alprazolam intensol 47alprazolam xr 47ALPROLIX 48ALREX 120ALTABAX21ALTACAINE 123ALTACE 50altachlore 123ALTAFLUOR BENOX 123altafrin 123altavera 99ALTERNARIA 112ALTOPREV50

ALTRENO 60alum amp mag hydroxide-simeth 86alumina-magnesia-simethicone 86ALUNBRIG36ALVESCO 130alvimopan86alyacen 13599alyacen 77799alyq 133amabelz 99amantadine hcl42AMARYL 72AMBIEN 134AMBIEN CR 134ambrisentan 133amcinonide60 61AMELUZ 61AMERGE 34AMERICAN BEECH112AMERICAN COCKROACH112AMERICAN ELM112amethia 99amethyst 99AMICAR 48amikacin sulfate 21amiloride hcl50amiloride-hydrochlorothiazide 50aminoacetic acid 92aminoamrms 77aminocaproic acid 48AMINOPMRMS112aminoreliefrms 77amiodarone hcl 50AMITIZA86amitriptyline hcl 29AMLODIPINE BES+SYRSPEND SF 50amlodipine besylate 50amlodipine besylate-benazepril hcl 50amlodipine besylate-valsartan 50amlodipine-atorvastatin50amlodipine-olmesartan50amlodipine-valsartan-hctz 50ammonium lactate61amnesteem 61AMONDYS 4591amoxapine 29amoxicill-clarithro-lansopraz 86amoxicillin 21amoxicillin-potassium clavulanate21

138

amoxicillin-potassium clavulanate er21AMPHETAMINE ER56amphetamine sulfate56amphetamine-dextroamphetamine 56amphetamine-dextroamphetamine er 56ampicillin 21ampicillin-sulbactam sodium 21AMPYRA57AMRIX134AMZEEQ61ANACAINE61ANAFRANIL29anagrelide hcl48ana-lex 110ANALPRAM HC 110ANALPRAM HC SINGLES 110ANALPRAM-HC110ANASPAZ 86anastrozole 36ANCOBON31ANDEXXA112ANDRODERM 96ANDROGEL96ANDROGEL PUMP 96ANGELIQ 99ANIMI-377ANIMI-3VITAMIN D77ANNOVERA99ANODYNE LPT17ANORO ELLIPTA 130antacid 86antacid anti-gas max strength86antacid calcium 86antacid calcium rich 86antacid extra strength 86antacid maximum86antacid regular strength 86antacid ultra strength 86antacidantigas86antacidanti-gas86ANTARA 50ANTICOAGULANT SODIUM CITRATE26anti-diarrheal 86 87antihistamine amp nasal deconges 126ANTIVENIN LATRODECTUS MACTANS 112ANTIVENIN MICRURUS FULVIUS112

anucort-hc 110ANUSOL-HC110ANZEMET30APADAZ9apap-caff-dihydrocodeine 9APEXICON E 61APIDRA SOLOSTAR 75APIDRA VIAL75APLENZIN 29APOKYN 42APP SLIM RMS 112apraclonidine hcl 122aprepitant 30apri 100APRISO 110APRIZIO PAK 17APRIZIO PAK II 17APTENSIO XR56APTIOM 27APTIVUS44AQUAPHILIC 61AQUASOL A 77ARAKODA 41ARALAST NP130aranelle 100ARANESP (ALBUMIN FREE)48ARAVA105ARAZLO61ARCALYST 105ARESTIN 59ARICEPT 29ARIDA 61ARIDOL113ARIKAYCE21ARIMIDEX36aripiprazole 43ARISTADA 43ARISTADA INITIO 43ARIXTRA 26ARIZONA CYPRESS113armodafinil 135ARMONAIR DIGIHALER 130ARMOUR THYROID104ARNUITY ELLIPTA130AROMASIN36ARRANON 36arsenic trioxide36arthritis pain reliever9ARTHROTEC14artificial eye 123artificial tears123ARTISS 113ARZERRA36

ARZOL SILVER NIT APPLICATORS61ASACOL HD 110ASCENIV 105ascomp-codeine9ASCOR 77ASCORBIC ACID77ascorbic acid 77asenapine maleate43ashlyna100asilnasalrms 113ASMANEX (120 METERED DOSES) 131ASMANEX (14 METERED DOSES) 131ASMANEX (30 METERED DOSES) 131ASMANEX (60 METERED DOSES) 131ASMANEX (7 METERED DOSES) 131ASMANEX HFA 131ASPARLAS 36ASPARTAME113ASPARTAME (NUTRASWEET) 113aspirin 14aspirin adult low strength 14aspirin childrens 14aspirin ec14aspirin ec low dose 14aspirin ec low strength 14aspirin low dose 14aspirin-dipyridamole er43ASPIRIN-OMEPRAZOLE 43ASTAGRAF XL 105ASTERO 17ASTRAZENECA COVID-19 VACCINE 109ASTRINGYN 48ATABEX OB77ATACAND50ATACAND HCT 50atazanavir sulfate44ATELVIA 111atenolol 50ATENOLOL+SYRSPEND SF 50atenolol-chlorthalidone50ATGAM 105athletes foot (terbinafine) 31ATIVAN 47atomoxetine hcl56ATOPADERM 61

139

ATOPICLAIR61atorvastatin calcium 50atovaquone 41atovaquone-proguanil hcl41ATRALIN61ATRIPLA 44ATROPEN87atropine sulfate 87 123ATROPINE SULFATE 87 123ATROVENT HFA 131AUBAGIO57aubra100aubra eq100AUGMENTIN 21AUGMENTIN ES-600 21AUREOBASIDIUM113aurodryl allergy childrens 126aurophen childrens 9aurovela 1530 100aurovela 120 100aurovela 24 fe 100aurovela fe 1530 100aurovela fe 120 100AURYXIA 92AUSTEDO58AUSTRALIAN PINE 113AUTOLET LANCING DEVICE 73AUTOSOFT 30 INFUSION SET 113AUTOSOFT 90 INFUSION SET 113AUTOSOFT XC INFUSION SET 113AUVI-Q131AVAILNEX 113AVALIDE50AVAPRO 50AVAR CLEANSER61AVAR LS CLEANSER 61AVAR-E EMOLLIENT 61AVAR-E GREEN61AVAR-E LS 61AVASTIN36AVEED96AVEIDAOXIA 61aviane 100avidoxy21AVIDOXY DK 21AVITA61AVITENE113AVITENE FLOUR 113AVODART94AVONEX PEN57

AVONEX PREFILLED 57AVSOLA105AXONA 113AYGESTIN100ayuna 100AYVAKIT36azacitidine 36AZADROX61AZALGIA113AZASAN105AZASITE 120azathioprine 105azathioprine sodium105azelaic acid 61AZELAIC ACID-NIACINAMIDE61azelastine hcl 120 126azelastine-fluticasone 126AZELEX 61AZESCHEW PRENATALPOSTNATAL77AZESCO 77AZILECT 42azithromycin21azo tabs 92AZOPT 122AZOR 50AZULFIDINE 110AZULFIDINE EN-TABS 110azurette 100B-12 COMPLIANCE INJECTION 77b-6 folic acid77bac 9BACICAP 87bacitracin21 120bacitracin zinc 21bacitracin-polymyxin b 123bacitra-neomycin-polymyxin-hc 123BACLOFEN134baclofen 134BACMIN 77BACTRIM21BACTRIM DS21BAFIERTAM 57BAHIA 113BALCOLTRA100BALD CYPRESS 113balsalazide disodium110balsam peru-castor oil 61BALVERSA 36balziva100BAMLANIVIMAB 105

banophen 126BANZEL 27BAQSIMI ONE PACK 75BAQSIMI TWO PACK75BARACLUDE 44BASAGLAR KWIKPEN 75BAVENCIO 36BAXDELA 21BAYBERRY (WAX MYRTLE) 113BAYER ASPIRIN 14BAYER ASPIRIN EC LOW DOSE14BCG VACCINE 109b-complexb-12 77BEAU RX 61BECONASE AQ126bekyree 100BELBUCA 9BELEODAQ 36belladonna alkaloids-opium 87BELRAPZO36BELSOMRA 135benazepril hcl50benazepril-hydrochlorothiazide 51BENDEKA36BENEFIX48BENICAR 51BENICAR HCT51BENLYSTA 105BENSAL HP61BENZ PER-CLIND-NIACIN-TRETIN 61BENZAC AC WASH61BENZACLIN61BENZACLIN WITH PUMP 61BENZALKONIUM CHLORIDE 21benzalkonium chloride 21BENZAMYCIN 61BENZEPRO 61benzepro 61BENZEPRO CREAMY WASH 61BENZEPRO FOAMING CLOTHS 61BENZEPRO SHORT CONTACT61BENZHYDROCODONE-ACETAMINOPHEN9BENZNIDAZOLE 41BENZODOX21BENZOIN 61benzoin compound61BENZO-LIDOCAINE-TETRACAINE 17

140

benzonatate 126BENZOYL PEROX-HYDROCORTISONE61benzoyl peroxide61BENZOYL PEROXIDE61BENZOYL PEROXIDE FORTE- HC 61benzoyl peroxide-erythromycin 61benzphetamine hcl58benztropine mesylate42BEOVU 123BEPREVE 120BERINERT105BERMUDA GRASS 113BESER61beser 61BESIVANCE 120BESPONSA 36BETA 1 KIT 94BETADINE OPHTHALMIC PREP 120BETALOAN SUIK 94BETAMETHASONE COMBO 94betamethasone dipropionate 61betamethasone dipropionate aug 61BETAMETHASONE DIPROP-MINOXIDIL61BETAMETHASONE SOD PHOS amp ACET94betamethasone sod phos amp acet 94betamethasone valerate 62BETAPACE51BETAPACE AF 51BETASERON57betaxolol hcl 51 122bethanechol chloride92BETHKIS133BETIMOL 122BETOPTIC-S 122BEVACIZUMAB 123BEVESPI AEROSPHERE131bexarotene 36BEXSERO109BEYAZ 100BHI URI-CONTROL 113BIAFINE 62bicalutamide36BICILLIN L-A21BICNU36BIDIL 51BIESTPROGESTERONE 100

BIIFENAC 1000 14BIIFENAC 500 14BIJUVA 100BIKTARVY 44BILTRICIDE 41bimatoprost 122 123BI-MIX 92BINOSTO111BIO GLO 123biocel77BIONECT 62biopetit 77BIOTHRAX109biotin 77bisacodyl 87bisacodyl ec 87bismuth subsalicylate87bisoprolol fumarate 51bisoprolol-hydrochlorothiazide 51BIVIGAM 105BLACK WILLOW113blanche 62BLENREP 36bleomycin sulfate 36BLEPH-10 120BLEPHAMIDE123BLEPHAMIDE SOP 123BLINCYTO 36blisovi 24 fe 100blisovi fe 1530 100blisovi fe 120 100blue tube aloe 17BLUESTAR 73BONIVA 111BONJESTA 30BOOSTRIX 109BORTEZOMIB 36bosentan 133BOSULIF36BOTOX 113BOTOX COSMETIC 62BOTRYTIS 113bp 10-162bp cleansing wash 62bp vit 3 77bp wash62BPCO62b-plex 77b-plex plus77BRAFTOVI 36BREATHE EASE HUMIDIFIER 113

BREATHE EASE NEB MASKCHILD 113BREATHE EASE NEB MASKINFANT113BREO ELLIPTA 131BREYANZI 36BREZTRI AEROSPHERE131BRIDION 113briellyn100BRILINTA43brimonidine tartrate 122BRIMONIDINE-DORZOLAMIDE122BRINEURA 91brinzolamide122BRISDELLE 29BRIVIACT 27BROME113bromfenac sodium (once-daily) 120bromocriptine mesylate42BROMSITE 120BRONCHITOL 133BRONCHITOL TOLERANCE TEST133BROVANA 131BRUKINSA36BRYHALI62BSP 082094budesonide 110 131budesonide er 110BUDESONIDE-FORMOTEROL FUMARATE131bumetanide 51BUMEX 51BUNAVAIL 20BUPAP9BUPHENYL91bupivacaine fisiopharma 17BUPIVACAINE HCL17 18bupivacaine hcl 17bupivacaine hcl (pf)17BUPRENEX 9buprenorphine9buprenorphine hcl 9 20buprenorphine hcl-naloxone hcl 20bupropion hcl 29bupropion hcl er (smoking det) 20bupropion hcl er (sr)29bupropion hcl er (xl) 29BUPROPION HCL ER (XL) 29buspirone hcl47

141

busulfan 36BUSULFEX 36butalbital-acetaminophen9BUTALBITAL-ACETAMINOPHEN9butalbital-apap-caff-cod 9butalbital-apap-caffeine9butalbital-asa-caff-codeine9butalbital-aspirin-caffeine 9butorphanol tartrate10BUTRANS10BYDUREON BCISE AUTOINJECTOR 72BYETTA 10 MCG PEN 72BYETTA 5 MCG PEN 72BYNFEZIA PEN 97BYSTOLIC 51CABENUVA 44cabergoline 97CABLIVI 43CABOMETYX 36CADIRAMD18CADUET 51CAFERGOT 34caffeine citrate58calamine62CALAN SR 51calcidol 77CALCIFOL 77calcipotriene62CALCIPOTRIENE 62calcipotriene-betameth diprop62CALCIPOTRIENE-CLOBETASOL PROP62calcitonin (salmon) 111CALCITRENE 62calcitriol 62 112calcium acetate 92calcium acetate (phos binder)92calcium-folic acid plus d 77CALDOLOR 14CALIFORNIA PEPPER TREE 113CALQUENCE36CAMBIA 14camila100CAMINO PRO COMPLETEGLYTACTIN 113CAMPATH 36CAMPTOSAR 36camrese 100camrese lo 100CANASA 110CANCIDAS 31

candesartan cilexetil 51candesartan cilexetil-hctz51CANDIDA ALBICANS EXTRACT 113CANTHARIDIN 62CAPASTAT SULFATE35capecitabine36CAPEX62CAPLYTA43CAPRELSA36capsaicin 62CAPSAICIN-MENTHOL18CAPSFENAC PAK14CAPSINAC14captopril 51captopril-hydrochlorothiazide 51capzix62CARAC 62CARAFATE85CARBAGLU 77carbamazepine 27carbamazepine er 27CARBATROL 27carbidopa 42carbidopa-levodopa 42carbidopa-levodopa er 42carbidopa-levodopa-entacapone 42carbinoxamine maleate127carboplatin 36carboxymethylcellulose sodium 123CARDIOPLEGIA DEL NIDO FORMULA 77CARDIOPLEGIA IND PLASMA HIGH K77CARDIOPLEGIA IND PLASMA-TROMET 77CARDIOPLEGIA INDUCTION HIGH K77CARDIOPLEGIA INDUCTION LOW DEX 77CARDIOPLEGIA INDUCTION NON-ENR 78CARDIOPLEGIA MAIN LOW DEXTROSE 78CARDIOPLEGIA MAIN LOW TROMETHA78CARDIOPLEGIA MAIN PLASMA-TROME 78CARDIOPLEGIA MAINTENANCE78

CARDIOPLEGIA REPERFUSATE 41 78CARDIOVID PLUS113CARDIZEM 51CARDIZEM CD 51CARDIZEM LA51CARDURA 51CARDURA XL94CARETOUCH 2 CPAP HOSE HANGER113CARETOUCH CONTROL SOL LEVEL 273CARETOUCH CPAP amp BIPAP HOSE113CARETOUCH CPAP MASK WIPES 113CARETOUCH CPAP PRE-WASH SOLN 113CARETOUCH CPAP TUBE BRUSH 113CARETOUCH LANCINGEJECTOR 73CARETOUCH TEST 73CARETOUCH UNIVERSL CPAP FILTER113CARIMUNE NF 105carisoprodol 134carisoprodol-aspirin-codeine10carmustine 36CARNITOR 78CARNITOR SF78CAROSPIR 51carteolol hcl122cartia xt 51CARTICEL 113carvedilol51carvedilol phosphate er51cascara sagrada 87CASIRIVIMAB105CASODEX 36caspofungin acetate32CAT HAIR EXTRACT 113CATAFLAM14CATAPRES-TTS-1 51CATAPRES-TTS-2 51CATAPRES-TTS-3 51CATHFLO ACTIVASE 26CATTLE EPITHELIUM113cavarest 59CAVERJECT92CAVERJECT IMPULSE92CAYA 113CAYSTON133

142

caziant100CEDAR ELM 113cefaclor 21cefaclor er 21cefadroxil 21cefazolin sodium 21cefazolin sodium-dextrose 22cefdinir 22cefepime hcl22cefixime22CEFOTAN22cefotaxime sodium 22cefotetan disodium22cefoxitin sodium 22cefpodoxime proxetil 22cefprozil 22ceftazidime22ceftriaxone sodium22cefuroxime axetil 22CELEBREX14celecoxib 14CELESTONE SOLUSPAN94CELEXA29CELLCEPT 105CELLCEPT INTRAVENOUS 105CELONTIN27CEM-UREA62CENFOL 78CENTANY22CENTANY AT 22CENTRATEX 78cephalexin22CEPROTIN 48CEQUA 123CEQUR SIMPLICITY 2U 73CERACADE 62CERDELGA 91CEREBYX27CEREFOLIN 78cerefolin nac78CEREZYME 91cerovel 62CERVIDIL 92CETACAINE 18cetirizine hcl 127cetirizine hcl childrens127cetirizine-pseudoephedrine er127CETRAXAL 126CETROTIDE 97cevimeline hcl 59CHANTIX 20CHANTIX CONTINUING MONTH PAK20

CHANTIX STARTING MONTH PAK20charlotte 24 fe 100chateal 100chateal eq 100CHEMET78CHENODAL 87chest congestion relief 127chest congestion relief dm 127CHLOOXIA 62chloramphenicol sod succinate22chlordiazepoxide hcl 47chlordiazepoxide-amitriptyline29chlordiazepoxide-clidinium87chlorhexidine gluconate 59chloroquine phosphate41chlorpheniramine maleate er 127chlorpromazine hcl43chlorthalidone51CHLOR-TRIMETON 127chlorzoxazone134chocolated laxative 87CHOLBAM 91CHOLECAL DF78cholestyramine51cholestyramine light 51CHONDROITIN SULFATE 123chorionic gonadotropin97CHROMAGEN 78CIALIS92ciclodan32ciclopirox 32ciclopirox olamine 32ciclopirox treatment32CICLOPIROX-CLOBETASOL62CICLOPIROX-CLOBETASOL-SAL ACID62CICLOPIROX-SALICYLIC ACID 62cidofovir44CIFEREX 78cilostazol 43CILOXAN 120CIMDUO 44cimetidine85cimetidine hcl 85CIMETIDINE-LIDO-SALICYLIC ACID 62CIMZIA105CIMZIA PREFILLED KIT105CIMZIA STARTER KIT 105cinacalcet hcl 112CINQAIR 127

CINRYZE 105CIPRO22CIPRO HC 126CIPRODEX 126ciprofloxacin hcl 22 120 126ciprofloxacin-dexamethasone 126CIPROFLOXACIN-FLUOCINOLONE PF 126cisplatin 36CISPLATIN 36citalopram hydrobromide 29CITRANATAL BLOOM78CITRANATAL MEDLEY78citroma 87CITRULLINE EASY 91CLADOSPORIUM CLADOSPORIOIDES 113CLADOSPORIUM SPHAEROSPERMUM 114cladribine36claravis62CLARINEX 127CLARINEX-D 12 HOUR127clarithromycin22clarithromycin er22CLARITIN127CLARITIN CHILDRENS127CLARITIN REDITABS127CLARITIN-D 12 HOUR 127clearlax87clemastine fumarate127CLENIA PLUS62CLENPIQ 87CLEOCIN 22CLEOCIN-T62CLIMARA 100CLIMARA PRO 100CLINDACIN ETZ62clindacin etz 62CLINDACIN PAC 62clindacin-p62CLINDAGEL62CLINDAMY-BENZOYL PER-NIACINAM 62clindamycin hcl22clindamycin palmitate hcl 22CLINDAMYCIN PHOS-NIACINAMIDE 62clindamycin phosphate 22 62 63CLINDAMYCIN PHOSPHATE 62clindamycin phosphate-benzoyl peroxide62

143

CLINDAMYCIN-NIACIN-TRETINOIN63clindamycin-tretinoin 63CLINDESSE22CLIND-NIACIN-SPIRONOLAC-TRETIN 63CLINOIN 63CLINPRO 5000 59clobazam27clobetasol prop emollient base 63clobetasol propionate63clobetasol propionate e63clobetasol propionate emulsion 63CLOBETASOL PROP-LEVOCETIRIZINE 63CLOBETASOL PROP-NIACINAMIDE 63CLOBETAVIX 63CLOBEX 63CLOBEX SPRAY 63clocortolone pivalate 63CLODAN 63clodan 63CLODERM 63clofarabine 36CLOLAR36clomiphene citrate97clomipramine hcl 29clonazepam47clonidine51clonidine hcl 51clonidine hcl er 56clopidogrel bisulfate 43clorazepate dipotassium 47clotrimazole32clotrimazole-betamethasone32clovique78clozapine43CLOZARIL 43COAGADEX48COAL TAR 63COARTEM 41COCAINE HCL 18COCKLEBUR114COD LIVER OIL78codeine sulfate10coenzyme q10114COLAZAL110COLCHICINE34colchicine 34colchicine-probenecid 34COLCIGEL114COLCRYS34

cold amp flu relief daytime127coldflu daytime relief 127COLD-EEZE NATURAL MULTI-SYMP114COLD-EEZE PLUS DEFENSE 114COLD-EEZE SUGAR FREE 114colesevelam hcl 51COLESTID 51COLESTID FLAVORED51colestipol hcl 51colistimethate sodium (cba) 22COLLATYL63COLY-MYCIN M 22COMBIGAN 122COMBIPATCH 100COMBIVENT RESPIMAT 131COMBIVIR 44COMETRIQ36COMFORT TOUCH ALCOHOL PREP 114COMPLERA44COMPRESSOR NEBULIZER114compro 30COMTAN 42CONCERTA56CONDOMS 114CONDYLOX63CONJUPRI51CONSENSI 51constulose87CONTOUR CONTROL SOLUTION73CONTOUR MONITOR DEVICE73CONTOUR MONITOR KIT WDEVICE 74CONTOUR NEXT CONTROL SOLUTION74CONTOUR NEXT EZ KIT WDEVICE 74CONTOUR NEXT LINK KIT WDEVICE 74CONTOUR NEXT MONITOR KIT WDEVICE74CONTOUR NEXT ONE KIT74CONTOUR NEXT TEST STRIPS 74CONTOUR TEST STRIPS74CONTRAST ALLERGY PREMED PACK94CONTRAVE 58CONVENIENCE PAK 58

CONZIP 10COPADERM 63COPASIL 63COPAXONE57COPIKTRA36CORDRAN63COREG51COREG CR51coremino 22CORGARD51CORIFACT48CORLANOR51corn amp callus remover 63CORN POLLEN 114CORTANE-B63CORTEF 94CORTENEMA 110cortic-nd 126CORTIFOAM 110CORTISPORIN-TC 126CORTROSYN 114CORVITE 150 78corvite fe 78COSELA 36COSENTYX (300 MG DOSE)105COSENTYX 150 MGML 105COSENTYX SENSOREADY (300 MG)105COSENTYX SENSOREADY PEN105COSMEGEN 36COSOPT122COSOPT PF 122cosyntropin114COTELLIC 36COTEMPLA XR-ODT 56cough dm 127coughchest congestion dm 127COVARYX 100COVARYX HS 100COVID-19 SPECIMEN COLLECTION 114COZAAR 51CREON 91CRESEMBA32CRESTOR 51CRINONE 100CRIXIVAN 44CROFAB 114cromolyn sodium87 120 131crotan 41cryselle-28100CRYSVITA 91

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CUBICIN 22CUBICIN RF 22CUPRIMINE92CUROSURF127CURVULARIA114CUTAQUIG 105CUTIVATE 63CUVITRU 105CUVPOSA 87cvs acetaminophen ex st 10cvs antacid extra strength 87cvs clotrimazole 3 32cvs gentle laxative87cvs lubricant eye drops 124cvs motion sickness 30cyanocobalamin 78CYANOCOBALAMIN 78cyclafem 135100cyclafem 777100CYCLOGABA 10300134cyclobenzaprine hcl 134cyclobenzaprine hcl er 134CYCLOGYL 124CYCLOMYDRIL 124CYCLOPAK 134cyclopentolate hcl 124CYCLOPHENE RAPIDPAQ134cyclophosphamide 36CYCLOPHOSPHAMIDE 36cycloserine 35CYCLOSET72cyclosporine 105CYCLOSPORINE IN KLARITY 124cyclosporine modified 105CYKLOKAPRON48CYMBALTA29cyproheptadine hcl127CYRAMZA 36cyred 100cyred eq 100CYSTADANE 91CYSTADROPS 124CYSTAGON91CYSTARAN 124cytarabine 36cytarabine (pf) 36CYTOGAM105CYTOMEL104CYTOTEC85cytra k crystals 78DHE 45 34d3 high potency78

d3 super strength 78dacarbazine 36DACOGEN37dactinomycin 37daflonex-xl78dalfampridine er 57DALIRESP 131danazol 96DANDELION 114DANTRIUM 134dantrolene sodium 134DANYELZA 37dapsone 35 63DAPSONE 63DAPSONE-NIACINAMIDE63DAPSONE-NIACINAMIDE-SPIRONOLAC 63DAPTACEL 109daptomycin22DARAPRIM 41darifenacin hydrobromide er 92DARZALEX 37DARZALEX FASPRO 37dasetta 135 100dasetta 777 100daunorubicin hcl37DAURISMO37DAYHIST ALLERGY 12 HOUR RELIEF 127DAYPRO14daysee 100daytime cold amp flu relief127daytime coldflu relief 127DAYTRANA 56DAYVIGO135DDAVP97DDAVP PF 97DDAVP RHINAL TUBE97DEBACTEROL59deblitane 100DECADRON 94DECARA 78decitabine37deferasirox 78deferasirox granules 78deferiprone78deferoxamine mesylate114DELESTROGEN100DELSTRIGO 45DELUO63delyla100DELZICOL 110demeclocycline hcl22

DEMEROL 10DEMSER51DENAVIR 45DENTA 5000 PLUS 59DENTAGEL59DEOXIA 63DEPAKOTE 27DEPAKOTE ER 27DEPAKOTE SPRINKLES 27DEPEN TITRATABS92DEPLIN 15 78DEPLIN 75 78DEPO-ESTRADIOL 100DEPO-MEDROL 94DEPO-PROVERA 100DEPO-SUBQ PROVERA 104100DEPO-TESTOSTERONE 96DERMACINRX AZENASE PAK127DERMACINRX CLORHEXACIN 59DERMACINRX EMPRICAINE 18DERMACINRX LEXITRAL PHARMAPAK 14DERMACINRX PENETRAL63DERMACINRX PHN 18DERMACINRX PRIZOPAK18DERMACINRX PUREFOLIX 78DERMACINRX SURGICAL COMBOPAK 63DERMACINRX THERAZOLE PAK32DERMACINRX ZRM 18DERMALID 18DERMA-SMOOTHEFS BODY63DERMA-SMOOTHEFS SCALP 63DERMELLE63DERMOTIC126DERMULCERA63DERPIXA 63DESCOVY 45DESENEX32DESFERAL 114desflurane 114desipramine hcl29desloratadine 127desmopressin ace spray refrig97desmopressin acetate97desmopressin acetate pf97desmopressin acetate spray 97desogestrel-ethinyl estradiol 100DESONATE 63

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desonide 63DESOWEN 63desoximetasone64DESOXYN 56DESVENLAFAXINE ER29desvenlafaxine succinate er29DETROL 92DETROL LA 92DEXABLISS 94dexamethasone 94dexamethasone intensol 94dexamethasone sod phosphate pf 94dexamethasone sodium phosphate 94 95 121DEXAMETHASONE SODIUM PHOSPHATE94 95dexchlorpheniramine maleate127DEXEDRINE 57DEXERYL 64DEXIFOL78DEXILANT 85dexmedetomidine hcl 114dexmedetomidine hcl in nacl114dexmethylphenidate hcl 57dexmethylphenidate hcl er 57DEXONTO 04 95dexrazoxane hcl37DEXTENZA121dextroamphetamine sulfate57dextroamphetamine sulfate er 57DEXYCU 121DFS DRMSMENTHCAP PAK15DFSMSMENTHCAP PAK 15DIACOMIT 27DIADIMAXIA 64DIALYVITE78DIALYVITE 300078DIALYVITE 500078DIALYVITE SUPREME D 78DIALYVITEZINC 78DIAOXIA 64diaper rash 64DIASDIMAXIA64DIASOXIA 64DIASTAT ACUDIAL 27DIASTAT PEDIATRIC27diazepam 27 47diazepam intensol 47diazoxide75DIBENZYLINE 51dibucaine (perianal) 64

DICLEGIS 30DICLOFENAC CAP 35MG15DICLOFENAC PATCH 13 15diclofenac potassium 15diclofenac sodium 15 64 121diclofenac sodium er 15diclofenac-misoprostol 15DICLOFENAC-NA HYALURON-NIACIN64DICLOFONO15DICLOPR 15DICLOSTREAM 15DICLOTREX 15DICLOVIX 15DICLOVIX M 15dicloxacillin sodium 22DICLOZOR 15DICOPANOL FUSEPAQ127DICOPANOL RAPIDPAQ 127dicyclomine hcl87diethylpropion hcl 58diethylpropion hcl er58DIFFERIN 64DIFICID 22diflorasone diacetate64DIFLUCAN 32diflunisal 15DIFMETIOXRIME 32DIGIFAB114digitek51digox 51digoxin51dihydroergotamine mesylate34DILANTIN27DILANTIN INFATABS 27DILATRATE-SR 51DILAUDID 10diltiazem hcl 52diltiazem hcl er 52diltiazem hcl er beads 51diltiazem hcl er coated beads 51DILTIAZEM HCL-DEXTROSE 52dilt-xr 52dimaphen dm coldcough127DIMENTHO15dimethyl fumarate 57dimethyl fumarate starter pack57DIMOXIA64DIOCHLOY 64diotame instydose 87DIOVAN 52DIOVAN HCT52DIPENTUM 110

diphen 127DI-PHEN 127diphenhydramine hcl127 128diphenoxylate-atropine87DIPHTHERIA-TETANUS TOXOIDS DT 109DIPROLENE 64DIPROLENE AF64dipyridamole43disopyramide phosphate52disulfiram20DITROPAN XL 92DIURIL 52divalproex sodium 27divalproex sodium er27DIVIGEL100DMT SUIK95docetaxel37docosanol64docusate calcium 87docusate mini87docusate sodium87docuzen 87dofetilide52DOG EPITHELIUM 114DOG FENNEL114DOJOLVI114dok 87donepezil hcl 29DONNATAL 87DOPTELET 48DORAL47DORYX 22DORYX MPC 22DORZOLAMIDE HCL 122dorzolamide hcl122dorzolamide hcl-timolol mal 122dorzolamide hcl-timolol mal pf 122dotti 100DOUBLE PM124DOUBLEDEX95DOVATO45DOVONEX 64doxazosin mesylate 52doxepin hcl29 64 135doxercalciferol112DOXIL 37doxorubicin hcl 37doxorubicin hcl liposomal37doxy 100 22doxycycline 64doxycycline hyclate 22 23DOXYCYCLINE HYCLATE23

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doxycycline monohydrate 23doxylamine-pyridoxine 30DR SMITHS ADULT BARRIER 64DRAXACE64DRAXACE LOTION CLEANSER64DRECHSLERA 114DRISDOL 78DRITHO-CREME HP 64DRIXECE 64DRIZALMA SPRINKLE 29dronabinol 30drospiren-eth estrad-levomefol100drospirenone-ethinyl estradiol100DROXIA 37droxidopa 52DRYSOL 64DSUVIA10DUAKLIR PRESSAIR 131DUAL COMPLEX FORMULA 1 KIT 15DUAVEE 100DUETACT 72DUEXIS15DULERA 131duloxetine hcl 29DUOBRII 64DUOPA 42DUPIXENT64DURAGESIC-100 10DURAGESIC-12 10DURAGESIC-25 10DURAGESIC-50 10DURAGESIC-75 10duramorph10DUREZOL121DURLAZA 43DUROLANE 114DURYSTA122DUST MITE MIXED ALLERGEN EXT114dutasteride 94dutasteride-tamsulosin hcl 94DUTOPROL 52d-vite pediatric78DXEVO 11-DAY95DYANAVEL XR57DYMISTA 128DYRENIUM52DYSPORT114DYURAL-40 95DYURAL-80 95DYURAL-L 95

DYURAL-LM 95EES GRANULES 23EASIVENT 114EASTERN COTTONWOOD 114easygel59EASYMAX 15 LEVEL 2-3 CONTROL 74EASYMAX CONTROL 74ECEOXIA 64EC-NAPROSYN15ec-naproxen 15ECONASIL32econazole nitrate32ECONAZOLE NITRATE-NIACINAMIDE 32ECOZA32EC-RX DHEA114EC-RX ESTRADIOL 100EC-RX PROGESTERONE 100EC-RX TESTOSTERONE 96ECZEMOL114EDARBI52EDARBYCLOR 52EDECRIN52EDEX 92EDLUAR 135ED-SPAZ 87EDURANT45EEMT 101EEMT HS 101efavirenz 45efavirenz-emtricitab-tenofovir45efavirenz-lamivudine-tenofovir 45EFFER-K78effer-k78EFFEXOR XR 29EFFIENT 43EFUDEX 64EGATEN 41EGRIFTA SV97EHA18ELAPRASE 91ELELYSO91ELEPSIA XR 27ELESTRIN 101ELETONE 64eletriptan hydrobromide 34ELFOLATE78ELFOLATE PLUS 78ELIDEL64ELIGARD 97ELIMITE 41elinest101

ELIQUIS26ELIQUIS DVTPE STARTER PACK 26ELITEK37ELIXOPHYLLIN 131ELLA 101ELLENCE37ELMIRON92ELOCTATE 48eluryng 101ELZONRIS 37EMCYT 37EMEND 31EMEND TRI-PACK 31EMFLAZA 34EMGALITY34EMGALITY (300 MG DOSE) 34emoquette 101EMPLICITI 37EMPRICAINE-II 18EMSAM29emtricitabine45emtricitabine-tenofovir df45EMTRIVA 45EMULSION SB 64EMVERM 41ENABLEX 92enalapril maleate52enalapril-hydrochlorothiazide 52ENBRACE HR 78ENBREL105ENBREL MINI 105ENBREL SURECLICK 105ENDARI 114ENDO AVITENE 114endocet 10ENDOMETRIN101ENFAGROW NEUROPRO TODDLER114ENFAMIL GENTLEASE114ENFAMIL INFANT 114ENFAMIL NEUROPRO INFANT 114ENFAMIL NEUROPRO SENSITIVE 115ENFAMIL NUTRAMIGEN 115ENFAMIL NUTRAMIGEN LIPIL115ENGERIX-B 109ENHERTU37ENLITE GLUCOSE SENSOR74ENLYTE 115enovarx-amitriptyline115

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enovarx-baclofen 134enovarx-cyclobenzaprine hcl 134ENOVARX-DICLOFENAC SODIUM15enovarx-ibuprofen 15enovarx-lidocaine hcl 18enovarx-naproxen 15enovarx-tramadol 64enoxaparin sodium26enpresse-28 101enskyce101ENSPRYNG105ENSTILAR 64entacapone 42entecavir 45ENTERAGAM 115ENTEREG87enteric fish oil 115ENTOCORT EC110ENTRESTO 52ENTTY SPRAY 64ENTYVIO 105ENU PRO3 PLUS 115enulose 87ENVARSUS XR 105ENZADYNE 91ENZNONUTY18ENZOCLEAR 64EPANED 52EPCLUSA 45ephedrine sulfate 52EPHEDRINE SULFATE-NACL 52EPICERAM 64EPICOCCUM 115EPIDIOLEX 27EPIDUO 64EPIDUO FORTE 64EPIFOAM64epinastine hcl 121epinephrine 131EPINEPHRINE PROFESSIONAL 131EPINEPHRINESNAP-EMS131EPINEPHRINESNAP-V 131EPIPEN 2-PAK 131EPIPEN JR 2-PAK 131epirubicin hcl 37EPISIL115EPISNAP 131epitol 27EPIVIR 45EPIVIR HBV45eplerenone 52

EPOGEN48epoprostenol sodium133EPZICOM45EQUACARE JR 115EQUETRO 47ERAXIS32ERBITUX 37ERGOCAL 78ergocalciferol79ergoloid mesylates 115ERGOMAR 34ergotamine-caffeine 34ERIVEDGE 37ERLEADA 37erlotinib hcl37errin101ERTACZO32ertapenem sodium 23ERWINAZE 37ery 64ERYGEL 64ERYPED 200 23ERYPED 400 23ERY-TAB 23ERYTHROCIN STEARATE 23erythromycin 23 64 121erythromycin base23erythromycin ethylsuccinate23ESBRIET131escitalopram oxalate 29ESGIC10ESKATA65ESMOLOL HCL 52ESOMEP-EZS 85esomeprazole magnesium85ESOMEPRAZOLE STRONTIUM85ESPEROCT 48ESSENTIAL CARE JR115est estrogens-methyltest101est estrogens-methyltest ds 101est estrogens-methyltest hs 101estarylla101estazolam47ESTRACE 101estradiol 101estradiol valerate101estradiol-norethindrone acet 101ESTRING 101ESTROGEL 101ESTROSTEP FE101eszopiclone 135ETESEVIMAB 105

ethacrynic acid 52ethambutol hcl35ethosuximide27ETHOXIA 65ethyl chloride18ethynodiol diac-eth estradiol 101ETHYOL37etodolac 15etodolac er 15etonogestrel-ethinyl estradiol 101ETOPOPHOS 37etoposide 37EUCRISA 65EUFLEXXA 115euthyrox 104EVAMIST 101EVEKEO 57EVEKEO ODT57EVENITY111everolimus37 106EVISTA 97EVKEEZA 52EVOCLIN 65EVOMELA37EVOTAZ45EVOXAC 59EVRYSDI 91EXELDERM 32EXELON 29exemestane 37EXFORGE 52EXFORGE HCT 52EXJADE 79EX-LAX ULTRA 87EXODERM32EXONDYS 51 91exotic-hc126EXPAREL 18EXTAVIA58EXTINA 32eye itch relief121EYLEA 124EYSUVIS 121EZALLOR SPRINKLE52ezetimibe52ezetimibe-simvastatin 52fabb 79FABIOR65FABRAZYME 91FALESSA101falmina 101famciclovir 45famotidine 85

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famotidine orig st85FANAPT43FANAPT TITRATION PACK 43FANATREX FUSEPAQ27FARESTON 37FARXIGA 72FARYDAK 37FASENRA 128FASENRA PEN128FASLODEX37FAVIPIRAVIR45fa-vitamin b-6-vitamin b-12 79fayosim101FBL KIT15febuxostat 34FEIBA48felbamate 27FELBATOL27FELDENE 15felodipine er 52FEM PH 92FEMARA 37FEMHRT LOW DOSE101FEMRING 101femynor 101fenofibrate 52fenofibrate micronized52fenofibric acid52FENOGLIDE 52fenoprofen calcium15fenortho15FENSOLVI (6 MONTH)97fentanyl 10fentanyl citrate10FENTANYL CITRATE10fentanyl citrate (pf) 10FENTANYL CITRATE-NACL 10FENTANYL-BUPIVACAINE-NACL 10 11FENTORA11FEONYX 79FERAHEME 79FERIVA 217 79FERIVAFA 79ferocon 79ferotrinsic 79FERRALET 90 79ferraplus 90 79FERRIPROX 79FERRIPROX TWICE-A-DAY 79FERRLECIT 79ferrocite plus 79FERRO-PLEX HEMATINIC 79

ferrous sulfate 79FETROJA23FETZIMA29FETZIMA TITRATION29FEXMID 134fexofenadine hcl128fexofenadine-pseudoephed er 128FIASP75FIASP FLEXTOUCH75FIASP PENFILL 75fiber 87fiber laxative87FIBRICOR52FIBRYGA 48FINACEA 65FINAPOD 65finasteride 65 94FINASTERIDE-MINOXIDIL65FINTEPLA27FIORICET 11FIORICETCODEINE11FIRAZYR106FIRDAPSE 115FIRE ANT115FIRMAGON97FIRMAGON (240 MG DOSE) 97FIRST-BACLOFEN 134FIRST-LANSOPRAZOLE 86FIRST-METRONIDAZOLE 23FIRST-MOUTHWASH BLM 59FIRST-OMEPRAZOLE 86FIRST-PROGESTERONE VGS 101FIRVANQ 23flac 126FLAGYL 23FLAREX 121flavoxate hcl 92FLEBOGAMMA DIF106flecainide acetate 53FLECTOR 15FLEXICHAMBER ADULT MASKSMALL 115FLEXICHAMBER CHILD MASKLARGE115FLEXICHAMBER CHILD MASKSMALL 115FLEXIN 18FLEXIPAK15FLOLAN 133FLOLIPID 53FLOMAX 94FLORIVA79

FLORIVA PLUS 79FLOVENT DISKUS 131FLOVENT HFA 131floxuridine37FLUAD 109FLUAD QUADRIVALENT 109FLUARIX QUADRIVALENT109FLUCAINE 124FLUCELVAX QUADRIVALENT 109fluconazole32FLUCON-IBUPROF-ITRACON-TERBINA 32flucytosine 32fludarabine phosphate 37fludrocortisone acetate95FLULAVAL QUADRIVALENT 109FLUMIST QUADRIVALENT109flunisolide 128FLUOCINOLONE ACET-NIACINAMIDE 65fluocinolone acetonide 65 126fluocinolone acetonide body 65fluocinolone acetonide scalp65fluocinonide65fluocinonide emulsified base65FLUOPAR 65FLUORESCEIN SODIUMBENOXINATE 124fluorescein-benoxinate124FLUORIDEX 59fluoridex daily renewal 59FLUORIDEX ENHANCED WHITENING 59FLUORIDEX SENSITIVITY RELIEF 59fluor-i-strips at 124fluoritab 79fluorometholone 121FLUOROPLEX65fluorouracil 37 65FLUOROURACIL65FLUOVIX65FLUOVIX PLUS 65fluoxetine hcl 29fluoxetine hcl (pmdd)29fluphenazine decanoate43fluphenazine hcl 43flurandrenolide 65FLURA-SAFE124flurazepam hcl135flurbiprofen 15flurbiprofen sodium 121

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flutamide 37fluticasone propionate65 128fluticasone-salmeterol 131 132FLUTICASONE-SALMETEROL132fluvastatin sodium 53fluvastatin sodium er 53fluvoxamine maleate 29fluvoxamine maleate er29FLUZONE HIGH-DOSE QUADRIVALENT 109FLUZONE QUADRIVALENT 109FML121FML FORTE121FML LIQUIFILM 121FOCALIN 57FOCALIN XR 57folbee 79folbee plus79FOLBEE PLUS CZ79FOLBIC RF 79FOLGARD OS 79FOLGARD RX79folic acid 79FOLIC D379FOLIC-K79FOLI-D 79FOLIKA PROBIOTIC 87FOLITE 79FOLITIN-Z79FOLIXAPURE 79FOLLISTIM AQ 97FOLOTYN 37folplex 2279foltanx 79FOLTANX RF79FOLTRATE 79FOLTREXYL 79foltrin 79FOLTX 79FOLVITE-D 79fondaparinux sodium26FORANE 115FORAXA 65FORFIVO XL30formaldehyde 115FORMALDEHYDE 115FORTAMET 72FORTAZ23FORTEO 111FORTESTA96FORTISCARE CONTROL 74

FORTISCARE GLUCOSE SYSTEM 74FORTISCARE T1 GLUCOSE SYSTEM 74FOSAMAX 111FOSAMAX PLUS D 111fosamprenavir calcium 45fosaprepitant dimeglumine31foscarnet sodium45FOSCAVIR45fosfomycin tromethamine23fosinopril sodium 53fosinopril sodium-hctz 53fosphenytoin sodium 27FOSRENOL 92FOSTEUM 79FOSTEUM PLUS 115FOTIVDA 37FRAGMIN 26FREESTYLE LIBRE 14 DAY READER 74FREESTYLE LIBRE 14 DAY SENSOR74FREESTYLE LIBRE 2 READER 74FREESTYLE LIBRE 2 SENSOR74FREESTYLE LIBRE READER74FREESTYLE LIBRE SENSOR SYSTEM 74FREESTYLE PRECISION NEO TEST 74FROTEK 15FROVA34frovatriptan succinate34FUL-GLO 124FULPHILA48fulvestrant 37FUNGIMEZ 32furosemide 53FUSARIUM 115FUSION PLUS 79FUZEON 45fyavolv101FYCOMPA 27gabapentin 27GABAPENTIN-NAPROXEN CMPD KIT15GABITRIL27GABLOFEN 134GALAFOLD91galantamine hydrobromide 29galantamine hydrobromide er 29

GALZIN 79GAMASTAN106GAMIFANT 106GAMMAGARD 106GAMMAGARD SD LESS IGA106GAMMAKED 106GAMMAPLEX 106GAMUNEX-C 106ganirelix acetate97 98GARDASIL 9109gas relief 87gas relief extra strength 87gas relief infants87GASTROCROM88gatifloxacin 121GATTEX88gavilax88gavilyte-c88gavilyte-g88gavilyte-h88gavilyte-n with flavor pack88GAVRETO 37GAZYVA 37GEAMETDRAY65GEBAUERS PAIN EASE 18GEBAUERS SPRAY AND STRETCH 18GELCLAIR 115GELFILM115 124GEL-FLOW 115GEL-FLOW NT 115GELFOAM 115GELFOAM COMPRESSED SIZE 100 115GELFOAM DENTAL PACK SIZE 4 115GELFOAM SPONGE 115GELFOAM SPONGE SIZE 100 115GELFOAM SPONGE SIZE 200 115GELFOAM SPONGE SIZE 50 115GELFOAM-JMI POWDER 115GELFOAM-JMI SPONGE 115GELNIQUE 92GELSYN-3 115GELUSIL88GELX 115gemcitabine hcl 37gemfibrozil 53gemmily101GEMTESA 92GEN7T 18

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GEN7T PLUS18GENADUR 65GENERESS FE 101generlac 88gengraf106GENICIN VITA-D 79GENICIN VITA-Q 79GENICIN VITA-S 79GENOTROPIN98GENOTROPIN MINIQUICK98gentak 121gentamicin sulfate 23 121GENTEAL TEARS 124GENTEAL TEARS NIGHT-TIME 124GENTEAL TEARS SEVERE DAYNIGHT 124gentle laxative 88GENVOYA 45GEODON 43geri-dryl 128geri-kot 88GERMAN COCKROACH115GIALAX 88GILENYA 58GILOTRIF 37GILPHEX TR128giltuss severe sinus128GIMOTI 31GIVLAARI 115GLASSIA132glatiramer acetate 58glatopa 58GLEEVEC 37GLEOLAN 115GLEOSTINE 37glimepiride72glipizide er72glipizide ir 72glipizide xl 72glipizide-metformin hcl 72GLOPERBA 34GLOSTRIPS 124GLUCAGEN HYPOKIT 75glucagon emergency kit 75GLUCAGON EMERGENCY KIT 75GLUCOSE CONTROL SOLUTIONS 74GLUCOTROL72GLUCOTROL XL 72GLUMETZA 72GLUTARALDEHYDE 115

glyburide 72glyburide micronized 72glyburide-metformin 72GLYCATE 88glycine92glycine urologic 92glycolax 88GLYCOPYRROLATE88glycopyrrolate88glycopyrrolate pf88glydo 18GLYNASE 72GLYRX-PF 88GLYTACTIN BETTERMILK 15115GLYTACTIN BETTERMILK DE-LITE 115GLYTACTIN BUILD 10PE 115GLYTACTIN BUILD 2020 116GLYTACTIN BUILD 2020 PKU116GLYTACTIN BURST116GLYTACTIN COMPLETE 10PE 116GLYTACTIN RESTORE 10 116GLYTACTIN RESTORE 5 116GLYTACTIN RESTORE LITE 10 116GLYTACTIN RESTORE LITE 10PE 116GLYTACTIN RTD 10 116GLYTACTIN RTD 15 116GLYTACTIN RTD LITE 15116GLYTACTIN SWIRL 15PE116GLYXAMBI72gnp senna lax88GOCOVRI 42GOLDENROD116GOLYTELY 88GONAL-F 98GONAL-F RFF 98GONAL-F RFF REDIJECT 98GONITRO 53goodsense antacid88goodsense antacid amp gas relief88goodsense anti-diarrheal 88goodsense aspirin low dose15goodsense ibuprofen 15goodsense motion sickness31goodsense nicotine 20goodsense pain relief11goodsense tussin dm max 128GOPRELTO 18GORDOFILM 65

GRALISE 58granisetron hcl 31GRANIX 48GRASTEK116GREEN GLO LISSAMINE GREEN 124griseofulvin microsize32griseofulvin ultramicrosize32guaiatussin ac 128guaifenesin128guaifenesin ac128guaifenesin-dm 128GUANENDRUX 65guanfacine hcl53guanfacine hcl er57GUANIDINE HCL35GUARDIAN CONNECT TRANSMITTER 74GUARDIAN LINK 3 TRANSMITTER 74GUARDIAN SENSOR (3) 74GVOKE HYPOPEN 1-PACK75GVOKE HYPOPEN 2-PACK75GVOKE PFS 75GYNAZOLE-1 32habitrol 20HACKBERRY116HAEGARDA106hailey 1530101hailey 24 fe101hailey fe 1530101hailey fe 120101HALAVEN 37halcinonide65HALCION 47HALDOL DECANOATE 43halobetasol propionate65HALOBETASOL PROPIONATE 65HALOG 65haloperidol 44haloperidol decanoate44haloperidol lactate44HALUCORT 65HARVONI45HAVRIX109HAXCHLO65HCU EASY116headache relief 11heather101HELIDAC THERAPY 88HEMADY95HEMANGEOL 53

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hematinic plus vitminerals79hematinicfolic acid79HEMATOGEN79HEMATOGEN FA 79HEMATRON-AF79HEMETAB79HEMLIBRA48HEMMOREX-HC 110HEMOCYTE PLUS 79hemocyte-f 79HEMOFIL M 48HEPAGAM B106heparin (porcine) in nacl 26heparin lock flush 116heparin sodium (porcine) 26heparin sodium (porcine) pf 26heparin sodium lock flush 116HEPLISAV-B109HEPMED116HEPSERA45HERCEPTIN 38HERCEPTIN HYLECTA37HERZUMA 38HETLIOZ135HETLIOZ LQ 135HIBERIX109HIBICLENS 116HIDEX 6-DAY 95high potency probiotic 88HIPREX23HIXDEFRIMA32HIZENTRA 106hm adult tussin cough amp chest 128hm stomach relief88hm stool softener 88HOMACTIN AA PLUS116homatropaire124HOME PAP KIT 116HONEY BEE VENOM116HORIZANT58HORSE EPITHELIUM116HPR PLUS 65hpr plus 65HPR PLUS HYDROGEL65HUMALOG KWIKPEN 75HUMALOG MIX 5050 KWIKPEN 75HUMALOG MIX 5050 VIAL76HUMALOG MIX 7525 KWIKPEN 76HUMALOG MIX 7525 VIAL76HUMALOG U-100 JUNIOR KWIKPEN 76

HUMALOG VIAL 76HUMATE-P 49HUMATROPE 98HUMATROPEN FOR 12MG 116HUMATROPEN FOR 24MG 116HUMATROPEN FOR 6MG 116HUMIRA106HUMIRA PEDIATRIC CROHNS START106HUMIRA PEN 106HUMIRA PEN-CDUCHS STARTER 106HUMIRA PEN-PEDIATRIC UC START 106HUMIRA PEN-PSUVADOL HS START 106HUMIRA PEN-PSORUVEIT STARTER 106HUMULIN 7030 KWIKPEN 76HUMULIN 7030 VIAL76HUMULIN N KWIKPEN 76HUMULIN N VIAL 76HUMULIN R U-500 KWIKPEN76HUMULIN R U-500 VIAL 76HUMULIN R VIAL 76HURRICAINE59HYALGAN116HYALURONATE-NIACINAM-TRETINOIN65HYALURONATE-NIACIN-TACROLIMUS 65HYALURONIC ACID-HYDROQUINONE 65HYCAMTIN 38HYCODAN 128hydralazine hcl 53HYDREA 38HYDRO 40 65hydrochlorothiazide53hydrocodone bitartrate er11hydrocodone polst-chlorphen polst er susp128hydrocodone-acetaminophen 11hydrocodone-homatropine 128hydrocodone-ibuprofen 11hydrocortisone 66 95 111hydrocortisone (perianal) 110hydrocortisone ace-pramoxine 65 110hydrocortisone acetate65 111hydrocortisone butyr lipo base 66hydrocortisone butyrate 66hydrocortisone valerate66

hydrocortisone-acetic acid 126hydrocortisone-iodoquinol32hydrocort-pramoxine (perianal) 111hydromet 128hydromorphone hcl 11hydromorphone hcl er 11HYDROMORPHONE HCL-NACL 11hydroquinone 66HYDROQUINONE 66HYDROQUINONE-HC-TRETINOIN66HYDROQUINONE-HYDROCORTISONE66hydroxychloroquine sulfate 41hydroxyprogesterone caproate101hydroxyurea 38hydroxyzine hcl 47hydroxyzine pamoate47HYLAFEM 116HYLATOPIC PLUS 66HYLAVITE79HYLAZINC 79HYMOVIS 116HYOPHEN 93hyoscyamine sulfate 88 89hyoscyamine sulfate er 88hyoscyamine sulfate sl88hyosyne89HYPERHEP B106HYPERRAB 106HYPERRAB SD 106HYPERRHO SD106HYPERSAL128HYPERTET SD106HYPOCYN 124HYQVIA 106HYSINGLA ER11HYZAAR 53ibandronate sodium 111IBRANCE 38IBUPAK15ibuprofen 15ibuprofen infants 15ICAR-C PLUS 80icatibant acetate106iclevia 101ICLUSIG38icosapent ethyl 53IDAMYCIN PFS 38idarubicin hcl 38IDELVION 49

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IDHIFA 38iferex 150 forte 80IFEX 38ifosfamide38ILARIS107ILEVRO121ILUMYA107ILUVIEN 121imatinib mesylate 38IMBRUVICA 38IMCIVREE58IMDEVIMAB107IMFINZI 38IMIOXIA 32imipenem-cilastatin 23imipramine hcl30imipramine pamoate 30imiquimod66IMIQUIMOD PUMP66IMIQUIMOD-LEVOCETIRIZIN-NIACIN66IMIQUIMOD-LEVOCET-TRETINOIN66IMITREX 34IMITREX STATDOSE REFILL34IMITREX STATDOSE SYSTEM 34IMLYGIC 38IMODIUM A-D89IMODIUM MULTI-SYMPTOM RELIEF 89IMOGAM RABIES-HT107IMOVAX RABIES109IMPAVIDO 41IMPEKLO 66IMPOYZ 66IMURAN107IMVEXXY MAINTENANCE PACK 101IMVEXXY STARTER PACK 101inavix15INBRIJA 42incassia 101INCRELEX 98INCRUSE ELLIPTA 132indapamide 53INDERAL LA 53INDERAL XL 53INDOCIN15INDOMETHACIN 15indomethacin15indomethacin er 15INFANRIX 109

infants gas relief89INFASURF 128INFED 80INFLAMMACIN 15INFLATHERM 16INFLECTRA 107INFUGEM 38INFUMORPH 200 11INFUMORPH 500 11INFUVITE ADULT80INFUVITE PEDIATRIC 80INGREZZA58INLYTA 38INNOPRAN XL53INOVA66INOVA 41 ACNE CONTROL THERAPY 66INOVA 82 ACNE CONTROL THERAPY 66INQOVI 38INREBIC 38INSPIREASE RESERVOIR BAGS 116INSPRA53instant oral pain relief max 59INSULIN ASP PROT amp ASP FLEXPEN76INSULIN ASPART 76INSULIN ASPART FLEXPEN 76INSULIN ASPART PENFILL76INSULIN ASPART PROT amp ASPART76INSULIN LISPRO76INSULIN LISPRO (1 UNIT DIAL)76INSULIN LISPRO JUNIOR KWIKPEN 76INSULIN LISPRO PROT amp LISPRO76INSULIN PEN NEEDLES76INSULIN SYRINGES 76INTEGRA F80INTEGRA PLUS80INTELENCE45INTERCEED 116INTRAROSA 93INTRON A45introvale 101INTUNIV57INVANZ23INVEGA 44INVEGA SUSTENNA44INVEGA TRINZA 44

INVELTYS121INVIRASE 45INVOKAMET72INVOKAMET XR72INVOKANA 72IODINE STRONG 80iodine tincture23IODOQUIMEZ-HC 32iodoquinol-hc-aloe polysacch32IODOQUINOL-HC-KETOCONAZOLE 32iodoquinol-hydrocortisone-aloe32IOPIDINE 122IOSAT 116IPOL109ipratropium bromide 128 132ipratropium-albuterol 132irbesartan 53irbesartan-hydrochlorothiazide53IRESSA38irinotecan hcl38IROSPAN 24680ISENTRESS45ISENTRESS HD 45isibloom101isoflurane 116ISOLYTE-S 80isoniazid 35ISOPTO ATROPINE 124ISOPTO CARPINE 122ISORDIL TITRADOSE 53isosorbide dinitrate53isosorbide mononitrate53isosorbide mononitrate er 53isotretinoin66ISOXSUPRINE HCL 53isoxsuprine hcl 53isradipine53ISTALOL 122ISTODAX (OVERFILL) 38ISTURISA 98ITHOXIA66itraconazole32ivermectin41IVERMECTIN-METRONIDAZOL-NIACIN 66IXEMPRA KIT 38IXIARO109IXINITY 49JADENU80JADENU SPRINKLE80jaimiess 101JAKAFI38

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JALYN94JANSSEN COVID-19 VACCINE 109jantoven 26JANUMET 72JANUMET XR 72JANUVIA72JARDIANCE72jasmiel101JATENZO96JELMYTO 38jencycla 101JENLIVA PRENATALPOSTNATAL80JENTADUETO 72JENTADUETO XR 72JEVTANA38jinteli 101JIVI49JOHNSON GRASS116jolessa101JORNAY PM 57JUBLIA32juleber 101JULUCA 45JUNE GRASS POLLEN STANDARDIZED 116junel 1530 101junel 120 101junel fe 1530 101junel fe 120 101junel fe 24 101JUXTAPID53JYNARQUE 80KBGL IN TERODERM 16KADCYLA 38kaitlib fe101KALBITOR 107KALETRA45kalliga102KALYDECO 133KAMDOY 66KANJINTI 38KANUMA91KAPOK116KAPSPARGO SPRINKLE53KAPVAY57kapzin dc16KARBINAL ER 128kariva 102KATARYA 66KATARYAXN 66KATERZIA 53

KAXM66KAZANO 72KCL-LIDOCAINE-NACL80KEDRAB 107KEFLEX 23KEIDO66KELARX66kelnor 135 102kelnor 150 102KENALOG66 95KENALOG-80 95KEPIVANCE 59KEPPRA 27KEPPRA XR 27KERAGEL 66KERALAC 66KERALYT66KERALYT SCALP66KERAMATRIX REPLICINE 5CMX5CM 66KERYDIN 32KESIMPTA58KETAMINE HCL 116KETAMINE HCL-SODIUM CHLORIDE 116KETARYA 66ketoconazole32KETOCONAZOLE-HYDROCORTISONE32ketodan 32KETODAN32KETONE TEST 74KETOPHENE RAPIDPAQ 16ketoprofen 16ketoprofen er16KETOROLAC TROMETHAMINE16ketorolac tromethamine 16 121KETOSTIX 74KETOVIE 116KETOVIE PEPTIDE 116KEVARYA 66KEVEYIS122KEVZARA 107KEXM66KEYA 66KEYTRUDA 38KHAPZORY 38KINERET 107KISQALI 38KISQALI FEMARA 38KITABIS PAK 133KIVIK66

KLARITY-A 121KLARITY-L121KLARON 66KLISYRI 66KLONOPIN 47klor-con 80klor-con 10 80klor-con m10 80KLOR-CON M15 80klor-con m20 80klor-conef 80KOATE49KOATE-DVI49KOCHIA 116KOGENATE FS 49KOMBIGLYZE XR72KORLYM99KOSELUGO38KOVALTRY49K-PHOS 80K-PHOS NO 280K-PHOS-NEUTRAL 80k-prime 80KRINTAFEL 41KRISTALOSE 89KRYSTEXXA 34K-TAB 80k-tan plus 80kurvelo 102KUTARYAXM66KUTARYAXMPA66KUTEA 66KUVAN91KUVARYA66KUVARYE66KUXM67KYLEENA 102KYMRIAH107KYNMOBI 42KYNMOBI TITRATION KIT42KYPROLIS 38labetalol hcl 53LACRISERT124LACTEROL 89lactic acid 67lactic acid e 67LACTIC ACID-NIACINAMIDE67lactobacillus 89LACTOJEN 89lactulose89lactulose encephalopathy 89LAMICTAL 27LAMICTAL ODT27

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LAMICTAL STARTER27LAMICTAL XR 27lamivudine45lamivudine-zidovudine 45lamotrigine 27 28lamotrigine er 27lamotrigine starter kit-blue28lamotrigine starter kit-green 28lamotrigine starter kit-orange 28LAMPIT 41LANOXIN 53lansoprazole86lanthanum carbonate 93LANTUS SOLOSTAR 76LANTUS U-100 VIAL 76lapatinib ditosylate 38larin 1530 102larin 120 102larin 24 fe 102larin fe 1530 102larin fe 120 102larissia102LASIX53LASTACAFT 124latanoprost 122LATANOPROST-TIMOLOL MALEATE 122LATISSE 124LATUDA44lavare wound wash 67laxative max str 89laxative regular strength89layolis fe 102LAZANDA 11L-CYSTINE 80LDO PLUS 18LEDIPASVIR-SOFOSBUVIR 45leena 102leflunomide107LEMTRADA 58LENSCALE 116LENVIMA 38LESCOL XL 53lessina102LETAIRIS 133letrozole 38lets 18leucovorin calcium 38LEUKERAN38LEUKINE49leuprolide acetate98levalbuterol hcl 132LEVALBUTEROL HFA132

LEVATIO18LEVBID 89LEVEMIR U-100 FLEXTOUCH76LEVEMIR U-100 VIAL76levetiracetam28levetiracetam er 28LEVITRA 93levobunolol hcl 122levocarnitine80levocarnitine sf 80levocetirizine dihydrochloride128levofloxacin 23 121levoleucovorin calcium38levoleucovorin calcium pf38levonest102levonorgest-eth est amp eth est 102levonorgest-eth estrad 91-day 102levonorgestrel 102levonorgestrel-ethinyl estrad102levonorg-eth estrad triphasic102levora 01530 (28)102levorphanol tartrate 11levo-t 104LEVOTHYROXINE SODIUM 104levothyroxine sodium 104levoxyl 104LEVSIN 89LEVSINSL89LEVULAN KERASTICK 67LEXAPRO 30LEXETTE 67LEXIVA 45LIALDA111LIBRAX 89LIBTAYO38LICART 16lice killing42lice treatment 42LIDO BDK 18lidocaine18LIDOCAINE (ANORECTAL) 67lidocaine hcl 18 59LIDOCAINE HCL 18lidocaine hcl (pf)18lidocaine hcl urethralmucosal18lidocaine viscous hcl 59lidocaine-hydrocort (perianal) 111LIDOCAINE-HYDROCORTISONE ACE67 111lidocaine-hydrocortisone ace 111lidocaine-prilocaine 18 19LIDOCAINE-TETRACAINE19LIDOCANNA 19

LIDOCORT 111LIDODERM 19LIDO-EPINEPHRINE-TETRACAINE 19LIDOMARK 25 19LIDOPAC 19lidopin19LIDOPIN19LIDOPRIL19LIDOPRIL XR19LIDO-PRILO CAINE PACK19LIDOPURE PATCH 19LIDORX19LIDO-SORB 19LIDOSTREAM19LIDOTHOL 19LIDOTRAL 19LIDOTREX (ALOE VERA) 67LIDOVIX L19LIDTOPIC MAX19LIFEMS NALOXONE 20LILETTA (52 MG)102lillow 102LIMBREL116LIMBREL250116LIMBREL500116LINCOCIN23lincomycin hcl23lindane 42linezolid 23linezolid in sodium chloride 23LINZESS 89LIORESAL 134liothyronine sodium 104LIPITOR 53LIPOFEN53LIPRITIN II 58liquid acetaminophen 11liquid allergy relief 128lisinopril 53lisinopril-hydrochlorothiazide53L-ISOLEUCINE 80lithium47lithium carbonate48lithium carbonate er 47LITHOBID 48LITHOSTAT 93LIVALO 53LIVIXIL PAK 19l-methylfolate80l-methylfolate ca me-cbl nac 80l-methylfolate calcium 80l-methylfolate forte 80

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l-methylfolate-algae80l-methylfolate-algae-b12-b6 80l-methylfolate-b6-b12 80l-methyl-mc 80l-methyl-mc nac80LMR PLUS 19LO LOESTRIN FE102LOCOID 67LOCOID LIPOCREAM 67LODINE16LODOSYN 42LOESTRIN 1530 (21)102LOESTRIN 120 (21)102LOESTRIN FE 1530 102LOESTRIN FE 120 102lojaimiess 102LOKELMA 80LOMAIRA58LOMOTIL 89LONHALA MAGNAIR REFILL KIT 132LONHALA MAGNAIR STARTER KIT132LONSURF38loperamide hcl89LOPID 53lopinavir-ritonavir45LOPRESSOR53LOPROX 33loratadine 128loratadine childrens128loratadine-d 12hr128loratadine-d 24hr128lorazepam 47lorazepam intensol47LORBRENA 38LORID 80LORMATE116LORTAB11loryna 102LORZONE134losartan potassium53losartan potassium-hctz 53LOSEASONIQUE 102LOTEMAX121LOTEMAX SM 121LOTENSIN 53LOTENSIN HCT53loteprednol etabonate 121LOTREL 53LOTRIMIN AF 33LOTRONEX 89lovastatin53

LOVAZA53LOVENOX26low-ogestrel102loxapine succinate 44lo-zumandimine102LUBIPROSTONE89lubricant eye drops124lubricant eye drops pf124lubricant eye pm124lubricant pm 124lubricating eye drops124lubricating plus eye drops 124LUCEMYRA 20LUCENTIS 124LUGOLS STRONG IODINE23LULICONAZOLE33LUMIGAN123LUMIZYME 91LUMOXITI 38LUNESTA 135LUPANETA PACK 98LUPKYNIS 107LUPRON DEPOT (1-MONTH)98LUPRON DEPOT (3-MONTH)98LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG98LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG98LUPRON DEPOT-PED (1-MONTH)98LUPRON DEPOT-PED (3-MONTH)98LUTATHERA38lutera 102LUXIQ 67LUXTURNA124LUZU33LYDEXA19lyleq102lyllana102LYNPARZA 38LYRICA 58LYRICA CR58lysiplex plus80LYSODREN 38LYSTEDA49LYUMJEV KWIKPEN76LYUMJEV VIAL76lyza102MVI ADULT80MVI PEDIATRIC 80MAALOX MULTI SYMPTOM MAX ST89

MACRILEN 116MACROBID23MACRODANTIN 23mafenide acetate 23MAGNEBIND 400 80magnesium citrate89magnesium oxide80 89magnesium sulfate80 81MAGNESIUM SULFATE81magnesium-oxide81mag-oxide 81MAKENA102MALARONE42malathion 42maprotiline hcl30MARCAINE 19MARCAINE PRESERVATIVE FREE 19MARINOL31marlido 19MARLIDO-25 19marlissa102MARPLAN30MARQIBO 38MARVONA SUIK 19MAS CARE-PAK95MATULANE 38matzim la53MAVENCLAD58MAVYRET45MAXALT34MAXALT-MLT 34MAXICOMFORT SYR 27G X 1276MAXIDEX121MAXITROL124maxi-tuss ac128maxi-tuss gmx128maxi-tuss pe max128MAXZIDE 53MAXZIDE-2553MAYZENT58m-dryl 128menaphosmbhyo1 93MEADOW FESCUE GRASS POLLEN116meclizine hcl 31meclofenamate sodium16MEDERMA67MEDERMA FOR KIDS67MEDERMA SPF 3067MEDPURA ALCOHOL PADS 67medpura hand sanitizer 67

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MEDROL95MEDROLOAN II SUIK 95MEDROLOAN SUIK 95medroxyprogesterone acetate 102mefenamic acid16mefloquine hcl42megestrol acetate 102MEKINIST 38MEKTOVI39MELALEUCA 117meloxicam16melphalan 39melphalan hcl39memantine hcl29memantine hcl er 29MENACTRA109MENEST 102MENOPUR98MENOSTAR102MENQUADFI 109MENTAX 33MENVEO 109meperidine hcl11MEPHYTON81meprobamate47MEPRON 42MEPSEVII 91mercaptopurine 39meropenem23MEROPENEM-SODIUM CHLORIDE 24merzee 102mesalamine111mesalamine er oral capsule 0375 gm 111mesalamine-cleanser111mesna 39MESNEX39MESQUITE 117MESTINON 35metafolbic81metafolbic plus 81METAFOLBIC PLUS RF81METANX 81METAXALL CP 134metaxalone 134metformin hcl er 72metformin hcl er (mod)72metformin hcl er (osm) 73metformin hcl ir 73METHACHOLINE CHLORIDE 117methadone hcl 11 12methadone hcl intensol 11

methadose 12methadose sugar-free12methamphetamine hcl57METHAVER 117methazolamide123methenamine hippurate 24methenamine mandelate 24methergine 117methimazole104METHITEST96methocarbamol 134METHOHEXITAL SODIUM117methotrexate 107methotrexate sodium 107methotrexate sodium (pf) 107methoxsalen rapid67methscopolamine bromide89methyl salicylate67methyldopa 53methyldopa-hydrochlorothiazide53methylergonovine maleate117methylfol-algae-b12-acetylcyst 81METHYLIN57methylphenidate hcl 57methylphenidate hcl er57methylphenidate hcl er (cd)57methylphenidate hcl er (la)57methylphenidate hcl er (xr) 57methylprednisolone95METHYLPREDNISOLONE ACETATE 95methylprednisolone acetate 95methyltestosterone96metoclopramide hcl31metolazone 54METOPIRONE117metoprolol succinate er54metoprolol tartrate54metoprolol-hydrochlorothiazide54METROCREAM 67METROGEL67METROLOTION67metronidazole 24 67METRONIDAZOLE BENZO+SYRSPEND24metyrosine 54mexiletine hcl 54MIACALCIN 111mibelas 24 fe102micaderm 33micafungin sodium 33MICARDIS 54

MICARDIS HCT 54MICLARA LQ 128miconazole 133miconazole 333miconazole 733miconazole nitrate33MICONAZOLE-ZINC OXIDE-PETROLAT 33MICRHOGAM ULTRA-FILTERED PLUS 107MICRODOT TEST 74microgestin 1530102microgestin 120102microgestin 24 fe102microgestin fe 1530102microgestin fe 120102MICROLET NEXT LANCING DEVICE74MICROPLEGIA MSA-MSG81midazolam hcl 47MIDAZOLAM HCL-SODIUM CHLORIDE 47MIDAZOLAM+SYRSPEND SF 47midodrine hcl54MIFEPREX81mifepristone 81MIGERGOT 34miglitol73miglustat91MIGRAINE PACK 34migraine relief 12MIGRANAL 34MIGRANOW 34mili 102milk of magnesia 89MILLIPRED 95milrinone lactate54milrinone lactate in dextrose 54mimvey102MIMYX 67MINASTRIN 24 FE102mineral oil heavy 89MINIMED PUMP RESERVOIR 3ML 117MINIPRESS 54minitran 54MINIVELLE 102minocycline hcl24MINOCYCLINE HCL ER24minocycline hcl er 24MINOLIRA24minoxidil 54

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MINOXIDIL-PROGEST-TRETINOIN67MIRAPEX42MIRAPEX ER42MIRCERA 49MIRCETTE102MIRENA (52 MG)102mirtazapine 30MIRVASO 67misoprostol86MITE (D FARINAE)117MITE (D PTERONYSSINUS)117MITIGARE34mitigo 12mitomycin39MITOMYCIN 39MITOSOL121mitoxantrone hcl39MIXED ASPERGILLUS117MIXED FEATHERS 117MIXED RAGWEED 117MIXED VESPID VENOM PROTEIN 117MKO MELT DOSE PACK 117mlk f1 117mlk f2 117mlk f3 117mlk f4 117mm clearlax89mm stool softener laxative 89M-M-R II 109M-NATAL PLUS81MOBIC 16modafinil 135MODERNA COVID-19 VACCINE 109moexipril hcl 54moisturel 67molindone hcl44mometasone furoate 67 128mondoxyne nl24MONJUVI39MONOFERRIC 81mono-linyah 102MONONINE 49MONOVISC 117monsels ferric subsulfate 49montelukast sodium 132MONUROL24MORCIN 117MORGIDOX 24morgidox 24MORPHINE SULFATE 12

morphine sulfate 12morphine sulfate (concentrate) 12morphine sulfate (pf) 12morphine sulfate er 12morphine sulfate er beads 12MORPHINE SULFATE-NACL12MOTEGRITY89motion sickness relief31MOTOFEN 89MOTRIN IB 16MOTRIN INFANTS DROPS16MOUNTAIN CEDAR 117MOUSE EPITHELIUM 117MOUTH KOTE REMINT 59MOVANTIK 89MOVIPREP 89MOXEZA121moxifloxacin hcl24 121MOXIFLOXACIN HCL121moxifloxacin hcl (2x day)121moxifloxacin hcl in nacl 24MOZOBIL49m-pap12MS CONTIN12MSUD EASY117MUCINEX CHILDRENS FREEFROM128MUCINEX CHILDRENS STUFFY NOSE128MUCINEX DM128MUCINEX FAST-MAX DM MAX 128MUCOR 117MUCOSITISRX 59MUCOTROL 117mucus dm 128mucus relief d128mucus relief dm128mucus relief max st 128mucus-d 128MUGARD 117MUGWORT117MULPLETA 49MULTAQ 54MULTIGEN 81MULTIGEN FOLIC81MULTIGEN PLUS 81MULTIPRO 81MULTI-SPECIALTY 95multi-vitironfluoride81multivitaminfluoride 81MULTIVITAMINFLUORIDE 81multi-vitaminfluoride 81

multi-vitaminfluorideiron 81mupirocin 24mupirocin calcium 24MURO 128 124MUSE93mutamycin39MVASI39MYALEPT 91MYAMBUTOL 35MYCAMINE33MYCAPSSA 98MYCOBUTIN 35mycophenolate mofetil 107mycophenolate mofetil hcl 107mycophenolate sodium 107MYCOZYL AP33MYDAYIS57MYDRIACYL 124myferon 150 forte81MYFORTIC 107MYLERAN39MYLOTARG39mynephrocaps 81MYNEPHRON81MYOBLOC 117myorisan 67MYRBETRIQ93MYSOLINE 28MYTESI89MYXREDLIN 76na ferric gluc cplx in sucrose81NABI-HB 107nabumetone 16n-acetyl-l-cysteine 81nadolol 54nafcillin sodium 24nafrinse 81NAFRINSE DAILY ACIDULATED 59NAFRINSE DAILYNEUTRAL59nafrinse drops 81NAFRINSE WEEKLY59naftifine hcl33NAFTIN 33NAGLAZYME91nalbuphine hcl12NALFON 16NALOCET 12naloxone hcl20NALTREXONE20naltrexone hcl20NAMENDA 29NAMENDA TITRATION PAK29

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NAMENDA XR 29NAMENDA XR TITRATION PACK 29NAMZARIC 29NAPRELAN16NAPROSYN16naproxen 16naproxen sodium 16naproxen sodium er 16NAPROXEN SODIUM ER 16naproxen-esomeprazole 16naratriptan hcl 34NARCAN20NARDIL30NASACORT ALLERGY 24HR 128nasal decongestant129nasal decongestant pe129nasal moisturizing spray 129nasal spray 12 hour 129nasal spray no drip129NASCOBAL 81NASONEX 129NATACYN121NATAZIA102nateglinide73NATESTO 96NATPARA 112NATROBA42natural senna laxative 89NATURE-THROID 104NAVELBINE39NAYZILAM 28NEBUPENT 42necon 0535 (28)103nefazodone hcl30NEODOT THERMOMETER 117neomycin sulfate 24neomycin-bacitracin zn-polymyx124neomycin-polymyxin b gu 24neomycin-polymyxin-dexameth 124neomycin-polymyxin-gramicidin124neomycin-polymyxin-hc 124 126NEONATAL + DHA81NEONATAL 1981NEONATAL COMPLETE81NEONATAL FE 81NEONATAL PLUS 81neo-polycin124neo-polycin hc125NEORAL 107

NEOSALUS 67NEOSPORIN ORIGINAL 67NEOSTIGMINE METHYLSULFATE 35NEO-SYNALAR 67NEO-SYNEPHRINE COLDALLRG MILD129NEO-SYNEPHRINE COLDALLRGY EXT129NEO-SYNEPHRINE COLDALLRGY REG 129NEOTUSS PLUS 129NEOVITE 81NEPHPLEX RX81nephronex 81NEPHRO-VITE RX 81NERLYNX 39NESINA73NESTABS 81NESTABS ONE 81neuac 67NEUAC 67NEULASTA 49NEULASTA ONPRO49NEUPOGEN 49NEUPRO42NEURAPTINE58NEURIN-SL81NEURONTIN28NEVANAC121nevirapine 45nevirapine er 45NEXAVAR39NEXIUM 86NEXLETOL 54NEXLIZET54NEXPLANON103niacin (antihyperlipidemic) 54niacin er (antihyperlipidemic) 54NIACINAMIDE-SPIRONOLACTONE 67NIACINAMIDE-SULFACETAMIDE67NIACINAMIDE-TACROLIMUS67NIACINAMIDE-TAZAROTENE 67NIACINAMIDE-TRETINOIN67NIACINAMIDE-TRIAMCINOLONE ACET 67NIACIN-SPIRONOLACTON-TRETINOIN67niacor 54NIASPAN 54NICADAN81

NICAPRIN117nicardipine hcl 54NICAZEL81NICAZEL FORTE81NICAZYME 117NICOMIDE 81NICORETTE 20nicotine polacrilex 21nicotine step 121nicotine step 221nicotine step 321NICOTROL 21NICOTROL NS 21nifedipine54nifedipine er 54nifedipine er osmotic release 54NIFEREX 81nikki103NILANDRON39nilutamide39nimodipine54NINLARO 39NIPENT39nisoldipine er54nitazoxanide42nitisinone91NITRO-BID54NITRO-DUR54nitrofurantoin 24nitrofurantoin macrocrystal24nitrofurantoin monohydrate macrocrystals24nitroglycerin54NITROLINGUAL 54NITROMIST 54NITROSTAT54NITRO-TIME 54NITYR 91NIVESTYM49nizatidine86NOCDURNA 98nolix67NOPIOID-LMC KIT 134nora-be103NORDIPEN 5 INJECTION DEVICE117NORDITROPIN FLEXPRO 98norethin ace-eth estrad-fe103norethindrone103norethindrone acetate 103norethindrone acet-ethinyl est103norethindrone-eth estradiol 103norethin-eth estradiol-fe 103

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NORGESIC FORTE134norgestimate-eth estradiol 103norgestimate-ethinyl estradiol triphasic103NORITATE67norlyda 103norlyroc 103NORPACE 54NORPACE CR 54NORPRAMIN 30NORTHERA54nortrel 0535 (28) 103nortrel 135 (21) 103nortrel 135 (28) 103nortrel 777103nortriptyline hcl30NORVASC 54NORVIR 45NOURIANZ 42NOVACORT67NOVAMV PEDIATRIC MULTI-VITAMIN 81novarel 98NOVAREL98NOVOEIGHT 49NOVOFINE AUTOCOVER PEN NEEDLE 76NOVOFINE PEN NEEDLE 76NOVOFINE PLUS PEN NEEDLE76NOVOLIN 7030 FLEXPEN 76NOVOLIN 7030 FLEXPEN RELION76NOVOLIN 7030 RELION 76NOVOLIN 7030 VIAL 76NOVOLIN N FLEXPEN76NOVOLIN N FLEXPEN RELION76NOVOLIN N RELION76NOVOLIN N VIAL 76NOVOLIN R FLEXPEN76NOVOLIN R FLEXPEN RELION77NOVOLIN R RELION77NOVOLIN R VIAL 77NOVOLOG FLEXPEN 77NOVOLOG MIX 7030 FLEXPEN77NOVOLOG MIX 7030 VIAL77NOVOLOG PENFILL 77NOVOLOG U-100 VIAL 77NOVOPEN ECHO74NOVOSEVEN RT 49

NOVOTWIST PEN NEEDLE 77NOXAFIL33NP 2 DRUG PREPARATION KIT 16np thyroid 104NPLATE 49NUBEQA39NUCALA 129NUCARACLINPAK 67NUCARARXPAK67NUCORT67NUCYNTA12NUCYNTA ER12NUDERMRXPAK 120 67NUDERMRXPAK 60 68NUDICLO SOLUPAK16NUDICLO TABPAK16NUDROXIPAK 16NUDROXIPAK DSDR-5017NUDROXIPAK DSDR-7517NUDROXIPAK E-40017NUDROXIPAK I-800 17NUDROXIPAK M-15 17NUDROXIPAK N-500 17NUEDEXTA 58NUFERA 81nufol 81NULEV 89NULOJIX107NULYTELY LEMON-LIME 89NUMBRINO 19NUPLAZID 44NURTEC 34NUSURGEPAK SURGICAL PREPCARE 59NUTRASEB 68NUTRIARX CREAMPAK 68NUTRICAP81NUTRIDOX 24nutrifac zx81NUTRIVIT 82NUTROPIN AQ NUSPIN 10 98NUTROPIN AQ NUSPIN 20 98NUTROPIN AQ NUSPIN 5 99NUVAIL 68NUVAKAAN 19NUVAKAAN-II 19NUVARING 103NUVESSA24NUVIGIL135NUWIQ49NUZYRA 24nyamyc33

nylia 777103NYMALIZE 54nymyo 103nystatin33nystatin-triamcinolone 33nystop 33NYVEPRIA49OBIZUR 49OCALIVA 91ocella103OCREVUS 58OCTAGAM107octreotide acetate 99OCUFLOX121OCUVEL 82ODACTRA 117ODEFSEY45ODOMZO39odorless coated fish oil 117OFEV 132ofloxacin24 121 126OGIVRI 39olanzapine44olanzapine-fluoxetine hcl 30OLIVE TREE117olmesartan medoxomil54olmesartan medoxomil-hctz 54olmesartan-amlodipine-hctz54olopatadine hcl121 129OLUMIANT 107OLUX 68OLUX-E68OMECLAMOX-PAK 89OMEGA-3 RX COMPLETE54omega-3-acid ethyl esters54omeprazole 86omeprazole magnesium86OMEPRAZOLE+SYRSPEND SF ALKA 86omeprazole-sodium bicarbonate 86OMNARIS 129OMNITROPE 99OMNIVEX 117ONCASPAR39ondansetron hcl 31ondansetron odt 31ONE VITE WOMENS82ONE VITE WOMENS PLUS 82ONETOUCH DELICA LANCING DEV74ONETOUCH DELICA PLUS LANCING 74

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ONETOUCH ULTRA74ONETOUCH ULTRA 2 KIT WDEVICE 74ONETOUCH ULTRA MINI KIT WDEVICE 74ONETOUCH VERIO FLEX SYSTEM KIT WDEVICE74ONETOUCH VERIO IQ SYSTEM 74ONETOUCH VERIO KIT WDEVICE 74ONETOUCH VERIO REFLECT74ONETOUCH VERIO SYNC SYSTEM KIT WDEVICE75ONEVITE 82ONEXTON 68ONFI 28ONGENTYS42ONGLYZA73ONIVYDE39ONPATTRO 58ONTRUZANT39ONUREG 39ONYCHO-MED 33ONZDEOXIA68ONZETRA XSAIL34OPDIVO 39opium 89OPSUMIT133ORACEA68ORACIT 82ORALAIR 117ORALAIR ADULT STARTER PACK 117ORALAIR CHILDRENS STARTER PACK 117oralone 59ORAMAGICRX 117ORAPRED ODT95ORAVIG 33ORCHARD GRASS POLLEN 117ORENCIA107ORENCIA CLICKJECT 107ORENITRAM 133ORFADIN91ORGOVYX39ORIAHNN 103ORILISSA 99ORKAMBI 133ORLADEYO 107ORMECA 17orphenadrine citrate er134

orphenadrine-asa-caffeine 134ORPHENGESIC FORTE 134orsythia 103ORTHO DF 82ORTHO MICRONOR 103ORTHOVISC117ORTIKOS111oscimin89oscimin sr89oseltamivir phosphate 45OSENI73OSMOLEX ER 42OSMOPREP 89OSPHENA 97OTEZLA 107OTIPRIO 126OTOVEL 126OTREXUP107OVACE PLUS 68OVACE PLUS WASH 68OVACE WASH68OVEEZA 82OVIDE42OVIDREL 99oxacillin sodium24oxaliplatin 39oxandrolone 97oxaprozin 17OXAYDO12oxazepam 47OXBRYTA117oxcarbazepine28OXERVATE 125OXIANUJO68OXIATAR 68OXIAVARRY 68OXIAZAR 68oxiconazole nitrate 33OXISTAT33OXLUMO 93OXOPOD 68OXSORALEN ULTRA68OXTELLAR XR 28oxybutynin chloride 93oxybutynin chloride er 93oxycodone hcl 12 13OXYCODONE HCL ER 12OXYCODONE-ACETAMINOPHEN13oxycodone-acetaminophen13oxycodone-aspirin13OXYCONTIN13oxymorphone hcl13

oxymorphone hcl er 13OXYTOCIN-LACTATED RINGERS99OXYTOCIN-SODIUM CHLORIDE 99OXYTROL93OXYTROL FOR WOMEN 93oyster shell calciumd82oyster shell calciumvitamin d 82OZEMPIC73OZOBAX 134OZURDEX 121PACERONE54paclitaxel 39PADCEV 39pain amp fever childrens 13pain amp fever infants 13pain relief 13pain relief childrens 13pain relief extra strength 13pain relief regular strength 13pain reliever extra strength 13pain relieving + lidocaine19PAINGO KFT 19PALFORZIA 117paliperidone er 44palonosetron hcl31PALYNZIQ 91PAMELOR 30pamidronate disodium111PANADOL CHILDRENS 13PANADOL EXTRA13PANADOL EXTRA STRENGTH 13PANADOL INFANTS 13PANCREAZE 91PANDEL68PANHEMATIN 49PANRETIN39pantoprazole sodium86PANZYGA107papaverine hcl54PARAGARD INTRAUTERINE COPPER103paraplatin 39PAREMYD 125PARI ALTERA NEBULIZER HANDSET117PARI TREK S COMBO PACK 117PARI VORTEX ADULT MASK 117paricalcitol 112PARLODEL42PARNATE 30

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paromomycin sulfate24paroxetine hcl30paroxetine hcl er 30paroxetine mesylate30PARSABIV 112PASER35PATADAY 121PATANASE129PAXIL30PAXIL CR30pb-hyoscy-atropine-scopolamine89P-CARE K40 95P-CARE K40G 95P-CARE K40MX95P-CARE K80 95P-CARE K80G 95P-CARE K80MX95PCP 10089pediaclear pd childrens 129PEDIAPRED 95PEDIATRIC COMPRESSOR NEBULIZER118pediatric electrolyte 82pediavit82PEDIZOLPAK 33PEDVAX HIB 109peg 3350-kcl-na bicarb-nacl89peg-3350electrolytes89peg-3350electrolytesascorbat89PEGASYS45PEGINTRON46peg-kcl-nacl-nasulf-na asc-c 89peg-prep90PEMAZYRE 39penicillamine 93penicillin g potassium24penicillin g procaine 24penicillin g sodium24penicillin v potassium 24PENICILLIUM NOTATUM118PENLEN68PENNSAID17PENTAM 42pentamidine isethionate 42PENTASA 111pentazocine-naloxone hcl 13PENTOSAN POLYSULFATE SODIUM93pentoxifylline er 54PEPCID86PERCOCET 13

PERDIEM OVERNIGHT RELIEF 90PERFOROMIST132PERIDEX 59perindopril erbumine 54periogard59PERJETA39permethrin42perphenazine 31perphenazine-amitriptyline30PERSERIS44PERTZYE 91PEXEVA30PFIZER-BIONTECH COVID-19 VACC 109PFIZERPEN24PH STRIPS 118phenazo 93phenazopyridine hcl 93phendimetrazine tartrate 58phendimetrazine tartrate er58phenelzine sulfate 30PHENERGAN 129phenobarbital 28phenobarbital-belladonna alk90PHENOHYTRO90phenoxybenzamine hcl 54phentermine hcl 58phentolamine mesylate 54PHENYLEPHRINE HCL 93phenylephrine hcl125PHENYLEPHRINE HCL-NACL55PHENYTEK28phenytoin 28phenytoin infatabs28phenytoin sodium extended 28PHEODOYO 33PHESGO39PHEXXI118PHEYO 33philith103PHLAG SPRAY68PHOMA EXIGUA 118PHOSLYRA 93PHOSPHA 250 NEUTRAL82PHOSPHASAL93PHOSPHOLINE IODIDE123phosphorous 82phosphorus supplement82phosphorus wsod amp potassium82phospho-trin 250 neutral 82PHOTOFRIN39

PHOTREXA-PHOTREXA VISCOUS KIT 118PHOXILLUM B22K40 82PHOXILLUM BK425 82PHYSICIANS EZ USE B-1282physicians ez use jointtunnel 95PHYSICIANS EZ USE M-PRED 95PHYSIOLYTE 82PHYSIOSOL IRRIGATION 82phytonadione 82PIFELTRO 46pilocarpine hcl 59 123pimecrolimus68pimozide44pimtrea 103pindolol55pink bismuth maximum strength 90pioglitazone hcl 73pioglitazone hcl-glimepiride73pioglitazone hcl-metformin hcl 73piperacillin sod-tazobactam so24PIQRAY 39pirmella 135 103pirmella 777 103piroxicam17PKU EASY 118PKU EASY MICROTABS118PKU GO 118PLAN B ONE-STEP103PLAQUENIL42PLASMA-LYTE 148 82PLASMA-LYTE A82PLAVIX 43PLEGRIDY58PLEGRIDY STARTER PACK 58PLENVU90PLEXION 68PLEXION CLEANSER 68PLEXION CLEANSING CLOTH68PLIAGLIS 19PNEUMOVAX 23 109PNV TABS 20-1 82POD-CARE 100K95PODIAPN82podocon 68podofilox68PODPROG68POINT OF CARE L2 95POINT OF CARE L5 95POINT OF CARE LM DEP 295

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POINT OF CARE LM-2219POINT OF CARE LM-2519POLIVY 39polycin125poly-iron 150 forte 82polymyxin b sulfate 24polymyxin b-trimethoprim125polysaccharide iron forte82POLYSPORIN25POLYTRIM125POLY-VI-FLOR 82POLY-VI-FLORIRON 82POLY-VITE PEDIATRIC 82POMALYST 39PONVORY 58PONVORY STARTER PACK 58portia-28103PORTRAZZA 39posaconazole33POTABA 82potassium chloride 82potassium chloride crys er 82potassium chloride er82potassium chloride in nacl82potassium citrate er82potassium citrate-citric acid82POTELIGEO 39POVIDONE-IODINE 121PR BENZOYL PEROXIDE68PR BENZOYL PEROXIDE WASH 68PR CREAM 68PRADAXA26PRALUENT55pramipexole dihydrochloride 42pramipexole dihydrochloride er42pramosone 68PRAMOSONE68PRAMOTIC 126pramox 68PRASTERA17prasugrel hcl 43pravastatin sodium55PRAXBIND118praziquantel 42prazosin hcl55PRE amp POST SX POUCH68PRECEDEX 118PRECISION LINK 75PRECISION PCX PLUS TEST 75PRECISION QID MONITOR75PRECISION QID TEST75

PRECISION SOF-TACT MONITOR 75PRECISION SOF-TACT TEST 75PRECISION XTRA75PRECISION XTRA BLOOD GLUCOSE 75PRECISION XTRA MONITOR75PRECOSE 73PRED FORTE121PRED MILD 121PRED-G 125PRED-G SOP 125prednicarbate 68PREDNISOL ACE-MOXIFLOX-BROMFEN 122prednisolone 95prednisolone acetate122prednisolone acetate p-f 122PREDNISOLONE ACETATE-NEPAFENAC 125PREDNISOLONE ACET-MOXIFLOXACIN125prednisolone sodium phosphate 96 122PREDNISOLONE-BROMFENAC 125PREDNISOLONE-GATIFLOXACIN125PREDNISOLONE-MOXIFLOXACIN125PREDNISOLON-GATIFLOX-BROMFENAC 125PREDNISOLON-MOXIFLOX-BROMFENAC 125PREDNISOLON-MOXIFLOX-NEPAFENAC 122prednisone 96prednisone intensol96PREFEST 103pregabalin 58PREGEN DHA 82PREGENNA82pregnyl 99PREMARIN 103PREMESISRX 82PREMIUM CONDOMS LUBRICATED 118premium lidocaine19PREMIUM SCAR 19PREMPHASE 103PREMPRO103PRENAISSANCE82PRENARA83

prenatal 83prenatal plus iron 83prenatal vitamin plus low iron83PRENATE 83PRENATE DHA 83PRENATE ELITE 83PRENATE ENHANCE 83PRENATE ESSENTIAL 83PRENATE MINI 83PRENATE PIXIE83PRENATE RESTORE83PRENATRIX 83PRENATRYL 83PRENATVITE COMPLETE83PRENATVITE PLUS 83PRENATVITE RX 83PREPIDIL93PREPIV SUPPLY19preplus 83PRESERA68PRESTALIA 55PRETAB83PRETOMANID 35PREVACID86PREVACID 24HR 86PREVACID SOLUTAB86prevalite 55PREVIDENT 59PREVIDENT 5000 BOOSTER PLUS59PREVIDENT 5000 DRY MOUTH59PREVIDENT 5000 ENAMEL PROTECT60PREVIDENT 5000 ORTHO DEFENSE 60PREVIDENT 5000 PLUS 60PREVIDENT 5000 SENSITIVE60PREVIDOLRX ANALGESIC 17previdolrx plus analgesic17previfem 103PREVNAR 13110PREVYMIS 46PREZCOBIX 46PREZISTA 46PRIALT 13PRID 118PRIFTIN 35PRILO PATCH 19PRILO PATCH II 19PRILOLID19PRILOSEC86PRILOVIX 19

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PRILOVIX LITE19PRILOVIX LITE PLUS 19PRILOVIX PLUS 19PRILOVIX ULTRALITE 19PRILOVIX ULTRALITE PLUS19PRILOVIXIL 19PRIMACARE83primaquine phosphate 42primidone 28PRIMSOL25PRINIVIL 55PRISTIQ30PRIVET 118PRIVIGEN107PRIZOPAK II19PRIZOTRAL19PRIZOTRAL-II19PRO HERS RX 83PRO HIS RX 83PRO PCOS RX 83PROAIR DIGIHALER132PROAIR HFA 132PROAIR RESPICLICK132probenecid 34PROBICHEW90PROBITROL 90PROBUPHINE IMPLANT KIT 13procainamide hcl55PROCARDIA55PROCARDIA XL 55PRO-C-DURE 5 96PRO-C-DURE 6 96PROCENTRA 57prochlorperazine 31prochlorperazine maleate 31PROCORT 111PROCRIT49PRO-CRITIC 118PROCTOCORT 111PROCTOFOAM HC 111procto-med hc 111procto-pak 111proctozone-hc 111PROCYSBI 91PRODIGEN90PROFESSIONAL DNA COLLECTION 118PROFILNINE 49progesterone103PROGESTERONE MICRONIZED 103PROGESTERONE-MINOXIDIL68

PROGLYCEM 75PROGRAF 107PROLASTIN-C132PROLATE 13PROLENSA 122PROLEUKIN 39PROLEVA 118PROLIA111PROMACTA49PROMELLA IN PREBIOTIC 90PROMEROL 90promethazine hcl129promethazine vc129promethazine vccodeine 129promethazine-codeine 129promethazine-dm 129promethazine-phenyleph-codeine 129promethazine-phenylephrine 129promethegan129PROMETRIUM 103PROMISEB 68PRONEB ULTRA FILTER SET 118propafenone hcl 55propafenone hcl er 55proparacaine hcl 125proparacaine-fluorescein 125PROPECIA 68PROPEL 129PROPEL MINI129propranolol hcl 55propranolol hcl er 55propranolol-hctz 55propylthiouracil 104PROSCAR 94PROSILK 68PROSTIN E293PROTEINEX P1883PROTEXA68PROTONIX 86PROTOPIC 68protriptyline hcl30PROTYL AG 68PROVENGE107PROVENTIL HFA 132PROVERA 103PROVIGIL 135PROZAC 30PRUCLAIR68PRUDOXIN 68PRUMYX68pseudoephedrine hcl er 129

pseudoephedrine-bromphen-dm 129pseudoephedrine-guaifenesin er129PSORCON68PSORIZIDE FORTE 118PSORIZIDE ULTRA118PULMICORT FLEXHALER132PULMICORT SUSPENSION 132PULMOZYME 133PURAMINO DHAARA118purevit dualfe plus83PURIXAN 39PYLERA90pyrazinamide35PYRIDIUM 93pyridostigmine bromide35pyridostigmine bromide er35pyridoxine hcl 83pyrimethamine 42PYRIMETHAMINE-LEUCOVORIN 42PYROGALLIC ACID 68QBRELIS 55QBREXZA68qc magnesium citrate90QDOLO 13QINLOCK39QMIIZ ODT 17QNASL129QNASL CHILDRENS 129QSYMIA 58QTERN 73QUAD-MIX 93quad-probiotic 90QUALAQUIN42QUARTETTE 103quazepam 47QUDEXY XR28QUEEN PALM 118QUESTRAN 55QUESTRAN LIGHT 55quetiapine fumarate 44quetiapine fumarate er 44QUFLORA FE 83QUFLORA FE PEDIATRIC83QUFLORA GUMMIES 83QUFLORA PEDIATRIC 83QUIHOXVAR 68QUILLICHEW ER57QUILLIVANT XR 57quinapril hcl55quinapril-hydrochlorothiazide 55

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quinidine gluconate er55quinidine sulfate 55quinine sulfate42QUINIXIL68QUINJA33QUTENZA68QUTENZA (2 PATCH) 68QUTENZA (4 PATCH) 68QVAR REDIHALER 132RABAVERT110RABBIT EPITHELIUM 118RABEPRAZOLE SODIUM 86rabeprazole sodium 86RADIAGEL68RADIAPLEXRX68RADICAVA58RADIOGARDASE 118RAGWITEK118raloxifene hcl97ramelteon 135ramipril 55RANEXA 55ranolazine er 55RAPAFLO 94RAPAMUNE107RAPID GEL RX118RAPIVAB 46rasagiline mesylate 42RASUVO108RAVICTI91RAYALDEE111RAYOS 96RAZADYNE ER 29READYSHARP ANESTH + METHYLPRED 96READYSHARP BETAMETHASONE96READYSHARP DEXAMETHASONE 96READYSHARP-A19REBIF 58REBIF REBIDOSE58REBIF REBIDOSE TITRATION PACK 58REBIF TITRATION PACK58REBINYN 49REBLOZYL 49RECARBRIO25RECEDO69RECLAST 112reclipsen103RECOMBINATE49RECOMBIVAX HB 110

RECOTHROM 49RECOTHROM SPRAY KIT49RECTIV55RECURA33RED MAPLE 118RED MULBERRY 118RED TOP GRASS POLLEN 118REDITREX108REFISSA69REFRESH RELIEVA125REFRESH RELIEVA PF 125REGENECARE69REGIOCIT26REGLAN 31REGRANEX69RELADOR PAK 19RELADOR PAK PLUS 19RELAFEN 17RELAFEN DS 17RELENZA DISKHALER 46relexxii 57RELION BLOOD GLUCOSE TEST75RELISTOR 90RELNATE DHA83RELPAX34RELTONE 90REMEDIENT83remergent hq69REMERON30REMERON SOLTAB 30REMICADE 108REMIGEN 69REMODULIN 133RENACIDIN 93RENAGEL93RENAL 83RENAL MULTIVITAMIN FORMULA 83RENATABS83RENATABS WITH IRON 83rena-vite 83RENFLEXIS 108reno caps 83RENOVA69RENOVA PUMP 69RENVELA 93repaglinide 73REPATHA 55REPATHA PUSHTRONEX SYSTEM 55REPATHA SURECLICK 55REQ 49+ 83

RESECTISOL 118RESORCINOL-SULFUR69RESOURCE THICKENUP JUICE118RESTASIS 125RESTASIS MULTIDOSE 125RESTORA RX90RESTORIL 135RETACRIT 49RETEVMO 39RETIN-A69RETIN-A MICRO GEL 004 01 69RETIN-A MICRO PUMP 69RETISERT 122RETROVIR 46REVATIO 133REVCOVI91REVESTA 83REVLIMID 39REXASIL PATCH amp VITAMIN E LIQ69REXULTI44REYATAZ 46REYVOW 34RHEUMATE118RHIZOPUS 118RHOFADE 69RHOGAM ULTRA-FILTERED PLUS108RHOPHYLAC108RHOPRESSA 123RIABNI 39RIASTAP49RIAX69ribavirin 46RIBOZEL118RIDAURA108rifabutin 35rifampin 35RIFAMPIN+SYRSPEND SF 35RILUTEK58riluzole59rimantadine hcl46RIMSO-50 93ringers irrigation 83RINVOQ108RIOMET 73risedronate sodium 112RISPERDAL44RISPERDAL CONSTA44risperidone 44RITALIN 57

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RITALIN LA57ritonavir 46RITUXAN 39RITUXAN HYCELA39rivastigmine29rivastigmine tartrate 29rivelsa103RIXUBIS49rizatriptan benzoate 34ROAOXIA69ROBITUSSIN 12 HOUR COUGH CHILD129ROBITUSSIN COUGH+CHEST CONG DM129ROCALTROL 112ROCKLATAN 123ROMIDEPSIN 39ropinirole hcl43ropinirole hcl er 43rosadan 69ROSADAN 69rosuvastatin calcium 55ROSZET 55ROTARIX 110ROTATEQ110ROUGH MARSH ELDER118ROWASA 111roweepra 28ROXICODONE 13ROZEREM 135ROZLYTREK 39RUBRACA 39RUCONEST108rufinamide 28RUKOBIA46RUSSIAN THISTLE 118RUXIENCE 39RUZURGI118RYBELSUS73RYCLORA129RYDAPT 39RYTARY 43RYTHMOL SR 55ryvent 129SABRIL 28saccharomyces boulardii 90SACCHAROMYCES CEREVISIAE 118SAFYRAL103SAIZEN 99SAIZENPREP 99SALAGEN 60SALEX 69

SALICEPT118salicylic acid 69salicylic acid er69salicylic acid wart remover 69salicylic acid-cleanser 69SALICYLIC ACID-SULFACETAMIDE69salimez69SALIMEZ FORTE 69SALIVAMAX60salsalate17SALVAX 69SALVAX DUO PLUS69SAMSCA83SANADERMRX SKIN REPAIR69SANCUSO 31SANDIMMUNE 108SANDOSTATIN 99SANDOSTATIN LAR DEPOT 99SANTYL 69SAPHRIS 44sapropterin dihydrochloride92SARCLISA 39SAVAYSA 26SAVELLA 59SAVELLA TITRATION PACK 59SAXENDA59SCALACORT DK 69SCARCARE GEL-PAD KITLARGE 69SCARCIN69SCARSILK 69SCARZEN SKIN REPAIR 69SCENESSE 69scopolamine31SCRUB CARE POVIDONE-IODINE25SEASONIQUE 103SECUADO 44SEEBRI NEOHALER 132SEGLUROMET73SELECT-OB83selegiline hcl 43selenium sulfide 69SELRX 69SELZENTRY46SEMGLEE77senexon-s 90senna 90senna plus90senna s 90senna smooth 90senna-docusate sodium90

senna-plus 90SENOKOT EXTRA STRENGTH 90SENOKOT S 90SENSIPAR112SENSORCAINE19SENSORCAINE-MPF 19 20sensorcaine-mpf 20SEREVENT DISKUS 132SERNIVO69SEROQUEL 44SEROQUEL XR 44SEROSTIM 90sertraline hcl30se-tan plus 83setlakin103sevelamer carbonate 93sevelamer hcl93SEVENFACT 49sevoflurane 118SEYSARA 25sf 60sf 5000 plus60SFROWASA 111SHAGBARK HICKORY118sharobel 103SHARPS CONTAINER 118SHEEP SORREL 118SHINGRIX110SHORT RAGWEED POLLEN EXT 118SIDEROL 83SIGNIFOR99SIGNIFOR LAR99SIKLOS 39SILA III 69sildenafil citrate 93 133SILENOR 135SILIPAC 69SILIQ108silodosin 94SILTREX 118SILVADENE25silver nitrate25silver sulfadiazine25SILVERSEAL HYDROGEL DRESSING 69SIMBRINZA 123simethicone90simethicone ultra strength90simliya 103simpesse103SIMPONI108

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SIMPONI ARIA 108SIMULECT108simvastatin 55SINEMET 43SINGULAIR132sinus 12 hour 129SINUVA129sirolimus108SIRTURO35SITAVIG46SIVEXTRO25skarjel69SKELAXIN 134SKYADERM-LP 20SKYLA 103SKYRIZI (150 MG DOSE)108sleep aid (diphenhydramine)135sleep-aid 135SLOWMAG MG MUSCLEHEART83SLYND 103sod citrate-citric acid 83sodium bicarbonate83 84 90SODIUM BICARBONATE84 90sodium chloride84 129sodium chloride (hypertonic)125sodium chloride (pf) 84sodium fluoride60 84sodium fluoride 5000 enamel60sodium fluoride 5000 plus 60sodium fluoride 5000 ppm60sodium fluoride 5000 sensitive60sodium phenylbutyrate92sodium polystyrene sulfonate 84sodium sulfacetamide 69sodium sulfacetamide wash69SODIUM SULFACETAMIDE-BAKUCHIOL 69SOFOSBUVIR-VELPATASVIR46SOLARAVIX70solifenacin succinate93SOLIQUA 73SOLIRIS49SOLODYN 25SOLOSEC25SOLOX70SOLTAMOX 39SOLU-CORTEF 96soluvita e84SOMA 134SOMATULINE DEPOT 99SOMAVERT99SOOLANTRA70

soothe 90SOOTHEE 20SORBITOL118sorbitol-mannitol118SORIATANE 70SORILUX 70SORRELDOCK MIX 118sotalol hcl 55sotalol hcl (af)55SOTYLIZE55SOVALDI 46SPEEDGEL RX118spinosad42SPINRAZA 118SPINY PIGWEED 118SPIRIVA HANDIHALER132SPIRIVA RESPIMAT 132spironolactone55spironolactone-hctz55SPORANOX33SPORANOX PULSEPAK33SPRAVATO (56 MG DOSE) 30SPRAVATO (84 MG DOSE) 30sprintec 28 103SPRITAM 28SPRIX 17SPRYCEL 39sps 84sronyx 103ssd 25SSKI129sss 10-5 70ST JOSEPH LOW DOSE17STALEVO 100 43STALEVO 125 43STALEVO 150 43STALEVO 200 43STALEVO 50 43STALEVO 75 43STAMARIL 110STARLIX 73stavudine46STAXYN93STEGLATRO 73STEGLUJAN73STELARA108STEMPHYLIUM 118STENDRA93STERILE TOPICAL LET GEL20STERITALC 132STIMATE 99stimulant laxative 90

STIOLTO RESPIMAT 132STIVARGA40stomach relief90stool softener 90stool softener laxative 90stool softener plus laxative90stool softenerlaxative 90stop lice complete treatment 42STRATA CTX70STRATA GRT 70STRATA MARK 70STRATA TRIZ70STRATA XRT70STRATTERA57STRENSIQ92streptomycin sulfate 25STRIBILD46STRIVERDI RESPIMAT 132STROMECTOL 42STROVITE FORTE84STROVITE ONE 84SUBLOCADE21SUBOXONE21SUBSYS 13subvenite28subvenite starter kit-blue28subvenite starter kit-green 28subvenite starter kit-orange 28SUCCINYLCHOLINE CHLORIDE 59SUCRAID92sucralfate 86SUDAFED CONGESTION129sudogest 129sudogest 12 hour 129sudogest maximum strength129SULAR 55SULCONAZOLE NITRATE33sulfacetamide sodium 70 122sulfacetamide sodium (acne) 70sulfacetamide sodium-sulfur 70sulfacetamide sod-sulfur wash70sulfacetamide-prednisolone 125sulfacetamide-sulfur in urea70SULFACLEANSE 8470sulfadiazine 25sulfamethoxazole-trimethoprim25sulfamez wash 70SULFAMYLON25sulfasalazine 111sulfatrim pediatric25SULFURATED LIME42sulindac17

167

SUMADAN 70SUMADAN WASH 70SUMADAN XLT 70SUMANSETRON 34sumatriptan 34sumatriptan succinate 34 35sumatriptan succinate refill 34sumatriptan-naproxen sodium 35SUMAXIN70SUMAXIN CP70SUMAXIN WASH70SUNOSI 135SUPARTZ FX118SUPER BI-MIX93SUPER QUAD-MIX93SUPER TRI-MIX 93SUPERVITE84support 84SUPPORT-500 84SUPPRELIN LA 99SUPRANE119SUPRAX 25SUPREP BOWEL PREP KIT90sure result dss premium pack 17SURE RESULT O3D3 SYSTEM 55SURESTEP PRO HIGH GLUCOSE 75SURESTEP PRO LOW GLUCOSE 75SURESTEP PRO NORMAL GLUCOSE 75SURVANTA 129SUSTIVA46SUSTOL31SUTAB 91SUTENT40SUVICORT 70SWEET GUM119SWEET VERNAL GRASS POLLEN119SX1 MEDICATED POST-OPERATIVE 20syeda 103SYLVANT40SYMAX DUOTAB 91SYMAX-SL91SYMAX-SR 91SYMBICORT132SYMBYAX30SYMDEKO 133SYMFI 46SYMFI LO 46

SYMJEPI132SYMLINPEN 120 73SYMLINPEN 60 73SYMPAZAN 28SYMPROIC91SYMTUZA46SYNAGIS 108SYNALAR 70SYNALAR (CREAM)70SYNALAR (OINTMENT) 70SYNALAR TS70SYNAPRYN FUSEPAQ 13SYNAREL 99SYNDROS 31SYNERA 20SYNERDERM 70SYNJARDY73SYNJARDY XR73SYNRIBO40SYNTHROID104SYNVISC 119SYNVISC ONE 119SYPRINE 84SYRINGE AVITENE 119SYSTANE COMPLETE 125SYSTANE HYDRATION PF 125SYSTANE ICAPS AREDS2 84SYSTANE ULTRA PF125TABLOID40TABRADOL FUSEPAQ 134TABRADOL RAPIDPAQ 134TABRECTA40TACHOSIL 119TACLONEX70TACROLIMUS 70tacrolimus70 108tadalafil 93tadalafil (pah) 133TAFINLAR40TAGRISSO 40TAKHZYRO 108TALICIA 91TALIVA84TALL RAGWEED119TALTZ 108TALZENNA 40TAMIFLU46tamoxifen citrate40tamsulosin hcl 94TAPAZOLE 104TAPERDEX 12-DAY 96TAPERDEX 6-DAY 96TAPERDEX 7-DAY 96

TARCEVA 40TARDEOXIA 70TARDIMAXIA 70TARGADOX25TARGRETIN 40tarina 24 fe 103tarina fe 120 104tarina fe 120 eq 104TARKA 55TAROXIA 70TASIGNA 40TASMAR 43TASOPROL 70tavaborole 33TAVALISSE 49TAYTULLA104tazarotene 70TAZAROTENE70tazicef25TAZORAC70 71taztia xt55TAZVERIK 40TDVAX 110TECARTUS40TECENTRIQ 40TECFIDERA58TEFLARO 25TEGRETOL28TEGRETOL-XR 28TEGSEDI 59TEKTURNA55TEKTURNA HCT 55telmisartan 55telmisartan-amlodipine55telmisartan-hctz55temazepam 135TEMIXYS 46TEMODAR 40TEMOVATE 71temozolomide40temsirolimus108TENCON13teniposide40TENIVAC 110tenofovir disoproxil fumarate46TENORETIC 100 55TENORETIC 50 56TENORMIN56TEPADINA 40TEPEZZA99TEPMETKO 40terazosin hcl94terbinafine hcl33

168

terbutaline sulfate132terconazole 33TERIPARATIDE (RECOMBINANT) 112terrell 119TESSALON PERLES129TESTIM97TESTONE CIK 97TESTOPEL 97TESTOSTERONE97testosterone 97TESTOSTERONE CYPIONATE 97testosterone cypionate97testosterone enanthate 97TETANUS-DIPHTHERIA TOXOIDS TD 110tetrabenazine 59tetracaine hcl125tetracycline hcl 25TETRIX 71TEXACORT 71THALOMID 40THEO-24132theophylline132theophylline er132thiamine hcl84THIOLA EC 93thioridazine hcl 44thiotepa 40thiothixene44THROMBATE III 26THROMBI-GEL 10 119THROMBI-GEL 100 119THROMBI-GEL 40 119THROMBIN-JMI50THROMBIN-JMI EPISTAXIS 50THROMBI-PAD119THROMBOGEN50THYMOGLOBULIN108THYQUIDITY 104THYROGEN119tiadylt er 56tiagabine hcl28TIAZAC 56TIBSOVO 40TICE BCG 108TIGAN 31tigecycline 25TIGLUTIK59TIKOSYN 56tilia fe104timolol maleate56 123

timolol maleate pf123TIMOLOL-BRIMON-DORZOL-LATANOPR123TIMOLOL-BRIMONIDINE-DORZOLAMID 123TIMOLOL-DORZOLAMID-LATANOPROST 123TIMOPTIC123TIMOPTIC OCUDOSE123TIMOPTIC-XE123TIMOTHY GRASS POLLEN ALLERGEN119tinidazole25TIROSINT 104TIROSINT-SOL104TISSEEL 119tis-u-sol 84TIVICAY 46TIVICAY PD 46TIVORBEX17tizanidine hcl 134tl-hem 150 84TOBAKIENT119TOBI NEBULIZER 133TOBI PODHALER133TOBRADEX 125TOBRADEX ST125tobramycin 122 133TOBRAMYCIN 133tobramycin-dexamethasone125TOBREX 122tolbutamide 73tolcapone 43tolmetin sodium17tolnaftate 33tolnaftate antifungal33TOLSURA 33tolterodine tartrate93tolterodine tartrate er93TOLVAPTAN84tolvaptan 84TOPAMAX 28TOPAMAX SPRINKLE28TOPICORT 71TOPICORT SPRAY 71TOPIDEX 96topiramate 28topiramate er28toposar 40topotecan hcl40TOPROL XL56toremifene citrate 40TORISEL108

TORONOVA II SUIK 17TORONOVA SUIK 17torsemide 56TOSYMRA 35TOTECT40TOUJEO MAX SOLOSTAR 77TOUJEO SOLOSTAR77tovet 71TOVET 71TOVIAZ 93TRACLEER133TRADJENTA73TRAMADOL HCL ER13tramadol hcl er 13tramadol hcl er (biphasic)13tramadol hcl ir 13tramadol-acetaminophen 13trandolapril 56trandolapril-verapamil hcl er56tranexamic acid50TRANEXAMIC ACID-NACL 50TRANSDERM SCOP (15 MG)31TRANSDERM-SCOP (15 MG)31TRANXENE-T 47tranylcypromine sulfate 30TRANZGEL119TRAUMEEL 119TRAVATAN Z123travoprost (bak free)123TRAZIMERA 40trazodone hcl 30TREANDA40TRECATOR 35TRELEGY ELLIPTA133TRELSTAR MIXJECT99TREMFYA108treprostinil 133TRESIBA77TRESIBA FLEXTOUCH77tretinoin 40 71tretinoin (emollient) 71tretinoin microsphere 71tretinoin microsphere pump 71TRETTEN 50TREXALL 108TREXIMET35TREZIX 14tri femynor 104triamcinolone acetonide 60 71 96TRIAMCINOLONE ACETONIDE 96triamterene56triamterene-hctz 56

169

TRIANEX 71triazolam 47TRIBENZOR 56tri-buffered aspirin 17TRICARE PRENATAL DHA ONE 84TRI-CHLOR 71TRICHOPHYTON 119TRICHOPHYTON MENTAGROPHYTES119TRICITRASOL 26tricitrates 84TRICON 84TRICOR 56triderm71TRIDESILON 71trientine hcl84tri-estarylla 104TRIFERIC 84trifluoperazine hcl44trifluridine 122trihexyphenidyl hcl 43TRIJARDY XR 73TRIKAFTA133tri-legest fe 104TRILEPTAL28tri-linyah 104TRILIPIX 56TRILOAN II SUIK 96TRILOAN SUIK 96TRILOCICLO 71tri-lo-estarylla 104tri-lo-marzia 104tri-lo-mili 104tri-lo-sprintec 104TRI-LUMA 71TRILURON119trimethobenzamide hcl31trimethoprim 25tri-mili 104trimipramine maleate 30TRI-MIX93TRINATE84TRINAZ 84TRINTELLIX30tri-nymyo 104triple antibiotic 71triple antibiotic+pain relief 71TRIPLE COMPLEX FORMULA 3 KIT 17TRIPLE PMB122TRIPLE PMK122tri-previfem 104

triprolidine hcl129TRIPTODUR 99TRISENOX40tri-sprintec 104TRISTART DHA84TRISTART FREE84TRISTART ONE84TRIUMEQ 46TRI-VI-FLOR84TRI-VI-FLORO 84tri-vite pediatric84tri-vitefluoride 84TRIVIX 71trivora (28)104tri-vylibra 104tri-vylibra lo104TRIZIVIR 46TRODELVY40TROGARZO46TROKENDI XR 28TRONVITE84tropicamide 125TROPICAMIDE-CYCLOPENTOLATE-PE 125TROPICAMIDE-PHENYLEPHRINE125TROPIC-CYCLOPENT-PE-KETOROLAC125TROPIC-CYCLOP-PE-KETO-PROPAR125TROPIC-PROPARACA-PE-KETOROLAC125trospium chloride93trospium chloride er 93TRUE METRIX BLOOD GLUCOSE TEST 75TRUE METRIX LEVEL 1 75TRUE METRIX LEVEL 2 75TRUE METRIX LEVEL 3 75TRUE METRIX PRO BLOOD GLUCOSE 75TRUETRACK TEST75TRULANCE91TRULICITY 73TRUMENBA110TRUSOPT123TRUSTEEL INFUSION SET 119TRUVADA46TRUXIMA40T-SUPPORT MAX 119TUDORZA PRESSAIR 133TUKYSA40tulana 104

TUMS CHEWY BITES 91TURALIO 40TURPENTINE 71TUSSICAPS130tussin cf multi-symptom cold130tussin dm130tussin dm max130tussin dm max adult 130TUXARIN ER 130TUZISTRA XR 130TWINRIX110TWIRLA 104TWYNSTA 56tyblume 104TYBOST46tydemy 104TYGACIL25TYKERB40TYLACTIN BUILD 20PE TYR 119TYLACTIN COMPLETE 15 PE 119TYLACTIN RESTORE 10 119TYLACTIN RESTORE 5PE 119TYLACTIN RTD 15 119TYLENOL14TYLENOL 8 HOUR 14TYLENOL EXTRA STRENGTH 14TYLENOL INFANTS PAIN+FEVER14TYMLOS 112TYPHIM VI 110TYR EASY 119TYROS 2119TYSABRI58TYVASO 134TYVASO REFILL 134TYVASO STARTER134UBRELVY 35UCERIS 111UDAMIN SP 84UDENYCA 50UKONIQ40ULORIC 34ULTANE119ULTOMIRIS 50ultra fresh pm 125ULTRA HERS RX 119ULTRA HIS 119ultra lubricating eye drops125ULTRA PCOS 119ULTRACET 14

170

ULTRAFOAM SPONGE 2X625X7CM119ULTRAFOAM SPONGE 8X125X1CM119ULTRAFOAM SPONGE 8X125X3CM119ULTRAFOAM SPONGE 8X25X1CM119ULTRAFOAM SPONGE 8X625X1CM119ULTRAM 14ULTRASAL-ER 71ULTRAVATE71UMECTA MOUSSE 71UNASYN 25UNISTRIP CONTROL75unithroid 104UNITUXIN 40UPLIZNA108UPNEEQ122UPTRAVI 134URAMAXIN 71urea71UREA 71urea hydrating 71urea nail 71ureacin-10 71ureacin-20 71uredeb71URELLE 93UREMEZ-4071URESOL 71uretron ds93URIBEL 93URIMAR-T 93urin ds 93urinary pain relief 93URO-45893UROCIT-K 1084UROCIT-K 1584UROCIT-K 584UROGESIC-BLUE 93uro-mp93urosex 84UROXATRAL 94URSO 25091URSO FORTE 91ursodiol 91URSODIOL+SYRSPEND SF91USTELL 93UTIBRON NEOHALER 133UTIRA-C 93UTOPIC 71

VAGIFEM104valacyclovir hcl46VALCHLOR40VALCYTE46valganciclovir hcl46VALIUM47valproic acid 28valrubicin40valsartan 56valsartan-hydrochlorothiazide 56VALSTAR40VALTOCO28VALTREX46VANADOM134VANCOCIN 25VANCOCIN HCL25vancomycin hcl 25VANCOMYCIN HCL 122vancomycin hcl in nacl 25VANCOMYCIN+SYRSPEND SF 25vandazole25VANICREAM71VANIQA 71VANOS 71VANOXIDE-HC 71VANTAS99VAQTA110vardenafil hcl93VARDIMAXIA71VARISOFT INFUSION SET119VARIVAX 110VARIZIG108VAROPHEN17VAROXIA 71VARUBI (180 MG DOSE) 31VASCEPA 56VASCULERA 119VASERETIC56VASOTEC56VAXCHORA110v-c forte 84VCF VAGINAL CONTRACEPTIVE 119vcf vaginal contraceptive119VECAMYL56VECTIBIX40VECTICAL 72VECURONIUM BROMIDE59vegetable lax+stool softener 91VELCADE 40VELETRI 134velivet104

VELPHORO 93VELTASSA 84VELTIN 72VEMLIDY 46VENCLEXTA40VENCLEXTA STARTING PACK 40VENELEX 72VENEXA 84VENIPUNCTURE PX1 PHLEBOTOMY 20venlafaxine hcl 30venlafaxine hcl er 30VENNGEL ONE 17VENOFER84VENTAVIS 134VENTOLIN HFA133verapamil hcl56verapamil hcl er56VERDESO 72VEREGEN 72VERELAN 56VERELAN PM56VERQUVO 56VERSACLOZ 44VERZENIO40VESICARE93VESICARE LS 93vestura 104VEXASYN 72VEXATROL20VFEND33VIAGRA 94VIBERZI 91VIBRAMYCIN25vic-forte 84VICTOZA 73VIDAZA 40VIEKIRA PAK46vienva104vigabatrin 28vigadrone 28VIGAMOX 122VIIBRYD30VIIBRYD STARTER PACK 30VILACTIN AA PLUS119VILAMIT MB94VILEVEV MB94VILTEPSO 119VIMIZIM 92VIMOVO17VIMPAT28VINATE ONE 84

171

vinblastine sulfate 40vincristine sulfate 41vinorelbine tartrate 41VIOKACE 92viorele 104VIRACEPT 46VIRAMUNE 46VIRAMUNE XR 46VIRASAL72VIRAZOLE 46VIREAD46virt-caps 84VIRT-FEFA PLUS 84virt-gard84virt-phos 250 neutral 84virtussin ac walc130VISBIOME91VISIONBLUE 125VISTA GEL DRY EYE RELIEF 126VISTA MEIBO TEARS 126VISTA TEARS126VISTARIL 47VISTOGARD119VISUDYNE126vita s forte 84vitacel84VITAFOL FE+ 85VITAFOL STRIPS 85VITAFOL-NANO 85VITAFOL-OB+DHA85VITAL-D RX 85VITAMEZ 85vitamin b complex 100 85vitamin b-complex 100 85vitamin d (ergocalciferol)85VITAMIN DEFICIENCY SYSTEM-B1285vitamin k185vitamins acd-fluoride 85VITAROCA PLUS 85VITA-RX DIABETIC VITAMIN85VITASURE 85VITATHELY WITH GINGER 85VITRAKVI41VITRANOL FE 85VITRASE119VITREXATE 85VITREXATE FE 85VITREXYL85VITREXYL + IRON85VIVELLE-DOT104VIVITROL21

VIVLODEX 17VIVOTIF 110VIZIMPRO41VOCABRIA 47VOGELXO 97VOGELXO PUMP 97volnea 104VOLTAREN17VONVENDI 50VORAXAZE 41voriconazole33VOSEVI47VOTRIENT41VP FC KIT17VP GKL KIT 17vp-pnv-dha 85VPRIV 92vp-vite rx 85VRAYLAR 44VTOL LQ14VUMERITY 58VUSION 33VYEPTI 35vyfemla104VYLEESI 59vylibra104VYNDAMAX56VYNDAQEL 56VYONDYS 53 92VYTONE 33VYTORIN 56VYVANSE 57VYXEOS 41VYZULTA123WAKIX 135wal-tap coldallergy 130warfarin sodium26WASP VENOM PROTEIN 120weekly-d85WELCHOL 56WELLBUTRIN SR30WELLBUTRIN XL 30WELLMIND VERTIGO120wera 104westab max120westab mini 85westab one85WESTAB PLUS 85WESTERN JUNIPER120WESTGEL DHA85WESTHROID 104WHEAT GERM OIL 85WHITE BIRCH 120

WHITE FACED HORNET VENOM120WHITE MULBERRY 120WHITE OAK120WHITE PINE 120WIDE-SEAL DIAPHRAGM 60 120WIDE-SEAL DIAPHRAGM 65 120WIDE-SEAL DIAPHRAGM 70 120WIDE-SEAL DIAPHRAGM 75 120WIDE-SEAL DIAPHRAGM 80 120WIDE-SEAL DIAPHRAGM 85 120WIDE-SEAL DIAPHRAGM 90 120WIDE-SEAL DIAPHRAGM 95 120WILATE50WILZIN85WINLEVI 72WINRHO SDF108wixela inhub 133womens 50 billion 91WP THYROID 104WPR PLUS WOUND HEALING SYSTEM 20wymzya fe 104WYNZORA72XADAGO43XALATAN123XALIX72XALKORI 41XANAX47XANAX XR47XAQUIL XR85XARACOLL20XARELTO 26XARELTO STARTER PACK26XATMEP 108XCOPRI 28XELJANZ 108XELJANZ XR 108XELODA 41XELPROS 123XEMBIFY 108XENAZINE 59XENICAL59XENLETA25 26XEOMIN120XEPI26XERAC AC72XERALUX 72XERESE 47XERMELO 91XEROSTOMIA RELIEF SPRAY60XGEVA112

172

XHANCE 130XIAFLEX 120XIFAXAN26XIGDUO XR73XIIDRA 126XIMINO 26XOFIGO 41XOFLUZA (40 MG DOSE) 47XOFLUZA (80 MG DOSE) 47XOLAIR130XOLEGEL 33XOLEGEL COREPAK33XOLEGEL DUOHEAD amp SHOULDERS33XOLEGEL DUOXOLEX 33XOPENEX CONCENTRATE 133XOPENEX HFA 133XOPENEX NEB 133XOSPATA 41XPOVIO (100 MG ONCE WEEKLY)41XPOVIO (40 MG ONCE WEEKLY)41XPOVIO (40 MG TWICE WEEKLY)41XPOVIO (60 MG ONCE WEEKLY)41XPOVIO (60 MG TWICE WEEKLY)41XPOVIO (80 MG ONCE WEEKLY)41XPOVIO (80 MG TWICE WEEKLY)41XRYLIX 17XTAMPZA ER 14XTANDI41xulane 104XULTOPHY73xurea 72XURIDEN92XVITE85XYLOCAINE 20XYLOCAINE-MPF20XYNTHA 50XYNTHA SOLOFUSE50XYOSTED97XYREM 135XYWAV 135XYZBAC120XYZMUNE 120YASMIN 28 104YAZ 104YELLOW DOCK120

YELLOW HORNET VENOM PROTEIN 120YELLOW JACKET VENOM PROTEIN 120YERVOY 41YESCARTA41YF-VAX 110YONDELIS41YONSA 41YOSPRALA43YUPELRI133YUTIQ 122yuvafem 104ZACARE 72zaclir cleansing 72ZADITOR 122zafemy 104zafirlukast133zaleplon135ZALTRAP41ZALVIT85ZANAFLEX 134ZANOSAR41zarah 104ZARONTIN28ZARXIO50ZAVESCA 92ZCORT 7-DAY 96ZEASORB-AF 33ZEBUTAL14ZEGERID 86ZEJULA41ZELAC 91ZELAPAR43ZELBORAF 41ZELNORM 91ZEMAIRA 133ZEMBRACE SYMTOUCH 35ZEMDRI 26ZEMPLAR 112zenatane 72ZENPEP92ZENZEDI57ZEPATIER 47ZEPOSIA 58ZEPOSIA 7-DAY STARTER PACK 58ZEPOSIA STARTER KIT 58ZEPZELCA 41ZERUVIA 20ZERVIATE 122ZESTORETIC 56ZESTRIL 56

ZETIA56ZETONNA130ZEVALIN Y-90 41ZIAC56ZIAGEN47ZIANA 72zidovudine47ZIEXTENZO50ZILACAINE PATCH 20zileuton er 133ZILRETTA 96ZILXI 72zinc sulfate 85ZINGO20ZINPLAVA108ZIONODIL 20ZIONODIL 100 20ZIOPTAN 123ziprasidone hcl 44ziprasidone mesylate 44ZIPSOR17ZIRABEV41ZIRGAN 122ZITHRANOL72ZITHROMAX26ZITHROMAX TRI-PAK26ZITHROMAX Z-PAK 26ZOCOR 56ZOFRAN 31ZOHYDRO ER 14ZOKINVY 120ZOLADEX 99zoledronic acid 112ZOLGENSMA 92ZOLINZA41ZOLMITRIPTAN35zolmitriptan35ZOLOFT30ZOLPAK33zolpidem tartrate 135zolpidem tartrate er 135ZOLPIMIST 135ZOMACTON 99ZOMACTON (FOR ZOMA-JET 10)99ZOMIG 35ZOMIG ZMT35ZONALON72ZONEGRAN28zonisamide28ZONTIVITY 43ZORBTIVE 91ZORTRESS 108

173

ZORVOLEX 17zovia 135 (28) 104zovia 135e (28) 104ZOVIRAX 47ZTLIDO 20ZUBSOLV 21ZULRESSO30zumandimine104ZUPLENZ31ZYCLARA 72ZYCLARA PUMP 72ZYDELIG41ZYFLO 133ZYKADIA41ZYLET126ZYLOPRIM34ZYMAXID 122ZYPITAMAG 56ZYPREXA 44ZYPREXA RELPREVV 44ZYPREXA ZYDIS44ZYRTEC ALLERGY 130ZYTIGA 41ZYVANA85ZYVEXOL 120ZYVIT120ZYVOX26

174

ldquoMy Medicationsrdquo worksheet

Take this worksheet with you each time you visit a doctor Each of your doctors should be aware of every drug you take and you should have a list as well

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

Example Lisinopril 20 mg Tier 1 High blood pressure One tablet daily Dr Johnson

-Continued on back-

Notice of Nondiscrimination

Optum companies (together ldquoOptumrdquo) provide services to health plans and other health programs or activities Optum on behalf of itself and its affiliated companies complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Optum does not exclude people or treat them differently because of race color national origin age disability or sex Optum provides free aids and services to people with disabilities to communicate effectively with us such as

bull Qualified sign language interpreters bull Written information in other formats (large print audio accessible electronic formats other formats) bull Provides free language services to people whose primary language is not English such as

Qualified interpreters bull Information written in other languages

If you need these services please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week If you believe that the Company has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance in writing by mail or email A grievance must be sent within 60 calendar days of the date that you become aware of the discriminatory action and contain the name and address of the person filing it along with the problem and the requested remedy A written decision will be sent to you within 30 calendar days If you disagree with the decision you may file an appeal within 15 calendar days of receiving the decision

Optum Civil Rights Coordinator 11000 Optum Circle Eden Prairie MN 55344 Phone (888) 445-8745 (TTY 711) Fax (855) 351-5495 Email Optum_Civil_RightsOptumcom

If you need help filing a grievance please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week You can also file a complaint directly with the US Dept of Health and Human services online by phone or mail Online httpsocrportalhhsgovocrportallobbyjsf Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml Phone Toll-free (800) 868-1019 (800) 537-7697 (TDD) Mail US Dept of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 English Text You have the right to get help and information in your language at no cost To request an interpreter please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week This letter is also available in other formats like large print To request the document in another format please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week

1 Spanish Tiene derecho a recibir ayuda e informacioacuten en su idioma sin costo Para solicitar un inteacuterprete llame al nuacutemero de teleacutefono gratuito para miembros que se encuentra en su tarjeta de identificacioacuten del plan de salud y presione 0 TTY 711

2 Vietnamese Quyacute vị coacute quyền được giuacutep đỡ vagrave cấp thocircng tin bằng ngocircn ngữ của quyacute vị miễn phiacute Để yecircu cầu được thocircng dịch viecircn giuacutep đỡ vui lograveng gọi số điện thoại miễn phiacute dagravenh cho hội viecircn được necircu trecircn thẻ ID chương trigravenh bảo hiểm y tế của quyacute vị bấm số 0 TTY 711

3 Chinese 您有權利免費以您的母語得到幫助和訊息洽詢一位翻譯員請撥打您健保計劃會員卡上的免付費會員電話號碼再按 0聽力語言殘障服務專線 711

4 Korean 귀하는 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 통역사를 요청하기 위해서는 귀하의 플랜 ID카드에 기재된 무료 회원 전화번호로 전화하여 0번을 누르십시오 TTY 711

5 Arabic يناجملا فتاھلا مقرب لصتا يروف مجرتم بلطل ةفلكت يأ لمحت نود كتغلب تامولعملاو ةدعاسملا ىلع لوصحلا يف قحلا كل TTY( 711( يصنلا فتاھلا 0 ىلع طغضاو ةیحصلا كتطخب ةصاخلا ةیوضعلا فرعم ةقاطبب جردملا ءاضعلأاب صاخلا

6 Urdu یرف لوٹ ےئل ےک ےنرک تاب ےس نامجرت یسک ےہ قح اک ےنرک لصاح تامولعم روا ددم تفم ںیم نابز ینپا وک پآ TTY 711 ںیئابد 0 ےہ جرد رپ ڈراک یڈ یئآ نلاپ ھتلیہ ےک پآ وج ںیرک لاک رپ ربمن نوف ربمم

7 Tagalog May karapatan kang makatanggap ng tulong at impormasyon sa iyong wika nang walang bayad Upang humiling ng tagasalin tawagan ang toll-free na numero ng telepono na nakalagay sa iyong ID card ng planong pangkalusugan pindutin ang 0 TTY 711

8 French Vous avez le droit dobtenir gratuitement de laide et des renseignements dans votre langue Pour demander agrave parler agrave un interpregravete appelez le numeacutero de teacuteleacutephone sans frais figurant sur votre carte drsquoaffilieacute du reacutegime de soins de santeacute et appuyez sur la touche 0 ATS 711

9 Hindi आप क पास अपनी भाषा म- सहायता एव जानकार6 7नशक ाltत करन का अ=धकार ह दभाBषए क Cलएअनरोध करन क Cलए अपन हथ ltलान ID काडH पर सचीबLध टोल-NO नबर पर फ़ोन कर- 0 दबाए TTY711

10 Persian هرامش اب یھافش مجرتم تساوخرد یارب دییامن تفایرد ناگیار روط ھب ار دوخ نابز ھب تاعلاطا و کمک ھک دیراد قح امش TTY 711 دیھد راشف ار 0 و هدومن لصاح سامت دوخ یتشادھب ھمانرب ییاسانش تراک رد هدش دیق ناگیار نفلت

11 German Sie haben das Recht kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten Um einen Dolmetscher anzufordern rufen Sie die gebuumlhrenfreie Nummer auf Ihrer Krankenversicherungskarte an und druumlcken Sie die 0 TTY 711

12 Gujarati તમન િવના (ય મદદ અન તમાર ભાષામા મા3હતી મળવવાનો અિધકાર છ ભાિષયા માટgt િવનતી કરવા તમારા હgtથ લાન ID કાડC પરની Eચીમા આપલ ટોલ-H મIબર ફોન નબર ઉપર કોલ કરો ૦

દબાવો TTY 711 13 Russian Вы имеете право на бесплатное получение помощи и информации на вашем языке

Чтобы подать запрос переводчика позвоните по бесплатному номеру телефона указанному на обратной стороне вашей идентификационной карты и нажмите 0 Линия TTY 711

14 Japanese ご希望の言語でサポートを受けたり情報を入手したりすることができます料金はか

かりません通訳をご希望の場合は医療プランのID カードに記載されているメンバー用のフリーダイヤルまでお電話の上0を押してくださいTTY専用番号は 711です

15 Laotian ທານມສ ດທ ຈະໄດຮບການຊວຍເຫອແລະຂມນຂາວສານທ ເປນພາສາຂອງທານບ ມຄາໃຊຈາຍ ເພອຂ ຮອງນາຍພາສາໂທຟຣ ຫາຫມາຍເລກໂທລະສບສ າລບ ສະມາຊ ກທ ໄດລະບໄວໃນບດສະມາຊ ກຂອງທານກດເລກ 0 TTY 711

72462-022018 INV-PSI3637-INS-MMISC-13918_MC_021318

(Farsi)

All Optum trademarks and logos are owned by Optum Inc in the US and other jurisdictions All other trademarks are the property of their respective owners

copy 2021 Optum Inc All rights reserved WF4412900_042021

HealthSelectSM

of Te

xas

Premium standard

  • Analgesics - Drugs for Pain
  • Analgesics - Drugs for Pain and Inflammation
  • Anesthetics
  • Anti-Addiction Substance Abuse Treatment Agents
  • Antibacterials
  • Anticoagulants
  • Anticonvulsants - Drugs for Seizures
  • Antidementia Agents - Drugs for Alzheimers Disease and Dementia
  • Antidepressants
  • Antiemetics - Drugs for Nausea and Vomiting
  • Antifungals
  • Antigout Agents
  • Anti-inflammatory Agents
  • Antimigraine Agents
  • Antimyasthenic Agents
  • Antimycobacterials
  • Antineoplastics - Drugs for Cancer
  • Antiparasitics
  • Antiparkinson Agents
  • Antiplatelets
  • Antipsychotics - Drugs for Mood Disorders
  • Antivirals
  • Anxiolytics - Drugs for Anxiety
  • Bipolar Agents - Drugs for Mood Disorders
  • Blood Products and Modifiers - Drugs for Blood Disorders
  • Cardiovascular Agents - Drugs for Heart and Circulation Conditions
  • Central Nervous System Agents - Drugs for Attention Deficit Disorder
  • Central Nervous System Agents - Drugs for Multiple Sclerosis
  • Central Nervous System Agents - Miscellaneous
  • Dental and Oral Agents - Drugs for Mouth and Throat Conditions
  • Dermatological Agents - Drugs for Skin Conditions
  • Diabetes - Antidiabetic Agents
  • Diabetes - Glucose Monitoring
  • Diabetes - Glycemic Agents
  • Diabetes - Insulins
  • Electrolytes Minerals Metals Vitamins
  • Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
  • Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions
  • Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment
  • Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions
  • Genitourinary Agents - Drugs for Prostate Conditions
  • Hormonal Agents - Adrenal
  • Hormonal Agents - Mens Health
  • Hormonal Agents - Osteoporosis
  • Hormonal Agents - Pituitary
  • Hormonal Agents - Prostaglandins
  • Hormonal Agents - Sex Hormones and Birth Control
  • Hormonal Agents - Thyroid
  • Immunological Agents - Drugs for Immune System Stimulation or Suppression
  • Immunological Agents - Drugs for Vaccination
  • Inflammatory Bowel Disease Agents
  • Metabolic Bone Disease Agents - Drugs for Osteoporosis
  • Metabolic Bone Disease Agents - Other
  • Miscellaneous Therapeutic Agents
  • Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation
  • Ophthalmic Agents - Drugs for Glaucoma
  • Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
  • Otic Agents - Drugs for Ear Conditions
  • Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold
  • Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
  • Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis
  • Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension
  • Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
  • Sleep Disorder Agents
Page 2: Your Prescription Drug List/Formulary

2

Your Prescription Drug List Formulary

This formulary outlines the most commonly prescribed medications covered under your planrsquos prescription drug benefits The formulary is also known as the Prescription Drug List (PDL) A formulary identifies the drugs available for certain conditions and organizes them into cost levels also known as tiers An important part of the formulary is giving you choices so you and your doctor can choose the best course of treatment for you

Go to wwwHealthSelectRxcom for complete and up-to-date drug information

Since the formulary may change we encourage you to visit our website wwwHealthSelectRxcom and click on Prescription Drug List This website is the best source for up-to-date information about all of the medications your pharmacy benefit covers possible lower-cost options and cost comparisons

3

Understanding your Prescription Drug ListformularyWhat is a formulary

This document is a list of prescription medications covered by your plan for their safety cost and effectiveness Medications are listed by categories or class and are placed into cost levels known as tiers It includes both brand and generic prescription medications approved by the US Food and Drug Administration (FDA)

Where differences exist between this formulary and your benefit plan documents the benefit plan documents will rule This may not be a complete list of medications and not all medications listed may be covered under your plan Please look at the Master Benefit Plan Document (MBPD) provided by your plan for full details

How do I use my formulary

You and your doctor can consult the formulary to help you select the most cost-effective prescription medications This guide tells you if a medication is generic or brand and if special rules apply Bring this list with you when you see your doctor It is organized by common medical conditions Medications are then listed alphabetically

If your medication is not listed on this document it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program Please visit wwwHealthSelectRxcom and click on Prescription Drug List for the most up to date list of medications covered under your plan If you have any questions call a customer care representative toll-free at (855) 828-9834 (TTY 711)

What are tiers

Tiers are the different cost levels you pay for a medication Each tier is assigned a cost which is determined by your plan This is how much you will pay when you fill a prescription The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met Tier 1 medications are your lowest-cost options If your medication is placed in Tier 2 or 3 look to see if there is a Tier 1 option available Discuss these options with your doctor

4

When does the formulary change

bull Medications may move to a lower tier at any time

bull Medications may move to a higher tier when its generic becomes available

bull Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year

When a medication changes tiers you may have to pay a different amount for that medication

For the most up-to-date list call a customer care representative 24 hours a day 7 days a week toll-free at (855) 828-9834 (TTY 711)

Why are some medications excluded from coverage

A medication may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective

What if I donrsquot agree with a decision about an excluded medication

You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711)

5

Medication Tips What is the difference between brand-name and generic medications

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications but they often cost less Once the patent of a brand-name medication ends the FDA can approve a generic version with the same active ingredients

What if my doctor writes a brand-name prescription

If your doctor gives you a prescription for a brand-name medication ask if a generic equivalent or lower-cost option is available and if it might be right for you Generic medications are usually your lowest-cost option but not always

An OTC medication may be the right treatment option for some conditions Talk to your doctor about available OTC options Even though these medications may not be covered under your pharmacy benefit they may cost less than prescription medications covered under your prescription drug plan

What if I am taking a specialty medication

Specialty medications treat rare or complex conditions and are typically higher cost medications Please note not all specialty medications are listed in the Formulary Optum Specialty Pharmacy can provide most of your specialty medications along with helpful programs and services Call Optum Specialty Pharmacy at (855) 427-4682 and have your prescriptions delivered right to your home or doctorrsquos office

6

Reading your formularyThe formulary give your choices so you and your doctor can determine your best course of treatment In this formulary brand-name medications are shown in UPPERCASE (for example CLOBEX) and generic medications in lowercase (for example clobetasol)

Tier information

Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost Your prescription drug plan has multiple tiers Please note If you have a high deductible plan the tier cost levels will apply once you hit your deductible

Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost commonly used generic drugs Some low-cost brands may be included

Use Tier 1 drugs for the lowest out-of-pocket costs

Tier 2 Mid-range Cost

Many common brand-name drugs called preferred brands

Use Tier 2 drugs instead of Tier 3 to help reduce your out-of-pocket costs

Tier 3 Highest Cost

Mostly higher-cost brand drugs also known as non-preferred brands

Many Tier 3 drugs have lower-cost options in Tier 1 or 2 Ask your doctor if they could work for you

Tier E Excluded May be excluded from coverage or subject to prior authorization Lower-cost options are available and covered

Drug list information

In this drug list some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits Your benefit plan determines how these medications may be covered for you

PA Prior Authorization ndash Your doctor is required to provide additional information before the drug will be covered by your prescription drug plan

ST Step Therapy ndash Requires you to first try a cost-effective medication before the more expensive medication will be covered

QL Quantity Limit ndash Limits the amount of a medication that will be covered under your prescription drug plan

SP Specialty Medication ndash Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused are high cost have special delivery and storage requirements or require close monitoring or care coordination with your doctor

E Excluded ndash Drugs that are not covered by your health plan Lower-cost options are available and covered

Table of Contents

Analgesics - Drugs for Pain9Analgesics - Drugs for Pain and Inflammation 14Anesthetics17Anti-Addiction Substance Abuse Treatment Agents 20Antibacterials21Anticoagulants26Anticonvulsants - Drugs for Seizures 27Antidementia Agents - Drugs for Alzheimers Disease and Dementia 29Antidepressants29Antiemetics - Drugs for Nausea and Vomiting 30Antifungals31Antigout Agents 34Anti-inflammatory Agents 34Antimigraine Agents 34Antimyasthenic Agents35Antimycobacterials 35Antineoplastics - Drugs for Cancer35Antiparasitics 41Antiparkinson Agents 42Antiplatelets43Antipsychotics - Drugs for Mood Disorders 43Antivirals44Anxiolytics - Drugs for Anxiety47Bipolar Agents - Drugs for Mood Disorders47Blood Products and Modifiers - Drugs for Blood Disorders48Cardiovascular Agents - Drugs for Heart and Circulation Conditions 50Central Nervous System Agents - Drugs for Attention Deficit Disorder 56Central Nervous System Agents - Drugs for Multiple Sclerosis 57Central Nervous System Agents - Miscellaneous 58Dental and Oral Agents - Drugs for Mouth and Throat Conditions59Dermatological Agents - Drugs for Skin Conditions 60Diabetes - Antidiabetic Agents 72Diabetes - Glucose Monitoring 73Diabetes - Glycemic Agents 75Diabetes - Insulins75Electrolytes Minerals Metals Vitamins77Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer85Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions86Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment 91Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions92Genitourinary Agents - Drugs for Prostate Conditions 94Hormonal Agents - Adrenal 94Hormonal Agents - Mens Health96Hormonal Agents - Osteoporosis 97Hormonal Agents - Pituitary 97Hormonal Agents - Prostaglandins99Hormonal Agents - Sex Hormones and Birth Control99Hormonal Agents - Thyroid 104Immunological Agents - Drugs for Immune System Stimulation or Suppression 105Immunological Agents - Drugs for Vaccination 108Inflammatory Bowel Disease Agents110

7

Metabolic Bone Disease Agents - Drugs for Osteoporosis 111Metabolic Bone Disease Agents - Other 112Miscellaneous Therapeutic Agents 112Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation120Ophthalmic Agents - Drugs for Glaucoma122Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions 123Otic Agents - Drugs for Ear Conditions 126Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold126Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions 130Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis 133Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension 133Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm 134Sleep Disorder Agents 134

8

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

8 hour pain reliever E

8 hr arthritis pain relief E

acetaminophen 8 hour oral tablet extended release

E

acetaminophen childrens oral solution

E

acetaminophen childrens oral suspension 160 mg5ml

E

acetaminophen childrens oral tablet chewable 160 mg

E

acetaminophen er E

acetaminophen extra strength oral tablet

E

acetaminophen oral solution 160 mg5ml 325 mg1015ml 650 mg203ml

E

acetaminophen oral suspension 160 mg5ml

E

acetaminophen oral tablet

E

acetaminophen oral tablet chewable 160 mg

E

acetaminophen rectal suppository 120 mg 650 mg

E

acetaminophen-codeine

1 QL

acetaminophen-codeine 2

1 QL

acetaminophen-codeine 3

1 QL

acetaminophen-codeine 4

1 QL

ACTIQ 3 PA QL

ALLZITAL E

APADAZ E

Drug Name Drug Tier Notes

apap-caff-dihydrocodeine oral capsule

1 QL

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

1 QL

arthritis pain reliever oral

E

ascomp-codeine 1

aurophen childrens E

bac 1

BELBUCA 2 PA QL

BENZHYDROCODONE-ACETAMINOPHEN

E

BUPAP ORAL TABLET 50-300 MG

3

BUPRENEX E

buprenorphine hcl injection solution 03 mgml

E

buprenorphine transdermal

1 PA QL

butalbital-acetaminophen capsule 50-300 mg oral

1

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

E

butalbital-acetaminophen oral tablet

1

butalbital-apap-caff-cod 1

butalbital-apap-caffeine oral capsule

1

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

1

butalbital-asa-caff-codeine

1

butalbital-aspirin-caffeine

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

9

Drug Name Drug Tier Notes

butorphanol tartrate injection

E

butorphanol tartrate nasal

1 QL

BUTRANS 3 PA QL

carisoprodol-aspirin-codeine

1

codeine sulfate oral tablet

1 QL

CONZIP E

cvs acetaminophen ex st oral tablet

E

DEMEROL INJECTION SOLUTION 50 MGML

E

DILAUDID ORAL E

DSUVIA E

DURAGESIC-100 E

DURAGESIC-12 E

DURAGESIC-25 E

DURAGESIC-50 E

DURAGESIC-75 E

duramorph E

endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 QL

ESGIC 3

fentanyl 1 PA QL

fentanyl citrate (pf) E

fentanyl citrate buccal lozenge on a handle

1 PA QL

FENTANYL CITRATE BUCCAL TABLET

E

FENTANYL CITRATE SOLUTION PREFILLED SYRINGE 100 MCG2ML INTRAVENOUS

E

FENTANYL CITRATE-NACL INJECTION

E

Drug Name Drug Tier Notes

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 125-09 MG250ML-

E

FENTANYL CITRATE-NACL SOLUTION 1-09 MG100ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION 25-09 MG250ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION 2-09 MG100ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION PREFILLED SYRINGE 500-09 MCG50ML- INTRAVENOUS

E

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 08-01667-09 MG200ML-

E

FENTANYL-BUPIVACAINE-NACL INJECTION

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 02-01-09 MG100ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 02-0125-09 MG100ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-00625-09 MG250ML- EPIDURAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

10

Drug Name Drug Tier Notes

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-01-09 MG250ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-0125-09 MG250ML- EPIDURAL

E

FENTORA BUCCAL TABLET 100 MCG 200 MCG 400 MCG 600 MCG 800 MCG

E

FIORICET ORAL CAPSULE

3

FIORICETCODEINE ORAL CAPSULE 50-300-40-30 MG

3

goodsense pain relief oral tablet

E

headache relief oral E

hydrocodone bitartrate er oral capsule extended release 12 hour

1 PA ST QL

hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent

1 PA QL

hydrocodone-acetaminophen oral solution 10-325 mg15ml 75-325 mg15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg

1 QL

hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg

1 QL

Drug Name Drug Tier Notes

hydromorphone hcl er oral tablet extended release 24 hour

1 PA QL

hydromorphone hcl injection solution 2 mgml

E

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal

E

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 25-09 MG50ML- 50-09 MG50ML-

E

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-09 MG50ML- 15-09 MG30ML-

E

HYSINGLA ER 2 PA QL

INFUMORPH 200 E

INFUMORPH 500 E

LAZANDA NASAL SOLUTION 100 MCGACT 400 MCGACT

E

levorphanol tartrate oral E

liquid acetaminophen E

LORTAB ORAL ELIXIR 10-300 MG15ML

3 QL

meperidine hcl injection solution 50 mgml

E

meperidine hcl oral solution

1 QL

meperidine hcl oral tablet 50 mg

1 QL

methadone hcl injection E

methadone hcl intensol 1

methadone hcl oral concentrate

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

11

Drug Name Drug Tier Notes

methadone hcl oral solution

1

methadone hcl oral tablet

1 PA

methadone hcl oral tablet soluble

1

methadose oral concentrate 10 mgml

1

methadose oral tablet soluble

1

methadose sugar-free 1

migraine relief E

mitigo E

morphine sulfate (concentrate) oral solution 100 mg5ml 20 mgml

1 QL

morphine sulfate (pf) injection

E

morphine sulfate (pf) intravenous solution 10 mgml 2 mgml 4 mgml 8 mgml

E

morphine sulfate er beads

1 PA QL

morphine sulfate er oral capsule extended release 24 hour

1 PA QL

morphine sulfate er oral tablet extended release

1 PA QL

MORPHINE SULFATE INJECTION SOLUTION 1 MGML

E

morphine sulfate injection solution 2 mgml 4 mgml

E

MORPHINE SULFATE INTRAVENOUS SOLUTION 05 MGML

E

morphine sulfate intravenous solution 50 mgml

E

morphine sulfate oral 1 QL

Drug Name Drug Tier Notes

morphine sulfate rectal E

MORPHINE SULFATE SOLUTION 1 MGML INTRAVENOUS

E

morphine sulfate solution 1 mgml intravenous

E

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-09 MG50ML-

E

m-pap E

MS CONTIN ORAL TABLET EXTENDED RELEASE

E

nalbuphine hcl injection solution 20 mgml

1

NALOCET E

NUCYNTA E

NUCYNTA ER E

OXAYDO ORAL TABLET

E

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG 30 MG 60 MG 80 MG

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG ORAL

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20 MG ORAL

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 40 MG ORAL

E

oxycodone hcl oral capsule

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

12

Drug Name Drug Tier Notes

oxycodone hcl oral concentrate 100 mg5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet

1 QL

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 10-300 MG5ML

E

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG 25-300 MG 5-300 MG

E

oxycodone-acetaminophen oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 QL

oxycodone-aspirin oral tablet 48355-325 mg

1 QL

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT

2 PA QL

oxymorphone hcl 1 QL

oxymorphone hcl er 1 PA QL

pain amp fever childrens oral suspension

E

pain amp fever infants E

pain relief childrens oral elixir

E

pain relief extra strength oral capsule 500 mg

E

pain relief extra strength oral tablet 500 mg

E

pain relief oral liquid E

pain relief regular strength

E

Drug Name Drug Tier Notes

pain reliever extra strength oral tablet 250-250-65 mg

E

PANADOL CHILDRENS

E

PANADOL EXTRA E

PANADOL EXTRA STRENGTH

E

PANADOL INFANTS E

pentazocine-naloxone hcl

1 QL

PERCOCET ORAL TABLET 10-325 MG 25-325 MG 5-325 MG 75-325 MG

E

PRIALT 2 SP

PROBUPHINE IMPLANT KIT

E

PROLATE E

QDOLO E

ROXICODONE ORAL TABLET

E

SUBSYS E

SYNAPRYN FUSEPAQ E

TENCON ORAL TABLET 50-325 MG

E

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

1 PA ST QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG 200 MG 300 MG

E

tramadol hcl er oral tablet extended release 24 hour

1 PA QL

tramadol hcl ir 1 QL

tramadol-acetaminophen

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

13

Drug Name Drug Tier Notes

TREZIX ORAL CAPSULE 3205-30-16 MG

3 QL

TYLENOL 8 HOUR E

TYLENOL EXTRA STRENGTH ORAL TABLET

E

TYLENOL INFANTS PAIN+FEVER

E

TYLENOL ORAL TABLET

E

ULTRACET E

ULTRAM E

VTOL LQ E

XTAMPZA ER 2 PA QL

ZEBUTAL ORAL CAPSULE 50-325-40 MG

3

ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR

E

Analgesics - Drugs for Pain and Inflammation

adult aspirin regimen $0

ADVIL E

ADVIL JUNIOR STRENGTH

E

ADVIL LIQUI-GELS MINIS

E

ADVIL MIGRAINE E

aif 2 drug preparation kit

E

AIF 3 DRUG PREPARATION KIT

E

ALEVE ORAL TABLET E

ARTHROTEC ORAL TABLET DELAYED RELEASE

E

aspirin adult low strength oral tablet delayed release

$0

Drug Name Drug Tier Notes

aspirin childrens $0

aspirin ec low dose $0

aspirin ec low strength $0

aspirin ec oral tablet delayed release 325 mg

$0

aspirin low dose oral tablet chewable

$0

aspirin low dose oral tablet delayed release

$0

aspirin oral tablet 325 mg

$0

aspirin oral tablet delayed release 325 mg 81 mg

$0

aspirin rectal suppository 300 mg 600 mg

E

BAYER ASPIRIN EC LOW DOSE

$0

BAYER ASPIRIN ORAL TABLET

$0

BAYER ASPIRIN ORAL TABLET DELAYED RELEASE

$0

BIIFENAC 1000 E

BIIFENAC 500 E

CALDOLOR INTRAVENOUS SOLUTION 800 MG200ML 800 MG8ML

E

CAMBIA E

CAPSFENAC PAK E

CAPSINAC E

CATAFLAM 3

CELEBREX E

celecoxib oral 1 QL

DAYPRO 3

DERMACINRX LEXITRAL PHARMAPAK

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

14

Drug Name Drug Tier Notes

DFS DRMSMENTHCAP PAK

E

DFSMSMENTHCAP PAK

E

DICLOFENAC CAP 35MG

E

DICLOFENAC PATCH EXTERNAL

E

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium external gel 1

1 QL

diclofenac sodium external solution

1 PA

diclofenac sodium oral 1

diclofenac-misoprostol oral tablet delayed release

1

DICLOFONO GEL 16 EXTERNAL

3

DICLOFONO GEL 16 EXTERNAL

E

DICLOPR E

DICLOSTREAM E

DICLOTREX E

DICLOVIX E

DICLOVIX M E

DICLOZOR EXTERNAL

E

diflunisal oral 1

DIMENTHO E

DUAL COMPLEX FORMULA 1 KIT

E

DUEXIS E

EC-NAPROSYN 3

ec-naproxen 1

ENOVARX-DICLOFENAC SODIUM EXTERNAL

E

enovarx-ibuprofen E

Drug Name Drug Tier Notes

enovarx-naproxen external

E

etodolac er 1

etodolac oral 1

FBL KIT E

FELDENE 3

fenoprofen calcium oral E

fenortho oral capsule 200 mg

E

FLECTOR EXTERNAL E

FLEXIPAK E

flurbiprofen oral 1

FROTEK E

GABAPENTIN-NAPROXEN CMPD KIT

E

goodsense aspirin low dose

$0

goodsense ibuprofen oral capsule

E

IBUPAK E

ibuprofen 1

ibuprofen infants E

ibuprofen oral capsule E

ibuprofen oral suspension

1

ibuprofen oral tablet 200 mg

E

inavix E

INDOCIN ORAL 3 ST

INDOCIN RECTAL E

indomethacin er 1

INDOMETHACIN ORAL CAPSULE 20 MG

E

indomethacin oral capsule 25 mg 50 mg

1 ST

INFLAMMACIN E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

15

Drug Name Drug Tier Notes

INFLATHERM COMBINATION THERAPY PACK

E

KBGL IN TERODERM

E

kapzin dc E

KETOPHENE RAPIDPAQ

E

ketoprofen er 1

ketoprofen oral 1

KETOROLAC TROMETHAMINE EXTERNAL

E

ketorolac tromethamine injection solution 15 mgml

1

ketorolac tromethamine intramuscular solution 60 mg2ml

1

KETOROLAC TROMETHAMINE NASAL

3 PA QL

ketorolac tromethamine oral

1 QL

ketorolac tromethamine solution 30 mgml injection

1

KETOROLAC TROMETHAMINE SOLUTION 30 MGML INJECTION

3

LICART EXTERNAL E

LODINE 3

meclofenamate sodium oral

1

mefenamic acid oral E

meloxicam oral capsule 1

meloxicam oral tablet 1

MOBIC ORAL TABLET E

MOTRIN IB ORAL CAPSULE

E

Drug Name Drug Tier Notes

MOTRIN INFANTS DROPS

E

nabumetone oral 1

NALFON ORAL CAPSULE 400 MG

3

NALFON ORAL TABLET

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG 500 MG

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

NAPROSYN ORAL SUSPENSION

3

NAPROSYN ORAL TABLET 500 MG

3

naproxen oral suspension

E

naproxen oral tablet 1

naproxen oral tablet delayed release

1

naproxen sodium er oral tablet extended release 24 hour 375 mg 500 mg

E

NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

naproxen sodium oral tablet 220 mg

E

naproxen sodium oral tablet 275 mg 550 mg

1

naproxen-esomeprazole

1 PA QL

NP 2 DRUG PREPARATION KIT

E

NUDICLO SOLUPAK E

NUDICLO TABPAK E

NUDROXIPAK E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

16

Drug Name Drug Tier Notes

NUDROXIPAK DSDR-50

E

NUDROXIPAK DSDR-75

E

NUDROXIPAK E-400 E

NUDROXIPAK I-800 E

NUDROXIPAK M-15 E

NUDROXIPAK N-500 E

ORMECA E

oxaprozin 1

PENNSAID EXTERNAL

E

piroxicam oral 1

PRASTERA E

PREVIDOLRX ANALGESIC

E

previdolrx plus analgesic

E

QMIIZ ODT E

RELAFEN E

RELAFEN DS E

salsalate oral E

SPRIX 3 PA QL

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE

$0

sulindac oral 1

sure result dss premium pack

E

TIVORBEX ORAL CAPSULE 20 MG

E

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet 600 mg

1

TORONOVA II SUIK E

TORONOVA SUIK E

tri-buffered aspirin oral tablet 325 mg

E

Drug Name Drug Tier Notes

TRIPLE COMPLEX FORMULA 3 KIT

E

VAROPHEN E

VENNGEL ONE E

VIMOVO E

VIVLODEX 3 ST

VOLTAREN EXTERNAL

E

VP FC KIT E

VP GKL KIT E

XRYLIX EXTERNAL E

ZIPSOR E

ZORVOLEX E

Anesthetics

1ST MEDX-PATCH LIDOCAINE EXTERNAL PATCH 4-00375-5-20

E

7T LIDO E

ACCUCAINE E

ACTIVE INJECTION LM-2

E

AGONEAZE E

ANODYNE LPT E

APRIZIO PAK E

APRIZIO PAK II E

ASTERO E

BENZO-LIDOCAINE-TETRACAINE

E

blue tube aloe E

bupivacaine fisiopharma

E

bupivacaine hcl (pf) E

BUPIVACAINE HCL INJECTION SOLUTION 0125

E

bupivacaine hcl injection solution 025 05

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

17

Drug Name Drug Tier Notes

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0125 (50 ML)

E

CADIRAMD E

CAPSAICIN-MENTHOL

E

CETACAINE EXTERNAL AEROSOL

E

COCAINE HCL NASAL E

DERMACINRX EMPRICAINE

E

DERMACINRX PHN E

DERMACINRX PRIZOPAK

E

DERMACINRX ZRM E

DERMALID E

EHA E

EMPRICAINE-II E

enovarx-lidocaine hcl E

ENZNONUTY E

ethyl chloride 1

EXPAREL E

FLEXIN E

GEBAUERS PAIN EASE

3

GEBAUERS SPRAY AND STRETCH

3

GEN7T E

GEN7T PLUS E

glydo external prefilled syringe

1

GOPRELTO E

LDO PLUS E

lets E

LEVATIO E

LIDO BDK E

lidocaine external cream 4

E

Drug Name Drug Tier Notes

lidocaine external patch 5

1

lidocaine hcl (pf) injection solution

1

lidocaine hcl external cream 3

E

LIDOCAINE HCL EXTERNAL CREAM 412

E

lidocaine hcl external lotion

E

lidocaine hcl external solution

1

lidocaine hcl injection solution 05

1

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MGML 100 MG10ML 100 MG5ML 200 MG10ML 60 MG3ML

E

LIDOCAINE HCL INTRADERMAL

E

LIDOCAINE HCL SOLUTION 1 INJECTION

3

lidocaine hcl solution 1 injection

1

LIDOCAINE HCL SOLUTION 2 INJECTION

3

lidocaine hcl solution 2 injection

1

lidocaine hcl urethralmucosal

1

lidocaine ointment 5 external

1 QL

lidocaine ointment 5 external

E

lidocaine-prilocaine external cream

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

18

Drug Name Drug Tier Notes

lidocaine-prilocaine external kit

E

LIDOCAINE-TETRACAINE

E

LIDOCANNA E

LIDODERM E

LIDO-EPINEPHRINE-TETRACAINE SOLUTION 4-005-05 EXTERNAL

3

LIDO-EPINEPHRINE-TETRACAINE SOLUTION 4-005-05 EXTERNAL

E

LIDOMARK 25 E

LIDOPAC E

lidopin external cream 3

E

LIDOPIN EXTERNAL CREAM 325

E

LIDOPRIL EXTERNAL KIT

E

LIDOPRIL XR E

LIDO-PRILO CAINE PACK

E

LIDOPURE PATCH E

LIDORX E

LIDO-SORB E

LIDOSTREAM E

LIDOTHOL E

LIDOTRAL E

LIDOVIX L E

LIDTOPIC MAX E

LIVIXIL PAK E

LMR PLUS E

LYDEXA E

MARCAINE E

MARCAINE PRESERVATIVE FREE

E

Drug Name Drug Tier Notes

marlido E

MARLIDO-25 E

MARVONA SUIK E

NUMBRINO E

NUVAKAAN E

NUVAKAAN-II E

pain relieving + lidocaine

E

PAINGO KFT E

PLIAGLIS E

POINT OF CARE LM-22

E

POINT OF CARE LM-25

E

premium lidocaine E

PREMIUM SCAR E

PREPIV SUPPLY 3

PRILO PATCH E

PRILO PATCH II E

PRILOLID E

PRILOVIX E

PRILOVIX LITE E

PRILOVIX LITE PLUS E

PRILOVIX PLUS E

PRILOVIX ULTRALITE E

PRILOVIX ULTRALITE PLUS

E

PRILOVIXIL E

PRIZOPAK II E

PRIZOTRAL E

PRIZOTRAL-II E

READYSHARP-A E

RELADOR PAK EXTERNAL KIT

E

RELADOR PAK PLUS E

SENSORCAINE E

SENSORCAINE-MPF INJECTION SOLUTION 075

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

19

Drug Name Drug Tier Notes

sensorcaine-mpf solution 025 injection

E

SENSORCAINE-MPF SOLUTION 025 INJECTION

E

sensorcaine-mpf solution 05 injection

E

SENSORCAINE-MPF SOLUTION 05 INJECTION

E

SKYADERM-LP E

SOOTHEE EXTERNAL PATCH 05-00375-5-2

E

STERILE TOPICAL LET GEL

3

SX1 MEDICATED POST-OPERATIVE

E

SYNERA E

VENIPUNCTURE PX1 PHLEBOTOMY

3

VEXATROL E

WPR PLUS WOUND HEALING SYSTEM

E

XARACOLL E

XYLOCAINE INJECTION

3

XYLOCAINE-MPF INJECTION SOLUTION 05 1 15 2

3

ZERUVIA E

ZILACAINE PATCH E

ZINGO INTRADERMAL JET-INJECTOR

E

ZIONODIL E

ZIONODIL 100 E

ZTLIDO E

Drug Name Drug Tier Notes

Anti-Addiction Substance Abuse Treatment Agents

acamprosate calcium 1

BUNAVAIL BUCCAL FILM 42-07 MG 63-1 MG

3 QL

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl

1 QL

bupropion hcl er (smoking det)

$0 QL

CHANTIX $0 QL

CHANTIX CONTINUING MONTH PAK

$0 QL

CHANTIX STARTING MONTH PAK

$0 QL

disulfiram oral 1

goodsense nicotine mouththroat lozenge 4 mg

$0 QL

habitrol $0 QL

LIFEMS NALOXONE E

LUCEMYRA 3 ST QL

naloxone hcl injection solution 04 mgml 4 mg10ml

E

naloxone hcl injection solution cartridge

E

naloxone hcl injection solution prefilled syringe

E

naltrexone hcl oral 1

NALTREXONE SUBCUTANEOUS

E

NARCAN 2

NICORETTE MOUTHTHROAT GUM 2 MG

$0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

20

Drug Name Drug Tier Notes

nicotine polacrilex mouththroat

$0 QL

nicotine step 1 $0 QL

nicotine step 2 $0 QL

nicotine step 3 $0 QL

NICOTROL $0 QL

NICOTROL NS $0 QL

SUBLOCADE 3 SP

SUBOXONE SUBLINGUAL FILM

2 QL

VIVITROL 3 SP

ZUBSOLV 2 QL

Antibacterials

ACTICLATE E

AEMCOLO 3 PA

ALTABAX 3

amikacin sulfate injection solution 500 mg2ml

E

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1

amoxicillin oral tablet chewable 125 mg 250 mg

1

amoxicillin-potassium clavulanate er

1

amoxicillin-potassium clavulanate oral

1

ampicillin oral capsule 500 mg

1

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

E

ARIKAYCE 3 PA SP

AUGMENTIN ES-600 3

Drug Name Drug Tier Notes

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-3125 MG5ML 250-625 MG5ML

3

AUGMENTIN ORAL TABLET 500-125 MG

3

avidoxy 1 ST

AVIDOXY DK E

azithromycin oral packet

1

azithromycin oral suspension reconstituted

1

azithromycin oral tablet 250 mg 500 mg 600 mg

1

bacitracin external E

bacitracin zinc external E

BACTRIM 3

BACTRIM DS 3

BAXDELA INTRAVENOUS

E

BAXDELA ORAL 3

BENZALKONIUM CHLORIDE EXTERNAL SOLUTION

3

benzalkonium chloride external solution 50

1

BENZODOX E

BICILLIN L-A E

cefaclor 1

cefaclor er 1

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm 10 gm

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

21

Drug Name Drug Tier Notes

cefazolin sodium-dextrose intravenous solution 2-4 gm100ml-

E

cefdinir 1

cefepime hcl injection solution reconstituted 2 gm

E

cefixime 1

CEFOTAN E

cefotaxime sodium injection solution reconstituted 1 gm 2 gm

E

cefotetan disodium injection solution reconstituted 1 gm 2 gm

E

cefoxitin sodium injection

E

cefpodoxime proxetil 1

cefprozil 1

ceftazidime injection solution reconstituted 1 gm 2 gm 6 gm

E

ceftriaxone sodium injection solution reconstituted 1 gm 2 gm 250 mg 500 mg

1

cefuroxime axetil oral tablet

1

CENTANY 3

CENTANY AT E

cephalexin 1

chloramphenicol sod succinate

E

CIPRO ORAL SUSPENSION RECONSTITUTED

3

CIPRO ORAL TABLET 250 MG 500 MG

3

ciprofloxacin hcl oral 1

Drug Name Drug Tier Notes

clarithromycin er 1

clarithromycin oral 1

CLEOCIN ORAL 3

CLEOCIN VAGINAL CREAM

3

CLEOCIN VAGINAL SUPPOSITORY

2

clindamycin hcl oral 1

clindamycin palmitate hcl

1

clindamycin phosphate vaginal

1

CLINDESSE 3

colistimethate sodium (cba)

E

COLY-MYCIN M E

coremino E

CUBICIN E

CUBICIN RF E

daptomycin E

demeclocycline hcl oral 1

dicloxacillin sodium 1

DIFICID 3

DORYX MPC E

DORYX ORAL TABLET DELAYED RELEASE 200 MG 50 MG

3 ST

DORYX ORAL TABLET DELAYED RELEASE 80 MG

E

doxy 100 E

doxycycline hyclate intravenous

E

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg 50 mg

1

doxycycline hyclate oral tablet 150 mg 75 mg

1 ST

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

22

Drug Name Drug Tier Notes

doxycycline hyclate oral tablet 20 mg

E

doxycycline hyclate oral tablet delayed release 100 mg 75 mg

1

doxycycline hyclate oral tablet delayed release 150 mg 200 mg 50 mg

1 ST

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

E

doxycycline monohydrate oral capsule 100 mg 150 mg 75 mg

1 ST

doxycycline monohydrate oral capsule 50 mg

1

doxycycline monohydrate oral suspension reconstituted

1

doxycycline monohydrate oral tablet

1 ST

EES GRANULES 3

ertapenem sodium E

ERYPED 200 3

ERYPED 400 3

ERY-TAB 3

ERYTHROCIN STEARATE ORAL TABLET 250 MG

3

erythromycin base oral 1

erythromycin ethylsuccinate oral

1

erythromycin oral 1

FETROJA E

FIRST-METRONIDAZOLE ORAL SUSPENSION RECONSTITUTED 50 MGML

E

Drug Name Drug Tier Notes

FIRVANQ 3

FLAGYL ORAL CAPSULE

3

FLAGYL ORAL TABLET 500 MG

3

FORTAZ INJECTION SOLUTION RECONSTITUTED 1 GM

E

fosfomycin tromethamine

1

gentamicin sulfate external

1

HIPREX 3

imipenem-cilastatin intravenous solution reconstituted 250 mg

E

INVANZ INJECTION E

iodine tincture external tincture 2

1

KEFLEX ORAL CAPSULE 750 MG

3

levofloxacin oral 1

LINCOCIN E

lincomycin hcl injection E

linezolid in sodium chloride

E

linezolid intravenous solution 600 mg300ml

E

linezolid oral 1 QL

LUGOLS STRONG IODINE

3

MACROBID 3

MACRODANTIN 3

mafenide acetate external

1

meropenem intravenous solution reconstituted 500 mg

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

23

Drug Name Drug Tier Notes

MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM50ML 500 MG50ML

E

methenamine hippurate 1

methenamine mandelate oral

E

METRONIDAZOLE BENZO+SYRSPEND

E

metronidazole oral 1

metronidazole vaginal 1

MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3

minocycline hcl er oral tablet extended release 24 hour

E

minocycline hcl oral 1

MINOLIRA E

mondoxyne nl oral capsule 100 mg 75 mg

1 ST

MONUROL 3

MORGIDOX COMBINATION KIT 1 X 100 MG 2 X 100 MG

E

morgidox oral capsule 100 mg

1

moxifloxacin hcl in nacl E

moxifloxacin hcl oral 1

mupirocin calcium E

mupirocin external 1

nafcillin sodium injection solution reconstituted 1 gm

E

nafcillin sodium intravenous solution reconstituted 10 gm

E

neomycin sulfate oral 1

Drug Name Drug Tier Notes

neomycin-polymyxin b gu

E

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

nitrofurantoin oral suspension

1

NUTRIDOX E

NUVESSA E

NUZYRA ORAL TABLET 150 MG

3

ofloxacin oral tablet 300 mg 400 mg

1

oxacillin sodium injection solution reconstituted 1 gm

E

oxacillin sodium intravenous

E

paromomycin sulfate oral

1

penicillin g potassium injection solution reconstituted 5000000 unit

E

penicillin g procaine E

penicillin g sodium E

penicillin v potassium 1

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 5000000 UNIT

E

piperacillin sod-tazobactam so intravenous solution reconstituted 45 (4-05) gm

E

polymyxin b sulfate injection

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

24

Drug Name Drug Tier Notes

POLYSPORIN EXTERNAL OINTMENT 500-10000 UNITGM

E

PRIMSOL 3

RECARBRIO E

SCRUB CARE POVIDONE-IODINE

E

SEYSARA 3 ST

SILVADENE 3

silver nitrate external solution

E

silver sulfadiazine external

1

SIVEXTRO E

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG 115 MG 55 MG 65 MG 80 MG

3

SOLOSEC 3

ssd 1

streptomycin sulfate intramuscular

E

sulfadiazine oral 1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5ml

1

sulfamethoxazole-trimethoprim oral tablet

1

SULFAMYLON EXTERNAL CREAM

E

SULFAMYLON EXTERNAL PACKET

3

sulfatrim pediatric 1

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION RECONSTITUTED

3

Drug Name Drug Tier Notes

SUPRAX ORAL TABLET CHEWABLE

3

TARGADOX E

tazicef injection E

tazicef intravenous solution reconstituted 1 gm

E

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

E

tetracycline hcl oral 1

tigecycline E

tinidazole oral 1

trimethoprim oral 1

TYGACIL E

UNASYN INJECTION SOLUTION RECONSTITUTED 3 (2-1) GM

E

VANCOCIN 3

VANCOCIN HCL ORAL CAPSULE 125 MG

3

vancomycin hcl in nacl intravenous solution 1-09 gm200ml-

E

vancomycin hcl intravenous solution 1000 mg200ml 1250 mg250ml 1500 mg300ml 1750 mg350ml 2000 mg400ml 500 mg100ml 750 mg150ml

E

vancomycin hcl oral 1

VANCOMYCIN+SYRSPEND SF

E

vandazole 1

VIBRAMYCIN 3 ST

XENLETA INTRAVENOUS

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

25

Drug Name Drug Tier Notes

XENLETA ORAL 3

XEPI 3

XIFAXAN 3 PA

XIMINO 3

ZEMDRI E

ZITHROMAX ORAL PACKET

3

ZITHROMAX ORAL SUSPENSION RECONSTITUTED

3

ZITHROMAX ORAL TABLET 250 MG 500 MG

3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZYVOX INTRAVENOUS SOLUTION 200 MG100ML 600 MG300ML

E

ZYVOX ORAL 3 QL

Anticoagulants

ACD-A NOCLOT-50 3

ACTIVASE E

ANTICOAGULANT SODIUM CITRATE

3

ARIXTRA 3 SP QL

CATHFLO ACTIVASE E

ELIQUIS 2 QL

ELIQUIS DVTPE STARTER PACK ORAL TABLET THERAPY PACK

2 QL

enoxaparin sodium 1 SP QL

fondaparinux sodium 1 SP QL

Drug Name Drug Tier Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNITML 12500 UNIT05ML 15000 UNIT06ML 18000 UNT072ML 2500 UNIT02ML 5000 UNIT02ML 7500 UNIT03ML 95000 UNIT38ML

3 SP QL

heparin (porcine) in nacl intravenous solution 1000-09 ut500ml- 2000-09 unitl-

E

heparin sodium (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml

1

heparin sodium (porcine) injection solution prefilled syringe

E

heparin sodium (porcine) pf injection solution 5000 unit05ml

1

heparin sodium (porcine) pf injection solution 5000 unitml

E

jantoven 1

LOVENOX 3 SP QL

PRADAXA 2 QL

REGIOCIT E

SAVAYSA 3 QL

THROMBATE III 3 SP

TRICITRASOL 3

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

26

Drug Name Drug Tier Notes

Anticonvulsants - Drugs for Seizures

APTIOM 3

BANZEL 3 PA

BRIVIACT INTRAVENOUS

E

BRIVIACT ORAL 3 ST

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

CELONTIN 3

CEREBYX INJECTION SOLUTION 500 MG PE10ML

E

clobazam 1 PA

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE

3

DIACOMIT 3 PA SP

DIASTAT ACUDIAL 3 QL

DIASTAT PEDIATRIC 3 QL

diazepam rectal 1 QL

DILANTIN INFATABS E

DILANTIN ORAL CAPSULE 100 MG

E

DILANTIN ORAL CAPSULE 30 MG

3

DILANTIN ORAL SUSPENSION

E

divalproex sodium er oral tablet extended release 24 hour

1

divalproex sodium oral capsule delayed release sprinkle

1

divalproex sodium oral tablet delayed release

1

ELEPSIA XR E

Drug Name Drug Tier Notes

EPIDIOLEX 3 PA SP

epitol 1

ethosuximide oral 1

FANATREX FUSEPAQ E

felbamate 1

FELBATOL 3

FINTEPLA 3 PA SP

fosphenytoin sodium injection solution 500 mg pe10ml

E

FYCOMPA 3

gabapentin oral capsule

1

gabapentin oral solution 250 mg5ml

1

gabapentin oral tablet 1

GABITRIL 3

KEPPRA INTRAVENOUS

E

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL ODT ORAL KIT 21 X 25 MG amp 7 X 50 MG 42 X 50 MG amp 14X100 MG

2

LAMICTAL ODT ORAL KIT 25 amp 50 amp 100 MG

E

LAMICTAL ODT ORAL TABLET DISPERSIBLE

3

LAMICTAL ORAL TABLET

3

LAMICTAL ORAL TABLET CHEWABLE 25 MG 5 MG

3

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine er 1

lamotrigine oral kit 25 amp 50 amp 100 mg

1

lamotrigine oral tablet 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

27

Drug Name Drug Tier Notes

lamotrigine oral tablet chewable

1

lamotrigine oral tablet dispersible

1

lamotrigine starter kit-blue

1

lamotrigine starter kit-green

1

lamotrigine starter kit-orange

1

levetiracetam er 1

levetiracetam intravenous

E

levetiracetam oral 1

MYSOLINE 3

NAYZILAM 3 QL

NEURONTIN 3

ONFI ORAL SUSPENSION

3 PA

ONFI ORAL TABLET 10 MG 20 MG

3 PA

oxcarbazepine 1

OXTELLAR XR E

phenobarbital oral elixir 1

phenobarbital oral tablet

1

PHENYTEK 3

phenytoin infatabs 1

phenytoin oral suspension 125 mg5ml

1

phenytoin oral tablet chewable

1

phenytoin sodium extended

1

primidone oral 1

QUDEXY XR 3

roweepra oral tablet 500 mg

1

rufinamide 1 PA

Drug Name Drug Tier Notes

SABRIL ORAL PACKET

E SP

SABRIL ORAL TABLET

3 PA SP

SPRITAM E

subvenite 1

subvenite starter kit-blue

1

subvenite starter kit-green

1

subvenite starter kit-orange

1

SYMPAZAN 3 PA

TEGRETOL ORAL SUSPENSION

3

TEGRETOL ORAL TABLET

3

TEGRETOL-XR 3

tiagabine hcl 1

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 1

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3 ST

valproic acid oral capsule

1

valproic acid oral solution

1

VALTOCO 3 QL

vigabatrin 1 PA SP

vigadrone 1 PA SP

VIMPAT INTRAVENOUS

E

VIMPAT ORAL 3

XCOPRI 3 ST

ZARONTIN 3

ZONEGRAN 3

zonisamide oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

28

Drug Name Drug Tier Notes

Antidementia Agents - Drugs for Alzheimers Disease and Dementia

ARICEPT 3

donepezil hcl 1

EXELON TRANSDERMAL

3

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl er 1 QL

memantine hcl oral solution 2 mgml

1

memantine hcl oral tablet

1

NAMENDA ORAL TABLET

3

NAMENDA TITRATION PAK

3

NAMENDA XR 3 QL

NAMENDA XR TITRATION PACK

3 QL

NAMZARIC 2 QL

RAZADYNE ER 3

rivastigmine 1

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL 3

APLENZIN E

BRISDELLE 3 ST QL

bupropion hcl er (sr) 1 QL

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

1 QL

Drug Name Drug Tier Notes

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

E

bupropion hcl oral 1

CELEXA ORAL TABLET

3

chlordiazepoxide-amitriptyline

1

citalopram hydrobromide

1

clomipramine hcl oral 1

CYMBALTA E

desipramine hcl oral 1

DESVENLAFAXINE ER

3 ST QL

desvenlafaxine succinate er

1 QL

doxepin hcl oral capsule

1

doxepin hcl oral concentrate

1

DRIZALMA SPRINKLE 3 ST QL

duloxetine hcl oral 1 QL

EFFEXOR XR E

EMSAM 3 QL

escitalopram oxalate 1

FETZIMA 3 ST QL

FETZIMA TITRATION 3 ST QL

fluoxetine hcl (pmdd) oral tablet

1

fluoxetine hcl oral capsule

1

fluoxetine hcl oral capsule delayed release

1 QL

fluoxetine hcl oral solution

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

fluvoxamine maleate er 1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

29

Drug Name Drug Tier Notes

FORFIVO XL E

imipramine hcl oral 1

imipramine pamoate 1

LEXAPRO ORAL TABLET

E

maprotiline hcl 1

MARPLAN 3

mirtazapine oral 1

NARDIL 3

nefazodone hcl 1

NORPRAMIN ORAL TABLET 10 MG 25 MG

3

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl

1 QL

PAMELOR ORAL CAPSULE

3

PARNATE 3

paroxetine hcl er 1

paroxetine hcl oral tablet

1

paroxetine mesylate 1 QL

PAXIL CR 3

PAXIL ORAL SUSPENSION

2 ST

PAXIL ORAL TABLET 3

perphenazine-amitriptyline

1

PEXEVA E

phenelzine sulfate oral 1

PRISTIQ E

protriptyline hcl 1

PROZAC ORAL CAPSULE

E

REMERON ORAL TABLET 15 MG 30 MG

3

REMERON SOLTAB 3

sertraline hcl oral 1

Drug Name Drug Tier Notes

SPRAVATO (56 MG DOSE)

3 PA SP

SPRAVATO (84 MG DOSE)

3 PA SP

SYMBYAX ORAL CAPSULE 12-50 MG 3-25 MG 6-25 MG 6-50 MG

3 QL

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral

1

TRINTELLIX 3 ST QL

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD ORAL TABLET

3 QL

VIIBRYD STARTER PACK

3 QL

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

ZULRESSO 3 PA SP

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS

E

AKYNZEO ORAL 3 QL

ALOXI INTRAVENOUS SOLUTION 025 MG5ML

E

ANZEMET ORAL 3 QL

aprepitant 1 QL

BONJESTA 3 PA QL

compro 1

cvs motion sickness E

DICLEGIS 3 PA QL

doxylamine-pyridoxine 1 PA QL

dronabinol 1 PA QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

30

Drug Name Drug Tier Notes

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

E

EMEND ORAL CAPSULE 80 MG

3 QL

EMEND ORAL SUSPENSION RECONSTITUTED

3

EMEND TRI-PACK 3 QL

fosaprepitant dimeglumine

E

GIMOTI E

goodsense motion sickness

E

granisetron hcl intravenous solution 1 mgml 4 mg4ml

E

granisetron hcl oral 1 QL

MARINOL 3 PA QL

meclizine hcl oral tablet 1

meclizine hcl tablet chewable 25 mg oral (otc)

E

meclizine hcl tablet chewable 25 mg oral (rx)

1

metoclopramide hcl oral solution 10 mg10ml 5 mg5ml

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet dispersible

1

motion sickness relief E

ondansetron hcl injection solution 4 mg2ml 40 mg20ml

E

ondansetron hcl oral solution

1 QL

ondansetron hcl oral tablet 24 mg

1 QL

Drug Name Drug Tier Notes

ondansetron hcl oral tablet 4 mg 8 mg

1

ondansetron odt 1

palonosetron hcl E

perphenazine oral 1

prochlorperazine 1

prochlorperazine maleate oral

1

REGLAN ORAL 3

SANCUSO 3 QL

scopolamine 1

SUSTOL E

SYNDROS 3 PA QL

TIGAN INTRAMUSCULAR

E

TIGAN ORAL 3

TRANSDERM SCOP (15 MG)

3

TRANSDERM-SCOP (15 MG)

3

trimethobenzamide hcl oral

1

VARUBI (180 MG DOSE)

3 QL

ZOFRAN ORAL TABLET 4 MG

3

ZUPLENZ E

Antifungals

ALA-QUIN E

ALCORTIN A E

ALOE VESTA CLEAR ANTIFUNGAL

E

ANCOBON 3

athletes foot (terbinafine)

E

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 70 MG

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

31

Drug Name Drug Tier Notes

caspofungin acetate intravenous solution reconstituted 70 mg

E

ciclodan external solution

1

ciclopirox external 1

ciclopirox olamine external

1

ciclopirox treatment E

clotrimazole external cream

1

clotrimazole external solution

1

clotrimazole mouththroat troche

1

clotrimazole vaginal cream 1

E

clotrimazole-betamethasone

1

CRESEMBA ORAL 3

cvs clotrimazole 3 E

DERMACINRX THERAZOLE PAK

E

DESENEX EXTERNAL POWDER

E

DIFLUCAN 3

DIFMETIOXRIME E

ECONASIL E

econazole nitrate external

1

ECONAZOLE NITRATE-NIACINAMIDE

E

ECOZA E

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

E

ERTACZO E

EXELDERM E

Drug Name Drug Tier Notes

EXODERM EXTERNAL LOTION

3

EXTINA 3

fluconazole oral 1

FLUCON-IBUPROF-ITRACON-TERBINA

E

flucytosine oral 1

FUNGIMEZ E

griseofulvin microsize oral

1

griseofulvin ultramicrosize

1

GYNAZOLE-1 3

HIXDEFRIMA E

hydrocortisone-iodoquinol external cream 1-1

E

IMIOXIA E

IODOQUIMEZ-HC E

iodoquinol-hc-aloe polysacch

E

IODOQUINOL-HC-KETOCONAZOLE

E

iodoquinol-hydrocortisone-aloe

E

itraconazole oral 1 PA

JUBLIA E

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external foam

E

ketoconazole external shampoo 2

1

ketoconazole oral 1

KETOCONAZOLE-HYDROCORTISONE

E

ketodan external foam E

KETODAN EXTERNAL KIT

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

32

Drug Name Drug Tier Notes

LOPROX EXTERNAL CREAM

3

LOPROX EXTERNAL KIT

E

LOPROX EXTERNAL SHAMPOO

3

LOPROX EXTERNAL SUSPENSION

3

LOTRIMIN AF EXTERNAL POWDER

E

LULICONAZOLE E

LUZU E

MENTAX E

micaderm E

micafungin sodium intravenous solution reconstituted 100 mg

E

miconazole 1 E

miconazole 3 vaginal suppository

1

miconazole 7 E

miconazole nitrate external cream

E

MICONAZOLE-ZINC OXIDE-PETROLAT

E

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

E

MYCOZYL AP E

naftifine hcl 1

NAFTIN EXTERNAL GEL

3

NOXAFIL ORAL 3 PA

nyamyc 1

nystatin external 1

nystatin mouththroat 1

nystatin oral tablet 1

nystatin-triamcinolone 1

nystop 1

Drug Name Drug Tier Notes

ONYCHO-MED E

ORAVIG E

oxiconazole nitrate E

OXISTAT EXTERNAL CREAM

3

OXISTAT EXTERNAL LOTION

E

PEDIZOLPAK E

PHEODOYO E

PHEYO E

posaconazole 1 PA

QUINJA E

RECURA E

SPORANOX 3 PA

SPORANOX PULSEPAK

3 PA

SULCONAZOLE NITRATE

E

tavaborole 1 PA

terbinafine hcl oral 1 QL

terconazole 1

tolnaftate antifungal E

tolnaftate external powder

E

TOLSURA E

VFEND 3

voriconazole oral 1

VUSION E

VYTONE E

XOLEGEL E

XOLEGEL COREPAK E

XOLEGEL DUOHEAD amp SHOULDERS

E

XOLEGEL DUOXOLEX

E

ZEASORB-AF EXTERNAL POWDER

E

ZOLPAK E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

33

Drug Name Drug Tier Notes

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

E

colchicine oral tablet 1

colchicine-probenecid 1

COLCRYS E

febuxostat 1 ST

GLOPERBA E

KRYSTEXXA 3 PA SP

MITIGARE E

probenecid oral 1

ULORIC 3 ST

ZYLOPRIM 3

Anti-inflammatory Agents

EMFLAZA 3 PA SP

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MGML 70 MGML

2 PA QL

AJOVY E

almotriptan malate 1 QL

AMERGE 3 QL

CAFERGOT 3

DHE 45 3 PA QL

dihydroergotamine mesylate injection

1 PA QL

dihydroergotamine mesylate nasal

1 PA QL

eletriptan hydrobromide 1 QL

EMGALITY 2 PA QL

EMGALITY (300 MG DOSE)

2 PA QL

ERGOMAR 3

ergotamine-caffeine 1

FROVA 3 QL

Drug Name Drug Tier Notes

frovatriptan succinate 1 QL

IMITREX 3 QL

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE

3 QL

IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 QL

MAXALT ORAL TABLET 10 MG

3 QL

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG

3 QL

MIGERGOT 3

MIGRAINE PACK E

MIGRANAL 3 PA QL

MIGRANOW E

naratriptan hcl 1 QL

NURTEC 2 PA QL

ONZETRA XSAIL 3 ST QL

RELPAX 3 QL

REYVOW E

rizatriptan benzoate 1 QL

SUMANSETRON E

sumatriptan nasal 1 QL

sumatriptan succinate oral

1 QL

sumatriptan succinate refill subcutaneous solution cartridge

1 QL

sumatriptan succinate subcutaneous solution 6 mg05ml

1 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg05ml 6 mg05ml

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

34

Drug Name Drug Tier Notes

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg05ml

1 QL

sumatriptan-naproxen sodium

1 QL

TOSYMRA E

TREXIMET ORAL TABLET 85-500 MG

3 ST QL

UBRELVY 2 PA QL

VYEPTI E

ZEMBRACE SYMTOUCH

E

ZOLMITRIPTAN NASAL

3 ST QL

zolmitriptan oral 1 QL

ZOMIG NASAL 3 ST QL

ZOMIG ORAL E

ZOMIG ZMT E

Antimyasthenic Agents

GUANIDINE HCL ORAL

3

MESTINON ORAL SOLUTION

3

MESTINON ORAL TABLET

3

MESTINON ORAL TABLET EXTENDED RELEASE

3

NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 5 MG5ML INTRAVENOUS

E

pyridostigmine bromide er

1

pyridostigmine bromide oral solution

1

pyridostigmine bromide oral tablet

1

Drug Name Drug Tier Notes

Antimycobacterials

CAPASTAT SULFATE E

cycloserine oral 1

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL ORAL TABLET 400 MG

3

MYCOBUTIN 3

PASER 3

PRETOMANID 3

PRIFTIN 3

pyrazinamide oral 1

rifabutin 1

rifampin oral 1

RIFAMPIN+SYRSPEND SF

E

SIRTURO 3

TRECATOR 3

Antineoplastics - Drugs for Cancer

abiraterone acetate 1 PA SP

ABRAXANE 2 SP

ADCETRIS 2 PA SP

adriamycin intravenous solution

1 SP

adriamycin intravenous solution reconstituted 10 mg 50 mg

1 SP

AFINITOR DISPERZ 3 PA SP

AFINITOR ORAL TABLET 10 MG

2 PA SP QL

AFINITOR ORAL TABLET 25 MG 5 MG 75 MG

E SP

ALECENSA 2 PA SP

ALIMTA 2 SP

ALIQOPA 3 PA SP

ALKERAN 3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

35

Drug Name Drug Tier Notes

ALUNBRIG 2 PA SP QL

anastrozole oral $0

ARIMIDEX E

AROMASIN 3

ARRANON 2 SP

arsenic trioxide intravenous

1 SP

ARZERRA 2 PA SP

ASPARLAS 3 SP

AVASTIN 3 PA SP

AYVAKIT 3 PA SP QL

azacitidine 1 PA SP

BALVERSA 3 PA SP

BAVENCIO 3 PA SP

BELEODAQ 3 PA SP

BELRAPZO E SP

BENDEKA 3 PA SP

BESPONSA 3 PA SP

bexarotene 1 PA SP

bicalutamide 1

BICNU 3 SP

BLENREP 3 PA SP

bleomycin sulfate 1 SP

BLINCYTO 3 PA SP

BORTEZOMIB 3 PA SP

BOSULIF 3 PA SP

BRAFTOVI ORAL CAPSULE 75 MG

3 PA SP

BREYANZI E SP

BRUKINSA 3 PA SP

busulfan 1 SP

BUSULFEX 3 SP

CABOMETYX 2 PA SP

CALQUENCE 3 PA SP

CAMPATH 2 SP

CAMPTOSAR 3 SP

capecitabine 1 PA SP

Drug Name Drug Tier Notes

CAPRELSA ORAL TABLET 100 MG

2 PA SP QL

CAPRELSA ORAL TABLET 300 MG

2 PA SP

carboplatin intravenous solution

1 SP

carmustine 1 SP

CASODEX 3

cisplatin intravenous solution 100 mg100ml 200 mg200ml 50 mg50ml

1 SP

CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED

3 SP

cladribine intravenous solution 10 mg10ml

1 SP

clofarabine 1 SP

CLOLAR 3 SP

COMETRIQ ORAL KIT 20 MG 3 X 20 MG amp 80 MG 80 amp 20 MG

3 PA SP

COPIKTRA 3 PA SP

COSELA E SP

COSMEGEN 3 SP

COTELLIC 3 PA SP

cyclophosphamide injection

1 SP

CYCLOPHOSPHAMIDE INTRAVENOUS

3 SP

cyclophosphamide oral capsule

1

CYCLOPHOSPHAMIDE ORAL TABLET

2

CYRAMZA 3 PA SP

cytarabine (pf) 1 SP

cytarabine injection solution

1 SP

dacarbazine intravenous

1 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

36

Drug Name Drug Tier Notes

DACOGEN 3 PA SP

dactinomycin 1 SP

DANYELZA 3 PA SP

DARZALEX 3 PA SP

DARZALEX FASPRO E SP

daunorubicin hcl intravenous solution

1 SP

DAURISMO 3 PA SP

decitabine 1 PA SP

dexrazoxane hcl 1 SP

docetaxel intravenous concentrate 160 mg8ml 20 mgml 80 mg4ml

1 SP

docetaxel intravenous solution 160 mg16ml 20 mg2ml 80 mg8ml

1 SP

DOXIL 3 SP

doxorubicin hcl intravenous solution

1 SP

doxorubicin hcl liposomal

1 SP

DROXIA 3

ELITEK 3 SP

ELLENCE 3 SP

ELZONRIS 3 PA SP

EMCYT 2

EMPLICITI 3 PA SP

ENHERTU 3 PA SP

epirubicin hcl intravenous solution 200 mg100ml 50 mg25ml

1 SP

ERBITUX 2 PA SP

ERIVEDGE 2 PA SP

ERLEADA E SP

erlotinib hcl oral tablet 100 mg 150 mg

1 PA SP

erlotinib hcl oral tablet 25 mg

1 PA SP QL

Drug Name Drug Tier Notes

ERWINAZE INJECTION

3 SP

ETHYOL 3 SP

ETOPOPHOS 3 SP

etoposide intravenous solution 1 gm50ml 100 mg5ml 500 mg25ml

1 SP

etoposide oral 1 SP

everolimus oral tablet 25 mg 5 mg 75 mg

1 PA SP QL

EVOMELA 3 SP

exemestane $0

FARESTON 3

FARYDAK 3 PA SP

FASLODEX INTRAMUSCULAR SOLUTION 250 MG5ML

3 SP

FEMARA 3

floxuridine injection 1 SP

fludarabine phosphate 1 SP

fluorouracil intravenous 1 SP

flutamide 1

FOLOTYN 2 PA SP

FOTIVDA E SP

fulvestrant 1 SP

GAVRETO E SP

GAZYVA 3 PA SP

gemcitabine hcl 1 SP

GILOTRIF 3 PA SP QL

GLEEVEC 3 PA SP

GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG

3 SP

HALAVEN 2 PA SP

HERCEPTIN HYLECTA

3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

37

Drug Name Drug Tier Notes

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

3 PA SP

HERZUMA E SP

HYCAMTIN 3 SP

HYDREA 3

hydroxyurea oral 1

IBRANCE 3 PA SP

ICLUSIG ORAL TABLET 10 MG 15 MG

3 PA SP QL

ICLUSIG ORAL TABLET 30 MG 45 MG

3 PA SP

IDAMYCIN PFS 3 SP

idarubicin hcl 1 SP

IDHIFA 3 PA SP QL

IFEX 3 SP

ifosfamide 1 SP

imatinib mesylate 1 PA SP

IMBRUVICA 3 PA SP

IMFINZI 3 PA SP

IMLYGIC 3 SP

INFUGEM 3 SP

INLYTA 3 PA SP

INQOVI E SP

INREBIC 3 PA SP

IRESSA 3 PA SP

irinotecan hcl 1 SP

ISTODAX (OVERFILL) 3 PA SP

IXEMPRA KIT 2 SP

JAKAFI ORAL TABLET 10 MG

2 PA SP QL

JAKAFI ORAL TABLET 15 MG 20 MG 25 MG 5 MG

2 PA SP

JELMYTO E SP

JEVTANA 2 PA SP

Drug Name Drug Tier Notes

KADCYLA 3 PA SP

KANJINTI 2 PA SP

KEYTRUDA INTRAVENOUS SOLUTION

3 PA SP

KHAPZORY 3 ST SP

KISQALI FEMARA 3 PA SP

KISQALI ORAL TABLET THERAPY PACK 200 MG

3 PA SP

KOSELUGO 3 PA SP

KYPROLIS 2 PA SP

lapatinib ditosylate 1 PA SP

LENVIMA ORAL CAPSULE THERAPY PACK 10 amp 4 MG 10 MG 10 MG amp 2 X 4 MG 2 X 10 MG 2 X 10 MG amp 4 MG 2 X 4 MG 3 X 4 MG 4 MG

3 PA SP

letrozole oral 1

leucovorin calcium injection

E

leucovorin calcium oral 1

LEUKERAN 2

levoleucovorin calcium intravenous solution reconstituted 50 mg

1 SP

levoleucovorin calcium pf

1 SP

LIBTAYO 3 PA SP

LONSURF 3 PA SP

LORBRENA 3 PA SP

LUMOXITI 3 PA SP

LUTATHERA E

LYNPARZA ORAL TABLET

2 PA SP

LYSODREN 2

MARQIBO 3 SP

MATULANE 2 SP

MEKINIST 2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

38

Drug Name Drug Tier Notes

MEKTOVI 3 PA SP

melphalan 1 SP

melphalan hcl 1 SP

mercaptopurine oral 1

mesna 1 SP

MESNEX 3 SP

mitomycin intravenous 1 SP

MITOMYCIN INTRAVESICAL

E SP

mitoxantrone hcl 1 PA SP

MONJUVI 3 PA SP

mutamycin 1 SP

MVASI 2 PA SP

MYLERAN 2

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 45 MG

3 PA SP

NAVELBINE 3 SP

NERLYNX 3 PA SP QL

NEXAVAR 2 PA SP

NILANDRON 3 SP

nilutamide 1 SP

NINLARO 3 PA SP

NIPENT 3 SP

NUBEQA 3 PA SP

ODOMZO 3 PA SP

OGIVRI E SP

ONCASPAR INJECTION

2 SP

ONIVYDE 3 SP

ONTRUZANT E SP

ONUREG 3 PA SP

OPDIVO 3 PA SP

ORGOVYX 3 PA SP

oxaliplatin intravenous solution 100 mg20ml 50 mg10ml

1 SP

Drug Name Drug Tier Notes

oxaliplatin intravenous solution 200 mg40ml

E

oxaliplatin intravenous solution reconstituted

1 SP

paclitaxel 1 SP

PADCEV 3 PA SP

PANRETIN 3

paraplatin 1 SP

PEMAZYRE 3 PA SP QL

PERJETA 2 PA SP

PHESGO 2 PA SP

PHOTOFRIN 3 SP

PIQRAY 3 PA SP

POLIVY 3 PA SP

POMALYST 3 PA SP

PORTRAZZA 3 PA SP

POTELIGEO 3 PA SP

PROLEUKIN 2 SP

PURIXAN 3 SP

QINLOCK 3 PA SP

RETEVMO 3 PA SP

REVLIMID 2 PA SP

RIABNI 3 PA SP

RITUXAN HYCELA 3 PA SP

RITUXAN INTRAVENOUS SOLUTION

3 PA SP

ROMIDEPSIN INTRAVENOUS SOLUTION

3 PA SP

ROZLYTREK 3 PA SP

RUBRACA 2 PA SP

RUXIENCE 2 PA SP

RYDAPT 3 PA SP

SARCLISA 3 PA SP

SIKLOS 3 PA

SOLTAMOX $0

SPRYCEL 2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

39

Drug Name Drug Tier Notes

STIVARGA 3 PA SP

SUTENT 2 PA SP

SYLVANT 3 PA SP

SYNRIBO 3 PA SP

TABLOID 2 SP

TABRECTA E SP

TAFINLAR 2 PA SP

TAGRISSO ORAL TABLET 40 MG

3 PA SP QL

TAGRISSO ORAL TABLET 80 MG

3 PA SP

TALZENNA 3 PA SP

tamoxifen citrate oral 1

TARCEVA ORAL TABLET 100 MG 150 MG

3 PA SP

TARCEVA ORAL TABLET 25 MG

3 PA SP QL

TARGRETIN EXTERNAL

3 PA SP

TARGRETIN ORAL E SP

TASIGNA 3 PA SP

TAZVERIK E SP

TECARTUS 3 PA SP

TECENTRIQ 3 PA SP

TEMODAR INTRAVENOUS

2 SP

TEMODAR ORAL CAPSULE 100 MG 140 MG 180 MG 250 MG

3 PA SP

temozolomide 1 PA SP

teniposide 1 SP

TEPADINA 3 SP

TEPMETKO E SP

THALOMID 2 PA SP

thiotepa injection 1 SP

TIBSOVO 3 PA SP

Drug Name Drug Tier Notes

toposar intravenous solution 1 gm50ml 100 mg5ml 500 mg25ml

1 SP

topotecan hcl 1 SP

toremifene citrate 1

TOTECT 3 SP

TRAZIMERA 2 PA SP

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

E SP

tretinoin oral 1 SP

TRISENOX INTRAVENOUS SOLUTION 12 MG6ML

3 SP

TRODELVY 3 PA SP

TRUXIMA E SP

TUKYSA 3 PA SP

TURALIO 3 PA SP

TYKERB 3 PA SP

UKONIQ E SP

UNITUXIN 3 PA SP

VALCHLOR 3 PA SP

valrubicin E

VALSTAR E

VECTIBIX INTRAVENOUS SOLUTION 100 MG5ML 400 MG20ML

3 SP

VELCADE INJECTION 2 PA SP

VENCLEXTA 3 PA SP

VENCLEXTA STARTING PACK

3 PA SP

VERZENIO 3 PA SP

VIDAZA 3 PA SP

vinblastine sulfate intravenous solution

1 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

40

Drug Name Drug Tier Notes

vincristine sulfate intravenous

1 SP

vinorelbine tartrate 1 SP

VITRAKVI 3 PA SP

VIZIMPRO 3 PA SP

VORAXAZE E

VOTRIENT 3 PA SP

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

3 PA SP

XALKORI 3 PA SP

XELODA 3 PA SP

XOFIGO INTRAVENOUS SOLUTION 30 MCCIML

E

XOSPATA 3 PA SP

XPOVIO (100 MG ONCE WEEKLY)

3 PA SP

XPOVIO (40 MG ONCE WEEKLY)

3 PA SP

XPOVIO (40 MG TWICE WEEKLY)

3 PA SP

XPOVIO (60 MG ONCE WEEKLY)

3 PA SP

XPOVIO (60 MG TWICE WEEKLY)

3 PA SP

XPOVIO (80 MG ONCE WEEKLY)

3 PA SP

XPOVIO (80 MG TWICE WEEKLY)

3 PA SP

XTANDI 3 PA SP

YERVOY 2 PA SP

YESCARTA 3 PA SP

YONDELIS 3 SP

YONSA E SP

ZALTRAP 2 PA SP

ZANOSAR 2 SP

ZEJULA 2 PA SP

Drug Name Drug Tier Notes

ZELBORAF 3 PA SP

ZEPZELCA 3 PA SP

ZEVALIN Y-90 3 SP

ZIRABEV 2 PA SP

ZOLINZA 2 PA SP

ZYDELIG 3 PA SP

ZYKADIA ORAL TABLET

3 PA SP

ZYTIGA E SP

Antiparasitics

albendazole oral 1 PA

ALBENZA 3 PA

ALINIA ORAL SUSPENSION RECONSTITUTED

2

ALINIA ORAL TABLET 3

ARAKODA 3

atovaquone oral 1

atovaquone-proguanil hcl

1

BENZNIDAZOLE 3

BILTRICIDE 3

chloroquine phosphate oral

1

COARTEM 3

crotan 1

DARAPRIM 3 PA SP

EGATEN 3

ELIMITE 3

EMVERM 2

hydroxychloroquine sulfate oral

1

IMPAVIDO 3

ivermectin external lotion

1

ivermectin oral 1

KRINTAFEL 3

LAMPIT 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

41

Drug Name Drug Tier Notes

lice killing external shampoo 4-033

E

lice treatment external liquid 1

E

lindane external shampoo

1

MALARONE 3

malathion external 1

mefloquine hcl 1

MEPRON 3

NATROBA 3

NEBUPENT 3

nitazoxanide 1

OVIDE 3

PENTAM E

pentamidine isethionate inhalation

1

pentamidine isethionate injection

E

permethrin external cream

1

PLAQUENIL 3

praziquantel oral 1

primaquine phosphate oral

1

pyrimethamine oral 1 PA SP

PYRIMETHAMINE-LEUCOVORIN

3

QUALAQUIN 3 PA

quinine sulfate oral 1 PA

spinosad 1

stop lice complete treatment

E

STROMECTOL 3

SULFURATED LIME 3

Antiparkinson Agents

amantadine hcl oral 1

Drug Name Drug Tier Notes

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

3 PA SP QL

AZILECT 3

benztropine mesylate oral

1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa 1

carbidopa-levodopa er oral tablet extended release 25-100 mg 50-200 mg

1

carbidopa-levodopa-entacapone

1

COMTAN 3

DUOPA ENTERAL 3 PA

entacapone 1

GOCOVRI E

INBRIJA 3 PA SP

KYNMOBI 3 PA SP QL

KYNMOBI TITRATION KIT

3 PA SP QL

LODOSYN 3

MIRAPEX ER 3

MIRAPEX ORAL TABLET 0125 MG 05 MG 075 MG 1 MG

3

NEUPRO 3 ST

NOURIANZ 3 PA

ONGENTYS 3 ST

OSMOLEX ER E

PARLODEL 3

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

1

rasagiline mesylate oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

42

Drug Name Drug Tier Notes

ropinirole hcl 1

ropinirole hcl er 1

RYTARY 3 ST

selegiline hcl oral 1

SINEMET ORAL TABLET 10-100 MG 25-100 MG

3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR ORAL TABLET 100 MG

3

tolcapone 1

trihexyphenidyl hcl 1

XADAGO 3 ST QL

ZELAPAR 3

Antiplatelets

aspirin-dipyridamole er 1

ASPIRIN-OMEPRAZOLE

E

BRILINTA 2

CABLIVI 3 PA SP QL

cilostazol 1

clopidogrel bisulfate oral

1

dipyridamole oral 1

DURLAZA E

EFFIENT 3

PLAVIX ORAL TABLET 75 MG

3

prasugrel hcl 1

YOSPRALA E

ZONTIVITY 3

Drug Name Drug Tier Notes

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

3

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

ABILIFY MYCITE E

ABILIFY MYCITE MAINTENANCE KIT

E

ABILIFY MYCITE STARTER KIT

E

ABILIFY ORAL TABLET

3 QL

ADASUVE 3 PA

aripiprazole 1 QL

ARISTADA E

ARISTADA INITIO E

asenapine maleate 1 QL

CAPLYTA 3 ST QL

chlorpromazine hcl injection

E

chlorpromazine hcl oral 1

clozapine 1 QL

CLOZARIL 3 QL

FANAPT 3 ST QL

FANAPT TITRATION PACK

3 ST QL

fluphenazine decanoate injection

E

fluphenazine hcl injection

E

fluphenazine hcl oral 1

GEODON INTRAMUSCULAR

E

GEODON ORAL 3 QL

HALDOL DECANOATE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

43

Drug Name Drug Tier Notes

haloperidol decanoate intramuscular solution 100 mgml 50 mgml

E

haloperidol lactate oral 1

haloperidol oral 1

INVEGA 3 QL

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

LATUDA 3 QL

loxapine succinate oral 1

molindone hcl 1

NUPLAZID ORAL CAPSULE

3 PA

NUPLAZID ORAL TABLET 10 MG

3 PA

olanzapine intramuscular

E

olanzapine oral 1 QL

paliperidone er 1 QL

PERSERIS E

pimozide 1

quetiapine fumarate 1 QL

quetiapine fumarate er 1 QL

REXULTI 3 QL

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

RISPERDAL ORAL SOLUTION

E

RISPERDAL ORAL TABLET 05 MG 1 MG 2 MG 3 MG 4 MG

E

risperidone 1 QL

Drug Name Drug Tier Notes

SAPHRIS E

SECUADO E

SEROQUEL 3 QL

SEROQUEL XR 3 QL

thioridazine hcl oral 1

thiothixene oral 1

trifluoperazine hcl oral 1

VERSACLOZ 3 QL

VRAYLAR 3 ST QL

ziprasidone hcl 1 QL

ziprasidone mesylate E

ZYPREXA INTRAMUSCULAR

3

ZYPREXA ORAL 3 QL

ZYPREXA RELPREVV E

ZYPREXA ZYDIS 3 QL

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1

abacavir-lamivudine-zidovudine

1

acyclovir external 1

acyclovir oral 1

ACYCLOVIX E

adefovir dipivoxil 1 SP

APTIVUS 2

atazanavir sulfate 1

ATRIPLA E

BARACLUDE 3 SP QL

BIKTARVY 3

CABENUVA E

cidofovir intravenous E

CIMDUO 2

COMBIVIR 3

COMPLERA 2

CRIXIVAN ORAL CAPSULE 400 MG

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

44

Drug Name Drug Tier Notes

DELSTRIGO 3

DENAVIR E

DESCOVY E

DOVATO 2

EDURANT 2

efavirenz 1

efavirenz-emtricitab-tenofovir

1

efavirenz-lamivudine-tenofovir

1

emtricitabine 1

emtricitabine-tenofovir df

1

EMTRIVA ORAL CAPSULE

3

EMTRIVA ORAL SOLUTION

2

entecavir 1 SP QL

EPCLUSA 2 PA SP QL

EPIVIR 3

EPIVIR HBV ORAL SOLUTION

2 SP

EPIVIR HBV ORAL TABLET

3 SP

EPZICOM 3

EVOTAZ 2

famciclovir oral 1

FAVIPIRAVIR 3

fosamprenavir calcium 1

foscarnet sodium intravenous solution 6000 mg250ml

E

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG250ML

E

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

E

GENVOYA 3

Drug Name Drug Tier Notes

HARVONI 2 PA SP QL

HEPSERA 3 SP

INTELENCE 2

INTRON A 3 PA SP

INVIRASE ORAL TABLET

2

ISENTRESS 2

ISENTRESS HD 2

JULUCA 2

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET

2

lamivudine oral solution 1

lamivudine oral tablet 100 mg

1 SP

lamivudine oral tablet 150 mg 300 mg

1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

E SP

LEXIVA ORAL SUSPENSION

2

LEXIVA ORAL TABLET 3

lopinavir-ritonavir 1

MAVYRET 2 PA SP QL

nevirapine 1

nevirapine er 1

NORVIR ORAL PACKET

2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET

3

ODEFSEY 3

oseltamivir phosphate oral

1 QL

PEGASYS SUBCUTANEOUS SOLUTION

2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

45

Drug Name Drug Tier Notes

PEGINTRON SUBCUTANEOUS KIT 50 MCG05ML

3 PA SP

PIFELTRO 3

PREVYMIS 3 SP

PREZCOBIX 2

PREZISTA ORAL SUSPENSION

2

PREZISTA ORAL TABLET 150 MG 600 MG 75 MG 800 MG

2

RAPIVAB E

RELENZA DISKHALER 3 QL

RETROVIR INTRAVENOUS

E

RETROVIR ORAL CAPSULE

3

RETROVIR ORAL SYRUP

3

REYATAZ ORAL CAPSULE 150 MG 200 MG 300 MG

3

REYATAZ ORAL PACKET

2

ribavirin inhalation 1

ribavirin oral capsule 1 SP

ribavirin oral tablet 200 mg

1 SP

rimantadine hcl 1

ritonavir 1

RUKOBIA 3

SELZENTRY 2 PA

SITAVIG E

SOFOSBUVIR-VELPATASVIR

E SP

SOVALDI 3 PA SP QL

stavudine oral capsule 1

STRIBILD 3

SUSTIVA 3

SYMFI 2

Drug Name Drug Tier Notes

SYMFI LO 2

SYMTUZA 3

TAMIFLU ORAL CAPSULE

E

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MGML

E

TEMIXYS E

tenofovir disoproxil fumarate

1

TIVICAY 2

TIVICAY PD 2

TRIUMEQ 2

TRIZIVIR 3

TROGARZO 3 PA

TRUVADA E

TYBOST 2

valacyclovir hcl oral 1 QL

VALCYTE 3

valganciclovir hcl 1

VALTREX 3 QL

VEMLIDY 3 SP

VIEKIRA PAK 3 PA SP QL

VIRACEPT ORAL TABLET

2

VIRAMUNE ORAL SUSPENSION

3

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG

3

VIRAZOLE 3

VIREAD ORAL POWDER

2

VIREAD ORAL TABLET 150 MG 200 MG 250 MG

2

VIREAD ORAL TABLET 300 MG

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

46

Drug Name Drug Tier Notes

VOCABRIA E

VOSEVI 2 PA SP QL

XERESE E

XOFLUZA (40 MG DOSE)

3 QL

XOFLUZA (80 MG DOSE)

3 QL

ZEPATIER 3 PA SP QL

ZIAGEN 3

zidovudine 1

ZOVIRAX EXTERNAL CREAM

3

ZOVIRAX EXTERNAL OINTMENT

E

ZOVIRAX ORAL SUSPENSION

E

Anxiolytics - Drugs for Anxiety

alprazolam er 1 QL

alprazolam intensol 1 QL

alprazolam oral 1 QL

alprazolam xr 1 QL

ATIVAN E

buspirone hcl oral 1

chlordiazepoxide hcl 1 QL

clonazepam oral 1 QL

clorazepate dipotassium

1 QL

diazepam intensol 1

diazepam oral concentrate

1

diazepam oral solution 5 mg5ml

1

diazepam oral tablet 1

DORAL 3 QL

estazolam 1 QL

HALCION 3 QL

hydroxyzine hcl oral syrup

1

Drug Name Drug Tier Notes

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral

1

KLONOPIN 3 QL

lorazepam injection E

lorazepam intensol 1 QL

lorazepam oral concentrate 2 mgml

1 QL

lorazepam oral tablet 1 QL

meprobamate 1

midazolam hcl oral 1

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-08 MG100ML- 50-08 MG50ML- 50-09 MG50ML-

E

MIDAZOLAM HCL-SODIUM CHLORIDE SOLUTION 100-09 MG100ML- INTRAVENOUS

E

MIDAZOLAM+SYRSPEND SF

E

oxazepam 1 QL

quazepam 1 QL

TRANXENE-T ORAL TABLET 75 MG

3 QL

triazolam 1 QL

VALIUM E

VISTARIL 3

XANAX E

XANAX XR E

Bipolar Agents - Drugs for Mood Disorders

EQUETRO 3

lithium 1

lithium carbonate er 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

47

Drug Name Drug Tier Notes

lithium carbonate oral 1

LITHOBID 3

Blood Products and Modifiers - Drugs for Blood Disorders

ADVATE 2 SP

ADYNOVATE 3 SP

AFSTYLA 3 SP

AGRYLIN 3

ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 500 UNIT

2 SP

ALPHANINE SD 2 SP

ALPROLIX 3 SP

AMICAR ORAL SOLUTION

3

AMICAR ORAL TABLET

3

aminocaproic acid oral solution

1

aminocaproic acid oral tablet

1

anagrelide hcl 1

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML

2 PA SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

2 PA SP

ASTRINGYN SOLUTION 259 MGGM EXTERNAL

3

Drug Name Drug Tier Notes

ASTRINGYN SOLUTION 259 MGGM EXTERNAL

E

BENEFIX INTRAVENOUS KIT

2 SP

CEPROTIN 3 SP

COAGADEX 3 SP

CORIFACT 2 SP

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG10ML

E

DOPTELET ORAL TABLET 20 MG

3 PA SP

ELOCTATE 3 SP

EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML

E SP

ESPEROCT E SP

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 2500 UNIT 500 UNIT

2 SP

FIBRYGA 2 SP

FULPHILA E SP

GRANIX E SP

HEMLIBRA 3 SP

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 1700 UNIT 250 UNIT 500 UNIT

3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

48

Drug Name Drug Tier Notes

HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT

2 SP

IDELVION 3 SP

IXINITY 3 SP

JIVI 3 SP

KOATE 2 SP

KOATE-DVI 2 SP

KOGENATE FS 3 SP

KOVALTRY 3 SP

LEUKINE INJECTION SOLUTION RECONSTITUTED

3 PA SP

LYSTEDA 3

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE

3 PA SP

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

2 SP

monsels ferric subsulfate external

E

MOZOBIL 2 PA SP QL

MULPLETA 2 PA SP

NEULASTA ONPRO 3 PA SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16ML

E SP

Drug Name Drug Tier Notes

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE

E SP

NIVESTYM 2 PA SP

NOVOEIGHT 2 SP

NOVOSEVEN RT 2 SP

NPLATE 3 PA SP

NUWIQ 2 SP

NYVEPRIA 3 PA SP

OBIZUR 3 SP

PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

3 SP

PROCRIT E SP

PROFILNINE 2 SP

PROMACTA 3 PA SP

REBINYN 3 SP

REBLOZYL 3 PA SP

RECOMBINATE 2 SP

RECOTHROM 3

RECOTHROM SPRAY KIT

3

RETACRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML

2 PA SP

RIASTAP 2 SP

RIXUBIS 3 SP

SEVENFACT E SP

SOLIRIS INTRAVENOUS SOLUTION 300 MG30ML

3 PA SP

TAVALISSE 3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

49

Drug Name Drug Tier Notes

THROMBIN-JMI EPISTAXIS

3

THROMBIN-JMI EXTERNAL KIT

3

THROMBOGEN 3

tranexamic acid intravenous solution 1000 mg10ml

E

tranexamic acid oral 1

TRANEXAMIC ACID-NACL

E

TRETTEN 3 SP

UDENYCA E SP

ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG11ML 300 MG3ML

3 PA SP

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG30ML

2 PA SP

VONVENDI 3 SP

WILATE INTRAVENOUS KIT

2 SP

XYNTHA INTRAVENOUS KIT 1000 UNIT 2000 UNIT 250 UNIT 500 UNIT

2 SP

XYNTHA SOLOFUSE 2 SP

ZARXIO 2 PA SP

ZIEXTENZO 3 PA SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL 3

ACCURETIC 3

acebutolol hcl oral 1

AKOVAZ SOLUTION 50 MGML INTRAVENOUS

E

Drug Name Drug Tier Notes

ALDACTAZIDE 3

ALDACTONE 3

aliskiren fumarate 1 ST

ALTACE ORAL CAPSULE

E

ALTOPREV E

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral 1

AMLODIPINE BES+SYRSPEND SF

E

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-atorvastatin 1

amlodipine-olmesartan 1

amlodipine-valsartan-hctz

1

ANTARA ORAL CAPSULE 30 MG 90 MG

E

ATACAND E

ATACAND HCT 3

atenolol oral 1

ATENOLOL+SYRSPEND SF

E

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

AVALIDE ORAL TABLET 150-125 MG 300-125 MG

3

AVAPRO 3

AZOR E

benazepril hcl oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

50

Drug Name Drug Tier Notes

benazepril-hydrochlorothiazide

1

BENICAR E

BENICAR HCT E

BETAPACE AF 3

BETAPACE ORAL TABLET 120 MG 160 MG 80 MG

3

betaxolol hcl oral 1

BIDIL 3

bisoprolol fumarate oral 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

BUMEX ORAL TABLET 05 MG

3

BYSTOLIC 2

CADUET ORAL TABLET 10-10 MG 10-20 MG 10-40 MG 10-80 MG 5-10 MG 5-20 MG 5-40 MG 5-80 MG

3

CALAN SR 3

candesartan cilexetil 1

candesartan cilexetil-hctz

1

captopril oral 1

captopril-hydrochlorothiazide

1

CARDIZEM CD 3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG 240 MG 300 MG 360 MG 420 MG

E

CARDIZEM ORAL TABLET 120 MG 30 MG 60 MG

3

Drug Name Drug Tier Notes

CARDURA 3

CAROSPIR 3

cartia xt 1

carvedilol 1

carvedilol phosphate er 1

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

chlorthalidone oral tablet 25 mg 50 mg

1

cholestyramine light 1

cholestyramine oral 1

clonidine 1

clonidine hcl oral 1

colesevelam hcl 1

COLESTID E

COLESTID FLAVORED

E

colestipol hcl 1

CONJUPRI E

CONSENSI E

COREG 3

COREG CR 3

CORGARD 3

CORLANOR 3 PA QL

COZAAR 3

CRESTOR E

DEMSER 3

DIBENZYLINE 3

digitek 1

digox 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er beads 1

diltiazem hcl er coated beads

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

51

Drug Name Drug Tier Notes

diltiazem hcl er oral capsule extended release 12 hour

1

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

1

diltiazem hcl oral 1

DILTIAZEM HCL-DEXTROSE SOLUTION 125-5 MG125ML- INTRAVENOUS

E

dilt-xr 1

DIOVAN E

DIOVAN HCT E

disopyramide phosphate oral

1

DIURIL 3

dofetilide 1

doxazosin mesylate oral

1

droxidopa 1 PA SP

DUTOPROL E

DYRENIUM 3

EDARBI 3 ST

EDARBYCLOR 3 ST

EDECRIN 3

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 QL

EPANED ORAL SOLUTION

E

ephedrine sulfate intravenous solution

E

EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-09 MG10ML- INTRAVENOUS

E

Drug Name Drug Tier Notes

EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-09 MG5ML- INTRAVENOUS

E

eplerenone 1

ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE

E

ethacrynic acid oral 1

EVKEEZA E SP

EXFORGE 3

EXFORGE HCT 3

EZALLOR SPRINKLE 3 ST

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized oral capsule 130 mg 43 mg

1

fenofibrate micronized oral capsule 134 mg 200 mg 67 mg

1 ST

fenofibrate oral capsule 134 mg 200 mg 67 mg

1 ST

fenofibrate oral capsule 150 mg 50 mg

1

fenofibrate oral tablet 120 mg 40 mg

E

fenofibrate oral tablet 145 mg 48 mg

1

fenofibrate oral tablet 160 mg 54 mg

1 ST

fenofibric acid oral capsule delayed release

1

fenofibric acid oral tablet

1 ST

FENOGLIDE 3 ST

FIBRICOR E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

52

Drug Name Drug Tier Notes

flecainide acetate 1

FLOLIPID 3 ST

fluvastatin sodium 1

fluvastatin sodium er 1

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide oral solution 10 mgml 8 mgml

1

furosemide oral tablet 1

gemfibrozil oral 1

GONITRO 3

guanfacine hcl oral 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral

1

HYZAAR 3

icosapent ethyl 1 PA

indapamide oral 1

INDERAL LA E

INDERAL XL E

INNOPRAN XL E

INSPRA 3

irbesartan 1

irbesartan-hydrochlorothiazide

1

ISORDIL TITRADOSE 3

isosorbide dinitrate oral 1

isosorbide mononitrate 1

isosorbide mononitrate er

1

ISOXSUPRINE HCL ORAL TABLET 10 MG

E

isoxsuprine hcl oral tablet 20 mg

E

isradipine 1

Drug Name Drug Tier Notes

JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 5 MG

3 PA SP QL

KAPSPARGO SPRINKLE

E

KATERZIA E

labetalol hcl oral 1

LANOXIN ORAL TABLET 125 MCG 250 MCG 625 MCG

2

LASIX 3

LESCOL XL E

LIPITOR E

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO E

LOPID 3

LOPRESSOR ORAL 3

losartan potassium oral 1

losartan potassium-hctz 1

LOTENSIN HCT ORAL TABLET 10-125 MG 20-125 MG 20-25 MG

3

LOTENSIN ORAL TABLET 10 MG 20 MG 40 MG

3

LOTREL ORAL CAPSULE 10-20 MG 10-40 MG 5-10 MG 5-20 MG

3

lovastatin oral 1

LOVAZA E

matzim la 1

MAXZIDE 3

MAXZIDE-25 3

methyldopa oral 1

methyldopa-hydrochlorothiazide

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

53

Drug Name Drug Tier Notes

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

metyrosine 1

mexiletine hcl oral 1

MICARDIS 3

MICARDIS HCT 3

midodrine hcl 1

milrinone lactate in dextrose

E

milrinone lactate intravenous solution 10 mg10ml 20 mg20ml 50 mg50ml

E

MINIPRESS 3

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 3

nadolol oral tablet 20 mg 40 mg 80 mg

1

NEXLETOL 2 PA QL

NEXLIZET 2 PA QL

niacin (antihyperlipidemic)

1

niacin er (antihyperlipidemic)

1

niacor 1

NIASPAN 3

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 1

NITRO-BID 3

Drug Name Drug Tier Notes

NITRO-DUR 3

nitroglycerin sublingual 1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual solution

1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT E

NITRO-TIME E

NORPACE 3

NORPACE CR 2

NORTHERA 3 PA SP

NORVASC E

NYMALIZE ORAL SOLUTION 6 MGML

3

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

1

OMEGA-3 RX COMPLETE

3

omega-3-acid ethyl esters

1 PA

PACERONE ORAL TABLET 100 MG 200 MG 400 MG

3

papaverine hcl injection E

pentoxifylline er 1

perindopril erbumine 1

phenoxybenzamine hcl oral

1

phentolamine mesylate injection solution reconstituted

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

54

Drug Name Drug Tier Notes

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-09 MG10ML- 100-09 MCG10ML- 20-09 MG50ML-

E

pindolol 1

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA QL

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA 3 ST

prevalite 1

PRINIVIL ORAL TABLET 20 MG

3

procainamide hcl injection

E

PROCARDIA 3

PROCARDIA XL 3

propafenone hcl 1

propafenone hcl er 1

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

QBRELIS E

QUESTRAN E

QUESTRAN LIGHT ORAL POWDER

E

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate oral 1

ramipril 1

RANEXA 3 ST

ranolazine er 1 ST

Drug Name Drug Tier Notes

RECTIV 3

REPATHA 2 PA QL

REPATHA PUSHTRONEX SYSTEM

2 PA QL

REPATHA SURECLICK

2 PA QL

rosuvastatin calcium 1

ROSZET TABLET 10-10 MG ORAL

3

ROSZET TABLET 10-20 MG ORAL

3

ROSZET TABLET 10-40 MG ORAL

3

ROSZET TABLET 10-5 MG ORAL

3

RYTHMOL SR 3

simvastatin oral tablet 1

sotalol hcl (af) 1

sotalol hcl oral 1

SOTYLIZE 3

spironolactone oral 1

spironolactone-hctz 1

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG 34 MG 85 MG

3

SURE RESULT O3D3 SYSTEM

E

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG 2-240 MG 4-240 MG

3

taztia xt 1

TEKTURNA 2 ST

TEKTURNA HCT 2 ST

telmisartan 1

telmisartan-amlodipine 1

telmisartan-hctz 1

TENORETIC 100 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

55

Drug Name Drug Tier Notes

TENORETIC 50 3

TENORMIN E

tiadylt er 1

TIAZAC 3

TIKOSYN E

timolol maleate oral 1

TOPROL XL E

torsemide oral 1

trandolapril 1

trandolapril-verapamil hcl er

1

triamterene oral 1

triamterene-hctz oral capsule 375-25 mg

1

triamterene-hctz oral tablet

1

TRIBENZOR E

TRICOR 3

TRILIPIX 3

TWYNSTA 3

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 2 PA

VASERETIC 3

VASOTEC 3

VECAMYL 3

verapamil hcl er oral capsule extended release 24 hour

1

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

1

verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VERQUVO E

VYNDAMAX 3 PA SP QL

Drug Name Drug Tier Notes

VYNDAQEL 3 PA SP QL

VYTORIN E

WELCHOL 3

ZESTORETIC 3

ZESTRIL ORAL TABLET 10 MG 20 MG 5 MG

3

ZESTRIL ORAL TABLET 25 MG 30 MG 40 MG

E

ZETIA E

ZIAC 3

ZOCOR ORAL TABLET 10 MG 20 MG 40 MG 80 MG

3

ZYPITAMAG ORAL TABLET 2 MG 4 MG

E

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL 3 PA QL

ADDERALL XR E

ADHANSIA XR E

ADZENYS ER 3 PA ST QL

ADZENYS XR-ODT 3 PA ST QL

AMPHETAMINE ER 3 PA ST QL

amphetamine sulfate 1 PA ST QL

amphetamine-dextroamphetamine

1 PA QL

amphetamine-dextroamphetamine er

1 PA QL

APTENSIO XR 3 PA ST QL

atomoxetine hcl 1 QL

clonidine hcl er 1 ST

CONCERTA E

COTEMPLA XR-ODT 3 PA ST QL

DAYTRANA 3 PA ST QL

DESOXYN 3 PA ST QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

56

Drug Name Drug Tier Notes

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA QL

dexmethylphenidate hcl 1 PA QL

dexmethylphenidate hcl er

1 PA ST QL

dextroamphetamine sulfate er

1 PA QL

dextroamphetamine sulfate oral

1 PA ST QL

DYANAVEL XR 3 PA ST QL

EVEKEO 3 PA ST QL

EVEKEO ODT 3 PA QL

FOCALIN 3 PA QL

FOCALIN XR 3 PA ST QL

guanfacine hcl er 1

INTUNIV 3

JORNAY PM 3 PA ST QL

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR

3 ST

methamphetamine hcl 1 PA ST QL

METHYLIN ORAL SOLUTION

3 PA ST QL

methylphenidate hcl er (cd)

1 PA ST QL

methylphenidate hcl er (la)

1 PA ST QL

methylphenidate hcl er (xr)

1 PA ST QL

methylphenidate hcl er oral tablet extended release

1 PA ST QL

methylphenidate hcl er oral tablet extended release 24 hour

1 PA QL

methylphenidate hcl oral solution

1 PA ST QL

methylphenidate hcl oral tablet

1 PA QL

Drug Name Drug Tier Notes

methylphenidate hcl oral tablet chewable

1 PA ST QL

MYDAYIS 3 PA ST QL

PROCENTRA 3 PA ST QL

QUILLICHEW ER 3 PA ST QL

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER

3 PA ST QL

relexxii 1 PA ST QL

RITALIN 3 PA QL

RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG 20 MG 30 MG 40 MG

3 PA ST QL

STRATTERA 3 QL

VYVANSE 2 PA QL

ZENZEDI 3 PA ST QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA SP QL

AUBAGIO 3 PA SP QL

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT

2 PA SP QL

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

2 PA SP QL

BAFIERTAM 2 PA SP QL

BETASERON SUBCUTANEOUS KIT

2 PA SP QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

dalfampridine er 1 PA SP QL

dimethyl fumarate oral 1 PA SP QL

dimethyl fumarate starter pack

1 PA SP QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

57

Drug Name Drug Tier Notes

EXTAVIA SUBCUTANEOUS KIT

E SP

GILENYA 3 PA SP QL

glatiramer acetate 1 PA SP QL

glatopa 1 PA SP QL

KESIMPTA 2 PA SP QL

LEMTRADA 3 PA SP

MAVENCLAD 3 PA SP

MAYZENT 3 PA SP QL

OCREVUS 3 PA SP QL

PLEGRIDY E SP

PLEGRIDY STARTER PACK

E SP

PONVORY E SP

PONVORY STARTER PACK

E SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

E SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

E SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E SP

TECFIDERA E SP

TYSABRI 3 PA SP QL

VUMERITY 2 PA SP QL

ZEPOSIA 3 PA SP QL

ZEPOSIA 7-DAY STARTER PACK

3 PA SP QL

ZEPOSIA STARTER KIT

3 PA SP QL

Drug Name Drug Tier Notes

Central Nervous System Agents - Miscellaneous

ADDYI 3 PA QL

ADIPEX-P E

AUSTEDO 3 PA SP QL

benzphetamine hcl E

caffeine citrate oral 1

CONTRAVE E

CONVENIENCE PAK E

diethylpropion hcl er E

diethylpropion hcl oral E

GRALISE 3 ST QL

HORIZANT ORAL TABLET EXTENDED RELEASE

3 PA QL

IMCIVREE 3 PA SP QL

INGREZZA 3 PA SP QL

LIPRITIN II COMBINATION THERAPY PACK 100 MG

E

LOMAIRA E

LYRICA CR 3 ST QL

LYRICA ORAL CAPSULE

2 QL

LYRICA ORAL SOLUTION

3 QL

NEURAPTINE E

NUEDEXTA 3 PA

ONPATTRO 3 PA SP

phendimetrazine tartrate

E

phendimetrazine tartrate er

E

phentermine hcl oral E

pregabalin oral 1 QL

QSYMIA E

RADICAVA 3 PA SP

RILUTEK 3 PA QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

58

Drug Name Drug Tier Notes

riluzole 1 PA QL

SAVELLA 3 ST QL

SAVELLA TITRATION PACK

3 ST QL

SAXENDA E

SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 140 MG7ML

E

TEGSEDI 3 PA SP

tetrabenazine 1 PA SP

TIGLUTIK 3 PA SP QL

VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE

E

VYLEESI 3 PA QL

XENAZINE 3 PA SP

XENICAL E

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN E

cavarest E

cevimeline hcl 1

chlorhexidine gluconate mouththroat

E

CLINPRO 5000 E

DEBACTEROL SOLUTION 30-50 MOUTHTHROAT

E

DENTA 5000 PLUS E

DENTAGEL E

DERMACINRX CLORHEXACIN

E

easygel dental E

EVOXAC 3

Drug Name Drug Tier Notes

FIRST-MOUTHWASH BLM

E

FLUORIDEX E

fluoridex daily renewal E

FLUORIDEX ENHANCED WHITENING DENTAL PASTE

E

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE

E

HURRICAINE MOUTHTHROAT GEL

E

instant oral pain relief max

E

KEPIVANCE 2 SP

lidocaine hcl mouththroat

1

lidocaine viscous hcl 1

MOUTH KOTE REMINT

E

MUCOSITISRX E

NAFRINSE DAILY ACIDULATED

E

NAFRINSE DAILYNEUTRAL

E

NAFRINSE WEEKLY E

NUSURGEPAK SURGICAL PREPCARE

E

oralone 1

PERIDEX E

periogard E

pilocarpine hcl oral 1

PREVIDENT E

PREVIDENT 5000 BOOSTER PLUS

E

PREVIDENT 5000 DRY MOUTH DENTAL GEL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

59

Drug Name Drug Tier Notes

PREVIDENT 5000 ENAMEL PROTECT

E

PREVIDENT 5000 ORTHO DEFENSE

E

PREVIDENT 5000 PLUS

E

PREVIDENT 5000 SENSITIVE

E

SALAGEN 3

SALIVAMAX E

sf E

sf 5000 plus E

sodium fluoride 5000 enamel

E

sodium fluoride 5000 plus

E

sodium fluoride 5000 ppm

E

sodium fluoride 5000 sensitive

E

sodium fluoride dental cream

E

sodium fluoride dental gel 11

E

triamcinolone acetonide mouththroat

1

XEROSTOMIA RELIEF SPRAY

E

Dermatological Agents - Drugs for Skin Conditions

AAGC KIT IN TERODERM

E

ABREVA E

ABSORICA E

ABSORICA LD 3 PA

ACANYA E

accutane oral capsule 20 mg 30 mg 40 mg

1 PA

ACESO AG E

ACIOXIAY E

Drug Name Drug Tier Notes

acitretin 1

ACZONE EXTERNAL GEL 5

E

ACZONE EXTERNAL GEL 75

2

ADAINZDE E

ADAINZOXIA E

adapalene external cream

1 PA

adapalene external gel 1 PA

ADAPALENE EXTERNAL PAD

E

ADAPALENE EXTERNAL SOLUTION

3 PA

ADAPALENE-BENZOYL PER-CLINDAMY

E

ADAPALENE-BENZOYL PER-NIACINAM

E

adapalene-benzoyl peroxide external gel

1

ADAPALENE-BENZOYL PEROXIDE EXTERNAL PAD

E

ADVANCED ALLERGY COLLECTION

E

AKLIEF E

ALA SCALP E

ala-cort external cream 1

alclometasone dipropionate

1

ALDARA E

ALEVAMAX E

ALTRENO 3 PA

amcinonide external cream

E

amcinonide external lotion

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

60

Drug Name Drug Tier Notes

amcinonide external ointment

1

AMELUZ E

ammonium lactate external

1

amnesteem 1 PA

AMZEEQ 3

ANACAINE E

APEXICON E E

AQUAPHILIC E

ARAZLO E

ARIDA E

ARZOL SILVER NIT APPLICATORS

E

ATOPADERM E

ATOPICLAIR E

ATRALIN 3 PA

AVAR CLEANSER E

AVAR LS CLEANSER E

AVAR-E EMOLLIENT E

AVAR-E GREEN E

AVAR-E LS E

AVEIDAOXIA E

AVITA E

AZADROX E

azelaic acid external 1 ST

AZELAIC ACID-NIACINAMIDE

E

AZELEX 3

balsam peru-castor oil 1

BEAU RX E

BENSAL HP EXTERNAL OINTMENT 3

E

BENZ PER-CLIND-NIACIN-TRETIN

E

BENZAC AC WASH EXTERNAL LIQUID

E

BENZACLIN E

Drug Name Drug Tier Notes

BENZACLIN WITH PUMP

E

BENZAMYCIN E

BENZEPRO CREAMY WASH

E

BENZEPRO EXTERNAL

E

BENZEPRO EXTERNAL FOAM 52 97

E

benzepro external foam 53

E

BENZEPRO EXTERNAL LIQUID

E

BENZEPRO FOAMING CLOTHS

E

BENZEPRO SHORT CONTACT

E

benzoin compound E

BENZOIN EXTERNAL TINCTURE

E

BENZOYL PEROX-HYDROCORTISONE

E

benzoyl peroxide external foam 98

E

BENZOYL PEROXIDE EXTERNAL GEL 65 8

E

BENZOYL PEROXIDE FORTE- HC

E

benzoyl peroxide-erythromycin

1 ST

BESER EXTERNAL KIT

E

beser external lotion 1

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

BETAMETHASONE DIPROP-MINOXIDIL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

61

Drug Name Drug Tier Notes

betamethasone valerate external

1

BIAFINE E

BIONECT EXTERNAL CREAM

E

blanche E

BOTOX COSMETIC 3 PA SP

bp 10-1 E

bp cleansing wash E

bp wash external liquid 25 7

E

BPCO 3

BRYHALI E

calamine external lotion 8-8

E

calcipotriene external cream

1 QL

CALCIPOTRIENE EXTERNAL FOAM

E

calcipotriene external ointment

1

calcipotriene external solution

1

calcipotriene-betameth diprop external ointment

E

calcipotriene-betameth diprop external suspension

1 QL

CALCIPOTRIENE-CLOBETASOL PROP

E

CALCITRENE 3

calcitriol external 1

CANTHARIDIN EXTERNAL

E

CAPEX E

capsaicin external cream 0025

E

capzix E

CARAC 3

CEM-UREA E

Drug Name Drug Tier Notes

CERACADE E

cerovel external lotion E

CHLOOXIA E

CICLOPIROX-CLOBETASOL

E

CICLOPIROX-CLOBETASOL-SAL ACID

E

CICLOPIROX-SALICYLIC ACID

E

CIMETIDINE-LIDO-SALICYLIC ACID

E

claravis 1 PA

CLENIA PLUS E

CLEOCIN-T EXTERNAL LOTION

3

CLINDACIN ETZ EXTERNAL KIT

E

clindacin etz external swab

1

CLINDACIN PAC E

clindacin-p 1

CLINDAGEL E

CLINDAMY-BENZOYL PER-NIACINAM

E

clindamycin phos-benzoyl perox external gel 1-5 12-25 12-5

1 ST

CLINDAMYCIN PHOS-NIACINAMIDE

E

clindamycin phosphate external foam

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 EXTERNAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

62

Drug Name Drug Tier Notes

clindamycin phosphate gel 1 external

1

CLINDAMYCIN-NIACIN-TRETINOIN

E

clindamycin-tretinoin 1 ST

CLIND-NIACIN-SPIRONOLAC-TRETIN

E

CLINOIN E

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate emulsion

1

clobetasol propionate external

1

CLOBETASOL PROP-LEVOCETIRIZINE

E

CLOBETASOL PROP-NIACINAMIDE

E

CLOBETAVIX E

CLOBEX 3

CLOBEX SPRAY 3

clocortolone pivalate 1

CLODAN EXTERNAL KIT

E

clodan external shampoo

1

CLODERM E

COAL TAR EXTERNAL SOLUTION

3

COLLATYL E

CONDYLOX EXTERNAL GEL

3

COPADERM E

COPASIL EXTERNAL E

CORDRAN EXTERNAL CREAM 0025

E

CORDRAN EXTERNAL CREAM 005

3

Drug Name Drug Tier Notes

CORDRAN EXTERNAL LOTION

3

CORDRAN EXTERNAL OINTMENT

3

CORDRAN EXTERNAL TAPE

E

corn amp callus remover E

CORTANE-B EXTERNAL

E

CUTIVATE EXTERNAL LOTION

3

dapsone external gel 5

1

dapsone gel 75 external

1

DAPSONE GEL 75 EXTERNAL

E

DAPSONE-NIACINAMIDE

E

DAPSONE-NIACINAMIDE-SPIRONOLAC

E

DELUO E

DEOXIA E

DERMACINRX PENETRAL

E

DERMACINRX SURGICAL COMBOPAK

E

DERMA-SMOOTHEFS BODY

3

DERMA-SMOOTHEFS SCALP

3

DERMELLE E

DERMULCERA 3

DERPIXA E

DESONATE E

desonide external 1

DESOWEN EXTERNAL CREAM

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

63

Drug Name Drug Tier Notes

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external liquid

E

desoximetasone external ointment 005

E

desoximetasone external ointment 025

1

DEXERYL E

DIADIMAXIA E

DIAOXIA E

diaper rash external ointment

E

DIASDIMAXIA E

DIASOXIA E

dibucaine (perianal) E

diclofenac sodium gel 3 external

1 ST QL

diclofenac sodium gel 3 external

1 PA QL

diclofenac sodium gel 3 external

E

DICLOFENAC-NA HYALURON-NIACIN

E

DIFFERIN EXTERNAL CREAM

E

DIFFERIN EXTERNAL GEL 03

E

DIFFERIN EXTERNAL LOTION

E

diflorasone diacetate external

E

DIMOXIA E

DIOCHLOY E

DIPROLENE AF 3

Drug Name Drug Tier Notes

DIPROLENE EXTERNAL OINTMENT

3

docosanol external E

DOVONEX EXTERNAL CREAM

3

doxepin hcl external 1 PA

doxycycline 1

DR SMITHS ADULT BARRIER EXTERNAL OINTMENT

E

DRAXACE E

DRAXACE LOTION CLEANSER

E

DRITHO-CREME HP E

DRIXECE E

DRYSOL 3

DUOBRII E

DUPIXENT 2 PA SP QL

ECEOXIA E

EFUDEX EXTERNAL CREAM

3

ELETONE E

ELIDEL 3 ST

EMULSION SB E

enovarx-tramadol E

ENSTILAR E

ENTTY SPRAY E

ENZOCLEAR E

EPICERAM E

EPIDUO 3

EPIDUO FORTE 3

EPIFOAM 3

ery 1

ERYGEL 3

erythromycin external gel

1

erythromycin external solution

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

64

Drug Name Drug Tier Notes

ESKATA E

ETHOXIA E

EUCRISA 2 ST

EVOCLIN 3

FABIOR E

FINACEA 3 ST

FINAPOD E

finasteride oral tablet 1 mg

E

FINASTERIDE-MINOXIDIL

E

FLUOCINOLONE ACET-NIACINAMIDE

E

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide cream 01 external

E

fluocinonide emulsified base

1

fluocinonide external cream 005

1

fluocinonide external gel

1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOPAR E

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 05

2

fluorouracil external cream 5

1

fluorouracil external solution

1

FLUOVIX E

Drug Name Drug Tier Notes

FLUOVIX PLUS E

flurandrenolide E

fluticasone propionate external

1

FORAXA E

GEAMETDRAY E

GENADUR E

GORDOFILM 3

GUANENDRUX E

halcinonide E

halobetasol propionate external cream

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

E

halobetasol propionate external ointment

1

HALOG E

HALUCORT E

HAXCHLO E

HPR PLUS EXTERNAL CREAM

E

hpr plus external foam E

HPR PLUS HYDROGEL

E

HYALURONATE-NIACINAM-TRETINOIN

E

HYALURONATE-NIACIN-TACROLIMUS

E

HYALURONIC ACID-HYDROQUINONE

E

HYDRO 40 E

hydrocortisone ace-pramoxine external cream 25-1

E

hydrocortisone acetate external cream

E

hydrocortisone acetate external ointment 1

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

65

Drug Name Drug Tier Notes

hydrocortisone butyr lipo base

E

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external lotion

E

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 05

E

hydrocortisone external cream 1 25

1

hydrocortisone external lotion 25

1

hydrocortisone external ointment 1 25

1

hydrocortisone valerate 1

hydroquinone external cream

E

HYDROQUINONE EXTERNAL EMULSION

E

HYDROQUINONE-HC-TRETINOIN

E

HYDROQUINONE-HYDROCORTISONE

E

HYLATOPIC PLUS EXTERNAL CREAM

E

HYLATOPIC PLUS EXTERNAL LOTION

E

imiquimod external E

IMIQUIMOD PUMP E

IMIQUIMOD-LEVOCETIRIZIN-NIACIN

E

IMIQUIMOD-LEVOCET-TRETINOIN

E

IMPEKLO E

IMPOYZ E

INOVA E

Drug Name Drug Tier Notes

INOVA 41 ACNE CONTROL THERAPY

E

INOVA 82 ACNE CONTROL THERAPY

E

isotretinoin oral 1 PA

ITHOXIA E

IVERMECTIN-METRONIDAZOL-NIACIN

E

KAMDOY E

KATARYA E

KATARYAXN E

KAXM E

KEIDO E

KELARX E

KENALOG EXTERNAL 3

KERAGEL E

KERALAC EXTERNAL CREAM 47

E

KERALYT EXTERNAL GEL 6

E

KERALYT EXTERNAL SHAMPOO

3

KERALYT SCALP E

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

3

KETARYA E

KEVARYA E

KEXM E

KEYA E

KIVIK E

KLARON 3

KLISYRI E

KUTARYAXM E

KUTARYAXMPA E

KUTEA E

KUVARYA E

KUVARYE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

66

Drug Name Drug Tier Notes

KUXM E

lactic acid e 1

lactic acid external lotion

1

LACTIC ACID-NIACINAMIDE

E

lavare wound wash E

LEVULAN KERASTICK 3

LEXETTE E

LIDOCAINE (ANORECTAL) RECTAL

E

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL CREAM 1-1

E

LIDOTREX (ALOE VERA)

E

LOCOID EXTERNAL LOTION

3

LOCOID LIPOCREAM E

LUXIQ 3

MEDERMA E

MEDERMA FOR KIDS E

MEDERMA SPF 30 E

MEDPURA ALCOHOL PADS

E

medpura hand sanitizer external gel 70

E

methoxsalen rapid 1

methyl salicylate external liquid

E

METROCREAM 3

METROGEL EXTERNAL GEL

E

METROLOTION 3

metronidazole external 1

MIMYX E

MINOXIDIL-PROGEST-TRETINOIN

E

Drug Name Drug Tier Notes

MIRVASO 3

moisturel external lotion 3

E

mometasone furoate external

1

myorisan 1 PA

NEOSALUS E

NEOSPORIN ORIGINAL EXTERNAL OINTMENT

E

NEO-SYNALAR EXTERNAL CREAM

3

NEO-SYNALAR EXTERNAL KIT

E

neuac external gel 1 ST

NEUAC EXTERNAL KIT

E

NIACINAMIDE-SPIRONOLACTONE

E

NIACINAMIDE-SULFACETAMIDE

E

NIACINAMIDE-TACROLIMUS

E

NIACINAMIDE-TAZAROTENE

E

NIACINAMIDE-TRETINOIN

E

NIACINAMIDE-TRIAMCINOLONE ACET

E

NIACIN-SPIRONOLACTON-TRETINOIN

E

nolix E

NORITATE E

NOVACORT EXTERNAL GEL 1-2

E

NUCARACLINPAK E

NUCARARXPAK E

NUCORT E

NUDERMRXPAK 120 E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

67

Drug Name Drug Tier Notes

NUDERMRXPAK 60 E

NUTRASEB E

NUTRIARX CREAMPAK

E

NUVAIL E

OLUX 3

OLUX-E 3

ONEXTON 3

ONZDEOXIA E

ORACEA 3

OVACE PLUS E

OVACE PLUS WASH E

OVACE WASH E

OXIANUJO E

OXIATAR E

OXIAVARRY E

OXIAZAR E

OXOPOD E

OXSORALEN ULTRA 3

PANDEL E

PENLEN E

PHLAG SPRAY E

pimecrolimus 1 ST

PLEXION E

PLEXION CLEANSER EXTERNAL LIQUID

E

PLEXION CLEANSING CLOTH EXTERNAL PAD

E

podocon E

podofilox external 1

PODPROG E

PR BENZOYL PEROXIDE

E

PR BENZOYL PEROXIDE WASH

E

PR CREAM E

pramosone external cream 1-1

1

Drug Name Drug Tier Notes

PRAMOSONE EXTERNAL CREAM 1-25

E

PRAMOSONE EXTERNAL LOTION

3

PRAMOSONE EXTERNAL OINTMENT

E

pramox E

PRE amp POST SX POUCH

E

prednicarbate 1

PRESERA E

PROGESTERONE-MINOXIDIL

E

PROMISEB CREAM EXTERNAL

3

PROMISEB EXTERNAL CREAM

E

PROPECIA E

PROSILK EXTERNAL E

PROTEXA E

PROTOPIC 3

PROTYL AG E

PRUCLAIR E

PRUDOXIN 3 PA

PRUMYX E

PSORCON E

PYROGALLIC ACID 3

QBREXZA 3 QL

QUIHOXVAR E

QUINIXIL E

QUTENZA E

QUTENZA (2 PATCH) E

QUTENZA (4 PATCH) E

RADIAGEL E

RADIAPLEXRX GEL EXTERNAL

3

RADIAPLEXRX GEL EXTERNAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

68

Drug Name Drug Tier Notes

RECEDO E

REFISSA E

REGENECARE 3

REGRANEX 3 PA

remergent hq E

REMIGEN E

RENOVA E

RENOVA PUMP E

RESORCINOL-SULFUR

E

RETIN-A 3 PA

RETIN-A MICRO GEL 004 01

E

RETIN-A MICRO PUMP EXTERNAL GEL 004 01

E

RETIN-A MICRO PUMP EXTERNAL GEL 006 008

2 PA

REXASIL PATCH amp VITAMIN E LIQ

E

RHOFADE 3

RIAX E

ROAOXIA E

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL KIT

E

SALEX EXTERNAL SHAMPOO

E

salicylic acid er E

salicylic acid external foam

E

salicylic acid external gel

E

salicylic acid external shampoo

E

salicylic acid external solution 26

E

Drug Name Drug Tier Notes

salicylic acid wart remover

E

salicylic acid-cleanser external kit 6 (cream)

E

SALICYLIC ACID-SULFACETAMIDE

E

salimez E

SALIMEZ FORTE E

SALVAX E

SALVAX DUO PLUS E

SANADERMRX SKIN REPAIR

E

SANTYL 3

SCALACORT DK E

SCARCARE GEL-PAD KITLARGE

E

SCARCIN E

SCARSILK EXTERNAL E

SCARZEN SKIN REPAIR

E

SCENESSE 3 PA SP

selenium sulfide external lotion

1

selenium sulfide external shampoo

E

SELRX E

SERNIVO 3

SILA III E

SILIPAC E

SILVERSEAL HYDROGEL DRESSING EXTERNAL PAD 2X3

E

skarjel E

sodium sulfacetamide external shampoo

E

sodium sulfacetamide wash

E

SODIUM SULFACETAMIDE-BAKUCHIOL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

69

Drug Name Drug Tier Notes

SOLARAVIX EXTERNAL

E

SOLOX E

SOOLANTRA 3

SORIATANE ORAL CAPSULE 10 MG 25 MG

3

SORILUX E

sss 10-5 E

STRATA CTX E

STRATA GRT E

STRATA MARK E

STRATA TRIZ E

STRATA XRT E

sulfacetamide sodium (acne)

1

sulfacetamide sodium external gel

E

sulfacetamide sodium external liquid

E

sulfacetamide sodium-sulfur emulsion 10-5 external

1

sulfacetamide sodium-sulfur emulsion 10-5 external

E

sulfacetamide sodium-sulfur external cream

E

sulfacetamide sodium-sulfur external liquid

E

sulfacetamide sodium-sulfur external lotion

E

sulfacetamide sodium-sulfur external pad 10-4

E

sulfacetamide sodium-sulfur external suspension

E

sulfacetamide sod-sulfur wash external kit

E

Drug Name Drug Tier Notes

sulfacetamide sod-sulfur wash external liquid

E

sulfacetamide-sulfur in urea external emulsion

E

SULFACLEANSE 84 E

sulfamez wash E

SUMADAN E

SUMADAN WASH E

SUMADAN XLT E

SUMAXIN E

SUMAXIN CP E

SUMAXIN WASH E

SUVICORT E

SYNALAR 3

SYNALAR (CREAM) E

SYNALAR (OINTMENT)

E

SYNALAR TS E

SYNERDERM E

TACLONEX EXTERNAL OINTMENT

E

TACLONEX EXTERNAL SUSPENSION

3 QL

TACROLIMUS EXTERNAL CREAM

E

tacrolimus external ointment

1

TARDEOXIA E

TARDIMAXIA E

TAROXIA E

TASOPROL E

tazarotene external cream

1 PA

TAZAROTENE EXTERNAL FOAM

E

TAZORAC EXTERNAL CREAM 005

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

70

Drug Name Drug Tier Notes

TAZORAC EXTERNAL CREAM 01

3 PA

TAZORAC EXTERNAL GEL

E

TEMOVATE EXTERNAL CREAM

3

TEMOVATE EXTERNAL OINTMENT

3

TETRIX EXTERNAL CREAM

E

TEXACORT 3

TOPICORT EXTERNAL CREAM

3

TOPICORT EXTERNAL GEL

3

TOPICORT EXTERNAL OINTMENT

3

TOPICORT SPRAY E

tovet external foam 1

TOVET EXTERNAL KIT

E

tretinoin (emollient) E

tretinoin external 1 PA

tretinoin microsphere 1 PA

tretinoin microsphere pump

1 PA

triamcinolone acetonide external aerosol solution

E

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment

1

TRIANEX E

TRI-CHLOR 3

triderm external cream 1

TRIDESILON 3

Drug Name Drug Tier Notes

TRILOCICLO E

TRI-LUMA E

triple antibiotic external ointment 35-400-5000 5-400-5000

E

triple antibiotic+pain relief

E

TRIVIX E

TURPENTINE EXTERNAL

E

ULTRASAL-ER E

ULTRAVATE EXTERNAL LOTION

E

UMECTA MOUSSE E

URAMAXIN EXTERNAL GEL

E

urea external cream 39 40 41 45 47

E

UREA EXTERNAL FOAM

E

urea external lotion 40

E

urea hydrating E

urea nail external gel 45

E

ureacin-10 E

ureacin-20 E

uredeb E

UREMEZ-40 E

URESOL E

UTOPIC E

VANICREAM EXTERNAL OINTMENT

E

VANIQA E

VANOS 3

VANOXIDE-HC E

VARDIMAXIA E

VAROXIA E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

71

Drug Name Drug Tier Notes

VECTICAL E

VELTIN E

VENELEX 3

VERDESO E

VEREGEN E

VEXASYN E

VIRASAL E

WINLEVI 3 PA

WYNZORA E

XALIX E

XERAC AC 3

XERALUX E

xurea E

ZACARE E

zaclir cleansing external lotion 8

E

zenatane 1 PA

ZIANA E

ZILXI 3 ST

ZITHRANOL E

ZONALON 3 PA

ZYCLARA E

ZYCLARA PUMP E

Diabetes - Antidiabetic Agents

acarbose oral 1

ACTOPLUS MET 3

ACTOS 3

ADLYXIN E

ADLYXIN STARTER PACK

E

ALOGLIPTIN BENZOATE

E

ALOGLIPTIN-METFORMIN HCL

E

ALOGLIPTIN-PIOGLITAZONE

E

AMARYL 3

Drug Name Drug Tier Notes

BYDUREON BCISE AUTOINJECTOR

2 ST QL

BYETTA 10 MCG PEN 2 ST QL

BYETTA 5 MCG PEN 2 ST QL

CYCLOSET 3 ST

DUETACT 3

FARXIGA 2 ST

FORTAMET E

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glipizide-metformin hcl 1 ST

GLUCOTROL ORAL TABLET 10 MG

3

GLUCOTROL XL 3

GLUMETZA E

glyburide micronized 1

glyburide oral 1

glyburide-metformin 1

GLYNASE 3

GLYXAMBI 2 ST

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2 ST

JENTADUETO 2 ST

JENTADUETO XR 2 ST

KAZANO E

KOMBIGLYZE XR E

metformin hcl er 1

metformin hcl er (mod) E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

72

Drug Name Drug Tier Notes

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg 500 mg

E

metformin hcl ir 1

miglitol 1

nateglinide 1

NESINA E

ONGLYZA E

OSENI E

OZEMPIC 2 ST QL

pioglitazone hcl 1

pioglitazone hcl-glimepiride

1

pioglitazone hcl-metformin hcl

1

PRECOSE 3

QTERN E

repaglinide 1

RIOMET 3 ST

RYBELSUS 2 ST QL

SEGLUROMET E

SOLIQUA 2 ST QL

STARLIX ORAL TABLET 120 MG

3

STEGLATRO E

STEGLUJAN E

SYMLINPEN 120 3 PA

SYMLINPEN 60 3 PA

SYNJARDY 2 ST

SYNJARDY XR 2 ST

tolbutamide 1 ST

TRADJENTA 2 ST

TRIJARDY XR 2 ST

TRULICITY 2 ST QL

VICTOZA 2 ST QL

XIGDUO XR 2 ST

XULTOPHY 3 ST QL

Drug Name Drug Tier Notes

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO SOLUTION

E

ACCU-CHEK AVIVA PLUS TEST STRIPS

E

ACCU-CHEK COMPACT PLUS CONTROL

E

ACCU-CHEK COMPACT PLUS TEST STRIPS

E

ACCU-CHEK FASTCLIX LANCET KIT

$0

ACCU-CHEK GUIDE TEST STRIPS

E

ACCU-CHEK GUIDE CONTROL

E

ACCU-CHEK SMARTVIEW CONTROL

E

ACCU-CHEK SMARTVIEW TEST STRIPS

E

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

$0

AUTOLET LANCING DEVICE

$0

BLUESTAR E

CARETOUCH CONTROL SOL LEVEL 2

E

CARETOUCH LANCINGEJECTOR

$0

CARETOUCH TEST E

CEQUR SIMPLICITY 2U

3

CONTOUR CONTROL SOLUTION

E

CONTOUR MONITOR DEVICE DEVICE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

73

Drug Name Drug Tier Notes

CONTOUR MONITOR KIT WDEVICE KIT

E

CONTOUR NEXT CONTROL SOLUTION

E

CONTOUR NEXT EZ KIT WDEVICE

E

CONTOUR NEXT LINK KIT WDEVICE

E

CONTOUR NEXT MONITOR KIT WDEVICE

E

CONTOUR NEXT ONE KIT

E

CONTOUR NEXT TEST STRIPS

E

CONTOUR TEST STRIPS

E

EASYMAX 15 LEVEL 2-3 CONTROL

E

EASYMAX CONTROL IN VITRO SOLUTION NORMAL

E

GLUCOSE CONTROL SOLUTIONS

E

ENLITE GLUCOSE SENSOR

E

FORTISCARE CONTROL

E

FORTISCARE GLUCOSE SYSTEM DEVICE

E

FORTISCARE T1 GLUCOSE SYSTEM

E

FREESTYLE LIBRE 14 DAY READER

E

FREESTYLE LIBRE 14 DAY SENSOR

E

FREESTYLE LIBRE 2 READER

E

FREESTYLE LIBRE 2 SENSOR

E

FREESTYLE LIBRE READER

E

Drug Name Drug Tier Notes

FREESTYLE LIBRE SENSOR SYSTEM

E

FREESTYLE PRECISION NEO TEST

E

GUARDIAN CONNECT TRANSMITTER

E

GUARDIAN LINK 3 TRANSMITTER

E

GUARDIAN SENSOR (3)

E

KETONE TEST 3

KETOSTIX 3

MICRODOT TEST E

MICROLET NEXT LANCING DEVICE

$0

NOVOPEN ECHO 3

ONETOUCH DELICA LANCING DEV

$0

ONETOUCH DELICA PLUS LANCING

$0

ONETOUCH ULTRA $0 QL

ONETOUCH ULTRA 2 KIT WDEVICE

2

ONETOUCH ULTRA MINI KIT WDEVICE

2

ONETOUCH VERIO KIT WDEVICE

2

ONETOUCH VERIO FLEX SYSTEM KIT WDEVICE

2

ONETOUCH VERIO IN VITRO SOLUTION HIGH

3

ONETOUCH VERIO TEST STRIPS

$0 QL

ONETOUCH VERIO IQ SYSTEM

2

ONETOUCH VERIO REFLECT

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

74

Drug Name Drug Tier Notes

ONETOUCH VERIO SYNC SYSTEM KIT WDEVICE

2

PRECISION LINK E

PRECISION PCX PLUS TEST

E

PRECISION QID MONITOR

E

PRECISION QID TEST E

PRECISION SOF-TACT MONITOR

E

PRECISION SOF-TACT TEST

E

PRECISION XTRA BLOOD GLUCOSE

E

PRECISION XTRA DEVICE

E

PRECISION XTRA KIT E

PRECISION XTRA MONITOR

E

RELION BLOOD GLUCOSE TEST

E

SURESTEP PRO HIGH GLUCOSE

3

SURESTEP PRO LOW GLUCOSE

3

SURESTEP PRO NORMAL GLUCOSE

3

TRUE METRIX BLOOD GLUCOSE TEST

E

TRUE METRIX LEVEL 1

E

TRUE METRIX LEVEL 2

E

TRUE METRIX LEVEL 3

E

TRUE METRIX PRO BLOOD GLUCOSE

E

TRUETRACK TEST E

UNISTRIP CONTROL IN VITRO SOLUTION LOW

E

Drug Name Drug Tier Notes

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

diazoxide oral 1

GLUCAGEN HYPOKIT 3 ST

glucagon emergency kit 1 mg injection 1 mg

1

GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG

3 Made by Lilly

GLUCAGON EMERGENCY KIT

2Made by Fresenius

GVOKE HYPOPEN 1-PACK

2

GVOKE HYPOPEN 2-PACK

2

GVOKE PFS 2

PROGLYCEM 3

Diabetes - Insulins

ADMELOG E

ADMELOG SOLOSTAR

E

AFREZZA INHALATION POWDER 12 UNIT 4 amp 8 amp 12 UNIT 4 UNIT 8 UNIT 90 X 4 UNIT amp 90X8 UNIT 90 X 8 UNIT amp 90X12 UNIT

3 PA

APIDRA SOLOSTAR E

APIDRA VIAL E

BASAGLAR KWIKPEN E

FIASP E

FIASP FLEXTOUCH E

FIASP PENFILL E

HUMALOG U-100 AND U-200 KWIKPEN

2

HUMALOG MIX 5050 KWIKPEN

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

75

Drug Name Drug Tier Notes

HUMALOG MIX 5050 VIAL

2

HUMALOG MIX 7525 KWIKPEN

2

HUMALOG MIX 7525 VIAL

2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMALOG VIAL 2

HUMULIN 7030 KWIKPEN

2

HUMULIN 7030 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN

2

HUMULIN R U-500 VIAL

2

HUMULIN R VIAL 2

INSULIN ASP PROT amp ASP FLEXPEN

E

INSULIN ASPART E

INSULIN ASPART FLEXPEN

E

INSULIN ASPART PENFILL

E

INSULIN ASPART PROT amp ASPART

E

INSULIN LISPRO (1 UNIT DIAL)

E

INSULIN LISPRO JUNIOR KWIKPEN

E

INSULIN LISPRO PROT amp LISPRO

E

INSULIN LISPRO SUBCUTANEOUS SOLUTION

E

Drug Name Drug Tier Notes

INSULIN PEN NEEDLES 29G X 127MM 29G X 12MM 29G X 5MM 29G X 8MM 31G X 5 MM 31G X 6 MM 31G X 8 MM 32G X 4 MM 33G X 4 MM 33G X 5 MM 33G X 6 MM

$0

INSULIN SYRINGES $0

LANTUS U-100 SOLOSTAR

2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

E

LEVEMIR U-100 VIAL E

LYUMJEV KWIKPEN 2

LYUMJEV VIAL 2

MAXICOMFORT SYR 27G X 12

$0

MYXREDLIN 3

NOVOFINE AUTOCOVER PEN NEEDLE

$0

NOVOFINE PEN NEEDLE 32G X 6 MM

$0

NOVOFINE PLUS PEN NEEDLE

$0

NOVOLIN 7030 FLEXPEN

E

NOVOLIN 7030 FLEXPEN RELION

E

NOVOLIN 7030 RELION

E

NOVOLIN 7030 VIAL E

NOVOLIN N FLEXPEN E

NOVOLIN N FLEXPEN RELION

E

NOVOLIN N RELION E

NOVOLIN N VIAL E

NOVOLIN R FLEXPEN E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

76

Drug Name Drug Tier Notes

NOVOLIN R FLEXPEN RELION

E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG U-100 FLEXPEN

E

NOVOLOG MIX 7030 FLEXPEN

E

NOVOLOG MIX 7030 VIAL

E

NOVOLOG U-100 PENFILL

E

NOVOLOG U-100 VIAL E

NOVOTWIST PEN NEEDLE 32G X 5 MM

$0

SEMGLEE E

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA E

TRESIBA FLEXTOUCH

E

Electrolytes Minerals Metals Vitamins

ABANEU-SL E

ACTITROM-D E

ACTIVE FE E

ACTIVITE E

adcf (05mgml) 1

ADRENAL C FORMULA

E

airavite E

aminoamrms E

aminoreliefrms E

ANIMI-3 E

ANIMI-3VITAMIN D E

AQUASOL A INTRAMUSCULAR SOLUTION 15 MGML 50000 UNITML

E

Drug Name Drug Tier Notes

ASCOR E

ASCORBIC ACID SOLUTION 500 MGML INJECTION

E

ascorbic acid solution 500 mgml injection

E

ATABEX OB 2

AZESCHEW PRENATALPOSTNATAL

E

AZESCO E

B-12 COMPLIANCE INJECTION

E

b-6 folic acid oral capsule 8333-100-1 mg

E

BACMIN E

b-complexb-12 oral E

biocel E

biopetit E

biotin oral tablet 1000 mcg

E

bp vit 3 E

b-plex E

b-plex plus E

calcidol oral solution 200 mcgml

E

CALCIFOL 3

calcium-folic acid plus d E

CARBAGLU 2 SP

CARDIOPLEGIA DEL NIDO FORMULA

E

CARDIOPLEGIA IND PLASMA HIGH K

E

CARDIOPLEGIA IND PLASMA-TROMET

E

CARDIOPLEGIA INDUCTION HIGH K

E

CARDIOPLEGIA INDUCTION LOW DEX

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

77

Drug Name Drug Tier Notes

CARDIOPLEGIA INDUCTION NON-ENR

E

CARDIOPLEGIA MAIN LOW DEXTROSE

E

CARDIOPLEGIA MAIN LOW TROMETHA

E

CARDIOPLEGIA MAIN PLASMA-TROME

E

CARDIOPLEGIA MAINTENANCE

E

CARDIOPLEGIA REPERFUSATE 41

E

CARNITOR INTRAVENOUS

E

CARNITOR ORAL 3

CARNITOR SF 3

CENFOL E

CENTRATEX E

CEREFOLIN E

cerefolin nac oral tablet 6-90314-2-600 mg

E

CHEMET 3

CHOLECAL DF E

CHROMAGEN ORAL CAPSULE

E

CIFEREX E

CITRANATAL BLOOM E

CITRANATAL MEDLEY

E

clovique 1 PA SP

COD LIVER OIL ORAL OIL

E

CORVITE 150 E

corvite fe E

cyanocobalamin injection solution 1000 mcgml

1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCGML

3

Drug Name Drug Tier Notes

cytra k crystals E

d3 high potency oral capsule 25 mcg (1000 ut)

E

d3 super strength E

daflonex-xl oral capsule E

DECARA E

deferasirox 1 PA

deferasirox granules 1 PA

deferiprone 1 PA

DEPLIN 15 E

DEPLIN 75 E

DERMACINRX PUREFOLIX

E

DEXIFOL E

DIALYVITE E

DIALYVITE 3000 E

DIALYVITE 5000 E

DIALYVITE SUPREME D

E

DIALYVITEZINC E

DRISDOL ORAL CAPSULE

3

d-vite pediatric E

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ 20 MEQ

3

effer-k tablet effervescent 25 meq oral

1

effer-k tablet effervescent 25 meq oral

E

ELFOLATE E

ELFOLATE PLUS ORAL TABLET 3-35-2 MG

E

ENBRACE HR E

ERGOCAL E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

78

Drug Name Drug Tier Notes

ergocalciferol oral capsule

1

ergocalciferol oral solution 200 mcgml

E

EXJADE 3 PA

fabb E

fa-vitamin b-6-vitamin b-12

E

FEONYX E

FERAHEME E

FERIVA 217 E

FERIVAFA E

ferocon E

ferotrinsic E

FERRALET 90 E

ferraplus 90 E

FERRIPROX 3 PA

FERRIPROX TWICE-A-DAY

3 PA

FERRLECIT E

ferrocite plus oral tablet E

FERRO-PLEX HEMATINIC

E

ferrous sulfate oral solution 75 (15 fe) mgml

E

ferrous sulfate oral syrup

E

ferrous sulfate oral tablet 325 (65 fe) mg

E

ferrous sulfate oral tablet delayed release 324 (65 fe) mg 325 (65 fe) mg

E

FLORIVA E

FLORIVA PLUS E

fluoritab oral solution $0

folbee E

folbee plus E

FOLBEE PLUS CZ E

Drug Name Drug Tier Notes

FOLBIC RF E

FOLGARD OS E

FOLGARD RX E

folic acid injection E

folic acid oral tablet 1 mg

1

FOLIC D3 E

FOLIC-K E

FOLI-D E

FOLITE E

FOLITIN-Z E

FOLIXAPURE E

folplex 22 E

foltanx E

FOLTANX RF E

FOLTRATE E

FOLTREXYL E

foltrin E

FOLTX ORAL TABLET 113-25-2 MG

E

FOLVITE-D E

FOSTEUM E

FUSION PLUS E

GALZIN 3

GENICIN VITA-D E

GENICIN VITA-Q E

GENICIN VITA-S E

hematinic plus vitminerals

E

hematinicfolic acid E

HEMATOGEN E

HEMATOGEN FA E

HEMATRON-AF E

HEMETAB E

HEMOCYTE PLUS E

hemocyte-f oral tablet E

HYLAVITE E

HYLAZINC E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

79

Drug Name Drug Tier Notes

ICAR-C PLUS E

iferex 150 forte E

INFED E

INFUVITE ADULT E

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

E

INTEGRA F E

INTEGRA PLUS E

IODINE STRONG ORAL

3

IROSPAN 246 E

ISOLYTE-S E

JADENU 3 PA

JADENU SPRINKLE 3 PA

JENLIVA PRENATALPOSTNATAL

E

JYNARQUE 3 SP QL

KCL-LIDOCAINE-NACL SOLUTION 10-10 MEQ-MG 100ML INTRAVENOUS

E

klor-con 10 1

klor-con m10 1

KLOR-CON M15 3

klor-con m20 1

klor-con oral packet 20 meq

1

klor-con oral tablet extended release

1

klor-conef 1

K-PHOS NO 2 E

K-PHOS TABLET 500 MG ORAL

3

K-PHOS TABLET 500 MG ORAL

E

K-PHOS-NEUTRAL E

k-prime 1

K-TAB 3

Drug Name Drug Tier Notes

k-tan plus E

L-CYSTINE E

levocarnitine oral solution

1

levocarnitine oral tablet 1

levocarnitine sf 1

L-ISOLEUCINE E

l-methylfolate E

l-methylfolate ca me-cbl nac

E

l-methylfolate calcium oral

E

l-methylfolate forte E

l-methylfolate-algae oral capsule 15-90314 mg

E

l-methylfolate-algae-b12-b6

E

l-methylfolate-b6-b12 oral tablet 3-35-2 mg

E

l-methyl-mc E

l-methyl-mc nac E

LOKELMA 3

LORID E

lysiplex plus oral tablet E

MVI ADULT E

MVI PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

E

MAGNEBIND 400 3

magnesium oxide oral tablet 400 (2413 mg) mg

E

magnesium sulfate intravenous solution 2 gm50ml 20 gm500ml 4 gm100ml 4 gm50ml 40 gm1000ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

80

Drug Name Drug Tier Notes

MAGNESIUM SULFATE SOLUTION 50 INJECTION

E

magnesium sulfate solution 50 injection

E

magnesium-oxide E

mag-oxide oral tablet 200 mg

E

MEPHYTON 3

metafolbic E

metafolbic plus E

METAFOLBIC PLUS RF

E

METANX ORAL CAPSULE

E

methylfol-algae-b12-acetylcyst

E

MICROPLEGIA MSA-MSG

E

MIFEPREX 3

mifepristone 1

M-NATAL PLUS 2

MONOFERRIC E

MULTIGEN E

MULTIGEN FOLIC E

MULTIGEN PLUS E

MULTIPRO E

multi-vitironfluoride 1

multivitaminfluoride oral solution

1

multi-vitaminfluoride oral solution

1

multivitaminfluoride oral tablet chewable 025 mg 05 mg 1 mg

1

MULTIVITAMINFLUORIDE ORAL TABLET CHEWABLE 025-03 MG 05-03 MG 1-03 MG

E

Drug Name Drug Tier Notes

multi-vitaminfluorideiron

1

myferon 150 forte E

mynephrocaps capsule 1 mg oral

E

MYNEPHRON E

na ferric gluc cplx in sucrose

E

n-acetyl-l-cysteine oral 1

nafrinse $0

nafrinse drops $0

NASCOBAL 3

NEONATAL + DHA E

NEONATAL 19 2

NEONATAL COMPLETE

E

NEONATAL FE E

NEONATAL PLUS 2

NEOVITE E

NEPHPLEX RX E

nephronex oral tablet E

NEPHRO-VITE RX E

NESTABS 2

NESTABS ONE E

NEURIN-SL E

NICADAN E

NICAZEL E

NICAZEL FORTE E

NICOMIDE ORAL TABLET 750-27-2-05 MG

E

NIFEREX ORAL TABLET

E

NOVAMV PEDIATRIC MULTI-VITAMIN

E

NUFERA E

nufol E

NUTRICAP E

nutrifac zx E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

81

Drug Name Drug Tier Notes

NUTRIVIT E

OCUVEL ORAL CAPSULE 05 MG

E

ONE VITE WOMENS $0

ONE VITE WOMENS PLUS

2

ONEVITE E

ORACIT 3

ORTHO DF E

OVEEZA E

oyster shell calciumd oral tablet 250-250 mg-unit 500-200 mg-unit 500-400 mg-unit

E

oyster shell calciumvitamin d oral tablet 500-200 mg-unit

E

pediatric electrolyte oral solution

E

pediavit E

PHOSPHA 250 NEUTRAL

3

phosphorous 1

phosphorus supplement

E

phosphorus wsod amp potassium

E

phospho-trin 250 neutral

1

PHOXILLUM B22K40 E

PHOXILLUM BK425 E

PHYSICIANS EZ USE B-12

E

PHYSIOLYTE E

PHYSIOSOL IRRIGATION

E

phytonadione injection solution 1 mg05ml 10 mgml

E

phytonadione oral 1

PLASMA-LYTE 148 E

Drug Name Drug Tier Notes

PLASMA-LYTE A E

PNV TABS 20-1 E

PODIAPN ORAL CAPSULE

E

poly-iron 150 forte E

polysaccharide iron forte

E

POLY-VI-FLOR ORAL SUSPENSION

3

POLY-VI-FLOR ORAL TABLET CHEWABLE

E

POLY-VI-FLORIRON ORAL SUSPENSION

2

POLY-VI-FLORIRON ORAL TABLET CHEWABLE

E

POLY-VITE PEDIATRIC ORAL SOLUTION

E

POTABA ORAL CAPSULE

E

potassium chloride crys er

1

potassium chloride er 1

potassium chloride in nacl intravenous solution 20-045 meql- 20-09 meql- 40-09 meql-

E

potassium chloride oral packet

1

potassium chloride oral solution 20 meq15ml (10) 40 meq15ml (20)

1

potassium citrate er 1

potassium citrate-citric acid oral solution

E

PREGEN DHA E

PREGENNA E

PREMESISRX E

PRENAISSANCE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

82

Drug Name Drug Tier Notes

PRENARA E

prenatal oral tablet 27-08 mg

$0

prenatal plus iron 1

prenatal tablet 27-1 mg oral

1

prenatal tablet 27-1 mg oral

E

prenatal vitamin plus low iron

1

PRENATE E

PRENATE DHA ORAL CAPSULE 18-06-04-300 MG

E

PRENATE ELITE ORAL TABLET 20-06-04 MG

E

PRENATE ENHANCE E

PRENATE ESSENTIAL ORAL CAPSULE 18-06-04-300 MG

E

PRENATE MINI ORAL CAPSULE 18-06-04-350 MG

E

PRENATE PIXIE E

PRENATE RESTORE E

PRENATRIX E

PRENATRYL E

PRENATVITE COMPLETE

E

PRENATVITE PLUS 2

PRENATVITE RX 2

preplus 1

PRETAB 2

PRIMACARE ORAL CAPSULE

E

PRO HERS RX E

PRO HIS RX E

PRO PCOS RX E

PROTEINEX P18 E

Drug Name Drug Tier Notes

purevit dualfe plus E

pyridoxine hcl injection E

QUFLORA FE E

QUFLORA FE PEDIATRIC

E

QUFLORA GUMMIES E

QUFLORA PEDIATRIC E

RELNATE DHA 2

REMEDIENT E

RENAL MULTIVITAMIN FORMULA

E

RENAL ORAL CAPSULE

E

RENATABS E

RENATABS WITH IRON

E

rena-vite E

reno caps capsule 1 mg oral (rx)

E

REQ 49+ E

REVESTA E

ringers irrigation E

SAMSCA 3 SP QL

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

E

se-tan plus E

SIDEROL ORAL TABLET

E

SLOWMAG MG MUSCLEHEART

E

sod citrate-citric acid 1

sodium bicarbonate intravenous solution 75

E

sodium bicarbonate solution 42 intravenous

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

83

Drug Name Drug Tier Notes

sodium bicarbonate solution 84 intravenous

E

SODIUM BICARBONATE SOLUTION 84 INTRAVENOUS

E

sodium chloride (pf) solution 09 injection

E

sodium chloride injection solution 25 meqml

E

sodium chloride intravenous solution 045 09 3 5

E

sodium chloride solution 4 meqml intravenous

E

sodium fluoride oral $0

sodium polystyrene sulfonate oral powder

1

soluvita e E

sps 1

STROVITE FORTE E

STROVITE ONE E

SUPERVITE E

support E

SUPPORT-500 E

SYPRINE 3 PA SP

SYSTANE ICAPS AREDS2 ORAL TABLET CHEWABLE

E

TALIVA E

thiamine hcl injection E

tis-u-sol E

tl-hem 150 E

TOLVAPTAN ORAL TABLET 15 MG

3 SP QL

tolvaptan oral tablet 30 mg

1 SP QL

Drug Name Drug Tier Notes

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

2

tricitrates E

TRICON E

trientine hcl 1 PA SP

TRIFERIC HEMODIALYSIS PACKET

E

TRINATE 2

TRINAZ E

TRISTART DHA E

TRISTART FREE E

TRISTART ONE E

TRI-VI-FLOR 3

TRI-VI-FLORO 3

tri-vite pediatric E

tri-vitefluoride 1

TRONVITE E

UDAMIN SP E

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

urosex E

v-c forte E

VELTASSA 3

VENEXA E

VENOFER E

vic-forte E

VINATE ONE 2

virt-caps E

VIRT-FEFA PLUS E

virt-gard E

virt-phos 250 neutral 1

vita s forte E

vitacel E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

84

Drug Name Drug Tier Notes

VITAFOL FE+ ORAL CAPSULE

E

VITAFOL STRIPS 2

VITAFOL-NANO E

VITAFOL-OB+DHA E

VITAL-D RX E

VITAMEZ E

vitamin b complex 100 E

vitamin b-complex 100 E

vitamin d (ergocalciferol) oral capsule 125 mg (50000 ut)

1

VITAMIN DEFICIENCY SYSTEM-B12

E

vitamin k1 injection solution 1 mg05ml 10 mgml

E

vitamins acd-fluoride 1

VITAROCA PLUS E

VITA-RX DIABETIC VITAMIN

E

VITASURE E

VITATHELY WITH GINGER

E

VITRANOL FE E

VITREXATE E

VITREXATE FE E

VITREXYL E

VITREXYL + IRON E

vp-pnv-dha 1

vp-vite rx E

weekly-d E

westab mini E

westab one E

WESTAB PLUS 2

WESTGEL DHA E

WHEAT GERM OIL ORAL OIL

E

Drug Name Drug Tier Notes

WILZIN 3

XAQUIL XR E

XVITE E

ZALVIT E

zinc sulfate oral tablet 220 (50 zn) mg

E

ZYVANA E

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

acid reducer oral tablet 10 mg

E

acid reducer oral tablet delayed release

E

ACIPHEX E

ACIPHEX SPRINKLE E

CARAFATE ORAL SUSPENSION

3

CARAFATE ORAL TABLET

E

cimetidine hcl oral 1

cimetidine oral 1

CYTOTEC 3

DEXILANT 2 QL

ESOMEP-EZS E

esomeprazole magnesium oral capsule delayed release

1 QL

esomeprazole magnesium oral packet

1 QL

ESOMEPRAZOLE STRONTIUM ORAL CAPSULE DELAYED RELEASE 493 MG

E

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg 40 mg

1

famotidine orig st E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

85

Drug Name Drug Tier Notes

FIRST-LANSOPRAZOLE

3 ST

FIRST-OMEPRAZOLE 3 ST

lansoprazole oral capsule delayed release

1 ST QL

lansoprazole oral tablet delayed release dispersible

1 QL

misoprostol oral 1

NEXIUM ORAL CAPSULE DELAYED RELEASE

E

NEXIUM ORAL PACKET

3 QL

nizatidine 1

omeprazole magnesium oral tablet delayed release

E

omeprazole oral capsule delayed release

1 ST QL

omeprazole oral tablet delayed release

E

OMEPRAZOLE+SYRSPEND SF ALKA

3 ST

omeprazole-sodium bicarbonate

E

pantoprazole sodium oral

1 ST QL

PEPCID ORAL TABLET

3

PREVACID E

PREVACID 24HR E

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE

3 ST QL

PRILOSEC ORAL PACKET

3 ST QL

PROTONIX ORAL 3 ST QL

Drug Name Drug Tier Notes

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

E

rabeprazole sodium oral tablet delayed release

1 ST QL

sucralfate oral 1

ZEGERID E

Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions

ACTIPHLORA E

alosetron hcl 1 PA

alum amp mag hydroxide-simeth

E

alumina-magnesia-simethicone

E

alvimopan 1

AMITIZA E

amoxicill-clarithro-lansopraz

1 ST

ANASPAZ 3

antacid anti-gas max strength

E

antacid calcium E

antacid calcium rich E

antacid extra strength oral tablet chewable 160-105 mg 750 mg

E

antacid maximum E

antacid oral tablet chewable 500 mg 750 mg

E

antacid regular strength E

antacid ultra strength oral tablet chewable 1000 mg

E

antacidantigas E

antacidanti-gas E

anti-diarrheal oral liquid E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

86

Drug Name Drug Tier Notes

anti-diarrheal oral tablet E

ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR

E

atropine sulfate injection solution 04 mgml 1 mgml

E

atropine sulfate injection solution prefilled syringe 025 mg5ml

E

atropine sulfate intravenous solution

E

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 08 MG2ML 1 MG25ML 12 MG3ML

E

atropine sulfate solution 8 mg20ml injection

E

atropine sulfate solution prefilled syringe 05 mg5ml injection

E

atropine sulfate solution prefilled syringe 1 mg10ml injection

E

BACICAP E

belladonna alkaloids-opium

E

bisacodyl ec $0 QL

bisacodyl rectal E

bismuth subsalicylate oral suspension 525 mg30ml

E

cascara sagrada oral fluid extract

1

CHENODAL 3 PA SP

chlordiazepoxide-clidinium

E

chocolated laxative E

Drug Name Drug Tier Notes

citroma $0 QL

clearlax oral powder $0 QL

CLENPIQ 3

constulose 1

cromolyn sodium oral 1

CUVPOSA 3

cvs antacid extra strength oral tablet chewable 750 mg

E

cvs gentle laxative rectal

E

dicyclomine hcl oral 1

diotame instydose E

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet 25-0025 mg

1

docusate calcium E

docusate mini E

docusate sodium oral capsule

E

docusate sodium oral syrup

E

docuzen E

dok oral tablet E

DONNATAL E

ED-SPAZ 3

ENTEREG 3

enulose 1

EX-LAX ULTRA E

fiber laxative oral tablet E

fiber oral powder 283

E

FOLIKA PROBIOTIC E

gas relief extra strength oral capsule

E

gas relief infants oral suspension

E

gas relief oral tablet chewable

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

87

Drug Name Drug Tier Notes

GASTROCROM 3

GATTEX 3 PA SP

gavilax oral powder $0 QL

gavilyte-c $0 QL

gavilyte-g $0 QL

gavilyte-h 1

gavilyte-n with flavor pack

$0 QL

GELUSIL E

generlac 1

gentle laxative oral $0 QL

gentle laxative rectal E

geri-kot E

GIALAX E

GLYCATE E

glycolax $0 QL

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE 06 MG3ML

E

glycopyrrolate oral tablet 1 mg 2 mg

1

GLYCOPYRROLATE ORAL TABLET 15 MG

E

glycopyrrolate pf E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 06 MG3ML INTRAVENOUS

E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 1 MG5ML INJECTION

E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 1 MG5ML INTRAVENOUS

E

Drug Name Drug Tier Notes

GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE

E

gnp senna lax E

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

goodsense antacid amp gas relief

E

goodsense antacid oral tablet chewable 500 mg 750 mg

E

goodsense anti-diarrheal

E

HELIDAC THERAPY 3

high potency probiotic E

hm stomach relief oral suspension 525 mg30ml

E

hm stool softener oral capsule 100 mg

E

hyoscyamine sulfate er oral tablet extended release 12 hour

E

hyoscyamine sulfate oral elixir

1

hyoscyamine sulfate oral tablet

1

hyoscyamine sulfate oral tablet dispersible

1

hyoscyamine sulfate sl 1

hyoscyamine sulfate solution 0125 mgml oral

E

hyoscyamine sulfate solution 0125 mgml oral

1

hyoscyamine sulfate tablet sublingual 0125 mg sublingual

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

88

Drug Name Drug Tier Notes

hyoscyamine sulfate tablet sublingual 0125 mg sublingual

E

hyosyne 1

IMODIUM A-D ORAL TABLET

E

IMODIUM MULTI-SYMPTOM RELIEF ORAL TABLET

E

infants gas relief oral suspension 20 mg03ml

E

KRISTALOSE E

LACTEROL E

lactobacillus oral tablet E

LACTOJEN E

lactulose encephalopathy

1

lactulose oral 1

laxative max str E

laxative regular strength

E

LEVBID E

LEVSIN ORAL TABLET

E

LEVSINSL E

LIBRAX 3

LINZESS 2 ST QL

LOMOTIL ORAL TABLET

3

loperamide hcl oral capsule

1

loperamide hcl oral solution

E

loperamide hcl oral suspension

E

LOTRONEX 3 PA

LUBIPROSTONE E

MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION

E

Drug Name Drug Tier Notes

magnesium citrate oral solution 1745 gm30ml

$0 QL

magnesium oxide oral tablet 400 mg 420 mg

E

methscopolamine bromide oral

1

milk of magnesia oral suspension 1200 mg15ml 400 mg5ml

E

mineral oil heavy oral 1

mm clearlax $0 QL

mm stool softener laxative

E

MOTEGRITY 3 ST QL

MOTOFEN E

MOVANTIK E

MOVIPREP E

MYTESI 3 QL

natural senna laxative oral tablet 86 mg

E

NULEV 3

NULYTELY LEMON-LIME

3

OMECLAMOX-PAK 2

opium E

oscimin oral tablet 1

oscimin sr E

oscimin sublingual 1

OSMOPREP E

pb-hyoscy-atropine-scopolamine

E

PCP 100 E

peg 3350-kcl-na bicarb-nacl

$0 QL

peg-3350electrolytes $0 QL

peg-3350electrolytesascorbat

1

peg-kcl-nacl-nasulf-na asc-c

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

89

Drug Name Drug Tier Notes

peg-prep 1

PERDIEM OVERNIGHT RELIEF

E

phenobarbital-belladonna alk oral elixir

E

phenobarbital-belladonna alk oral tablet

1

PHENOHYTRO E

pink bismuth maximum strength

E

PLENVU E

PROBICHEW E

PROBITROL E

PRODIGEN E

PROMELLA IN PREBIOTIC

E

PROMEROL E

PYLERA 2

qc magnesium citrate $0 QL

quad-probiotic E

RELISTOR ORAL E

RELISTOR SUBCUTANEOUS SOLUTION 12 MG06ML 8 MG04ML

E

RELTONE E

RESTORA RX 3

saccharomyces boulardii

E

senexon-s E

senna oral liquid E

senna oral syrup 88 mg5ml

E

senna oral tablet 86 mg

E

senna plus oral tablet E

senna s E

Drug Name Drug Tier Notes

senna smooth E

senna-docusate sodium

E

senna-plus E

SENOKOT EXTRA STRENGTH

E

SENOKOT S E

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG 5 MG 6 MG

3 PA SP

simethicone oral capsule 125 mg

E

simethicone oral suspension 40 mg06ml

E

simethicone oral tablet chewable 80 mg

E

simethicone ultra strength

E

SODIUM BICARBONATE ORAL POWDER

3

sodium bicarbonate oral tablet 325 mg 650 mg

E

soothe oral tablet E

stimulant laxative oral tablet

E

stomach relief oral tablet chewable

E

stool softener laxative oral capsule 100 mg

E

stool softener oral capsule 100 mg 250 mg

E

stool softener plus laxative

E

stool softenerlaxative oral tablet

E

SUPREP BOWEL PREP KIT

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

90

Drug Name Drug Tier Notes

SUTAB 3

SYMAX DUOTAB E

SYMAX-SL E

SYMAX-SR E

SYMPROIC 2 ST QL

TALICIA 3

TRULANCE E

TUMS CHEWY BITES E

URSO 250 3

URSO FORTE 3

ursodiol oral 1

URSODIOL+SYRSPEND SF

E

vegetable lax+stool softener

E

VIBERZI 3 PA QL

VISBIOME E

womens 50 billion E

XERMELO TABLET 250 MG ORAL

3 PA SP QL

ZELAC E

ZELNORM 3 PA QL

ZORBTIVE 3 PA SP

Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment

ALDURAZYME 2 PA SP

AMONDYS 45 E SP

BRINEURA KIT 3 PA SP

BUPHENYL ORAL POWDER 3 GMTSP

3 SP

BUPHENYL ORAL TABLET

3 SP

CERDELGA 3 PA SP

Drug Name Drug Tier Notes

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

2 PA SP

CHOLBAM 3 PA SP

CITRULLINE EASY E

CREON 2

CRYSVITA 3 PA SP

CYSTADANE 3 SP

CYSTAGON 3 SP

ELAPRASE 2 PA SP

ELELYSO 3 PA SP

ENZADYNE E

EVRYSDI 3 PA SP QL

EXONDYS 51 E SP

FABRAZYME 2 PA SP

GALAFOLD 3 PA SP QL

KANUMA 3 PA SP

KUVAN ORAL PACKET

E SP

KUVAN ORAL TABLET E SP

LUMIZYME 2 PA SP

MEPSEVII 3 PA SP

miglustat 1 PA SP

MYALEPT 3 PA SP

NAGLAZYME 2 PA SP

nitisinone 1 PA SP

NITYR 3 PA SP

OCALIVA 3 PA SP QL

ORFADIN 3 PA SP

PALYNZIQ 3 PA SP QL

PANCREAZE E

PERTZYE E

PROCYSBI 3 PA SP

RAVICTI 3 PA SP

REVCOVI 3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

91

Drug Name Drug Tier Notes

sapropterin dihydrochloride oral packet

1 PA SP

sapropterin dihydrochloride oral tablet

1 PA SP

sodium phenylbutyrate oral powder 3 gmtsp

1 SP

sodium phenylbutyrate oral tablet

1 SP

STRENSIQ 2 PA SP

SUCRAID 3 SP

VIMIZIM 3 PA SP

VIOKACE E

VPRIV 3 PA SP

VYONDYS 53 E SP

XURIDEN 3 PA SP QL

ZAVESCA 3 PA SP

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT 15000-47000 UNIT 20000-63000 UNIT 25000-79000 UNIT 3000-14000 UNIT 40000-126000 UNIT 5000-24000 UNIT

2

ZOLGENSMA 3 PA SP

Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions

aminoacetic acid E

AURYXIA 3

azo tabs E

bethanechol chloride oral

1

BI-MIX 3

calcium acetate (phos binder)

1

Drug Name Drug Tier Notes

calcium acetate oral tablet 667 mg

1

CAVERJECT IMPULSE

3 QL

CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 40 MCG

3 QL

CERVIDIL 3

CIALIS 3 QL

CUPRIMINE ORAL CAPSULE 250 MG

3 PA SP

darifenacin hydrobromide er

1

DEPEN TITRATABS 2 SP

DETROL 3

DETROL LA 3

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG 5 MG

3

EDEX 3 QL

ELMIRON E

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 75 MG

3

FEM PH E

flavoxate hcl 1

FOSRENOL ORAL PACKET

3

FOSRENOL ORAL TABLET CHEWABLE 1000 MG 500 MG 750 MG

3

GELNIQUE TRANSDERMAL GEL 10

3 ST

GEMTESA E

glycine irrigation E

glycine urologic E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

92

Drug Name Drug Tier Notes

HYOPHEN E

INTRAROSA 3 ST

lanthanum carbonate 1

LEVITRA ORAL TABLET 10 MG 20 MG

E

LITHOSTAT 3

menaphosmbhyo1 E

MUSE 3 QL

MYRBETRIQ 2

OXLUMO 3 PA SP

oxybutynin chloride er 1

oxybutynin chloride oral 1

OXYTROL 3 ST QL

OXYTROL FOR WOMEN

E

penicillamine oral capsule

1 PA SP

penicillamine oral tablet 1 SP

PENTOSAN POLYSULFATE SODIUM ORAL

E

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg 200 mg

1

PHENYLEPHRINE HCL INTRACAVERNOSAL

E

PHOSLYRA 3

PHOSPHASAL E

PREPIDIL 3

PROSTIN E2 3

PYRIDIUM E

QUAD-MIX 3

RENACIDIN E

RENAGEL ORAL TABLET 800 MG

E

RENVELA 3

Drug Name Drug Tier Notes

RIMSO-50 E

sevelamer carbonate 1

sevelamer hcl 1

sildenafil citrate oral tablet 100 mg 25 mg 50 mg

1 QL

solifenacin succinate 1

STAXYN E

STENDRA E

SUPER BI-MIX 3

SUPER QUAD-MIX 3

SUPER TRI-MIX E

tadalafil oral 1 QL

THIOLA EC 3 SP

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 3

TRI-MIX E

trospium chloride 1 ST

trospium chloride er 1

URELLE E

uretron ds oral tablet 816 mg

1

URIBEL E

URIMAR-T E

urin ds oral tablet 816 mg

1

urinary pain relief oral tablet 95 mg

E

URO-458 E

UROGESIC-BLUE E

uro-mp E

USTELL E

UTIRA-C E

vardenafil hcl oral 1 QL

VELPHORO 3

VESICARE 3

VESICARE LS E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

93

Drug Name Drug Tier Notes

VIAGRA E

VILAMIT MB E

VILEVEV MB E

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART 3

CARDURA XL 3 ST

dutasteride oral 1

dutasteride-tamsulosin hcl

1

finasteride oral tablet 5 mg

1

FLOMAX E

JALYN 3

PROSCAR 3

RAPAFLO 3

silodosin 1

tamsulosin hcl 1

terazosin hcl oral 1

UROXATRAL 3

Hormonal Agents - Adrenal

ACTIVE INJECTION D E

ACTIVE INJECTION KIT L

E

ACTIVE INJECTION KL-3

E

ACTIVE INJECTION LM-DEP-2

E

ALKINDI SPRINKLE E

BETA 1 KIT E

BETALOAN SUIK E

BETAMETHASONE COMBO

E

Drug Name Drug Tier Notes

BETAMETHASONE SOD PHOS amp ACET INJECTION SUSPENSION 7 (4-3) MGML

E

BETAMETHASONE SOD PHOS amp ACET SUSPENSION 6 (3-3) MGML INJECTION

E

betamethasone sod phos amp acet suspension 6 (3-3) mgml injection

E

BSP 0820 E

CELESTONE SOLUSPAN

E

CONTRAST ALLERGY PREMED PACK

E

CORTEF 3

DECADRON ORAL TABLET

E

DEPO-MEDROL E

DEXABLISS E

dexamethasone intensol

1

dexamethasone oral 1

dexamethasone sod phosphate pf

E

dexamethasone sodium phosphate injection solution 100 mg10ml 120 mg30ml 20 mg5ml

E

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MGML INJECTION

E

dexamethasone sodium phosphate solution 10 mgml injection

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

94

Drug Name Drug Tier Notes

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 MGML INJECTION

E

dexamethasone sodium phosphate solution 4 mgml injection

E

DEXONTO 04 3

DMT SUIK E

DOUBLEDEX E

DXEVO 11-DAY E

DYURAL-40 E

DYURAL-80 E

DYURAL-L E

DYURAL-LM E

fludrocortisone acetate oral

1

HEMADY E

HIDEX 6-DAY E

hydrocortisone oral 1

KENALOG INJECTION 3

KENALOG-80 3

MAS CARE-PAK E

MEDROL ORAL TABLET 16 MG 32 MG 4 MG 8 MG

3

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK

3

MEDROLOAN II SUIK E

MEDROLOAN SUIK E

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MGML

E

Drug Name Drug Tier Notes

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MGML INJECTION

E

methylprednisolone acetate suspension 40 mgml injection

E

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MGML INJECTION

E

methylprednisolone acetate suspension 80 mgml injection

E

methylprednisolone oral

1

MILLIPRED ORAL TABLET

E

MULTI-SPECIALTY E

ORAPRED ODT 3

P-CARE K40 E

P-CARE K40G E

P-CARE K40MX E

P-CARE K80 E

P-CARE K80G E

P-CARE K80MX E

PEDIAPRED 3

physicians ez use jointtunnel

E

PHYSICIANS EZ USE M-PRED

E

POD-CARE 100K E

POINT OF CARE L2 E

POINT OF CARE L5 E

POINT OF CARE LM DEP 2

E

prednisolone oral solution

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

95

Drug Name Drug Tier Notes

prednisolone sodium phosphate oral solution 10 mg5ml 15 mg5ml 20 mg5ml 25 mg5ml 67 (5 base) mg5ml

1

prednisolone sodium phosphate oral tablet dispersible

1

prednisone intensol 1

prednisone oral 1

PRO-C-DURE 5 E

PRO-C-DURE 6 E

RAYOS E

READYSHARP ANESTH + METHYLPRED

E

READYSHARP BETAMETHASONE

E

READYSHARP DEXAMETHASONE

E

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG

3

TAPERDEX 12-DAY E

TAPERDEX 6-DAY E

TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 15 MG (27)

E

TOPIDEX E

TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 MGML

E

triamcinolone acetonide suspension 40 mgml injection

1

Drug Name Drug Tier Notes

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MGML INJECTION

3

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MGML INJECTION

E

TRILOAN II SUIK E

TRILOAN SUIK E

ZCORT 7-DAY E

ZILRETTA E

Hormonal Agents - Mens Health

ANDRODERM TRANSDERMAL PATCH 24 HOUR

2 PA

ANDROGEL PUMP TRANSDERMAL GEL 2025 MGACT (162)

3 PA

ANDROGEL TRANSDERMAL GEL 2025 MG125GM (162) 405 MG25GM (162)

3 PA

ANDROGEL TRANSDERMAL GEL 25 MG25GM (1) 50 MG5GM (1)

E

AVEED E

danazol oral 1

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION

E

EC-RX TESTOSTERONE

E

FORTESTA E

JATENZO E

METHITEST 3 PA

methyltestosterone oral 1 PA

NATESTO E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

96

Drug Name Drug Tier Notes

oxandrolone oral 1 PA QL

TESTIM E

TESTONE CIK E

TESTOPEL E

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MGML

E

testosterone cypionate intramuscular solution 100 mgml 200 mgml

1 PA

testosterone enanthate intramuscular solution

1 PA

TESTOSTERONE IMPLANT PELLET 100 MG 200 MG 25 MG 50 MG

E

testosterone transdermal gel 162 10 mgact (2) 125 mgact (1) 2025 mg125gm (162) 2025 mgact (162) 25 mg25gm (1) 405 mg25gm (162) 50 mg5gm (1)

1 PA

testosterone transdermal solution

1 PA

VOGELXO PUMP E

VOGELXO TRANSDERMAL GEL 50 MG5GM (1)

E

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

EVISTA 3

OSPHENA 3

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 2 PA SP

Drug Name Drug Tier Notes

BYNFEZIA PEN E SP

cabergoline 1

CETROTIDE SUBCUTANEOUS KIT 025 MG

E SP

chorionic gonadotropin intramuscular

1 PA SP

clomiphene citrate oral 1 PA

DDAVP INJECTION SOLUTION 4 MCGML

3

DDAVP ORAL 3

DDAVP PF 3

DDAVP RHINAL TUBE 2

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate pf

1

desmopressin acetate spray

1

EGRIFTA SV 3 PA SP QL

ELIGARD 3 PA SP QL

FENSOLVI (6 MONTH) 3 PA SP QL

FIRMAGON (240 MG DOSE)

3 PA SP QL

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

3 PA SP QL

FOLLISTIM AQ SUBCUTANEOUS

2 PA SP

ganirelix acetate solution prefilled syringe 250 mcg05ml subcutaneous

1 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

97

Drug Name Drug Tier Notes

ganirelix acetate solution prefilled syringe 250 mcg05ml subcutaneous

1PA Made by Organon SP

GENOTROPIN E SP

GENOTROPIN MINIQUICK

E SP

GONAL-F E SP

GONAL-F RFF E SP

GONAL-F RFF REDIJECT

E SP

HUMATROPE E SP

INCRELEX 2 PA SP

ISTURISA E SP

leuprolide acetate injection

1 PA SP

LUPANETA PACK 3 PA SP QL

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 375 MG

3 PA SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 75 MG

2 PA SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 1125 MG

3 PA SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 225 MG

2 PA SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 PA SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 PA SP

Drug Name Drug Tier Notes

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 1125 MG

3 PA SP

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG 75 MG

2 PA SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 1125 MG (PED)

3 PA SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED)

2 PA SP

MENOPUR 3 PA SP

MYCAPSSA E SP

NOCDURNA 3

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

novarel intramuscular solution reconstituted 10000 unit

1 PA SP

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

3 PA SP

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

98

Drug Name Drug Tier Notes

NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

octreotide acetate injection solution 100 mcgml 1000 mcgml 200 mcgml 50 mcgml 500 mcgml

1 PA SP

OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE

E SP

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

E SP

ORILISSA 2 PA QL

OVIDREL 3 PA SP

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 30 UNIT500ML

E

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 20-09 UNITL- 20-09 UNTL-

E

pregnyl 1 PA SP

SAIZEN E SP

SAIZENPREP E SP

SANDOSTATIN INJECTION SOLUTION 100 MCGML 50 MCGML 500 MCGML

E SP

SANDOSTATIN LAR DEPOT

E SP

SIGNIFOR E SP

Drug Name Drug Tier Notes

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3 PA SP QL

SOMATULINE DEPOT 3 PA SP

SOMAVERT 3 PA SP

STIMATE 3

SUPPRELIN LA 2 PA SP QL

SYNAREL 2

TEPEZZA 3 PA SP

TRELSTAR MIXJECT 3 PA SP QL

TRIPTODUR 3 PA SP QL

VANTAS 3 PA SP QL

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG

3 SP QL

ZOLADEX SUBCUTANEOUS IMPLANT 36 MG

2 SP QL

ZOMACTON E SP

ZOMACTON (FOR ZOMA-JET 10)

E SP

Hormonal Agents - Prostaglandins

KORLYM 3 PA SP QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 1-05 MG

3

afirmelle $0 QL

ALORA 3 ST

altavera $0 QL

alyacen 135 $0 QL

alyacen 777 $0 QL

amabelz 1

amethia $0 QL

amethyst $0 QL

ANGELIQ 3

ANNOVERA E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

99

Drug Name Drug Tier Notes

apri $0 QL

aranelle $0 QL

ashlyna $0 QL

aubra $0 QL

aubra eq $0 QL

aurovela 1530 $0 QL

aurovela 120 $0 QL

aurovela 24 fe $0 QL

aurovela fe 1530 $0 QL

aurovela fe 120 $0 QL

aviane $0 QL

AYGESTIN 3

ayuna $0 QL

azurette $0 QL

BALCOLTRA E

balziva $0 QL

bekyree $0 QL

BEYAZ E

BIESTPROGESTERONE

E

BIJUVA 3

blisovi 24 fe $0 QL

blisovi fe 1530 $0 QL

blisovi fe 120 $0 QL

briellyn $0 QL

camila $0 QL

camrese $0 QL

camrese lo $0 QL

caziant $0 QL

charlotte 24 fe $0 QL

chateal $0 QL

chateal eq $0 QL

CLIMARA 3

CLIMARA PRO 2

COMBIPATCH 3

COVARYX E

COVARYX HS E

Drug Name Drug Tier Notes

CRINONE VAGINAL GEL 4

3 QL

CRINONE VAGINAL GEL 8

3 PA QL

cryselle-28 $0 QL

cyclafem 135 $0 QL

cyclafem 777 $0 QL

cyred $0 QL

cyred eq $0 QL

dasetta 135 $0 QL

dasetta 777 $0 QL

daysee $0 QL

deblitane $0 QL

DELESTROGEN 3

delyla $0 QL

DEPO-ESTRADIOL 3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML

3 QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3 QL

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE

$0 QL

desogestrel-ethinyl estradiol

$0 QL

DIVIGEL 3

dotti 1

drospiren-eth estrad-levomefol

$0 QL

drospirenone-ethinyl estradiol

$0 QL

DUAVEE 2

EC-RX ESTRADIOL E

EC-RX PROGESTERONE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

100

Drug Name Drug Tier Notes

EEMT E

EEMT HS E

ELESTRIN 3

elinest $0 QL

ELLA $0 QL

eluryng $0 QL

emoquette $0 QL

ENDOMETRIN 2 PA

enpresse-28 $0 QL

enskyce oral tablet 015-30 mg-mcg

$0 QL

errin $0 QL

est estrogens-methyltest

E

est estrogens-methyltest ds

E

est estrogens-methyltest hs

E

estarylla $0 QL

ESTRACE 3

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

estradiol valerate intramuscular oil 20 mgml 40 mgml

1

estradiol-norethindrone acet

1

ESTRING 3 QL

ESTROGEL 3

ESTROSTEP FE 3 QL

ethynodiol diac-eth estradiol

$0 QL

etonogestrel-ethinyl estradiol

$0 QL

EVAMIST 3

FALESSA ORAL KIT 20-1-01 MCG-MG

E

falmina $0 QL

Drug Name Drug Tier Notes

fayosim $0 QL

FEMHRT LOW DOSE 3

FEMRING 3 ST QL

femynor $0 QL

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG 200 MG

E

fyavolv 1

gemmily $0 QL

GENERESS FE 3 QL

hailey 1530 $0 QL

hailey 24 fe $0 QL

hailey fe 1530 $0 QL

hailey fe 120 $0 QL

heather $0 QL

hydroxyprogesterone caproate intramuscular

1 PA SP

iclevia $0 QL

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

incassia $0 QL

introvale $0 QL

isibloom $0 QL

jaimiess $0 QL

jasmiel $0 QL

jencycla $0 QL

jinteli 1

jolessa $0 QL

juleber $0 QL

junel 1530 $0 QL

junel 120 $0 QL

junel fe 1530 $0 QL

junel fe 120 $0 QL

junel fe 24 $0 QL

kaitlib fe $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

101

Drug Name Drug Tier Notes

kalliga $0 QL

kariva $0 QL

kelnor 135 $0 QL

kelnor 150 $0 QL

kurvelo $0 QL

KYLEENA E

larin 1530 $0 QL

larin 120 $0 QL

larin 24 fe $0 QL

larin fe 1530 $0 QL

larin fe 120 $0 QL

larissia $0 QL

layolis fe $0 QL

leena $0 QL

lessina $0 QL

levonest $0 QL

levonorgest-eth est amp eth est

$0 QL

levonorgest-eth estrad 91-day

$0 QL

levonorgestrel oral tablet 15 mg

$0 QL

levonorgestrel-ethinyl estrad

$0 QL

levonorg-eth estrad triphasic oral tablet 50-3075-40 125-30 mcg

$0 QL

levora 01530 (28) $0 QL

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 195 MCGDAY

E

lillow $0 QL

LO LOESTRIN FE $0 QL

LOESTRIN 1530 (21) 3 QL

LOESTRIN 120 (21) 3 QL

LOESTRIN FE 1530 3 QL

LOESTRIN FE 120 3 QL

Drug Name Drug Tier Notes

lojaimiess $0 QL

loryna $0 QL

LOSEASONIQUE 3 QL

low-ogestrel $0 QL

lo-zumandimine $0 QL

lutera $0 QL

lyleq $0 QL

lyllana 1

lyza $0 QL

MAKENA 2 PA SP

marlissa $0 QL

medroxyprogesterone acetate intramuscular

$0 QL

medroxyprogesterone acetate oral

1

megestrol acetate oral suspension 40 mgml 625 mg5ml

1

megestrol acetate oral tablet

1

MENEST ORAL TABLET 03 MG 0625 MG 125 MG

2

MENOSTAR 3 ST

merzee $0 QL

mibelas 24 fe $0 QL

microgestin 1530 $0 QL

microgestin 120 $0 QL

microgestin 24 fe $0 QL

microgestin fe 1530 $0 QL

microgestin fe 120 $0 QL

mili $0 QL

mimvey 1

MINASTRIN 24 FE E

MINIVELLE 3 ST

MIRCETTE 3 QL

MIRENA (52 MG) E

mono-linyah $0 QL

NATAZIA $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

102

Drug Name Drug Tier Notes

necon 0535 (28) $0 QL

NEXPLANON E

nikki $0 QL

nora-be $0 QL

norethin ace-eth estrad-fe oral capsule

$0 QL

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg 15-30 mg-mcg

$0 QL

norethin ace-eth estrad-fe oral tablet chewable

$0 QL

norethindrone acetate oral

1

norethindrone acet-ethinyl est oral tablet

$0 QL

norethindrone oral $0 QL

norethindrone-eth estradiol

1

norethin-eth estradiol-fe $0 QL

norgestimate-eth estradiol oral tablet 025-35 mg-mcg

$0 QL

norgestimate-ethinyl estradiol triphasic

$0 QL

norlyda $0 QL

norlyroc $0 QL

nortrel 0535 (28) $0 QL

nortrel 135 (21) $0 QL

nortrel 135 (28) $0 QL

nortrel 777 $0 QL

NUVARING 3 QL

nylia 777 $0 QL

nymyo $0 QL

ocella $0 QL

ORIAHNN 2 PA QL

orsythia $0 QL

ORTHO MICRONOR E

Drug Name Drug Tier Notes

PARAGARD INTRAUTERINE COPPER

E

philith $0 QL

pimtrea $0 QL

pirmella 135 $0 QL

pirmella 777 $0 QL

PLAN B ONE-STEP $0 QL

portia-28 $0 QL

PREFEST 3

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

previfem $0 QL

progesterone intramuscular

1

PROGESTERONE MICRONIZED TRANSDERMAL

E

progesterone oral 1

PROMETRIUM 3

PROVERA 3

QUARTETTE 3 QL

reclipsen $0 QL

rivelsa $0 QL

SAFYRAL 3 QL

SEASONIQUE 3 QL

setlakin $0 QL

sharobel $0 QL

simliya $0 QL

simpesse $0 QL

SKYLA E

SLYND E

sprintec 28 $0 QL

sronyx $0 QL

syeda $0 QL

tarina 24 fe $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

103

Drug Name Drug Tier Notes

tarina fe 120 $0 QL

tarina fe 120 eq $0 QL

TAYTULLA E

tilia fe $0 QL

tri femynor $0 QL

tri-estarylla $0 QL

tri-legest fe $0 QL

tri-linyah $0 QL

tri-lo-estarylla $0 QL

tri-lo-marzia $0 QL

tri-lo-mili $0 QL

tri-lo-sprintec $0 QL

tri-mili $0 QL

tri-nymyo $0 QL

tri-previfem $0 QL

tri-sprintec $0 QL

trivora (28) $0 QL

tri-vylibra $0 QL

tri-vylibra lo $0 QL

tulana $0 QL

TWIRLA E

tyblume oral tablet chewable

$0 QL

tydemy $0 QL

VAGIFEM VAGINAL TABLET 10 MCG

E

velivet $0 QL

vestura $0 QL

vienva $0 QL

viorele $0 QL

VIVELLE-DOT E

volnea $0 QL

vyfemla $0 QL

vylibra $0 QL

wera $0 QL

wymzya fe $0 QL

xulane $0 QL

Drug Name Drug Tier Notes

YASMIN 28 3 QL

YAZ E

yuvafem 1

zafemy $0 QL

zarah $0 QL

zovia 135 (28) $0 QL

zovia 135e (28) $0 QL

zumandimine $0 QL

Hormonal Agents - Thyroid

ARMOUR THYROID 3 ST

CYTOMEL E

euthyrox 1

levo-t 1

LEVOTHYROXINE SODIUM ORAL CAPSULE

E

levothyroxine sodium oral tablet

1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3 ST

np thyroid 1

propylthiouracil oral 1

SYNTHROID 3

TAPAZOLE 3

THYQUIDITY 3

TIROSINT E

TIROSINT-SOL 3

unithroid 1

WESTHROID ORAL TABLET 130 MG 195 MG 325 MG 65 MG 975 MG

3 ST

WP THYROID 3 ST

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

104

Drug Name Drug Tier Notes

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA 3 PA SP

ACTEMRA ACTPEN 3 PA SP

ACTIMMUNE 2 PA SP

ALFERON N 2 SP

ARAVA 3

ARCALYST 3 PA SP

ASCENIV E SP

ASTAGRAF XL 3 SP

ATGAM 2 SP

AVSOLA 2 PA SP

AZASAN 3

azathioprine oral 1

azathioprine sodium E

BAMLANIVIMAB E

BENLYSTA 3 PA SP

BERINERT 3 PA SP QL

BIVIGAM INTRAVENOUS SOLUTION 5 GM50ML

3 PA SP

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM 6 GM

3 PA SP

CASIRIVIMAB E

CELLCEPT 3 SP

CELLCEPT INTRAVENOUS

3 SP

CIMZIA PREFILLED KIT

2 PA SP

CIMZIA STARTER KIT 2 PA SP

CIMZIA VIAL KIT 2 PA SP

CINRYZE 2 PA SP

Drug Name Drug Tier Notes

COSENTYX (300 MG DOSE)

E SP

COSENTYX 150 MGML

E SP

COSENTYX SENSOREADY (300 MG)

E SP

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MGML

E SP

CUTAQUIG E SP

CUVITRU 3 PA SP

cyclosporine intravenous

1 SP

cyclosporine modified 1 SP

cyclosporine oral capsule

1 SP

CYTOGAM 2 PA SP

ENBREL MINI 3 PA SP

ENBREL SUBCUTANEOUS SOLUTION 25 MG05ML

3 PA SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA SP

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA SP

ENSPRYNG 3 PA SP

ENTYVIO 3 PA SP

ENVARSUS XR 3 SP

ETESEVIMAB E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

105

Drug Name Drug Tier Notes

everolimus oral tablet 025 mg 05 mg 075 mg

1 SP

FIRAZYR 3 PA SP QL

FLEBOGAMMA DIF 3 PA SP

GAMASTAN 2 PA SP

GAMIFANT 3 PA SP

GAMMAGARD 3 PA SP

GAMMAGARD SD LESS IGA

3 PA SP

GAMMAKED INJECTION SOLUTION 1 GM10ML 10 GM100ML 20 GM200ML 5 GM50ML

3 PA SP

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM100ML 10 GM200ML 20 GM200ML 20 GM400ML 5 GM100ML 5 GM50ML

3 PA SP

GAMUNEX-C 3 PA SP

gengraf oral capsule 100 mg 25 mg

1 SP

gengraf oral solution 1 SP

HAEGARDA 3 PA SP

HEPAGAM B E

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM5ML 10 GM50ML 2 GM10ML 4 GM20ML

3 PA SP

HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

Drug Name Drug Tier Notes

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG08ML 80 MG08ML amp 40MG04ML

2 PA SP

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

2 PA SP

HUMIRA PEN-CDUCHS STARTER

2 PA SP

HUMIRA PEN-PEDIATRIC UC START

2 PA SP

HUMIRA PEN-PSUVADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG08ML

2 PA SP

HUMIRA PEN-PSORUVEIT STARTER

2 PA SP

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG01ML 20 MG02ML 40 MG04ML 40 MG08ML

2 PA SP

HYPERHEP B E

HYPERRAB E

HYPERRAB SD INJECTION

E

HYPERRHO SD INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

HYPERTET SD E

HYQVIA 3 PA SP

icatibant acetate 1 PA SP QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

106

Drug Name Drug Tier Notes

ILARIS SUBCUTANEOUS SOLUTION

2 PA SP QL

ILUMYA 3 PA SP

IMDEVIMAB E

IMOGAM RABIES-HT INJECTION

E

IMURAN 3

INFLECTRA 2 PA SP

KALBITOR 3 PA SP QL

KEDRAB INJECTION E

KEVZARA 3 PA SP

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

KYMRIAH 3 PA SP

leflunomide oral 1

LUPKYNIS E SP

methotrexate oral 1

methotrexate sodium (pf) injection solution 1 gm40ml 250 mg10ml 50 mg2ml

1

methotrexate sodium injection solution 250 mg10ml 50 mg2ml

1

methotrexate sodium injection solution reconstituted

1

methotrexate sodium oral

1

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

mycophenolate mofetil hcl

1 SP

mycophenolate mofetil intravenous

1 SP

Drug Name Drug Tier Notes

mycophenolate mofetil oral

1 SP

mycophenolate sodium 1 SP

MYFORTIC 3 SP

NABI-HB E

NEORAL 3 SP

NULOJIX 3 SP

OCTAGAM 3 PA SP

OLUMIANT E SP

ORENCIA CLICKJECT 3 PA SP

ORENCIA INTRAVENOUS

3 PA SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

ORLADEYO 3 PA SP QL

OTEZLA ORAL TABLET

2 PA SP

OTEZLA ORAL TABLET THERAPY PACK

2 PA SP

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG04ML 15 MG04ML 20 MG04ML 25 MG04ML

3 PA QL

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG04ML 175 MG04ML 225 MG04ML

E

PANZYGA E SP

PRIVIGEN 3 PA SP

PROGRAF 3 SP

PROVENGE 2 PA SP

RAPAMUNE 3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

107

Drug Name Drug Tier Notes

RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG02ML 125 MG025ML 15 MG03ML 175 MG035ML 20 MG04ML 225 MG045ML 25 MG05ML 30 MG06ML 75 MG015ML

2 PA QL

REDITREX E

REMICADE E SP

RENFLEXIS E SP

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE

E

RIDAURA 3 SP

RINVOQ 2 PA SP

RUCONEST 3 PA SP QL

SANDIMMUNE INTRAVENOUS

2 SP

SANDIMMUNE ORAL CAPSULE

3 SP

SANDIMMUNE ORAL SOLUTION

2 SP

SILIQ 3 PA SP

SIMPONI ARIA 2 PA SP

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA SP

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP

Drug Name Drug Tier Notes

SIMULECT E

sirolimus oral 1 SP

SKYRIZI (150 MG DOSE)

2 PA SP QL

STELARA INTRAVENOUS

2 PA SP

STELARA SUBCUTANEOUS SOLUTION 45 MG05ML

2 PA SP QL

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

SYNAGIS 2 PA SP

tacrolimus oral 1 SP

TAKHZYRO 3 PA SP

TALTZ 3 PA SP

temsirolimus 1 SP

THYMOGLOBULIN E

TICE BCG 2 SP

TORISEL 3 SP

TREMFYA 2 PA SP

TREXALL 3

UPLIZNA 3 PA SP

VARIZIG INTRAMUSCULAR SOLUTION

E

WINRHO SDF 2 SP

XATMEP 3

XELJANZ 2 PA SP

XELJANZ XR 2 PA SP

XEMBIFY 3 PA SP

ZINPLAVA E

ZORTRESS 3 SP

Immunological Agents - Drugs for Vaccination

ACTHIB $0

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

108

Drug Name Drug Tier Notes

ADACEL INTRAMUSCULAR SUSPENSION 5-2-155 LF-MCG05

$0

AFLURIA QUADRIVALENT

$0

ASTRAZENECA COVID-19 VACCINE

3

BCG VACCINE E

BEXSERO $0

BIOTHRAX E

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-25-185 LF-MCG05

$0

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

$0

DIPHTHERIA-TETANUS TOXOIDS DT

$0

ENGERIX-B INJECTION SUSPENSION 10 MCG05ML 20 MCGML

$0

FLUAD $0

FLUAD QUADRIVALENT

$0

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

FLUCELVAX QUADRIVALENT

$0

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

FLUMIST QUADRIVALENT

$0

Drug Name Drug Tier Notes

FLUZONE HIGH-DOSE QUADRIVALENT

$0

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 05 ML

$0

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 05 ML

$0

GARDASIL 9 $0

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL UML 720 EL U05ML

$0

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

$0

HIBERIX INJECTION $0

IMOVAX RABIES E

INFANRIX $0

IPOL INJECTION INJECTABLE

$0

IXIARO E

JANSSEN COVID-19 VACCINE

$0

MENACTRA $0

MENQUADFI $0

MENVEO $0

M-M-R II INJECTION $0

MODERNA COVID-19 VACCINE

$0

PEDVAX HIB INTRAMUSCULAR SUSPENSION

$0

PFIZER-BIONTECH COVID-19 VACC

$0

PNEUMOVAX 23 $0

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

109

Drug Name Drug Tier Notes

PREVNAR 13 $0

RABAVERT E

RECOMBIVAX HB INJECTION SUSPENSION 10 MCGML 40 MCGML 5 MCG05ML

$0

ROTARIX $0

ROTATEQ ORAL SOLUTION

$0

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG05ML

$0

STAMARIL E

TDVAX $0

TENIVAC $0

TETANUS-DIPHTHERIA TOXOIDS TD

$0

TRUMENBA $0

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05ML

E

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT05ML 50 UNITML

$0

VARIVAX $0

VAXCHORA E

VIVOTIF E

YF-VAX E

Inflammatory Bowel Disease Agents

ana-lex E

Drug Name Drug Tier Notes

ANALPRAM HC EXTERNAL

E

ANALPRAM HC SINGLES EXTERNAL

E

ANALPRAM-HC EXTERNAL CREAM

3

ANALPRAM-HC EXTERNAL LOTION

E

anucort-hc E

ANUSOL-HC EXTERNAL

3

ANUSOL-HC RECTAL SUPPOSITORY

E

APRISO 2

ASACOL HD E

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

budesonide er oral tablet extended release 24 hour

1

budesonide oral 1

CANASA E

COLAZAL 3

CORTENEMA 3

CORTIFOAM EXTERNAL

3

DELZICOL E

DIPENTUM E

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES

3

HEMMOREX-HC RECTAL SUPPOSITORY 25 MG

E

hydrocortisone (perianal)

1

hydrocortisone ace-pramoxine external cream 1-1

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

110

Drug Name Drug Tier Notes

hydrocortisone acetate rectal

E

hydrocortisone rectal enema

1

hydrocort-pramoxine (perianal)

E

LIALDA E

lidocaine-hydrocort (perianal)

E

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

E

lidocaine-hydrocortisone ace rectal kit

E

LIDOCORT EXTERNAL

E

mesalamine er oral capsule 0375 gm

1

mesalamine oral 1

mesalamine rectal 1

mesalamine-cleanser 1

ORTIKOS E

PENTASA 3

PROCORT EXTERNAL E

PROCTOCORT EXTERNAL

3

PROCTOCORT RECTAL SUPPOSITORY

E

PROCTOFOAM HC EXTERNAL

2

procto-med hc external 1

procto-pak external 1

proctozone-hc external 1

ROWASA RECTAL 3

SFROWASA 2

sulfasalazine oral 1

UCERIS 3

Drug Name Drug Tier Notes

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG 35 MG

3 QL

alendronate sodium oral solution

1

alendronate sodium oral tablet 10 mg 5 mg

1

alendronate sodium oral tablet 35 mg 70 mg

1 QL

ATELVIA 3 QL

BINOSTO 3 QL

BONIVA INTRAVENOUS

E

BONIVA ORAL TABLET 150 MG

3 QL

calcitonin (salmon) 1 QL

EVENITY 3 PA SP QL

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG248ML

E SP

FOSAMAX ORAL TABLET 70 MG

3 QL

FOSAMAX PLUS D E

ibandronate sodium intravenous solution 3 mg3ml

E

ibandronate sodium oral

1 QL

MIACALCIN INJECTION

3

pamidronate disodium 1 SP

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

RAYALDEE 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

111

Drug Name Drug Tier Notes

RECLAST 3 SP

risedronate sodium oral tablet 150 mg 35 mg

1 QL

risedronate sodium oral tablet 30 mg 5 mg

1

risedronate sodium oral tablet delayed release

1 QL

TERIPARATIDE (RECOMBINANT)

2 PA SP

TYMLOS 2 PA SP

XGEVA 2 PA SP

zoledronic acid intravenous concentrate

1 SP

zoledronic acid intravenous solution

1 SP

Metabolic Bone Disease Agents - Other

calcitriol intravenous solution 1 mcgml

E

calcitriol oral 1

cinacalcet hcl 1 PA

doxercalciferol oral 1

NATPARA 3 PA SP QL

paricalcitol intravenous E

paricalcitol oral 1

PARSABIV 3 SP

ROCALTROL 3

SENSIPAR 3 PA

ZEMPLAR INTRAVENOUS

E

ZEMPLAR ORAL CAPSULE 1 MCG 2 MCG

3

Miscellaneous Therapeutic Agents

3232a infant formula E

ACACIA SUBCUTANEOUS

E

Drug Name Drug Tier Notes

ACCU-CHEK TENDER 1 INFUSION

E

ACCU-CHEK ULTRAFLEX INF SET

E

ACREMONIUM E

ACST KIT E

ACTIFOAM COLLAGEN SPONGE

E

ACUNOL E

ADAKVEO 3 PA SP

ADULT AEROSOL MASK

E

AERIVA CONCENTRATOR NEBULIZER

E

ALCOHOL PREP PADS PAD

3

ALCOHOL PREP PADS PAD 70

3

ALCOHOL PREP PADS SHEET 70

3

ALDER E

ALTERNARIA E

AMERICAN BEECH E

AMERICAN COCKROACH

E

AMERICAN ELM E

AMINOPMRMS E

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

E

ANTIVENIN LATRODECTUS MACTANS

E

ANTIVENIN MICRURUS FULVIUS INTRAVENOUS

E

APP SLIM RMS E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

112

Drug Name Drug Tier Notes

ARIDOL INHALATION KIT 0 amp 5 amp 10 amp 20 amp 40 MG

E

ARIZONA CYPRESS E

ARTISS EXTERNAL SOLUTION

3

asilnasalrms E

ASPARTAME E

ASPARTAME (NUTRASWEET)

E

AUREOBASIDIUM E

AUSTRALIAN PINE E

AUTOSOFT 30 INFUSION SET

E

AUTOSOFT 90 INFUSION SET

E

AUTOSOFT XC INFUSION SET

E

AVAILNEX E

AVITENE E

AVITENE FLOUR E

AXONA E

AZALGIA E

BAHIA E

BALD CYPRESS E

BAYBERRY (WAX MYRTLE)

E

BERMUDA GRASS SUBCUTANEOUS

E

BHI URI-CONTROL E

BLACK WILLOW E

BOTOX 2PA Non-Cosmetic SP

BOTRYTIS SUBCUTANEOUS

E

BREATHE EASE HUMIDIFIER

E

BREATHE EASE NEB MASKCHILD

E

Drug Name Drug Tier Notes

BREATHE EASE NEB MASKINFANT

E

BRIDION INTRAVENOUS SOLUTION 500 MG5ML

E

BRIDION SOLUTION 200 MG2ML INTRAVENOUS

E

BROME E

CALIFORNIA PEPPER TREE

E

CAMINO PRO COMPLETEGLYTACTIN

E

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNUML

E

CARDIOVID PLUS E

CARETOUCH 2 CPAP HOSE HANGER

E

CARETOUCH CPAP amp BIPAP HOSE

E

CARETOUCH CPAP MASK WIPES

E

CARETOUCH CPAP PRE-WASH SOLN

E

CARETOUCH CPAP TUBE BRUSH

E

CARETOUCH UNIVERSL CPAP FILTER

E

CARTICEL E

CAT HAIR EXTRACT SUBCUTANEOUS

E

CATTLE EPITHELIUM E

CAYA $0 QL

CEDAR ELM E

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

113

Drug Name Drug Tier Notes

CLADOSPORIUM SPHAEROSPERMUM

E

COCKLEBUR E

coenzyme q10 oral capsule 100 mg 50 mg

E

COLCIGEL E

COLD-EEZE NATURAL MULTI-SYMP MOUTHTHROAT

E

COLD-EEZE PLUS DEFENSE MOUTHTHROAT

E

COLD-EEZE SUGAR FREE MOUTHTHROAT LOZENGE

E

COMFORT TOUCH ALCOHOL PREP

3

COMPRESSOR NEBULIZER

E

CONDOMS E

CORN POLLEN E

CORTROSYN E

cosyntropin injection E

COVID-19 SPECIMEN COLLECTION

E

CROFAB E

CURVULARIA E

DANDELION E

deferoxamine mesylate E

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

E

desflurane 1

dexmedetomidine hcl in nacl intravenous solution 200-09 mcg50ml-

E

Drug Name Drug Tier Notes

dexmedetomidine hcl in nacl solution 200 mcg50ml intravenous

E

dexmedetomidine hcl in nacl solution 400 mcg100ml intravenous

E

dexmedetomidine hcl in nacl solution 80 mcg20ml intravenous

E

dexmedetomidine hcl intravenous solution 200 mcg2ml

E

DIGIFAB E

DOG EPITHELIUM E

DOG FENNEL E

DOJOLVI E

DRECHSLERA E

DUROLANE INTRA-ARTICULAR

2 PA SP

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS

E

DYSPORT 3 PA SP

EASIVENT 2

EASTERN COTTONWOOD

E

EC-RX DHEA E

ECZEMOL E

ENDARI 3 PA

ENDO AVITENE E

ENFAGROW NEUROPRO TODDLER

E

ENFAMIL GENTLEASE ORAL POWDER

E

ENFAMIL INFANT ORAL POWDER

E

ENFAMIL NEUROPRO INFANT ORAL POWDER

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

114

Drug Name Drug Tier Notes

ENFAMIL NEUROPRO SENSITIVE

E

ENFAMIL NUTRAMIGEN LIPIL ORAL LIQUID

E

ENFAMIL NUTRAMIGEN LIPIL ORAL POWDER

E

ENFAMIL NUTRAMIGEN ORAL LIQUID

E

ENLYTE E

enovarx-amitriptyline E

ENTERAGAM E

enteric fish oil E

ENU PRO3 PLUS E

EPICOCCUM E

EPISIL E

EQUACARE JR E

ergoloid mesylates oral 1

ESSENTIAL CARE JR E

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

2 PA SP

FIRDAPSE E SP

FIRE ANT E

FLEXICHAMBER ADULT MASKSMALL

2

FLEXICHAMBER CHILD MASKLARGE

2

FLEXICHAMBER CHILD MASKSMALL

2

FORANE 3

formaldehyde external solution 10

E

FORMALDEHYDE SOLUTION 37 EXTERNAL (RX)

3

Drug Name Drug Tier Notes

FORMALDEHYDE SOLUTION 37 EXTERNAL (RX)

E

FOSTEUM PLUS E

FUSARIUM E

GELCLAIR E

GELFILM EXTERNAL E

GEL-FLOW E

GEL-FLOW NT E

GELFOAM E

GELFOAM COMPRESSED SIZE 100

E

GELFOAM DENTAL PACK SIZE 4

E

GELFOAM SPONGE E

GELFOAM SPONGE SIZE 100

E

GELFOAM SPONGE SIZE 200

E

GELFOAM SPONGE SIZE 50

E

GELFOAM-JMI POWDER

E

GELFOAM-JMI SPONGE

E

GELSYN-3 2 PA SP

GELX E

GERMAN COCKROACH

E

GIVLAARI 3 PA SP

GLEOLAN E

GLUTARALDEHYDE EXTERNAL

3

GLYTACTIN BETTERMILK 15

E

GLYTACTIN BETTERMILK DE-LITE

E

GLYTACTIN BUILD 10PE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

115

Drug Name Drug Tier Notes

GLYTACTIN BUILD 2020

E

GLYTACTIN BUILD 2020 PKU

E

GLYTACTIN BURST E

GLYTACTIN COMPLETE 10PE

E

GLYTACTIN RESTORE 10

E

GLYTACTIN RESTORE 5

E

GLYTACTIN RESTORE LITE 10

E

GLYTACTIN RESTORE LITE 10PE

E

GLYTACTIN RTD 10 LIQUID ORAL

E

GLYTACTIN RTD 15 E

GLYTACTIN RTD LITE 15 LIQUID ORAL

E

GLYTACTIN SWIRL 15PE

E

GOLDENROD E

GRASTEK 3 PA QL

HACKBERRY E

HCU EASY E

heparin lock flush intravenous solution 10 unitml

1

heparin sodium lock flush intravenous solution 100 unitml

1

HEPMED E

HIBICLENS E

HOMACTIN AA PLUS E

HOME PAP KIT E

HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

Drug Name Drug Tier Notes

HORSE EPITHELIUM E

HUMATROPEN FOR 12MG

E

HUMATROPEN FOR 24MG

E

HUMATROPEN FOR 6MG

E

HYALGAN E SP

HYLAFEM E

HYMOVIS E SP

INSPIREASE RESERVOIR BAGS

2

INTERCEED E

IOSAT E

isoflurane 1

JOHNSON GRASS E

JUNE GRASS POLLEN STANDARDIZED

E

KAPOK E

KETAMINE HCL SUBLINGUAL

3

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-09 MG5ML-

E

KETOVIE LIQUID ORAL

E

KETOVIE PEPTIDE E

KOCHIA E

LENSCALE E

LIMBREL E

LIMBREL250 E

LIMBREL500 E

LORMATE E

MACRILEN E

MEADOW FESCUE GRASS POLLEN

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

116

Drug Name Drug Tier Notes

MELALEUCA E

MESQUITE E

METHACHOLINE CHLORIDE INHALATION

E

METHAVER E

methergine oral 1 QL

METHOHEXITAL SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG10ML

E

methylergonovine maleate oral

1 QL

METOPIRONE E

MINIMED PUMP RESERVOIR 3ML

E

MITE (D FARINAE) SUBCUTANEOUS

E

MITE (D PTERONYSSINUS) SUBCUTANEOUS

E

MIXED ASPERGILLUS E

MIXED FEATHERS E

MIXED RAGWEED E

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100-1100-1100 MCG

E

MKO MELT DOSE PACK

E

mlk f1 E

mlk f2 E

mlk f3 E

mlk f4 E

MONOVISC E SP

MORCIN E

MOUNTAIN CEDAR E

Drug Name Drug Tier Notes

MOUSE EPITHELIUM E

MSUD EASY E

MUCOR SUBCUTANEOUS

E

MUCOTROL E

MUGARD E

MUGWORT E

MYOBLOC 3 PA SP

NEODOT THERMOMETER

E

NICAPRIN E

NICAZYME E

NORDIPEN 5 INJECTION DEVICE

E

ODACTRA 3 PA QL

odorless coated fish oil E

OLIVE TREE E

OMNIVEX E

ORALAIR 3 PA QL

ORALAIR ADULT STARTER PACK

3 PA QL

ORALAIR CHILDRENS STARTER PACK

3 PA QL

ORAMAGICRX E

ORCHARD GRASS POLLEN

E

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

OXBRYTA E SP

PALFORZIA E SP

PARI ALTERA NEBULIZER HANDSET

E

PARI TREK S COMBO PACK

E

PARI VORTEX ADULT MASK

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

117

Drug Name Drug Tier Notes

PEDIATRIC COMPRESSOR NEBULIZER

E

PENICILLIUM NOTATUM SUBCUTANEOUS

E

PH STRIPS E

PHEXXI E

PHOMA EXIGUA E

PHOTREXA-PHOTREXA VISCOUS KIT

3

PKU EASY E

PKU EASY MICROTABS

E

PKU GO E

PRAXBIND E

PRECEDEX INTRAVENOUS SOLUTION 1000 MCG250ML 200 MCG2ML 200 MCG50ML 400 MCG100ML 80 MCG20ML

E

PREMIUM CONDOMS LUBRICATED

E

PRID E

PRIVET E

PRO-CRITIC E

PROFESSIONAL DNA COLLECTION

E

PROLEVA E

PRONEB ULTRA FILTER SET

E

PSORIZIDE FORTE E

PSORIZIDE ULTRA E

PURAMINO DHAARA E

QUEEN PALM E

RABBIT EPITHELIUM E

RADIOGARDASE 3

Drug Name Drug Tier Notes

RAGWITEK 3 PA QL

RAPID GEL RX E

RED MAPLE E

RED MULBERRY E

RED TOP GRASS POLLEN

E

RESECTISOL E

RESOURCE THICKENUP JUICE

E

RHEUMATE E

RHIZOPUS E

RIBOZEL E

ROUGH MARSH ELDER

E

RUSSIAN THISTLE E

RUZURGI 3 PA SP

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS

E

SALICEPT MOUTHTHROAT SUSPENSION RECONSTITUTED

E

sevoflurane 1

SHAGBARK HICKORY E

SHARPS CONTAINER E

SHEEP SORREL E

SHORT RAGWEED POLLEN EXT

E

SILTREX E

SORBITOL IRRIGATION

E

sorbitol-mannitol E

SORRELDOCK MIX E

SPEEDGEL RX E

SPINRAZA 3 PA SP

SPINY PIGWEED E

STEMPHYLIUM E

SUPARTZ FX E SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

118

Drug Name Drug Tier Notes

SUPRANE 3

SWEET GUM E

SWEET VERNAL GRASS POLLEN

E

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

SYRINGE AVITENE E

TACHOSIL 3

TALL RAGWEED E

terrell 1

THROMBI-GEL 10 E

THROMBI-GEL 100 E

THROMBI-GEL 40 E

THROMBI-PAD E

THYROGEN 2 PA SP

TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS

E

TISSEEL EXTERNAL KIT

3

TOBAKIENT E

TRANZGEL E

TRAUMEEL EXTERNAL OINTMENT

E

TRAUMEEL ORAL TABLET

E

TRICHOPHYTON MENTAGROPHYTES

E

TRICHOPHYTON SUBCUTANEOUS

E

TRILURON E SP

TRUSTEEL INFUSION SET

E

T-SUPPORT MAX E

Drug Name Drug Tier Notes

TYLACTIN BUILD 20PE TYR

E

TYLACTIN COMPLETE 15 PE

E

TYLACTIN RESTORE 10

E

TYLACTIN RESTORE 5PE

E

TYLACTIN RTD 15 E

TYR EASY E

TYROS 2 E

ULTANE 3

ULTRA HERS RX E

ULTRA HIS E

ULTRA PCOS E

ULTRAFOAM SPONGE 2X625X7CM

E

ULTRAFOAM SPONGE 8X125X1CM

E

ULTRAFOAM SPONGE 8X125X3CM

E

ULTRAFOAM SPONGE 8X25X1CM

E

ULTRAFOAM SPONGE 8X625X1CM

E

VARISOFT INFUSION SET

E

VASCULERA E

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

$0 QL

vcf vaginal contraceptive vaginal gel

$0 QL

VILACTIN AA PLUS E

VILTEPSO E SP

VISTOGARD 3

VITRASE INJECTION SOLUTION

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

119

Drug Name Drug Tier Notes

WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

WELLMIND VERTIGO E

westab max E

WESTERN JUNIPER E

WHITE BIRCH E

WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

WHITE MULBERRY E

WHITE OAK E

WHITE PINE E

WIDE-SEAL DIAPHRAGM 60

$0 QL

WIDE-SEAL DIAPHRAGM 65

$0 QL

WIDE-SEAL DIAPHRAGM 70

$0 QL

WIDE-SEAL DIAPHRAGM 75

$0 QL

WIDE-SEAL DIAPHRAGM 80

$0 QL

WIDE-SEAL DIAPHRAGM 85

$0 QL

WIDE-SEAL DIAPHRAGM 90

$0 QL

WIDE-SEAL DIAPHRAGM 95

$0 QL

XEOMIN 3 PA SP

XIAFLEX 2 PA SP

XYZBAC E

XYZMUNE E

YELLOW DOCK E

Drug Name Drug Tier Notes

YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS

E

ZOKINVY 3 PA SP QL

ZYVEXOL E

ZYVIT E

Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation

ACULAR 3

ACULAR LS 3

ACUVAIL E

ALAWAY E

ALOCRIL E

ALOMIDE 3

ALREX E

AZASITE 3

azelastine hcl ophthalmic

1

bacitracin ophthalmic 1

BEPREVE E

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

BLEPH-10 3

bromfenac sodium (once-daily)

1 QL

BROMSITE E

CILOXAN 3

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

120

Drug Name Drug Tier Notes

dexamethasone sodium phosphate ophthalmic

1

DEXTENZA E SP

DEXYCU E

diclofenac sodium ophthalmic

1

DUREZOL E

epinastine hcl 1

erythromycin ophthalmic

1

eye itch relief E

EYSUVIS 3 PA

FLAREX 3

fluorometholone ophthalmic

1

flurbiprofen sodium 1

FML 2

FML FORTE 3

FML LIQUIFILM 3

gatifloxacin ophthalmic 1

gentak ophthalmic ointment

1

gentamicin sulfate ophthalmic solution

1

ILEVRO E

ILUVIEN INTRAVITREAL

E SP

INVELTYS 3

ketorolac tromethamine ophthalmic

1

KLARITY-A E

KLARITY-L E

levofloxacin ophthalmic 1

LOTEMAX OPHTHALMIC GEL

E

LOTEMAX OPHTHALMIC OINTMENT

E

Drug Name Drug Tier Notes

LOTEMAX OPHTHALMIC SUSPENSION

3

LOTEMAX SM 3

loteprednol etabonate ophthalmic gel

1 QL

loteprednol etabonate ophthalmic suspension

1

MAXIDEX 3

MITOSOL 3

MOXEZA 2

moxifloxacin hcl (2x day)

1

moxifloxacin hcl ophthalmic solution

1

MOXIFLOXACIN HCL OPHTHALMIC SOLUTION PREFILLED SYRINGE

E

NATACYN 2

NEVANAC E

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl solution 01 ophthalmic (otc)

E

olopatadine hcl solution 01 ophthalmic (rx)

1

olopatadine hcl solution 02 ophthalmic (otc)

E

olopatadine hcl solution 02 ophthalmic (rx)

1

OZURDEX INTRAVITREAL

E SP

PATADAY OPHTHALMIC SOLUTION 01 02

E

POVIDONE-IODINE OPHTHALMIC

3

PRED FORTE 3

PRED MILD 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

121

Drug Name Drug Tier Notes

PREDNISOL ACE-MOXIFLOX-BROMFEN

E

prednisolone acetate ophthalmic

1

prednisolone acetate p-f

E

prednisolone sodium phosphate ophthalmic

1

PREDNISOLON-MOXIFLOX-NEPAFENAC

E

PROLENSA 2 QL

RETISERT INTRAVITREAL

E SP

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX 3

trifluridine ophthalmic 1

TRIPLE PMB E

TRIPLE PMK E

UPNEEQ 3 PA

VANCOMYCIN HCL OPHTHALMIC

3

VIGAMOX 3

YUTIQ E SP

ZADITOR E

ZERVIATE E

ZIRGAN 3

ZYMAXID 3

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

ALPHAGAN P OPHTHALMIC SOLUTION 01

2

ALPHAGAN P OPHTHALMIC SOLUTION 015

E

Drug Name Drug Tier Notes

apraclonidine hcl 1

AZOPT 3

betaxolol hcl ophthalmic

1

BETIMOL 3

BETOPTIC-S 3

bimatoprost ophthalmic 1 QL

brimonidine tartrate ophthalmic

1

BRIMONIDINE-DORZOLAMIDE

E

brinzolamide 1

carteolol hcl 1

COMBIGAN 2

COSOPT 3

COSOPT PF OPHTHALMIC SOLUTION 2-05

3

DORZOLAMIDE HCL SOLUTION 2 OPHTHALMIC

3

dorzolamide hcl solution 2 ophthalmic

1

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

1

DURYSTA E

IOPIDINE OPHTHALMIC SOLUTION 1

3

ISOPTO CARPINE 3

ISTALOL 3

KEVEYIS 3 PA SP QL

latanoprost ophthalmic 1

LATANOPROST-TIMOLOL MALEATE

E

levobunolol hcl ophthalmic solution 05

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

122

Drug Name Drug Tier Notes

LUMIGAN OPHTHALMIC SOLUTION 001

2 QL

methazolamide oral 1

PHOSPHOLINE IODIDE

2

pilocarpine hcl ophthalmic solution 1 2 4

1

RHOPRESSA 3 QL

ROCKLATAN 3 QL

SIMBRINZA 2

timolol maleate ophthalmic

1

timolol maleate pf 1

TIMOLOL-BRIMON-DORZOL-LATANOPR

E

TIMOLOL-BRIMONIDINE-DORZOLAMID

E

TIMOLOL-DORZOLAMID-LATANOPROST

E

TIMOPTIC E

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 025

3

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 05

E

TIMOPTIC-XE E

TRAVATAN Z 3 QL

travoprost (bak free) 1 QL

TRUSOPT 3

VYZULTA E

XALATAN 3

XELPROS 3 ST QL

ZIOPTAN E

Drug Name Drug Tier Notes

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac 1

AKTEN 3

ALCAINE 3

ALTACAINE 3

altachlore E

ALTAFLUOR BENOX E

altafrin ophthalmic solution 10 25

1

artificial eye E

artificial tears ophthalmic solution 05-06 14

E

atropine sulfate ophthalmic ointment

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 001

E

atropine sulfate ophthalmic solution 1

1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unitgm

1

bacitra-neomycin-polymyxin-hc

1

BEOVU E SP

BEVACIZUMAB 3 SP

bimatoprost external E

BIO GLO E

BLEPHAMIDE 3

BLEPHAMIDE SOP 3

carboxymethylcellulose sodium ophthalmic solution 05

E

CEQUA E

CHONDROITIN SULFATE OPHTHALMIC

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

123

Drug Name Drug Tier Notes

cvs lubricant eye drops ophthalmic solution 04-03

E

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

E

CYSTADROPS 3 PA SP QL

CYSTARAN 3 PA SP QL

DOUBLE PM E

EYLEA INTRAVITREAL

3 PA SP

FLUCAINE E

FLUORESCEIN SODIUMBENOXINATE

E

fluorescein-benoxinate E

fluor-i-strips at E

FLURA-SAFE E

FUL-GLO E

GELFILM OPHTHALMIC

E

GENTEAL TEARS NIGHT-TIME

E

GENTEAL TEARS OPHTHALMIC SOLUTION 01-03

E

GENTEAL TEARS SEVERE DAYNIGHT

E

GLOSTRIPS OPHTHALMIC STRIP 1 MG

E

GREEN GLO LISSAMINE GREEN

E

homatropaire 1

HYPOCYN EXTERNAL SOLUTION

E

ISOPTO ATROPINE 3

LACRISERT 3

Drug Name Drug Tier Notes

LASTACAFT E

LATISSE E

lubricant eye drops ophthalmic solution 04-03

E

lubricant eye drops pf E

lubricant eye pm E

lubricant pm E

lubricating eye drops E

lubricating plus eye drops

E

LUCENTIS INTRAVITREAL

2 PA SP

LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 VGML

3 PA SP

MAXITROL 3

MURO 128 OPHTHALMIC OINTMENT

E

MURO 128 OPHTHALMIC SOLUTION 5

E

MYDRIACYL E

neomycin-bacitracin zn-polymyx

1

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 35-10000-01

1

neomycin-polymyxin-gramicidin ophthalmic solution 175-10000-025

1

neomycin-polymyxin-hc ophthalmic suspension 35-10000-1

1

neo-polycin 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

124

Drug Name Drug Tier Notes

neo-polycin hc 1

OXERVATE 3 PA SP QL

PAREMYD E

phenylephrine hcl ophthalmic solution 10 25

1

polycin 1

polymyxin b-trimethoprim

1

POLYTRIM 3

PRED-G 3

PRED-G SOP 3

PREDNISOLONE ACETATE-NEPAFENAC

E

PREDNISOLONE ACET-MOXIFLOXACIN

E

PREDNISOLONE-BROMFENAC

E

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION

E

PREDNISOLONE-MOXIFLOXACIN

E

PREDNISOLON-GATIFLOX-BROMFENAC

E

PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-05-0075

E

proparacaine hcl ophthalmic

1

proparacaine-fluorescein

E

REFRESH RELIEVA E

REFRESH RELIEVA PF OPHTHALMIC SOLUTION 05-09

E

Drug Name Drug Tier Notes

RESTASIS 2 PA

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 005

2 PA

sodium chloride (hypertonic)

E

sulfacetamide-prednisolone ophthalmic solution

1

SYSTANE COMPLETE E

SYSTANE HYDRATION PF

E

SYSTANE ULTRA PF E

tetracaine hcl ophthalmic

1

TOBRADEX OPHTHALMIC OINTMENT

3

TOBRADEX OPHTHALMIC SUSPENSION

E

TOBRADEX ST 3

tobramycin-dexamethasone

1

tropicamide ophthalmic E

TROPICAMIDE-CYCLOPENTOLATE-PE

E

TROPICAMIDE-PHENYLEPHRINE

E

TROPIC-CYCLOPENT-PE-KETOROLAC

E

TROPIC-CYCLOP-PE-KETO-PROPAR

E

TROPIC-PROPARACA-PE-KETOROLAC

E

ultra fresh pm E

ultra lubricating eye drops

E

VISIONBLUE 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

125

Drug Name Drug Tier Notes

VISTA GEL DRY EYE RELIEF

E

VISTA MEIBO TEARS E

VISTA TEARS E

VISUDYNE 3 SP

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CETRAXAL 3 ST

CIPRO HC 3

CIPRODEX E

ciprofloxacin hcl otic 1 ST

ciprofloxacin-dexamethasone

1

CIPROFLOXACIN-FLUOCINOLONE PF

E

cortic-nd 1

CORTISPORIN-TC 3

DERMOTIC 3

exotic-hc 1

flac 1

fluocinolone acetonide otic

1

hydrocortisone-acetic acid

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTIPRIO E

OTOVEL E

PRAMOTIC 3

Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold

12 hour allergy-d E

12 hour nasal decongestant nasal

E

Drug Name Drug Tier Notes

12hr allergy amp congestion

E

24hr allergy relief E

ADRENALIN NASAL E

all day allergy d E

all day allergy d-12 E

allergy 24hour indooroutdoor

E

allergy 24-hr E

allergy childrens E

allergy rel child (loratadine)

E

allergy relief cetirizine E

allergy relief d-12 E

allergy relief oral capsule 10 mg

E

allergy relief oral tablet 10 mg 180 mg 25 mg 4 mg

E

allergy relief oral tablet dispersible

E

allergy reliefindooroutdoor

E

allergy reliefnasal decongest oral tablet extended release 12 hour

E

allergy relief-d oral tablet extended release 12 hour

E

antihistamine amp nasal deconges

E

aurodryl allergy childrens

E

azelastine hcl nasal 1 QL

azelastine-fluticasone 1 QL

banophen oral capsule 25 mg

E

banophen oral tablet E

BECONASE AQ 3 QL

benzonatate 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

126

Drug Name Drug Tier Notes

carbinoxamine maleate oral solution

1

carbinoxamine maleate oral tablet 4 mg

1

carbinoxamine maleate oral tablet 6 mg

E

cetirizine hcl childrens oral tablet chewable 5 mg

E

cetirizine hcl oral solution

1

cetirizine hcl oral tablet E

cetirizine hcl oral tablet chewable 10 mg

E

cetirizine-pseudoephedrine er

E

chest congestion relief dm oral syrup

E

chest congestion relief oral syrup

E

chlorpheniramine maleate er

E

CHLOR-TRIMETON ORAL TABLET

E

CINQAIR 3 PA SP

CLARINEX ORAL TABLET

E

CLARINEX-D 12 HOUR

E

CLARITIN CHILDRENS TABLET CHEWABLE 5 MG ORAL

E

CLARITIN ORAL TABLET

E

CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG

E

CLARITIN-D 12 HOUR E

clemastine fumarate oral tablet 268 mg

1

cold amp flu relief daytime E

Drug Name Drug Tier Notes

coldflu daytime relief E

cough dm oral suspension extended release

E

coughchest congestion dm

E

CUROSURF INTRATRACHEAL SUSPENSION 120 MG15ML

3

cyproheptadine hcl oral 1

DAYHIST ALLERGY 12 HOUR RELIEF

E

daytime cold amp flu relief oral capsule

E

daytime coldflu relief oral capsule

E

DERMACINRX AZENASE PAK

E

desloratadine oral tablet

1

desloratadine oral tablet dispersible 5 mg

1

dexchlorpheniramine maleate oral solution

E

DICOPANOL FUSEPAQ

E

DICOPANOL RAPIDPAQ

E

dimaphen dm coldcough oral liquid

E

DI-PHEN E

diphen oral elixir 1

diphenhydramine hcl injection

E

diphenhydramine hcl oral capsule

E

diphenhydramine hcl oral elixir

1

diphenhydramine hcl oral liquid 125 mg5ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

127

Drug Name Drug Tier Notes

diphenhydramine hcl oral tablet 25 mg

E

DYMISTA 2 QL

FASENRA 2 PA SP

FASENRA PEN 2 PA SP

fexofenadine hcl oral tablet 180 mg 60 mg

E

fexofenadine-pseudoephed er oral tablet extended release 12 hour

E

flunisolide nasal solution 25 mcgact (0025)

1 QL

fluticasone propionate nasal

1

geri-dryl oral liquid E

geri-dryl oral tablet E

GILPHEX TR E

giltuss severe sinus E

goodsense tussin dm max

E

guaiatussin ac 1 PA QL

guaifenesin ac 1 PA QL

guaifenesin oral tablet 400 mg

E

guaifenesin-dm oral syrup

E

hm adult tussin cough amp chest

E

HYCODAN 3 PA QL

hydrocodone polst-chlorphen polst er susp oral suspension extended release

1 PA QL

hydrocodone-homatropine

1 PA QL

hydromet 1 PA QL

HYPERSAL 3

INFASURF INTRATRACHEAL

3

Drug Name Drug Tier Notes

ipratropium bromide nasal

1

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE

E

levocetirizine dihydrochloride oral

1

liquid allergy relief E

loratadine childrens oral tablet chewable

E

loratadine oral syrup E

loratadine oral tablet E

loratadine-d 12hr E

loratadine-d 24hr E

maxi-tuss ac 1 PA QL

maxi-tuss gmx E

maxi-tuss pe max E

m-dryl E

MICLARA LQ E

mometasone furoate nasal

1 QL

MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG5ML

E

MUCINEX CHILDRENS STUFFY NOSE

E

MUCINEX DM E

MUCINEX FAST-MAX DM MAX

E

mucus dm E

mucus relief d oral tablet extended release 12 hour 60-600 mg

E

mucus relief dm oral liquid

E

mucus relief max st E

mucus-d E

NASACORT ALLERGY 24HR

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

128

Drug Name Drug Tier Notes

nasal decongestant oral tablet 30 mg

E

nasal decongestant pe E

nasal moisturizing spray

E

nasal spray 12 hour E

nasal spray no drip E

NASONEX E

NEO-SYNEPHRINE COLDALLRG MILD

E

NEO-SYNEPHRINE COLDALLRGY EXT

E

NEO-SYNEPHRINE COLDALLRGY REG

E

NEOTUSS PLUS E

NUCALA 2 PA SP QL

olopatadine hcl nasal 1 QL

OMNARIS 3 QL

PATANASE 3 QL

pediaclear pd childrens E

PHENERGAN INJECTION

E

promethazine hcl injection

E

promethazine hcl oral 1

promethazine hcl rectal suppository 125 mg 25 mg

1

promethazine vc 1

promethazine vccodeine

1 PA QL

promethazine-codeine 1 PA QL

promethazine-dm oral syrup

1

promethazine-phenyleph-codeine

1 PA QL

promethazine-phenylephrine

1

promethegan 1

PROPEL E

Drug Name Drug Tier Notes

PROPEL MINI E

pseudoephedrine hcl er E

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg5ml

1

pseudoephedrine-guaifenesin er

E

QNASL 3 QL

QNASL CHILDRENS 3 QL

ROBITUSSIN 12 HOUR COUGH CHILD

E

ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG20ML

E

RYCLORA ORAL SOLUTION

3

ryvent E

sinus 12 hour E

SINUVA E

sodium chloride inhalation nebulization solution 09 10 3 7

1

SSKI E

SUDAFED CONGESTION

E

sudogest 12 hour E

sudogest maximum strength

E

sudogest oral tablet 30 mg

E

SURVANTA INTRATRACHEAL

3

TESSALON PERLES 3

triprolidine hcl oral liquid 0313 mgml 0625 mgml 0938 mgml 25 mg5ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

129

Drug Name Drug Tier Notes

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG

E

tussin cf multi-symptom cold

E

tussin dm max adult oral liquid 5-100 mg5ml

E

tussin dm max oral liquid 20-400 mg20ml

E

tussin dm oral syrup 100-10 mg5ml

E

TUXARIN ER E

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE

E

virtussin ac walc 1 PA QL

wal-tap coldallergy oral elixir

E

XHANCE E

XOLAIR 2 PA SP

ZETONNA 3 QL

ZYRTEC ALLERGY ORAL TABLET

E

Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE 3

acetylcysteine inhalation

1

ADRENALIN INJECTION SOLUTION 1 MGML

3

ADVAIR DISKUS 1 QL

ADVAIR HFA 2 QL

ADYPHREN E

ADYPHREN AMP E

ADYPHREN AMP II E

ADYPHREN II E

Drug Name Drug Tier Notes

AIRDUO DIGIHALER E

AIRDUO RESPICLICK 11314

E

AIRDUO RESPICLICK 23214

E

AIRDUO RESPICLICK 5514

E

albuterol sulfate er 1

albuterol sulfate hfa aerosol solution 108 (90 base) mcgact inhalation

1 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCGACT INHALATION

E

albuterol sulfate inhalation nebulization solution (25 mg3ml) 0083 063 mg3ml 125 mg3ml 25 mg05ml

1 QL

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MGML) 05 INHALATION

E

albuterol sulfate nebulization solution (5 mgml) 05 inhalation

1 QL

albuterol sulfate oral 1

ALVESCO E

ANORO ELLIPTA 2 QL

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG

3 PA SP

ARMONAIR DIGIHALER

E

ARNUITY ELLIPTA 2 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

130

Drug Name Drug Tier Notes

ASMANEX (120 METERED DOSES)

E

ASMANEX (14 METERED DOSES)

E

ASMANEX (30 METERED DOSES)

E

ASMANEX (60 METERED DOSES)

E

ASMANEX (7 METERED DOSES)

E

ASMANEX HFA E

ATROVENT HFA 3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 01 MG01ML

3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 015 MG015ML 03 MG03ML

E

BEVESPI AEROSPHERE

E

BREO ELLIPTA 2 QL

BREZTRI AEROSPHERE

2 QL

BROVANA 3 QL

budesonide inhalation 1 QL

BUDESONIDE-FORMOTEROL FUMARATE

E

COMBIVENT RESPIMAT

2 QL

cromolyn sodium inhalation

1

DALIRESP 3 PA

DUAKLIR PRESSAIR E

DULERA E

ELIXOPHYLLIN 2

epinephrine injection solution auto-injector 015 mg015ml

1 ST

Drug Name Drug Tier Notes

epinephrine injection solution auto-injector 015 mg03ml

1

EPINEPHRINE PROFESSIONAL

E

epinephrine solution auto-injector 03 mg03ml injection

1 ST

epinephrine solution auto-injector 03 mg03ml injection

1

EPINEPHRINESNAP-EMS

E

EPINEPHRINESNAP-V E

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR

3 ST

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR

E

EPISNAP E

ESBRIET 3 PA SP

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcgdose inhalation

1 QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcgdose inhalation

E

fluticasone-salmeterol aerosol powder breath activated 250-50 mcgdose inhalation

1 QL

fluticasone-salmeterol aerosol powder breath activated 250-50 mcgdose inhalation

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

131

Drug Name Drug Tier Notes

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCGACT 232-14 MCGACT 55-14 MCGACT

1 ST QL

fluticasone-salmeterol inhalation aerosol powder breath activated 500-50 mcgdose

E

GLASSIA 3 PA SP

INCRUSE ELLIPTA E

ipratropium bromide inhalation

1 QL

ipratropium-albuterol 1 QL

levalbuterol hcl inhalation nebulization solution 031 mg3ml 063 mg3ml 125 mg05ml 125 mg3ml

1 QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCGACT

E

LONHALA MAGNAIR REFILL KIT

3 QL

LONHALA MAGNAIR STARTER KIT

3 QL

montelukast sodium oral

1

OFEV 3 PA SP

PERFOROMIST 3 QL

PROAIR DIGIHALER E

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROLASTIN-C INTRAVENOUS SOLUTION

3 PA SP

Drug Name Drug Tier Notes

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

3 PA SP

PROVENTIL HFA E

PULMICORT FLEXHALER

2 QL

PULMICORT SUSPENSION

E

QVAR REDIHALER E

SEEBRI NEOHALER E

SEREVENT DISKUS 2 QL

SINGULAIR E

SPIRIVA HANDIHALER

2 QL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 125 MCGACT 25 MCGACT

2 QL

STERITALC 3

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 25-25 MCGACT

2 QL

STRIVERDI RESPIMAT

2 ST QL

SYMBICORT 2 QL

SYMJEPI 3

terbutaline sulfate injection

E

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

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

1

theophylline er oral tablet extended release 24 hour

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

132

INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCGACT

E

UTIBRON NEOHALER E

VENTOLIN HFA 2 QL

wixela inhub E

XOPENEX NEB 3 QL

XOPENEX CONCENTRATE

3 QL

XOPENEX HFA E

YUPELRI 3 QL

zafirlukast 1

ZEMAIRA 3 PA SP

zileuton er 1 ST

ZYFLO E

Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS E SP

BRONCHITOL E

BRONCHITOL TOLERANCE TEST

E

CAYSTON E SP

KALYDECO 3 PA SP

KITABIS PAK E SP

ORKAMBI 3 PA SP QL

PULMOZYME 2 PA SP

SYMDEKO 3 PA SP QL

TOBI NEBULIZER E SP

TOBI PODHALER 3 ST SP QL

tobramycin inhalation nebulization solution 300 mg4ml

1 SP

tobramycin nebulization solution 300 mg5ml inhalation

E SP

Drug Name Drug Tier Notes

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG5ML INHALATION

E SP

TRIKAFTA 3 PA SP QL

Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA 3 PA SP QL

ADEMPAS 2 PA SP QL

alyq 1 PA SP QL

ambrisentan 1 PA SP QL

bosentan 1 PA SP QL

epoprostenol sodium 1 PA SP

FLOLAN 3 PA SP

LETAIRIS 3 PA SP QL

OPSUMIT 2 PA SP QL

ORENITRAM 3 PA SP

REMODULIN INJECTION SOLUTION 100 MG20ML 20 MG20ML 200 MG20ML 50 MG20ML

E SP

REVATIO INTRAVENOUS

3 PA SP

REVATIO ORAL 3 PA SP QL

sildenafil citrate intravenous

1 PA SP

sildenafil citrate oral suspension reconstituted

1 PA SP QL

sildenafil citrate oral tablet 20 mg

1 PA SP QL

tadalafil (pah) 1 PA SP QL

TRACLEER 625 MG 125 MG

E SP

TRACLEER 32 MG 3 PA SP QL

treprostinil 1 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

133

Drug Name Drug Tier Notes

TRELEGY ELLIPTA 2 QL

TUDORZA PRESSAIR

Drug Name Drug Tier Notes

TYVASO 3 PA SP QL

TYVASO REFILL 3 PA SP QL

TYVASO STARTER 3 PA SP QL

UPTRAVI 3 PA SP QL

VELETRI 3 PA SP

VENTAVIS 3 PA SP QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX E

BACLOFEN EXTERNAL

E

baclofen intrathecal E

baclofen oral 1

carisoprodol oral 1

chlorzoxazone oral tablet 250 mg

1 QL

chlorzoxazone oral tablet 375 mg 500 mg 750 mg

1

CYCLOGABA 10300 E

cyclobenzaprine hcl er 1

cyclobenzaprine hcl oral tablet 5 mg 75 mg

1

cyclobenzaprine hcl tablet 10 mg oral

1

cyclobenzaprine hcl tablet 10 mg oral

E

CYCLOPAK E

CYCLOPHENE RAPIDPAQ

E

DANTRIUM ORAL CAPSULE 25 MG 50 MG

3

dantrolene sodium oral 1

enovarx-baclofen E

enovarx-cyclobenzaprine hcl

E

FEXMID 3

Drug Name Drug Tier Notes

FIRST-BACLOFEN E

GABLOFEN INTRATHECAL SOLUTION 10000 MCG20ML 20000 MCG20ML 40000 MCG20ML

E

GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 10000 MCG20ML 20000 MCG20ML 40000 MCG20ML 50 MCGML

E

LIORESAL E

LORZONE 3

METAXALL CP E

metaxalone 1

methocarbamol oral 1

NOPIOID-LMC KIT E

NORGESIC FORTE E

orphenadrine citrate er 1

orphenadrine-asa-caffeine

1

ORPHENGESIC FORTE ORAL TABLET 50-770-60 MG

E

OZOBAX E

SKELAXIN E

SOMA 3

TABRADOL FUSEPAQ E

TABRADOL RAPIDPAQ

E

tizanidine hcl oral 1

VANADOM 3

ZANAFLEX E

Sleep Disorder Agents

AMBIEN E

AMBIEN CR E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

134

Drug Name Drug Tier Notes

armodafinil 1 PA QL

BELSOMRA 3 ST QL

DAYVIGO 3 ST QL

doxepin hcl oral tablet 1 QL

EDLUAR E

eszopiclone 1 QL

flurazepam hcl 1 PA QL

HETLIOZ 3 PA SP QL

HETLIOZ LQ E SP

LUNESTA E

modafinil 1 PA QL

NUVIGIL E

PROVIGIL E

ramelteon 1 QL

RESTORIL E

ROZEREM 3 QL

SILENOR 3 QL

sleep aid (diphenhydramine)

E

sleep-aid oral capsule E

SUNOSI 2 PA QL

temazepam 1 QL

WAKIX 3 PA SP QL

XYREM 3 PA SP QL

XYWAV 3 PA SP QL

zaleplon 1 QL

zolpidem tartrate 1 QL

zolpidem tartrate er 1 QL

ZOLPIMIST 3 ST QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

135

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

136

Index of Drugs

12 hour allergy-d 12612 hour nasal decongestant12612hr allergy amp congestion 1261ST MEDX-PATCH LIDOCAINE1724hr allergy relief 1263232a infant formula 1127T LIDO 178 hour pain reliever 98 hr arthritis pain relief 9AAGC KIT IN TERODERM 60abacavir sulfate44abacavir sulfate-lamivudine 44abacavir-lamivudine-zidovudine44ABANEU-SL77ABILIFY43ABILIFY MAINTENA 43ABILIFY MYCITE 43ABILIFY MYCITE MAINTENANCE KIT 43ABILIFY MYCITE STARTER KIT 43abiraterone acetate 35ABRAXANE 35ABREVA 60ABSORICA 60ABSORICA LD60ACACIA112acamprosate calcium 20ACANYA 60acarbose 72ACCOLATE130ACCUCAINE17ACCU-CHEK AVIVA DEVICE73ACCU-CHEK AVIVA PLUS KIT WDEVICE73ACCU-CHEK COMPACT PLUS CONTROL 73ACCU-CHEK COMPACT PLUS TEST STRIPS 73ACCU-CHEK FASTCLIX LANCET KIT 73ACCU-CHEK GUIDE CONTROL 73ACCU-CHEK GUIDE TEST STRIPS 73ACCU-CHEK SMARTVIEW CONTROL 73ACCU-CHEK SMARTVIEW TEST STRIPS73ACCU-CHEK SOFTCLIX LANCET DEVICE KIT73

ACCU-CHEK TENDER 1 INFUSION112ACCU-CHEK ULTRAFLEX INF SET 112ACCUPRIL50ACCURETIC 50accutane 60ACD-A NOCLOT-5026acebutolol hcl 50ACESO AG 60acetaminophen 9acetaminophen 8 hour 9acetaminophen childrens 9acetaminophen er 9acetaminophen extra strength 9acetaminophen-codeine9acetaminophen-codeine 29acetaminophen-codeine 39acetaminophen-codeine 49acetazolamide122acetazolamide er122acetic acid 126acetylcysteine 130acid reducer 85ACIOXIAY 60ACIPHEX 85ACIPHEX SPRINKLE 85acitretin 60ACREMONIUM 112ACST KIT112ACTEMRA 105ACTEMRA ACTPEN105ACTHAR 97ACTHIB108ACTICLATE 21ACTIFOAM COLLAGEN SPONGE112ACTIMMUNE 105ACTIPHLORA 86ACTIQ 9ACTITROM-D 77ACTIVASE 26ACTIVE FE 77ACTIVE INJECTION D 94ACTIVE INJECTION KIT L 94ACTIVE INJECTION KL-3 94ACTIVE INJECTION LM-217ACTIVE INJECTION LM-DEP-2 94ACTIVELLA99ACTIVITE77ACTONEL 111ACTOPLUS MET 72

ACTOS72ACULAR 120ACULAR LS 120ACUNOL 112ACUVAIL120acyclovir 44ACYCLOVIX 44ACZONE 60ADACEL109ADAINZDE60ADAINZOXIA 60ADAKVEO112adapalene 60ADAPALENE 60ADAPALENE-BENZOYL PER-CLINDAMY 60ADAPALENE-BENZOYL PER-NIACINAM 60adapalene-benzoyl peroxide60ADAPALENE-BENZOYL PEROXIDE 60ADASUVE43adcf (05mgml) 77ADCETRIS35ADCIRCA133ADDERALL 56ADDERALL XR 56ADDYI 58adefovir dipivoxil 44ADEMPAS 133ADHANSIA XR56ADIPEX-P 58ADLYXIN72ADLYXIN STARTER PACK 72ADMELOG 75ADMELOG SOLOSTAR 75ADRENAL C FORMULA77ADRENALIN 126 130adriamycin35ADULT AEROSOL MASK112adult aspirin regimen14ADVAIR DISKUS 130ADVAIR HFA 130ADVANCED ALLERGY COLLECTION 60ADVATE48ADVIL14ADVIL JUNIOR STRENGTH 14ADVIL LIQUI-GELS MINIS 14ADVIL MIGRAINE14ADYNOVATE48ADYPHREN 130ADYPHREN AMP 130

137

ADYPHREN AMP II 130ADYPHREN II 130ADZENYS ER 56ADZENYS XR-ODT 56AEMCOLO 21AERIVA CONCENTRATOR NEBULIZER112AFINITOR 35AFINITOR DISPERZ35afirmelle 99AFLURIA QUADRIVALENT109AFREZZA75AFSTYLA 48AGONEAZE 17AGRYLIN 48aif 2 drug preparation kit 14AIF 3 DRUG PREPARATION KIT 14AIMOVIG34airavite 77AIRDUO DIGIHALER130AIRDUO RESPICLICK 11314130AIRDUO RESPICLICK 23214130AIRDUO RESPICLICK 5514130AJOVY 34AKLIEF60AKOVAZ 50ak-poly-bac 123AKTEN 123AKYNZEO30ALA SCALP 60ala-cort 60ALA-QUIN 31ALAWAY 120albendazole41ALBENZA41albuterol sulfate130ALBUTEROL SULFATE 130albuterol sulfate er 130albuterol sulfate hfa130ALBUTEROL SULFATE HFA 130ALCAINE123alclometasone dipropionate 60ALCOHOL PREP PADS 112ALCORTIN A 31ALDACTAZIDE 50ALDACTONE 50ALDARA60ALDER 112ALDURAZYME 91ALECENSA35alendronate sodium 111ALEVAMAX60

ALEVE 14ALFERON N 105alfuzosin hcl er 94ALIMTA 35ALINIA41ALIQOPA 35aliskiren fumarate50ALKERAN 35ALKINDI SPRINKLE 94all day allergy d 126all day allergy d-12126allergy 24hour indooroutdoor 126allergy 24-hr 126allergy childrens 126allergy rel child (loratadine)126allergy relief126allergy relief cetirizine 126allergy relief d-12 126allergy reliefindooroutdoor 126allergy reliefnasal decongest 126allergy relief-d 126allopurinol34ALLZITAL9almotriptan malate 34ALOCRIL120ALOE VESTA CLEAR ANTIFUNGAL 31ALOGLIPTIN BENZOATE 72ALOGLIPTIN-METFORMIN HCL72ALOGLIPTIN-PIOGLITAZONE 72ALOMIDE120ALORA99alosetron hcl86ALOXI 30ALPHAGAN P 122ALPHANATE48ALPHANINE SD48alprazolam 47alprazolam er 47alprazolam intensol 47alprazolam xr 47ALPROLIX 48ALREX 120ALTABAX21ALTACAINE 123ALTACE 50altachlore 123ALTAFLUOR BENOX 123altafrin 123altavera 99ALTERNARIA 112ALTOPREV50

ALTRENO 60alum amp mag hydroxide-simeth 86alumina-magnesia-simethicone 86ALUNBRIG36ALVESCO 130alvimopan86alyacen 13599alyacen 77799alyq 133amabelz 99amantadine hcl42AMARYL 72AMBIEN 134AMBIEN CR 134ambrisentan 133amcinonide60 61AMELUZ 61AMERGE 34AMERICAN BEECH112AMERICAN COCKROACH112AMERICAN ELM112amethia 99amethyst 99AMICAR 48amikacin sulfate 21amiloride hcl50amiloride-hydrochlorothiazide 50aminoacetic acid 92aminoamrms 77aminocaproic acid 48AMINOPMRMS112aminoreliefrms 77amiodarone hcl 50AMITIZA86amitriptyline hcl 29AMLODIPINE BES+SYRSPEND SF 50amlodipine besylate 50amlodipine besylate-benazepril hcl 50amlodipine besylate-valsartan 50amlodipine-atorvastatin50amlodipine-olmesartan50amlodipine-valsartan-hctz 50ammonium lactate61amnesteem 61AMONDYS 4591amoxapine 29amoxicill-clarithro-lansopraz 86amoxicillin 21amoxicillin-potassium clavulanate21

138

amoxicillin-potassium clavulanate er21AMPHETAMINE ER56amphetamine sulfate56amphetamine-dextroamphetamine 56amphetamine-dextroamphetamine er 56ampicillin 21ampicillin-sulbactam sodium 21AMPYRA57AMRIX134AMZEEQ61ANACAINE61ANAFRANIL29anagrelide hcl48ana-lex 110ANALPRAM HC 110ANALPRAM HC SINGLES 110ANALPRAM-HC110ANASPAZ 86anastrozole 36ANCOBON31ANDEXXA112ANDRODERM 96ANDROGEL96ANDROGEL PUMP 96ANGELIQ 99ANIMI-377ANIMI-3VITAMIN D77ANNOVERA99ANODYNE LPT17ANORO ELLIPTA 130antacid 86antacid anti-gas max strength86antacid calcium 86antacid calcium rich 86antacid extra strength 86antacid maximum86antacid regular strength 86antacid ultra strength 86antacidantigas86antacidanti-gas86ANTARA 50ANTICOAGULANT SODIUM CITRATE26anti-diarrheal 86 87antihistamine amp nasal deconges 126ANTIVENIN LATRODECTUS MACTANS 112ANTIVENIN MICRURUS FULVIUS112

anucort-hc 110ANUSOL-HC110ANZEMET30APADAZ9apap-caff-dihydrocodeine 9APEXICON E 61APIDRA SOLOSTAR 75APIDRA VIAL75APLENZIN 29APOKYN 42APP SLIM RMS 112apraclonidine hcl 122aprepitant 30apri 100APRISO 110APRIZIO PAK 17APRIZIO PAK II 17APTENSIO XR56APTIOM 27APTIVUS44AQUAPHILIC 61AQUASOL A 77ARAKODA 41ARALAST NP130aranelle 100ARANESP (ALBUMIN FREE)48ARAVA105ARAZLO61ARCALYST 105ARESTIN 59ARICEPT 29ARIDA 61ARIDOL113ARIKAYCE21ARIMIDEX36aripiprazole 43ARISTADA 43ARISTADA INITIO 43ARIXTRA 26ARIZONA CYPRESS113armodafinil 135ARMONAIR DIGIHALER 130ARMOUR THYROID104ARNUITY ELLIPTA130AROMASIN36ARRANON 36arsenic trioxide36arthritis pain reliever9ARTHROTEC14artificial eye 123artificial tears123ARTISS 113ARZERRA36

ARZOL SILVER NIT APPLICATORS61ASACOL HD 110ASCENIV 105ascomp-codeine9ASCOR 77ASCORBIC ACID77ascorbic acid 77asenapine maleate43ashlyna100asilnasalrms 113ASMANEX (120 METERED DOSES) 131ASMANEX (14 METERED DOSES) 131ASMANEX (30 METERED DOSES) 131ASMANEX (60 METERED DOSES) 131ASMANEX (7 METERED DOSES) 131ASMANEX HFA 131ASPARLAS 36ASPARTAME113ASPARTAME (NUTRASWEET) 113aspirin 14aspirin adult low strength 14aspirin childrens 14aspirin ec14aspirin ec low dose 14aspirin ec low strength 14aspirin low dose 14aspirin-dipyridamole er43ASPIRIN-OMEPRAZOLE 43ASTAGRAF XL 105ASTERO 17ASTRAZENECA COVID-19 VACCINE 109ASTRINGYN 48ATABEX OB77ATACAND50ATACAND HCT 50atazanavir sulfate44ATELVIA 111atenolol 50ATENOLOL+SYRSPEND SF 50atenolol-chlorthalidone50ATGAM 105athletes foot (terbinafine) 31ATIVAN 47atomoxetine hcl56ATOPADERM 61

139

ATOPICLAIR61atorvastatin calcium 50atovaquone 41atovaquone-proguanil hcl41ATRALIN61ATRIPLA 44ATROPEN87atropine sulfate 87 123ATROPINE SULFATE 87 123ATROVENT HFA 131AUBAGIO57aubra100aubra eq100AUGMENTIN 21AUGMENTIN ES-600 21AUREOBASIDIUM113aurodryl allergy childrens 126aurophen childrens 9aurovela 1530 100aurovela 120 100aurovela 24 fe 100aurovela fe 1530 100aurovela fe 120 100AURYXIA 92AUSTEDO58AUSTRALIAN PINE 113AUTOLET LANCING DEVICE 73AUTOSOFT 30 INFUSION SET 113AUTOSOFT 90 INFUSION SET 113AUTOSOFT XC INFUSION SET 113AUVI-Q131AVAILNEX 113AVALIDE50AVAPRO 50AVAR CLEANSER61AVAR LS CLEANSER 61AVAR-E EMOLLIENT 61AVAR-E GREEN61AVAR-E LS 61AVASTIN36AVEED96AVEIDAOXIA 61aviane 100avidoxy21AVIDOXY DK 21AVITA61AVITENE113AVITENE FLOUR 113AVODART94AVONEX PEN57

AVONEX PREFILLED 57AVSOLA105AXONA 113AYGESTIN100ayuna 100AYVAKIT36azacitidine 36AZADROX61AZALGIA113AZASAN105AZASITE 120azathioprine 105azathioprine sodium105azelaic acid 61AZELAIC ACID-NIACINAMIDE61azelastine hcl 120 126azelastine-fluticasone 126AZELEX 61AZESCHEW PRENATALPOSTNATAL77AZESCO 77AZILECT 42azithromycin21azo tabs 92AZOPT 122AZOR 50AZULFIDINE 110AZULFIDINE EN-TABS 110azurette 100B-12 COMPLIANCE INJECTION 77b-6 folic acid77bac 9BACICAP 87bacitracin21 120bacitracin zinc 21bacitracin-polymyxin b 123bacitra-neomycin-polymyxin-hc 123BACLOFEN134baclofen 134BACMIN 77BACTRIM21BACTRIM DS21BAFIERTAM 57BAHIA 113BALCOLTRA100BALD CYPRESS 113balsalazide disodium110balsam peru-castor oil 61BALVERSA 36balziva100BAMLANIVIMAB 105

banophen 126BANZEL 27BAQSIMI ONE PACK 75BAQSIMI TWO PACK75BARACLUDE 44BASAGLAR KWIKPEN 75BAVENCIO 36BAXDELA 21BAYBERRY (WAX MYRTLE) 113BAYER ASPIRIN 14BAYER ASPIRIN EC LOW DOSE14BCG VACCINE 109b-complexb-12 77BEAU RX 61BECONASE AQ126bekyree 100BELBUCA 9BELEODAQ 36belladonna alkaloids-opium 87BELRAPZO36BELSOMRA 135benazepril hcl50benazepril-hydrochlorothiazide 51BENDEKA36BENEFIX48BENICAR 51BENICAR HCT51BENLYSTA 105BENSAL HP61BENZ PER-CLIND-NIACIN-TRETIN 61BENZAC AC WASH61BENZACLIN61BENZACLIN WITH PUMP 61BENZALKONIUM CHLORIDE 21benzalkonium chloride 21BENZAMYCIN 61BENZEPRO 61benzepro 61BENZEPRO CREAMY WASH 61BENZEPRO FOAMING CLOTHS 61BENZEPRO SHORT CONTACT61BENZHYDROCODONE-ACETAMINOPHEN9BENZNIDAZOLE 41BENZODOX21BENZOIN 61benzoin compound61BENZO-LIDOCAINE-TETRACAINE 17

140

benzonatate 126BENZOYL PEROX-HYDROCORTISONE61benzoyl peroxide61BENZOYL PEROXIDE61BENZOYL PEROXIDE FORTE- HC 61benzoyl peroxide-erythromycin 61benzphetamine hcl58benztropine mesylate42BEOVU 123BEPREVE 120BERINERT105BERMUDA GRASS 113BESER61beser 61BESIVANCE 120BESPONSA 36BETA 1 KIT 94BETADINE OPHTHALMIC PREP 120BETALOAN SUIK 94BETAMETHASONE COMBO 94betamethasone dipropionate 61betamethasone dipropionate aug 61BETAMETHASONE DIPROP-MINOXIDIL61BETAMETHASONE SOD PHOS amp ACET94betamethasone sod phos amp acet 94betamethasone valerate 62BETAPACE51BETAPACE AF 51BETASERON57betaxolol hcl 51 122bethanechol chloride92BETHKIS133BETIMOL 122BETOPTIC-S 122BEVACIZUMAB 123BEVESPI AEROSPHERE131bexarotene 36BEXSERO109BEYAZ 100BHI URI-CONTROL 113BIAFINE 62bicalutamide36BICILLIN L-A21BICNU36BIDIL 51BIESTPROGESTERONE 100

BIIFENAC 1000 14BIIFENAC 500 14BIJUVA 100BIKTARVY 44BILTRICIDE 41bimatoprost 122 123BI-MIX 92BINOSTO111BIO GLO 123biocel77BIONECT 62biopetit 77BIOTHRAX109biotin 77bisacodyl 87bisacodyl ec 87bismuth subsalicylate87bisoprolol fumarate 51bisoprolol-hydrochlorothiazide 51BIVIGAM 105BLACK WILLOW113blanche 62BLENREP 36bleomycin sulfate 36BLEPH-10 120BLEPHAMIDE123BLEPHAMIDE SOP 123BLINCYTO 36blisovi 24 fe 100blisovi fe 1530 100blisovi fe 120 100blue tube aloe 17BLUESTAR 73BONIVA 111BONJESTA 30BOOSTRIX 109BORTEZOMIB 36bosentan 133BOSULIF36BOTOX 113BOTOX COSMETIC 62BOTRYTIS 113bp 10-162bp cleansing wash 62bp vit 3 77bp wash62BPCO62b-plex 77b-plex plus77BRAFTOVI 36BREATHE EASE HUMIDIFIER 113

BREATHE EASE NEB MASKCHILD 113BREATHE EASE NEB MASKINFANT113BREO ELLIPTA 131BREYANZI 36BREZTRI AEROSPHERE131BRIDION 113briellyn100BRILINTA43brimonidine tartrate 122BRIMONIDINE-DORZOLAMIDE122BRINEURA 91brinzolamide122BRISDELLE 29BRIVIACT 27BROME113bromfenac sodium (once-daily) 120bromocriptine mesylate42BROMSITE 120BRONCHITOL 133BRONCHITOL TOLERANCE TEST133BROVANA 131BRUKINSA36BRYHALI62BSP 082094budesonide 110 131budesonide er 110BUDESONIDE-FORMOTEROL FUMARATE131bumetanide 51BUMEX 51BUNAVAIL 20BUPAP9BUPHENYL91bupivacaine fisiopharma 17BUPIVACAINE HCL17 18bupivacaine hcl 17bupivacaine hcl (pf)17BUPRENEX 9buprenorphine9buprenorphine hcl 9 20buprenorphine hcl-naloxone hcl 20bupropion hcl 29bupropion hcl er (smoking det) 20bupropion hcl er (sr)29bupropion hcl er (xl) 29BUPROPION HCL ER (XL) 29buspirone hcl47

141

busulfan 36BUSULFEX 36butalbital-acetaminophen9BUTALBITAL-ACETAMINOPHEN9butalbital-apap-caff-cod 9butalbital-apap-caffeine9butalbital-asa-caff-codeine9butalbital-aspirin-caffeine 9butorphanol tartrate10BUTRANS10BYDUREON BCISE AUTOINJECTOR 72BYETTA 10 MCG PEN 72BYETTA 5 MCG PEN 72BYNFEZIA PEN 97BYSTOLIC 51CABENUVA 44cabergoline 97CABLIVI 43CABOMETYX 36CADIRAMD18CADUET 51CAFERGOT 34caffeine citrate58calamine62CALAN SR 51calcidol 77CALCIFOL 77calcipotriene62CALCIPOTRIENE 62calcipotriene-betameth diprop62CALCIPOTRIENE-CLOBETASOL PROP62calcitonin (salmon) 111CALCITRENE 62calcitriol 62 112calcium acetate 92calcium acetate (phos binder)92calcium-folic acid plus d 77CALDOLOR 14CALIFORNIA PEPPER TREE 113CALQUENCE36CAMBIA 14camila100CAMINO PRO COMPLETEGLYTACTIN 113CAMPATH 36CAMPTOSAR 36camrese 100camrese lo 100CANASA 110CANCIDAS 31

candesartan cilexetil 51candesartan cilexetil-hctz51CANDIDA ALBICANS EXTRACT 113CANTHARIDIN 62CAPASTAT SULFATE35capecitabine36CAPEX62CAPLYTA43CAPRELSA36capsaicin 62CAPSAICIN-MENTHOL18CAPSFENAC PAK14CAPSINAC14captopril 51captopril-hydrochlorothiazide 51capzix62CARAC 62CARAFATE85CARBAGLU 77carbamazepine 27carbamazepine er 27CARBATROL 27carbidopa 42carbidopa-levodopa 42carbidopa-levodopa er 42carbidopa-levodopa-entacapone 42carbinoxamine maleate127carboplatin 36carboxymethylcellulose sodium 123CARDIOPLEGIA DEL NIDO FORMULA 77CARDIOPLEGIA IND PLASMA HIGH K77CARDIOPLEGIA IND PLASMA-TROMET 77CARDIOPLEGIA INDUCTION HIGH K77CARDIOPLEGIA INDUCTION LOW DEX 77CARDIOPLEGIA INDUCTION NON-ENR 78CARDIOPLEGIA MAIN LOW DEXTROSE 78CARDIOPLEGIA MAIN LOW TROMETHA78CARDIOPLEGIA MAIN PLASMA-TROME 78CARDIOPLEGIA MAINTENANCE78

CARDIOPLEGIA REPERFUSATE 41 78CARDIOVID PLUS113CARDIZEM 51CARDIZEM CD 51CARDIZEM LA51CARDURA 51CARDURA XL94CARETOUCH 2 CPAP HOSE HANGER113CARETOUCH CONTROL SOL LEVEL 273CARETOUCH CPAP amp BIPAP HOSE113CARETOUCH CPAP MASK WIPES 113CARETOUCH CPAP PRE-WASH SOLN 113CARETOUCH CPAP TUBE BRUSH 113CARETOUCH LANCINGEJECTOR 73CARETOUCH TEST 73CARETOUCH UNIVERSL CPAP FILTER113CARIMUNE NF 105carisoprodol 134carisoprodol-aspirin-codeine10carmustine 36CARNITOR 78CARNITOR SF78CAROSPIR 51carteolol hcl122cartia xt 51CARTICEL 113carvedilol51carvedilol phosphate er51cascara sagrada 87CASIRIVIMAB105CASODEX 36caspofungin acetate32CAT HAIR EXTRACT 113CATAFLAM14CATAPRES-TTS-1 51CATAPRES-TTS-2 51CATAPRES-TTS-3 51CATHFLO ACTIVASE 26CATTLE EPITHELIUM113cavarest 59CAVERJECT92CAVERJECT IMPULSE92CAYA 113CAYSTON133

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caziant100CEDAR ELM 113cefaclor 21cefaclor er 21cefadroxil 21cefazolin sodium 21cefazolin sodium-dextrose 22cefdinir 22cefepime hcl22cefixime22CEFOTAN22cefotaxime sodium 22cefotetan disodium22cefoxitin sodium 22cefpodoxime proxetil 22cefprozil 22ceftazidime22ceftriaxone sodium22cefuroxime axetil 22CELEBREX14celecoxib 14CELESTONE SOLUSPAN94CELEXA29CELLCEPT 105CELLCEPT INTRAVENOUS 105CELONTIN27CEM-UREA62CENFOL 78CENTANY22CENTANY AT 22CENTRATEX 78cephalexin22CEPROTIN 48CEQUA 123CEQUR SIMPLICITY 2U 73CERACADE 62CERDELGA 91CEREBYX27CEREFOLIN 78cerefolin nac78CEREZYME 91cerovel 62CERVIDIL 92CETACAINE 18cetirizine hcl 127cetirizine hcl childrens127cetirizine-pseudoephedrine er127CETRAXAL 126CETROTIDE 97cevimeline hcl 59CHANTIX 20CHANTIX CONTINUING MONTH PAK20

CHANTIX STARTING MONTH PAK20charlotte 24 fe 100chateal 100chateal eq 100CHEMET78CHENODAL 87chest congestion relief 127chest congestion relief dm 127CHLOOXIA 62chloramphenicol sod succinate22chlordiazepoxide hcl 47chlordiazepoxide-amitriptyline29chlordiazepoxide-clidinium87chlorhexidine gluconate 59chloroquine phosphate41chlorpheniramine maleate er 127chlorpromazine hcl43chlorthalidone51CHLOR-TRIMETON 127chlorzoxazone134chocolated laxative 87CHOLBAM 91CHOLECAL DF78cholestyramine51cholestyramine light 51CHONDROITIN SULFATE 123chorionic gonadotropin97CHROMAGEN 78CIALIS92ciclodan32ciclopirox 32ciclopirox olamine 32ciclopirox treatment32CICLOPIROX-CLOBETASOL62CICLOPIROX-CLOBETASOL-SAL ACID62CICLOPIROX-SALICYLIC ACID 62cidofovir44CIFEREX 78cilostazol 43CILOXAN 120CIMDUO 44cimetidine85cimetidine hcl 85CIMETIDINE-LIDO-SALICYLIC ACID 62CIMZIA105CIMZIA PREFILLED KIT105CIMZIA STARTER KIT 105cinacalcet hcl 112CINQAIR 127

CINRYZE 105CIPRO22CIPRO HC 126CIPRODEX 126ciprofloxacin hcl 22 120 126ciprofloxacin-dexamethasone 126CIPROFLOXACIN-FLUOCINOLONE PF 126cisplatin 36CISPLATIN 36citalopram hydrobromide 29CITRANATAL BLOOM78CITRANATAL MEDLEY78citroma 87CITRULLINE EASY 91CLADOSPORIUM CLADOSPORIOIDES 113CLADOSPORIUM SPHAEROSPERMUM 114cladribine36claravis62CLARINEX 127CLARINEX-D 12 HOUR127clarithromycin22clarithromycin er22CLARITIN127CLARITIN CHILDRENS127CLARITIN REDITABS127CLARITIN-D 12 HOUR 127clearlax87clemastine fumarate127CLENIA PLUS62CLENPIQ 87CLEOCIN 22CLEOCIN-T62CLIMARA 100CLIMARA PRO 100CLINDACIN ETZ62clindacin etz 62CLINDACIN PAC 62clindacin-p62CLINDAGEL62CLINDAMY-BENZOYL PER-NIACINAM 62clindamycin hcl22clindamycin palmitate hcl 22CLINDAMYCIN PHOS-NIACINAMIDE 62clindamycin phosphate 22 62 63CLINDAMYCIN PHOSPHATE 62clindamycin phosphate-benzoyl peroxide62

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CLINDAMYCIN-NIACIN-TRETINOIN63clindamycin-tretinoin 63CLINDESSE22CLIND-NIACIN-SPIRONOLAC-TRETIN 63CLINOIN 63CLINPRO 5000 59clobazam27clobetasol prop emollient base 63clobetasol propionate63clobetasol propionate e63clobetasol propionate emulsion 63CLOBETASOL PROP-LEVOCETIRIZINE 63CLOBETASOL PROP-NIACINAMIDE 63CLOBETAVIX 63CLOBEX 63CLOBEX SPRAY 63clocortolone pivalate 63CLODAN 63clodan 63CLODERM 63clofarabine 36CLOLAR36clomiphene citrate97clomipramine hcl 29clonazepam47clonidine51clonidine hcl 51clonidine hcl er 56clopidogrel bisulfate 43clorazepate dipotassium 47clotrimazole32clotrimazole-betamethasone32clovique78clozapine43CLOZARIL 43COAGADEX48COAL TAR 63COARTEM 41COCAINE HCL 18COCKLEBUR114COD LIVER OIL78codeine sulfate10coenzyme q10114COLAZAL110COLCHICINE34colchicine 34colchicine-probenecid 34COLCIGEL114COLCRYS34

cold amp flu relief daytime127coldflu daytime relief 127COLD-EEZE NATURAL MULTI-SYMP114COLD-EEZE PLUS DEFENSE 114COLD-EEZE SUGAR FREE 114colesevelam hcl 51COLESTID 51COLESTID FLAVORED51colestipol hcl 51colistimethate sodium (cba) 22COLLATYL63COLY-MYCIN M 22COMBIGAN 122COMBIPATCH 100COMBIVENT RESPIMAT 131COMBIVIR 44COMETRIQ36COMFORT TOUCH ALCOHOL PREP 114COMPLERA44COMPRESSOR NEBULIZER114compro 30COMTAN 42CONCERTA56CONDOMS 114CONDYLOX63CONJUPRI51CONSENSI 51constulose87CONTOUR CONTROL SOLUTION73CONTOUR MONITOR DEVICE73CONTOUR MONITOR KIT WDEVICE 74CONTOUR NEXT CONTROL SOLUTION74CONTOUR NEXT EZ KIT WDEVICE 74CONTOUR NEXT LINK KIT WDEVICE 74CONTOUR NEXT MONITOR KIT WDEVICE74CONTOUR NEXT ONE KIT74CONTOUR NEXT TEST STRIPS 74CONTOUR TEST STRIPS74CONTRAST ALLERGY PREMED PACK94CONTRAVE 58CONVENIENCE PAK 58

CONZIP 10COPADERM 63COPASIL 63COPAXONE57COPIKTRA36CORDRAN63COREG51COREG CR51coremino 22CORGARD51CORIFACT48CORLANOR51corn amp callus remover 63CORN POLLEN 114CORTANE-B63CORTEF 94CORTENEMA 110cortic-nd 126CORTIFOAM 110CORTISPORIN-TC 126CORTROSYN 114CORVITE 150 78corvite fe 78COSELA 36COSENTYX (300 MG DOSE)105COSENTYX 150 MGML 105COSENTYX SENSOREADY (300 MG)105COSENTYX SENSOREADY PEN105COSMEGEN 36COSOPT122COSOPT PF 122cosyntropin114COTELLIC 36COTEMPLA XR-ODT 56cough dm 127coughchest congestion dm 127COVARYX 100COVARYX HS 100COVID-19 SPECIMEN COLLECTION 114COZAAR 51CREON 91CRESEMBA32CRESTOR 51CRINONE 100CRIXIVAN 44CROFAB 114cromolyn sodium87 120 131crotan 41cryselle-28100CRYSVITA 91

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CUBICIN 22CUBICIN RF 22CUPRIMINE92CUROSURF127CURVULARIA114CUTAQUIG 105CUTIVATE 63CUVITRU 105CUVPOSA 87cvs acetaminophen ex st 10cvs antacid extra strength 87cvs clotrimazole 3 32cvs gentle laxative87cvs lubricant eye drops 124cvs motion sickness 30cyanocobalamin 78CYANOCOBALAMIN 78cyclafem 135100cyclafem 777100CYCLOGABA 10300134cyclobenzaprine hcl 134cyclobenzaprine hcl er 134CYCLOGYL 124CYCLOMYDRIL 124CYCLOPAK 134cyclopentolate hcl 124CYCLOPHENE RAPIDPAQ134cyclophosphamide 36CYCLOPHOSPHAMIDE 36cycloserine 35CYCLOSET72cyclosporine 105CYCLOSPORINE IN KLARITY 124cyclosporine modified 105CYKLOKAPRON48CYMBALTA29cyproheptadine hcl127CYRAMZA 36cyred 100cyred eq 100CYSTADANE 91CYSTADROPS 124CYSTAGON91CYSTARAN 124cytarabine 36cytarabine (pf) 36CYTOGAM105CYTOMEL104CYTOTEC85cytra k crystals 78DHE 45 34d3 high potency78

d3 super strength 78dacarbazine 36DACOGEN37dactinomycin 37daflonex-xl78dalfampridine er 57DALIRESP 131danazol 96DANDELION 114DANTRIUM 134dantrolene sodium 134DANYELZA 37dapsone 35 63DAPSONE 63DAPSONE-NIACINAMIDE63DAPSONE-NIACINAMIDE-SPIRONOLAC 63DAPTACEL 109daptomycin22DARAPRIM 41darifenacin hydrobromide er 92DARZALEX 37DARZALEX FASPRO 37dasetta 135 100dasetta 777 100daunorubicin hcl37DAURISMO37DAYHIST ALLERGY 12 HOUR RELIEF 127DAYPRO14daysee 100daytime cold amp flu relief127daytime coldflu relief 127DAYTRANA 56DAYVIGO135DDAVP97DDAVP PF 97DDAVP RHINAL TUBE97DEBACTEROL59deblitane 100DECADRON 94DECARA 78decitabine37deferasirox 78deferasirox granules 78deferiprone78deferoxamine mesylate114DELESTROGEN100DELSTRIGO 45DELUO63delyla100DELZICOL 110demeclocycline hcl22

DEMEROL 10DEMSER51DENAVIR 45DENTA 5000 PLUS 59DENTAGEL59DEOXIA 63DEPAKOTE 27DEPAKOTE ER 27DEPAKOTE SPRINKLES 27DEPEN TITRATABS92DEPLIN 15 78DEPLIN 75 78DEPO-ESTRADIOL 100DEPO-MEDROL 94DEPO-PROVERA 100DEPO-SUBQ PROVERA 104100DEPO-TESTOSTERONE 96DERMACINRX AZENASE PAK127DERMACINRX CLORHEXACIN 59DERMACINRX EMPRICAINE 18DERMACINRX LEXITRAL PHARMAPAK 14DERMACINRX PENETRAL63DERMACINRX PHN 18DERMACINRX PRIZOPAK18DERMACINRX PUREFOLIX 78DERMACINRX SURGICAL COMBOPAK 63DERMACINRX THERAZOLE PAK32DERMACINRX ZRM 18DERMALID 18DERMA-SMOOTHEFS BODY63DERMA-SMOOTHEFS SCALP 63DERMELLE63DERMOTIC126DERMULCERA63DERPIXA 63DESCOVY 45DESENEX32DESFERAL 114desflurane 114desipramine hcl29desloratadine 127desmopressin ace spray refrig97desmopressin acetate97desmopressin acetate pf97desmopressin acetate spray 97desogestrel-ethinyl estradiol 100DESONATE 63

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desonide 63DESOWEN 63desoximetasone64DESOXYN 56DESVENLAFAXINE ER29desvenlafaxine succinate er29DETROL 92DETROL LA 92DEXABLISS 94dexamethasone 94dexamethasone intensol 94dexamethasone sod phosphate pf 94dexamethasone sodium phosphate 94 95 121DEXAMETHASONE SODIUM PHOSPHATE94 95dexchlorpheniramine maleate127DEXEDRINE 57DEXERYL 64DEXIFOL78DEXILANT 85dexmedetomidine hcl 114dexmedetomidine hcl in nacl114dexmethylphenidate hcl 57dexmethylphenidate hcl er 57DEXONTO 04 95dexrazoxane hcl37DEXTENZA121dextroamphetamine sulfate57dextroamphetamine sulfate er 57DEXYCU 121DFS DRMSMENTHCAP PAK15DFSMSMENTHCAP PAK 15DIACOMIT 27DIADIMAXIA 64DIALYVITE78DIALYVITE 300078DIALYVITE 500078DIALYVITE SUPREME D 78DIALYVITEZINC 78DIAOXIA 64diaper rash 64DIASDIMAXIA64DIASOXIA 64DIASTAT ACUDIAL 27DIASTAT PEDIATRIC27diazepam 27 47diazepam intensol 47diazoxide75DIBENZYLINE 51dibucaine (perianal) 64

DICLEGIS 30DICLOFENAC CAP 35MG15DICLOFENAC PATCH 13 15diclofenac potassium 15diclofenac sodium 15 64 121diclofenac sodium er 15diclofenac-misoprostol 15DICLOFENAC-NA HYALURON-NIACIN64DICLOFONO15DICLOPR 15DICLOSTREAM 15DICLOTREX 15DICLOVIX 15DICLOVIX M 15dicloxacillin sodium 22DICLOZOR 15DICOPANOL FUSEPAQ127DICOPANOL RAPIDPAQ 127dicyclomine hcl87diethylpropion hcl 58diethylpropion hcl er58DIFFERIN 64DIFICID 22diflorasone diacetate64DIFLUCAN 32diflunisal 15DIFMETIOXRIME 32DIGIFAB114digitek51digox 51digoxin51dihydroergotamine mesylate34DILANTIN27DILANTIN INFATABS 27DILATRATE-SR 51DILAUDID 10diltiazem hcl 52diltiazem hcl er 52diltiazem hcl er beads 51diltiazem hcl er coated beads 51DILTIAZEM HCL-DEXTROSE 52dilt-xr 52dimaphen dm coldcough127DIMENTHO15dimethyl fumarate 57dimethyl fumarate starter pack57DIMOXIA64DIOCHLOY 64diotame instydose 87DIOVAN 52DIOVAN HCT52DIPENTUM 110

diphen 127DI-PHEN 127diphenhydramine hcl127 128diphenoxylate-atropine87DIPHTHERIA-TETANUS TOXOIDS DT 109DIPROLENE 64DIPROLENE AF64dipyridamole43disopyramide phosphate52disulfiram20DITROPAN XL 92DIURIL 52divalproex sodium 27divalproex sodium er27DIVIGEL100DMT SUIK95docetaxel37docosanol64docusate calcium 87docusate mini87docusate sodium87docuzen 87dofetilide52DOG EPITHELIUM 114DOG FENNEL114DOJOLVI114dok 87donepezil hcl 29DONNATAL 87DOPTELET 48DORAL47DORYX 22DORYX MPC 22DORZOLAMIDE HCL 122dorzolamide hcl122dorzolamide hcl-timolol mal 122dorzolamide hcl-timolol mal pf 122dotti 100DOUBLE PM124DOUBLEDEX95DOVATO45DOVONEX 64doxazosin mesylate 52doxepin hcl29 64 135doxercalciferol112DOXIL 37doxorubicin hcl 37doxorubicin hcl liposomal37doxy 100 22doxycycline 64doxycycline hyclate 22 23DOXYCYCLINE HYCLATE23

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doxycycline monohydrate 23doxylamine-pyridoxine 30DR SMITHS ADULT BARRIER 64DRAXACE64DRAXACE LOTION CLEANSER64DRECHSLERA 114DRISDOL 78DRITHO-CREME HP 64DRIXECE 64DRIZALMA SPRINKLE 29dronabinol 30drospiren-eth estrad-levomefol100drospirenone-ethinyl estradiol100DROXIA 37droxidopa 52DRYSOL 64DSUVIA10DUAKLIR PRESSAIR 131DUAL COMPLEX FORMULA 1 KIT 15DUAVEE 100DUETACT 72DUEXIS15DULERA 131duloxetine hcl 29DUOBRII 64DUOPA 42DUPIXENT64DURAGESIC-100 10DURAGESIC-12 10DURAGESIC-25 10DURAGESIC-50 10DURAGESIC-75 10duramorph10DUREZOL121DURLAZA 43DUROLANE 114DURYSTA122DUST MITE MIXED ALLERGEN EXT114dutasteride 94dutasteride-tamsulosin hcl 94DUTOPROL 52d-vite pediatric78DXEVO 11-DAY95DYANAVEL XR57DYMISTA 128DYRENIUM52DYSPORT114DYURAL-40 95DYURAL-80 95DYURAL-L 95

DYURAL-LM 95EES GRANULES 23EASIVENT 114EASTERN COTTONWOOD 114easygel59EASYMAX 15 LEVEL 2-3 CONTROL 74EASYMAX CONTROL 74ECEOXIA 64EC-NAPROSYN15ec-naproxen 15ECONASIL32econazole nitrate32ECONAZOLE NITRATE-NIACINAMIDE 32ECOZA32EC-RX DHEA114EC-RX ESTRADIOL 100EC-RX PROGESTERONE 100EC-RX TESTOSTERONE 96ECZEMOL114EDARBI52EDARBYCLOR 52EDECRIN52EDEX 92EDLUAR 135ED-SPAZ 87EDURANT45EEMT 101EEMT HS 101efavirenz 45efavirenz-emtricitab-tenofovir45efavirenz-lamivudine-tenofovir 45EFFER-K78effer-k78EFFEXOR XR 29EFFIENT 43EFUDEX 64EGATEN 41EGRIFTA SV97EHA18ELAPRASE 91ELELYSO91ELEPSIA XR 27ELESTRIN 101ELETONE 64eletriptan hydrobromide 34ELFOLATE78ELFOLATE PLUS 78ELIDEL64ELIGARD 97ELIMITE 41elinest101

ELIQUIS26ELIQUIS DVTPE STARTER PACK 26ELITEK37ELIXOPHYLLIN 131ELLA 101ELLENCE37ELMIRON92ELOCTATE 48eluryng 101ELZONRIS 37EMCYT 37EMEND 31EMEND TRI-PACK 31EMFLAZA 34EMGALITY34EMGALITY (300 MG DOSE) 34emoquette 101EMPLICITI 37EMPRICAINE-II 18EMSAM29emtricitabine45emtricitabine-tenofovir df45EMTRIVA 45EMULSION SB 64EMVERM 41ENABLEX 92enalapril maleate52enalapril-hydrochlorothiazide 52ENBRACE HR 78ENBREL105ENBREL MINI 105ENBREL SURECLICK 105ENDARI 114ENDO AVITENE 114endocet 10ENDOMETRIN101ENFAGROW NEUROPRO TODDLER114ENFAMIL GENTLEASE114ENFAMIL INFANT 114ENFAMIL NEUROPRO INFANT 114ENFAMIL NEUROPRO SENSITIVE 115ENFAMIL NUTRAMIGEN 115ENFAMIL NUTRAMIGEN LIPIL115ENGERIX-B 109ENHERTU37ENLITE GLUCOSE SENSOR74ENLYTE 115enovarx-amitriptyline115

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enovarx-baclofen 134enovarx-cyclobenzaprine hcl 134ENOVARX-DICLOFENAC SODIUM15enovarx-ibuprofen 15enovarx-lidocaine hcl 18enovarx-naproxen 15enovarx-tramadol 64enoxaparin sodium26enpresse-28 101enskyce101ENSPRYNG105ENSTILAR 64entacapone 42entecavir 45ENTERAGAM 115ENTEREG87enteric fish oil 115ENTOCORT EC110ENTRESTO 52ENTTY SPRAY 64ENTYVIO 105ENU PRO3 PLUS 115enulose 87ENVARSUS XR 105ENZADYNE 91ENZNONUTY18ENZOCLEAR 64EPANED 52EPCLUSA 45ephedrine sulfate 52EPHEDRINE SULFATE-NACL 52EPICERAM 64EPICOCCUM 115EPIDIOLEX 27EPIDUO 64EPIDUO FORTE 64EPIFOAM64epinastine hcl 121epinephrine 131EPINEPHRINE PROFESSIONAL 131EPINEPHRINESNAP-EMS131EPINEPHRINESNAP-V 131EPIPEN 2-PAK 131EPIPEN JR 2-PAK 131epirubicin hcl 37EPISIL115EPISNAP 131epitol 27EPIVIR 45EPIVIR HBV45eplerenone 52

EPOGEN48epoprostenol sodium133EPZICOM45EQUACARE JR 115EQUETRO 47ERAXIS32ERBITUX 37ERGOCAL 78ergocalciferol79ergoloid mesylates 115ERGOMAR 34ergotamine-caffeine 34ERIVEDGE 37ERLEADA 37erlotinib hcl37errin101ERTACZO32ertapenem sodium 23ERWINAZE 37ery 64ERYGEL 64ERYPED 200 23ERYPED 400 23ERY-TAB 23ERYTHROCIN STEARATE 23erythromycin 23 64 121erythromycin base23erythromycin ethylsuccinate23ESBRIET131escitalopram oxalate 29ESGIC10ESKATA65ESMOLOL HCL 52ESOMEP-EZS 85esomeprazole magnesium85ESOMEPRAZOLE STRONTIUM85ESPEROCT 48ESSENTIAL CARE JR115est estrogens-methyltest101est estrogens-methyltest ds 101est estrogens-methyltest hs 101estarylla101estazolam47ESTRACE 101estradiol 101estradiol valerate101estradiol-norethindrone acet 101ESTRING 101ESTROGEL 101ESTROSTEP FE101eszopiclone 135ETESEVIMAB 105

ethacrynic acid 52ethambutol hcl35ethosuximide27ETHOXIA 65ethyl chloride18ethynodiol diac-eth estradiol 101ETHYOL37etodolac 15etodolac er 15etonogestrel-ethinyl estradiol 101ETOPOPHOS 37etoposide 37EUCRISA 65EUFLEXXA 115euthyrox 104EVAMIST 101EVEKEO 57EVEKEO ODT57EVENITY111everolimus37 106EVISTA 97EVKEEZA 52EVOCLIN 65EVOMELA37EVOTAZ45EVOXAC 59EVRYSDI 91EXELDERM 32EXELON 29exemestane 37EXFORGE 52EXFORGE HCT 52EXJADE 79EX-LAX ULTRA 87EXODERM32EXONDYS 51 91exotic-hc126EXPAREL 18EXTAVIA58EXTINA 32eye itch relief121EYLEA 124EYSUVIS 121EZALLOR SPRINKLE52ezetimibe52ezetimibe-simvastatin 52fabb 79FABIOR65FABRAZYME 91FALESSA101falmina 101famciclovir 45famotidine 85

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famotidine orig st85FANAPT43FANAPT TITRATION PACK 43FANATREX FUSEPAQ27FARESTON 37FARXIGA 72FARYDAK 37FASENRA 128FASENRA PEN128FASLODEX37FAVIPIRAVIR45fa-vitamin b-6-vitamin b-12 79fayosim101FBL KIT15febuxostat 34FEIBA48felbamate 27FELBATOL27FELDENE 15felodipine er 52FEM PH 92FEMARA 37FEMHRT LOW DOSE101FEMRING 101femynor 101fenofibrate 52fenofibrate micronized52fenofibric acid52FENOGLIDE 52fenoprofen calcium15fenortho15FENSOLVI (6 MONTH)97fentanyl 10fentanyl citrate10FENTANYL CITRATE10fentanyl citrate (pf) 10FENTANYL CITRATE-NACL 10FENTANYL-BUPIVACAINE-NACL 10 11FENTORA11FEONYX 79FERAHEME 79FERIVA 217 79FERIVAFA 79ferocon 79ferotrinsic 79FERRALET 90 79ferraplus 90 79FERRIPROX 79FERRIPROX TWICE-A-DAY 79FERRLECIT 79ferrocite plus 79FERRO-PLEX HEMATINIC 79

ferrous sulfate 79FETROJA23FETZIMA29FETZIMA TITRATION29FEXMID 134fexofenadine hcl128fexofenadine-pseudoephed er 128FIASP75FIASP FLEXTOUCH75FIASP PENFILL 75fiber 87fiber laxative87FIBRICOR52FIBRYGA 48FINACEA 65FINAPOD 65finasteride 65 94FINASTERIDE-MINOXIDIL65FINTEPLA27FIORICET 11FIORICETCODEINE11FIRAZYR106FIRDAPSE 115FIRE ANT115FIRMAGON97FIRMAGON (240 MG DOSE) 97FIRST-BACLOFEN 134FIRST-LANSOPRAZOLE 86FIRST-METRONIDAZOLE 23FIRST-MOUTHWASH BLM 59FIRST-OMEPRAZOLE 86FIRST-PROGESTERONE VGS 101FIRVANQ 23flac 126FLAGYL 23FLAREX 121flavoxate hcl 92FLEBOGAMMA DIF106flecainide acetate 53FLECTOR 15FLEXICHAMBER ADULT MASKSMALL 115FLEXICHAMBER CHILD MASKLARGE115FLEXICHAMBER CHILD MASKSMALL 115FLEXIN 18FLEXIPAK15FLOLAN 133FLOLIPID 53FLOMAX 94FLORIVA79

FLORIVA PLUS 79FLOVENT DISKUS 131FLOVENT HFA 131floxuridine37FLUAD 109FLUAD QUADRIVALENT 109FLUARIX QUADRIVALENT109FLUCAINE 124FLUCELVAX QUADRIVALENT 109fluconazole32FLUCON-IBUPROF-ITRACON-TERBINA 32flucytosine 32fludarabine phosphate 37fludrocortisone acetate95FLULAVAL QUADRIVALENT 109FLUMIST QUADRIVALENT109flunisolide 128FLUOCINOLONE ACET-NIACINAMIDE 65fluocinolone acetonide 65 126fluocinolone acetonide body 65fluocinolone acetonide scalp65fluocinonide65fluocinonide emulsified base65FLUOPAR 65FLUORESCEIN SODIUMBENOXINATE 124fluorescein-benoxinate124FLUORIDEX 59fluoridex daily renewal 59FLUORIDEX ENHANCED WHITENING 59FLUORIDEX SENSITIVITY RELIEF 59fluor-i-strips at 124fluoritab 79fluorometholone 121FLUOROPLEX65fluorouracil 37 65FLUOROURACIL65FLUOVIX65FLUOVIX PLUS 65fluoxetine hcl 29fluoxetine hcl (pmdd)29fluphenazine decanoate43fluphenazine hcl 43flurandrenolide 65FLURA-SAFE124flurazepam hcl135flurbiprofen 15flurbiprofen sodium 121

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flutamide 37fluticasone propionate65 128fluticasone-salmeterol 131 132FLUTICASONE-SALMETEROL132fluvastatin sodium 53fluvastatin sodium er 53fluvoxamine maleate 29fluvoxamine maleate er29FLUZONE HIGH-DOSE QUADRIVALENT 109FLUZONE QUADRIVALENT 109FML121FML FORTE121FML LIQUIFILM 121FOCALIN 57FOCALIN XR 57folbee 79folbee plus79FOLBEE PLUS CZ79FOLBIC RF 79FOLGARD OS 79FOLGARD RX79folic acid 79FOLIC D379FOLIC-K79FOLI-D 79FOLIKA PROBIOTIC 87FOLITE 79FOLITIN-Z79FOLIXAPURE 79FOLLISTIM AQ 97FOLOTYN 37folplex 2279foltanx 79FOLTANX RF79FOLTRATE 79FOLTREXYL 79foltrin 79FOLTX 79FOLVITE-D 79fondaparinux sodium26FORANE 115FORAXA 65FORFIVO XL30formaldehyde 115FORMALDEHYDE 115FORTAMET 72FORTAZ23FORTEO 111FORTESTA96FORTISCARE CONTROL 74

FORTISCARE GLUCOSE SYSTEM 74FORTISCARE T1 GLUCOSE SYSTEM 74FOSAMAX 111FOSAMAX PLUS D 111fosamprenavir calcium 45fosaprepitant dimeglumine31foscarnet sodium45FOSCAVIR45fosfomycin tromethamine23fosinopril sodium 53fosinopril sodium-hctz 53fosphenytoin sodium 27FOSRENOL 92FOSTEUM 79FOSTEUM PLUS 115FOTIVDA 37FRAGMIN 26FREESTYLE LIBRE 14 DAY READER 74FREESTYLE LIBRE 14 DAY SENSOR74FREESTYLE LIBRE 2 READER 74FREESTYLE LIBRE 2 SENSOR74FREESTYLE LIBRE READER74FREESTYLE LIBRE SENSOR SYSTEM 74FREESTYLE PRECISION NEO TEST 74FROTEK 15FROVA34frovatriptan succinate34FUL-GLO 124FULPHILA48fulvestrant 37FUNGIMEZ 32furosemide 53FUSARIUM 115FUSION PLUS 79FUZEON 45fyavolv101FYCOMPA 27gabapentin 27GABAPENTIN-NAPROXEN CMPD KIT15GABITRIL27GABLOFEN 134GALAFOLD91galantamine hydrobromide 29galantamine hydrobromide er 29

GALZIN 79GAMASTAN106GAMIFANT 106GAMMAGARD 106GAMMAGARD SD LESS IGA106GAMMAKED 106GAMMAPLEX 106GAMUNEX-C 106ganirelix acetate97 98GARDASIL 9109gas relief 87gas relief extra strength 87gas relief infants87GASTROCROM88gatifloxacin 121GATTEX88gavilax88gavilyte-c88gavilyte-g88gavilyte-h88gavilyte-n with flavor pack88GAVRETO 37GAZYVA 37GEAMETDRAY65GEBAUERS PAIN EASE 18GEBAUERS SPRAY AND STRETCH 18GELCLAIR 115GELFILM115 124GEL-FLOW 115GEL-FLOW NT 115GELFOAM 115GELFOAM COMPRESSED SIZE 100 115GELFOAM DENTAL PACK SIZE 4 115GELFOAM SPONGE 115GELFOAM SPONGE SIZE 100 115GELFOAM SPONGE SIZE 200 115GELFOAM SPONGE SIZE 50 115GELFOAM-JMI POWDER 115GELFOAM-JMI SPONGE 115GELNIQUE 92GELSYN-3 115GELUSIL88GELX 115gemcitabine hcl 37gemfibrozil 53gemmily101GEMTESA 92GEN7T 18

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GEN7T PLUS18GENADUR 65GENERESS FE 101generlac 88gengraf106GENICIN VITA-D 79GENICIN VITA-Q 79GENICIN VITA-S 79GENOTROPIN98GENOTROPIN MINIQUICK98gentak 121gentamicin sulfate 23 121GENTEAL TEARS 124GENTEAL TEARS NIGHT-TIME 124GENTEAL TEARS SEVERE DAYNIGHT 124gentle laxative 88GENVOYA 45GEODON 43geri-dryl 128geri-kot 88GERMAN COCKROACH115GIALAX 88GILENYA 58GILOTRIF 37GILPHEX TR128giltuss severe sinus128GIMOTI 31GIVLAARI 115GLASSIA132glatiramer acetate 58glatopa 58GLEEVEC 37GLEOLAN 115GLEOSTINE 37glimepiride72glipizide er72glipizide ir 72glipizide xl 72glipizide-metformin hcl 72GLOPERBA 34GLOSTRIPS 124GLUCAGEN HYPOKIT 75glucagon emergency kit 75GLUCAGON EMERGENCY KIT 75GLUCOSE CONTROL SOLUTIONS 74GLUCOTROL72GLUCOTROL XL 72GLUMETZA 72GLUTARALDEHYDE 115

glyburide 72glyburide micronized 72glyburide-metformin 72GLYCATE 88glycine92glycine urologic 92glycolax 88GLYCOPYRROLATE88glycopyrrolate88glycopyrrolate pf88glydo 18GLYNASE 72GLYRX-PF 88GLYTACTIN BETTERMILK 15115GLYTACTIN BETTERMILK DE-LITE 115GLYTACTIN BUILD 10PE 115GLYTACTIN BUILD 2020 116GLYTACTIN BUILD 2020 PKU116GLYTACTIN BURST116GLYTACTIN COMPLETE 10PE 116GLYTACTIN RESTORE 10 116GLYTACTIN RESTORE 5 116GLYTACTIN RESTORE LITE 10 116GLYTACTIN RESTORE LITE 10PE 116GLYTACTIN RTD 10 116GLYTACTIN RTD 15 116GLYTACTIN RTD LITE 15116GLYTACTIN SWIRL 15PE116GLYXAMBI72gnp senna lax88GOCOVRI 42GOLDENROD116GOLYTELY 88GONAL-F 98GONAL-F RFF 98GONAL-F RFF REDIJECT 98GONITRO 53goodsense antacid88goodsense antacid amp gas relief88goodsense anti-diarrheal 88goodsense aspirin low dose15goodsense ibuprofen 15goodsense motion sickness31goodsense nicotine 20goodsense pain relief11goodsense tussin dm max 128GOPRELTO 18GORDOFILM 65

GRALISE 58granisetron hcl 31GRANIX 48GRASTEK116GREEN GLO LISSAMINE GREEN 124griseofulvin microsize32griseofulvin ultramicrosize32guaiatussin ac 128guaifenesin128guaifenesin ac128guaifenesin-dm 128GUANENDRUX 65guanfacine hcl53guanfacine hcl er57GUANIDINE HCL35GUARDIAN CONNECT TRANSMITTER 74GUARDIAN LINK 3 TRANSMITTER 74GUARDIAN SENSOR (3) 74GVOKE HYPOPEN 1-PACK75GVOKE HYPOPEN 2-PACK75GVOKE PFS 75GYNAZOLE-1 32habitrol 20HACKBERRY116HAEGARDA106hailey 1530101hailey 24 fe101hailey fe 1530101hailey fe 120101HALAVEN 37halcinonide65HALCION 47HALDOL DECANOATE 43halobetasol propionate65HALOBETASOL PROPIONATE 65HALOG 65haloperidol 44haloperidol decanoate44haloperidol lactate44HALUCORT 65HARVONI45HAVRIX109HAXCHLO65HCU EASY116headache relief 11heather101HELIDAC THERAPY 88HEMADY95HEMANGEOL 53

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hematinic plus vitminerals79hematinicfolic acid79HEMATOGEN79HEMATOGEN FA 79HEMATRON-AF79HEMETAB79HEMLIBRA48HEMMOREX-HC 110HEMOCYTE PLUS 79hemocyte-f 79HEMOFIL M 48HEPAGAM B106heparin (porcine) in nacl 26heparin lock flush 116heparin sodium (porcine) 26heparin sodium (porcine) pf 26heparin sodium lock flush 116HEPLISAV-B109HEPMED116HEPSERA45HERCEPTIN 38HERCEPTIN HYLECTA37HERZUMA 38HETLIOZ135HETLIOZ LQ 135HIBERIX109HIBICLENS 116HIDEX 6-DAY 95high potency probiotic 88HIPREX23HIXDEFRIMA32HIZENTRA 106hm adult tussin cough amp chest 128hm stomach relief88hm stool softener 88HOMACTIN AA PLUS116homatropaire124HOME PAP KIT 116HONEY BEE VENOM116HORIZANT58HORSE EPITHELIUM116HPR PLUS 65hpr plus 65HPR PLUS HYDROGEL65HUMALOG KWIKPEN 75HUMALOG MIX 5050 KWIKPEN 75HUMALOG MIX 5050 VIAL76HUMALOG MIX 7525 KWIKPEN 76HUMALOG MIX 7525 VIAL76HUMALOG U-100 JUNIOR KWIKPEN 76

HUMALOG VIAL 76HUMATE-P 49HUMATROPE 98HUMATROPEN FOR 12MG 116HUMATROPEN FOR 24MG 116HUMATROPEN FOR 6MG 116HUMIRA106HUMIRA PEDIATRIC CROHNS START106HUMIRA PEN 106HUMIRA PEN-CDUCHS STARTER 106HUMIRA PEN-PEDIATRIC UC START 106HUMIRA PEN-PSUVADOL HS START 106HUMIRA PEN-PSORUVEIT STARTER 106HUMULIN 7030 KWIKPEN 76HUMULIN 7030 VIAL76HUMULIN N KWIKPEN 76HUMULIN N VIAL 76HUMULIN R U-500 KWIKPEN76HUMULIN R U-500 VIAL 76HUMULIN R VIAL 76HURRICAINE59HYALGAN116HYALURONATE-NIACINAM-TRETINOIN65HYALURONATE-NIACIN-TACROLIMUS 65HYALURONIC ACID-HYDROQUINONE 65HYCAMTIN 38HYCODAN 128hydralazine hcl 53HYDREA 38HYDRO 40 65hydrochlorothiazide53hydrocodone bitartrate er11hydrocodone polst-chlorphen polst er susp128hydrocodone-acetaminophen 11hydrocodone-homatropine 128hydrocodone-ibuprofen 11hydrocortisone 66 95 111hydrocortisone (perianal) 110hydrocortisone ace-pramoxine 65 110hydrocortisone acetate65 111hydrocortisone butyr lipo base 66hydrocortisone butyrate 66hydrocortisone valerate66

hydrocortisone-acetic acid 126hydrocortisone-iodoquinol32hydrocort-pramoxine (perianal) 111hydromet 128hydromorphone hcl 11hydromorphone hcl er 11HYDROMORPHONE HCL-NACL 11hydroquinone 66HYDROQUINONE 66HYDROQUINONE-HC-TRETINOIN66HYDROQUINONE-HYDROCORTISONE66hydroxychloroquine sulfate 41hydroxyprogesterone caproate101hydroxyurea 38hydroxyzine hcl 47hydroxyzine pamoate47HYLAFEM 116HYLATOPIC PLUS 66HYLAVITE79HYLAZINC 79HYMOVIS 116HYOPHEN 93hyoscyamine sulfate 88 89hyoscyamine sulfate er 88hyoscyamine sulfate sl88hyosyne89HYPERHEP B106HYPERRAB 106HYPERRAB SD 106HYPERRHO SD106HYPERSAL128HYPERTET SD106HYPOCYN 124HYQVIA 106HYSINGLA ER11HYZAAR 53ibandronate sodium 111IBRANCE 38IBUPAK15ibuprofen 15ibuprofen infants 15ICAR-C PLUS 80icatibant acetate106iclevia 101ICLUSIG38icosapent ethyl 53IDAMYCIN PFS 38idarubicin hcl 38IDELVION 49

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IDHIFA 38iferex 150 forte 80IFEX 38ifosfamide38ILARIS107ILEVRO121ILUMYA107ILUVIEN 121imatinib mesylate 38IMBRUVICA 38IMCIVREE58IMDEVIMAB107IMFINZI 38IMIOXIA 32imipenem-cilastatin 23imipramine hcl30imipramine pamoate 30imiquimod66IMIQUIMOD PUMP66IMIQUIMOD-LEVOCETIRIZIN-NIACIN66IMIQUIMOD-LEVOCET-TRETINOIN66IMITREX 34IMITREX STATDOSE REFILL34IMITREX STATDOSE SYSTEM 34IMLYGIC 38IMODIUM A-D89IMODIUM MULTI-SYMPTOM RELIEF 89IMOGAM RABIES-HT107IMOVAX RABIES109IMPAVIDO 41IMPEKLO 66IMPOYZ 66IMURAN107IMVEXXY MAINTENANCE PACK 101IMVEXXY STARTER PACK 101inavix15INBRIJA 42incassia 101INCRELEX 98INCRUSE ELLIPTA 132indapamide 53INDERAL LA 53INDERAL XL 53INDOCIN15INDOMETHACIN 15indomethacin15indomethacin er 15INFANRIX 109

infants gas relief89INFASURF 128INFED 80INFLAMMACIN 15INFLATHERM 16INFLECTRA 107INFUGEM 38INFUMORPH 200 11INFUMORPH 500 11INFUVITE ADULT80INFUVITE PEDIATRIC 80INGREZZA58INLYTA 38INNOPRAN XL53INOVA66INOVA 41 ACNE CONTROL THERAPY 66INOVA 82 ACNE CONTROL THERAPY 66INQOVI 38INREBIC 38INSPIREASE RESERVOIR BAGS 116INSPRA53instant oral pain relief max 59INSULIN ASP PROT amp ASP FLEXPEN76INSULIN ASPART 76INSULIN ASPART FLEXPEN 76INSULIN ASPART PENFILL76INSULIN ASPART PROT amp ASPART76INSULIN LISPRO76INSULIN LISPRO (1 UNIT DIAL)76INSULIN LISPRO JUNIOR KWIKPEN 76INSULIN LISPRO PROT amp LISPRO76INSULIN PEN NEEDLES76INSULIN SYRINGES 76INTEGRA F80INTEGRA PLUS80INTELENCE45INTERCEED 116INTRAROSA 93INTRON A45introvale 101INTUNIV57INVANZ23INVEGA 44INVEGA SUSTENNA44INVEGA TRINZA 44

INVELTYS121INVIRASE 45INVOKAMET72INVOKAMET XR72INVOKANA 72IODINE STRONG 80iodine tincture23IODOQUIMEZ-HC 32iodoquinol-hc-aloe polysacch32IODOQUINOL-HC-KETOCONAZOLE 32iodoquinol-hydrocortisone-aloe32IOPIDINE 122IOSAT 116IPOL109ipratropium bromide 128 132ipratropium-albuterol 132irbesartan 53irbesartan-hydrochlorothiazide53IRESSA38irinotecan hcl38IROSPAN 24680ISENTRESS45ISENTRESS HD 45isibloom101isoflurane 116ISOLYTE-S 80isoniazid 35ISOPTO ATROPINE 124ISOPTO CARPINE 122ISORDIL TITRADOSE 53isosorbide dinitrate53isosorbide mononitrate53isosorbide mononitrate er 53isotretinoin66ISOXSUPRINE HCL 53isoxsuprine hcl 53isradipine53ISTALOL 122ISTODAX (OVERFILL) 38ISTURISA 98ITHOXIA66itraconazole32ivermectin41IVERMECTIN-METRONIDAZOL-NIACIN 66IXEMPRA KIT 38IXIARO109IXINITY 49JADENU80JADENU SPRINKLE80jaimiess 101JAKAFI38

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JALYN94JANSSEN COVID-19 VACCINE 109jantoven 26JANUMET 72JANUMET XR 72JANUVIA72JARDIANCE72jasmiel101JATENZO96JELMYTO 38jencycla 101JENLIVA PRENATALPOSTNATAL80JENTADUETO 72JENTADUETO XR 72JEVTANA38jinteli 101JIVI49JOHNSON GRASS116jolessa101JORNAY PM 57JUBLIA32juleber 101JULUCA 45JUNE GRASS POLLEN STANDARDIZED 116junel 1530 101junel 120 101junel fe 1530 101junel fe 120 101junel fe 24 101JUXTAPID53JYNARQUE 80KBGL IN TERODERM 16KADCYLA 38kaitlib fe101KALBITOR 107KALETRA45kalliga102KALYDECO 133KAMDOY 66KANJINTI 38KANUMA91KAPOK116KAPSPARGO SPRINKLE53KAPVAY57kapzin dc16KARBINAL ER 128kariva 102KATARYA 66KATARYAXN 66KATERZIA 53

KAXM66KAZANO 72KCL-LIDOCAINE-NACL80KEDRAB 107KEFLEX 23KEIDO66KELARX66kelnor 135 102kelnor 150 102KENALOG66 95KENALOG-80 95KEPIVANCE 59KEPPRA 27KEPPRA XR 27KERAGEL 66KERALAC 66KERALYT66KERALYT SCALP66KERAMATRIX REPLICINE 5CMX5CM 66KERYDIN 32KESIMPTA58KETAMINE HCL 116KETAMINE HCL-SODIUM CHLORIDE 116KETARYA 66ketoconazole32KETOCONAZOLE-HYDROCORTISONE32ketodan 32KETODAN32KETONE TEST 74KETOPHENE RAPIDPAQ 16ketoprofen 16ketoprofen er16KETOROLAC TROMETHAMINE16ketorolac tromethamine 16 121KETOSTIX 74KETOVIE 116KETOVIE PEPTIDE 116KEVARYA 66KEVEYIS122KEVZARA 107KEXM66KEYA 66KEYTRUDA 38KHAPZORY 38KINERET 107KISQALI 38KISQALI FEMARA 38KITABIS PAK 133KIVIK66

KLARITY-A 121KLARITY-L121KLARON 66KLISYRI 66KLONOPIN 47klor-con 80klor-con 10 80klor-con m10 80KLOR-CON M15 80klor-con m20 80klor-conef 80KOATE49KOATE-DVI49KOCHIA 116KOGENATE FS 49KOMBIGLYZE XR72KORLYM99KOSELUGO38KOVALTRY49K-PHOS 80K-PHOS NO 280K-PHOS-NEUTRAL 80k-prime 80KRINTAFEL 41KRISTALOSE 89KRYSTEXXA 34K-TAB 80k-tan plus 80kurvelo 102KUTARYAXM66KUTARYAXMPA66KUTEA 66KUVAN91KUVARYA66KUVARYE66KUXM67KYLEENA 102KYMRIAH107KYNMOBI 42KYNMOBI TITRATION KIT42KYPROLIS 38labetalol hcl 53LACRISERT124LACTEROL 89lactic acid 67lactic acid e 67LACTIC ACID-NIACINAMIDE67lactobacillus 89LACTOJEN 89lactulose89lactulose encephalopathy 89LAMICTAL 27LAMICTAL ODT27

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LAMICTAL STARTER27LAMICTAL XR 27lamivudine45lamivudine-zidovudine 45lamotrigine 27 28lamotrigine er 27lamotrigine starter kit-blue28lamotrigine starter kit-green 28lamotrigine starter kit-orange 28LAMPIT 41LANOXIN 53lansoprazole86lanthanum carbonate 93LANTUS SOLOSTAR 76LANTUS U-100 VIAL 76lapatinib ditosylate 38larin 1530 102larin 120 102larin 24 fe 102larin fe 1530 102larin fe 120 102larissia102LASIX53LASTACAFT 124latanoprost 122LATANOPROST-TIMOLOL MALEATE 122LATISSE 124LATUDA44lavare wound wash 67laxative max str 89laxative regular strength89layolis fe 102LAZANDA 11L-CYSTINE 80LDO PLUS 18LEDIPASVIR-SOFOSBUVIR 45leena 102leflunomide107LEMTRADA 58LENSCALE 116LENVIMA 38LESCOL XL 53lessina102LETAIRIS 133letrozole 38lets 18leucovorin calcium 38LEUKERAN38LEUKINE49leuprolide acetate98levalbuterol hcl 132LEVALBUTEROL HFA132

LEVATIO18LEVBID 89LEVEMIR U-100 FLEXTOUCH76LEVEMIR U-100 VIAL76levetiracetam28levetiracetam er 28LEVITRA 93levobunolol hcl 122levocarnitine80levocarnitine sf 80levocetirizine dihydrochloride128levofloxacin 23 121levoleucovorin calcium38levoleucovorin calcium pf38levonest102levonorgest-eth est amp eth est 102levonorgest-eth estrad 91-day 102levonorgestrel 102levonorgestrel-ethinyl estrad102levonorg-eth estrad triphasic102levora 01530 (28)102levorphanol tartrate 11levo-t 104LEVOTHYROXINE SODIUM 104levothyroxine sodium 104levoxyl 104LEVSIN 89LEVSINSL89LEVULAN KERASTICK 67LEXAPRO 30LEXETTE 67LEXIVA 45LIALDA111LIBRAX 89LIBTAYO38LICART 16lice killing42lice treatment 42LIDO BDK 18lidocaine18LIDOCAINE (ANORECTAL) 67lidocaine hcl 18 59LIDOCAINE HCL 18lidocaine hcl (pf)18lidocaine hcl urethralmucosal18lidocaine viscous hcl 59lidocaine-hydrocort (perianal) 111LIDOCAINE-HYDROCORTISONE ACE67 111lidocaine-hydrocortisone ace 111lidocaine-prilocaine 18 19LIDOCAINE-TETRACAINE19LIDOCANNA 19

LIDOCORT 111LIDODERM 19LIDO-EPINEPHRINE-TETRACAINE 19LIDOMARK 25 19LIDOPAC 19lidopin19LIDOPIN19LIDOPRIL19LIDOPRIL XR19LIDO-PRILO CAINE PACK19LIDOPURE PATCH 19LIDORX19LIDO-SORB 19LIDOSTREAM19LIDOTHOL 19LIDOTRAL 19LIDOTREX (ALOE VERA) 67LIDOVIX L19LIDTOPIC MAX19LIFEMS NALOXONE 20LILETTA (52 MG)102lillow 102LIMBREL116LIMBREL250116LIMBREL500116LINCOCIN23lincomycin hcl23lindane 42linezolid 23linezolid in sodium chloride 23LINZESS 89LIORESAL 134liothyronine sodium 104LIPITOR 53LIPOFEN53LIPRITIN II 58liquid acetaminophen 11liquid allergy relief 128lisinopril 53lisinopril-hydrochlorothiazide53L-ISOLEUCINE 80lithium47lithium carbonate48lithium carbonate er 47LITHOBID 48LITHOSTAT 93LIVALO 53LIVIXIL PAK 19l-methylfolate80l-methylfolate ca me-cbl nac 80l-methylfolate calcium 80l-methylfolate forte 80

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l-methylfolate-algae80l-methylfolate-algae-b12-b6 80l-methylfolate-b6-b12 80l-methyl-mc 80l-methyl-mc nac80LMR PLUS 19LO LOESTRIN FE102LOCOID 67LOCOID LIPOCREAM 67LODINE16LODOSYN 42LOESTRIN 1530 (21)102LOESTRIN 120 (21)102LOESTRIN FE 1530 102LOESTRIN FE 120 102lojaimiess 102LOKELMA 80LOMAIRA58LOMOTIL 89LONHALA MAGNAIR REFILL KIT 132LONHALA MAGNAIR STARTER KIT132LONSURF38loperamide hcl89LOPID 53lopinavir-ritonavir45LOPRESSOR53LOPROX 33loratadine 128loratadine childrens128loratadine-d 12hr128loratadine-d 24hr128lorazepam 47lorazepam intensol47LORBRENA 38LORID 80LORMATE116LORTAB11loryna 102LORZONE134losartan potassium53losartan potassium-hctz 53LOSEASONIQUE 102LOTEMAX121LOTEMAX SM 121LOTENSIN 53LOTENSIN HCT53loteprednol etabonate 121LOTREL 53LOTRIMIN AF 33LOTRONEX 89lovastatin53

LOVAZA53LOVENOX26low-ogestrel102loxapine succinate 44lo-zumandimine102LUBIPROSTONE89lubricant eye drops124lubricant eye drops pf124lubricant eye pm124lubricant pm 124lubricating eye drops124lubricating plus eye drops 124LUCEMYRA 20LUCENTIS 124LUGOLS STRONG IODINE23LULICONAZOLE33LUMIGAN123LUMIZYME 91LUMOXITI 38LUNESTA 135LUPANETA PACK 98LUPKYNIS 107LUPRON DEPOT (1-MONTH)98LUPRON DEPOT (3-MONTH)98LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG98LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG98LUPRON DEPOT-PED (1-MONTH)98LUPRON DEPOT-PED (3-MONTH)98LUTATHERA38lutera 102LUXIQ 67LUXTURNA124LUZU33LYDEXA19lyleq102lyllana102LYNPARZA 38LYRICA 58LYRICA CR58lysiplex plus80LYSODREN 38LYSTEDA49LYUMJEV KWIKPEN76LYUMJEV VIAL76lyza102MVI ADULT80MVI PEDIATRIC 80MAALOX MULTI SYMPTOM MAX ST89

MACRILEN 116MACROBID23MACRODANTIN 23mafenide acetate 23MAGNEBIND 400 80magnesium citrate89magnesium oxide80 89magnesium sulfate80 81MAGNESIUM SULFATE81magnesium-oxide81mag-oxide 81MAKENA102MALARONE42malathion 42maprotiline hcl30MARCAINE 19MARCAINE PRESERVATIVE FREE 19MARINOL31marlido 19MARLIDO-25 19marlissa102MARPLAN30MARQIBO 38MARVONA SUIK 19MAS CARE-PAK95MATULANE 38matzim la53MAVENCLAD58MAVYRET45MAXALT34MAXALT-MLT 34MAXICOMFORT SYR 27G X 1276MAXIDEX121MAXITROL124maxi-tuss ac128maxi-tuss gmx128maxi-tuss pe max128MAXZIDE 53MAXZIDE-2553MAYZENT58m-dryl 128menaphosmbhyo1 93MEADOW FESCUE GRASS POLLEN116meclizine hcl 31meclofenamate sodium16MEDERMA67MEDERMA FOR KIDS67MEDERMA SPF 3067MEDPURA ALCOHOL PADS 67medpura hand sanitizer 67

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MEDROL95MEDROLOAN II SUIK 95MEDROLOAN SUIK 95medroxyprogesterone acetate 102mefenamic acid16mefloquine hcl42megestrol acetate 102MEKINIST 38MEKTOVI39MELALEUCA 117meloxicam16melphalan 39melphalan hcl39memantine hcl29memantine hcl er 29MENACTRA109MENEST 102MENOPUR98MENOSTAR102MENQUADFI 109MENTAX 33MENVEO 109meperidine hcl11MEPHYTON81meprobamate47MEPRON 42MEPSEVII 91mercaptopurine 39meropenem23MEROPENEM-SODIUM CHLORIDE 24merzee 102mesalamine111mesalamine er oral capsule 0375 gm 111mesalamine-cleanser111mesna 39MESNEX39MESQUITE 117MESTINON 35metafolbic81metafolbic plus 81METAFOLBIC PLUS RF81METANX 81METAXALL CP 134metaxalone 134metformin hcl er 72metformin hcl er (mod)72metformin hcl er (osm) 73metformin hcl ir 73METHACHOLINE CHLORIDE 117methadone hcl 11 12methadone hcl intensol 11

methadose 12methadose sugar-free12methamphetamine hcl57METHAVER 117methazolamide123methenamine hippurate 24methenamine mandelate 24methergine 117methimazole104METHITEST96methocarbamol 134METHOHEXITAL SODIUM117methotrexate 107methotrexate sodium 107methotrexate sodium (pf) 107methoxsalen rapid67methscopolamine bromide89methyl salicylate67methyldopa 53methyldopa-hydrochlorothiazide53methylergonovine maleate117methylfol-algae-b12-acetylcyst 81METHYLIN57methylphenidate hcl 57methylphenidate hcl er57methylphenidate hcl er (cd)57methylphenidate hcl er (la)57methylphenidate hcl er (xr) 57methylprednisolone95METHYLPREDNISOLONE ACETATE 95methylprednisolone acetate 95methyltestosterone96metoclopramide hcl31metolazone 54METOPIRONE117metoprolol succinate er54metoprolol tartrate54metoprolol-hydrochlorothiazide54METROCREAM 67METROGEL67METROLOTION67metronidazole 24 67METRONIDAZOLE BENZO+SYRSPEND24metyrosine 54mexiletine hcl 54MIACALCIN 111mibelas 24 fe102micaderm 33micafungin sodium 33MICARDIS 54

MICARDIS HCT 54MICLARA LQ 128miconazole 133miconazole 333miconazole 733miconazole nitrate33MICONAZOLE-ZINC OXIDE-PETROLAT 33MICRHOGAM ULTRA-FILTERED PLUS 107MICRODOT TEST 74microgestin 1530102microgestin 120102microgestin 24 fe102microgestin fe 1530102microgestin fe 120102MICROLET NEXT LANCING DEVICE74MICROPLEGIA MSA-MSG81midazolam hcl 47MIDAZOLAM HCL-SODIUM CHLORIDE 47MIDAZOLAM+SYRSPEND SF 47midodrine hcl54MIFEPREX81mifepristone 81MIGERGOT 34miglitol73miglustat91MIGRAINE PACK 34migraine relief 12MIGRANAL 34MIGRANOW 34mili 102milk of magnesia 89MILLIPRED 95milrinone lactate54milrinone lactate in dextrose 54mimvey102MIMYX 67MINASTRIN 24 FE102mineral oil heavy 89MINIMED PUMP RESERVOIR 3ML 117MINIPRESS 54minitran 54MINIVELLE 102minocycline hcl24MINOCYCLINE HCL ER24minocycline hcl er 24MINOLIRA24minoxidil 54

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MINOXIDIL-PROGEST-TRETINOIN67MIRAPEX42MIRAPEX ER42MIRCERA 49MIRCETTE102MIRENA (52 MG)102mirtazapine 30MIRVASO 67misoprostol86MITE (D FARINAE)117MITE (D PTERONYSSINUS)117MITIGARE34mitigo 12mitomycin39MITOMYCIN 39MITOSOL121mitoxantrone hcl39MIXED ASPERGILLUS117MIXED FEATHERS 117MIXED RAGWEED 117MIXED VESPID VENOM PROTEIN 117MKO MELT DOSE PACK 117mlk f1 117mlk f2 117mlk f3 117mlk f4 117mm clearlax89mm stool softener laxative 89M-M-R II 109M-NATAL PLUS81MOBIC 16modafinil 135MODERNA COVID-19 VACCINE 109moexipril hcl 54moisturel 67molindone hcl44mometasone furoate 67 128mondoxyne nl24MONJUVI39MONOFERRIC 81mono-linyah 102MONONINE 49MONOVISC 117monsels ferric subsulfate 49montelukast sodium 132MONUROL24MORCIN 117MORGIDOX 24morgidox 24MORPHINE SULFATE 12

morphine sulfate 12morphine sulfate (concentrate) 12morphine sulfate (pf) 12morphine sulfate er 12morphine sulfate er beads 12MORPHINE SULFATE-NACL12MOTEGRITY89motion sickness relief31MOTOFEN 89MOTRIN IB 16MOTRIN INFANTS DROPS16MOUNTAIN CEDAR 117MOUSE EPITHELIUM 117MOUTH KOTE REMINT 59MOVANTIK 89MOVIPREP 89MOXEZA121moxifloxacin hcl24 121MOXIFLOXACIN HCL121moxifloxacin hcl (2x day)121moxifloxacin hcl in nacl 24MOZOBIL49m-pap12MS CONTIN12MSUD EASY117MUCINEX CHILDRENS FREEFROM128MUCINEX CHILDRENS STUFFY NOSE128MUCINEX DM128MUCINEX FAST-MAX DM MAX 128MUCOR 117MUCOSITISRX 59MUCOTROL 117mucus dm 128mucus relief d128mucus relief dm128mucus relief max st 128mucus-d 128MUGARD 117MUGWORT117MULPLETA 49MULTAQ 54MULTIGEN 81MULTIGEN FOLIC81MULTIGEN PLUS 81MULTIPRO 81MULTI-SPECIALTY 95multi-vitironfluoride81multivitaminfluoride 81MULTIVITAMINFLUORIDE 81multi-vitaminfluoride 81

multi-vitaminfluorideiron 81mupirocin 24mupirocin calcium 24MURO 128 124MUSE93mutamycin39MVASI39MYALEPT 91MYAMBUTOL 35MYCAMINE33MYCAPSSA 98MYCOBUTIN 35mycophenolate mofetil 107mycophenolate mofetil hcl 107mycophenolate sodium 107MYCOZYL AP33MYDAYIS57MYDRIACYL 124myferon 150 forte81MYFORTIC 107MYLERAN39MYLOTARG39mynephrocaps 81MYNEPHRON81MYOBLOC 117myorisan 67MYRBETRIQ93MYSOLINE 28MYTESI89MYXREDLIN 76na ferric gluc cplx in sucrose81NABI-HB 107nabumetone 16n-acetyl-l-cysteine 81nadolol 54nafcillin sodium 24nafrinse 81NAFRINSE DAILY ACIDULATED 59NAFRINSE DAILYNEUTRAL59nafrinse drops 81NAFRINSE WEEKLY59naftifine hcl33NAFTIN 33NAGLAZYME91nalbuphine hcl12NALFON 16NALOCET 12naloxone hcl20NALTREXONE20naltrexone hcl20NAMENDA 29NAMENDA TITRATION PAK29

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NAMENDA XR 29NAMENDA XR TITRATION PACK 29NAMZARIC 29NAPRELAN16NAPROSYN16naproxen 16naproxen sodium 16naproxen sodium er 16NAPROXEN SODIUM ER 16naproxen-esomeprazole 16naratriptan hcl 34NARCAN20NARDIL30NASACORT ALLERGY 24HR 128nasal decongestant129nasal decongestant pe129nasal moisturizing spray 129nasal spray 12 hour 129nasal spray no drip129NASCOBAL 81NASONEX 129NATACYN121NATAZIA102nateglinide73NATESTO 96NATPARA 112NATROBA42natural senna laxative 89NATURE-THROID 104NAVELBINE39NAYZILAM 28NEBUPENT 42necon 0535 (28)103nefazodone hcl30NEODOT THERMOMETER 117neomycin sulfate 24neomycin-bacitracin zn-polymyx124neomycin-polymyxin b gu 24neomycin-polymyxin-dexameth 124neomycin-polymyxin-gramicidin124neomycin-polymyxin-hc 124 126NEONATAL + DHA81NEONATAL 1981NEONATAL COMPLETE81NEONATAL FE 81NEONATAL PLUS 81neo-polycin124neo-polycin hc125NEORAL 107

NEOSALUS 67NEOSPORIN ORIGINAL 67NEOSTIGMINE METHYLSULFATE 35NEO-SYNALAR 67NEO-SYNEPHRINE COLDALLRG MILD129NEO-SYNEPHRINE COLDALLRGY EXT129NEO-SYNEPHRINE COLDALLRGY REG 129NEOTUSS PLUS 129NEOVITE 81NEPHPLEX RX81nephronex 81NEPHRO-VITE RX 81NERLYNX 39NESINA73NESTABS 81NESTABS ONE 81neuac 67NEUAC 67NEULASTA 49NEULASTA ONPRO49NEUPOGEN 49NEUPRO42NEURAPTINE58NEURIN-SL81NEURONTIN28NEVANAC121nevirapine 45nevirapine er 45NEXAVAR39NEXIUM 86NEXLETOL 54NEXLIZET54NEXPLANON103niacin (antihyperlipidemic) 54niacin er (antihyperlipidemic) 54NIACINAMIDE-SPIRONOLACTONE 67NIACINAMIDE-SULFACETAMIDE67NIACINAMIDE-TACROLIMUS67NIACINAMIDE-TAZAROTENE 67NIACINAMIDE-TRETINOIN67NIACINAMIDE-TRIAMCINOLONE ACET 67NIACIN-SPIRONOLACTON-TRETINOIN67niacor 54NIASPAN 54NICADAN81

NICAPRIN117nicardipine hcl 54NICAZEL81NICAZEL FORTE81NICAZYME 117NICOMIDE 81NICORETTE 20nicotine polacrilex 21nicotine step 121nicotine step 221nicotine step 321NICOTROL 21NICOTROL NS 21nifedipine54nifedipine er 54nifedipine er osmotic release 54NIFEREX 81nikki103NILANDRON39nilutamide39nimodipine54NINLARO 39NIPENT39nisoldipine er54nitazoxanide42nitisinone91NITRO-BID54NITRO-DUR54nitrofurantoin 24nitrofurantoin macrocrystal24nitrofurantoin monohydrate macrocrystals24nitroglycerin54NITROLINGUAL 54NITROMIST 54NITROSTAT54NITRO-TIME 54NITYR 91NIVESTYM49nizatidine86NOCDURNA 98nolix67NOPIOID-LMC KIT 134nora-be103NORDIPEN 5 INJECTION DEVICE117NORDITROPIN FLEXPRO 98norethin ace-eth estrad-fe103norethindrone103norethindrone acetate 103norethindrone acet-ethinyl est103norethindrone-eth estradiol 103norethin-eth estradiol-fe 103

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NORGESIC FORTE134norgestimate-eth estradiol 103norgestimate-ethinyl estradiol triphasic103NORITATE67norlyda 103norlyroc 103NORPACE 54NORPACE CR 54NORPRAMIN 30NORTHERA54nortrel 0535 (28) 103nortrel 135 (21) 103nortrel 135 (28) 103nortrel 777103nortriptyline hcl30NORVASC 54NORVIR 45NOURIANZ 42NOVACORT67NOVAMV PEDIATRIC MULTI-VITAMIN 81novarel 98NOVAREL98NOVOEIGHT 49NOVOFINE AUTOCOVER PEN NEEDLE 76NOVOFINE PEN NEEDLE 76NOVOFINE PLUS PEN NEEDLE76NOVOLIN 7030 FLEXPEN 76NOVOLIN 7030 FLEXPEN RELION76NOVOLIN 7030 RELION 76NOVOLIN 7030 VIAL 76NOVOLIN N FLEXPEN76NOVOLIN N FLEXPEN RELION76NOVOLIN N RELION76NOVOLIN N VIAL 76NOVOLIN R FLEXPEN76NOVOLIN R FLEXPEN RELION77NOVOLIN R RELION77NOVOLIN R VIAL 77NOVOLOG FLEXPEN 77NOVOLOG MIX 7030 FLEXPEN77NOVOLOG MIX 7030 VIAL77NOVOLOG PENFILL 77NOVOLOG U-100 VIAL 77NOVOPEN ECHO74NOVOSEVEN RT 49

NOVOTWIST PEN NEEDLE 77NOXAFIL33NP 2 DRUG PREPARATION KIT 16np thyroid 104NPLATE 49NUBEQA39NUCALA 129NUCARACLINPAK 67NUCARARXPAK67NUCORT67NUCYNTA12NUCYNTA ER12NUDERMRXPAK 120 67NUDERMRXPAK 60 68NUDICLO SOLUPAK16NUDICLO TABPAK16NUDROXIPAK 16NUDROXIPAK DSDR-5017NUDROXIPAK DSDR-7517NUDROXIPAK E-40017NUDROXIPAK I-800 17NUDROXIPAK M-15 17NUDROXIPAK N-500 17NUEDEXTA 58NUFERA 81nufol 81NULEV 89NULOJIX107NULYTELY LEMON-LIME 89NUMBRINO 19NUPLAZID 44NURTEC 34NUSURGEPAK SURGICAL PREPCARE 59NUTRASEB 68NUTRIARX CREAMPAK 68NUTRICAP81NUTRIDOX 24nutrifac zx81NUTRIVIT 82NUTROPIN AQ NUSPIN 10 98NUTROPIN AQ NUSPIN 20 98NUTROPIN AQ NUSPIN 5 99NUVAIL 68NUVAKAAN 19NUVAKAAN-II 19NUVARING 103NUVESSA24NUVIGIL135NUWIQ49NUZYRA 24nyamyc33

nylia 777103NYMALIZE 54nymyo 103nystatin33nystatin-triamcinolone 33nystop 33NYVEPRIA49OBIZUR 49OCALIVA 91ocella103OCREVUS 58OCTAGAM107octreotide acetate 99OCUFLOX121OCUVEL 82ODACTRA 117ODEFSEY45ODOMZO39odorless coated fish oil 117OFEV 132ofloxacin24 121 126OGIVRI 39olanzapine44olanzapine-fluoxetine hcl 30OLIVE TREE117olmesartan medoxomil54olmesartan medoxomil-hctz 54olmesartan-amlodipine-hctz54olopatadine hcl121 129OLUMIANT 107OLUX 68OLUX-E68OMECLAMOX-PAK 89OMEGA-3 RX COMPLETE54omega-3-acid ethyl esters54omeprazole 86omeprazole magnesium86OMEPRAZOLE+SYRSPEND SF ALKA 86omeprazole-sodium bicarbonate 86OMNARIS 129OMNITROPE 99OMNIVEX 117ONCASPAR39ondansetron hcl 31ondansetron odt 31ONE VITE WOMENS82ONE VITE WOMENS PLUS 82ONETOUCH DELICA LANCING DEV74ONETOUCH DELICA PLUS LANCING 74

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ONETOUCH ULTRA74ONETOUCH ULTRA 2 KIT WDEVICE 74ONETOUCH ULTRA MINI KIT WDEVICE 74ONETOUCH VERIO FLEX SYSTEM KIT WDEVICE74ONETOUCH VERIO IQ SYSTEM 74ONETOUCH VERIO KIT WDEVICE 74ONETOUCH VERIO REFLECT74ONETOUCH VERIO SYNC SYSTEM KIT WDEVICE75ONEVITE 82ONEXTON 68ONFI 28ONGENTYS42ONGLYZA73ONIVYDE39ONPATTRO 58ONTRUZANT39ONUREG 39ONYCHO-MED 33ONZDEOXIA68ONZETRA XSAIL34OPDIVO 39opium 89OPSUMIT133ORACEA68ORACIT 82ORALAIR 117ORALAIR ADULT STARTER PACK 117ORALAIR CHILDRENS STARTER PACK 117oralone 59ORAMAGICRX 117ORAPRED ODT95ORAVIG 33ORCHARD GRASS POLLEN 117ORENCIA107ORENCIA CLICKJECT 107ORENITRAM 133ORFADIN91ORGOVYX39ORIAHNN 103ORILISSA 99ORKAMBI 133ORLADEYO 107ORMECA 17orphenadrine citrate er134

orphenadrine-asa-caffeine 134ORPHENGESIC FORTE 134orsythia 103ORTHO DF 82ORTHO MICRONOR 103ORTHOVISC117ORTIKOS111oscimin89oscimin sr89oseltamivir phosphate 45OSENI73OSMOLEX ER 42OSMOPREP 89OSPHENA 97OTEZLA 107OTIPRIO 126OTOVEL 126OTREXUP107OVACE PLUS 68OVACE PLUS WASH 68OVACE WASH68OVEEZA 82OVIDE42OVIDREL 99oxacillin sodium24oxaliplatin 39oxandrolone 97oxaprozin 17OXAYDO12oxazepam 47OXBRYTA117oxcarbazepine28OXERVATE 125OXIANUJO68OXIATAR 68OXIAVARRY 68OXIAZAR 68oxiconazole nitrate 33OXISTAT33OXLUMO 93OXOPOD 68OXSORALEN ULTRA68OXTELLAR XR 28oxybutynin chloride 93oxybutynin chloride er 93oxycodone hcl 12 13OXYCODONE HCL ER 12OXYCODONE-ACETAMINOPHEN13oxycodone-acetaminophen13oxycodone-aspirin13OXYCONTIN13oxymorphone hcl13

oxymorphone hcl er 13OXYTOCIN-LACTATED RINGERS99OXYTOCIN-SODIUM CHLORIDE 99OXYTROL93OXYTROL FOR WOMEN 93oyster shell calciumd82oyster shell calciumvitamin d 82OZEMPIC73OZOBAX 134OZURDEX 121PACERONE54paclitaxel 39PADCEV 39pain amp fever childrens 13pain amp fever infants 13pain relief 13pain relief childrens 13pain relief extra strength 13pain relief regular strength 13pain reliever extra strength 13pain relieving + lidocaine19PAINGO KFT 19PALFORZIA 117paliperidone er 44palonosetron hcl31PALYNZIQ 91PAMELOR 30pamidronate disodium111PANADOL CHILDRENS 13PANADOL EXTRA13PANADOL EXTRA STRENGTH 13PANADOL INFANTS 13PANCREAZE 91PANDEL68PANHEMATIN 49PANRETIN39pantoprazole sodium86PANZYGA107papaverine hcl54PARAGARD INTRAUTERINE COPPER103paraplatin 39PAREMYD 125PARI ALTERA NEBULIZER HANDSET117PARI TREK S COMBO PACK 117PARI VORTEX ADULT MASK 117paricalcitol 112PARLODEL42PARNATE 30

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paromomycin sulfate24paroxetine hcl30paroxetine hcl er 30paroxetine mesylate30PARSABIV 112PASER35PATADAY 121PATANASE129PAXIL30PAXIL CR30pb-hyoscy-atropine-scopolamine89P-CARE K40 95P-CARE K40G 95P-CARE K40MX95P-CARE K80 95P-CARE K80G 95P-CARE K80MX95PCP 10089pediaclear pd childrens 129PEDIAPRED 95PEDIATRIC COMPRESSOR NEBULIZER118pediatric electrolyte 82pediavit82PEDIZOLPAK 33PEDVAX HIB 109peg 3350-kcl-na bicarb-nacl89peg-3350electrolytes89peg-3350electrolytesascorbat89PEGASYS45PEGINTRON46peg-kcl-nacl-nasulf-na asc-c 89peg-prep90PEMAZYRE 39penicillamine 93penicillin g potassium24penicillin g procaine 24penicillin g sodium24penicillin v potassium 24PENICILLIUM NOTATUM118PENLEN68PENNSAID17PENTAM 42pentamidine isethionate 42PENTASA 111pentazocine-naloxone hcl 13PENTOSAN POLYSULFATE SODIUM93pentoxifylline er 54PEPCID86PERCOCET 13

PERDIEM OVERNIGHT RELIEF 90PERFOROMIST132PERIDEX 59perindopril erbumine 54periogard59PERJETA39permethrin42perphenazine 31perphenazine-amitriptyline30PERSERIS44PERTZYE 91PEXEVA30PFIZER-BIONTECH COVID-19 VACC 109PFIZERPEN24PH STRIPS 118phenazo 93phenazopyridine hcl 93phendimetrazine tartrate 58phendimetrazine tartrate er58phenelzine sulfate 30PHENERGAN 129phenobarbital 28phenobarbital-belladonna alk90PHENOHYTRO90phenoxybenzamine hcl 54phentermine hcl 58phentolamine mesylate 54PHENYLEPHRINE HCL 93phenylephrine hcl125PHENYLEPHRINE HCL-NACL55PHENYTEK28phenytoin 28phenytoin infatabs28phenytoin sodium extended 28PHEODOYO 33PHESGO39PHEXXI118PHEYO 33philith103PHLAG SPRAY68PHOMA EXIGUA 118PHOSLYRA 93PHOSPHA 250 NEUTRAL82PHOSPHASAL93PHOSPHOLINE IODIDE123phosphorous 82phosphorus supplement82phosphorus wsod amp potassium82phospho-trin 250 neutral 82PHOTOFRIN39

PHOTREXA-PHOTREXA VISCOUS KIT 118PHOXILLUM B22K40 82PHOXILLUM BK425 82PHYSICIANS EZ USE B-1282physicians ez use jointtunnel 95PHYSICIANS EZ USE M-PRED 95PHYSIOLYTE 82PHYSIOSOL IRRIGATION 82phytonadione 82PIFELTRO 46pilocarpine hcl 59 123pimecrolimus68pimozide44pimtrea 103pindolol55pink bismuth maximum strength 90pioglitazone hcl 73pioglitazone hcl-glimepiride73pioglitazone hcl-metformin hcl 73piperacillin sod-tazobactam so24PIQRAY 39pirmella 135 103pirmella 777 103piroxicam17PKU EASY 118PKU EASY MICROTABS118PKU GO 118PLAN B ONE-STEP103PLAQUENIL42PLASMA-LYTE 148 82PLASMA-LYTE A82PLAVIX 43PLEGRIDY58PLEGRIDY STARTER PACK 58PLENVU90PLEXION 68PLEXION CLEANSER 68PLEXION CLEANSING CLOTH68PLIAGLIS 19PNEUMOVAX 23 109PNV TABS 20-1 82POD-CARE 100K95PODIAPN82podocon 68podofilox68PODPROG68POINT OF CARE L2 95POINT OF CARE L5 95POINT OF CARE LM DEP 295

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POINT OF CARE LM-2219POINT OF CARE LM-2519POLIVY 39polycin125poly-iron 150 forte 82polymyxin b sulfate 24polymyxin b-trimethoprim125polysaccharide iron forte82POLYSPORIN25POLYTRIM125POLY-VI-FLOR 82POLY-VI-FLORIRON 82POLY-VITE PEDIATRIC 82POMALYST 39PONVORY 58PONVORY STARTER PACK 58portia-28103PORTRAZZA 39posaconazole33POTABA 82potassium chloride 82potassium chloride crys er 82potassium chloride er82potassium chloride in nacl82potassium citrate er82potassium citrate-citric acid82POTELIGEO 39POVIDONE-IODINE 121PR BENZOYL PEROXIDE68PR BENZOYL PEROXIDE WASH 68PR CREAM 68PRADAXA26PRALUENT55pramipexole dihydrochloride 42pramipexole dihydrochloride er42pramosone 68PRAMOSONE68PRAMOTIC 126pramox 68PRASTERA17prasugrel hcl 43pravastatin sodium55PRAXBIND118praziquantel 42prazosin hcl55PRE amp POST SX POUCH68PRECEDEX 118PRECISION LINK 75PRECISION PCX PLUS TEST 75PRECISION QID MONITOR75PRECISION QID TEST75

PRECISION SOF-TACT MONITOR 75PRECISION SOF-TACT TEST 75PRECISION XTRA75PRECISION XTRA BLOOD GLUCOSE 75PRECISION XTRA MONITOR75PRECOSE 73PRED FORTE121PRED MILD 121PRED-G 125PRED-G SOP 125prednicarbate 68PREDNISOL ACE-MOXIFLOX-BROMFEN 122prednisolone 95prednisolone acetate122prednisolone acetate p-f 122PREDNISOLONE ACETATE-NEPAFENAC 125PREDNISOLONE ACET-MOXIFLOXACIN125prednisolone sodium phosphate 96 122PREDNISOLONE-BROMFENAC 125PREDNISOLONE-GATIFLOXACIN125PREDNISOLONE-MOXIFLOXACIN125PREDNISOLON-GATIFLOX-BROMFENAC 125PREDNISOLON-MOXIFLOX-BROMFENAC 125PREDNISOLON-MOXIFLOX-NEPAFENAC 122prednisone 96prednisone intensol96PREFEST 103pregabalin 58PREGEN DHA 82PREGENNA82pregnyl 99PREMARIN 103PREMESISRX 82PREMIUM CONDOMS LUBRICATED 118premium lidocaine19PREMIUM SCAR 19PREMPHASE 103PREMPRO103PRENAISSANCE82PRENARA83

prenatal 83prenatal plus iron 83prenatal vitamin plus low iron83PRENATE 83PRENATE DHA 83PRENATE ELITE 83PRENATE ENHANCE 83PRENATE ESSENTIAL 83PRENATE MINI 83PRENATE PIXIE83PRENATE RESTORE83PRENATRIX 83PRENATRYL 83PRENATVITE COMPLETE83PRENATVITE PLUS 83PRENATVITE RX 83PREPIDIL93PREPIV SUPPLY19preplus 83PRESERA68PRESTALIA 55PRETAB83PRETOMANID 35PREVACID86PREVACID 24HR 86PREVACID SOLUTAB86prevalite 55PREVIDENT 59PREVIDENT 5000 BOOSTER PLUS59PREVIDENT 5000 DRY MOUTH59PREVIDENT 5000 ENAMEL PROTECT60PREVIDENT 5000 ORTHO DEFENSE 60PREVIDENT 5000 PLUS 60PREVIDENT 5000 SENSITIVE60PREVIDOLRX ANALGESIC 17previdolrx plus analgesic17previfem 103PREVNAR 13110PREVYMIS 46PREZCOBIX 46PREZISTA 46PRIALT 13PRID 118PRIFTIN 35PRILO PATCH 19PRILO PATCH II 19PRILOLID19PRILOSEC86PRILOVIX 19

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PRILOVIX LITE19PRILOVIX LITE PLUS 19PRILOVIX PLUS 19PRILOVIX ULTRALITE 19PRILOVIX ULTRALITE PLUS19PRILOVIXIL 19PRIMACARE83primaquine phosphate 42primidone 28PRIMSOL25PRINIVIL 55PRISTIQ30PRIVET 118PRIVIGEN107PRIZOPAK II19PRIZOTRAL19PRIZOTRAL-II19PRO HERS RX 83PRO HIS RX 83PRO PCOS RX 83PROAIR DIGIHALER132PROAIR HFA 132PROAIR RESPICLICK132probenecid 34PROBICHEW90PROBITROL 90PROBUPHINE IMPLANT KIT 13procainamide hcl55PROCARDIA55PROCARDIA XL 55PRO-C-DURE 5 96PRO-C-DURE 6 96PROCENTRA 57prochlorperazine 31prochlorperazine maleate 31PROCORT 111PROCRIT49PRO-CRITIC 118PROCTOCORT 111PROCTOFOAM HC 111procto-med hc 111procto-pak 111proctozone-hc 111PROCYSBI 91PRODIGEN90PROFESSIONAL DNA COLLECTION 118PROFILNINE 49progesterone103PROGESTERONE MICRONIZED 103PROGESTERONE-MINOXIDIL68

PROGLYCEM 75PROGRAF 107PROLASTIN-C132PROLATE 13PROLENSA 122PROLEUKIN 39PROLEVA 118PROLIA111PROMACTA49PROMELLA IN PREBIOTIC 90PROMEROL 90promethazine hcl129promethazine vc129promethazine vccodeine 129promethazine-codeine 129promethazine-dm 129promethazine-phenyleph-codeine 129promethazine-phenylephrine 129promethegan129PROMETRIUM 103PROMISEB 68PRONEB ULTRA FILTER SET 118propafenone hcl 55propafenone hcl er 55proparacaine hcl 125proparacaine-fluorescein 125PROPECIA 68PROPEL 129PROPEL MINI129propranolol hcl 55propranolol hcl er 55propranolol-hctz 55propylthiouracil 104PROSCAR 94PROSILK 68PROSTIN E293PROTEINEX P1883PROTEXA68PROTONIX 86PROTOPIC 68protriptyline hcl30PROTYL AG 68PROVENGE107PROVENTIL HFA 132PROVERA 103PROVIGIL 135PROZAC 30PRUCLAIR68PRUDOXIN 68PRUMYX68pseudoephedrine hcl er 129

pseudoephedrine-bromphen-dm 129pseudoephedrine-guaifenesin er129PSORCON68PSORIZIDE FORTE 118PSORIZIDE ULTRA118PULMICORT FLEXHALER132PULMICORT SUSPENSION 132PULMOZYME 133PURAMINO DHAARA118purevit dualfe plus83PURIXAN 39PYLERA90pyrazinamide35PYRIDIUM 93pyridostigmine bromide35pyridostigmine bromide er35pyridoxine hcl 83pyrimethamine 42PYRIMETHAMINE-LEUCOVORIN 42PYROGALLIC ACID 68QBRELIS 55QBREXZA68qc magnesium citrate90QDOLO 13QINLOCK39QMIIZ ODT 17QNASL129QNASL CHILDRENS 129QSYMIA 58QTERN 73QUAD-MIX 93quad-probiotic 90QUALAQUIN42QUARTETTE 103quazepam 47QUDEXY XR28QUEEN PALM 118QUESTRAN 55QUESTRAN LIGHT 55quetiapine fumarate 44quetiapine fumarate er 44QUFLORA FE 83QUFLORA FE PEDIATRIC83QUFLORA GUMMIES 83QUFLORA PEDIATRIC 83QUIHOXVAR 68QUILLICHEW ER57QUILLIVANT XR 57quinapril hcl55quinapril-hydrochlorothiazide 55

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quinidine gluconate er55quinidine sulfate 55quinine sulfate42QUINIXIL68QUINJA33QUTENZA68QUTENZA (2 PATCH) 68QUTENZA (4 PATCH) 68QVAR REDIHALER 132RABAVERT110RABBIT EPITHELIUM 118RABEPRAZOLE SODIUM 86rabeprazole sodium 86RADIAGEL68RADIAPLEXRX68RADICAVA58RADIOGARDASE 118RAGWITEK118raloxifene hcl97ramelteon 135ramipril 55RANEXA 55ranolazine er 55RAPAFLO 94RAPAMUNE107RAPID GEL RX118RAPIVAB 46rasagiline mesylate 42RASUVO108RAVICTI91RAYALDEE111RAYOS 96RAZADYNE ER 29READYSHARP ANESTH + METHYLPRED 96READYSHARP BETAMETHASONE96READYSHARP DEXAMETHASONE 96READYSHARP-A19REBIF 58REBIF REBIDOSE58REBIF REBIDOSE TITRATION PACK 58REBIF TITRATION PACK58REBINYN 49REBLOZYL 49RECARBRIO25RECEDO69RECLAST 112reclipsen103RECOMBINATE49RECOMBIVAX HB 110

RECOTHROM 49RECOTHROM SPRAY KIT49RECTIV55RECURA33RED MAPLE 118RED MULBERRY 118RED TOP GRASS POLLEN 118REDITREX108REFISSA69REFRESH RELIEVA125REFRESH RELIEVA PF 125REGENECARE69REGIOCIT26REGLAN 31REGRANEX69RELADOR PAK 19RELADOR PAK PLUS 19RELAFEN 17RELAFEN DS 17RELENZA DISKHALER 46relexxii 57RELION BLOOD GLUCOSE TEST75RELISTOR 90RELNATE DHA83RELPAX34RELTONE 90REMEDIENT83remergent hq69REMERON30REMERON SOLTAB 30REMICADE 108REMIGEN 69REMODULIN 133RENACIDIN 93RENAGEL93RENAL 83RENAL MULTIVITAMIN FORMULA 83RENATABS83RENATABS WITH IRON 83rena-vite 83RENFLEXIS 108reno caps 83RENOVA69RENOVA PUMP 69RENVELA 93repaglinide 73REPATHA 55REPATHA PUSHTRONEX SYSTEM 55REPATHA SURECLICK 55REQ 49+ 83

RESECTISOL 118RESORCINOL-SULFUR69RESOURCE THICKENUP JUICE118RESTASIS 125RESTASIS MULTIDOSE 125RESTORA RX90RESTORIL 135RETACRIT 49RETEVMO 39RETIN-A69RETIN-A MICRO GEL 004 01 69RETIN-A MICRO PUMP 69RETISERT 122RETROVIR 46REVATIO 133REVCOVI91REVESTA 83REVLIMID 39REXASIL PATCH amp VITAMIN E LIQ69REXULTI44REYATAZ 46REYVOW 34RHEUMATE118RHIZOPUS 118RHOFADE 69RHOGAM ULTRA-FILTERED PLUS108RHOPHYLAC108RHOPRESSA 123RIABNI 39RIASTAP49RIAX69ribavirin 46RIBOZEL118RIDAURA108rifabutin 35rifampin 35RIFAMPIN+SYRSPEND SF 35RILUTEK58riluzole59rimantadine hcl46RIMSO-50 93ringers irrigation 83RINVOQ108RIOMET 73risedronate sodium 112RISPERDAL44RISPERDAL CONSTA44risperidone 44RITALIN 57

165

RITALIN LA57ritonavir 46RITUXAN 39RITUXAN HYCELA39rivastigmine29rivastigmine tartrate 29rivelsa103RIXUBIS49rizatriptan benzoate 34ROAOXIA69ROBITUSSIN 12 HOUR COUGH CHILD129ROBITUSSIN COUGH+CHEST CONG DM129ROCALTROL 112ROCKLATAN 123ROMIDEPSIN 39ropinirole hcl43ropinirole hcl er 43rosadan 69ROSADAN 69rosuvastatin calcium 55ROSZET 55ROTARIX 110ROTATEQ110ROUGH MARSH ELDER118ROWASA 111roweepra 28ROXICODONE 13ROZEREM 135ROZLYTREK 39RUBRACA 39RUCONEST108rufinamide 28RUKOBIA46RUSSIAN THISTLE 118RUXIENCE 39RUZURGI118RYBELSUS73RYCLORA129RYDAPT 39RYTARY 43RYTHMOL SR 55ryvent 129SABRIL 28saccharomyces boulardii 90SACCHAROMYCES CEREVISIAE 118SAFYRAL103SAIZEN 99SAIZENPREP 99SALAGEN 60SALEX 69

SALICEPT118salicylic acid 69salicylic acid er69salicylic acid wart remover 69salicylic acid-cleanser 69SALICYLIC ACID-SULFACETAMIDE69salimez69SALIMEZ FORTE 69SALIVAMAX60salsalate17SALVAX 69SALVAX DUO PLUS69SAMSCA83SANADERMRX SKIN REPAIR69SANCUSO 31SANDIMMUNE 108SANDOSTATIN 99SANDOSTATIN LAR DEPOT 99SANTYL 69SAPHRIS 44sapropterin dihydrochloride92SARCLISA 39SAVAYSA 26SAVELLA 59SAVELLA TITRATION PACK 59SAXENDA59SCALACORT DK 69SCARCARE GEL-PAD KITLARGE 69SCARCIN69SCARSILK 69SCARZEN SKIN REPAIR 69SCENESSE 69scopolamine31SCRUB CARE POVIDONE-IODINE25SEASONIQUE 103SECUADO 44SEEBRI NEOHALER 132SEGLUROMET73SELECT-OB83selegiline hcl 43selenium sulfide 69SELRX 69SELZENTRY46SEMGLEE77senexon-s 90senna 90senna plus90senna s 90senna smooth 90senna-docusate sodium90

senna-plus 90SENOKOT EXTRA STRENGTH 90SENOKOT S 90SENSIPAR112SENSORCAINE19SENSORCAINE-MPF 19 20sensorcaine-mpf 20SEREVENT DISKUS 132SERNIVO69SEROQUEL 44SEROQUEL XR 44SEROSTIM 90sertraline hcl30se-tan plus 83setlakin103sevelamer carbonate 93sevelamer hcl93SEVENFACT 49sevoflurane 118SEYSARA 25sf 60sf 5000 plus60SFROWASA 111SHAGBARK HICKORY118sharobel 103SHARPS CONTAINER 118SHEEP SORREL 118SHINGRIX110SHORT RAGWEED POLLEN EXT 118SIDEROL 83SIGNIFOR99SIGNIFOR LAR99SIKLOS 39SILA III 69sildenafil citrate 93 133SILENOR 135SILIPAC 69SILIQ108silodosin 94SILTREX 118SILVADENE25silver nitrate25silver sulfadiazine25SILVERSEAL HYDROGEL DRESSING 69SIMBRINZA 123simethicone90simethicone ultra strength90simliya 103simpesse103SIMPONI108

166

SIMPONI ARIA 108SIMULECT108simvastatin 55SINEMET 43SINGULAIR132sinus 12 hour 129SINUVA129sirolimus108SIRTURO35SITAVIG46SIVEXTRO25skarjel69SKELAXIN 134SKYADERM-LP 20SKYLA 103SKYRIZI (150 MG DOSE)108sleep aid (diphenhydramine)135sleep-aid 135SLOWMAG MG MUSCLEHEART83SLYND 103sod citrate-citric acid 83sodium bicarbonate83 84 90SODIUM BICARBONATE84 90sodium chloride84 129sodium chloride (hypertonic)125sodium chloride (pf) 84sodium fluoride60 84sodium fluoride 5000 enamel60sodium fluoride 5000 plus 60sodium fluoride 5000 ppm60sodium fluoride 5000 sensitive60sodium phenylbutyrate92sodium polystyrene sulfonate 84sodium sulfacetamide 69sodium sulfacetamide wash69SODIUM SULFACETAMIDE-BAKUCHIOL 69SOFOSBUVIR-VELPATASVIR46SOLARAVIX70solifenacin succinate93SOLIQUA 73SOLIRIS49SOLODYN 25SOLOSEC25SOLOX70SOLTAMOX 39SOLU-CORTEF 96soluvita e84SOMA 134SOMATULINE DEPOT 99SOMAVERT99SOOLANTRA70

soothe 90SOOTHEE 20SORBITOL118sorbitol-mannitol118SORIATANE 70SORILUX 70SORRELDOCK MIX 118sotalol hcl 55sotalol hcl (af)55SOTYLIZE55SOVALDI 46SPEEDGEL RX118spinosad42SPINRAZA 118SPINY PIGWEED 118SPIRIVA HANDIHALER132SPIRIVA RESPIMAT 132spironolactone55spironolactone-hctz55SPORANOX33SPORANOX PULSEPAK33SPRAVATO (56 MG DOSE) 30SPRAVATO (84 MG DOSE) 30sprintec 28 103SPRITAM 28SPRIX 17SPRYCEL 39sps 84sronyx 103ssd 25SSKI129sss 10-5 70ST JOSEPH LOW DOSE17STALEVO 100 43STALEVO 125 43STALEVO 150 43STALEVO 200 43STALEVO 50 43STALEVO 75 43STAMARIL 110STARLIX 73stavudine46STAXYN93STEGLATRO 73STEGLUJAN73STELARA108STEMPHYLIUM 118STENDRA93STERILE TOPICAL LET GEL20STERITALC 132STIMATE 99stimulant laxative 90

STIOLTO RESPIMAT 132STIVARGA40stomach relief90stool softener 90stool softener laxative 90stool softener plus laxative90stool softenerlaxative 90stop lice complete treatment 42STRATA CTX70STRATA GRT 70STRATA MARK 70STRATA TRIZ70STRATA XRT70STRATTERA57STRENSIQ92streptomycin sulfate 25STRIBILD46STRIVERDI RESPIMAT 132STROMECTOL 42STROVITE FORTE84STROVITE ONE 84SUBLOCADE21SUBOXONE21SUBSYS 13subvenite28subvenite starter kit-blue28subvenite starter kit-green 28subvenite starter kit-orange 28SUCCINYLCHOLINE CHLORIDE 59SUCRAID92sucralfate 86SUDAFED CONGESTION129sudogest 129sudogest 12 hour 129sudogest maximum strength129SULAR 55SULCONAZOLE NITRATE33sulfacetamide sodium 70 122sulfacetamide sodium (acne) 70sulfacetamide sodium-sulfur 70sulfacetamide sod-sulfur wash70sulfacetamide-prednisolone 125sulfacetamide-sulfur in urea70SULFACLEANSE 8470sulfadiazine 25sulfamethoxazole-trimethoprim25sulfamez wash 70SULFAMYLON25sulfasalazine 111sulfatrim pediatric25SULFURATED LIME42sulindac17

167

SUMADAN 70SUMADAN WASH 70SUMADAN XLT 70SUMANSETRON 34sumatriptan 34sumatriptan succinate 34 35sumatriptan succinate refill 34sumatriptan-naproxen sodium 35SUMAXIN70SUMAXIN CP70SUMAXIN WASH70SUNOSI 135SUPARTZ FX118SUPER BI-MIX93SUPER QUAD-MIX93SUPER TRI-MIX 93SUPERVITE84support 84SUPPORT-500 84SUPPRELIN LA 99SUPRANE119SUPRAX 25SUPREP BOWEL PREP KIT90sure result dss premium pack 17SURE RESULT O3D3 SYSTEM 55SURESTEP PRO HIGH GLUCOSE 75SURESTEP PRO LOW GLUCOSE 75SURESTEP PRO NORMAL GLUCOSE 75SURVANTA 129SUSTIVA46SUSTOL31SUTAB 91SUTENT40SUVICORT 70SWEET GUM119SWEET VERNAL GRASS POLLEN119SX1 MEDICATED POST-OPERATIVE 20syeda 103SYLVANT40SYMAX DUOTAB 91SYMAX-SL91SYMAX-SR 91SYMBICORT132SYMBYAX30SYMDEKO 133SYMFI 46SYMFI LO 46

SYMJEPI132SYMLINPEN 120 73SYMLINPEN 60 73SYMPAZAN 28SYMPROIC91SYMTUZA46SYNAGIS 108SYNALAR 70SYNALAR (CREAM)70SYNALAR (OINTMENT) 70SYNALAR TS70SYNAPRYN FUSEPAQ 13SYNAREL 99SYNDROS 31SYNERA 20SYNERDERM 70SYNJARDY73SYNJARDY XR73SYNRIBO40SYNTHROID104SYNVISC 119SYNVISC ONE 119SYPRINE 84SYRINGE AVITENE 119SYSTANE COMPLETE 125SYSTANE HYDRATION PF 125SYSTANE ICAPS AREDS2 84SYSTANE ULTRA PF125TABLOID40TABRADOL FUSEPAQ 134TABRADOL RAPIDPAQ 134TABRECTA40TACHOSIL 119TACLONEX70TACROLIMUS 70tacrolimus70 108tadalafil 93tadalafil (pah) 133TAFINLAR40TAGRISSO 40TAKHZYRO 108TALICIA 91TALIVA84TALL RAGWEED119TALTZ 108TALZENNA 40TAMIFLU46tamoxifen citrate40tamsulosin hcl 94TAPAZOLE 104TAPERDEX 12-DAY 96TAPERDEX 6-DAY 96TAPERDEX 7-DAY 96

TARCEVA 40TARDEOXIA 70TARDIMAXIA 70TARGADOX25TARGRETIN 40tarina 24 fe 103tarina fe 120 104tarina fe 120 eq 104TARKA 55TAROXIA 70TASIGNA 40TASMAR 43TASOPROL 70tavaborole 33TAVALISSE 49TAYTULLA104tazarotene 70TAZAROTENE70tazicef25TAZORAC70 71taztia xt55TAZVERIK 40TDVAX 110TECARTUS40TECENTRIQ 40TECFIDERA58TEFLARO 25TEGRETOL28TEGRETOL-XR 28TEGSEDI 59TEKTURNA55TEKTURNA HCT 55telmisartan 55telmisartan-amlodipine55telmisartan-hctz55temazepam 135TEMIXYS 46TEMODAR 40TEMOVATE 71temozolomide40temsirolimus108TENCON13teniposide40TENIVAC 110tenofovir disoproxil fumarate46TENORETIC 100 55TENORETIC 50 56TENORMIN56TEPADINA 40TEPEZZA99TEPMETKO 40terazosin hcl94terbinafine hcl33

168

terbutaline sulfate132terconazole 33TERIPARATIDE (RECOMBINANT) 112terrell 119TESSALON PERLES129TESTIM97TESTONE CIK 97TESTOPEL 97TESTOSTERONE97testosterone 97TESTOSTERONE CYPIONATE 97testosterone cypionate97testosterone enanthate 97TETANUS-DIPHTHERIA TOXOIDS TD 110tetrabenazine 59tetracaine hcl125tetracycline hcl 25TETRIX 71TEXACORT 71THALOMID 40THEO-24132theophylline132theophylline er132thiamine hcl84THIOLA EC 93thioridazine hcl 44thiotepa 40thiothixene44THROMBATE III 26THROMBI-GEL 10 119THROMBI-GEL 100 119THROMBI-GEL 40 119THROMBIN-JMI50THROMBIN-JMI EPISTAXIS 50THROMBI-PAD119THROMBOGEN50THYMOGLOBULIN108THYQUIDITY 104THYROGEN119tiadylt er 56tiagabine hcl28TIAZAC 56TIBSOVO 40TICE BCG 108TIGAN 31tigecycline 25TIGLUTIK59TIKOSYN 56tilia fe104timolol maleate56 123

timolol maleate pf123TIMOLOL-BRIMON-DORZOL-LATANOPR123TIMOLOL-BRIMONIDINE-DORZOLAMID 123TIMOLOL-DORZOLAMID-LATANOPROST 123TIMOPTIC123TIMOPTIC OCUDOSE123TIMOPTIC-XE123TIMOTHY GRASS POLLEN ALLERGEN119tinidazole25TIROSINT 104TIROSINT-SOL104TISSEEL 119tis-u-sol 84TIVICAY 46TIVICAY PD 46TIVORBEX17tizanidine hcl 134tl-hem 150 84TOBAKIENT119TOBI NEBULIZER 133TOBI PODHALER133TOBRADEX 125TOBRADEX ST125tobramycin 122 133TOBRAMYCIN 133tobramycin-dexamethasone125TOBREX 122tolbutamide 73tolcapone 43tolmetin sodium17tolnaftate 33tolnaftate antifungal33TOLSURA 33tolterodine tartrate93tolterodine tartrate er93TOLVAPTAN84tolvaptan 84TOPAMAX 28TOPAMAX SPRINKLE28TOPICORT 71TOPICORT SPRAY 71TOPIDEX 96topiramate 28topiramate er28toposar 40topotecan hcl40TOPROL XL56toremifene citrate 40TORISEL108

TORONOVA II SUIK 17TORONOVA SUIK 17torsemide 56TOSYMRA 35TOTECT40TOUJEO MAX SOLOSTAR 77TOUJEO SOLOSTAR77tovet 71TOVET 71TOVIAZ 93TRACLEER133TRADJENTA73TRAMADOL HCL ER13tramadol hcl er 13tramadol hcl er (biphasic)13tramadol hcl ir 13tramadol-acetaminophen 13trandolapril 56trandolapril-verapamil hcl er56tranexamic acid50TRANEXAMIC ACID-NACL 50TRANSDERM SCOP (15 MG)31TRANSDERM-SCOP (15 MG)31TRANXENE-T 47tranylcypromine sulfate 30TRANZGEL119TRAUMEEL 119TRAVATAN Z123travoprost (bak free)123TRAZIMERA 40trazodone hcl 30TREANDA40TRECATOR 35TRELEGY ELLIPTA133TRELSTAR MIXJECT99TREMFYA108treprostinil 133TRESIBA77TRESIBA FLEXTOUCH77tretinoin 40 71tretinoin (emollient) 71tretinoin microsphere 71tretinoin microsphere pump 71TRETTEN 50TREXALL 108TREXIMET35TREZIX 14tri femynor 104triamcinolone acetonide 60 71 96TRIAMCINOLONE ACETONIDE 96triamterene56triamterene-hctz 56

169

TRIANEX 71triazolam 47TRIBENZOR 56tri-buffered aspirin 17TRICARE PRENATAL DHA ONE 84TRI-CHLOR 71TRICHOPHYTON 119TRICHOPHYTON MENTAGROPHYTES119TRICITRASOL 26tricitrates 84TRICON 84TRICOR 56triderm71TRIDESILON 71trientine hcl84tri-estarylla 104TRIFERIC 84trifluoperazine hcl44trifluridine 122trihexyphenidyl hcl 43TRIJARDY XR 73TRIKAFTA133tri-legest fe 104TRILEPTAL28tri-linyah 104TRILIPIX 56TRILOAN II SUIK 96TRILOAN SUIK 96TRILOCICLO 71tri-lo-estarylla 104tri-lo-marzia 104tri-lo-mili 104tri-lo-sprintec 104TRI-LUMA 71TRILURON119trimethobenzamide hcl31trimethoprim 25tri-mili 104trimipramine maleate 30TRI-MIX93TRINATE84TRINAZ 84TRINTELLIX30tri-nymyo 104triple antibiotic 71triple antibiotic+pain relief 71TRIPLE COMPLEX FORMULA 3 KIT 17TRIPLE PMB122TRIPLE PMK122tri-previfem 104

triprolidine hcl129TRIPTODUR 99TRISENOX40tri-sprintec 104TRISTART DHA84TRISTART FREE84TRISTART ONE84TRIUMEQ 46TRI-VI-FLOR84TRI-VI-FLORO 84tri-vite pediatric84tri-vitefluoride 84TRIVIX 71trivora (28)104tri-vylibra 104tri-vylibra lo104TRIZIVIR 46TRODELVY40TROGARZO46TROKENDI XR 28TRONVITE84tropicamide 125TROPICAMIDE-CYCLOPENTOLATE-PE 125TROPICAMIDE-PHENYLEPHRINE125TROPIC-CYCLOPENT-PE-KETOROLAC125TROPIC-CYCLOP-PE-KETO-PROPAR125TROPIC-PROPARACA-PE-KETOROLAC125trospium chloride93trospium chloride er 93TRUE METRIX BLOOD GLUCOSE TEST 75TRUE METRIX LEVEL 1 75TRUE METRIX LEVEL 2 75TRUE METRIX LEVEL 3 75TRUE METRIX PRO BLOOD GLUCOSE 75TRUETRACK TEST75TRULANCE91TRULICITY 73TRUMENBA110TRUSOPT123TRUSTEEL INFUSION SET 119TRUVADA46TRUXIMA40T-SUPPORT MAX 119TUDORZA PRESSAIR 133TUKYSA40tulana 104

TUMS CHEWY BITES 91TURALIO 40TURPENTINE 71TUSSICAPS130tussin cf multi-symptom cold130tussin dm130tussin dm max130tussin dm max adult 130TUXARIN ER 130TUZISTRA XR 130TWINRIX110TWIRLA 104TWYNSTA 56tyblume 104TYBOST46tydemy 104TYGACIL25TYKERB40TYLACTIN BUILD 20PE TYR 119TYLACTIN COMPLETE 15 PE 119TYLACTIN RESTORE 10 119TYLACTIN RESTORE 5PE 119TYLACTIN RTD 15 119TYLENOL14TYLENOL 8 HOUR 14TYLENOL EXTRA STRENGTH 14TYLENOL INFANTS PAIN+FEVER14TYMLOS 112TYPHIM VI 110TYR EASY 119TYROS 2119TYSABRI58TYVASO 134TYVASO REFILL 134TYVASO STARTER134UBRELVY 35UCERIS 111UDAMIN SP 84UDENYCA 50UKONIQ40ULORIC 34ULTANE119ULTOMIRIS 50ultra fresh pm 125ULTRA HERS RX 119ULTRA HIS 119ultra lubricating eye drops125ULTRA PCOS 119ULTRACET 14

170

ULTRAFOAM SPONGE 2X625X7CM119ULTRAFOAM SPONGE 8X125X1CM119ULTRAFOAM SPONGE 8X125X3CM119ULTRAFOAM SPONGE 8X25X1CM119ULTRAFOAM SPONGE 8X625X1CM119ULTRAM 14ULTRASAL-ER 71ULTRAVATE71UMECTA MOUSSE 71UNASYN 25UNISTRIP CONTROL75unithroid 104UNITUXIN 40UPLIZNA108UPNEEQ122UPTRAVI 134URAMAXIN 71urea71UREA 71urea hydrating 71urea nail 71ureacin-10 71ureacin-20 71uredeb71URELLE 93UREMEZ-4071URESOL 71uretron ds93URIBEL 93URIMAR-T 93urin ds 93urinary pain relief 93URO-45893UROCIT-K 1084UROCIT-K 1584UROCIT-K 584UROGESIC-BLUE 93uro-mp93urosex 84UROXATRAL 94URSO 25091URSO FORTE 91ursodiol 91URSODIOL+SYRSPEND SF91USTELL 93UTIBRON NEOHALER 133UTIRA-C 93UTOPIC 71

VAGIFEM104valacyclovir hcl46VALCHLOR40VALCYTE46valganciclovir hcl46VALIUM47valproic acid 28valrubicin40valsartan 56valsartan-hydrochlorothiazide 56VALSTAR40VALTOCO28VALTREX46VANADOM134VANCOCIN 25VANCOCIN HCL25vancomycin hcl 25VANCOMYCIN HCL 122vancomycin hcl in nacl 25VANCOMYCIN+SYRSPEND SF 25vandazole25VANICREAM71VANIQA 71VANOS 71VANOXIDE-HC 71VANTAS99VAQTA110vardenafil hcl93VARDIMAXIA71VARISOFT INFUSION SET119VARIVAX 110VARIZIG108VAROPHEN17VAROXIA 71VARUBI (180 MG DOSE) 31VASCEPA 56VASCULERA 119VASERETIC56VASOTEC56VAXCHORA110v-c forte 84VCF VAGINAL CONTRACEPTIVE 119vcf vaginal contraceptive119VECAMYL56VECTIBIX40VECTICAL 72VECURONIUM BROMIDE59vegetable lax+stool softener 91VELCADE 40VELETRI 134velivet104

VELPHORO 93VELTASSA 84VELTIN 72VEMLIDY 46VENCLEXTA40VENCLEXTA STARTING PACK 40VENELEX 72VENEXA 84VENIPUNCTURE PX1 PHLEBOTOMY 20venlafaxine hcl 30venlafaxine hcl er 30VENNGEL ONE 17VENOFER84VENTAVIS 134VENTOLIN HFA133verapamil hcl56verapamil hcl er56VERDESO 72VEREGEN 72VERELAN 56VERELAN PM56VERQUVO 56VERSACLOZ 44VERZENIO40VESICARE93VESICARE LS 93vestura 104VEXASYN 72VEXATROL20VFEND33VIAGRA 94VIBERZI 91VIBRAMYCIN25vic-forte 84VICTOZA 73VIDAZA 40VIEKIRA PAK46vienva104vigabatrin 28vigadrone 28VIGAMOX 122VIIBRYD30VIIBRYD STARTER PACK 30VILACTIN AA PLUS119VILAMIT MB94VILEVEV MB94VILTEPSO 119VIMIZIM 92VIMOVO17VIMPAT28VINATE ONE 84

171

vinblastine sulfate 40vincristine sulfate 41vinorelbine tartrate 41VIOKACE 92viorele 104VIRACEPT 46VIRAMUNE 46VIRAMUNE XR 46VIRASAL72VIRAZOLE 46VIREAD46virt-caps 84VIRT-FEFA PLUS 84virt-gard84virt-phos 250 neutral 84virtussin ac walc130VISBIOME91VISIONBLUE 125VISTA GEL DRY EYE RELIEF 126VISTA MEIBO TEARS 126VISTA TEARS126VISTARIL 47VISTOGARD119VISUDYNE126vita s forte 84vitacel84VITAFOL FE+ 85VITAFOL STRIPS 85VITAFOL-NANO 85VITAFOL-OB+DHA85VITAL-D RX 85VITAMEZ 85vitamin b complex 100 85vitamin b-complex 100 85vitamin d (ergocalciferol)85VITAMIN DEFICIENCY SYSTEM-B1285vitamin k185vitamins acd-fluoride 85VITAROCA PLUS 85VITA-RX DIABETIC VITAMIN85VITASURE 85VITATHELY WITH GINGER 85VITRAKVI41VITRANOL FE 85VITRASE119VITREXATE 85VITREXATE FE 85VITREXYL85VITREXYL + IRON85VIVELLE-DOT104VIVITROL21

VIVLODEX 17VIVOTIF 110VIZIMPRO41VOCABRIA 47VOGELXO 97VOGELXO PUMP 97volnea 104VOLTAREN17VONVENDI 50VORAXAZE 41voriconazole33VOSEVI47VOTRIENT41VP FC KIT17VP GKL KIT 17vp-pnv-dha 85VPRIV 92vp-vite rx 85VRAYLAR 44VTOL LQ14VUMERITY 58VUSION 33VYEPTI 35vyfemla104VYLEESI 59vylibra104VYNDAMAX56VYNDAQEL 56VYONDYS 53 92VYTONE 33VYTORIN 56VYVANSE 57VYXEOS 41VYZULTA123WAKIX 135wal-tap coldallergy 130warfarin sodium26WASP VENOM PROTEIN 120weekly-d85WELCHOL 56WELLBUTRIN SR30WELLBUTRIN XL 30WELLMIND VERTIGO120wera 104westab max120westab mini 85westab one85WESTAB PLUS 85WESTERN JUNIPER120WESTGEL DHA85WESTHROID 104WHEAT GERM OIL 85WHITE BIRCH 120

WHITE FACED HORNET VENOM120WHITE MULBERRY 120WHITE OAK120WHITE PINE 120WIDE-SEAL DIAPHRAGM 60 120WIDE-SEAL DIAPHRAGM 65 120WIDE-SEAL DIAPHRAGM 70 120WIDE-SEAL DIAPHRAGM 75 120WIDE-SEAL DIAPHRAGM 80 120WIDE-SEAL DIAPHRAGM 85 120WIDE-SEAL DIAPHRAGM 90 120WIDE-SEAL DIAPHRAGM 95 120WILATE50WILZIN85WINLEVI 72WINRHO SDF108wixela inhub 133womens 50 billion 91WP THYROID 104WPR PLUS WOUND HEALING SYSTEM 20wymzya fe 104WYNZORA72XADAGO43XALATAN123XALIX72XALKORI 41XANAX47XANAX XR47XAQUIL XR85XARACOLL20XARELTO 26XARELTO STARTER PACK26XATMEP 108XCOPRI 28XELJANZ 108XELJANZ XR 108XELODA 41XELPROS 123XEMBIFY 108XENAZINE 59XENICAL59XENLETA25 26XEOMIN120XEPI26XERAC AC72XERALUX 72XERESE 47XERMELO 91XEROSTOMIA RELIEF SPRAY60XGEVA112

172

XHANCE 130XIAFLEX 120XIFAXAN26XIGDUO XR73XIIDRA 126XIMINO 26XOFIGO 41XOFLUZA (40 MG DOSE) 47XOFLUZA (80 MG DOSE) 47XOLAIR130XOLEGEL 33XOLEGEL COREPAK33XOLEGEL DUOHEAD amp SHOULDERS33XOLEGEL DUOXOLEX 33XOPENEX CONCENTRATE 133XOPENEX HFA 133XOPENEX NEB 133XOSPATA 41XPOVIO (100 MG ONCE WEEKLY)41XPOVIO (40 MG ONCE WEEKLY)41XPOVIO (40 MG TWICE WEEKLY)41XPOVIO (60 MG ONCE WEEKLY)41XPOVIO (60 MG TWICE WEEKLY)41XPOVIO (80 MG ONCE WEEKLY)41XPOVIO (80 MG TWICE WEEKLY)41XRYLIX 17XTAMPZA ER 14XTANDI41xulane 104XULTOPHY73xurea 72XURIDEN92XVITE85XYLOCAINE 20XYLOCAINE-MPF20XYNTHA 50XYNTHA SOLOFUSE50XYOSTED97XYREM 135XYWAV 135XYZBAC120XYZMUNE 120YASMIN 28 104YAZ 104YELLOW DOCK120

YELLOW HORNET VENOM PROTEIN 120YELLOW JACKET VENOM PROTEIN 120YERVOY 41YESCARTA41YF-VAX 110YONDELIS41YONSA 41YOSPRALA43YUPELRI133YUTIQ 122yuvafem 104ZACARE 72zaclir cleansing 72ZADITOR 122zafemy 104zafirlukast133zaleplon135ZALTRAP41ZALVIT85ZANAFLEX 134ZANOSAR41zarah 104ZARONTIN28ZARXIO50ZAVESCA 92ZCORT 7-DAY 96ZEASORB-AF 33ZEBUTAL14ZEGERID 86ZEJULA41ZELAC 91ZELAPAR43ZELBORAF 41ZELNORM 91ZEMAIRA 133ZEMBRACE SYMTOUCH 35ZEMDRI 26ZEMPLAR 112zenatane 72ZENPEP92ZENZEDI57ZEPATIER 47ZEPOSIA 58ZEPOSIA 7-DAY STARTER PACK 58ZEPOSIA STARTER KIT 58ZEPZELCA 41ZERUVIA 20ZERVIATE 122ZESTORETIC 56ZESTRIL 56

ZETIA56ZETONNA130ZEVALIN Y-90 41ZIAC56ZIAGEN47ZIANA 72zidovudine47ZIEXTENZO50ZILACAINE PATCH 20zileuton er 133ZILRETTA 96ZILXI 72zinc sulfate 85ZINGO20ZINPLAVA108ZIONODIL 20ZIONODIL 100 20ZIOPTAN 123ziprasidone hcl 44ziprasidone mesylate 44ZIPSOR17ZIRABEV41ZIRGAN 122ZITHRANOL72ZITHROMAX26ZITHROMAX TRI-PAK26ZITHROMAX Z-PAK 26ZOCOR 56ZOFRAN 31ZOHYDRO ER 14ZOKINVY 120ZOLADEX 99zoledronic acid 112ZOLGENSMA 92ZOLINZA41ZOLMITRIPTAN35zolmitriptan35ZOLOFT30ZOLPAK33zolpidem tartrate 135zolpidem tartrate er 135ZOLPIMIST 135ZOMACTON 99ZOMACTON (FOR ZOMA-JET 10)99ZOMIG 35ZOMIG ZMT35ZONALON72ZONEGRAN28zonisamide28ZONTIVITY 43ZORBTIVE 91ZORTRESS 108

173

ZORVOLEX 17zovia 135 (28) 104zovia 135e (28) 104ZOVIRAX 47ZTLIDO 20ZUBSOLV 21ZULRESSO30zumandimine104ZUPLENZ31ZYCLARA 72ZYCLARA PUMP 72ZYDELIG41ZYFLO 133ZYKADIA41ZYLET126ZYLOPRIM34ZYMAXID 122ZYPITAMAG 56ZYPREXA 44ZYPREXA RELPREVV 44ZYPREXA ZYDIS44ZYRTEC ALLERGY 130ZYTIGA 41ZYVANA85ZYVEXOL 120ZYVIT120ZYVOX26

174

ldquoMy Medicationsrdquo worksheet

Take this worksheet with you each time you visit a doctor Each of your doctors should be aware of every drug you take and you should have a list as well

Name of Medicine and Strength

Drug Tier

I Take This Medicine For

Directions Doctor

Example Lisinopril 20 mg Tier 1 High blood pressure One tablet daily Dr Johnson

-Continued on back-

Notice of Nondiscrimination

Optum companies (together ldquoOptumrdquo) provide services to health plans and other health programs or activities Optum on behalf of itself and its affiliated companies complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Optum does not exclude people or treat them differently because of race color national origin age disability or sex Optum provides free aids and services to people with disabilities to communicate effectively with us such as

bull Qualified sign language interpreters bull Written information in other formats (large print audio accessible electronic formats other formats) bull Provides free language services to people whose primary language is not English such as

Qualified interpreters bull Information written in other languages

If you need these services please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week If you believe that the Company has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance in writing by mail or email A grievance must be sent within 60 calendar days of the date that you become aware of the discriminatory action and contain the name and address of the person filing it along with the problem and the requested remedy A written decision will be sent to you within 30 calendar days If you disagree with the decision you may file an appeal within 15 calendar days of receiving the decision

Optum Civil Rights Coordinator 11000 Optum Circle Eden Prairie MN 55344 Phone (888) 445-8745 (TTY 711) Fax (855) 351-5495 Email Optum_Civil_RightsOptumcom

If you need help filing a grievance please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week You can also file a complaint directly with the US Dept of Health and Human services online by phone or mail Online httpsocrportalhhsgovocrportallobbyjsf Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml Phone Toll-free (800) 868-1019 (800) 537-7697 (TDD) Mail US Dept of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 English Text You have the right to get help and information in your language at no cost To request an interpreter please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week This letter is also available in other formats like large print To request the document in another format please call toll-free (855) 828-9834 (TTY 711) 24 hours a day 7 days a week

1 Spanish Tiene derecho a recibir ayuda e informacioacuten en su idioma sin costo Para solicitar un inteacuterprete llame al nuacutemero de teleacutefono gratuito para miembros que se encuentra en su tarjeta de identificacioacuten del plan de salud y presione 0 TTY 711

2 Vietnamese Quyacute vị coacute quyền được giuacutep đỡ vagrave cấp thocircng tin bằng ngocircn ngữ của quyacute vị miễn phiacute Để yecircu cầu được thocircng dịch viecircn giuacutep đỡ vui lograveng gọi số điện thoại miễn phiacute dagravenh cho hội viecircn được necircu trecircn thẻ ID chương trigravenh bảo hiểm y tế của quyacute vị bấm số 0 TTY 711

3 Chinese 您有權利免費以您的母語得到幫助和訊息洽詢一位翻譯員請撥打您健保計劃會員卡上的免付費會員電話號碼再按 0聽力語言殘障服務專線 711

4 Korean 귀하는 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다 통역사를 요청하기 위해서는 귀하의 플랜 ID카드에 기재된 무료 회원 전화번호로 전화하여 0번을 누르십시오 TTY 711

5 Arabic يناجملا فتاھلا مقرب لصتا يروف مجرتم بلطل ةفلكت يأ لمحت نود كتغلب تامولعملاو ةدعاسملا ىلع لوصحلا يف قحلا كل TTY( 711( يصنلا فتاھلا 0 ىلع طغضاو ةیحصلا كتطخب ةصاخلا ةیوضعلا فرعم ةقاطبب جردملا ءاضعلأاب صاخلا

6 Urdu یرف لوٹ ےئل ےک ےنرک تاب ےس نامجرت یسک ےہ قح اک ےنرک لصاح تامولعم روا ددم تفم ںیم نابز ینپا وک پآ TTY 711 ںیئابد 0 ےہ جرد رپ ڈراک یڈ یئآ نلاپ ھتلیہ ےک پآ وج ںیرک لاک رپ ربمن نوف ربمم

7 Tagalog May karapatan kang makatanggap ng tulong at impormasyon sa iyong wika nang walang bayad Upang humiling ng tagasalin tawagan ang toll-free na numero ng telepono na nakalagay sa iyong ID card ng planong pangkalusugan pindutin ang 0 TTY 711

8 French Vous avez le droit dobtenir gratuitement de laide et des renseignements dans votre langue Pour demander agrave parler agrave un interpregravete appelez le numeacutero de teacuteleacutephone sans frais figurant sur votre carte drsquoaffilieacute du reacutegime de soins de santeacute et appuyez sur la touche 0 ATS 711

9 Hindi आप क पास अपनी भाषा म- सहायता एव जानकार6 7नशक ाltत करन का अ=धकार ह दभाBषए क Cलएअनरोध करन क Cलए अपन हथ ltलान ID काडH पर सचीबLध टोल-NO नबर पर फ़ोन कर- 0 दबाए TTY711

10 Persian هرامش اب یھافش مجرتم تساوخرد یارب دییامن تفایرد ناگیار روط ھب ار دوخ نابز ھب تاعلاطا و کمک ھک دیراد قح امش TTY 711 دیھد راشف ار 0 و هدومن لصاح سامت دوخ یتشادھب ھمانرب ییاسانش تراک رد هدش دیق ناگیار نفلت

11 German Sie haben das Recht kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten Um einen Dolmetscher anzufordern rufen Sie die gebuumlhrenfreie Nummer auf Ihrer Krankenversicherungskarte an und druumlcken Sie die 0 TTY 711

12 Gujarati તમન િવના (ય મદદ અન તમાર ભાષામા મા3હતી મળવવાનો અિધકાર છ ભાિષયા માટgt િવનતી કરવા તમારા હgtથ લાન ID કાડC પરની Eચીમા આપલ ટોલ-H મIબર ફોન નબર ઉપર કોલ કરો ૦

દબાવો TTY 711 13 Russian Вы имеете право на бесплатное получение помощи и информации на вашем языке

Чтобы подать запрос переводчика позвоните по бесплатному номеру телефона указанному на обратной стороне вашей идентификационной карты и нажмите 0 Линия TTY 711

14 Japanese ご希望の言語でサポートを受けたり情報を入手したりすることができます料金はか

かりません通訳をご希望の場合は医療プランのID カードに記載されているメンバー用のフリーダイヤルまでお電話の上0を押してくださいTTY専用番号は 711です

15 Laotian ທານມສ ດທ ຈະໄດຮບການຊວຍເຫອແລະຂມນຂາວສານທ ເປນພາສາຂອງທານບ ມຄາໃຊຈາຍ ເພອຂ ຮອງນາຍພາສາໂທຟຣ ຫາຫມາຍເລກໂທລະສບສ າລບ ສະມາຊ ກທ ໄດລະບໄວໃນບດສະມາຊ ກຂອງທານກດເລກ 0 TTY 711

72462-022018 INV-PSI3637-INS-MMISC-13918_MC_021318

(Farsi)

All Optum trademarks and logos are owned by Optum Inc in the US and other jurisdictions All other trademarks are the property of their respective owners

copy 2021 Optum Inc All rights reserved WF4412900_042021

HealthSelectSM

of Te

xas

Premium standard

  • Analgesics - Drugs for Pain
  • Analgesics - Drugs for Pain and Inflammation
  • Anesthetics
  • Anti-Addiction Substance Abuse Treatment Agents
  • Antibacterials
  • Anticoagulants
  • Anticonvulsants - Drugs for Seizures
  • Antidementia Agents - Drugs for Alzheimers Disease and Dementia
  • Antidepressants
  • Antiemetics - Drugs for Nausea and Vomiting
  • Antifungals
  • Antigout Agents
  • Anti-inflammatory Agents
  • Antimigraine Agents
  • Antimyasthenic Agents
  • Antimycobacterials
  • Antineoplastics - Drugs for Cancer
  • Antiparasitics
  • Antiparkinson Agents
  • Antiplatelets
  • Antipsychotics - Drugs for Mood Disorders
  • Antivirals
  • Anxiolytics - Drugs for Anxiety
  • Bipolar Agents - Drugs for Mood Disorders
  • Blood Products and Modifiers - Drugs for Blood Disorders
  • Cardiovascular Agents - Drugs for Heart and Circulation Conditions
  • Central Nervous System Agents - Drugs for Attention Deficit Disorder
  • Central Nervous System Agents - Drugs for Multiple Sclerosis
  • Central Nervous System Agents - Miscellaneous
  • Dental and Oral Agents - Drugs for Mouth and Throat Conditions
  • Dermatological Agents - Drugs for Skin Conditions
  • Diabetes - Antidiabetic Agents
  • Diabetes - Glucose Monitoring
  • Diabetes - Glycemic Agents
  • Diabetes - Insulins
  • Electrolytes Minerals Metals Vitamins
  • Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
  • Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions
  • Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment
  • Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions
  • Genitourinary Agents - Drugs for Prostate Conditions
  • Hormonal Agents - Adrenal
  • Hormonal Agents - Mens Health
  • Hormonal Agents - Osteoporosis
  • Hormonal Agents - Pituitary
  • Hormonal Agents - Prostaglandins
  • Hormonal Agents - Sex Hormones and Birth Control
  • Hormonal Agents - Thyroid
  • Immunological Agents - Drugs for Immune System Stimulation or Suppression
  • Immunological Agents - Drugs for Vaccination
  • Inflammatory Bowel Disease Agents
  • Metabolic Bone Disease Agents - Drugs for Osteoporosis
  • Metabolic Bone Disease Agents - Other
  • Miscellaneous Therapeutic Agents
  • Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation
  • Ophthalmic Agents - Drugs for Glaucoma
  • Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
  • Otic Agents - Drugs for Ear Conditions
  • Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold
  • Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
  • Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis
  • Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension
  • Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
  • Sleep Disorder Agents
Page 3: Your Prescription Drug List/Formulary

3

Understanding your Prescription Drug ListformularyWhat is a formulary

This document is a list of prescription medications covered by your plan for their safety cost and effectiveness Medications are listed by categories or class and are placed into cost levels known as tiers It includes both brand and generic prescription medications approved by the US Food and Drug Administration (FDA)

Where differences exist between this formulary and your benefit plan documents the benefit plan documents will rule This may not be a complete list of medications and not all medications listed may be covered under your plan Please look at the Master Benefit Plan Document (MBPD) provided by your plan for full details

How do I use my formulary

You and your doctor can consult the formulary to help you select the most cost-effective prescription medications This guide tells you if a medication is generic or brand and if special rules apply Bring this list with you when you see your doctor It is organized by common medical conditions Medications are then listed alphabetically

If your medication is not listed on this document it may not be covered by the HealthSelect Prescription Drug Program or Consumer Directed HealthSelect Prescription Drug Program Please visit wwwHealthSelectRxcom and click on Prescription Drug List for the most up to date list of medications covered under your plan If you have any questions call a customer care representative toll-free at (855) 828-9834 (TTY 711)

What are tiers

Tiers are the different cost levels you pay for a medication Each tier is assigned a cost which is determined by your plan This is how much you will pay when you fill a prescription The HealthSelect of Texas Prescription Drug Program has different copays assigned depending on which tier a drug is The Consumer Directed HealthSelect Prescription Drug Program has coinsurance assigned for each drug tier that applies once the annual combined medical and pharmacy deductible is met Tier 1 medications are your lowest-cost options If your medication is placed in Tier 2 or 3 look to see if there is a Tier 1 option available Discuss these options with your doctor

4

When does the formulary change

bull Medications may move to a lower tier at any time

bull Medications may move to a higher tier when its generic becomes available

bull Medications may move to a higher tier or be excluded from coverage on January 1 or July 1 of each year

When a medication changes tiers you may have to pay a different amount for that medication

For the most up-to-date list call a customer care representative 24 hours a day 7 days a week toll-free at (855) 828-9834 (TTY 711)

Why are some medications excluded from coverage

A medication may be excluded from coverage under your prescription drug plan when it works the same as or similar to another prescription medication or an over-the-counter (OTC) medication that is more cost-effective

What if I donrsquot agree with a decision about an excluded medication

You (or your authorized representative) and your doctor can ask for an appeal to cover an excluded medication by calling a customer care representative toll-free at (855) 828-9834 (TTY 711)

5

Medication Tips What is the difference between brand-name and generic medications

Generic medications contain the same active ingredients (what makes the medication work) as brand-name medications but they often cost less Once the patent of a brand-name medication ends the FDA can approve a generic version with the same active ingredients

What if my doctor writes a brand-name prescription

If your doctor gives you a prescription for a brand-name medication ask if a generic equivalent or lower-cost option is available and if it might be right for you Generic medications are usually your lowest-cost option but not always

An OTC medication may be the right treatment option for some conditions Talk to your doctor about available OTC options Even though these medications may not be covered under your pharmacy benefit they may cost less than prescription medications covered under your prescription drug plan

What if I am taking a specialty medication

Specialty medications treat rare or complex conditions and are typically higher cost medications Please note not all specialty medications are listed in the Formulary Optum Specialty Pharmacy can provide most of your specialty medications along with helpful programs and services Call Optum Specialty Pharmacy at (855) 427-4682 and have your prescriptions delivered right to your home or doctorrsquos office

6

Reading your formularyThe formulary give your choices so you and your doctor can determine your best course of treatment In this formulary brand-name medications are shown in UPPERCASE (for example CLOBEX) and generic medications in lowercase (for example clobetasol)

Tier information

Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost Your prescription drug plan has multiple tiers Please note If you have a high deductible plan the tier cost levels will apply once you hit your deductible

Drug Tier Includes Helpful Tips

Tier 1 Lowest Cost

Lower-cost commonly used generic drugs Some low-cost brands may be included

Use Tier 1 drugs for the lowest out-of-pocket costs

Tier 2 Mid-range Cost

Many common brand-name drugs called preferred brands

Use Tier 2 drugs instead of Tier 3 to help reduce your out-of-pocket costs

Tier 3 Highest Cost

Mostly higher-cost brand drugs also known as non-preferred brands

Many Tier 3 drugs have lower-cost options in Tier 1 or 2 Ask your doctor if they could work for you

Tier E Excluded May be excluded from coverage or subject to prior authorization Lower-cost options are available and covered

Drug list information

In this drug list some medications are noted with letters next to them to help you see which ones may have coverage requirements or limits Your benefit plan determines how these medications may be covered for you

PA Prior Authorization ndash Your doctor is required to provide additional information before the drug will be covered by your prescription drug plan

ST Step Therapy ndash Requires you to first try a cost-effective medication before the more expensive medication will be covered

QL Quantity Limit ndash Limits the amount of a medication that will be covered under your prescription drug plan

SP Specialty Medication ndash Drugs that are used in the treatment of rare or complex conditions and are typically injected or infused are high cost have special delivery and storage requirements or require close monitoring or care coordination with your doctor

E Excluded ndash Drugs that are not covered by your health plan Lower-cost options are available and covered

Table of Contents

Analgesics - Drugs for Pain9Analgesics - Drugs for Pain and Inflammation 14Anesthetics17Anti-Addiction Substance Abuse Treatment Agents 20Antibacterials21Anticoagulants26Anticonvulsants - Drugs for Seizures 27Antidementia Agents - Drugs for Alzheimers Disease and Dementia 29Antidepressants29Antiemetics - Drugs for Nausea and Vomiting 30Antifungals31Antigout Agents 34Anti-inflammatory Agents 34Antimigraine Agents 34Antimyasthenic Agents35Antimycobacterials 35Antineoplastics - Drugs for Cancer35Antiparasitics 41Antiparkinson Agents 42Antiplatelets43Antipsychotics - Drugs for Mood Disorders 43Antivirals44Anxiolytics - Drugs for Anxiety47Bipolar Agents - Drugs for Mood Disorders47Blood Products and Modifiers - Drugs for Blood Disorders48Cardiovascular Agents - Drugs for Heart and Circulation Conditions 50Central Nervous System Agents - Drugs for Attention Deficit Disorder 56Central Nervous System Agents - Drugs for Multiple Sclerosis 57Central Nervous System Agents - Miscellaneous 58Dental and Oral Agents - Drugs for Mouth and Throat Conditions59Dermatological Agents - Drugs for Skin Conditions 60Diabetes - Antidiabetic Agents 72Diabetes - Glucose Monitoring 73Diabetes - Glycemic Agents 75Diabetes - Insulins75Electrolytes Minerals Metals Vitamins77Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer85Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions86Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment 91Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions92Genitourinary Agents - Drugs for Prostate Conditions 94Hormonal Agents - Adrenal 94Hormonal Agents - Mens Health96Hormonal Agents - Osteoporosis 97Hormonal Agents - Pituitary 97Hormonal Agents - Prostaglandins99Hormonal Agents - Sex Hormones and Birth Control99Hormonal Agents - Thyroid 104Immunological Agents - Drugs for Immune System Stimulation or Suppression 105Immunological Agents - Drugs for Vaccination 108Inflammatory Bowel Disease Agents110

7

Metabolic Bone Disease Agents - Drugs for Osteoporosis 111Metabolic Bone Disease Agents - Other 112Miscellaneous Therapeutic Agents 112Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation120Ophthalmic Agents - Drugs for Glaucoma122Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions 123Otic Agents - Drugs for Ear Conditions 126Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold126Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions 130Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis 133Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension 133Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm 134Sleep Disorder Agents 134

8

Drug Name Drug Tier Notes

Analgesics - Drugs for Pain

8 hour pain reliever E

8 hr arthritis pain relief E

acetaminophen 8 hour oral tablet extended release

E

acetaminophen childrens oral solution

E

acetaminophen childrens oral suspension 160 mg5ml

E

acetaminophen childrens oral tablet chewable 160 mg

E

acetaminophen er E

acetaminophen extra strength oral tablet

E

acetaminophen oral solution 160 mg5ml 325 mg1015ml 650 mg203ml

E

acetaminophen oral suspension 160 mg5ml

E

acetaminophen oral tablet

E

acetaminophen oral tablet chewable 160 mg

E

acetaminophen rectal suppository 120 mg 650 mg

E

acetaminophen-codeine

1 QL

acetaminophen-codeine 2

1 QL

acetaminophen-codeine 3

1 QL

acetaminophen-codeine 4

1 QL

ACTIQ 3 PA QL

ALLZITAL E

APADAZ E

Drug Name Drug Tier Notes

apap-caff-dihydrocodeine oral capsule

1 QL

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

1 QL

arthritis pain reliever oral

E

ascomp-codeine 1

aurophen childrens E

bac 1

BELBUCA 2 PA QL

BENZHYDROCODONE-ACETAMINOPHEN

E

BUPAP ORAL TABLET 50-300 MG

3

BUPRENEX E

buprenorphine hcl injection solution 03 mgml

E

buprenorphine transdermal

1 PA QL

butalbital-acetaminophen capsule 50-300 mg oral

1

BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL

E

butalbital-acetaminophen oral tablet

1

butalbital-apap-caff-cod 1

butalbital-apap-caffeine oral capsule

1

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

1

butalbital-asa-caff-codeine

1

butalbital-aspirin-caffeine

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

9

Drug Name Drug Tier Notes

butorphanol tartrate injection

E

butorphanol tartrate nasal

1 QL

BUTRANS 3 PA QL

carisoprodol-aspirin-codeine

1

codeine sulfate oral tablet

1 QL

CONZIP E

cvs acetaminophen ex st oral tablet

E

DEMEROL INJECTION SOLUTION 50 MGML

E

DILAUDID ORAL E

DSUVIA E

DURAGESIC-100 E

DURAGESIC-12 E

DURAGESIC-25 E

DURAGESIC-50 E

DURAGESIC-75 E

duramorph E

endocet oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 QL

ESGIC 3

fentanyl 1 PA QL

fentanyl citrate (pf) E

fentanyl citrate buccal lozenge on a handle

1 PA QL

FENTANYL CITRATE BUCCAL TABLET

E

FENTANYL CITRATE SOLUTION PREFILLED SYRINGE 100 MCG2ML INTRAVENOUS

E

FENTANYL CITRATE-NACL INJECTION

E

Drug Name Drug Tier Notes

FENTANYL CITRATE-NACL INTRAVENOUS SOLUTION 125-09 MG250ML-

E

FENTANYL CITRATE-NACL SOLUTION 1-09 MG100ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION 25-09 MG250ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION 2-09 MG100ML- INTRAVENOUS

E

FENTANYL CITRATE-NACL SOLUTION PREFILLED SYRINGE 500-09 MCG50ML- INTRAVENOUS

E

FENTANYL-BUPIVACAINE-NACL EPIDURAL SOLUTION 08-01667-09 MG200ML-

E

FENTANYL-BUPIVACAINE-NACL INJECTION

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 02-01-09 MG100ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 02-0125-09 MG100ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-00625-09 MG250ML- EPIDURAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

10

Drug Name Drug Tier Notes

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-01-09 MG250ML- EPIDURAL

E

FENTANYL-BUPIVACAINE-NACL SOLUTION 05-0125-09 MG250ML- EPIDURAL

E

FENTORA BUCCAL TABLET 100 MCG 200 MCG 400 MCG 600 MCG 800 MCG

E

FIORICET ORAL CAPSULE

3

FIORICETCODEINE ORAL CAPSULE 50-300-40-30 MG

3

goodsense pain relief oral tablet

E

headache relief oral E

hydrocodone bitartrate er oral capsule extended release 12 hour

1 PA ST QL

hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent

1 PA QL

hydrocodone-acetaminophen oral solution 10-325 mg15ml 75-325 mg15ml

1 QL

hydrocodone-acetaminophen oral tablet 10-300 mg 10-325 mg 5-300 mg 5-325 mg 75-300 mg 75-325 mg

1 QL

hydrocodone-ibuprofen oral tablet 10-200 mg 5-200 mg 75-200 mg

1 QL

Drug Name Drug Tier Notes

hydromorphone hcl er oral tablet extended release 24 hour

1 PA QL

hydromorphone hcl injection solution 2 mgml

E

hydromorphone hcl oral 1 QL

hydromorphone hcl rectal

E

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION 25-09 MG50ML- 50-09 MG50ML-

E

HYDROMORPHONE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 10-09 MG50ML- 15-09 MG30ML-

E

HYSINGLA ER 2 PA QL

INFUMORPH 200 E

INFUMORPH 500 E

LAZANDA NASAL SOLUTION 100 MCGACT 400 MCGACT

E

levorphanol tartrate oral E

liquid acetaminophen E

LORTAB ORAL ELIXIR 10-300 MG15ML

3 QL

meperidine hcl injection solution 50 mgml

E

meperidine hcl oral solution

1 QL

meperidine hcl oral tablet 50 mg

1 QL

methadone hcl injection E

methadone hcl intensol 1

methadone hcl oral concentrate

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

11

Drug Name Drug Tier Notes

methadone hcl oral solution

1

methadone hcl oral tablet

1 PA

methadone hcl oral tablet soluble

1

methadose oral concentrate 10 mgml

1

methadose oral tablet soluble

1

methadose sugar-free 1

migraine relief E

mitigo E

morphine sulfate (concentrate) oral solution 100 mg5ml 20 mgml

1 QL

morphine sulfate (pf) injection

E

morphine sulfate (pf) intravenous solution 10 mgml 2 mgml 4 mgml 8 mgml

E

morphine sulfate er beads

1 PA QL

morphine sulfate er oral capsule extended release 24 hour

1 PA QL

morphine sulfate er oral tablet extended release

1 PA QL

MORPHINE SULFATE INJECTION SOLUTION 1 MGML

E

morphine sulfate injection solution 2 mgml 4 mgml

E

MORPHINE SULFATE INTRAVENOUS SOLUTION 05 MGML

E

morphine sulfate intravenous solution 50 mgml

E

morphine sulfate oral 1 QL

Drug Name Drug Tier Notes

morphine sulfate rectal E

MORPHINE SULFATE SOLUTION 1 MGML INTRAVENOUS

E

morphine sulfate solution 1 mgml intravenous

E

MORPHINE SULFATE-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-09 MG50ML-

E

m-pap E

MS CONTIN ORAL TABLET EXTENDED RELEASE

E

nalbuphine hcl injection solution 20 mgml

1

NALOCET E

NUCYNTA E

NUCYNTA ER E

OXAYDO ORAL TABLET

E

OXYCODONE HCL ER ORAL TABLET ER 12 HOUR ABUSE-DETERRENT 15 MG 30 MG 60 MG 80 MG

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 10 MG ORAL

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 20 MG ORAL

E

OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-DETERRENT 40 MG ORAL

E

oxycodone hcl oral capsule

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

12

Drug Name Drug Tier Notes

oxycodone hcl oral concentrate 100 mg5ml

1 QL

oxycodone hcl oral solution

1 QL

oxycodone hcl oral tablet

1 QL

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 10-300 MG5ML

E

OXYCODONE-ACETAMINOPHEN ORAL TABLET 10-300 MG 25-300 MG 5-300 MG

E

oxycodone-acetaminophen oral tablet 10-325 mg 25-325 mg 5-325 mg 75-325 mg

1 QL

oxycodone-aspirin oral tablet 48355-325 mg

1 QL

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-DETERRENT

2 PA QL

oxymorphone hcl 1 QL

oxymorphone hcl er 1 PA QL

pain amp fever childrens oral suspension

E

pain amp fever infants E

pain relief childrens oral elixir

E

pain relief extra strength oral capsule 500 mg

E

pain relief extra strength oral tablet 500 mg

E

pain relief oral liquid E

pain relief regular strength

E

Drug Name Drug Tier Notes

pain reliever extra strength oral tablet 250-250-65 mg

E

PANADOL CHILDRENS

E

PANADOL EXTRA E

PANADOL EXTRA STRENGTH

E

PANADOL INFANTS E

pentazocine-naloxone hcl

1 QL

PERCOCET ORAL TABLET 10-325 MG 25-325 MG 5-325 MG 75-325 MG

E

PRIALT 2 SP

PROBUPHINE IMPLANT KIT

E

PROLATE E

QDOLO E

ROXICODONE ORAL TABLET

E

SUBSYS E

SYNAPRYN FUSEPAQ E

TENCON ORAL TABLET 50-325 MG

E

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

1 PA ST QL

TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG 200 MG 300 MG

E

tramadol hcl er oral tablet extended release 24 hour

1 PA QL

tramadol hcl ir 1 QL

tramadol-acetaminophen

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

13

Drug Name Drug Tier Notes

TREZIX ORAL CAPSULE 3205-30-16 MG

3 QL

TYLENOL 8 HOUR E

TYLENOL EXTRA STRENGTH ORAL TABLET

E

TYLENOL INFANTS PAIN+FEVER

E

TYLENOL ORAL TABLET

E

ULTRACET E

ULTRAM E

VTOL LQ E

XTAMPZA ER 2 PA QL

ZEBUTAL ORAL CAPSULE 50-325-40 MG

3

ZOHYDRO ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR

E

Analgesics - Drugs for Pain and Inflammation

adult aspirin regimen $0

ADVIL E

ADVIL JUNIOR STRENGTH

E

ADVIL LIQUI-GELS MINIS

E

ADVIL MIGRAINE E

aif 2 drug preparation kit

E

AIF 3 DRUG PREPARATION KIT

E

ALEVE ORAL TABLET E

ARTHROTEC ORAL TABLET DELAYED RELEASE

E

aspirin adult low strength oral tablet delayed release

$0

Drug Name Drug Tier Notes

aspirin childrens $0

aspirin ec low dose $0

aspirin ec low strength $0

aspirin ec oral tablet delayed release 325 mg

$0

aspirin low dose oral tablet chewable

$0

aspirin low dose oral tablet delayed release

$0

aspirin oral tablet 325 mg

$0

aspirin oral tablet delayed release 325 mg 81 mg

$0

aspirin rectal suppository 300 mg 600 mg

E

BAYER ASPIRIN EC LOW DOSE

$0

BAYER ASPIRIN ORAL TABLET

$0

BAYER ASPIRIN ORAL TABLET DELAYED RELEASE

$0

BIIFENAC 1000 E

BIIFENAC 500 E

CALDOLOR INTRAVENOUS SOLUTION 800 MG200ML 800 MG8ML

E

CAMBIA E

CAPSFENAC PAK E

CAPSINAC E

CATAFLAM 3

CELEBREX E

celecoxib oral 1 QL

DAYPRO 3

DERMACINRX LEXITRAL PHARMAPAK

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

14

Drug Name Drug Tier Notes

DFS DRMSMENTHCAP PAK

E

DFSMSMENTHCAP PAK

E

DICLOFENAC CAP 35MG

E

DICLOFENAC PATCH EXTERNAL

E

diclofenac potassium 1

diclofenac sodium er 1

diclofenac sodium external gel 1

1 QL

diclofenac sodium external solution

1 PA

diclofenac sodium oral 1

diclofenac-misoprostol oral tablet delayed release

1

DICLOFONO GEL 16 EXTERNAL

3

DICLOFONO GEL 16 EXTERNAL

E

DICLOPR E

DICLOSTREAM E

DICLOTREX E

DICLOVIX E

DICLOVIX M E

DICLOZOR EXTERNAL

E

diflunisal oral 1

DIMENTHO E

DUAL COMPLEX FORMULA 1 KIT

E

DUEXIS E

EC-NAPROSYN 3

ec-naproxen 1

ENOVARX-DICLOFENAC SODIUM EXTERNAL

E

enovarx-ibuprofen E

Drug Name Drug Tier Notes

enovarx-naproxen external

E

etodolac er 1

etodolac oral 1

FBL KIT E

FELDENE 3

fenoprofen calcium oral E

fenortho oral capsule 200 mg

E

FLECTOR EXTERNAL E

FLEXIPAK E

flurbiprofen oral 1

FROTEK E

GABAPENTIN-NAPROXEN CMPD KIT

E

goodsense aspirin low dose

$0

goodsense ibuprofen oral capsule

E

IBUPAK E

ibuprofen 1

ibuprofen infants E

ibuprofen oral capsule E

ibuprofen oral suspension

1

ibuprofen oral tablet 200 mg

E

inavix E

INDOCIN ORAL 3 ST

INDOCIN RECTAL E

indomethacin er 1

INDOMETHACIN ORAL CAPSULE 20 MG

E

indomethacin oral capsule 25 mg 50 mg

1 ST

INFLAMMACIN E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

15

Drug Name Drug Tier Notes

INFLATHERM COMBINATION THERAPY PACK

E

KBGL IN TERODERM

E

kapzin dc E

KETOPHENE RAPIDPAQ

E

ketoprofen er 1

ketoprofen oral 1

KETOROLAC TROMETHAMINE EXTERNAL

E

ketorolac tromethamine injection solution 15 mgml

1

ketorolac tromethamine intramuscular solution 60 mg2ml

1

KETOROLAC TROMETHAMINE NASAL

3 PA QL

ketorolac tromethamine oral

1 QL

ketorolac tromethamine solution 30 mgml injection

1

KETOROLAC TROMETHAMINE SOLUTION 30 MGML INJECTION

3

LICART EXTERNAL E

LODINE 3

meclofenamate sodium oral

1

mefenamic acid oral E

meloxicam oral capsule 1

meloxicam oral tablet 1

MOBIC ORAL TABLET E

MOTRIN IB ORAL CAPSULE

E

Drug Name Drug Tier Notes

MOTRIN INFANTS DROPS

E

nabumetone oral 1

NALFON ORAL CAPSULE 400 MG

3

NALFON ORAL TABLET

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG 500 MG

3

NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

NAPROSYN ORAL SUSPENSION

3

NAPROSYN ORAL TABLET 500 MG

3

naproxen oral suspension

E

naproxen oral tablet 1

naproxen oral tablet delayed release

1

naproxen sodium er oral tablet extended release 24 hour 375 mg 500 mg

E

NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24 HOUR 750 MG

E

naproxen sodium oral tablet 220 mg

E

naproxen sodium oral tablet 275 mg 550 mg

1

naproxen-esomeprazole

1 PA QL

NP 2 DRUG PREPARATION KIT

E

NUDICLO SOLUPAK E

NUDICLO TABPAK E

NUDROXIPAK E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

16

Drug Name Drug Tier Notes

NUDROXIPAK DSDR-50

E

NUDROXIPAK DSDR-75

E

NUDROXIPAK E-400 E

NUDROXIPAK I-800 E

NUDROXIPAK M-15 E

NUDROXIPAK N-500 E

ORMECA E

oxaprozin 1

PENNSAID EXTERNAL

E

piroxicam oral 1

PRASTERA E

PREVIDOLRX ANALGESIC

E

previdolrx plus analgesic

E

QMIIZ ODT E

RELAFEN E

RELAFEN DS E

salsalate oral E

SPRIX 3 PA QL

ST JOSEPH LOW DOSE ORAL TABLET DELAYED RELEASE

$0

sulindac oral 1

sure result dss premium pack

E

TIVORBEX ORAL CAPSULE 20 MG

E

tolmetin sodium oral capsule

1

tolmetin sodium oral tablet 600 mg

1

TORONOVA II SUIK E

TORONOVA SUIK E

tri-buffered aspirin oral tablet 325 mg

E

Drug Name Drug Tier Notes

TRIPLE COMPLEX FORMULA 3 KIT

E

VAROPHEN E

VENNGEL ONE E

VIMOVO E

VIVLODEX 3 ST

VOLTAREN EXTERNAL

E

VP FC KIT E

VP GKL KIT E

XRYLIX EXTERNAL E

ZIPSOR E

ZORVOLEX E

Anesthetics

1ST MEDX-PATCH LIDOCAINE EXTERNAL PATCH 4-00375-5-20

E

7T LIDO E

ACCUCAINE E

ACTIVE INJECTION LM-2

E

AGONEAZE E

ANODYNE LPT E

APRIZIO PAK E

APRIZIO PAK II E

ASTERO E

BENZO-LIDOCAINE-TETRACAINE

E

blue tube aloe E

bupivacaine fisiopharma

E

bupivacaine hcl (pf) E

BUPIVACAINE HCL INJECTION SOLUTION 0125

E

bupivacaine hcl injection solution 025 05

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

17

Drug Name Drug Tier Notes

BUPIVACAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 0125 (50 ML)

E

CADIRAMD E

CAPSAICIN-MENTHOL

E

CETACAINE EXTERNAL AEROSOL

E

COCAINE HCL NASAL E

DERMACINRX EMPRICAINE

E

DERMACINRX PHN E

DERMACINRX PRIZOPAK

E

DERMACINRX ZRM E

DERMALID E

EHA E

EMPRICAINE-II E

enovarx-lidocaine hcl E

ENZNONUTY E

ethyl chloride 1

EXPAREL E

FLEXIN E

GEBAUERS PAIN EASE

3

GEBAUERS SPRAY AND STRETCH

3

GEN7T E

GEN7T PLUS E

glydo external prefilled syringe

1

GOPRELTO E

LDO PLUS E

lets E

LEVATIO E

LIDO BDK E

lidocaine external cream 4

E

Drug Name Drug Tier Notes

lidocaine external patch 5

1

lidocaine hcl (pf) injection solution

1

lidocaine hcl external cream 3

E

LIDOCAINE HCL EXTERNAL CREAM 412

E

lidocaine hcl external lotion

E

lidocaine hcl external solution

1

lidocaine hcl injection solution 05

1

LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE 10 MGML 100 MG10ML 100 MG5ML 200 MG10ML 60 MG3ML

E

LIDOCAINE HCL INTRADERMAL

E

LIDOCAINE HCL SOLUTION 1 INJECTION

3

lidocaine hcl solution 1 injection

1

LIDOCAINE HCL SOLUTION 2 INJECTION

3

lidocaine hcl solution 2 injection

1

lidocaine hcl urethralmucosal

1

lidocaine ointment 5 external

1 QL

lidocaine ointment 5 external

E

lidocaine-prilocaine external cream

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

18

Drug Name Drug Tier Notes

lidocaine-prilocaine external kit

E

LIDOCAINE-TETRACAINE

E

LIDOCANNA E

LIDODERM E

LIDO-EPINEPHRINE-TETRACAINE SOLUTION 4-005-05 EXTERNAL

3

LIDO-EPINEPHRINE-TETRACAINE SOLUTION 4-005-05 EXTERNAL

E

LIDOMARK 25 E

LIDOPAC E

lidopin external cream 3

E

LIDOPIN EXTERNAL CREAM 325

E

LIDOPRIL EXTERNAL KIT

E

LIDOPRIL XR E

LIDO-PRILO CAINE PACK

E

LIDOPURE PATCH E

LIDORX E

LIDO-SORB E

LIDOSTREAM E

LIDOTHOL E

LIDOTRAL E

LIDOVIX L E

LIDTOPIC MAX E

LIVIXIL PAK E

LMR PLUS E

LYDEXA E

MARCAINE E

MARCAINE PRESERVATIVE FREE

E

Drug Name Drug Tier Notes

marlido E

MARLIDO-25 E

MARVONA SUIK E

NUMBRINO E

NUVAKAAN E

NUVAKAAN-II E

pain relieving + lidocaine

E

PAINGO KFT E

PLIAGLIS E

POINT OF CARE LM-22

E

POINT OF CARE LM-25

E

premium lidocaine E

PREMIUM SCAR E

PREPIV SUPPLY 3

PRILO PATCH E

PRILO PATCH II E

PRILOLID E

PRILOVIX E

PRILOVIX LITE E

PRILOVIX LITE PLUS E

PRILOVIX PLUS E

PRILOVIX ULTRALITE E

PRILOVIX ULTRALITE PLUS

E

PRILOVIXIL E

PRIZOPAK II E

PRIZOTRAL E

PRIZOTRAL-II E

READYSHARP-A E

RELADOR PAK EXTERNAL KIT

E

RELADOR PAK PLUS E

SENSORCAINE E

SENSORCAINE-MPF INJECTION SOLUTION 075

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

19

Drug Name Drug Tier Notes

sensorcaine-mpf solution 025 injection

E

SENSORCAINE-MPF SOLUTION 025 INJECTION

E

sensorcaine-mpf solution 05 injection

E

SENSORCAINE-MPF SOLUTION 05 INJECTION

E

SKYADERM-LP E

SOOTHEE EXTERNAL PATCH 05-00375-5-2

E

STERILE TOPICAL LET GEL

3

SX1 MEDICATED POST-OPERATIVE

E

SYNERA E

VENIPUNCTURE PX1 PHLEBOTOMY

3

VEXATROL E

WPR PLUS WOUND HEALING SYSTEM

E

XARACOLL E

XYLOCAINE INJECTION

3

XYLOCAINE-MPF INJECTION SOLUTION 05 1 15 2

3

ZERUVIA E

ZILACAINE PATCH E

ZINGO INTRADERMAL JET-INJECTOR

E

ZIONODIL E

ZIONODIL 100 E

ZTLIDO E

Drug Name Drug Tier Notes

Anti-Addiction Substance Abuse Treatment Agents

acamprosate calcium 1

BUNAVAIL BUCCAL FILM 42-07 MG 63-1 MG

3 QL

buprenorphine hcl sublingual

1 QL

buprenorphine hcl-naloxone hcl

1 QL

bupropion hcl er (smoking det)

$0 QL

CHANTIX $0 QL

CHANTIX CONTINUING MONTH PAK

$0 QL

CHANTIX STARTING MONTH PAK

$0 QL

disulfiram oral 1

goodsense nicotine mouththroat lozenge 4 mg

$0 QL

habitrol $0 QL

LIFEMS NALOXONE E

LUCEMYRA 3 ST QL

naloxone hcl injection solution 04 mgml 4 mg10ml

E

naloxone hcl injection solution cartridge

E

naloxone hcl injection solution prefilled syringe

E

naltrexone hcl oral 1

NALTREXONE SUBCUTANEOUS

E

NARCAN 2

NICORETTE MOUTHTHROAT GUM 2 MG

$0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

20

Drug Name Drug Tier Notes

nicotine polacrilex mouththroat

$0 QL

nicotine step 1 $0 QL

nicotine step 2 $0 QL

nicotine step 3 $0 QL

NICOTROL $0 QL

NICOTROL NS $0 QL

SUBLOCADE 3 SP

SUBOXONE SUBLINGUAL FILM

2 QL

VIVITROL 3 SP

ZUBSOLV 2 QL

Antibacterials

ACTICLATE E

AEMCOLO 3 PA

ALTABAX 3

amikacin sulfate injection solution 500 mg2ml

E

amoxicillin oral capsule 1

amoxicillin oral suspension reconstituted

1

amoxicillin oral tablet 1

amoxicillin oral tablet chewable 125 mg 250 mg

1

amoxicillin-potassium clavulanate er

1

amoxicillin-potassium clavulanate oral

1

ampicillin oral capsule 500 mg

1

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

E

ARIKAYCE 3 PA SP

AUGMENTIN ES-600 3

Drug Name Drug Tier Notes

AUGMENTIN ORAL SUSPENSION RECONSTITUTED 125-3125 MG5ML 250-625 MG5ML

3

AUGMENTIN ORAL TABLET 500-125 MG

3

avidoxy 1 ST

AVIDOXY DK E

azithromycin oral packet

1

azithromycin oral suspension reconstituted

1

azithromycin oral tablet 250 mg 500 mg 600 mg

1

bacitracin external E

bacitracin zinc external E

BACTRIM 3

BACTRIM DS 3

BAXDELA INTRAVENOUS

E

BAXDELA ORAL 3

BENZALKONIUM CHLORIDE EXTERNAL SOLUTION

3

benzalkonium chloride external solution 50

1

BENZODOX E

BICILLIN L-A E

cefaclor 1

cefaclor er 1

cefadroxil 1

cefazolin sodium injection solution reconstituted 1 gm 10 gm

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

21

Drug Name Drug Tier Notes

cefazolin sodium-dextrose intravenous solution 2-4 gm100ml-

E

cefdinir 1

cefepime hcl injection solution reconstituted 2 gm

E

cefixime 1

CEFOTAN E

cefotaxime sodium injection solution reconstituted 1 gm 2 gm

E

cefotetan disodium injection solution reconstituted 1 gm 2 gm

E

cefoxitin sodium injection

E

cefpodoxime proxetil 1

cefprozil 1

ceftazidime injection solution reconstituted 1 gm 2 gm 6 gm

E

ceftriaxone sodium injection solution reconstituted 1 gm 2 gm 250 mg 500 mg

1

cefuroxime axetil oral tablet

1

CENTANY 3

CENTANY AT E

cephalexin 1

chloramphenicol sod succinate

E

CIPRO ORAL SUSPENSION RECONSTITUTED

3

CIPRO ORAL TABLET 250 MG 500 MG

3

ciprofloxacin hcl oral 1

Drug Name Drug Tier Notes

clarithromycin er 1

clarithromycin oral 1

CLEOCIN ORAL 3

CLEOCIN VAGINAL CREAM

3

CLEOCIN VAGINAL SUPPOSITORY

2

clindamycin hcl oral 1

clindamycin palmitate hcl

1

clindamycin phosphate vaginal

1

CLINDESSE 3

colistimethate sodium (cba)

E

COLY-MYCIN M E

coremino E

CUBICIN E

CUBICIN RF E

daptomycin E

demeclocycline hcl oral 1

dicloxacillin sodium 1

DIFICID 3

DORYX MPC E

DORYX ORAL TABLET DELAYED RELEASE 200 MG 50 MG

3 ST

DORYX ORAL TABLET DELAYED RELEASE 80 MG

E

doxy 100 E

doxycycline hyclate intravenous

E

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet 100 mg 50 mg

1

doxycycline hyclate oral tablet 150 mg 75 mg

1 ST

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

22

Drug Name Drug Tier Notes

doxycycline hyclate oral tablet 20 mg

E

doxycycline hyclate oral tablet delayed release 100 mg 75 mg

1

doxycycline hyclate oral tablet delayed release 150 mg 200 mg 50 mg

1 ST

DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG

E

doxycycline monohydrate oral capsule 100 mg 150 mg 75 mg

1 ST

doxycycline monohydrate oral capsule 50 mg

1

doxycycline monohydrate oral suspension reconstituted

1

doxycycline monohydrate oral tablet

1 ST

EES GRANULES 3

ertapenem sodium E

ERYPED 200 3

ERYPED 400 3

ERY-TAB 3

ERYTHROCIN STEARATE ORAL TABLET 250 MG

3

erythromycin base oral 1

erythromycin ethylsuccinate oral

1

erythromycin oral 1

FETROJA E

FIRST-METRONIDAZOLE ORAL SUSPENSION RECONSTITUTED 50 MGML

E

Drug Name Drug Tier Notes

FIRVANQ 3

FLAGYL ORAL CAPSULE

3

FLAGYL ORAL TABLET 500 MG

3

FORTAZ INJECTION SOLUTION RECONSTITUTED 1 GM

E

fosfomycin tromethamine

1

gentamicin sulfate external

1

HIPREX 3

imipenem-cilastatin intravenous solution reconstituted 250 mg

E

INVANZ INJECTION E

iodine tincture external tincture 2

1

KEFLEX ORAL CAPSULE 750 MG

3

levofloxacin oral 1

LINCOCIN E

lincomycin hcl injection E

linezolid in sodium chloride

E

linezolid intravenous solution 600 mg300ml

E

linezolid oral 1 QL

LUGOLS STRONG IODINE

3

MACROBID 3

MACRODANTIN 3

mafenide acetate external

1

meropenem intravenous solution reconstituted 500 mg

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

23

Drug Name Drug Tier Notes

MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM50ML 500 MG50ML

E

methenamine hippurate 1

methenamine mandelate oral

E

METRONIDAZOLE BENZO+SYRSPEND

E

metronidazole oral 1

metronidazole vaginal 1

MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3

minocycline hcl er oral tablet extended release 24 hour

E

minocycline hcl oral 1

MINOLIRA E

mondoxyne nl oral capsule 100 mg 75 mg

1 ST

MONUROL 3

MORGIDOX COMBINATION KIT 1 X 100 MG 2 X 100 MG

E

morgidox oral capsule 100 mg

1

moxifloxacin hcl in nacl E

moxifloxacin hcl oral 1

mupirocin calcium E

mupirocin external 1

nafcillin sodium injection solution reconstituted 1 gm

E

nafcillin sodium intravenous solution reconstituted 10 gm

E

neomycin sulfate oral 1

Drug Name Drug Tier Notes

neomycin-polymyxin b gu

E

nitrofurantoin macrocrystal oral

1

nitrofurantoin monohydrate macrocrystals

1

nitrofurantoin oral suspension

1

NUTRIDOX E

NUVESSA E

NUZYRA ORAL TABLET 150 MG

3

ofloxacin oral tablet 300 mg 400 mg

1

oxacillin sodium injection solution reconstituted 1 gm

E

oxacillin sodium intravenous

E

paromomycin sulfate oral

1

penicillin g potassium injection solution reconstituted 5000000 unit

E

penicillin g procaine E

penicillin g sodium E

penicillin v potassium 1

PFIZERPEN INJECTION SOLUTION RECONSTITUTED 5000000 UNIT

E

piperacillin sod-tazobactam so intravenous solution reconstituted 45 (4-05) gm

E

polymyxin b sulfate injection

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

24

Drug Name Drug Tier Notes

POLYSPORIN EXTERNAL OINTMENT 500-10000 UNITGM

E

PRIMSOL 3

RECARBRIO E

SCRUB CARE POVIDONE-IODINE

E

SEYSARA 3 ST

SILVADENE 3

silver nitrate external solution

E

silver sulfadiazine external

1

SIVEXTRO E

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HOUR 105 MG 115 MG 55 MG 65 MG 80 MG

3

SOLOSEC 3

ssd 1

streptomycin sulfate intramuscular

E

sulfadiazine oral 1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg5ml

1

sulfamethoxazole-trimethoprim oral tablet

1

SULFAMYLON EXTERNAL CREAM

E

SULFAMYLON EXTERNAL PACKET

3

sulfatrim pediatric 1

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION RECONSTITUTED

3

Drug Name Drug Tier Notes

SUPRAX ORAL TABLET CHEWABLE

3

TARGADOX E

tazicef injection E

tazicef intravenous solution reconstituted 1 gm

E

TEFLARO INTRAVENOUS SOLUTION RECONSTITUTED 600 MG

E

tetracycline hcl oral 1

tigecycline E

tinidazole oral 1

trimethoprim oral 1

TYGACIL E

UNASYN INJECTION SOLUTION RECONSTITUTED 3 (2-1) GM

E

VANCOCIN 3

VANCOCIN HCL ORAL CAPSULE 125 MG

3

vancomycin hcl in nacl intravenous solution 1-09 gm200ml-

E

vancomycin hcl intravenous solution 1000 mg200ml 1250 mg250ml 1500 mg300ml 1750 mg350ml 2000 mg400ml 500 mg100ml 750 mg150ml

E

vancomycin hcl oral 1

VANCOMYCIN+SYRSPEND SF

E

vandazole 1

VIBRAMYCIN 3 ST

XENLETA INTRAVENOUS

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

25

Drug Name Drug Tier Notes

XENLETA ORAL 3

XEPI 3

XIFAXAN 3 PA

XIMINO 3

ZEMDRI E

ZITHROMAX ORAL PACKET

3

ZITHROMAX ORAL SUSPENSION RECONSTITUTED

3

ZITHROMAX ORAL TABLET 250 MG 500 MG

3

ZITHROMAX TRI-PAK 3

ZITHROMAX Z-PAK 3

ZYVOX INTRAVENOUS SOLUTION 200 MG100ML 600 MG300ML

E

ZYVOX ORAL 3 QL

Anticoagulants

ACD-A NOCLOT-50 3

ACTIVASE E

ANTICOAGULANT SODIUM CITRATE

3

ARIXTRA 3 SP QL

CATHFLO ACTIVASE E

ELIQUIS 2 QL

ELIQUIS DVTPE STARTER PACK ORAL TABLET THERAPY PACK

2 QL

enoxaparin sodium 1 SP QL

fondaparinux sodium 1 SP QL

Drug Name Drug Tier Notes

FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNITML 12500 UNIT05ML 15000 UNIT06ML 18000 UNT072ML 2500 UNIT02ML 5000 UNIT02ML 7500 UNIT03ML 95000 UNIT38ML

3 SP QL

heparin (porcine) in nacl intravenous solution 1000-09 ut500ml- 2000-09 unitl-

E

heparin sodium (porcine) injection solution 1000 unitml 10000 unitml 20000 unitml 5000 unitml

1

heparin sodium (porcine) injection solution prefilled syringe

E

heparin sodium (porcine) pf injection solution 5000 unit05ml

1

heparin sodium (porcine) pf injection solution 5000 unitml

E

jantoven 1

LOVENOX 3 SP QL

PRADAXA 2 QL

REGIOCIT E

SAVAYSA 3 QL

THROMBATE III 3 SP

TRICITRASOL 3

warfarin sodium oral 1

XARELTO 2 QL

XARELTO STARTER PACK

2 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

26

Drug Name Drug Tier Notes

Anticonvulsants - Drugs for Seizures

APTIOM 3

BANZEL 3 PA

BRIVIACT INTRAVENOUS

E

BRIVIACT ORAL 3 ST

carbamazepine er 1

carbamazepine oral 1

CARBATROL 3

CELONTIN 3

CEREBYX INJECTION SOLUTION 500 MG PE10ML

E

clobazam 1 PA

DEPAKOTE 3

DEPAKOTE ER 3

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED RELEASE SPRINKLE

3

DIACOMIT 3 PA SP

DIASTAT ACUDIAL 3 QL

DIASTAT PEDIATRIC 3 QL

diazepam rectal 1 QL

DILANTIN INFATABS E

DILANTIN ORAL CAPSULE 100 MG

E

DILANTIN ORAL CAPSULE 30 MG

3

DILANTIN ORAL SUSPENSION

E

divalproex sodium er oral tablet extended release 24 hour

1

divalproex sodium oral capsule delayed release sprinkle

1

divalproex sodium oral tablet delayed release

1

ELEPSIA XR E

Drug Name Drug Tier Notes

EPIDIOLEX 3 PA SP

epitol 1

ethosuximide oral 1

FANATREX FUSEPAQ E

felbamate 1

FELBATOL 3

FINTEPLA 3 PA SP

fosphenytoin sodium injection solution 500 mg pe10ml

E

FYCOMPA 3

gabapentin oral capsule

1

gabapentin oral solution 250 mg5ml

1

gabapentin oral tablet 1

GABITRIL 3

KEPPRA INTRAVENOUS

E

KEPPRA ORAL 3

KEPPRA XR 3

LAMICTAL ODT ORAL KIT 21 X 25 MG amp 7 X 50 MG 42 X 50 MG amp 14X100 MG

2

LAMICTAL ODT ORAL KIT 25 amp 50 amp 100 MG

E

LAMICTAL ODT ORAL TABLET DISPERSIBLE

3

LAMICTAL ORAL TABLET

3

LAMICTAL ORAL TABLET CHEWABLE 25 MG 5 MG

3

LAMICTAL STARTER 3

LAMICTAL XR 3

lamotrigine er 1

lamotrigine oral kit 25 amp 50 amp 100 mg

1

lamotrigine oral tablet 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

27

Drug Name Drug Tier Notes

lamotrigine oral tablet chewable

1

lamotrigine oral tablet dispersible

1

lamotrigine starter kit-blue

1

lamotrigine starter kit-green

1

lamotrigine starter kit-orange

1

levetiracetam er 1

levetiracetam intravenous

E

levetiracetam oral 1

MYSOLINE 3

NAYZILAM 3 QL

NEURONTIN 3

ONFI ORAL SUSPENSION

3 PA

ONFI ORAL TABLET 10 MG 20 MG

3 PA

oxcarbazepine 1

OXTELLAR XR E

phenobarbital oral elixir 1

phenobarbital oral tablet

1

PHENYTEK 3

phenytoin infatabs 1

phenytoin oral suspension 125 mg5ml

1

phenytoin oral tablet chewable

1

phenytoin sodium extended

1

primidone oral 1

QUDEXY XR 3

roweepra oral tablet 500 mg

1

rufinamide 1 PA

Drug Name Drug Tier Notes

SABRIL ORAL PACKET

E SP

SABRIL ORAL TABLET

3 PA SP

SPRITAM E

subvenite 1

subvenite starter kit-blue

1

subvenite starter kit-green

1

subvenite starter kit-orange

1

SYMPAZAN 3 PA

TEGRETOL ORAL SUSPENSION

3

TEGRETOL ORAL TABLET

3

TEGRETOL-XR 3

tiagabine hcl 1

TOPAMAX 3

TOPAMAX SPRINKLE 3

topiramate er 1

topiramate oral 1

TRILEPTAL 3

TROKENDI XR 3 ST

valproic acid oral capsule

1

valproic acid oral solution

1

VALTOCO 3 QL

vigabatrin 1 PA SP

vigadrone 1 PA SP

VIMPAT INTRAVENOUS

E

VIMPAT ORAL 3

XCOPRI 3 ST

ZARONTIN 3

ZONEGRAN 3

zonisamide oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

28

Drug Name Drug Tier Notes

Antidementia Agents - Drugs for Alzheimers Disease and Dementia

ARICEPT 3

donepezil hcl 1

EXELON TRANSDERMAL

3

galantamine hydrobromide

1

galantamine hydrobromide er

1

memantine hcl er 1 QL

memantine hcl oral solution 2 mgml

1

memantine hcl oral tablet

1

NAMENDA ORAL TABLET

3

NAMENDA TITRATION PAK

3

NAMENDA XR 3 QL

NAMENDA XR TITRATION PACK

3 QL

NAMZARIC 2 QL

RAZADYNE ER 3

rivastigmine 1

rivastigmine tartrate 1

Antidepressants

amitriptyline hcl oral 1

amoxapine 1

ANAFRANIL 3

APLENZIN E

BRISDELLE 3 ST QL

bupropion hcl er (sr) 1 QL

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

1 QL

Drug Name Drug Tier Notes

BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG

E

bupropion hcl oral 1

CELEXA ORAL TABLET

3

chlordiazepoxide-amitriptyline

1

citalopram hydrobromide

1

clomipramine hcl oral 1

CYMBALTA E

desipramine hcl oral 1

DESVENLAFAXINE ER

3 ST QL

desvenlafaxine succinate er

1 QL

doxepin hcl oral capsule

1

doxepin hcl oral concentrate

1

DRIZALMA SPRINKLE 3 ST QL

duloxetine hcl oral 1 QL

EFFEXOR XR E

EMSAM 3 QL

escitalopram oxalate 1

FETZIMA 3 ST QL

FETZIMA TITRATION 3 ST QL

fluoxetine hcl (pmdd) oral tablet

1

fluoxetine hcl oral capsule

1

fluoxetine hcl oral capsule delayed release

1 QL

fluoxetine hcl oral solution

1

fluoxetine hcl oral tablet 1

fluvoxamine maleate 1

fluvoxamine maleate er 1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

29

Drug Name Drug Tier Notes

FORFIVO XL E

imipramine hcl oral 1

imipramine pamoate 1

LEXAPRO ORAL TABLET

E

maprotiline hcl 1

MARPLAN 3

mirtazapine oral 1

NARDIL 3

nefazodone hcl 1

NORPRAMIN ORAL TABLET 10 MG 25 MG

3

nortriptyline hcl oral 1

olanzapine-fluoxetine hcl

1 QL

PAMELOR ORAL CAPSULE

3

PARNATE 3

paroxetine hcl er 1

paroxetine hcl oral tablet

1

paroxetine mesylate 1 QL

PAXIL CR 3

PAXIL ORAL SUSPENSION

2 ST

PAXIL ORAL TABLET 3

perphenazine-amitriptyline

1

PEXEVA E

phenelzine sulfate oral 1

PRISTIQ E

protriptyline hcl 1

PROZAC ORAL CAPSULE

E

REMERON ORAL TABLET 15 MG 30 MG

3

REMERON SOLTAB 3

sertraline hcl oral 1

Drug Name Drug Tier Notes

SPRAVATO (56 MG DOSE)

3 PA SP

SPRAVATO (84 MG DOSE)

3 PA SP

SYMBYAX ORAL CAPSULE 12-50 MG 3-25 MG 6-25 MG 6-50 MG

3 QL

tranylcypromine sulfate 1

trazodone hcl oral 1

trimipramine maleate oral

1

TRINTELLIX 3 ST QL

venlafaxine hcl 1

venlafaxine hcl er 1

VIIBRYD ORAL TABLET

3 QL

VIIBRYD STARTER PACK

3 QL

WELLBUTRIN SR E

WELLBUTRIN XL E

ZOLOFT E

ZULRESSO 3 PA SP

Antiemetics - Drugs for Nausea and Vomiting

AKYNZEO INTRAVENOUS

E

AKYNZEO ORAL 3 QL

ALOXI INTRAVENOUS SOLUTION 025 MG5ML

E

ANZEMET ORAL 3 QL

aprepitant 1 QL

BONJESTA 3 PA QL

compro 1

cvs motion sickness E

DICLEGIS 3 PA QL

doxylamine-pyridoxine 1 PA QL

dronabinol 1 PA QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

30

Drug Name Drug Tier Notes

EMEND INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

E

EMEND ORAL CAPSULE 80 MG

3 QL

EMEND ORAL SUSPENSION RECONSTITUTED

3

EMEND TRI-PACK 3 QL

fosaprepitant dimeglumine

E

GIMOTI E

goodsense motion sickness

E

granisetron hcl intravenous solution 1 mgml 4 mg4ml

E

granisetron hcl oral 1 QL

MARINOL 3 PA QL

meclizine hcl oral tablet 1

meclizine hcl tablet chewable 25 mg oral (otc)

E

meclizine hcl tablet chewable 25 mg oral (rx)

1

metoclopramide hcl oral solution 10 mg10ml 5 mg5ml

1

metoclopramide hcl oral tablet

1

metoclopramide hcl oral tablet dispersible

1

motion sickness relief E

ondansetron hcl injection solution 4 mg2ml 40 mg20ml

E

ondansetron hcl oral solution

1 QL

ondansetron hcl oral tablet 24 mg

1 QL

Drug Name Drug Tier Notes

ondansetron hcl oral tablet 4 mg 8 mg

1

ondansetron odt 1

palonosetron hcl E

perphenazine oral 1

prochlorperazine 1

prochlorperazine maleate oral

1

REGLAN ORAL 3

SANCUSO 3 QL

scopolamine 1

SUSTOL E

SYNDROS 3 PA QL

TIGAN INTRAMUSCULAR

E

TIGAN ORAL 3

TRANSDERM SCOP (15 MG)

3

TRANSDERM-SCOP (15 MG)

3

trimethobenzamide hcl oral

1

VARUBI (180 MG DOSE)

3 QL

ZOFRAN ORAL TABLET 4 MG

3

ZUPLENZ E

Antifungals

ALA-QUIN E

ALCORTIN A E

ALOE VESTA CLEAR ANTIFUNGAL

E

ANCOBON 3

athletes foot (terbinafine)

E

CANCIDAS INTRAVENOUS SOLUTION RECONSTITUTED 70 MG

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

31

Drug Name Drug Tier Notes

caspofungin acetate intravenous solution reconstituted 70 mg

E

ciclodan external solution

1

ciclopirox external 1

ciclopirox olamine external

1

ciclopirox treatment E

clotrimazole external cream

1

clotrimazole external solution

1

clotrimazole mouththroat troche

1

clotrimazole vaginal cream 1

E

clotrimazole-betamethasone

1

CRESEMBA ORAL 3

cvs clotrimazole 3 E

DERMACINRX THERAZOLE PAK

E

DESENEX EXTERNAL POWDER

E

DIFLUCAN 3

DIFMETIOXRIME E

ECONASIL E

econazole nitrate external

1

ECONAZOLE NITRATE-NIACINAMIDE

E

ECOZA E

ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

E

ERTACZO E

EXELDERM E

Drug Name Drug Tier Notes

EXODERM EXTERNAL LOTION

3

EXTINA 3

fluconazole oral 1

FLUCON-IBUPROF-ITRACON-TERBINA

E

flucytosine oral 1

FUNGIMEZ E

griseofulvin microsize oral

1

griseofulvin ultramicrosize

1

GYNAZOLE-1 3

HIXDEFRIMA E

hydrocortisone-iodoquinol external cream 1-1

E

IMIOXIA E

IODOQUIMEZ-HC E

iodoquinol-hc-aloe polysacch

E

IODOQUINOL-HC-KETOCONAZOLE

E

iodoquinol-hydrocortisone-aloe

E

itraconazole oral 1 PA

JUBLIA E

KERYDIN 3 PA

ketoconazole external cream

1

ketoconazole external foam

E

ketoconazole external shampoo 2

1

ketoconazole oral 1

KETOCONAZOLE-HYDROCORTISONE

E

ketodan external foam E

KETODAN EXTERNAL KIT

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

32

Drug Name Drug Tier Notes

LOPROX EXTERNAL CREAM

3

LOPROX EXTERNAL KIT

E

LOPROX EXTERNAL SHAMPOO

3

LOPROX EXTERNAL SUSPENSION

3

LOTRIMIN AF EXTERNAL POWDER

E

LULICONAZOLE E

LUZU E

MENTAX E

micaderm E

micafungin sodium intravenous solution reconstituted 100 mg

E

miconazole 1 E

miconazole 3 vaginal suppository

1

miconazole 7 E

miconazole nitrate external cream

E

MICONAZOLE-ZINC OXIDE-PETROLAT

E

MYCAMINE INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

E

MYCOZYL AP E

naftifine hcl 1

NAFTIN EXTERNAL GEL

3

NOXAFIL ORAL 3 PA

nyamyc 1

nystatin external 1

nystatin mouththroat 1

nystatin oral tablet 1

nystatin-triamcinolone 1

nystop 1

Drug Name Drug Tier Notes

ONYCHO-MED E

ORAVIG E

oxiconazole nitrate E

OXISTAT EXTERNAL CREAM

3

OXISTAT EXTERNAL LOTION

E

PEDIZOLPAK E

PHEODOYO E

PHEYO E

posaconazole 1 PA

QUINJA E

RECURA E

SPORANOX 3 PA

SPORANOX PULSEPAK

3 PA

SULCONAZOLE NITRATE

E

tavaborole 1 PA

terbinafine hcl oral 1 QL

terconazole 1

tolnaftate antifungal E

tolnaftate external powder

E

TOLSURA E

VFEND 3

voriconazole oral 1

VUSION E

VYTONE E

XOLEGEL E

XOLEGEL COREPAK E

XOLEGEL DUOHEAD amp SHOULDERS

E

XOLEGEL DUOXOLEX

E

ZEASORB-AF EXTERNAL POWDER

E

ZOLPAK E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

33

Drug Name Drug Tier Notes

Antigout Agents

allopurinol oral 1

COLCHICINE ORAL CAPSULE

E

colchicine oral tablet 1

colchicine-probenecid 1

COLCRYS E

febuxostat 1 ST

GLOPERBA E

KRYSTEXXA 3 PA SP

MITIGARE E

probenecid oral 1

ULORIC 3 ST

ZYLOPRIM 3

Anti-inflammatory Agents

EMFLAZA 3 PA SP

Antimigraine Agents

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-INJECTOR 140 MGML 70 MGML

2 PA QL

AJOVY E

almotriptan malate 1 QL

AMERGE 3 QL

CAFERGOT 3

DHE 45 3 PA QL

dihydroergotamine mesylate injection

1 PA QL

dihydroergotamine mesylate nasal

1 PA QL

eletriptan hydrobromide 1 QL

EMGALITY 2 PA QL

EMGALITY (300 MG DOSE)

2 PA QL

ERGOMAR 3

ergotamine-caffeine 1

FROVA 3 QL

Drug Name Drug Tier Notes

frovatriptan succinate 1 QL

IMITREX 3 QL

IMITREX STATDOSE REFILL SUBCUTANEOUS SOLUTION CARTRIDGE

3 QL

IMITREX STATDOSE SYSTEM SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 QL

MAXALT ORAL TABLET 10 MG

3 QL

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG

3 QL

MIGERGOT 3

MIGRAINE PACK E

MIGRANAL 3 PA QL

MIGRANOW E

naratriptan hcl 1 QL

NURTEC 2 PA QL

ONZETRA XSAIL 3 ST QL

RELPAX 3 QL

REYVOW E

rizatriptan benzoate 1 QL

SUMANSETRON E

sumatriptan nasal 1 QL

sumatriptan succinate oral

1 QL

sumatriptan succinate refill subcutaneous solution cartridge

1 QL

sumatriptan succinate subcutaneous solution 6 mg05ml

1 QL

sumatriptan succinate subcutaneous solution auto-injector 4 mg05ml 6 mg05ml

1 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

34

Drug Name Drug Tier Notes

sumatriptan succinate subcutaneous solution prefilled syringe 6 mg05ml

1 QL

sumatriptan-naproxen sodium

1 QL

TOSYMRA E

TREXIMET ORAL TABLET 85-500 MG

3 ST QL

UBRELVY 2 PA QL

VYEPTI E

ZEMBRACE SYMTOUCH

E

ZOLMITRIPTAN NASAL

3 ST QL

zolmitriptan oral 1 QL

ZOMIG NASAL 3 ST QL

ZOMIG ORAL E

ZOMIG ZMT E

Antimyasthenic Agents

GUANIDINE HCL ORAL

3

MESTINON ORAL SOLUTION

3

MESTINON ORAL TABLET

3

MESTINON ORAL TABLET EXTENDED RELEASE

3

NEOSTIGMINE METHYLSULFATE SOLUTION PREFILLED SYRINGE 5 MG5ML INTRAVENOUS

E

pyridostigmine bromide er

1

pyridostigmine bromide oral solution

1

pyridostigmine bromide oral tablet

1

Drug Name Drug Tier Notes

Antimycobacterials

CAPASTAT SULFATE E

cycloserine oral 1

dapsone oral 1

ethambutol hcl oral 1

isoniazid oral 1

MYAMBUTOL ORAL TABLET 400 MG

3

MYCOBUTIN 3

PASER 3

PRETOMANID 3

PRIFTIN 3

pyrazinamide oral 1

rifabutin 1

rifampin oral 1

RIFAMPIN+SYRSPEND SF

E

SIRTURO 3

TRECATOR 3

Antineoplastics - Drugs for Cancer

abiraterone acetate 1 PA SP

ABRAXANE 2 SP

ADCETRIS 2 PA SP

adriamycin intravenous solution

1 SP

adriamycin intravenous solution reconstituted 10 mg 50 mg

1 SP

AFINITOR DISPERZ 3 PA SP

AFINITOR ORAL TABLET 10 MG

2 PA SP QL

AFINITOR ORAL TABLET 25 MG 5 MG 75 MG

E SP

ALECENSA 2 PA SP

ALIMTA 2 SP

ALIQOPA 3 PA SP

ALKERAN 3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

35

Drug Name Drug Tier Notes

ALUNBRIG 2 PA SP QL

anastrozole oral $0

ARIMIDEX E

AROMASIN 3

ARRANON 2 SP

arsenic trioxide intravenous

1 SP

ARZERRA 2 PA SP

ASPARLAS 3 SP

AVASTIN 3 PA SP

AYVAKIT 3 PA SP QL

azacitidine 1 PA SP

BALVERSA 3 PA SP

BAVENCIO 3 PA SP

BELEODAQ 3 PA SP

BELRAPZO E SP

BENDEKA 3 PA SP

BESPONSA 3 PA SP

bexarotene 1 PA SP

bicalutamide 1

BICNU 3 SP

BLENREP 3 PA SP

bleomycin sulfate 1 SP

BLINCYTO 3 PA SP

BORTEZOMIB 3 PA SP

BOSULIF 3 PA SP

BRAFTOVI ORAL CAPSULE 75 MG

3 PA SP

BREYANZI E SP

BRUKINSA 3 PA SP

busulfan 1 SP

BUSULFEX 3 SP

CABOMETYX 2 PA SP

CALQUENCE 3 PA SP

CAMPATH 2 SP

CAMPTOSAR 3 SP

capecitabine 1 PA SP

Drug Name Drug Tier Notes

CAPRELSA ORAL TABLET 100 MG

2 PA SP QL

CAPRELSA ORAL TABLET 300 MG

2 PA SP

carboplatin intravenous solution

1 SP

carmustine 1 SP

CASODEX 3

cisplatin intravenous solution 100 mg100ml 200 mg200ml 50 mg50ml

1 SP

CISPLATIN INTRAVENOUS SOLUTION RECONSTITUTED

3 SP

cladribine intravenous solution 10 mg10ml

1 SP

clofarabine 1 SP

CLOLAR 3 SP

COMETRIQ ORAL KIT 20 MG 3 X 20 MG amp 80 MG 80 amp 20 MG

3 PA SP

COPIKTRA 3 PA SP

COSELA E SP

COSMEGEN 3 SP

COTELLIC 3 PA SP

cyclophosphamide injection

1 SP

CYCLOPHOSPHAMIDE INTRAVENOUS

3 SP

cyclophosphamide oral capsule

1

CYCLOPHOSPHAMIDE ORAL TABLET

2

CYRAMZA 3 PA SP

cytarabine (pf) 1 SP

cytarabine injection solution

1 SP

dacarbazine intravenous

1 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

36

Drug Name Drug Tier Notes

DACOGEN 3 PA SP

dactinomycin 1 SP

DANYELZA 3 PA SP

DARZALEX 3 PA SP

DARZALEX FASPRO E SP

daunorubicin hcl intravenous solution

1 SP

DAURISMO 3 PA SP

decitabine 1 PA SP

dexrazoxane hcl 1 SP

docetaxel intravenous concentrate 160 mg8ml 20 mgml 80 mg4ml

1 SP

docetaxel intravenous solution 160 mg16ml 20 mg2ml 80 mg8ml

1 SP

DOXIL 3 SP

doxorubicin hcl intravenous solution

1 SP

doxorubicin hcl liposomal

1 SP

DROXIA 3

ELITEK 3 SP

ELLENCE 3 SP

ELZONRIS 3 PA SP

EMCYT 2

EMPLICITI 3 PA SP

ENHERTU 3 PA SP

epirubicin hcl intravenous solution 200 mg100ml 50 mg25ml

1 SP

ERBITUX 2 PA SP

ERIVEDGE 2 PA SP

ERLEADA E SP

erlotinib hcl oral tablet 100 mg 150 mg

1 PA SP

erlotinib hcl oral tablet 25 mg

1 PA SP QL

Drug Name Drug Tier Notes

ERWINAZE INJECTION

3 SP

ETHYOL 3 SP

ETOPOPHOS 3 SP

etoposide intravenous solution 1 gm50ml 100 mg5ml 500 mg25ml

1 SP

etoposide oral 1 SP

everolimus oral tablet 25 mg 5 mg 75 mg

1 PA SP QL

EVOMELA 3 SP

exemestane $0

FARESTON 3

FARYDAK 3 PA SP

FASLODEX INTRAMUSCULAR SOLUTION 250 MG5ML

3 SP

FEMARA 3

floxuridine injection 1 SP

fludarabine phosphate 1 SP

fluorouracil intravenous 1 SP

flutamide 1

FOLOTYN 2 PA SP

FOTIVDA E SP

fulvestrant 1 SP

GAVRETO E SP

GAZYVA 3 PA SP

gemcitabine hcl 1 SP

GILOTRIF 3 PA SP QL

GLEEVEC 3 PA SP

GLEOSTINE ORAL CAPSULE 10 MG 100 MG 40 MG

3 SP

HALAVEN 2 PA SP

HERCEPTIN HYLECTA

3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

37

Drug Name Drug Tier Notes

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG

3 PA SP

HERZUMA E SP

HYCAMTIN 3 SP

HYDREA 3

hydroxyurea oral 1

IBRANCE 3 PA SP

ICLUSIG ORAL TABLET 10 MG 15 MG

3 PA SP QL

ICLUSIG ORAL TABLET 30 MG 45 MG

3 PA SP

IDAMYCIN PFS 3 SP

idarubicin hcl 1 SP

IDHIFA 3 PA SP QL

IFEX 3 SP

ifosfamide 1 SP

imatinib mesylate 1 PA SP

IMBRUVICA 3 PA SP

IMFINZI 3 PA SP

IMLYGIC 3 SP

INFUGEM 3 SP

INLYTA 3 PA SP

INQOVI E SP

INREBIC 3 PA SP

IRESSA 3 PA SP

irinotecan hcl 1 SP

ISTODAX (OVERFILL) 3 PA SP

IXEMPRA KIT 2 SP

JAKAFI ORAL TABLET 10 MG

2 PA SP QL

JAKAFI ORAL TABLET 15 MG 20 MG 25 MG 5 MG

2 PA SP

JELMYTO E SP

JEVTANA 2 PA SP

Drug Name Drug Tier Notes

KADCYLA 3 PA SP

KANJINTI 2 PA SP

KEYTRUDA INTRAVENOUS SOLUTION

3 PA SP

KHAPZORY 3 ST SP

KISQALI FEMARA 3 PA SP

KISQALI ORAL TABLET THERAPY PACK 200 MG

3 PA SP

KOSELUGO 3 PA SP

KYPROLIS 2 PA SP

lapatinib ditosylate 1 PA SP

LENVIMA ORAL CAPSULE THERAPY PACK 10 amp 4 MG 10 MG 10 MG amp 2 X 4 MG 2 X 10 MG 2 X 10 MG amp 4 MG 2 X 4 MG 3 X 4 MG 4 MG

3 PA SP

letrozole oral 1

leucovorin calcium injection

E

leucovorin calcium oral 1

LEUKERAN 2

levoleucovorin calcium intravenous solution reconstituted 50 mg

1 SP

levoleucovorin calcium pf

1 SP

LIBTAYO 3 PA SP

LONSURF 3 PA SP

LORBRENA 3 PA SP

LUMOXITI 3 PA SP

LUTATHERA E

LYNPARZA ORAL TABLET

2 PA SP

LYSODREN 2

MARQIBO 3 SP

MATULANE 2 SP

MEKINIST 2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

38

Drug Name Drug Tier Notes

MEKTOVI 3 PA SP

melphalan 1 SP

melphalan hcl 1 SP

mercaptopurine oral 1

mesna 1 SP

MESNEX 3 SP

mitomycin intravenous 1 SP

MITOMYCIN INTRAVESICAL

E SP

mitoxantrone hcl 1 PA SP

MONJUVI 3 PA SP

mutamycin 1 SP

MVASI 2 PA SP

MYLERAN 2

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 45 MG

3 PA SP

NAVELBINE 3 SP

NERLYNX 3 PA SP QL

NEXAVAR 2 PA SP

NILANDRON 3 SP

nilutamide 1 SP

NINLARO 3 PA SP

NIPENT 3 SP

NUBEQA 3 PA SP

ODOMZO 3 PA SP

OGIVRI E SP

ONCASPAR INJECTION

2 SP

ONIVYDE 3 SP

ONTRUZANT E SP

ONUREG 3 PA SP

OPDIVO 3 PA SP

ORGOVYX 3 PA SP

oxaliplatin intravenous solution 100 mg20ml 50 mg10ml

1 SP

Drug Name Drug Tier Notes

oxaliplatin intravenous solution 200 mg40ml

E

oxaliplatin intravenous solution reconstituted

1 SP

paclitaxel 1 SP

PADCEV 3 PA SP

PANRETIN 3

paraplatin 1 SP

PEMAZYRE 3 PA SP QL

PERJETA 2 PA SP

PHESGO 2 PA SP

PHOTOFRIN 3 SP

PIQRAY 3 PA SP

POLIVY 3 PA SP

POMALYST 3 PA SP

PORTRAZZA 3 PA SP

POTELIGEO 3 PA SP

PROLEUKIN 2 SP

PURIXAN 3 SP

QINLOCK 3 PA SP

RETEVMO 3 PA SP

REVLIMID 2 PA SP

RIABNI 3 PA SP

RITUXAN HYCELA 3 PA SP

RITUXAN INTRAVENOUS SOLUTION

3 PA SP

ROMIDEPSIN INTRAVENOUS SOLUTION

3 PA SP

ROZLYTREK 3 PA SP

RUBRACA 2 PA SP

RUXIENCE 2 PA SP

RYDAPT 3 PA SP

SARCLISA 3 PA SP

SIKLOS 3 PA

SOLTAMOX $0

SPRYCEL 2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

39

Drug Name Drug Tier Notes

STIVARGA 3 PA SP

SUTENT 2 PA SP

SYLVANT 3 PA SP

SYNRIBO 3 PA SP

TABLOID 2 SP

TABRECTA E SP

TAFINLAR 2 PA SP

TAGRISSO ORAL TABLET 40 MG

3 PA SP QL

TAGRISSO ORAL TABLET 80 MG

3 PA SP

TALZENNA 3 PA SP

tamoxifen citrate oral 1

TARCEVA ORAL TABLET 100 MG 150 MG

3 PA SP

TARCEVA ORAL TABLET 25 MG

3 PA SP QL

TARGRETIN EXTERNAL

3 PA SP

TARGRETIN ORAL E SP

TASIGNA 3 PA SP

TAZVERIK E SP

TECARTUS 3 PA SP

TECENTRIQ 3 PA SP

TEMODAR INTRAVENOUS

2 SP

TEMODAR ORAL CAPSULE 100 MG 140 MG 180 MG 250 MG

3 PA SP

temozolomide 1 PA SP

teniposide 1 SP

TEPADINA 3 SP

TEPMETKO E SP

THALOMID 2 PA SP

thiotepa injection 1 SP

TIBSOVO 3 PA SP

Drug Name Drug Tier Notes

toposar intravenous solution 1 gm50ml 100 mg5ml 500 mg25ml

1 SP

topotecan hcl 1 SP

toremifene citrate 1

TOTECT 3 SP

TRAZIMERA 2 PA SP

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED

E SP

tretinoin oral 1 SP

TRISENOX INTRAVENOUS SOLUTION 12 MG6ML

3 SP

TRODELVY 3 PA SP

TRUXIMA E SP

TUKYSA 3 PA SP

TURALIO 3 PA SP

TYKERB 3 PA SP

UKONIQ E SP

UNITUXIN 3 PA SP

VALCHLOR 3 PA SP

valrubicin E

VALSTAR E

VECTIBIX INTRAVENOUS SOLUTION 100 MG5ML 400 MG20ML

3 SP

VELCADE INJECTION 2 PA SP

VENCLEXTA 3 PA SP

VENCLEXTA STARTING PACK

3 PA SP

VERZENIO 3 PA SP

VIDAZA 3 PA SP

vinblastine sulfate intravenous solution

1 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

40

Drug Name Drug Tier Notes

vincristine sulfate intravenous

1 SP

vinorelbine tartrate 1 SP

VITRAKVI 3 PA SP

VIZIMPRO 3 PA SP

VORAXAZE E

VOTRIENT 3 PA SP

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG

3 PA SP

XALKORI 3 PA SP

XELODA 3 PA SP

XOFIGO INTRAVENOUS SOLUTION 30 MCCIML

E

XOSPATA 3 PA SP

XPOVIO (100 MG ONCE WEEKLY)

3 PA SP

XPOVIO (40 MG ONCE WEEKLY)

3 PA SP

XPOVIO (40 MG TWICE WEEKLY)

3 PA SP

XPOVIO (60 MG ONCE WEEKLY)

3 PA SP

XPOVIO (60 MG TWICE WEEKLY)

3 PA SP

XPOVIO (80 MG ONCE WEEKLY)

3 PA SP

XPOVIO (80 MG TWICE WEEKLY)

3 PA SP

XTANDI 3 PA SP

YERVOY 2 PA SP

YESCARTA 3 PA SP

YONDELIS 3 SP

YONSA E SP

ZALTRAP 2 PA SP

ZANOSAR 2 SP

ZEJULA 2 PA SP

Drug Name Drug Tier Notes

ZELBORAF 3 PA SP

ZEPZELCA 3 PA SP

ZEVALIN Y-90 3 SP

ZIRABEV 2 PA SP

ZOLINZA 2 PA SP

ZYDELIG 3 PA SP

ZYKADIA ORAL TABLET

3 PA SP

ZYTIGA E SP

Antiparasitics

albendazole oral 1 PA

ALBENZA 3 PA

ALINIA ORAL SUSPENSION RECONSTITUTED

2

ALINIA ORAL TABLET 3

ARAKODA 3

atovaquone oral 1

atovaquone-proguanil hcl

1

BENZNIDAZOLE 3

BILTRICIDE 3

chloroquine phosphate oral

1

COARTEM 3

crotan 1

DARAPRIM 3 PA SP

EGATEN 3

ELIMITE 3

EMVERM 2

hydroxychloroquine sulfate oral

1

IMPAVIDO 3

ivermectin external lotion

1

ivermectin oral 1

KRINTAFEL 3

LAMPIT 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

41

Drug Name Drug Tier Notes

lice killing external shampoo 4-033

E

lice treatment external liquid 1

E

lindane external shampoo

1

MALARONE 3

malathion external 1

mefloquine hcl 1

MEPRON 3

NATROBA 3

NEBUPENT 3

nitazoxanide 1

OVIDE 3

PENTAM E

pentamidine isethionate inhalation

1

pentamidine isethionate injection

E

permethrin external cream

1

PLAQUENIL 3

praziquantel oral 1

primaquine phosphate oral

1

pyrimethamine oral 1 PA SP

PYRIMETHAMINE-LEUCOVORIN

3

QUALAQUIN 3 PA

quinine sulfate oral 1 PA

spinosad 1

stop lice complete treatment

E

STROMECTOL 3

SULFURATED LIME 3

Antiparkinson Agents

amantadine hcl oral 1

Drug Name Drug Tier Notes

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

3 PA SP QL

AZILECT 3

benztropine mesylate oral

1

bromocriptine mesylate oral

1

carbidopa oral 1

carbidopa-levodopa 1

carbidopa-levodopa er oral tablet extended release 25-100 mg 50-200 mg

1

carbidopa-levodopa-entacapone

1

COMTAN 3

DUOPA ENTERAL 3 PA

entacapone 1

GOCOVRI E

INBRIJA 3 PA SP

KYNMOBI 3 PA SP QL

KYNMOBI TITRATION KIT

3 PA SP QL

LODOSYN 3

MIRAPEX ER 3

MIRAPEX ORAL TABLET 0125 MG 05 MG 075 MG 1 MG

3

NEUPRO 3 ST

NOURIANZ 3 PA

ONGENTYS 3 ST

OSMOLEX ER E

PARLODEL 3

pramipexole dihydrochloride

1

pramipexole dihydrochloride er

1

rasagiline mesylate oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

42

Drug Name Drug Tier Notes

ropinirole hcl 1

ropinirole hcl er 1

RYTARY 3 ST

selegiline hcl oral 1

SINEMET ORAL TABLET 10-100 MG 25-100 MG

3

STALEVO 100 3

STALEVO 125 3

STALEVO 150 3

STALEVO 200 3

STALEVO 50 3

STALEVO 75 3

TASMAR ORAL TABLET 100 MG

3

tolcapone 1

trihexyphenidyl hcl 1

XADAGO 3 ST QL

ZELAPAR 3

Antiplatelets

aspirin-dipyridamole er 1

ASPIRIN-OMEPRAZOLE

E

BRILINTA 2

CABLIVI 3 PA SP QL

cilostazol 1

clopidogrel bisulfate oral

1

dipyridamole oral 1

DURLAZA E

EFFIENT 3

PLAVIX ORAL TABLET 75 MG

3

prasugrel hcl 1

YOSPRALA E

ZONTIVITY 3

Drug Name Drug Tier Notes

Antipsychotics - Drugs for Mood Disorders

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE

3

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

ABILIFY MYCITE E

ABILIFY MYCITE MAINTENANCE KIT

E

ABILIFY MYCITE STARTER KIT

E

ABILIFY ORAL TABLET

3 QL

ADASUVE 3 PA

aripiprazole 1 QL

ARISTADA E

ARISTADA INITIO E

asenapine maleate 1 QL

CAPLYTA 3 ST QL

chlorpromazine hcl injection

E

chlorpromazine hcl oral 1

clozapine 1 QL

CLOZARIL 3 QL

FANAPT 3 ST QL

FANAPT TITRATION PACK

3 ST QL

fluphenazine decanoate injection

E

fluphenazine hcl injection

E

fluphenazine hcl oral 1

GEODON INTRAMUSCULAR

E

GEODON ORAL 3 QL

HALDOL DECANOATE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

43

Drug Name Drug Tier Notes

haloperidol decanoate intramuscular solution 100 mgml 50 mgml

E

haloperidol lactate oral 1

haloperidol oral 1

INVEGA 3 QL

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3

LATUDA 3 QL

loxapine succinate oral 1

molindone hcl 1

NUPLAZID ORAL CAPSULE

3 PA

NUPLAZID ORAL TABLET 10 MG

3 PA

olanzapine intramuscular

E

olanzapine oral 1 QL

paliperidone er 1 QL

PERSERIS E

pimozide 1

quetiapine fumarate 1 QL

quetiapine fumarate er 1 QL

REXULTI 3 QL

RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3

RISPERDAL ORAL SOLUTION

E

RISPERDAL ORAL TABLET 05 MG 1 MG 2 MG 3 MG 4 MG

E

risperidone 1 QL

Drug Name Drug Tier Notes

SAPHRIS E

SECUADO E

SEROQUEL 3 QL

SEROQUEL XR 3 QL

thioridazine hcl oral 1

thiothixene oral 1

trifluoperazine hcl oral 1

VERSACLOZ 3 QL

VRAYLAR 3 ST QL

ziprasidone hcl 1 QL

ziprasidone mesylate E

ZYPREXA INTRAMUSCULAR

3

ZYPREXA ORAL 3 QL

ZYPREXA RELPREVV E

ZYPREXA ZYDIS 3 QL

Antivirals

abacavir sulfate 1

abacavir sulfate-lamivudine

1

abacavir-lamivudine-zidovudine

1

acyclovir external 1

acyclovir oral 1

ACYCLOVIX E

adefovir dipivoxil 1 SP

APTIVUS 2

atazanavir sulfate 1

ATRIPLA E

BARACLUDE 3 SP QL

BIKTARVY 3

CABENUVA E

cidofovir intravenous E

CIMDUO 2

COMBIVIR 3

COMPLERA 2

CRIXIVAN ORAL CAPSULE 400 MG

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

44

Drug Name Drug Tier Notes

DELSTRIGO 3

DENAVIR E

DESCOVY E

DOVATO 2

EDURANT 2

efavirenz 1

efavirenz-emtricitab-tenofovir

1

efavirenz-lamivudine-tenofovir

1

emtricitabine 1

emtricitabine-tenofovir df

1

EMTRIVA ORAL CAPSULE

3

EMTRIVA ORAL SOLUTION

2

entecavir 1 SP QL

EPCLUSA 2 PA SP QL

EPIVIR 3

EPIVIR HBV ORAL SOLUTION

2 SP

EPIVIR HBV ORAL TABLET

3 SP

EPZICOM 3

EVOTAZ 2

famciclovir oral 1

FAVIPIRAVIR 3

fosamprenavir calcium 1

foscarnet sodium intravenous solution 6000 mg250ml

E

FOSCAVIR INTRAVENOUS SOLUTION 6000 MG250ML

E

FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

E

GENVOYA 3

Drug Name Drug Tier Notes

HARVONI 2 PA SP QL

HEPSERA 3 SP

INTELENCE 2

INTRON A 3 PA SP

INVIRASE ORAL TABLET

2

ISENTRESS 2

ISENTRESS HD 2

JULUCA 2

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET

2

lamivudine oral solution 1

lamivudine oral tablet 100 mg

1 SP

lamivudine oral tablet 150 mg 300 mg

1

lamivudine-zidovudine 1

LEDIPASVIR-SOFOSBUVIR

E SP

LEXIVA ORAL SUSPENSION

2

LEXIVA ORAL TABLET 3

lopinavir-ritonavir 1

MAVYRET 2 PA SP QL

nevirapine 1

nevirapine er 1

NORVIR ORAL PACKET

2

NORVIR ORAL SOLUTION

2

NORVIR ORAL TABLET

3

ODEFSEY 3

oseltamivir phosphate oral

1 QL

PEGASYS SUBCUTANEOUS SOLUTION

2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

45

Drug Name Drug Tier Notes

PEGINTRON SUBCUTANEOUS KIT 50 MCG05ML

3 PA SP

PIFELTRO 3

PREVYMIS 3 SP

PREZCOBIX 2

PREZISTA ORAL SUSPENSION

2

PREZISTA ORAL TABLET 150 MG 600 MG 75 MG 800 MG

2

RAPIVAB E

RELENZA DISKHALER 3 QL

RETROVIR INTRAVENOUS

E

RETROVIR ORAL CAPSULE

3

RETROVIR ORAL SYRUP

3

REYATAZ ORAL CAPSULE 150 MG 200 MG 300 MG

3

REYATAZ ORAL PACKET

2

ribavirin inhalation 1

ribavirin oral capsule 1 SP

ribavirin oral tablet 200 mg

1 SP

rimantadine hcl 1

ritonavir 1

RUKOBIA 3

SELZENTRY 2 PA

SITAVIG E

SOFOSBUVIR-VELPATASVIR

E SP

SOVALDI 3 PA SP QL

stavudine oral capsule 1

STRIBILD 3

SUSTIVA 3

SYMFI 2

Drug Name Drug Tier Notes

SYMFI LO 2

SYMTUZA 3

TAMIFLU ORAL CAPSULE

E

TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MGML

E

TEMIXYS E

tenofovir disoproxil fumarate

1

TIVICAY 2

TIVICAY PD 2

TRIUMEQ 2

TRIZIVIR 3

TROGARZO 3 PA

TRUVADA E

TYBOST 2

valacyclovir hcl oral 1 QL

VALCYTE 3

valganciclovir hcl 1

VALTREX 3 QL

VEMLIDY 3 SP

VIEKIRA PAK 3 PA SP QL

VIRACEPT ORAL TABLET

2

VIRAMUNE ORAL SUSPENSION

3

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HOUR 400 MG

3

VIRAZOLE 3

VIREAD ORAL POWDER

2

VIREAD ORAL TABLET 150 MG 200 MG 250 MG

2

VIREAD ORAL TABLET 300 MG

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

46

Drug Name Drug Tier Notes

VOCABRIA E

VOSEVI 2 PA SP QL

XERESE E

XOFLUZA (40 MG DOSE)

3 QL

XOFLUZA (80 MG DOSE)

3 QL

ZEPATIER 3 PA SP QL

ZIAGEN 3

zidovudine 1

ZOVIRAX EXTERNAL CREAM

3

ZOVIRAX EXTERNAL OINTMENT

E

ZOVIRAX ORAL SUSPENSION

E

Anxiolytics - Drugs for Anxiety

alprazolam er 1 QL

alprazolam intensol 1 QL

alprazolam oral 1 QL

alprazolam xr 1 QL

ATIVAN E

buspirone hcl oral 1

chlordiazepoxide hcl 1 QL

clonazepam oral 1 QL

clorazepate dipotassium

1 QL

diazepam intensol 1

diazepam oral concentrate

1

diazepam oral solution 5 mg5ml

1

diazepam oral tablet 1

DORAL 3 QL

estazolam 1 QL

HALCION 3 QL

hydroxyzine hcl oral syrup

1

Drug Name Drug Tier Notes

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral

1

KLONOPIN 3 QL

lorazepam injection E

lorazepam intensol 1 QL

lorazepam oral concentrate 2 mgml

1 QL

lorazepam oral tablet 1 QL

meprobamate 1

midazolam hcl oral 1

MIDAZOLAM HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION 100-08 MG100ML- 50-08 MG50ML- 50-09 MG50ML-

E

MIDAZOLAM HCL-SODIUM CHLORIDE SOLUTION 100-09 MG100ML- INTRAVENOUS

E

MIDAZOLAM+SYRSPEND SF

E

oxazepam 1 QL

quazepam 1 QL

TRANXENE-T ORAL TABLET 75 MG

3 QL

triazolam 1 QL

VALIUM E

VISTARIL 3

XANAX E

XANAX XR E

Bipolar Agents - Drugs for Mood Disorders

EQUETRO 3

lithium 1

lithium carbonate er 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

47

Drug Name Drug Tier Notes

lithium carbonate oral 1

LITHOBID 3

Blood Products and Modifiers - Drugs for Blood Disorders

ADVATE 2 SP

ADYNOVATE 3 SP

AFSTYLA 3 SP

AGRYLIN 3

ALPHANATE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 1500 UNIT 2000 UNIT 250 UNIT 500 UNIT

2 SP

ALPHANINE SD 2 SP

ALPROLIX 3 SP

AMICAR ORAL SOLUTION

3

AMICAR ORAL TABLET

3

aminocaproic acid oral solution

1

aminocaproic acid oral tablet

1

anagrelide hcl 1

ARANESP (ALBUMIN FREE) INJECTION SOLUTION 100 MCGML 200 MCGML 25 MCGML 300 MCGML 40 MCGML 60 MCGML

2 PA SP

ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED SYRINGE

2 PA SP

ASTRINGYN SOLUTION 259 MGGM EXTERNAL

3

Drug Name Drug Tier Notes

ASTRINGYN SOLUTION 259 MGGM EXTERNAL

E

BENEFIX INTRAVENOUS KIT

2 SP

CEPROTIN 3 SP

COAGADEX 3 SP

CORIFACT 2 SP

CYKLOKAPRON INTRAVENOUS SOLUTION 1000 MG10ML

E

DOPTELET ORAL TABLET 20 MG

3 PA SP

ELOCTATE 3 SP

EPOGEN INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML

E SP

ESPEROCT E SP

FEIBA INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 2500 UNIT 500 UNIT

2 SP

FIBRYGA 2 SP

FULPHILA E SP

GRANIX E SP

HEMLIBRA 3 SP

HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT 1700 UNIT 250 UNIT 500 UNIT

3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

48

Drug Name Drug Tier Notes

HUMATE-P INTRAVENOUS SOLUTION RECONSTITUTED 1000-2400 UNIT 250-600 UNIT 500-1200 UNIT

2 SP

IDELVION 3 SP

IXINITY 3 SP

JIVI 3 SP

KOATE 2 SP

KOATE-DVI 2 SP

KOGENATE FS 3 SP

KOVALTRY 3 SP

LEUKINE INJECTION SOLUTION RECONSTITUTED

3 PA SP

LYSTEDA 3

MIRCERA INJECTION SOLUTION PREFILLED SYRINGE

3 PA SP

MONONINE INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT

2 SP

monsels ferric subsulfate external

E

MOZOBIL 2 PA SP QL

MULPLETA 2 PA SP

NEULASTA ONPRO 3 PA SP

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

NEUPOGEN INJECTION SOLUTION 300 MCGML 480 MCG16ML

E SP

Drug Name Drug Tier Notes

NEUPOGEN INJECTION SOLUTION PREFILLED SYRINGE

E SP

NIVESTYM 2 PA SP

NOVOEIGHT 2 SP

NOVOSEVEN RT 2 SP

NPLATE 3 PA SP

NUWIQ 2 SP

NYVEPRIA 3 PA SP

OBIZUR 3 SP

PANHEMATIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

3 SP

PROCRIT E SP

PROFILNINE 2 SP

PROMACTA 3 PA SP

REBINYN 3 SP

REBLOZYL 3 PA SP

RECOMBINATE 2 SP

RECOTHROM 3

RECOTHROM SPRAY KIT

3

RETACRIT INJECTION SOLUTION 10000 UNITML 2000 UNITML 20000 UNITML 3000 UNITML 4000 UNITML 40000 UNITML

2 PA SP

RIASTAP 2 SP

RIXUBIS 3 SP

SEVENFACT E SP

SOLIRIS INTRAVENOUS SOLUTION 300 MG30ML

3 PA SP

TAVALISSE 3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

49

Drug Name Drug Tier Notes

THROMBIN-JMI EPISTAXIS

3

THROMBIN-JMI EXTERNAL KIT

3

THROMBOGEN 3

tranexamic acid intravenous solution 1000 mg10ml

E

tranexamic acid oral 1

TRANEXAMIC ACID-NACL

E

TRETTEN 3 SP

UDENYCA E SP

ULTOMIRIS INTRAVENOUS SOLUTION 1100 MG11ML 300 MG3ML

3 PA SP

ULTOMIRIS INTRAVENOUS SOLUTION 300 MG30ML

2 PA SP

VONVENDI 3 SP

WILATE INTRAVENOUS KIT

2 SP

XYNTHA INTRAVENOUS KIT 1000 UNIT 2000 UNIT 250 UNIT 500 UNIT

2 SP

XYNTHA SOLOFUSE 2 SP

ZARXIO 2 PA SP

ZIEXTENZO 3 PA SP

Cardiovascular Agents - Drugs for Heart and Circulation Conditions

ACCUPRIL 3

ACCURETIC 3

acebutolol hcl oral 1

AKOVAZ SOLUTION 50 MGML INTRAVENOUS

E

Drug Name Drug Tier Notes

ALDACTAZIDE 3

ALDACTONE 3

aliskiren fumarate 1 ST

ALTACE ORAL CAPSULE

E

ALTOPREV E

amiloride hcl oral 1

amiloride-hydrochlorothiazide

1

amiodarone hcl oral 1

AMLODIPINE BES+SYRSPEND SF

E

amlodipine besylate oral

1

amlodipine besylate-benazepril hcl

1

amlodipine besylate-valsartan

1

amlodipine-atorvastatin 1

amlodipine-olmesartan 1

amlodipine-valsartan-hctz

1

ANTARA ORAL CAPSULE 30 MG 90 MG

E

ATACAND E

ATACAND HCT 3

atenolol oral 1

ATENOLOL+SYRSPEND SF

E

atenolol-chlorthalidone 1

atorvastatin calcium oral

1

AVALIDE ORAL TABLET 150-125 MG 300-125 MG

3

AVAPRO 3

AZOR E

benazepril hcl oral 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

50

Drug Name Drug Tier Notes

benazepril-hydrochlorothiazide

1

BENICAR E

BENICAR HCT E

BETAPACE AF 3

BETAPACE ORAL TABLET 120 MG 160 MG 80 MG

3

betaxolol hcl oral 1

BIDIL 3

bisoprolol fumarate oral 1

bisoprolol-hydrochlorothiazide

1

bumetanide oral 1

BUMEX ORAL TABLET 05 MG

3

BYSTOLIC 2

CADUET ORAL TABLET 10-10 MG 10-20 MG 10-40 MG 10-80 MG 5-10 MG 5-20 MG 5-40 MG 5-80 MG

3

CALAN SR 3

candesartan cilexetil 1

candesartan cilexetil-hctz

1

captopril oral 1

captopril-hydrochlorothiazide

1

CARDIZEM CD 3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 120 MG

3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HOUR 180 MG 240 MG 300 MG 360 MG 420 MG

E

CARDIZEM ORAL TABLET 120 MG 30 MG 60 MG

3

Drug Name Drug Tier Notes

CARDURA 3

CAROSPIR 3

cartia xt 1

carvedilol 1

carvedilol phosphate er 1

CATAPRES-TTS-1 3

CATAPRES-TTS-2 3

CATAPRES-TTS-3 3

chlorthalidone oral tablet 25 mg 50 mg

1

cholestyramine light 1

cholestyramine oral 1

clonidine 1

clonidine hcl oral 1

colesevelam hcl 1

COLESTID E

COLESTID FLAVORED

E

colestipol hcl 1

CONJUPRI E

CONSENSI E

COREG 3

COREG CR 3

CORGARD 3

CORLANOR 3 PA QL

COZAAR 3

CRESTOR E

DEMSER 3

DIBENZYLINE 3

digitek 1

digox 1

digoxin oral 1

DILATRATE-SR 3

diltiazem hcl er beads 1

diltiazem hcl er coated beads

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

51

Drug Name Drug Tier Notes

diltiazem hcl er oral capsule extended release 12 hour

1

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

1

diltiazem hcl oral 1

DILTIAZEM HCL-DEXTROSE SOLUTION 125-5 MG125ML- INTRAVENOUS

E

dilt-xr 1

DIOVAN E

DIOVAN HCT E

disopyramide phosphate oral

1

DIURIL 3

dofetilide 1

doxazosin mesylate oral

1

droxidopa 1 PA SP

DUTOPROL E

DYRENIUM 3

EDARBI 3 ST

EDARBYCLOR 3 ST

EDECRIN 3

enalapril maleate oral 1

enalapril-hydrochlorothiazide

1

ENTRESTO 2 QL

EPANED ORAL SOLUTION

E

ephedrine sulfate intravenous solution

E

EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-09 MG10ML- INTRAVENOUS

E

Drug Name Drug Tier Notes

EPHEDRINE SULFATE-NACL SOLUTION PREFILLED SYRINGE 50-09 MG5ML- INTRAVENOUS

E

eplerenone 1

ESMOLOL HCL INTRAVENOUS SOLUTION PREFILLED SYRINGE

E

ethacrynic acid oral 1

EVKEEZA E SP

EXFORGE 3

EXFORGE HCT 3

EZALLOR SPRINKLE 3 ST

ezetimibe 1

ezetimibe-simvastatin 1

felodipine er 1

fenofibrate micronized oral capsule 130 mg 43 mg

1

fenofibrate micronized oral capsule 134 mg 200 mg 67 mg

1 ST

fenofibrate oral capsule 134 mg 200 mg 67 mg

1 ST

fenofibrate oral capsule 150 mg 50 mg

1

fenofibrate oral tablet 120 mg 40 mg

E

fenofibrate oral tablet 145 mg 48 mg

1

fenofibrate oral tablet 160 mg 54 mg

1 ST

fenofibric acid oral capsule delayed release

1

fenofibric acid oral tablet

1 ST

FENOGLIDE 3 ST

FIBRICOR E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

52

Drug Name Drug Tier Notes

flecainide acetate 1

FLOLIPID 3 ST

fluvastatin sodium 1

fluvastatin sodium er 1

fosinopril sodium 1

fosinopril sodium-hctz 1

furosemide oral solution 10 mgml 8 mgml

1

furosemide oral tablet 1

gemfibrozil oral 1

GONITRO 3

guanfacine hcl oral 1

HEMANGEOL 3

hydralazine hcl oral 1

hydrochlorothiazide oral

1

HYZAAR 3

icosapent ethyl 1 PA

indapamide oral 1

INDERAL LA E

INDERAL XL E

INNOPRAN XL E

INSPRA 3

irbesartan 1

irbesartan-hydrochlorothiazide

1

ISORDIL TITRADOSE 3

isosorbide dinitrate oral 1

isosorbide mononitrate 1

isosorbide mononitrate er

1

ISOXSUPRINE HCL ORAL TABLET 10 MG

E

isoxsuprine hcl oral tablet 20 mg

E

isradipine 1

Drug Name Drug Tier Notes

JUXTAPID ORAL CAPSULE 10 MG 20 MG 30 MG 5 MG

3 PA SP QL

KAPSPARGO SPRINKLE

E

KATERZIA E

labetalol hcl oral 1

LANOXIN ORAL TABLET 125 MCG 250 MCG 625 MCG

2

LASIX 3

LESCOL XL E

LIPITOR E

LIPOFEN 3

lisinopril oral 1

lisinopril-hydrochlorothiazide

1

LIVALO E

LOPID 3

LOPRESSOR ORAL 3

losartan potassium oral 1

losartan potassium-hctz 1

LOTENSIN HCT ORAL TABLET 10-125 MG 20-125 MG 20-25 MG

3

LOTENSIN ORAL TABLET 10 MG 20 MG 40 MG

3

LOTREL ORAL CAPSULE 10-20 MG 10-40 MG 5-10 MG 5-20 MG

3

lovastatin oral 1

LOVAZA E

matzim la 1

MAXZIDE 3

MAXZIDE-25 3

methyldopa oral 1

methyldopa-hydrochlorothiazide

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

53

Drug Name Drug Tier Notes

metolazone 1

metoprolol succinate er 1

metoprolol tartrate oral 1

metoprolol-hydrochlorothiazide

1

metyrosine 1

mexiletine hcl oral 1

MICARDIS 3

MICARDIS HCT 3

midodrine hcl 1

milrinone lactate in dextrose

E

milrinone lactate intravenous solution 10 mg10ml 20 mg20ml 50 mg50ml

E

MINIPRESS 3

minitran 1

minoxidil oral 1

moexipril hcl 1

MULTAQ 3

nadolol oral tablet 20 mg 40 mg 80 mg

1

NEXLETOL 2 PA QL

NEXLIZET 2 PA QL

niacin (antihyperlipidemic)

1

niacin er (antihyperlipidemic)

1

niacor 1

NIASPAN 3

nicardipine hcl oral 1

nifedipine er 1

nifedipine er osmotic release

1

nifedipine oral 1

nimodipine oral 1

nisoldipine er 1

NITRO-BID 3

Drug Name Drug Tier Notes

NITRO-DUR 3

nitroglycerin sublingual 1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual solution

1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT E

NITRO-TIME E

NORPACE 3

NORPACE CR 2

NORTHERA 3 PA SP

NORVASC E

NYMALIZE ORAL SOLUTION 6 MGML

3

olmesartan medoxomil oral

1

olmesartan medoxomil-hctz

1

olmesartan-amlodipine-hctz

1

OMEGA-3 RX COMPLETE

3

omega-3-acid ethyl esters

1 PA

PACERONE ORAL TABLET 100 MG 200 MG 400 MG

3

papaverine hcl injection E

pentoxifylline er 1

perindopril erbumine 1

phenoxybenzamine hcl oral

1

phentolamine mesylate injection solution reconstituted

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

54

Drug Name Drug Tier Notes

PHENYLEPHRINE HCL-NACL INTRAVENOUS SOLUTION PREFILLED SYRINGE 1-09 MG10ML- 100-09 MCG10ML- 20-09 MG50ML-

E

pindolol 1

PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA QL

pravastatin sodium 1

prazosin hcl oral 1

PRESTALIA 3 ST

prevalite 1

PRINIVIL ORAL TABLET 20 MG

3

procainamide hcl injection

E

PROCARDIA 3

PROCARDIA XL 3

propafenone hcl 1

propafenone hcl er 1

propranolol hcl er 1

propranolol hcl oral 1

propranolol-hctz 1

QBRELIS E

QUESTRAN E

QUESTRAN LIGHT ORAL POWDER

E

quinapril hcl 1

quinapril-hydrochlorothiazide

1

quinidine gluconate er 1

quinidine sulfate oral 1

ramipril 1

RANEXA 3 ST

ranolazine er 1 ST

Drug Name Drug Tier Notes

RECTIV 3

REPATHA 2 PA QL

REPATHA PUSHTRONEX SYSTEM

2 PA QL

REPATHA SURECLICK

2 PA QL

rosuvastatin calcium 1

ROSZET TABLET 10-10 MG ORAL

3

ROSZET TABLET 10-20 MG ORAL

3

ROSZET TABLET 10-40 MG ORAL

3

ROSZET TABLET 10-5 MG ORAL

3

RYTHMOL SR 3

simvastatin oral tablet 1

sotalol hcl (af) 1

sotalol hcl oral 1

SOTYLIZE 3

spironolactone oral 1

spironolactone-hctz 1

SULAR ORAL TABLET EXTENDED RELEASE 24 HOUR 17 MG 34 MG 85 MG

3

SURE RESULT O3D3 SYSTEM

E

TARKA ORAL TABLET EXTENDED RELEASE 2-180 MG 2-240 MG 4-240 MG

3

taztia xt 1

TEKTURNA 2 ST

TEKTURNA HCT 2 ST

telmisartan 1

telmisartan-amlodipine 1

telmisartan-hctz 1

TENORETIC 100 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

55

Drug Name Drug Tier Notes

TENORETIC 50 3

TENORMIN E

tiadylt er 1

TIAZAC 3

TIKOSYN E

timolol maleate oral 1

TOPROL XL E

torsemide oral 1

trandolapril 1

trandolapril-verapamil hcl er

1

triamterene oral 1

triamterene-hctz oral capsule 375-25 mg

1

triamterene-hctz oral tablet

1

TRIBENZOR E

TRICOR 3

TRILIPIX 3

TWYNSTA 3

valsartan 1

valsartan-hydrochlorothiazide

1

VASCEPA 2 PA

VASERETIC 3

VASOTEC 3

VECAMYL 3

verapamil hcl er oral capsule extended release 24 hour

1

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

1

verapamil hcl oral 1

VERELAN 3

VERELAN PM 3

VERQUVO E

VYNDAMAX 3 PA SP QL

Drug Name Drug Tier Notes

VYNDAQEL 3 PA SP QL

VYTORIN E

WELCHOL 3

ZESTORETIC 3

ZESTRIL ORAL TABLET 10 MG 20 MG 5 MG

3

ZESTRIL ORAL TABLET 25 MG 30 MG 40 MG

E

ZETIA E

ZIAC 3

ZOCOR ORAL TABLET 10 MG 20 MG 40 MG 80 MG

3

ZYPITAMAG ORAL TABLET 2 MG 4 MG

E

Central Nervous System Agents - Drugs for Attention Deficit Disorder

ADDERALL 3 PA QL

ADDERALL XR E

ADHANSIA XR E

ADZENYS ER 3 PA ST QL

ADZENYS XR-ODT 3 PA ST QL

AMPHETAMINE ER 3 PA ST QL

amphetamine sulfate 1 PA ST QL

amphetamine-dextroamphetamine

1 PA QL

amphetamine-dextroamphetamine er

1 PA QL

APTENSIO XR 3 PA ST QL

atomoxetine hcl 1 QL

clonidine hcl er 1 ST

CONCERTA E

COTEMPLA XR-ODT 3 PA ST QL

DAYTRANA 3 PA ST QL

DESOXYN 3 PA ST QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

56

Drug Name Drug Tier Notes

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE 24 HOUR

3 PA QL

dexmethylphenidate hcl 1 PA QL

dexmethylphenidate hcl er

1 PA ST QL

dextroamphetamine sulfate er

1 PA QL

dextroamphetamine sulfate oral

1 PA ST QL

DYANAVEL XR 3 PA ST QL

EVEKEO 3 PA ST QL

EVEKEO ODT 3 PA QL

FOCALIN 3 PA QL

FOCALIN XR 3 PA ST QL

guanfacine hcl er 1

INTUNIV 3

JORNAY PM 3 PA ST QL

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HOUR

3 ST

methamphetamine hcl 1 PA ST QL

METHYLIN ORAL SOLUTION

3 PA ST QL

methylphenidate hcl er (cd)

1 PA ST QL

methylphenidate hcl er (la)

1 PA ST QL

methylphenidate hcl er (xr)

1 PA ST QL

methylphenidate hcl er oral tablet extended release

1 PA ST QL

methylphenidate hcl er oral tablet extended release 24 hour

1 PA QL

methylphenidate hcl oral solution

1 PA ST QL

methylphenidate hcl oral tablet

1 PA QL

Drug Name Drug Tier Notes

methylphenidate hcl oral tablet chewable

1 PA ST QL

MYDAYIS 3 PA ST QL

PROCENTRA 3 PA ST QL

QUILLICHEW ER 3 PA ST QL

QUILLIVANT XR ORAL SUSPENSION RECONSTITUTED ER

3 PA ST QL

relexxii 1 PA ST QL

RITALIN 3 PA QL

RITALIN LA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG 20 MG 30 MG 40 MG

3 PA ST QL

STRATTERA 3 QL

VYVANSE 2 PA QL

ZENZEDI 3 PA ST QL

Central Nervous System Agents - Drugs for Multiple Sclerosis

AMPYRA 3 PA SP QL

AUBAGIO 3 PA SP QL

AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR KIT

2 PA SP QL

AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

2 PA SP QL

BAFIERTAM 2 PA SP QL

BETASERON SUBCUTANEOUS KIT

2 PA SP QL

COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

dalfampridine er 1 PA SP QL

dimethyl fumarate oral 1 PA SP QL

dimethyl fumarate starter pack

1 PA SP QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

57

Drug Name Drug Tier Notes

EXTAVIA SUBCUTANEOUS KIT

E SP

GILENYA 3 PA SP QL

glatiramer acetate 1 PA SP QL

glatopa 1 PA SP QL

KESIMPTA 2 PA SP QL

LEMTRADA 3 PA SP

MAVENCLAD 3 PA SP

MAYZENT 3 PA SP QL

OCREVUS 3 PA SP QL

PLEGRIDY E SP

PLEGRIDY STARTER PACK

E SP

PONVORY E SP

PONVORY STARTER PACK

E SP

REBIF REBIDOSE SUBCUTANEOUS SOLUTION AUTO-INJECTOR

E SP

REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

E SP

REBIF SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E SP

REBIF TITRATION PACK SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

E SP

TECFIDERA E SP

TYSABRI 3 PA SP QL

VUMERITY 2 PA SP QL

ZEPOSIA 3 PA SP QL

ZEPOSIA 7-DAY STARTER PACK

3 PA SP QL

ZEPOSIA STARTER KIT

3 PA SP QL

Drug Name Drug Tier Notes

Central Nervous System Agents - Miscellaneous

ADDYI 3 PA QL

ADIPEX-P E

AUSTEDO 3 PA SP QL

benzphetamine hcl E

caffeine citrate oral 1

CONTRAVE E

CONVENIENCE PAK E

diethylpropion hcl er E

diethylpropion hcl oral E

GRALISE 3 ST QL

HORIZANT ORAL TABLET EXTENDED RELEASE

3 PA QL

IMCIVREE 3 PA SP QL

INGREZZA 3 PA SP QL

LIPRITIN II COMBINATION THERAPY PACK 100 MG

E

LOMAIRA E

LYRICA CR 3 ST QL

LYRICA ORAL CAPSULE

2 QL

LYRICA ORAL SOLUTION

3 QL

NEURAPTINE E

NUEDEXTA 3 PA

ONPATTRO 3 PA SP

phendimetrazine tartrate

E

phendimetrazine tartrate er

E

phentermine hcl oral E

pregabalin oral 1 QL

QSYMIA E

RADICAVA 3 PA SP

RILUTEK 3 PA QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

58

Drug Name Drug Tier Notes

riluzole 1 PA QL

SAVELLA 3 ST QL

SAVELLA TITRATION PACK

3 ST QL

SAXENDA E

SUCCINYLCHOLINE CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 140 MG7ML

E

TEGSEDI 3 PA SP

tetrabenazine 1 PA SP

TIGLUTIK 3 PA SP QL

VECURONIUM BROMIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE

E

VYLEESI 3 PA QL

XENAZINE 3 PA SP

XENICAL E

Dental and Oral Agents - Drugs for Mouth and Throat Conditions

ARESTIN E

cavarest E

cevimeline hcl 1

chlorhexidine gluconate mouththroat

E

CLINPRO 5000 E

DEBACTEROL SOLUTION 30-50 MOUTHTHROAT

E

DENTA 5000 PLUS E

DENTAGEL E

DERMACINRX CLORHEXACIN

E

easygel dental E

EVOXAC 3

Drug Name Drug Tier Notes

FIRST-MOUTHWASH BLM

E

FLUORIDEX E

fluoridex daily renewal E

FLUORIDEX ENHANCED WHITENING DENTAL PASTE

E

FLUORIDEX SENSITIVITY RELIEF DENTAL PASTE

E

HURRICAINE MOUTHTHROAT GEL

E

instant oral pain relief max

E

KEPIVANCE 2 SP

lidocaine hcl mouththroat

1

lidocaine viscous hcl 1

MOUTH KOTE REMINT

E

MUCOSITISRX E

NAFRINSE DAILY ACIDULATED

E

NAFRINSE DAILYNEUTRAL

E

NAFRINSE WEEKLY E

NUSURGEPAK SURGICAL PREPCARE

E

oralone 1

PERIDEX E

periogard E

pilocarpine hcl oral 1

PREVIDENT E

PREVIDENT 5000 BOOSTER PLUS

E

PREVIDENT 5000 DRY MOUTH DENTAL GEL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

59

Drug Name Drug Tier Notes

PREVIDENT 5000 ENAMEL PROTECT

E

PREVIDENT 5000 ORTHO DEFENSE

E

PREVIDENT 5000 PLUS

E

PREVIDENT 5000 SENSITIVE

E

SALAGEN 3

SALIVAMAX E

sf E

sf 5000 plus E

sodium fluoride 5000 enamel

E

sodium fluoride 5000 plus

E

sodium fluoride 5000 ppm

E

sodium fluoride 5000 sensitive

E

sodium fluoride dental cream

E

sodium fluoride dental gel 11

E

triamcinolone acetonide mouththroat

1

XEROSTOMIA RELIEF SPRAY

E

Dermatological Agents - Drugs for Skin Conditions

AAGC KIT IN TERODERM

E

ABREVA E

ABSORICA E

ABSORICA LD 3 PA

ACANYA E

accutane oral capsule 20 mg 30 mg 40 mg

1 PA

ACESO AG E

ACIOXIAY E

Drug Name Drug Tier Notes

acitretin 1

ACZONE EXTERNAL GEL 5

E

ACZONE EXTERNAL GEL 75

2

ADAINZDE E

ADAINZOXIA E

adapalene external cream

1 PA

adapalene external gel 1 PA

ADAPALENE EXTERNAL PAD

E

ADAPALENE EXTERNAL SOLUTION

3 PA

ADAPALENE-BENZOYL PER-CLINDAMY

E

ADAPALENE-BENZOYL PER-NIACINAM

E

adapalene-benzoyl peroxide external gel

1

ADAPALENE-BENZOYL PEROXIDE EXTERNAL PAD

E

ADVANCED ALLERGY COLLECTION

E

AKLIEF E

ALA SCALP E

ala-cort external cream 1

alclometasone dipropionate

1

ALDARA E

ALEVAMAX E

ALTRENO 3 PA

amcinonide external cream

E

amcinonide external lotion

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

60

Drug Name Drug Tier Notes

amcinonide external ointment

1

AMELUZ E

ammonium lactate external

1

amnesteem 1 PA

AMZEEQ 3

ANACAINE E

APEXICON E E

AQUAPHILIC E

ARAZLO E

ARIDA E

ARZOL SILVER NIT APPLICATORS

E

ATOPADERM E

ATOPICLAIR E

ATRALIN 3 PA

AVAR CLEANSER E

AVAR LS CLEANSER E

AVAR-E EMOLLIENT E

AVAR-E GREEN E

AVAR-E LS E

AVEIDAOXIA E

AVITA E

AZADROX E

azelaic acid external 1 ST

AZELAIC ACID-NIACINAMIDE

E

AZELEX 3

balsam peru-castor oil 1

BEAU RX E

BENSAL HP EXTERNAL OINTMENT 3

E

BENZ PER-CLIND-NIACIN-TRETIN

E

BENZAC AC WASH EXTERNAL LIQUID

E

BENZACLIN E

Drug Name Drug Tier Notes

BENZACLIN WITH PUMP

E

BENZAMYCIN E

BENZEPRO CREAMY WASH

E

BENZEPRO EXTERNAL

E

BENZEPRO EXTERNAL FOAM 52 97

E

benzepro external foam 53

E

BENZEPRO EXTERNAL LIQUID

E

BENZEPRO FOAMING CLOTHS

E

BENZEPRO SHORT CONTACT

E

benzoin compound E

BENZOIN EXTERNAL TINCTURE

E

BENZOYL PEROX-HYDROCORTISONE

E

benzoyl peroxide external foam 98

E

BENZOYL PEROXIDE EXTERNAL GEL 65 8

E

BENZOYL PEROXIDE FORTE- HC

E

benzoyl peroxide-erythromycin

1 ST

BESER EXTERNAL KIT

E

beser external lotion 1

betamethasone dipropionate aug

1

betamethasone dipropionate external

1

BETAMETHASONE DIPROP-MINOXIDIL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

61

Drug Name Drug Tier Notes

betamethasone valerate external

1

BIAFINE E

BIONECT EXTERNAL CREAM

E

blanche E

BOTOX COSMETIC 3 PA SP

bp 10-1 E

bp cleansing wash E

bp wash external liquid 25 7

E

BPCO 3

BRYHALI E

calamine external lotion 8-8

E

calcipotriene external cream

1 QL

CALCIPOTRIENE EXTERNAL FOAM

E

calcipotriene external ointment

1

calcipotriene external solution

1

calcipotriene-betameth diprop external ointment

E

calcipotriene-betameth diprop external suspension

1 QL

CALCIPOTRIENE-CLOBETASOL PROP

E

CALCITRENE 3

calcitriol external 1

CANTHARIDIN EXTERNAL

E

CAPEX E

capsaicin external cream 0025

E

capzix E

CARAC 3

CEM-UREA E

Drug Name Drug Tier Notes

CERACADE E

cerovel external lotion E

CHLOOXIA E

CICLOPIROX-CLOBETASOL

E

CICLOPIROX-CLOBETASOL-SAL ACID

E

CICLOPIROX-SALICYLIC ACID

E

CIMETIDINE-LIDO-SALICYLIC ACID

E

claravis 1 PA

CLENIA PLUS E

CLEOCIN-T EXTERNAL LOTION

3

CLINDACIN ETZ EXTERNAL KIT

E

clindacin etz external swab

1

CLINDACIN PAC E

clindacin-p 1

CLINDAGEL E

CLINDAMY-BENZOYL PER-NIACINAM

E

clindamycin phos-benzoyl perox external gel 1-5 12-25 12-5

1 ST

CLINDAMYCIN PHOS-NIACINAMIDE

E

clindamycin phosphate external foam

1

clindamycin phosphate external lotion

1

clindamycin phosphate external solution

1

clindamycin phosphate external swab

1

CLINDAMYCIN PHOSPHATE GEL 1 EXTERNAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

62

Drug Name Drug Tier Notes

clindamycin phosphate gel 1 external

1

CLINDAMYCIN-NIACIN-TRETINOIN

E

clindamycin-tretinoin 1 ST

CLIND-NIACIN-SPIRONOLAC-TRETIN

E

CLINOIN E

clobetasol prop emollient base

1

clobetasol propionate e 1

clobetasol propionate emulsion

1

clobetasol propionate external

1

CLOBETASOL PROP-LEVOCETIRIZINE

E

CLOBETASOL PROP-NIACINAMIDE

E

CLOBETAVIX E

CLOBEX 3

CLOBEX SPRAY 3

clocortolone pivalate 1

CLODAN EXTERNAL KIT

E

clodan external shampoo

1

CLODERM E

COAL TAR EXTERNAL SOLUTION

3

COLLATYL E

CONDYLOX EXTERNAL GEL

3

COPADERM E

COPASIL EXTERNAL E

CORDRAN EXTERNAL CREAM 0025

E

CORDRAN EXTERNAL CREAM 005

3

Drug Name Drug Tier Notes

CORDRAN EXTERNAL LOTION

3

CORDRAN EXTERNAL OINTMENT

3

CORDRAN EXTERNAL TAPE

E

corn amp callus remover E

CORTANE-B EXTERNAL

E

CUTIVATE EXTERNAL LOTION

3

dapsone external gel 5

1

dapsone gel 75 external

1

DAPSONE GEL 75 EXTERNAL

E

DAPSONE-NIACINAMIDE

E

DAPSONE-NIACINAMIDE-SPIRONOLAC

E

DELUO E

DEOXIA E

DERMACINRX PENETRAL

E

DERMACINRX SURGICAL COMBOPAK

E

DERMA-SMOOTHEFS BODY

3

DERMA-SMOOTHEFS SCALP

3

DERMELLE E

DERMULCERA 3

DERPIXA E

DESONATE E

desonide external 1

DESOWEN EXTERNAL CREAM

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

63

Drug Name Drug Tier Notes

desoximetasone external cream

1

desoximetasone external gel

1

desoximetasone external liquid

E

desoximetasone external ointment 005

E

desoximetasone external ointment 025

1

DEXERYL E

DIADIMAXIA E

DIAOXIA E

diaper rash external ointment

E

DIASDIMAXIA E

DIASOXIA E

dibucaine (perianal) E

diclofenac sodium gel 3 external

1 ST QL

diclofenac sodium gel 3 external

1 PA QL

diclofenac sodium gel 3 external

E

DICLOFENAC-NA HYALURON-NIACIN

E

DIFFERIN EXTERNAL CREAM

E

DIFFERIN EXTERNAL GEL 03

E

DIFFERIN EXTERNAL LOTION

E

diflorasone diacetate external

E

DIMOXIA E

DIOCHLOY E

DIPROLENE AF 3

Drug Name Drug Tier Notes

DIPROLENE EXTERNAL OINTMENT

3

docosanol external E

DOVONEX EXTERNAL CREAM

3

doxepin hcl external 1 PA

doxycycline 1

DR SMITHS ADULT BARRIER EXTERNAL OINTMENT

E

DRAXACE E

DRAXACE LOTION CLEANSER

E

DRITHO-CREME HP E

DRIXECE E

DRYSOL 3

DUOBRII E

DUPIXENT 2 PA SP QL

ECEOXIA E

EFUDEX EXTERNAL CREAM

3

ELETONE E

ELIDEL 3 ST

EMULSION SB E

enovarx-tramadol E

ENSTILAR E

ENTTY SPRAY E

ENZOCLEAR E

EPICERAM E

EPIDUO 3

EPIDUO FORTE 3

EPIFOAM 3

ery 1

ERYGEL 3

erythromycin external gel

1

erythromycin external solution

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

64

Drug Name Drug Tier Notes

ESKATA E

ETHOXIA E

EUCRISA 2 ST

EVOCLIN 3

FABIOR E

FINACEA 3 ST

FINAPOD E

finasteride oral tablet 1 mg

E

FINASTERIDE-MINOXIDIL

E

FLUOCINOLONE ACET-NIACINAMIDE

E

fluocinolone acetonide body

1

fluocinolone acetonide external

1

fluocinolone acetonide scalp

1

fluocinonide cream 01 external

E

fluocinonide emulsified base

1

fluocinonide external cream 005

1

fluocinonide external gel

1

fluocinonide external ointment

1

fluocinonide external solution

1

FLUOPAR E

FLUOROPLEX 3

FLUOROURACIL EXTERNAL CREAM 05

2

fluorouracil external cream 5

1

fluorouracil external solution

1

FLUOVIX E

Drug Name Drug Tier Notes

FLUOVIX PLUS E

flurandrenolide E

fluticasone propionate external

1

FORAXA E

GEAMETDRAY E

GENADUR E

GORDOFILM 3

GUANENDRUX E

halcinonide E

halobetasol propionate external cream

1

HALOBETASOL PROPIONATE EXTERNAL FOAM

E

halobetasol propionate external ointment

1

HALOG E

HALUCORT E

HAXCHLO E

HPR PLUS EXTERNAL CREAM

E

hpr plus external foam E

HPR PLUS HYDROGEL

E

HYALURONATE-NIACINAM-TRETINOIN

E

HYALURONATE-NIACIN-TACROLIMUS

E

HYALURONIC ACID-HYDROQUINONE

E

HYDRO 40 E

hydrocortisone ace-pramoxine external cream 25-1

E

hydrocortisone acetate external cream

E

hydrocortisone acetate external ointment 1

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

65

Drug Name Drug Tier Notes

hydrocortisone butyr lipo base

E

hydrocortisone butyrate external cream

1

hydrocortisone butyrate external lotion

E

hydrocortisone butyrate external ointment

1

hydrocortisone butyrate external solution

1

hydrocortisone external cream 05

E

hydrocortisone external cream 1 25

1

hydrocortisone external lotion 25

1

hydrocortisone external ointment 1 25

1

hydrocortisone valerate 1

hydroquinone external cream

E

HYDROQUINONE EXTERNAL EMULSION

E

HYDROQUINONE-HC-TRETINOIN

E

HYDROQUINONE-HYDROCORTISONE

E

HYLATOPIC PLUS EXTERNAL CREAM

E

HYLATOPIC PLUS EXTERNAL LOTION

E

imiquimod external E

IMIQUIMOD PUMP E

IMIQUIMOD-LEVOCETIRIZIN-NIACIN

E

IMIQUIMOD-LEVOCET-TRETINOIN

E

IMPEKLO E

IMPOYZ E

INOVA E

Drug Name Drug Tier Notes

INOVA 41 ACNE CONTROL THERAPY

E

INOVA 82 ACNE CONTROL THERAPY

E

isotretinoin oral 1 PA

ITHOXIA E

IVERMECTIN-METRONIDAZOL-NIACIN

E

KAMDOY E

KATARYA E

KATARYAXN E

KAXM E

KEIDO E

KELARX E

KENALOG EXTERNAL 3

KERAGEL E

KERALAC EXTERNAL CREAM 47

E

KERALYT EXTERNAL GEL 6

E

KERALYT EXTERNAL SHAMPOO

3

KERALYT SCALP E

KERAMATRIX REPLICINE 5CMX5CM EXTERNAL SHEET

3

KETARYA E

KEVARYA E

KEXM E

KEYA E

KIVIK E

KLARON 3

KLISYRI E

KUTARYAXM E

KUTARYAXMPA E

KUTEA E

KUVARYA E

KUVARYE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

66

Drug Name Drug Tier Notes

KUXM E

lactic acid e 1

lactic acid external lotion

1

LACTIC ACID-NIACINAMIDE

E

lavare wound wash E

LEVULAN KERASTICK 3

LEXETTE E

LIDOCAINE (ANORECTAL) RECTAL

E

LIDOCAINE-HYDROCORTISONE ACE EXTERNAL CREAM 1-1

E

LIDOTREX (ALOE VERA)

E

LOCOID EXTERNAL LOTION

3

LOCOID LIPOCREAM E

LUXIQ 3

MEDERMA E

MEDERMA FOR KIDS E

MEDERMA SPF 30 E

MEDPURA ALCOHOL PADS

E

medpura hand sanitizer external gel 70

E

methoxsalen rapid 1

methyl salicylate external liquid

E

METROCREAM 3

METROGEL EXTERNAL GEL

E

METROLOTION 3

metronidazole external 1

MIMYX E

MINOXIDIL-PROGEST-TRETINOIN

E

Drug Name Drug Tier Notes

MIRVASO 3

moisturel external lotion 3

E

mometasone furoate external

1

myorisan 1 PA

NEOSALUS E

NEOSPORIN ORIGINAL EXTERNAL OINTMENT

E

NEO-SYNALAR EXTERNAL CREAM

3

NEO-SYNALAR EXTERNAL KIT

E

neuac external gel 1 ST

NEUAC EXTERNAL KIT

E

NIACINAMIDE-SPIRONOLACTONE

E

NIACINAMIDE-SULFACETAMIDE

E

NIACINAMIDE-TACROLIMUS

E

NIACINAMIDE-TAZAROTENE

E

NIACINAMIDE-TRETINOIN

E

NIACINAMIDE-TRIAMCINOLONE ACET

E

NIACIN-SPIRONOLACTON-TRETINOIN

E

nolix E

NORITATE E

NOVACORT EXTERNAL GEL 1-2

E

NUCARACLINPAK E

NUCARARXPAK E

NUCORT E

NUDERMRXPAK 120 E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

67

Drug Name Drug Tier Notes

NUDERMRXPAK 60 E

NUTRASEB E

NUTRIARX CREAMPAK

E

NUVAIL E

OLUX 3

OLUX-E 3

ONEXTON 3

ONZDEOXIA E

ORACEA 3

OVACE PLUS E

OVACE PLUS WASH E

OVACE WASH E

OXIANUJO E

OXIATAR E

OXIAVARRY E

OXIAZAR E

OXOPOD E

OXSORALEN ULTRA 3

PANDEL E

PENLEN E

PHLAG SPRAY E

pimecrolimus 1 ST

PLEXION E

PLEXION CLEANSER EXTERNAL LIQUID

E

PLEXION CLEANSING CLOTH EXTERNAL PAD

E

podocon E

podofilox external 1

PODPROG E

PR BENZOYL PEROXIDE

E

PR BENZOYL PEROXIDE WASH

E

PR CREAM E

pramosone external cream 1-1

1

Drug Name Drug Tier Notes

PRAMOSONE EXTERNAL CREAM 1-25

E

PRAMOSONE EXTERNAL LOTION

3

PRAMOSONE EXTERNAL OINTMENT

E

pramox E

PRE amp POST SX POUCH

E

prednicarbate 1

PRESERA E

PROGESTERONE-MINOXIDIL

E

PROMISEB CREAM EXTERNAL

3

PROMISEB EXTERNAL CREAM

E

PROPECIA E

PROSILK EXTERNAL E

PROTEXA E

PROTOPIC 3

PROTYL AG E

PRUCLAIR E

PRUDOXIN 3 PA

PRUMYX E

PSORCON E

PYROGALLIC ACID 3

QBREXZA 3 QL

QUIHOXVAR E

QUINIXIL E

QUTENZA E

QUTENZA (2 PATCH) E

QUTENZA (4 PATCH) E

RADIAGEL E

RADIAPLEXRX GEL EXTERNAL

3

RADIAPLEXRX GEL EXTERNAL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

68

Drug Name Drug Tier Notes

RECEDO E

REFISSA E

REGENECARE 3

REGRANEX 3 PA

remergent hq E

REMIGEN E

RENOVA E

RENOVA PUMP E

RESORCINOL-SULFUR

E

RETIN-A 3 PA

RETIN-A MICRO GEL 004 01

E

RETIN-A MICRO PUMP EXTERNAL GEL 004 01

E

RETIN-A MICRO PUMP EXTERNAL GEL 006 008

2 PA

REXASIL PATCH amp VITAMIN E LIQ

E

RHOFADE 3

RIAX E

ROAOXIA E

rosadan external cream 1

rosadan external gel 1

ROSADAN EXTERNAL KIT

E

SALEX EXTERNAL SHAMPOO

E

salicylic acid er E

salicylic acid external foam

E

salicylic acid external gel

E

salicylic acid external shampoo

E

salicylic acid external solution 26

E

Drug Name Drug Tier Notes

salicylic acid wart remover

E

salicylic acid-cleanser external kit 6 (cream)

E

SALICYLIC ACID-SULFACETAMIDE

E

salimez E

SALIMEZ FORTE E

SALVAX E

SALVAX DUO PLUS E

SANADERMRX SKIN REPAIR

E

SANTYL 3

SCALACORT DK E

SCARCARE GEL-PAD KITLARGE

E

SCARCIN E

SCARSILK EXTERNAL E

SCARZEN SKIN REPAIR

E

SCENESSE 3 PA SP

selenium sulfide external lotion

1

selenium sulfide external shampoo

E

SELRX E

SERNIVO 3

SILA III E

SILIPAC E

SILVERSEAL HYDROGEL DRESSING EXTERNAL PAD 2X3

E

skarjel E

sodium sulfacetamide external shampoo

E

sodium sulfacetamide wash

E

SODIUM SULFACETAMIDE-BAKUCHIOL

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

69

Drug Name Drug Tier Notes

SOLARAVIX EXTERNAL

E

SOLOX E

SOOLANTRA 3

SORIATANE ORAL CAPSULE 10 MG 25 MG

3

SORILUX E

sss 10-5 E

STRATA CTX E

STRATA GRT E

STRATA MARK E

STRATA TRIZ E

STRATA XRT E

sulfacetamide sodium (acne)

1

sulfacetamide sodium external gel

E

sulfacetamide sodium external liquid

E

sulfacetamide sodium-sulfur emulsion 10-5 external

1

sulfacetamide sodium-sulfur emulsion 10-5 external

E

sulfacetamide sodium-sulfur external cream

E

sulfacetamide sodium-sulfur external liquid

E

sulfacetamide sodium-sulfur external lotion

E

sulfacetamide sodium-sulfur external pad 10-4

E

sulfacetamide sodium-sulfur external suspension

E

sulfacetamide sod-sulfur wash external kit

E

Drug Name Drug Tier Notes

sulfacetamide sod-sulfur wash external liquid

E

sulfacetamide-sulfur in urea external emulsion

E

SULFACLEANSE 84 E

sulfamez wash E

SUMADAN E

SUMADAN WASH E

SUMADAN XLT E

SUMAXIN E

SUMAXIN CP E

SUMAXIN WASH E

SUVICORT E

SYNALAR 3

SYNALAR (CREAM) E

SYNALAR (OINTMENT)

E

SYNALAR TS E

SYNERDERM E

TACLONEX EXTERNAL OINTMENT

E

TACLONEX EXTERNAL SUSPENSION

3 QL

TACROLIMUS EXTERNAL CREAM

E

tacrolimus external ointment

1

TARDEOXIA E

TARDIMAXIA E

TAROXIA E

TASOPROL E

tazarotene external cream

1 PA

TAZAROTENE EXTERNAL FOAM

E

TAZORAC EXTERNAL CREAM 005

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

70

Drug Name Drug Tier Notes

TAZORAC EXTERNAL CREAM 01

3 PA

TAZORAC EXTERNAL GEL

E

TEMOVATE EXTERNAL CREAM

3

TEMOVATE EXTERNAL OINTMENT

3

TETRIX EXTERNAL CREAM

E

TEXACORT 3

TOPICORT EXTERNAL CREAM

3

TOPICORT EXTERNAL GEL

3

TOPICORT EXTERNAL OINTMENT

3

TOPICORT SPRAY E

tovet external foam 1

TOVET EXTERNAL KIT

E

tretinoin (emollient) E

tretinoin external 1 PA

tretinoin microsphere 1 PA

tretinoin microsphere pump

1 PA

triamcinolone acetonide external aerosol solution

E

triamcinolone acetonide external cream

1

triamcinolone acetonide external lotion

1

triamcinolone acetonide external ointment

1

TRIANEX E

TRI-CHLOR 3

triderm external cream 1

TRIDESILON 3

Drug Name Drug Tier Notes

TRILOCICLO E

TRI-LUMA E

triple antibiotic external ointment 35-400-5000 5-400-5000

E

triple antibiotic+pain relief

E

TRIVIX E

TURPENTINE EXTERNAL

E

ULTRASAL-ER E

ULTRAVATE EXTERNAL LOTION

E

UMECTA MOUSSE E

URAMAXIN EXTERNAL GEL

E

urea external cream 39 40 41 45 47

E

UREA EXTERNAL FOAM

E

urea external lotion 40

E

urea hydrating E

urea nail external gel 45

E

ureacin-10 E

ureacin-20 E

uredeb E

UREMEZ-40 E

URESOL E

UTOPIC E

VANICREAM EXTERNAL OINTMENT

E

VANIQA E

VANOS 3

VANOXIDE-HC E

VARDIMAXIA E

VAROXIA E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

71

Drug Name Drug Tier Notes

VECTICAL E

VELTIN E

VENELEX 3

VERDESO E

VEREGEN E

VEXASYN E

VIRASAL E

WINLEVI 3 PA

WYNZORA E

XALIX E

XERAC AC 3

XERALUX E

xurea E

ZACARE E

zaclir cleansing external lotion 8

E

zenatane 1 PA

ZIANA E

ZILXI 3 ST

ZITHRANOL E

ZONALON 3 PA

ZYCLARA E

ZYCLARA PUMP E

Diabetes - Antidiabetic Agents

acarbose oral 1

ACTOPLUS MET 3

ACTOS 3

ADLYXIN E

ADLYXIN STARTER PACK

E

ALOGLIPTIN BENZOATE

E

ALOGLIPTIN-METFORMIN HCL

E

ALOGLIPTIN-PIOGLITAZONE

E

AMARYL 3

Drug Name Drug Tier Notes

BYDUREON BCISE AUTOINJECTOR

2 ST QL

BYETTA 10 MCG PEN 2 ST QL

BYETTA 5 MCG PEN 2 ST QL

CYCLOSET 3 ST

DUETACT 3

FARXIGA 2 ST

FORTAMET E

glimepiride 1

glipizide er 1

glipizide ir 1

glipizide xl 1

glipizide-metformin hcl 1 ST

GLUCOTROL ORAL TABLET 10 MG

3

GLUCOTROL XL 3

GLUMETZA E

glyburide micronized 1

glyburide oral 1

glyburide-metformin 1

GLYNASE 3

GLYXAMBI 2 ST

INVOKAMET E

INVOKAMET XR E

INVOKANA E

JANUMET 2 ST

JANUMET XR 2 ST

JANUVIA 2 ST

JARDIANCE 2 ST

JENTADUETO 2 ST

JENTADUETO XR 2 ST

KAZANO E

KOMBIGLYZE XR E

metformin hcl er 1

metformin hcl er (mod) E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

72

Drug Name Drug Tier Notes

metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg 500 mg

E

metformin hcl ir 1

miglitol 1

nateglinide 1

NESINA E

ONGLYZA E

OSENI E

OZEMPIC 2 ST QL

pioglitazone hcl 1

pioglitazone hcl-glimepiride

1

pioglitazone hcl-metformin hcl

1

PRECOSE 3

QTERN E

repaglinide 1

RIOMET 3 ST

RYBELSUS 2 ST QL

SEGLUROMET E

SOLIQUA 2 ST QL

STARLIX ORAL TABLET 120 MG

3

STEGLATRO E

STEGLUJAN E

SYMLINPEN 120 3 PA

SYMLINPEN 60 3 PA

SYNJARDY 2 ST

SYNJARDY XR 2 ST

tolbutamide 1 ST

TRADJENTA 2 ST

TRIJARDY XR 2 ST

TRULICITY 2 ST QL

VICTOZA 2 ST QL

XIGDUO XR 2 ST

XULTOPHY 3 ST QL

Drug Name Drug Tier Notes

Diabetes - Glucose Monitoring

ACCU-CHEK AVIVA IN VITRO SOLUTION

E

ACCU-CHEK AVIVA PLUS TEST STRIPS

E

ACCU-CHEK COMPACT PLUS CONTROL

E

ACCU-CHEK COMPACT PLUS TEST STRIPS

E

ACCU-CHEK FASTCLIX LANCET KIT

$0

ACCU-CHEK GUIDE TEST STRIPS

E

ACCU-CHEK GUIDE CONTROL

E

ACCU-CHEK SMARTVIEW CONTROL

E

ACCU-CHEK SMARTVIEW TEST STRIPS

E

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT

$0

AUTOLET LANCING DEVICE

$0

BLUESTAR E

CARETOUCH CONTROL SOL LEVEL 2

E

CARETOUCH LANCINGEJECTOR

$0

CARETOUCH TEST E

CEQUR SIMPLICITY 2U

3

CONTOUR CONTROL SOLUTION

E

CONTOUR MONITOR DEVICE DEVICE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

73

Drug Name Drug Tier Notes

CONTOUR MONITOR KIT WDEVICE KIT

E

CONTOUR NEXT CONTROL SOLUTION

E

CONTOUR NEXT EZ KIT WDEVICE

E

CONTOUR NEXT LINK KIT WDEVICE

E

CONTOUR NEXT MONITOR KIT WDEVICE

E

CONTOUR NEXT ONE KIT

E

CONTOUR NEXT TEST STRIPS

E

CONTOUR TEST STRIPS

E

EASYMAX 15 LEVEL 2-3 CONTROL

E

EASYMAX CONTROL IN VITRO SOLUTION NORMAL

E

GLUCOSE CONTROL SOLUTIONS

E

ENLITE GLUCOSE SENSOR

E

FORTISCARE CONTROL

E

FORTISCARE GLUCOSE SYSTEM DEVICE

E

FORTISCARE T1 GLUCOSE SYSTEM

E

FREESTYLE LIBRE 14 DAY READER

E

FREESTYLE LIBRE 14 DAY SENSOR

E

FREESTYLE LIBRE 2 READER

E

FREESTYLE LIBRE 2 SENSOR

E

FREESTYLE LIBRE READER

E

Drug Name Drug Tier Notes

FREESTYLE LIBRE SENSOR SYSTEM

E

FREESTYLE PRECISION NEO TEST

E

GUARDIAN CONNECT TRANSMITTER

E

GUARDIAN LINK 3 TRANSMITTER

E

GUARDIAN SENSOR (3)

E

KETONE TEST 3

KETOSTIX 3

MICRODOT TEST E

MICROLET NEXT LANCING DEVICE

$0

NOVOPEN ECHO 3

ONETOUCH DELICA LANCING DEV

$0

ONETOUCH DELICA PLUS LANCING

$0

ONETOUCH ULTRA $0 QL

ONETOUCH ULTRA 2 KIT WDEVICE

2

ONETOUCH ULTRA MINI KIT WDEVICE

2

ONETOUCH VERIO KIT WDEVICE

2

ONETOUCH VERIO FLEX SYSTEM KIT WDEVICE

2

ONETOUCH VERIO IN VITRO SOLUTION HIGH

3

ONETOUCH VERIO TEST STRIPS

$0 QL

ONETOUCH VERIO IQ SYSTEM

2

ONETOUCH VERIO REFLECT

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

74

Drug Name Drug Tier Notes

ONETOUCH VERIO SYNC SYSTEM KIT WDEVICE

2

PRECISION LINK E

PRECISION PCX PLUS TEST

E

PRECISION QID MONITOR

E

PRECISION QID TEST E

PRECISION SOF-TACT MONITOR

E

PRECISION SOF-TACT TEST

E

PRECISION XTRA BLOOD GLUCOSE

E

PRECISION XTRA DEVICE

E

PRECISION XTRA KIT E

PRECISION XTRA MONITOR

E

RELION BLOOD GLUCOSE TEST

E

SURESTEP PRO HIGH GLUCOSE

3

SURESTEP PRO LOW GLUCOSE

3

SURESTEP PRO NORMAL GLUCOSE

3

TRUE METRIX BLOOD GLUCOSE TEST

E

TRUE METRIX LEVEL 1

E

TRUE METRIX LEVEL 2

E

TRUE METRIX LEVEL 3

E

TRUE METRIX PRO BLOOD GLUCOSE

E

TRUETRACK TEST E

UNISTRIP CONTROL IN VITRO SOLUTION LOW

E

Drug Name Drug Tier Notes

Diabetes - Glycemic Agents

BAQSIMI ONE PACK 2

BAQSIMI TWO PACK 2

diazoxide oral 1

GLUCAGEN HYPOKIT 3 ST

glucagon emergency kit 1 mg injection 1 mg

1

GLUCAGON EMERGENCY KIT 1 MG INJECTION 1 MG

3 Made by Lilly

GLUCAGON EMERGENCY KIT

2Made by Fresenius

GVOKE HYPOPEN 1-PACK

2

GVOKE HYPOPEN 2-PACK

2

GVOKE PFS 2

PROGLYCEM 3

Diabetes - Insulins

ADMELOG E

ADMELOG SOLOSTAR

E

AFREZZA INHALATION POWDER 12 UNIT 4 amp 8 amp 12 UNIT 4 UNIT 8 UNIT 90 X 4 UNIT amp 90X8 UNIT 90 X 8 UNIT amp 90X12 UNIT

3 PA

APIDRA SOLOSTAR E

APIDRA VIAL E

BASAGLAR KWIKPEN E

FIASP E

FIASP FLEXTOUCH E

FIASP PENFILL E

HUMALOG U-100 AND U-200 KWIKPEN

2

HUMALOG MIX 5050 KWIKPEN

2

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

75

Drug Name Drug Tier Notes

HUMALOG MIX 5050 VIAL

2

HUMALOG MIX 7525 KWIKPEN

2

HUMALOG MIX 7525 VIAL

2

HUMALOG U-100 JUNIOR KWIKPEN

2

HUMALOG VIAL 2

HUMULIN 7030 KWIKPEN

2

HUMULIN 7030 VIAL 2

HUMULIN N KWIKPEN 2

HUMULIN N VIAL 2

HUMULIN R U-500 KWIKPEN

2

HUMULIN R U-500 VIAL

2

HUMULIN R VIAL 2

INSULIN ASP PROT amp ASP FLEXPEN

E

INSULIN ASPART E

INSULIN ASPART FLEXPEN

E

INSULIN ASPART PENFILL

E

INSULIN ASPART PROT amp ASPART

E

INSULIN LISPRO (1 UNIT DIAL)

E

INSULIN LISPRO JUNIOR KWIKPEN

E

INSULIN LISPRO PROT amp LISPRO

E

INSULIN LISPRO SUBCUTANEOUS SOLUTION

E

Drug Name Drug Tier Notes

INSULIN PEN NEEDLES 29G X 127MM 29G X 12MM 29G X 5MM 29G X 8MM 31G X 5 MM 31G X 6 MM 31G X 8 MM 32G X 4 MM 33G X 4 MM 33G X 5 MM 33G X 6 MM

$0

INSULIN SYRINGES $0

LANTUS U-100 SOLOSTAR

2

LANTUS U-100 VIAL 2

LEVEMIR U-100 FLEXTOUCH

E

LEVEMIR U-100 VIAL E

LYUMJEV KWIKPEN 2

LYUMJEV VIAL 2

MAXICOMFORT SYR 27G X 12

$0

MYXREDLIN 3

NOVOFINE AUTOCOVER PEN NEEDLE

$0

NOVOFINE PEN NEEDLE 32G X 6 MM

$0

NOVOFINE PLUS PEN NEEDLE

$0

NOVOLIN 7030 FLEXPEN

E

NOVOLIN 7030 FLEXPEN RELION

E

NOVOLIN 7030 RELION

E

NOVOLIN 7030 VIAL E

NOVOLIN N FLEXPEN E

NOVOLIN N FLEXPEN RELION

E

NOVOLIN N RELION E

NOVOLIN N VIAL E

NOVOLIN R FLEXPEN E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

76

Drug Name Drug Tier Notes

NOVOLIN R FLEXPEN RELION

E

NOVOLIN R RELION E

NOVOLIN R VIAL E

NOVOLOG U-100 FLEXPEN

E

NOVOLOG MIX 7030 FLEXPEN

E

NOVOLOG MIX 7030 VIAL

E

NOVOLOG U-100 PENFILL

E

NOVOLOG U-100 VIAL E

NOVOTWIST PEN NEEDLE 32G X 5 MM

$0

SEMGLEE E

TOUJEO MAX SOLOSTAR

2

TOUJEO SOLOSTAR 2

TRESIBA E

TRESIBA FLEXTOUCH

E

Electrolytes Minerals Metals Vitamins

ABANEU-SL E

ACTITROM-D E

ACTIVE FE E

ACTIVITE E

adcf (05mgml) 1

ADRENAL C FORMULA

E

airavite E

aminoamrms E

aminoreliefrms E

ANIMI-3 E

ANIMI-3VITAMIN D E

AQUASOL A INTRAMUSCULAR SOLUTION 15 MGML 50000 UNITML

E

Drug Name Drug Tier Notes

ASCOR E

ASCORBIC ACID SOLUTION 500 MGML INJECTION

E

ascorbic acid solution 500 mgml injection

E

ATABEX OB 2

AZESCHEW PRENATALPOSTNATAL

E

AZESCO E

B-12 COMPLIANCE INJECTION

E

b-6 folic acid oral capsule 8333-100-1 mg

E

BACMIN E

b-complexb-12 oral E

biocel E

biopetit E

biotin oral tablet 1000 mcg

E

bp vit 3 E

b-plex E

b-plex plus E

calcidol oral solution 200 mcgml

E

CALCIFOL 3

calcium-folic acid plus d E

CARBAGLU 2 SP

CARDIOPLEGIA DEL NIDO FORMULA

E

CARDIOPLEGIA IND PLASMA HIGH K

E

CARDIOPLEGIA IND PLASMA-TROMET

E

CARDIOPLEGIA INDUCTION HIGH K

E

CARDIOPLEGIA INDUCTION LOW DEX

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

77

Drug Name Drug Tier Notes

CARDIOPLEGIA INDUCTION NON-ENR

E

CARDIOPLEGIA MAIN LOW DEXTROSE

E

CARDIOPLEGIA MAIN LOW TROMETHA

E

CARDIOPLEGIA MAIN PLASMA-TROME

E

CARDIOPLEGIA MAINTENANCE

E

CARDIOPLEGIA REPERFUSATE 41

E

CARNITOR INTRAVENOUS

E

CARNITOR ORAL 3

CARNITOR SF 3

CENFOL E

CENTRATEX E

CEREFOLIN E

cerefolin nac oral tablet 6-90314-2-600 mg

E

CHEMET 3

CHOLECAL DF E

CHROMAGEN ORAL CAPSULE

E

CIFEREX E

CITRANATAL BLOOM E

CITRANATAL MEDLEY

E

clovique 1 PA SP

COD LIVER OIL ORAL OIL

E

CORVITE 150 E

corvite fe E

cyanocobalamin injection solution 1000 mcgml

1

CYANOCOBALAMIN INJECTION SOLUTION 2000 MCGML

3

Drug Name Drug Tier Notes

cytra k crystals E

d3 high potency oral capsule 25 mcg (1000 ut)

E

d3 super strength E

daflonex-xl oral capsule E

DECARA E

deferasirox 1 PA

deferasirox granules 1 PA

deferiprone 1 PA

DEPLIN 15 E

DEPLIN 75 E

DERMACINRX PUREFOLIX

E

DEXIFOL E

DIALYVITE E

DIALYVITE 3000 E

DIALYVITE 5000 E

DIALYVITE SUPREME D

E

DIALYVITEZINC E

DRISDOL ORAL CAPSULE

3

d-vite pediatric E

EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ 20 MEQ

3

effer-k tablet effervescent 25 meq oral

1

effer-k tablet effervescent 25 meq oral

E

ELFOLATE E

ELFOLATE PLUS ORAL TABLET 3-35-2 MG

E

ENBRACE HR E

ERGOCAL E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

78

Drug Name Drug Tier Notes

ergocalciferol oral capsule

1

ergocalciferol oral solution 200 mcgml

E

EXJADE 3 PA

fabb E

fa-vitamin b-6-vitamin b-12

E

FEONYX E

FERAHEME E

FERIVA 217 E

FERIVAFA E

ferocon E

ferotrinsic E

FERRALET 90 E

ferraplus 90 E

FERRIPROX 3 PA

FERRIPROX TWICE-A-DAY

3 PA

FERRLECIT E

ferrocite plus oral tablet E

FERRO-PLEX HEMATINIC

E

ferrous sulfate oral solution 75 (15 fe) mgml

E

ferrous sulfate oral syrup

E

ferrous sulfate oral tablet 325 (65 fe) mg

E

ferrous sulfate oral tablet delayed release 324 (65 fe) mg 325 (65 fe) mg

E

FLORIVA E

FLORIVA PLUS E

fluoritab oral solution $0

folbee E

folbee plus E

FOLBEE PLUS CZ E

Drug Name Drug Tier Notes

FOLBIC RF E

FOLGARD OS E

FOLGARD RX E

folic acid injection E

folic acid oral tablet 1 mg

1

FOLIC D3 E

FOLIC-K E

FOLI-D E

FOLITE E

FOLITIN-Z E

FOLIXAPURE E

folplex 22 E

foltanx E

FOLTANX RF E

FOLTRATE E

FOLTREXYL E

foltrin E

FOLTX ORAL TABLET 113-25-2 MG

E

FOLVITE-D E

FOSTEUM E

FUSION PLUS E

GALZIN 3

GENICIN VITA-D E

GENICIN VITA-Q E

GENICIN VITA-S E

hematinic plus vitminerals

E

hematinicfolic acid E

HEMATOGEN E

HEMATOGEN FA E

HEMATRON-AF E

HEMETAB E

HEMOCYTE PLUS E

hemocyte-f oral tablet E

HYLAVITE E

HYLAZINC E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

79

Drug Name Drug Tier Notes

ICAR-C PLUS E

iferex 150 forte E

INFED E

INFUVITE ADULT E

INFUVITE PEDIATRIC INTRAVENOUS SOLUTION

E

INTEGRA F E

INTEGRA PLUS E

IODINE STRONG ORAL

3

IROSPAN 246 E

ISOLYTE-S E

JADENU 3 PA

JADENU SPRINKLE 3 PA

JENLIVA PRENATALPOSTNATAL

E

JYNARQUE 3 SP QL

KCL-LIDOCAINE-NACL SOLUTION 10-10 MEQ-MG 100ML INTRAVENOUS

E

klor-con 10 1

klor-con m10 1

KLOR-CON M15 3

klor-con m20 1

klor-con oral packet 20 meq

1

klor-con oral tablet extended release

1

klor-conef 1

K-PHOS NO 2 E

K-PHOS TABLET 500 MG ORAL

3

K-PHOS TABLET 500 MG ORAL

E

K-PHOS-NEUTRAL E

k-prime 1

K-TAB 3

Drug Name Drug Tier Notes

k-tan plus E

L-CYSTINE E

levocarnitine oral solution

1

levocarnitine oral tablet 1

levocarnitine sf 1

L-ISOLEUCINE E

l-methylfolate E

l-methylfolate ca me-cbl nac

E

l-methylfolate calcium oral

E

l-methylfolate forte E

l-methylfolate-algae oral capsule 15-90314 mg

E

l-methylfolate-algae-b12-b6

E

l-methylfolate-b6-b12 oral tablet 3-35-2 mg

E

l-methyl-mc E

l-methyl-mc nac E

LOKELMA 3

LORID E

lysiplex plus oral tablet E

MVI ADULT E

MVI PEDIATRIC INTRAVENOUS SOLUTION RECONSTITUTED

E

MAGNEBIND 400 3

magnesium oxide oral tablet 400 (2413 mg) mg

E

magnesium sulfate intravenous solution 2 gm50ml 20 gm500ml 4 gm100ml 4 gm50ml 40 gm1000ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

80

Drug Name Drug Tier Notes

MAGNESIUM SULFATE SOLUTION 50 INJECTION

E

magnesium sulfate solution 50 injection

E

magnesium-oxide E

mag-oxide oral tablet 200 mg

E

MEPHYTON 3

metafolbic E

metafolbic plus E

METAFOLBIC PLUS RF

E

METANX ORAL CAPSULE

E

methylfol-algae-b12-acetylcyst

E

MICROPLEGIA MSA-MSG

E

MIFEPREX 3

mifepristone 1

M-NATAL PLUS 2

MONOFERRIC E

MULTIGEN E

MULTIGEN FOLIC E

MULTIGEN PLUS E

MULTIPRO E

multi-vitironfluoride 1

multivitaminfluoride oral solution

1

multi-vitaminfluoride oral solution

1

multivitaminfluoride oral tablet chewable 025 mg 05 mg 1 mg

1

MULTIVITAMINFLUORIDE ORAL TABLET CHEWABLE 025-03 MG 05-03 MG 1-03 MG

E

Drug Name Drug Tier Notes

multi-vitaminfluorideiron

1

myferon 150 forte E

mynephrocaps capsule 1 mg oral

E

MYNEPHRON E

na ferric gluc cplx in sucrose

E

n-acetyl-l-cysteine oral 1

nafrinse $0

nafrinse drops $0

NASCOBAL 3

NEONATAL + DHA E

NEONATAL 19 2

NEONATAL COMPLETE

E

NEONATAL FE E

NEONATAL PLUS 2

NEOVITE E

NEPHPLEX RX E

nephronex oral tablet E

NEPHRO-VITE RX E

NESTABS 2

NESTABS ONE E

NEURIN-SL E

NICADAN E

NICAZEL E

NICAZEL FORTE E

NICOMIDE ORAL TABLET 750-27-2-05 MG

E

NIFEREX ORAL TABLET

E

NOVAMV PEDIATRIC MULTI-VITAMIN

E

NUFERA E

nufol E

NUTRICAP E

nutrifac zx E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

81

Drug Name Drug Tier Notes

NUTRIVIT E

OCUVEL ORAL CAPSULE 05 MG

E

ONE VITE WOMENS $0

ONE VITE WOMENS PLUS

2

ONEVITE E

ORACIT 3

ORTHO DF E

OVEEZA E

oyster shell calciumd oral tablet 250-250 mg-unit 500-200 mg-unit 500-400 mg-unit

E

oyster shell calciumvitamin d oral tablet 500-200 mg-unit

E

pediatric electrolyte oral solution

E

pediavit E

PHOSPHA 250 NEUTRAL

3

phosphorous 1

phosphorus supplement

E

phosphorus wsod amp potassium

E

phospho-trin 250 neutral

1

PHOXILLUM B22K40 E

PHOXILLUM BK425 E

PHYSICIANS EZ USE B-12

E

PHYSIOLYTE E

PHYSIOSOL IRRIGATION

E

phytonadione injection solution 1 mg05ml 10 mgml

E

phytonadione oral 1

PLASMA-LYTE 148 E

Drug Name Drug Tier Notes

PLASMA-LYTE A E

PNV TABS 20-1 E

PODIAPN ORAL CAPSULE

E

poly-iron 150 forte E

polysaccharide iron forte

E

POLY-VI-FLOR ORAL SUSPENSION

3

POLY-VI-FLOR ORAL TABLET CHEWABLE

E

POLY-VI-FLORIRON ORAL SUSPENSION

2

POLY-VI-FLORIRON ORAL TABLET CHEWABLE

E

POLY-VITE PEDIATRIC ORAL SOLUTION

E

POTABA ORAL CAPSULE

E

potassium chloride crys er

1

potassium chloride er 1

potassium chloride in nacl intravenous solution 20-045 meql- 20-09 meql- 40-09 meql-

E

potassium chloride oral packet

1

potassium chloride oral solution 20 meq15ml (10) 40 meq15ml (20)

1

potassium citrate er 1

potassium citrate-citric acid oral solution

E

PREGEN DHA E

PREGENNA E

PREMESISRX E

PRENAISSANCE E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

82

Drug Name Drug Tier Notes

PRENARA E

prenatal oral tablet 27-08 mg

$0

prenatal plus iron 1

prenatal tablet 27-1 mg oral

1

prenatal tablet 27-1 mg oral

E

prenatal vitamin plus low iron

1

PRENATE E

PRENATE DHA ORAL CAPSULE 18-06-04-300 MG

E

PRENATE ELITE ORAL TABLET 20-06-04 MG

E

PRENATE ENHANCE E

PRENATE ESSENTIAL ORAL CAPSULE 18-06-04-300 MG

E

PRENATE MINI ORAL CAPSULE 18-06-04-350 MG

E

PRENATE PIXIE E

PRENATE RESTORE E

PRENATRIX E

PRENATRYL E

PRENATVITE COMPLETE

E

PRENATVITE PLUS 2

PRENATVITE RX 2

preplus 1

PRETAB 2

PRIMACARE ORAL CAPSULE

E

PRO HERS RX E

PRO HIS RX E

PRO PCOS RX E

PROTEINEX P18 E

Drug Name Drug Tier Notes

purevit dualfe plus E

pyridoxine hcl injection E

QUFLORA FE E

QUFLORA FE PEDIATRIC

E

QUFLORA GUMMIES E

QUFLORA PEDIATRIC E

RELNATE DHA 2

REMEDIENT E

RENAL MULTIVITAMIN FORMULA

E

RENAL ORAL CAPSULE

E

RENATABS E

RENATABS WITH IRON

E

rena-vite E

reno caps capsule 1 mg oral (rx)

E

REQ 49+ E

REVESTA E

ringers irrigation E

SAMSCA 3 SP QL

SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

E

se-tan plus E

SIDEROL ORAL TABLET

E

SLOWMAG MG MUSCLEHEART

E

sod citrate-citric acid 1

sodium bicarbonate intravenous solution 75

E

sodium bicarbonate solution 42 intravenous

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

83

Drug Name Drug Tier Notes

sodium bicarbonate solution 84 intravenous

E

SODIUM BICARBONATE SOLUTION 84 INTRAVENOUS

E

sodium chloride (pf) solution 09 injection

E

sodium chloride injection solution 25 meqml

E

sodium chloride intravenous solution 045 09 3 5

E

sodium chloride solution 4 meqml intravenous

E

sodium fluoride oral $0

sodium polystyrene sulfonate oral powder

1

soluvita e E

sps 1

STROVITE FORTE E

STROVITE ONE E

SUPERVITE E

support E

SUPPORT-500 E

SYPRINE 3 PA SP

SYSTANE ICAPS AREDS2 ORAL TABLET CHEWABLE

E

TALIVA E

thiamine hcl injection E

tis-u-sol E

tl-hem 150 E

TOLVAPTAN ORAL TABLET 15 MG

3 SP QL

tolvaptan oral tablet 30 mg

1 SP QL

Drug Name Drug Tier Notes

TRICARE PRENATAL DHA ONE ORAL CAPSULE 27-1-500 MG

2

tricitrates E

TRICON E

trientine hcl 1 PA SP

TRIFERIC HEMODIALYSIS PACKET

E

TRINATE 2

TRINAZ E

TRISTART DHA E

TRISTART FREE E

TRISTART ONE E

TRI-VI-FLOR 3

TRI-VI-FLORO 3

tri-vite pediatric E

tri-vitefluoride 1

TRONVITE E

UDAMIN SP E

UROCIT-K 10 3

UROCIT-K 15 3

UROCIT-K 5 3

urosex E

v-c forte E

VELTASSA 3

VENEXA E

VENOFER E

vic-forte E

VINATE ONE 2

virt-caps E

VIRT-FEFA PLUS E

virt-gard E

virt-phos 250 neutral 1

vita s forte E

vitacel E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

84

Drug Name Drug Tier Notes

VITAFOL FE+ ORAL CAPSULE

E

VITAFOL STRIPS 2

VITAFOL-NANO E

VITAFOL-OB+DHA E

VITAL-D RX E

VITAMEZ E

vitamin b complex 100 E

vitamin b-complex 100 E

vitamin d (ergocalciferol) oral capsule 125 mg (50000 ut)

1

VITAMIN DEFICIENCY SYSTEM-B12

E

vitamin k1 injection solution 1 mg05ml 10 mgml

E

vitamins acd-fluoride 1

VITAROCA PLUS E

VITA-RX DIABETIC VITAMIN

E

VITASURE E

VITATHELY WITH GINGER

E

VITRANOL FE E

VITREXATE E

VITREXATE FE E

VITREXYL E

VITREXYL + IRON E

vp-pnv-dha 1

vp-vite rx E

weekly-d E

westab mini E

westab one E

WESTAB PLUS 2

WESTGEL DHA E

WHEAT GERM OIL ORAL OIL

E

Drug Name Drug Tier Notes

WILZIN 3

XAQUIL XR E

XVITE E

ZALVIT E

zinc sulfate oral tablet 220 (50 zn) mg

E

ZYVANA E

Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer

acid reducer oral tablet 10 mg

E

acid reducer oral tablet delayed release

E

ACIPHEX E

ACIPHEX SPRINKLE E

CARAFATE ORAL SUSPENSION

3

CARAFATE ORAL TABLET

E

cimetidine hcl oral 1

cimetidine oral 1

CYTOTEC 3

DEXILANT 2 QL

ESOMEP-EZS E

esomeprazole magnesium oral capsule delayed release

1 QL

esomeprazole magnesium oral packet

1 QL

ESOMEPRAZOLE STRONTIUM ORAL CAPSULE DELAYED RELEASE 493 MG

E

famotidine oral suspension reconstituted

1

famotidine oral tablet 20 mg 40 mg

1

famotidine orig st E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

85

Drug Name Drug Tier Notes

FIRST-LANSOPRAZOLE

3 ST

FIRST-OMEPRAZOLE 3 ST

lansoprazole oral capsule delayed release

1 ST QL

lansoprazole oral tablet delayed release dispersible

1 QL

misoprostol oral 1

NEXIUM ORAL CAPSULE DELAYED RELEASE

E

NEXIUM ORAL PACKET

3 QL

nizatidine 1

omeprazole magnesium oral tablet delayed release

E

omeprazole oral capsule delayed release

1 ST QL

omeprazole oral tablet delayed release

E

OMEPRAZOLE+SYRSPEND SF ALKA

3 ST

omeprazole-sodium bicarbonate

E

pantoprazole sodium oral

1 ST QL

PEPCID ORAL TABLET

3

PREVACID E

PREVACID 24HR E

PREVACID SOLUTAB ORAL TABLET DELAYED RELEASE DISPERSIBLE

3 ST QL

PRILOSEC ORAL PACKET

3 ST QL

PROTONIX ORAL 3 ST QL

Drug Name Drug Tier Notes

RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE

E

rabeprazole sodium oral tablet delayed release

1 ST QL

sucralfate oral 1

ZEGERID E

Gastrointestinal Agents - Drugs for Bowel Intestine and Stomach Conditions

ACTIPHLORA E

alosetron hcl 1 PA

alum amp mag hydroxide-simeth

E

alumina-magnesia-simethicone

E

alvimopan 1

AMITIZA E

amoxicill-clarithro-lansopraz

1 ST

ANASPAZ 3

antacid anti-gas max strength

E

antacid calcium E

antacid calcium rich E

antacid extra strength oral tablet chewable 160-105 mg 750 mg

E

antacid maximum E

antacid oral tablet chewable 500 mg 750 mg

E

antacid regular strength E

antacid ultra strength oral tablet chewable 1000 mg

E

antacidantigas E

antacidanti-gas E

anti-diarrheal oral liquid E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

86

Drug Name Drug Tier Notes

anti-diarrheal oral tablet E

ATROPEN INTRAMUSCULAR SOLUTION AUTO-INJECTOR

E

atropine sulfate injection solution 04 mgml 1 mgml

E

atropine sulfate injection solution prefilled syringe 025 mg5ml

E

atropine sulfate intravenous solution

E

ATROPINE SULFATE INTRAVENOUS SOLUTION PREFILLED SYRINGE 08 MG2ML 1 MG25ML 12 MG3ML

E

atropine sulfate solution 8 mg20ml injection

E

atropine sulfate solution prefilled syringe 05 mg5ml injection

E

atropine sulfate solution prefilled syringe 1 mg10ml injection

E

BACICAP E

belladonna alkaloids-opium

E

bisacodyl ec $0 QL

bisacodyl rectal E

bismuth subsalicylate oral suspension 525 mg30ml

E

cascara sagrada oral fluid extract

1

CHENODAL 3 PA SP

chlordiazepoxide-clidinium

E

chocolated laxative E

Drug Name Drug Tier Notes

citroma $0 QL

clearlax oral powder $0 QL

CLENPIQ 3

constulose 1

cromolyn sodium oral 1

CUVPOSA 3

cvs antacid extra strength oral tablet chewable 750 mg

E

cvs gentle laxative rectal

E

dicyclomine hcl oral 1

diotame instydose E

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet 25-0025 mg

1

docusate calcium E

docusate mini E

docusate sodium oral capsule

E

docusate sodium oral syrup

E

docuzen E

dok oral tablet E

DONNATAL E

ED-SPAZ 3

ENTEREG 3

enulose 1

EX-LAX ULTRA E

fiber laxative oral tablet E

fiber oral powder 283

E

FOLIKA PROBIOTIC E

gas relief extra strength oral capsule

E

gas relief infants oral suspension

E

gas relief oral tablet chewable

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

87

Drug Name Drug Tier Notes

GASTROCROM 3

GATTEX 3 PA SP

gavilax oral powder $0 QL

gavilyte-c $0 QL

gavilyte-g $0 QL

gavilyte-h 1

gavilyte-n with flavor pack

$0 QL

GELUSIL E

generlac 1

gentle laxative oral $0 QL

gentle laxative rectal E

geri-kot E

GIALAX E

GLYCATE E

glycolax $0 QL

GLYCOPYRROLATE INJECTION SOLUTION PREFILLED SYRINGE 06 MG3ML

E

glycopyrrolate oral tablet 1 mg 2 mg

1

GLYCOPYRROLATE ORAL TABLET 15 MG

E

glycopyrrolate pf E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 06 MG3ML INTRAVENOUS

E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 1 MG5ML INJECTION

E

GLYCOPYRROLATE SOLUTION PREFILLED SYRINGE 1 MG5ML INTRAVENOUS

E

Drug Name Drug Tier Notes

GLYRX-PF INJECTION SOLUTION PREFILLED SYRINGE

E

gnp senna lax E

GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM

3

goodsense antacid amp gas relief

E

goodsense antacid oral tablet chewable 500 mg 750 mg

E

goodsense anti-diarrheal

E

HELIDAC THERAPY 3

high potency probiotic E

hm stomach relief oral suspension 525 mg30ml

E

hm stool softener oral capsule 100 mg

E

hyoscyamine sulfate er oral tablet extended release 12 hour

E

hyoscyamine sulfate oral elixir

1

hyoscyamine sulfate oral tablet

1

hyoscyamine sulfate oral tablet dispersible

1

hyoscyamine sulfate sl 1

hyoscyamine sulfate solution 0125 mgml oral

E

hyoscyamine sulfate solution 0125 mgml oral

1

hyoscyamine sulfate tablet sublingual 0125 mg sublingual

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

88

Drug Name Drug Tier Notes

hyoscyamine sulfate tablet sublingual 0125 mg sublingual

E

hyosyne 1

IMODIUM A-D ORAL TABLET

E

IMODIUM MULTI-SYMPTOM RELIEF ORAL TABLET

E

infants gas relief oral suspension 20 mg03ml

E

KRISTALOSE E

LACTEROL E

lactobacillus oral tablet E

LACTOJEN E

lactulose encephalopathy

1

lactulose oral 1

laxative max str E

laxative regular strength

E

LEVBID E

LEVSIN ORAL TABLET

E

LEVSINSL E

LIBRAX 3

LINZESS 2 ST QL

LOMOTIL ORAL TABLET

3

loperamide hcl oral capsule

1

loperamide hcl oral solution

E

loperamide hcl oral suspension

E

LOTRONEX 3 PA

LUBIPROSTONE E

MAALOX MULTI SYMPTOM MAX ST ORAL SUSPENSION

E

Drug Name Drug Tier Notes

magnesium citrate oral solution 1745 gm30ml

$0 QL

magnesium oxide oral tablet 400 mg 420 mg

E

methscopolamine bromide oral

1

milk of magnesia oral suspension 1200 mg15ml 400 mg5ml

E

mineral oil heavy oral 1

mm clearlax $0 QL

mm stool softener laxative

E

MOTEGRITY 3 ST QL

MOTOFEN E

MOVANTIK E

MOVIPREP E

MYTESI 3 QL

natural senna laxative oral tablet 86 mg

E

NULEV 3

NULYTELY LEMON-LIME

3

OMECLAMOX-PAK 2

opium E

oscimin oral tablet 1

oscimin sr E

oscimin sublingual 1

OSMOPREP E

pb-hyoscy-atropine-scopolamine

E

PCP 100 E

peg 3350-kcl-na bicarb-nacl

$0 QL

peg-3350electrolytes $0 QL

peg-3350electrolytesascorbat

1

peg-kcl-nacl-nasulf-na asc-c

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

89

Drug Name Drug Tier Notes

peg-prep 1

PERDIEM OVERNIGHT RELIEF

E

phenobarbital-belladonna alk oral elixir

E

phenobarbital-belladonna alk oral tablet

1

PHENOHYTRO E

pink bismuth maximum strength

E

PLENVU E

PROBICHEW E

PROBITROL E

PRODIGEN E

PROMELLA IN PREBIOTIC

E

PROMEROL E

PYLERA 2

qc magnesium citrate $0 QL

quad-probiotic E

RELISTOR ORAL E

RELISTOR SUBCUTANEOUS SOLUTION 12 MG06ML 8 MG04ML

E

RELTONE E

RESTORA RX 3

saccharomyces boulardii

E

senexon-s E

senna oral liquid E

senna oral syrup 88 mg5ml

E

senna oral tablet 86 mg

E

senna plus oral tablet E

senna s E

Drug Name Drug Tier Notes

senna smooth E

senna-docusate sodium

E

senna-plus E

SENOKOT EXTRA STRENGTH

E

SENOKOT S E

SEROSTIM SUBCUTANEOUS SOLUTION RECONSTITUTED 4 MG 5 MG 6 MG

3 PA SP

simethicone oral capsule 125 mg

E

simethicone oral suspension 40 mg06ml

E

simethicone oral tablet chewable 80 mg

E

simethicone ultra strength

E

SODIUM BICARBONATE ORAL POWDER

3

sodium bicarbonate oral tablet 325 mg 650 mg

E

soothe oral tablet E

stimulant laxative oral tablet

E

stomach relief oral tablet chewable

E

stool softener laxative oral capsule 100 mg

E

stool softener oral capsule 100 mg 250 mg

E

stool softener plus laxative

E

stool softenerlaxative oral tablet

E

SUPREP BOWEL PREP KIT

3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

90

Drug Name Drug Tier Notes

SUTAB 3

SYMAX DUOTAB E

SYMAX-SL E

SYMAX-SR E

SYMPROIC 2 ST QL

TALICIA 3

TRULANCE E

TUMS CHEWY BITES E

URSO 250 3

URSO FORTE 3

ursodiol oral 1

URSODIOL+SYRSPEND SF

E

vegetable lax+stool softener

E

VIBERZI 3 PA QL

VISBIOME E

womens 50 billion E

XERMELO TABLET 250 MG ORAL

3 PA SP QL

ZELAC E

ZELNORM 3 PA QL

ZORBTIVE 3 PA SP

Genetic or Enzyme Disorder - Drugs for Replacement Modification Treatment

ALDURAZYME 2 PA SP

AMONDYS 45 E SP

BRINEURA KIT 3 PA SP

BUPHENYL ORAL POWDER 3 GMTSP

3 SP

BUPHENYL ORAL TABLET

3 SP

CERDELGA 3 PA SP

Drug Name Drug Tier Notes

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

2 PA SP

CHOLBAM 3 PA SP

CITRULLINE EASY E

CREON 2

CRYSVITA 3 PA SP

CYSTADANE 3 SP

CYSTAGON 3 SP

ELAPRASE 2 PA SP

ELELYSO 3 PA SP

ENZADYNE E

EVRYSDI 3 PA SP QL

EXONDYS 51 E SP

FABRAZYME 2 PA SP

GALAFOLD 3 PA SP QL

KANUMA 3 PA SP

KUVAN ORAL PACKET

E SP

KUVAN ORAL TABLET E SP

LUMIZYME 2 PA SP

MEPSEVII 3 PA SP

miglustat 1 PA SP

MYALEPT 3 PA SP

NAGLAZYME 2 PA SP

nitisinone 1 PA SP

NITYR 3 PA SP

OCALIVA 3 PA SP QL

ORFADIN 3 PA SP

PALYNZIQ 3 PA SP QL

PANCREAZE E

PERTZYE E

PROCYSBI 3 PA SP

RAVICTI 3 PA SP

REVCOVI 3 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

91

Drug Name Drug Tier Notes

sapropterin dihydrochloride oral packet

1 PA SP

sapropterin dihydrochloride oral tablet

1 PA SP

sodium phenylbutyrate oral powder 3 gmtsp

1 SP

sodium phenylbutyrate oral tablet

1 SP

STRENSIQ 2 PA SP

SUCRAID 3 SP

VIMIZIM 3 PA SP

VIOKACE E

VPRIV 3 PA SP

VYONDYS 53 E SP

XURIDEN 3 PA SP QL

ZAVESCA 3 PA SP

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT 15000-47000 UNIT 20000-63000 UNIT 25000-79000 UNIT 3000-14000 UNIT 40000-126000 UNIT 5000-24000 UNIT

2

ZOLGENSMA 3 PA SP

Genitourinary Agents - Drugs for Bladder Genital and Kidney Conditions

aminoacetic acid E

AURYXIA 3

azo tabs E

bethanechol chloride oral

1

BI-MIX 3

calcium acetate (phos binder)

1

Drug Name Drug Tier Notes

calcium acetate oral tablet 667 mg

1

CAVERJECT IMPULSE

3 QL

CAVERJECT INTRACAVERNOSAL SOLUTION RECONSTITUTED 40 MCG

3 QL

CERVIDIL 3

CIALIS 3 QL

CUPRIMINE ORAL CAPSULE 250 MG

3 PA SP

darifenacin hydrobromide er

1

DEPEN TITRATABS 2 SP

DETROL 3

DETROL LA 3

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24 HOUR 10 MG 5 MG

3

EDEX 3 QL

ELMIRON E

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HOUR 75 MG

3

FEM PH E

flavoxate hcl 1

FOSRENOL ORAL PACKET

3

FOSRENOL ORAL TABLET CHEWABLE 1000 MG 500 MG 750 MG

3

GELNIQUE TRANSDERMAL GEL 10

3 ST

GEMTESA E

glycine irrigation E

glycine urologic E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

92

Drug Name Drug Tier Notes

HYOPHEN E

INTRAROSA 3 ST

lanthanum carbonate 1

LEVITRA ORAL TABLET 10 MG 20 MG

E

LITHOSTAT 3

menaphosmbhyo1 E

MUSE 3 QL

MYRBETRIQ 2

OXLUMO 3 PA SP

oxybutynin chloride er 1

oxybutynin chloride oral 1

OXYTROL 3 ST QL

OXYTROL FOR WOMEN

E

penicillamine oral capsule

1 PA SP

penicillamine oral tablet 1 SP

PENTOSAN POLYSULFATE SODIUM ORAL

E

phenazo oral tablet 200 mg

1

phenazopyridine hcl oral tablet 100 mg 200 mg

1

PHENYLEPHRINE HCL INTRACAVERNOSAL

E

PHOSLYRA 3

PHOSPHASAL E

PREPIDIL 3

PROSTIN E2 3

PYRIDIUM E

QUAD-MIX 3

RENACIDIN E

RENAGEL ORAL TABLET 800 MG

E

RENVELA 3

Drug Name Drug Tier Notes

RIMSO-50 E

sevelamer carbonate 1

sevelamer hcl 1

sildenafil citrate oral tablet 100 mg 25 mg 50 mg

1 QL

solifenacin succinate 1

STAXYN E

STENDRA E

SUPER BI-MIX 3

SUPER QUAD-MIX 3

SUPER TRI-MIX E

tadalafil oral 1 QL

THIOLA EC 3 SP

tolterodine tartrate 1

tolterodine tartrate er 1

TOVIAZ 3

TRI-MIX E

trospium chloride 1 ST

trospium chloride er 1

URELLE E

uretron ds oral tablet 816 mg

1

URIBEL E

URIMAR-T E

urin ds oral tablet 816 mg

1

urinary pain relief oral tablet 95 mg

E

URO-458 E

UROGESIC-BLUE E

uro-mp E

USTELL E

UTIRA-C E

vardenafil hcl oral 1 QL

VELPHORO 3

VESICARE 3

VESICARE LS E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

93

Drug Name Drug Tier Notes

VIAGRA E

VILAMIT MB E

VILEVEV MB E

Genitourinary Agents - Drugs for Prostate Conditions

alfuzosin hcl er 1

AVODART 3

CARDURA XL 3 ST

dutasteride oral 1

dutasteride-tamsulosin hcl

1

finasteride oral tablet 5 mg

1

FLOMAX E

JALYN 3

PROSCAR 3

RAPAFLO 3

silodosin 1

tamsulosin hcl 1

terazosin hcl oral 1

UROXATRAL 3

Hormonal Agents - Adrenal

ACTIVE INJECTION D E

ACTIVE INJECTION KIT L

E

ACTIVE INJECTION KL-3

E

ACTIVE INJECTION LM-DEP-2

E

ALKINDI SPRINKLE E

BETA 1 KIT E

BETALOAN SUIK E

BETAMETHASONE COMBO

E

Drug Name Drug Tier Notes

BETAMETHASONE SOD PHOS amp ACET INJECTION SUSPENSION 7 (4-3) MGML

E

BETAMETHASONE SOD PHOS amp ACET SUSPENSION 6 (3-3) MGML INJECTION

E

betamethasone sod phos amp acet suspension 6 (3-3) mgml injection

E

BSP 0820 E

CELESTONE SOLUSPAN

E

CONTRAST ALLERGY PREMED PACK

E

CORTEF 3

DECADRON ORAL TABLET

E

DEPO-MEDROL E

DEXABLISS E

dexamethasone intensol

1

dexamethasone oral 1

dexamethasone sod phosphate pf

E

dexamethasone sodium phosphate injection solution 100 mg10ml 120 mg30ml 20 mg5ml

E

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 10 MGML INJECTION

E

dexamethasone sodium phosphate solution 10 mgml injection

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

94

Drug Name Drug Tier Notes

DEXAMETHASONE SODIUM PHOSPHATE SOLUTION 4 MGML INJECTION

E

dexamethasone sodium phosphate solution 4 mgml injection

E

DEXONTO 04 3

DMT SUIK E

DOUBLEDEX E

DXEVO 11-DAY E

DYURAL-40 E

DYURAL-80 E

DYURAL-L E

DYURAL-LM E

fludrocortisone acetate oral

1

HEMADY E

HIDEX 6-DAY E

hydrocortisone oral 1

KENALOG INJECTION 3

KENALOG-80 3

MAS CARE-PAK E

MEDROL ORAL TABLET 16 MG 32 MG 4 MG 8 MG

3

MEDROL ORAL TABLET 2 MG

2

MEDROL ORAL TABLET THERAPY PACK

3

MEDROLOAN II SUIK E

MEDROLOAN SUIK E

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 50 MGML

E

Drug Name Drug Tier Notes

METHYLPREDNISOLONE ACETATE SUSPENSION 40 MGML INJECTION

E

methylprednisolone acetate suspension 40 mgml injection

E

METHYLPREDNISOLONE ACETATE SUSPENSION 80 MGML INJECTION

E

methylprednisolone acetate suspension 80 mgml injection

E

methylprednisolone oral

1

MILLIPRED ORAL TABLET

E

MULTI-SPECIALTY E

ORAPRED ODT 3

P-CARE K40 E

P-CARE K40G E

P-CARE K40MX E

P-CARE K80 E

P-CARE K80G E

P-CARE K80MX E

PEDIAPRED 3

physicians ez use jointtunnel

E

PHYSICIANS EZ USE M-PRED

E

POD-CARE 100K E

POINT OF CARE L2 E

POINT OF CARE L5 E

POINT OF CARE LM DEP 2

E

prednisolone oral solution

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

95

Drug Name Drug Tier Notes

prednisolone sodium phosphate oral solution 10 mg5ml 15 mg5ml 20 mg5ml 25 mg5ml 67 (5 base) mg5ml

1

prednisolone sodium phosphate oral tablet dispersible

1

prednisone intensol 1

prednisone oral 1

PRO-C-DURE 5 E

PRO-C-DURE 6 E

RAYOS E

READYSHARP ANESTH + METHYLPRED

E

READYSHARP BETAMETHASONE

E

READYSHARP DEXAMETHASONE

E

SOLU-CORTEF INJECTION SOLUTION RECONSTITUTED 100 MG

3

TAPERDEX 12-DAY E

TAPERDEX 6-DAY E

TAPERDEX 7-DAY ORAL TABLET THERAPY PACK 15 MG (27)

E

TOPIDEX E

TRIAMCINOLONE ACETONIDE INJECTION SUSPENSION 50 MGML

E

triamcinolone acetonide suspension 40 mgml injection

1

Drug Name Drug Tier Notes

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MGML INJECTION

3

TRIAMCINOLONE ACETONIDE SUSPENSION 40 MGML INJECTION

E

TRILOAN II SUIK E

TRILOAN SUIK E

ZCORT 7-DAY E

ZILRETTA E

Hormonal Agents - Mens Health

ANDRODERM TRANSDERMAL PATCH 24 HOUR

2 PA

ANDROGEL PUMP TRANSDERMAL GEL 2025 MGACT (162)

3 PA

ANDROGEL TRANSDERMAL GEL 2025 MG125GM (162) 405 MG25GM (162)

3 PA

ANDROGEL TRANSDERMAL GEL 25 MG25GM (1) 50 MG5GM (1)

E

AVEED E

danazol oral 1

DEPO-TESTOSTERONE INTRAMUSCULAR SOLUTION

E

EC-RX TESTOSTERONE

E

FORTESTA E

JATENZO E

METHITEST 3 PA

methyltestosterone oral 1 PA

NATESTO E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

96

Drug Name Drug Tier Notes

oxandrolone oral 1 PA QL

TESTIM E

TESTONE CIK E

TESTOPEL E

TESTOSTERONE CYPIONATE INJECTION SOLUTION 200 MGML

E

testosterone cypionate intramuscular solution 100 mgml 200 mgml

1 PA

testosterone enanthate intramuscular solution

1 PA

TESTOSTERONE IMPLANT PELLET 100 MG 200 MG 25 MG 50 MG

E

testosterone transdermal gel 162 10 mgact (2) 125 mgact (1) 2025 mg125gm (162) 2025 mgact (162) 25 mg25gm (1) 405 mg25gm (162) 50 mg5gm (1)

1 PA

testosterone transdermal solution

1 PA

VOGELXO PUMP E

VOGELXO TRANSDERMAL GEL 50 MG5GM (1)

E

XYOSTED 3 PA

Hormonal Agents - Osteoporosis

EVISTA 3

OSPHENA 3

raloxifene hcl 1

Hormonal Agents - Pituitary

ACTHAR 2 PA SP

Drug Name Drug Tier Notes

BYNFEZIA PEN E SP

cabergoline 1

CETROTIDE SUBCUTANEOUS KIT 025 MG

E SP

chorionic gonadotropin intramuscular

1 PA SP

clomiphene citrate oral 1 PA

DDAVP INJECTION SOLUTION 4 MCGML

3

DDAVP ORAL 3

DDAVP PF 3

DDAVP RHINAL TUBE 2

desmopressin ace spray refrig

1

desmopressin acetate injection

1

desmopressin acetate oral

1

desmopressin acetate pf

1

desmopressin acetate spray

1

EGRIFTA SV 3 PA SP QL

ELIGARD 3 PA SP QL

FENSOLVI (6 MONTH) 3 PA SP QL

FIRMAGON (240 MG DOSE)

3 PA SP QL

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

3 PA SP QL

FOLLISTIM AQ SUBCUTANEOUS

2 PA SP

ganirelix acetate solution prefilled syringe 250 mcg05ml subcutaneous

1 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

97

Drug Name Drug Tier Notes

ganirelix acetate solution prefilled syringe 250 mcg05ml subcutaneous

1PA Made by Organon SP

GENOTROPIN E SP

GENOTROPIN MINIQUICK

E SP

GONAL-F E SP

GONAL-F RFF E SP

GONAL-F RFF REDIJECT

E SP

HUMATROPE E SP

INCRELEX 2 PA SP

ISTURISA E SP

leuprolide acetate injection

1 PA SP

LUPANETA PACK 3 PA SP QL

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 375 MG

3 PA SP

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 75 MG

2 PA SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 1125 MG

3 PA SP

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 225 MG

2 PA SP

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG

2 PA SP

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG

2 PA SP

Drug Name Drug Tier Notes

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 1125 MG

3 PA SP

LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 15 MG 75 MG

2 PA SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 1125 MG (PED)

3 PA SP

LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR KIT 30 MG (PED)

2 PA SP

MENOPUR 3 PA SP

MYCAPSSA E SP

NOCDURNA 3

NORDITROPIN FLEXPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

novarel intramuscular solution reconstituted 10000 unit

1 PA SP

NOVAREL INTRAMUSCULAR SOLUTION RECONSTITUTED 5000 UNIT

3 PA SP

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

98

Drug Name Drug Tier Notes

NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS SOLUTION PEN-INJECTOR

2 PA SP

octreotide acetate injection solution 100 mcgml 1000 mcgml 200 mcgml 50 mcgml 500 mcgml

1 PA SP

OMNITROPE SUBCUTANEOUS SOLUTION CARTRIDGE

E SP

OMNITROPE SUBCUTANEOUS SOLUTION RECONSTITUTED

E SP

ORILISSA 2 PA QL

OVIDREL 3 PA SP

OXYTOCIN-LACTATED RINGERS INTRAVENOUS SOLUTION 30 UNIT500ML

E

OXYTOCIN-SODIUM CHLORIDE INTRAVENOUS SOLUTION 20-09 UNITL- 20-09 UNTL-

E

pregnyl 1 PA SP

SAIZEN E SP

SAIZENPREP E SP

SANDOSTATIN INJECTION SOLUTION 100 MCGML 50 MCGML 500 MCGML

E SP

SANDOSTATIN LAR DEPOT

E SP

SIGNIFOR E SP

Drug Name Drug Tier Notes

SIGNIFOR LAR INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

3 PA SP QL

SOMATULINE DEPOT 3 PA SP

SOMAVERT 3 PA SP

STIMATE 3

SUPPRELIN LA 2 PA SP QL

SYNAREL 2

TEPEZZA 3 PA SP

TRELSTAR MIXJECT 3 PA SP QL

TRIPTODUR 3 PA SP QL

VANTAS 3 PA SP QL

ZOLADEX SUBCUTANEOUS IMPLANT 108 MG

3 SP QL

ZOLADEX SUBCUTANEOUS IMPLANT 36 MG

2 SP QL

ZOMACTON E SP

ZOMACTON (FOR ZOMA-JET 10)

E SP

Hormonal Agents - Prostaglandins

KORLYM 3 PA SP QL

Hormonal Agents - Sex Hormones and Birth Control

ACTIVELLA ORAL TABLET 1-05 MG

3

afirmelle $0 QL

ALORA 3 ST

altavera $0 QL

alyacen 135 $0 QL

alyacen 777 $0 QL

amabelz 1

amethia $0 QL

amethyst $0 QL

ANGELIQ 3

ANNOVERA E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

99

Drug Name Drug Tier Notes

apri $0 QL

aranelle $0 QL

ashlyna $0 QL

aubra $0 QL

aubra eq $0 QL

aurovela 1530 $0 QL

aurovela 120 $0 QL

aurovela 24 fe $0 QL

aurovela fe 1530 $0 QL

aurovela fe 120 $0 QL

aviane $0 QL

AYGESTIN 3

ayuna $0 QL

azurette $0 QL

BALCOLTRA E

balziva $0 QL

bekyree $0 QL

BEYAZ E

BIESTPROGESTERONE

E

BIJUVA 3

blisovi 24 fe $0 QL

blisovi fe 1530 $0 QL

blisovi fe 120 $0 QL

briellyn $0 QL

camila $0 QL

camrese $0 QL

camrese lo $0 QL

caziant $0 QL

charlotte 24 fe $0 QL

chateal $0 QL

chateal eq $0 QL

CLIMARA 3

CLIMARA PRO 2

COMBIPATCH 3

COVARYX E

COVARYX HS E

Drug Name Drug Tier Notes

CRINONE VAGINAL GEL 4

3 QL

CRINONE VAGINAL GEL 8

3 PA QL

cryselle-28 $0 QL

cyclafem 135 $0 QL

cyclafem 777 $0 QL

cyred $0 QL

cyred eq $0 QL

dasetta 135 $0 QL

dasetta 777 $0 QL

daysee $0 QL

deblitane $0 QL

DELESTROGEN 3

delyla $0 QL

DEPO-ESTRADIOL 3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 150 MGML

3 QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

3 QL

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE

$0 QL

desogestrel-ethinyl estradiol

$0 QL

DIVIGEL 3

dotti 1

drospiren-eth estrad-levomefol

$0 QL

drospirenone-ethinyl estradiol

$0 QL

DUAVEE 2

EC-RX ESTRADIOL E

EC-RX PROGESTERONE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

100

Drug Name Drug Tier Notes

EEMT E

EEMT HS E

ELESTRIN 3

elinest $0 QL

ELLA $0 QL

eluryng $0 QL

emoquette $0 QL

ENDOMETRIN 2 PA

enpresse-28 $0 QL

enskyce oral tablet 015-30 mg-mcg

$0 QL

errin $0 QL

est estrogens-methyltest

E

est estrogens-methyltest ds

E

est estrogens-methyltest hs

E

estarylla $0 QL

ESTRACE 3

estradiol oral 1

estradiol transdermal 1

estradiol vaginal 1

estradiol valerate intramuscular oil 20 mgml 40 mgml

1

estradiol-norethindrone acet

1

ESTRING 3 QL

ESTROGEL 3

ESTROSTEP FE 3 QL

ethynodiol diac-eth estradiol

$0 QL

etonogestrel-ethinyl estradiol

$0 QL

EVAMIST 3

FALESSA ORAL KIT 20-1-01 MCG-MG

E

falmina $0 QL

Drug Name Drug Tier Notes

fayosim $0 QL

FEMHRT LOW DOSE 3

FEMRING 3 ST QL

femynor $0 QL

FIRST-PROGESTERONE VGS VAGINAL SUPPOSITORY 100 MG 200 MG

E

fyavolv 1

gemmily $0 QL

GENERESS FE 3 QL

hailey 1530 $0 QL

hailey 24 fe $0 QL

hailey fe 1530 $0 QL

hailey fe 120 $0 QL

heather $0 QL

hydroxyprogesterone caproate intramuscular

1 PA SP

iclevia $0 QL

IMVEXXY MAINTENANCE PACK

3

IMVEXXY STARTER PACK

3

incassia $0 QL

introvale $0 QL

isibloom $0 QL

jaimiess $0 QL

jasmiel $0 QL

jencycla $0 QL

jinteli 1

jolessa $0 QL

juleber $0 QL

junel 1530 $0 QL

junel 120 $0 QL

junel fe 1530 $0 QL

junel fe 120 $0 QL

junel fe 24 $0 QL

kaitlib fe $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

101

Drug Name Drug Tier Notes

kalliga $0 QL

kariva $0 QL

kelnor 135 $0 QL

kelnor 150 $0 QL

kurvelo $0 QL

KYLEENA E

larin 1530 $0 QL

larin 120 $0 QL

larin 24 fe $0 QL

larin fe 1530 $0 QL

larin fe 120 $0 QL

larissia $0 QL

layolis fe $0 QL

leena $0 QL

lessina $0 QL

levonest $0 QL

levonorgest-eth est amp eth est

$0 QL

levonorgest-eth estrad 91-day

$0 QL

levonorgestrel oral tablet 15 mg

$0 QL

levonorgestrel-ethinyl estrad

$0 QL

levonorg-eth estrad triphasic oral tablet 50-3075-40 125-30 mcg

$0 QL

levora 01530 (28) $0 QL

LILETTA (52 MG) INTRAUTERINE INTRAUTERINE DEVICE 195 MCGDAY

E

lillow $0 QL

LO LOESTRIN FE $0 QL

LOESTRIN 1530 (21) 3 QL

LOESTRIN 120 (21) 3 QL

LOESTRIN FE 1530 3 QL

LOESTRIN FE 120 3 QL

Drug Name Drug Tier Notes

lojaimiess $0 QL

loryna $0 QL

LOSEASONIQUE 3 QL

low-ogestrel $0 QL

lo-zumandimine $0 QL

lutera $0 QL

lyleq $0 QL

lyllana 1

lyza $0 QL

MAKENA 2 PA SP

marlissa $0 QL

medroxyprogesterone acetate intramuscular

$0 QL

medroxyprogesterone acetate oral

1

megestrol acetate oral suspension 40 mgml 625 mg5ml

1

megestrol acetate oral tablet

1

MENEST ORAL TABLET 03 MG 0625 MG 125 MG

2

MENOSTAR 3 ST

merzee $0 QL

mibelas 24 fe $0 QL

microgestin 1530 $0 QL

microgestin 120 $0 QL

microgestin 24 fe $0 QL

microgestin fe 1530 $0 QL

microgestin fe 120 $0 QL

mili $0 QL

mimvey 1

MINASTRIN 24 FE E

MINIVELLE 3 ST

MIRCETTE 3 QL

MIRENA (52 MG) E

mono-linyah $0 QL

NATAZIA $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

102

Drug Name Drug Tier Notes

necon 0535 (28) $0 QL

NEXPLANON E

nikki $0 QL

nora-be $0 QL

norethin ace-eth estrad-fe oral capsule

$0 QL

norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg 15-30 mg-mcg

$0 QL

norethin ace-eth estrad-fe oral tablet chewable

$0 QL

norethindrone acetate oral

1

norethindrone acet-ethinyl est oral tablet

$0 QL

norethindrone oral $0 QL

norethindrone-eth estradiol

1

norethin-eth estradiol-fe $0 QL

norgestimate-eth estradiol oral tablet 025-35 mg-mcg

$0 QL

norgestimate-ethinyl estradiol triphasic

$0 QL

norlyda $0 QL

norlyroc $0 QL

nortrel 0535 (28) $0 QL

nortrel 135 (21) $0 QL

nortrel 135 (28) $0 QL

nortrel 777 $0 QL

NUVARING 3 QL

nylia 777 $0 QL

nymyo $0 QL

ocella $0 QL

ORIAHNN 2 PA QL

orsythia $0 QL

ORTHO MICRONOR E

Drug Name Drug Tier Notes

PARAGARD INTRAUTERINE COPPER

E

philith $0 QL

pimtrea $0 QL

pirmella 135 $0 QL

pirmella 777 $0 QL

PLAN B ONE-STEP $0 QL

portia-28 $0 QL

PREFEST 3

PREMARIN ORAL 2

PREMARIN VAGINAL 2

PREMPHASE 2

PREMPRO 2

previfem $0 QL

progesterone intramuscular

1

PROGESTERONE MICRONIZED TRANSDERMAL

E

progesterone oral 1

PROMETRIUM 3

PROVERA 3

QUARTETTE 3 QL

reclipsen $0 QL

rivelsa $0 QL

SAFYRAL 3 QL

SEASONIQUE 3 QL

setlakin $0 QL

sharobel $0 QL

simliya $0 QL

simpesse $0 QL

SKYLA E

SLYND E

sprintec 28 $0 QL

sronyx $0 QL

syeda $0 QL

tarina 24 fe $0 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

103

Drug Name Drug Tier Notes

tarina fe 120 $0 QL

tarina fe 120 eq $0 QL

TAYTULLA E

tilia fe $0 QL

tri femynor $0 QL

tri-estarylla $0 QL

tri-legest fe $0 QL

tri-linyah $0 QL

tri-lo-estarylla $0 QL

tri-lo-marzia $0 QL

tri-lo-mili $0 QL

tri-lo-sprintec $0 QL

tri-mili $0 QL

tri-nymyo $0 QL

tri-previfem $0 QL

tri-sprintec $0 QL

trivora (28) $0 QL

tri-vylibra $0 QL

tri-vylibra lo $0 QL

tulana $0 QL

TWIRLA E

tyblume oral tablet chewable

$0 QL

tydemy $0 QL

VAGIFEM VAGINAL TABLET 10 MCG

E

velivet $0 QL

vestura $0 QL

vienva $0 QL

viorele $0 QL

VIVELLE-DOT E

volnea $0 QL

vyfemla $0 QL

vylibra $0 QL

wera $0 QL

wymzya fe $0 QL

xulane $0 QL

Drug Name Drug Tier Notes

YASMIN 28 3 QL

YAZ E

yuvafem 1

zafemy $0 QL

zarah $0 QL

zovia 135 (28) $0 QL

zovia 135e (28) $0 QL

zumandimine $0 QL

Hormonal Agents - Thyroid

ARMOUR THYROID 3 ST

CYTOMEL E

euthyrox 1

levo-t 1

LEVOTHYROXINE SODIUM ORAL CAPSULE

E

levothyroxine sodium oral tablet

1

levoxyl 1

liothyronine sodium oral 1

methimazole oral 1

NATURE-THROID 3 ST

np thyroid 1

propylthiouracil oral 1

SYNTHROID 3

TAPAZOLE 3

THYQUIDITY 3

TIROSINT E

TIROSINT-SOL 3

unithroid 1

WESTHROID ORAL TABLET 130 MG 195 MG 325 MG 65 MG 975 MG

3 ST

WP THYROID 3 ST

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

104

Drug Name Drug Tier Notes

Immunological Agents - Drugs for Immune System Stimulation or Suppression

ACTEMRA 3 PA SP

ACTEMRA ACTPEN 3 PA SP

ACTIMMUNE 2 PA SP

ALFERON N 2 SP

ARAVA 3

ARCALYST 3 PA SP

ASCENIV E SP

ASTAGRAF XL 3 SP

ATGAM 2 SP

AVSOLA 2 PA SP

AZASAN 3

azathioprine oral 1

azathioprine sodium E

BAMLANIVIMAB E

BENLYSTA 3 PA SP

BERINERT 3 PA SP QL

BIVIGAM INTRAVENOUS SOLUTION 5 GM50ML

3 PA SP

CARIMUNE NF INTRAVENOUS SOLUTION RECONSTITUTED 12 GM 6 GM

3 PA SP

CASIRIVIMAB E

CELLCEPT 3 SP

CELLCEPT INTRAVENOUS

3 SP

CIMZIA PREFILLED KIT

2 PA SP

CIMZIA STARTER KIT 2 PA SP

CIMZIA VIAL KIT 2 PA SP

CINRYZE 2 PA SP

Drug Name Drug Tier Notes

COSENTYX (300 MG DOSE)

E SP

COSENTYX 150 MGML

E SP

COSENTYX SENSOREADY (300 MG)

E SP

COSENTYX SENSOREADY PEN SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150 MGML

E SP

CUTAQUIG E SP

CUVITRU 3 PA SP

cyclosporine intravenous

1 SP

cyclosporine modified 1 SP

cyclosporine oral capsule

1 SP

CYTOGAM 2 PA SP

ENBREL MINI 3 PA SP

ENBREL SUBCUTANEOUS SOLUTION 25 MG05ML

3 PA SP

ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED

3 PA SP

ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

3 PA SP

ENSPRYNG 3 PA SP

ENTYVIO 3 PA SP

ENVARSUS XR 3 SP

ETESEVIMAB E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

105

Drug Name Drug Tier Notes

everolimus oral tablet 025 mg 05 mg 075 mg

1 SP

FIRAZYR 3 PA SP QL

FLEBOGAMMA DIF 3 PA SP

GAMASTAN 2 PA SP

GAMIFANT 3 PA SP

GAMMAGARD 3 PA SP

GAMMAGARD SD LESS IGA

3 PA SP

GAMMAKED INJECTION SOLUTION 1 GM10ML 10 GM100ML 20 GM200ML 5 GM50ML

3 PA SP

GAMMAPLEX INTRAVENOUS SOLUTION 10 GM100ML 10 GM200ML 20 GM200ML 20 GM400ML 5 GM100ML 5 GM50ML

3 PA SP

GAMUNEX-C 3 PA SP

gengraf oral capsule 100 mg 25 mg

1 SP

gengraf oral solution 1 SP

HAEGARDA 3 PA SP

HEPAGAM B E

HIZENTRA SUBCUTANEOUS SOLUTION 1 GM5ML 10 GM50ML 2 GM10ML 4 GM20ML

3 PA SP

HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

Drug Name Drug Tier Notes

HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG08ML 80 MG08ML amp 40MG04ML

2 PA SP

HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT

2 PA SP

HUMIRA PEN-CDUCHS STARTER

2 PA SP

HUMIRA PEN-PEDIATRIC UC START

2 PA SP

HUMIRA PEN-PSUVADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG08ML

2 PA SP

HUMIRA PEN-PSORUVEIT STARTER

2 PA SP

HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG01ML 20 MG02ML 40 MG04ML 40 MG08ML

2 PA SP

HYPERHEP B E

HYPERRAB E

HYPERRAB SD INJECTION

E

HYPERRHO SD INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

HYPERTET SD E

HYQVIA 3 PA SP

icatibant acetate 1 PA SP QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

106

Drug Name Drug Tier Notes

ILARIS SUBCUTANEOUS SOLUTION

2 PA SP QL

ILUMYA 3 PA SP

IMDEVIMAB E

IMOGAM RABIES-HT INJECTION

E

IMURAN 3

INFLECTRA 2 PA SP

KALBITOR 3 PA SP QL

KEDRAB INJECTION E

KEVZARA 3 PA SP

KINERET SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

KYMRIAH 3 PA SP

leflunomide oral 1

LUPKYNIS E SP

methotrexate oral 1

methotrexate sodium (pf) injection solution 1 gm40ml 250 mg10ml 50 mg2ml

1

methotrexate sodium injection solution 250 mg10ml 50 mg2ml

1

methotrexate sodium injection solution reconstituted

1

methotrexate sodium oral

1

MICRHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

mycophenolate mofetil hcl

1 SP

mycophenolate mofetil intravenous

1 SP

Drug Name Drug Tier Notes

mycophenolate mofetil oral

1 SP

mycophenolate sodium 1 SP

MYFORTIC 3 SP

NABI-HB E

NEORAL 3 SP

NULOJIX 3 SP

OCTAGAM 3 PA SP

OLUMIANT E SP

ORENCIA CLICKJECT 3 PA SP

ORENCIA INTRAVENOUS

3 PA SP

ORENCIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

3 PA SP

ORLADEYO 3 PA SP QL

OTEZLA ORAL TABLET

2 PA SP

OTEZLA ORAL TABLET THERAPY PACK

2 PA SP

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG04ML 15 MG04ML 20 MG04ML 25 MG04ML

3 PA QL

OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 125 MG04ML 175 MG04ML 225 MG04ML

E

PANZYGA E SP

PRIVIGEN 3 PA SP

PROGRAF 3 SP

PROVENGE 2 PA SP

RAPAMUNE 3 SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

107

Drug Name Drug Tier Notes

RASUVO SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG02ML 125 MG025ML 15 MG03ML 175 MG035ML 20 MG04ML 225 MG045ML 25 MG05ML 30 MG06ML 75 MG015ML

2 PA QL

REDITREX E

REMICADE E SP

RENFLEXIS E SP

RHOGAM ULTRA-FILTERED PLUS INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

2 SP

RHOPHYLAC INJECTION SOLUTION PREFILLED SYRINGE

E

RIDAURA 3 SP

RINVOQ 2 PA SP

RUCONEST 3 PA SP QL

SANDIMMUNE INTRAVENOUS

2 SP

SANDIMMUNE ORAL CAPSULE

3 SP

SANDIMMUNE ORAL SOLUTION

2 SP

SILIQ 3 PA SP

SIMPONI ARIA 2 PA SP

SIMPONI SUBCUTANEOUS SOLUTION AUTO-INJECTOR

2 PA SP

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP

Drug Name Drug Tier Notes

SIMULECT E

sirolimus oral 1 SP

SKYRIZI (150 MG DOSE)

2 PA SP QL

STELARA INTRAVENOUS

2 PA SP

STELARA SUBCUTANEOUS SOLUTION 45 MG05ML

2 PA SP QL

STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

SYNAGIS 2 PA SP

tacrolimus oral 1 SP

TAKHZYRO 3 PA SP

TALTZ 3 PA SP

temsirolimus 1 SP

THYMOGLOBULIN E

TICE BCG 2 SP

TORISEL 3 SP

TREMFYA 2 PA SP

TREXALL 3

UPLIZNA 3 PA SP

VARIZIG INTRAMUSCULAR SOLUTION

E

WINRHO SDF 2 SP

XATMEP 3

XELJANZ 2 PA SP

XELJANZ XR 2 PA SP

XEMBIFY 3 PA SP

ZINPLAVA E

ZORTRESS 3 SP

Immunological Agents - Drugs for Vaccination

ACTHIB $0

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

108

Drug Name Drug Tier Notes

ADACEL INTRAMUSCULAR SUSPENSION 5-2-155 LF-MCG05

$0

AFLURIA QUADRIVALENT

$0

ASTRAZENECA COVID-19 VACCINE

3

BCG VACCINE E

BEXSERO $0

BIOTHRAX E

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-25-185 LF-MCG05

$0

DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

$0

DIPHTHERIA-TETANUS TOXOIDS DT

$0

ENGERIX-B INJECTION SUSPENSION 10 MCG05ML 20 MCGML

$0

FLUAD $0

FLUAD QUADRIVALENT

$0

FLUARIX QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

FLUCELVAX QUADRIVALENT

$0

FLULAVAL QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

FLUMIST QUADRIVALENT

$0

Drug Name Drug Tier Notes

FLUZONE HIGH-DOSE QUADRIVALENT

$0

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION 05 ML

$0

FLUZONE QUADRIVALENT INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 05 ML

$0

GARDASIL 9 $0

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL UML 720 EL U05ML

$0

HEPLISAV-B INTRAMUSCULAR SOLUTION PREFILLED SYRINGE

$0

HIBERIX INJECTION $0

IMOVAX RABIES E

INFANRIX $0

IPOL INJECTION INJECTABLE

$0

IXIARO E

JANSSEN COVID-19 VACCINE

$0

MENACTRA $0

MENQUADFI $0

MENVEO $0

M-M-R II INJECTION $0

MODERNA COVID-19 VACCINE

$0

PEDVAX HIB INTRAMUSCULAR SUSPENSION

$0

PFIZER-BIONTECH COVID-19 VACC

$0

PNEUMOVAX 23 $0

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

109

Drug Name Drug Tier Notes

PREVNAR 13 $0

RABAVERT E

RECOMBIVAX HB INJECTION SUSPENSION 10 MCGML 40 MCGML 5 MCG05ML

$0

ROTARIX $0

ROTATEQ ORAL SOLUTION

$0

SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG05ML

$0

STAMARIL E

TDVAX $0

TENIVAC $0

TETANUS-DIPHTHERIA TOXOIDS TD

$0

TRUMENBA $0

TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

$0

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05ML

E

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT05ML 50 UNITML

$0

VARIVAX $0

VAXCHORA E

VIVOTIF E

YF-VAX E

Inflammatory Bowel Disease Agents

ana-lex E

Drug Name Drug Tier Notes

ANALPRAM HC EXTERNAL

E

ANALPRAM HC SINGLES EXTERNAL

E

ANALPRAM-HC EXTERNAL CREAM

3

ANALPRAM-HC EXTERNAL LOTION

E

anucort-hc E

ANUSOL-HC EXTERNAL

3

ANUSOL-HC RECTAL SUPPOSITORY

E

APRISO 2

ASACOL HD E

AZULFIDINE 3

AZULFIDINE EN-TABS 3

balsalazide disodium 1

budesonide er oral tablet extended release 24 hour

1

budesonide oral 1

CANASA E

COLAZAL 3

CORTENEMA 3

CORTIFOAM EXTERNAL

3

DELZICOL E

DIPENTUM E

ENTOCORT EC ORAL CAPSULE DELAYED RELEASE PARTICLES

3

HEMMOREX-HC RECTAL SUPPOSITORY 25 MG

E

hydrocortisone (perianal)

1

hydrocortisone ace-pramoxine external cream 1-1

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

110

Drug Name Drug Tier Notes

hydrocortisone acetate rectal

E

hydrocortisone rectal enema

1

hydrocort-pramoxine (perianal)

E

LIALDA E

lidocaine-hydrocort (perianal)

E

LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL

E

lidocaine-hydrocortisone ace rectal kit

E

LIDOCORT EXTERNAL

E

mesalamine er oral capsule 0375 gm

1

mesalamine oral 1

mesalamine rectal 1

mesalamine-cleanser 1

ORTIKOS E

PENTASA 3

PROCORT EXTERNAL E

PROCTOCORT EXTERNAL

3

PROCTOCORT RECTAL SUPPOSITORY

E

PROCTOFOAM HC EXTERNAL

2

procto-med hc external 1

procto-pak external 1

proctozone-hc external 1

ROWASA RECTAL 3

SFROWASA 2

sulfasalazine oral 1

UCERIS 3

Drug Name Drug Tier Notes

Metabolic Bone Disease Agents - Drugs for Osteoporosis

ACTONEL ORAL TABLET 150 MG 35 MG

3 QL

alendronate sodium oral solution

1

alendronate sodium oral tablet 10 mg 5 mg

1

alendronate sodium oral tablet 35 mg 70 mg

1 QL

ATELVIA 3 QL

BINOSTO 3 QL

BONIVA INTRAVENOUS

E

BONIVA ORAL TABLET 150 MG

3 QL

calcitonin (salmon) 1 QL

EVENITY 3 PA SP QL

FORTEO SUBCUTANEOUS SOLUTION PEN-INJECTOR 620 MCG248ML

E SP

FOSAMAX ORAL TABLET 70 MG

3 QL

FOSAMAX PLUS D E

ibandronate sodium intravenous solution 3 mg3ml

E

ibandronate sodium oral

1 QL

MIACALCIN INJECTION

3

pamidronate disodium 1 SP

PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

2 PA SP QL

RAYALDEE 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

111

Drug Name Drug Tier Notes

RECLAST 3 SP

risedronate sodium oral tablet 150 mg 35 mg

1 QL

risedronate sodium oral tablet 30 mg 5 mg

1

risedronate sodium oral tablet delayed release

1 QL

TERIPARATIDE (RECOMBINANT)

2 PA SP

TYMLOS 2 PA SP

XGEVA 2 PA SP

zoledronic acid intravenous concentrate

1 SP

zoledronic acid intravenous solution

1 SP

Metabolic Bone Disease Agents - Other

calcitriol intravenous solution 1 mcgml

E

calcitriol oral 1

cinacalcet hcl 1 PA

doxercalciferol oral 1

NATPARA 3 PA SP QL

paricalcitol intravenous E

paricalcitol oral 1

PARSABIV 3 SP

ROCALTROL 3

SENSIPAR 3 PA

ZEMPLAR INTRAVENOUS

E

ZEMPLAR ORAL CAPSULE 1 MCG 2 MCG

3

Miscellaneous Therapeutic Agents

3232a infant formula E

ACACIA SUBCUTANEOUS

E

Drug Name Drug Tier Notes

ACCU-CHEK TENDER 1 INFUSION

E

ACCU-CHEK ULTRAFLEX INF SET

E

ACREMONIUM E

ACST KIT E

ACTIFOAM COLLAGEN SPONGE

E

ACUNOL E

ADAKVEO 3 PA SP

ADULT AEROSOL MASK

E

AERIVA CONCENTRATOR NEBULIZER

E

ALCOHOL PREP PADS PAD

3

ALCOHOL PREP PADS PAD 70

3

ALCOHOL PREP PADS SHEET 70

3

ALDER E

ALTERNARIA E

AMERICAN BEECH E

AMERICAN COCKROACH

E

AMERICAN ELM E

AMINOPMRMS E

ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 200 MG

E

ANTIVENIN LATRODECTUS MACTANS

E

ANTIVENIN MICRURUS FULVIUS INTRAVENOUS

E

APP SLIM RMS E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

112

Drug Name Drug Tier Notes

ARIDOL INHALATION KIT 0 amp 5 amp 10 amp 20 amp 40 MG

E

ARIZONA CYPRESS E

ARTISS EXTERNAL SOLUTION

3

asilnasalrms E

ASPARTAME E

ASPARTAME (NUTRASWEET)

E

AUREOBASIDIUM E

AUSTRALIAN PINE E

AUTOSOFT 30 INFUSION SET

E

AUTOSOFT 90 INFUSION SET

E

AUTOSOFT XC INFUSION SET

E

AVAILNEX E

AVITENE E

AVITENE FLOUR E

AXONA E

AZALGIA E

BAHIA E

BALD CYPRESS E

BAYBERRY (WAX MYRTLE)

E

BERMUDA GRASS SUBCUTANEOUS

E

BHI URI-CONTROL E

BLACK WILLOW E

BOTOX 2PA Non-Cosmetic SP

BOTRYTIS SUBCUTANEOUS

E

BREATHE EASE HUMIDIFIER

E

BREATHE EASE NEB MASKCHILD

E

Drug Name Drug Tier Notes

BREATHE EASE NEB MASKINFANT

E

BRIDION INTRAVENOUS SOLUTION 500 MG5ML

E

BRIDION SOLUTION 200 MG2ML INTRAVENOUS

E

BROME E

CALIFORNIA PEPPER TREE

E

CAMINO PRO COMPLETEGLYTACTIN

E

CANDIDA ALBICANS EXTRACT SUBCUTANEOUS SOLUTION 10000 PNUML

E

CARDIOVID PLUS E

CARETOUCH 2 CPAP HOSE HANGER

E

CARETOUCH CPAP amp BIPAP HOSE

E

CARETOUCH CPAP MASK WIPES

E

CARETOUCH CPAP PRE-WASH SOLN

E

CARETOUCH CPAP TUBE BRUSH

E

CARETOUCH UNIVERSL CPAP FILTER

E

CARTICEL E

CAT HAIR EXTRACT SUBCUTANEOUS

E

CATTLE EPITHELIUM E

CAYA $0 QL

CEDAR ELM E

CLADOSPORIUM CLADOSPORIOIDES SUBCUTANEOUS

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

113

Drug Name Drug Tier Notes

CLADOSPORIUM SPHAEROSPERMUM

E

COCKLEBUR E

coenzyme q10 oral capsule 100 mg 50 mg

E

COLCIGEL E

COLD-EEZE NATURAL MULTI-SYMP MOUTHTHROAT

E

COLD-EEZE PLUS DEFENSE MOUTHTHROAT

E

COLD-EEZE SUGAR FREE MOUTHTHROAT LOZENGE

E

COMFORT TOUCH ALCOHOL PREP

3

COMPRESSOR NEBULIZER

E

CONDOMS E

CORN POLLEN E

CORTROSYN E

cosyntropin injection E

COVID-19 SPECIMEN COLLECTION

E

CROFAB E

CURVULARIA E

DANDELION E

deferoxamine mesylate E

DESFERAL INJECTION SOLUTION RECONSTITUTED 500 MG

E

desflurane 1

dexmedetomidine hcl in nacl intravenous solution 200-09 mcg50ml-

E

Drug Name Drug Tier Notes

dexmedetomidine hcl in nacl solution 200 mcg50ml intravenous

E

dexmedetomidine hcl in nacl solution 400 mcg100ml intravenous

E

dexmedetomidine hcl in nacl solution 80 mcg20ml intravenous

E

dexmedetomidine hcl intravenous solution 200 mcg2ml

E

DIGIFAB E

DOG EPITHELIUM E

DOG FENNEL E

DOJOLVI E

DRECHSLERA E

DUROLANE INTRA-ARTICULAR

2 PA SP

DUST MITE MIXED ALLERGEN EXT SUBCUTANEOUS

E

DYSPORT 3 PA SP

EASIVENT 2

EASTERN COTTONWOOD

E

EC-RX DHEA E

ECZEMOL E

ENDARI 3 PA

ENDO AVITENE E

ENFAGROW NEUROPRO TODDLER

E

ENFAMIL GENTLEASE ORAL POWDER

E

ENFAMIL INFANT ORAL POWDER

E

ENFAMIL NEUROPRO INFANT ORAL POWDER

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

114

Drug Name Drug Tier Notes

ENFAMIL NEUROPRO SENSITIVE

E

ENFAMIL NUTRAMIGEN LIPIL ORAL LIQUID

E

ENFAMIL NUTRAMIGEN LIPIL ORAL POWDER

E

ENFAMIL NUTRAMIGEN ORAL LIQUID

E

ENLYTE E

enovarx-amitriptyline E

ENTERAGAM E

enteric fish oil E

ENU PRO3 PLUS E

EPICOCCUM E

EPISIL E

EQUACARE JR E

ergoloid mesylates oral 1

ESSENTIAL CARE JR E

EUFLEXXA INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

2 PA SP

FIRDAPSE E SP

FIRE ANT E

FLEXICHAMBER ADULT MASKSMALL

2

FLEXICHAMBER CHILD MASKLARGE

2

FLEXICHAMBER CHILD MASKSMALL

2

FORANE 3

formaldehyde external solution 10

E

FORMALDEHYDE SOLUTION 37 EXTERNAL (RX)

3

Drug Name Drug Tier Notes

FORMALDEHYDE SOLUTION 37 EXTERNAL (RX)

E

FOSTEUM PLUS E

FUSARIUM E

GELCLAIR E

GELFILM EXTERNAL E

GEL-FLOW E

GEL-FLOW NT E

GELFOAM E

GELFOAM COMPRESSED SIZE 100

E

GELFOAM DENTAL PACK SIZE 4

E

GELFOAM SPONGE E

GELFOAM SPONGE SIZE 100

E

GELFOAM SPONGE SIZE 200

E

GELFOAM SPONGE SIZE 50

E

GELFOAM-JMI POWDER

E

GELFOAM-JMI SPONGE

E

GELSYN-3 2 PA SP

GELX E

GERMAN COCKROACH

E

GIVLAARI 3 PA SP

GLEOLAN E

GLUTARALDEHYDE EXTERNAL

3

GLYTACTIN BETTERMILK 15

E

GLYTACTIN BETTERMILK DE-LITE

E

GLYTACTIN BUILD 10PE

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

115

Drug Name Drug Tier Notes

GLYTACTIN BUILD 2020

E

GLYTACTIN BUILD 2020 PKU

E

GLYTACTIN BURST E

GLYTACTIN COMPLETE 10PE

E

GLYTACTIN RESTORE 10

E

GLYTACTIN RESTORE 5

E

GLYTACTIN RESTORE LITE 10

E

GLYTACTIN RESTORE LITE 10PE

E

GLYTACTIN RTD 10 LIQUID ORAL

E

GLYTACTIN RTD 15 E

GLYTACTIN RTD LITE 15 LIQUID ORAL

E

GLYTACTIN SWIRL 15PE

E

GOLDENROD E

GRASTEK 3 PA QL

HACKBERRY E

HCU EASY E

heparin lock flush intravenous solution 10 unitml

1

heparin sodium lock flush intravenous solution 100 unitml

1

HEPMED E

HIBICLENS E

HOMACTIN AA PLUS E

HOME PAP KIT E

HONEY BEE VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

Drug Name Drug Tier Notes

HORSE EPITHELIUM E

HUMATROPEN FOR 12MG

E

HUMATROPEN FOR 24MG

E

HUMATROPEN FOR 6MG

E

HYALGAN E SP

HYLAFEM E

HYMOVIS E SP

INSPIREASE RESERVOIR BAGS

2

INTERCEED E

IOSAT E

isoflurane 1

JOHNSON GRASS E

JUNE GRASS POLLEN STANDARDIZED

E

KAPOK E

KETAMINE HCL SUBLINGUAL

3

KETAMINE HCL-SODIUM CHLORIDE INTRAVENOUS SOLUTION PREFILLED SYRINGE 50-09 MG5ML-

E

KETOVIE LIQUID ORAL

E

KETOVIE PEPTIDE E

KOCHIA E

LENSCALE E

LIMBREL E

LIMBREL250 E

LIMBREL500 E

LORMATE E

MACRILEN E

MEADOW FESCUE GRASS POLLEN

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

116

Drug Name Drug Tier Notes

MELALEUCA E

MESQUITE E

METHACHOLINE CHLORIDE INHALATION

E

METHAVER E

methergine oral 1 QL

METHOHEXITAL SODIUM INTRAVENOUS SOLUTION PREFILLED SYRINGE 100 MG10ML

E

methylergonovine maleate oral

1 QL

METOPIRONE E

MINIMED PUMP RESERVOIR 3ML

E

MITE (D FARINAE) SUBCUTANEOUS

E

MITE (D PTERONYSSINUS) SUBCUTANEOUS

E

MIXED ASPERGILLUS E

MIXED FEATHERS E

MIXED RAGWEED E

MIXED VESPID VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100-1100-1100 MCG

E

MKO MELT DOSE PACK

E

mlk f1 E

mlk f2 E

mlk f3 E

mlk f4 E

MONOVISC E SP

MORCIN E

MOUNTAIN CEDAR E

Drug Name Drug Tier Notes

MOUSE EPITHELIUM E

MSUD EASY E

MUCOR SUBCUTANEOUS

E

MUCOTROL E

MUGARD E

MUGWORT E

MYOBLOC 3 PA SP

NEODOT THERMOMETER

E

NICAPRIN E

NICAZYME E

NORDIPEN 5 INJECTION DEVICE

E

ODACTRA 3 PA QL

odorless coated fish oil E

OLIVE TREE E

OMNIVEX E

ORALAIR 3 PA QL

ORALAIR ADULT STARTER PACK

3 PA QL

ORALAIR CHILDRENS STARTER PACK

3 PA QL

ORAMAGICRX E

ORCHARD GRASS POLLEN

E

ORTHOVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

OXBRYTA E SP

PALFORZIA E SP

PARI ALTERA NEBULIZER HANDSET

E

PARI TREK S COMBO PACK

E

PARI VORTEX ADULT MASK

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

117

Drug Name Drug Tier Notes

PEDIATRIC COMPRESSOR NEBULIZER

E

PENICILLIUM NOTATUM SUBCUTANEOUS

E

PH STRIPS E

PHEXXI E

PHOMA EXIGUA E

PHOTREXA-PHOTREXA VISCOUS KIT

3

PKU EASY E

PKU EASY MICROTABS

E

PKU GO E

PRAXBIND E

PRECEDEX INTRAVENOUS SOLUTION 1000 MCG250ML 200 MCG2ML 200 MCG50ML 400 MCG100ML 80 MCG20ML

E

PREMIUM CONDOMS LUBRICATED

E

PRID E

PRIVET E

PRO-CRITIC E

PROFESSIONAL DNA COLLECTION

E

PROLEVA E

PRONEB ULTRA FILTER SET

E

PSORIZIDE FORTE E

PSORIZIDE ULTRA E

PURAMINO DHAARA E

QUEEN PALM E

RABBIT EPITHELIUM E

RADIOGARDASE 3

Drug Name Drug Tier Notes

RAGWITEK 3 PA QL

RAPID GEL RX E

RED MAPLE E

RED MULBERRY E

RED TOP GRASS POLLEN

E

RESECTISOL E

RESOURCE THICKENUP JUICE

E

RHEUMATE E

RHIZOPUS E

RIBOZEL E

ROUGH MARSH ELDER

E

RUSSIAN THISTLE E

RUZURGI 3 PA SP

SACCHAROMYCES CEREVISIAE SUBCUTANEOUS

E

SALICEPT MOUTHTHROAT SUSPENSION RECONSTITUTED

E

sevoflurane 1

SHAGBARK HICKORY E

SHARPS CONTAINER E

SHEEP SORREL E

SHORT RAGWEED POLLEN EXT

E

SILTREX E

SORBITOL IRRIGATION

E

sorbitol-mannitol E

SORRELDOCK MIX E

SPEEDGEL RX E

SPINRAZA 3 PA SP

SPINY PIGWEED E

STEMPHYLIUM E

SUPARTZ FX E SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

118

Drug Name Drug Tier Notes

SUPRANE 3

SWEET GUM E

SWEET VERNAL GRASS POLLEN

E

SYNVISC INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

SYNVISC ONE INTRA-ARTICULAR SOLUTION PREFILLED SYRINGE

E SP

SYRINGE AVITENE E

TACHOSIL 3

TALL RAGWEED E

terrell 1

THROMBI-GEL 10 E

THROMBI-GEL 100 E

THROMBI-GEL 40 E

THROMBI-PAD E

THYROGEN 2 PA SP

TIMOTHY GRASS POLLEN ALLERGEN SUBCUTANEOUS

E

TISSEEL EXTERNAL KIT

3

TOBAKIENT E

TRANZGEL E

TRAUMEEL EXTERNAL OINTMENT

E

TRAUMEEL ORAL TABLET

E

TRICHOPHYTON MENTAGROPHYTES

E

TRICHOPHYTON SUBCUTANEOUS

E

TRILURON E SP

TRUSTEEL INFUSION SET

E

T-SUPPORT MAX E

Drug Name Drug Tier Notes

TYLACTIN BUILD 20PE TYR

E

TYLACTIN COMPLETE 15 PE

E

TYLACTIN RESTORE 10

E

TYLACTIN RESTORE 5PE

E

TYLACTIN RTD 15 E

TYR EASY E

TYROS 2 E

ULTANE 3

ULTRA HERS RX E

ULTRA HIS E

ULTRA PCOS E

ULTRAFOAM SPONGE 2X625X7CM

E

ULTRAFOAM SPONGE 8X125X1CM

E

ULTRAFOAM SPONGE 8X125X3CM

E

ULTRAFOAM SPONGE 8X25X1CM

E

ULTRAFOAM SPONGE 8X625X1CM

E

VARISOFT INFUSION SET

E

VASCULERA E

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

$0 QL

vcf vaginal contraceptive vaginal gel

$0 QL

VILACTIN AA PLUS E

VILTEPSO E SP

VISTOGARD 3

VITRASE INJECTION SOLUTION

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

119

Drug Name Drug Tier Notes

WASP VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

WELLMIND VERTIGO E

westab max E

WESTERN JUNIPER E

WHITE BIRCH E

WHITE FACED HORNET VENOM SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

WHITE MULBERRY E

WHITE OAK E

WHITE PINE E

WIDE-SEAL DIAPHRAGM 60

$0 QL

WIDE-SEAL DIAPHRAGM 65

$0 QL

WIDE-SEAL DIAPHRAGM 70

$0 QL

WIDE-SEAL DIAPHRAGM 75

$0 QL

WIDE-SEAL DIAPHRAGM 80

$0 QL

WIDE-SEAL DIAPHRAGM 85

$0 QL

WIDE-SEAL DIAPHRAGM 90

$0 QL

WIDE-SEAL DIAPHRAGM 95

$0 QL

XEOMIN 3 PA SP

XIAFLEX 2 PA SP

XYZBAC E

XYZMUNE E

YELLOW DOCK E

Drug Name Drug Tier Notes

YELLOW HORNET VENOM PROTEIN SUBCUTANEOUS SOLUTION RECONSTITUTED 1100 MCG

E

YELLOW JACKET VENOM PROTEIN SUBCUTANEOUS

E

ZOKINVY 3 PA SP QL

ZYVEXOL E

ZYVIT E

Ophthalmic Agents - Drugs for Eye Allergy Infection and Inflammation

ACULAR 3

ACULAR LS 3

ACUVAIL E

ALAWAY E

ALOCRIL E

ALOMIDE 3

ALREX E

AZASITE 3

azelastine hcl ophthalmic

1

bacitracin ophthalmic 1

BEPREVE E

BESIVANCE 3

BETADINE OPHTHALMIC PREP

3

BLEPH-10 3

bromfenac sodium (once-daily)

1 QL

BROMSITE E

CILOXAN 3

ciprofloxacin hcl ophthalmic

1

cromolyn sodium ophthalmic

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

120

Drug Name Drug Tier Notes

dexamethasone sodium phosphate ophthalmic

1

DEXTENZA E SP

DEXYCU E

diclofenac sodium ophthalmic

1

DUREZOL E

epinastine hcl 1

erythromycin ophthalmic

1

eye itch relief E

EYSUVIS 3 PA

FLAREX 3

fluorometholone ophthalmic

1

flurbiprofen sodium 1

FML 2

FML FORTE 3

FML LIQUIFILM 3

gatifloxacin ophthalmic 1

gentak ophthalmic ointment

1

gentamicin sulfate ophthalmic solution

1

ILEVRO E

ILUVIEN INTRAVITREAL

E SP

INVELTYS 3

ketorolac tromethamine ophthalmic

1

KLARITY-A E

KLARITY-L E

levofloxacin ophthalmic 1

LOTEMAX OPHTHALMIC GEL

E

LOTEMAX OPHTHALMIC OINTMENT

E

Drug Name Drug Tier Notes

LOTEMAX OPHTHALMIC SUSPENSION

3

LOTEMAX SM 3

loteprednol etabonate ophthalmic gel

1 QL

loteprednol etabonate ophthalmic suspension

1

MAXIDEX 3

MITOSOL 3

MOXEZA 2

moxifloxacin hcl (2x day)

1

moxifloxacin hcl ophthalmic solution

1

MOXIFLOXACIN HCL OPHTHALMIC SOLUTION PREFILLED SYRINGE

E

NATACYN 2

NEVANAC E

OCUFLOX 3

ofloxacin ophthalmic 1

olopatadine hcl solution 01 ophthalmic (otc)

E

olopatadine hcl solution 01 ophthalmic (rx)

1

olopatadine hcl solution 02 ophthalmic (otc)

E

olopatadine hcl solution 02 ophthalmic (rx)

1

OZURDEX INTRAVITREAL

E SP

PATADAY OPHTHALMIC SOLUTION 01 02

E

POVIDONE-IODINE OPHTHALMIC

3

PRED FORTE 3

PRED MILD 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

121

Drug Name Drug Tier Notes

PREDNISOL ACE-MOXIFLOX-BROMFEN

E

prednisolone acetate ophthalmic

1

prednisolone acetate p-f

E

prednisolone sodium phosphate ophthalmic

1

PREDNISOLON-MOXIFLOX-NEPAFENAC

E

PROLENSA 2 QL

RETISERT INTRAVITREAL

E SP

sulfacetamide sodium ophthalmic

1

tobramycin ophthalmic 1

TOBREX 3

trifluridine ophthalmic 1

TRIPLE PMB E

TRIPLE PMK E

UPNEEQ 3 PA

VANCOMYCIN HCL OPHTHALMIC

3

VIGAMOX 3

YUTIQ E SP

ZADITOR E

ZERVIATE E

ZIRGAN 3

ZYMAXID 3

Ophthalmic Agents - Drugs for Glaucoma

acetazolamide er 1

acetazolamide oral 1

ALPHAGAN P OPHTHALMIC SOLUTION 01

2

ALPHAGAN P OPHTHALMIC SOLUTION 015

E

Drug Name Drug Tier Notes

apraclonidine hcl 1

AZOPT 3

betaxolol hcl ophthalmic

1

BETIMOL 3

BETOPTIC-S 3

bimatoprost ophthalmic 1 QL

brimonidine tartrate ophthalmic

1

BRIMONIDINE-DORZOLAMIDE

E

brinzolamide 1

carteolol hcl 1

COMBIGAN 2

COSOPT 3

COSOPT PF OPHTHALMIC SOLUTION 2-05

3

DORZOLAMIDE HCL SOLUTION 2 OPHTHALMIC

3

dorzolamide hcl solution 2 ophthalmic

1

dorzolamide hcl-timolol mal

1

dorzolamide hcl-timolol mal pf

1

DURYSTA E

IOPIDINE OPHTHALMIC SOLUTION 1

3

ISOPTO CARPINE 3

ISTALOL 3

KEVEYIS 3 PA SP QL

latanoprost ophthalmic 1

LATANOPROST-TIMOLOL MALEATE

E

levobunolol hcl ophthalmic solution 05

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

122

Drug Name Drug Tier Notes

LUMIGAN OPHTHALMIC SOLUTION 001

2 QL

methazolamide oral 1

PHOSPHOLINE IODIDE

2

pilocarpine hcl ophthalmic solution 1 2 4

1

RHOPRESSA 3 QL

ROCKLATAN 3 QL

SIMBRINZA 2

timolol maleate ophthalmic

1

timolol maleate pf 1

TIMOLOL-BRIMON-DORZOL-LATANOPR

E

TIMOLOL-BRIMONIDINE-DORZOLAMID

E

TIMOLOL-DORZOLAMID-LATANOPROST

E

TIMOPTIC E

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 025

3

TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 05

E

TIMOPTIC-XE E

TRAVATAN Z 3 QL

travoprost (bak free) 1 QL

TRUSOPT 3

VYZULTA E

XALATAN 3

XELPROS 3 ST QL

ZIOPTAN E

Drug Name Drug Tier Notes

Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions

ak-poly-bac 1

AKTEN 3

ALCAINE 3

ALTACAINE 3

altachlore E

ALTAFLUOR BENOX E

altafrin ophthalmic solution 10 25

1

artificial eye E

artificial tears ophthalmic solution 05-06 14

E

atropine sulfate ophthalmic ointment

1

ATROPINE SULFATE OPHTHALMIC SOLUTION 001

E

atropine sulfate ophthalmic solution 1

1

bacitracin-polymyxin b ophthalmic ointment 500-10000 unitgm

1

bacitra-neomycin-polymyxin-hc

1

BEOVU E SP

BEVACIZUMAB 3 SP

bimatoprost external E

BIO GLO E

BLEPHAMIDE 3

BLEPHAMIDE SOP 3

carboxymethylcellulose sodium ophthalmic solution 05

E

CEQUA E

CHONDROITIN SULFATE OPHTHALMIC

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

123

Drug Name Drug Tier Notes

cvs lubricant eye drops ophthalmic solution 04-03

E

CYCLOGYL 3

CYCLOMYDRIL 3

cyclopentolate hcl ophthalmic

1

CYCLOSPORINE IN KLARITY

E

CYSTADROPS 3 PA SP QL

CYSTARAN 3 PA SP QL

DOUBLE PM E

EYLEA INTRAVITREAL

3 PA SP

FLUCAINE E

FLUORESCEIN SODIUMBENOXINATE

E

fluorescein-benoxinate E

fluor-i-strips at E

FLURA-SAFE E

FUL-GLO E

GELFILM OPHTHALMIC

E

GENTEAL TEARS NIGHT-TIME

E

GENTEAL TEARS OPHTHALMIC SOLUTION 01-03

E

GENTEAL TEARS SEVERE DAYNIGHT

E

GLOSTRIPS OPHTHALMIC STRIP 1 MG

E

GREEN GLO LISSAMINE GREEN

E

homatropaire 1

HYPOCYN EXTERNAL SOLUTION

E

ISOPTO ATROPINE 3

LACRISERT 3

Drug Name Drug Tier Notes

LASTACAFT E

LATISSE E

lubricant eye drops ophthalmic solution 04-03

E

lubricant eye drops pf E

lubricant eye pm E

lubricant pm E

lubricating eye drops E

lubricating plus eye drops

E

LUCENTIS INTRAVITREAL

2 PA SP

LUXTURNA INTRAOCULAR SUSPENSION 5000000000000 VGML

3 PA SP

MAXITROL 3

MURO 128 OPHTHALMIC OINTMENT

E

MURO 128 OPHTHALMIC SOLUTION 5

E

MYDRIACYL E

neomycin-bacitracin zn-polymyx

1

neomycin-polymyxin-dexameth ophthalmic ointment

1

neomycin-polymyxin-dexameth ophthalmic suspension 35-10000-01

1

neomycin-polymyxin-gramicidin ophthalmic solution 175-10000-025

1

neomycin-polymyxin-hc ophthalmic suspension 35-10000-1

1

neo-polycin 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

124

Drug Name Drug Tier Notes

neo-polycin hc 1

OXERVATE 3 PA SP QL

PAREMYD E

phenylephrine hcl ophthalmic solution 10 25

1

polycin 1

polymyxin b-trimethoprim

1

POLYTRIM 3

PRED-G 3

PRED-G SOP 3

PREDNISOLONE ACETATE-NEPAFENAC

E

PREDNISOLONE ACET-MOXIFLOXACIN

E

PREDNISOLONE-BROMFENAC

E

PREDNISOLONE-GATIFLOXACIN OPHTHALMIC SUSPENSION

E

PREDNISOLONE-MOXIFLOXACIN

E

PREDNISOLON-GATIFLOX-BROMFENAC

E

PREDNISOLON-MOXIFLOX-BROMFENAC OPHTHALMIC SOLUTION 1-05-0075

E

proparacaine hcl ophthalmic

1

proparacaine-fluorescein

E

REFRESH RELIEVA E

REFRESH RELIEVA PF OPHTHALMIC SOLUTION 05-09

E

Drug Name Drug Tier Notes

RESTASIS 2 PA

RESTASIS MULTIDOSE OPHTHALMIC EMULSION 005

2 PA

sodium chloride (hypertonic)

E

sulfacetamide-prednisolone ophthalmic solution

1

SYSTANE COMPLETE E

SYSTANE HYDRATION PF

E

SYSTANE ULTRA PF E

tetracaine hcl ophthalmic

1

TOBRADEX OPHTHALMIC OINTMENT

3

TOBRADEX OPHTHALMIC SUSPENSION

E

TOBRADEX ST 3

tobramycin-dexamethasone

1

tropicamide ophthalmic E

TROPICAMIDE-CYCLOPENTOLATE-PE

E

TROPICAMIDE-PHENYLEPHRINE

E

TROPIC-CYCLOPENT-PE-KETOROLAC

E

TROPIC-CYCLOP-PE-KETO-PROPAR

E

TROPIC-PROPARACA-PE-KETOROLAC

E

ultra fresh pm E

ultra lubricating eye drops

E

VISIONBLUE 3

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

125

Drug Name Drug Tier Notes

VISTA GEL DRY EYE RELIEF

E

VISTA MEIBO TEARS E

VISTA TEARS E

VISUDYNE 3 SP

XIIDRA 2 PA

ZYLET 3

Otic Agents - Drugs for Ear Conditions

acetic acid otic 1

CETRAXAL 3 ST

CIPRO HC 3

CIPRODEX E

ciprofloxacin hcl otic 1 ST

ciprofloxacin-dexamethasone

1

CIPROFLOXACIN-FLUOCINOLONE PF

E

cortic-nd 1

CORTISPORIN-TC 3

DERMOTIC 3

exotic-hc 1

flac 1

fluocinolone acetonide otic

1

hydrocortisone-acetic acid

1

neomycin-polymyxin-hc otic

1

ofloxacin otic 1

OTIPRIO E

OTOVEL E

PRAMOTIC 3

Respiratory Tract Pulmonary Agents - Drugs for Allergies Cough Cold

12 hour allergy-d E

12 hour nasal decongestant nasal

E

Drug Name Drug Tier Notes

12hr allergy amp congestion

E

24hr allergy relief E

ADRENALIN NASAL E

all day allergy d E

all day allergy d-12 E

allergy 24hour indooroutdoor

E

allergy 24-hr E

allergy childrens E

allergy rel child (loratadine)

E

allergy relief cetirizine E

allergy relief d-12 E

allergy relief oral capsule 10 mg

E

allergy relief oral tablet 10 mg 180 mg 25 mg 4 mg

E

allergy relief oral tablet dispersible

E

allergy reliefindooroutdoor

E

allergy reliefnasal decongest oral tablet extended release 12 hour

E

allergy relief-d oral tablet extended release 12 hour

E

antihistamine amp nasal deconges

E

aurodryl allergy childrens

E

azelastine hcl nasal 1 QL

azelastine-fluticasone 1 QL

banophen oral capsule 25 mg

E

banophen oral tablet E

BECONASE AQ 3 QL

benzonatate 1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

126

Drug Name Drug Tier Notes

carbinoxamine maleate oral solution

1

carbinoxamine maleate oral tablet 4 mg

1

carbinoxamine maleate oral tablet 6 mg

E

cetirizine hcl childrens oral tablet chewable 5 mg

E

cetirizine hcl oral solution

1

cetirizine hcl oral tablet E

cetirizine hcl oral tablet chewable 10 mg

E

cetirizine-pseudoephedrine er

E

chest congestion relief dm oral syrup

E

chest congestion relief oral syrup

E

chlorpheniramine maleate er

E

CHLOR-TRIMETON ORAL TABLET

E

CINQAIR 3 PA SP

CLARINEX ORAL TABLET

E

CLARINEX-D 12 HOUR

E

CLARITIN CHILDRENS TABLET CHEWABLE 5 MG ORAL

E

CLARITIN ORAL TABLET

E

CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG

E

CLARITIN-D 12 HOUR E

clemastine fumarate oral tablet 268 mg

1

cold amp flu relief daytime E

Drug Name Drug Tier Notes

coldflu daytime relief E

cough dm oral suspension extended release

E

coughchest congestion dm

E

CUROSURF INTRATRACHEAL SUSPENSION 120 MG15ML

3

cyproheptadine hcl oral 1

DAYHIST ALLERGY 12 HOUR RELIEF

E

daytime cold amp flu relief oral capsule

E

daytime coldflu relief oral capsule

E

DERMACINRX AZENASE PAK

E

desloratadine oral tablet

1

desloratadine oral tablet dispersible 5 mg

1

dexchlorpheniramine maleate oral solution

E

DICOPANOL FUSEPAQ

E

DICOPANOL RAPIDPAQ

E

dimaphen dm coldcough oral liquid

E

DI-PHEN E

diphen oral elixir 1

diphenhydramine hcl injection

E

diphenhydramine hcl oral capsule

E

diphenhydramine hcl oral elixir

1

diphenhydramine hcl oral liquid 125 mg5ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

127

Drug Name Drug Tier Notes

diphenhydramine hcl oral tablet 25 mg

E

DYMISTA 2 QL

FASENRA 2 PA SP

FASENRA PEN 2 PA SP

fexofenadine hcl oral tablet 180 mg 60 mg

E

fexofenadine-pseudoephed er oral tablet extended release 12 hour

E

flunisolide nasal solution 25 mcgact (0025)

1 QL

fluticasone propionate nasal

1

geri-dryl oral liquid E

geri-dryl oral tablet E

GILPHEX TR E

giltuss severe sinus E

goodsense tussin dm max

E

guaiatussin ac 1 PA QL

guaifenesin ac 1 PA QL

guaifenesin oral tablet 400 mg

E

guaifenesin-dm oral syrup

E

hm adult tussin cough amp chest

E

HYCODAN 3 PA QL

hydrocodone polst-chlorphen polst er susp oral suspension extended release

1 PA QL

hydrocodone-homatropine

1 PA QL

hydromet 1 PA QL

HYPERSAL 3

INFASURF INTRATRACHEAL

3

Drug Name Drug Tier Notes

ipratropium bromide nasal

1

KARBINAL ER ORAL SUSPENSION EXTENDED RELEASE

E

levocetirizine dihydrochloride oral

1

liquid allergy relief E

loratadine childrens oral tablet chewable

E

loratadine oral syrup E

loratadine oral tablet E

loratadine-d 12hr E

loratadine-d 24hr E

maxi-tuss ac 1 PA QL

maxi-tuss gmx E

maxi-tuss pe max E

m-dryl E

MICLARA LQ E

mometasone furoate nasal

1 QL

MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG5ML

E

MUCINEX CHILDRENS STUFFY NOSE

E

MUCINEX DM E

MUCINEX FAST-MAX DM MAX

E

mucus dm E

mucus relief d oral tablet extended release 12 hour 60-600 mg

E

mucus relief dm oral liquid

E

mucus relief max st E

mucus-d E

NASACORT ALLERGY 24HR

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

128

Drug Name Drug Tier Notes

nasal decongestant oral tablet 30 mg

E

nasal decongestant pe E

nasal moisturizing spray

E

nasal spray 12 hour E

nasal spray no drip E

NASONEX E

NEO-SYNEPHRINE COLDALLRG MILD

E

NEO-SYNEPHRINE COLDALLRGY EXT

E

NEO-SYNEPHRINE COLDALLRGY REG

E

NEOTUSS PLUS E

NUCALA 2 PA SP QL

olopatadine hcl nasal 1 QL

OMNARIS 3 QL

PATANASE 3 QL

pediaclear pd childrens E

PHENERGAN INJECTION

E

promethazine hcl injection

E

promethazine hcl oral 1

promethazine hcl rectal suppository 125 mg 25 mg

1

promethazine vc 1

promethazine vccodeine

1 PA QL

promethazine-codeine 1 PA QL

promethazine-dm oral syrup

1

promethazine-phenyleph-codeine

1 PA QL

promethazine-phenylephrine

1

promethegan 1

PROPEL E

Drug Name Drug Tier Notes

PROPEL MINI E

pseudoephedrine hcl er E

pseudoephedrine-bromphen-dm oral syrup 30-2-10 mg5ml

1

pseudoephedrine-guaifenesin er

E

QNASL 3 QL

QNASL CHILDRENS 3 QL

ROBITUSSIN 12 HOUR COUGH CHILD

E

ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400 MG20ML

E

RYCLORA ORAL SOLUTION

3

ryvent E

sinus 12 hour E

SINUVA E

sodium chloride inhalation nebulization solution 09 10 3 7

1

SSKI E

SUDAFED CONGESTION

E

sudogest 12 hour E

sudogest maximum strength

E

sudogest oral tablet 30 mg

E

SURVANTA INTRATRACHEAL

3

TESSALON PERLES 3

triprolidine hcl oral liquid 0313 mgml 0625 mgml 0938 mgml 25 mg5ml

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

129

Drug Name Drug Tier Notes

TUSSICAPS ORAL CAPSULE EXTENDED RELEASE 12 HOUR 10-8 MG

E

tussin cf multi-symptom cold

E

tussin dm max adult oral liquid 5-100 mg5ml

E

tussin dm max oral liquid 20-400 mg20ml

E

tussin dm oral syrup 100-10 mg5ml

E

TUXARIN ER E

TUZISTRA XR ORAL SUSPENSION EXTENDED RELEASE

E

virtussin ac walc 1 PA QL

wal-tap coldallergy oral elixir

E

XHANCE E

XOLAIR 2 PA SP

ZETONNA 3 QL

ZYRTEC ALLERGY ORAL TABLET

E

Respiratory Tract Pulmonary Agents - Drugs for Asthma and Other Lung Conditions

ACCOLATE 3

acetylcysteine inhalation

1

ADRENALIN INJECTION SOLUTION 1 MGML

3

ADVAIR DISKUS 1 QL

ADVAIR HFA 2 QL

ADYPHREN E

ADYPHREN AMP E

ADYPHREN AMP II E

ADYPHREN II E

Drug Name Drug Tier Notes

AIRDUO DIGIHALER E

AIRDUO RESPICLICK 11314

E

AIRDUO RESPICLICK 23214

E

AIRDUO RESPICLICK 5514

E

albuterol sulfate er 1

albuterol sulfate hfa aerosol solution 108 (90 base) mcgact inhalation

1 QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE) MCGACT INHALATION

E

albuterol sulfate inhalation nebulization solution (25 mg3ml) 0083 063 mg3ml 125 mg3ml 25 mg05ml

1 QL

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MGML) 05 INHALATION

E

albuterol sulfate nebulization solution (5 mgml) 05 inhalation

1 QL

albuterol sulfate oral 1

ALVESCO E

ANORO ELLIPTA 2 QL

ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG 500 MG

3 PA SP

ARMONAIR DIGIHALER

E

ARNUITY ELLIPTA 2 QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

130

Drug Name Drug Tier Notes

ASMANEX (120 METERED DOSES)

E

ASMANEX (14 METERED DOSES)

E

ASMANEX (30 METERED DOSES)

E

ASMANEX (60 METERED DOSES)

E

ASMANEX (7 METERED DOSES)

E

ASMANEX HFA E

ATROVENT HFA 3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 01 MG01ML

3 QL

AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 015 MG015ML 03 MG03ML

E

BEVESPI AEROSPHERE

E

BREO ELLIPTA 2 QL

BREZTRI AEROSPHERE

2 QL

BROVANA 3 QL

budesonide inhalation 1 QL

BUDESONIDE-FORMOTEROL FUMARATE

E

COMBIVENT RESPIMAT

2 QL

cromolyn sodium inhalation

1

DALIRESP 3 PA

DUAKLIR PRESSAIR E

DULERA E

ELIXOPHYLLIN 2

epinephrine injection solution auto-injector 015 mg015ml

1 ST

Drug Name Drug Tier Notes

epinephrine injection solution auto-injector 015 mg03ml

1

EPINEPHRINE PROFESSIONAL

E

epinephrine solution auto-injector 03 mg03ml injection

1 ST

epinephrine solution auto-injector 03 mg03ml injection

1

EPINEPHRINESNAP-EMS

E

EPINEPHRINESNAP-V E

EPIPEN 2-PAK INJECTION SOLUTION AUTO-INJECTOR

3 ST

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-INJECTOR

E

EPISNAP E

ESBRIET 3 PA SP

FLOVENT DISKUS 2 QL

FLOVENT HFA 2 QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcgdose inhalation

1 QL

fluticasone-salmeterol aerosol powder breath activated 100-50 mcgdose inhalation

E

fluticasone-salmeterol aerosol powder breath activated 250-50 mcgdose inhalation

1 QL

fluticasone-salmeterol aerosol powder breath activated 250-50 mcgdose inhalation

E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

131

Drug Name Drug Tier Notes

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCGACT 232-14 MCGACT 55-14 MCGACT

1 ST QL

fluticasone-salmeterol inhalation aerosol powder breath activated 500-50 mcgdose

E

GLASSIA 3 PA SP

INCRUSE ELLIPTA E

ipratropium bromide inhalation

1 QL

ipratropium-albuterol 1 QL

levalbuterol hcl inhalation nebulization solution 031 mg3ml 063 mg3ml 125 mg05ml 125 mg3ml

1 QL

LEVALBUTEROL HFA INHALATION AEROSOL 45 MCGACT

E

LONHALA MAGNAIR REFILL KIT

3 QL

LONHALA MAGNAIR STARTER KIT

3 QL

montelukast sodium oral

1

OFEV 3 PA SP

PERFOROMIST 3 QL

PROAIR DIGIHALER E

PROAIR HFA 2 QL

PROAIR RESPICLICK 2 QL

PROLASTIN-C INTRAVENOUS SOLUTION

3 PA SP

Drug Name Drug Tier Notes

PROLASTIN-C INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG

3 PA SP

PROVENTIL HFA E

PULMICORT FLEXHALER

2 QL

PULMICORT SUSPENSION

E

QVAR REDIHALER E

SEEBRI NEOHALER E

SEREVENT DISKUS 2 QL

SINGULAIR E

SPIRIVA HANDIHALER

2 QL

SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 125 MCGACT 25 MCGACT

2 QL

STERITALC 3

STIOLTO RESPIMAT INHALATION AEROSOL SOLUTION 25-25 MCGACT

2 QL

STRIVERDI RESPIMAT

2 ST QL

SYMBICORT 2 QL

SYMJEPI 3

terbutaline sulfate injection

E

terbutaline sulfate oral 1

THEO-24 3

theophylline 1

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

1

theophylline er oral tablet extended release 24 hour

1

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

132

INHALATION AEROSOL POWDER BREATH ACTIVATED 400 MCGACT

E

UTIBRON NEOHALER E

VENTOLIN HFA 2 QL

wixela inhub E

XOPENEX NEB 3 QL

XOPENEX CONCENTRATE

3 QL

XOPENEX HFA E

YUPELRI 3 QL

zafirlukast 1

ZEMAIRA 3 PA SP

zileuton er 1 ST

ZYFLO E

Respiratory Tract Pulmonary Agents - Drugs for Cystic Fibrosis

BETHKIS E SP

BRONCHITOL E

BRONCHITOL TOLERANCE TEST

E

CAYSTON E SP

KALYDECO 3 PA SP

KITABIS PAK E SP

ORKAMBI 3 PA SP QL

PULMOZYME 2 PA SP

SYMDEKO 3 PA SP QL

TOBI NEBULIZER E SP

TOBI PODHALER 3 ST SP QL

tobramycin inhalation nebulization solution 300 mg4ml

1 SP

tobramycin nebulization solution 300 mg5ml inhalation

E SP

Drug Name Drug Tier Notes

TOBRAMYCIN NEBULIZATION SOLUTION 300 MG5ML INHALATION

E SP

TRIKAFTA 3 PA SP QL

Respiratory Tract Pulmonary Agents - Drugs for Pulmonary Hypertension

ADCIRCA 3 PA SP QL

ADEMPAS 2 PA SP QL

alyq 1 PA SP QL

ambrisentan 1 PA SP QL

bosentan 1 PA SP QL

epoprostenol sodium 1 PA SP

FLOLAN 3 PA SP

LETAIRIS 3 PA SP QL

OPSUMIT 2 PA SP QL

ORENITRAM 3 PA SP

REMODULIN INJECTION SOLUTION 100 MG20ML 20 MG20ML 200 MG20ML 50 MG20ML

E SP

REVATIO INTRAVENOUS

3 PA SP

REVATIO ORAL 3 PA SP QL

sildenafil citrate intravenous

1 PA SP

sildenafil citrate oral suspension reconstituted

1 PA SP QL

sildenafil citrate oral tablet 20 mg

1 PA SP QL

tadalafil (pah) 1 PA SP QL

TRACLEER 625 MG 125 MG

E SP

TRACLEER 32 MG 3 PA SP QL

treprostinil 1 PA SP

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

133

Drug Name Drug Tier Notes

TRELEGY ELLIPTA 2 QL

TUDORZA PRESSAIR

Drug Name Drug Tier Notes

TYVASO 3 PA SP QL

TYVASO REFILL 3 PA SP QL

TYVASO STARTER 3 PA SP QL

UPTRAVI 3 PA SP QL

VELETRI 3 PA SP

VENTAVIS 3 PA SP QL

Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm

AMRIX E

BACLOFEN EXTERNAL

E

baclofen intrathecal E

baclofen oral 1

carisoprodol oral 1

chlorzoxazone oral tablet 250 mg

1 QL

chlorzoxazone oral tablet 375 mg 500 mg 750 mg

1

CYCLOGABA 10300 E

cyclobenzaprine hcl er 1

cyclobenzaprine hcl oral tablet 5 mg 75 mg

1

cyclobenzaprine hcl tablet 10 mg oral

1

cyclobenzaprine hcl tablet 10 mg oral

E

CYCLOPAK E

CYCLOPHENE RAPIDPAQ

E

DANTRIUM ORAL CAPSULE 25 MG 50 MG

3

dantrolene sodium oral 1

enovarx-baclofen E

enovarx-cyclobenzaprine hcl

E

FEXMID 3

Drug Name Drug Tier Notes

FIRST-BACLOFEN E

GABLOFEN INTRATHECAL SOLUTION 10000 MCG20ML 20000 MCG20ML 40000 MCG20ML

E

GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 10000 MCG20ML 20000 MCG20ML 40000 MCG20ML 50 MCGML

E

LIORESAL E

LORZONE 3

METAXALL CP E

metaxalone 1

methocarbamol oral 1

NOPIOID-LMC KIT E

NORGESIC FORTE E

orphenadrine citrate er 1

orphenadrine-asa-caffeine

1

ORPHENGESIC FORTE ORAL TABLET 50-770-60 MG

E

OZOBAX E

SKELAXIN E

SOMA 3

TABRADOL FUSEPAQ E

TABRADOL RAPIDPAQ

E

tizanidine hcl oral 1

VANADOM 3

ZANAFLEX E

Sleep Disorder Agents

AMBIEN E

AMBIEN CR E

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

134

Drug Name Drug Tier Notes

armodafinil 1 PA QL

BELSOMRA 3 ST QL

DAYVIGO 3 ST QL

doxepin hcl oral tablet 1 QL

EDLUAR E

eszopiclone 1 QL

flurazepam hcl 1 PA QL

HETLIOZ 3 PA SP QL

HETLIOZ LQ E SP

LUNESTA E

modafinil 1 PA QL

NUVIGIL E

PROVIGIL E

ramelteon 1 QL

RESTORIL E

ROZEREM 3 QL

SILENOR 3 QL

sleep aid (diphenhydramine)

E

sleep-aid oral capsule E

SUNOSI 2 PA QL

temazepam 1 QL

WAKIX 3 PA SP QL

XYREM 3 PA SP QL

XYWAV 3 PA SP QL

zaleplon 1 QL

zolpidem tartrate 1 QL

zolpidem tartrate er 1 QL

ZOLPIMIST 3 ST QL

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

135

For more information regarding the tiers and designations in this drug list please see the Reading your formulary section on page 6 of this booklet

136

Index of Drugs

12 hour allergy-d 12612 hour nasal decongestant12612hr allergy amp congestion 1261ST MEDX-PATCH LIDOCAINE1724hr allergy relief 1263232a infant formula 1127T LIDO 178 hour pain reliever 98 hr arthritis pain relief 9AAGC KIT IN TERODERM 60abacavir sulfate44abacavir sulfate-lamivudine 44abacavir-lamivudine-zidovudine44ABANEU-SL77ABILIFY43ABILIFY MAINTENA 43ABILIFY MYCITE 43ABILIFY MYCITE MAINTENANCE KIT 43ABILIFY MYCITE STARTER KIT 43abiraterone acetate 35ABRAXANE 35ABREVA 60ABSORICA 60ABSORICA LD60ACACIA112acamprosate calcium 20ACANYA 60acarbose 72ACCOLATE130ACCUCAINE17ACCU-CHEK AVIVA DEVICE73ACCU-CHEK AVIVA PLUS KIT WDEVICE73ACCU-CHEK COMPACT PLUS CONTROL 73ACCU-CHEK COMPACT PLUS TEST STRIPS 73ACCU-CHEK FASTCLIX LANCET KIT 73ACCU-CHEK GUIDE CONTROL 73ACCU-CHEK GUIDE TEST STRIPS 73ACCU-CHEK SMARTVIEW CONTROL 73ACCU-CHEK SMARTVIEW TEST STRIPS73ACCU-CHEK SOFTCLIX LANCET DEVICE KIT73

ACCU-CHEK TENDER 1 INFUSION112ACCU-CHEK ULTRAFLEX INF SET 112ACCUPRIL50ACCURETIC 50accutane 60ACD-A NOCLOT-5026acebutolol hcl 50ACESO AG 60acetaminophen 9acetaminophen 8 hour 9acetaminophen childrens 9acetaminophen er 9acetaminophen extra strength 9acetaminophen-codeine9acetaminophen-codeine 29acetaminophen-codeine 39acetaminophen-codeine 49acetazolamide122acetazolamide er122acetic acid 126acetylcysteine 130acid reducer 85ACIOXIAY 60ACIPHEX 85ACIPHEX SPRINKLE 85acitretin 60ACREMONIUM 112ACST KIT112ACTEMRA 105ACTEMRA ACTPEN105ACTHAR 97ACTHIB108ACTICLATE 21ACTIFOAM COLLAGEN SPONGE112ACTIMMUNE 105ACTIPHLORA 86ACTIQ 9ACTITROM-D 77ACTIVASE 26ACTIVE FE 77ACTIVE INJECTION D 94ACTIVE INJECTION KIT L 94ACTIVE INJECTION KL-3 94ACTIVE INJECTION LM-217ACTIVE INJECTION LM-DEP-2 94ACTIVELLA99ACTIVITE77ACTONEL 111ACTOPLUS MET 72

ACTOS72ACULAR 120ACULAR LS 120ACUNOL 112ACUVAIL120acyclovir 44ACYCLOVIX 44ACZONE 60ADACEL109ADAINZDE60ADAINZOXIA 60ADAKVEO112adapalene 60ADAPALENE 60ADAPALENE-BENZOYL PER-CLINDAMY 60ADAPALENE-BENZOYL PER-NIACINAM 60adapalene-benzoyl peroxide60ADAPALENE-BENZOYL PEROXIDE 60ADASUVE43adcf (05mgml) 77ADCETRIS35ADCIRCA133ADDERALL 56ADDERALL XR 56ADDYI 58adefovir dipivoxil 44ADEMPAS 133ADHANSIA XR56ADIPEX-P 58ADLYXIN72ADLYXIN STARTER PACK 72ADMELOG 75ADMELOG SOLOSTAR 75ADRENAL C FORMULA77ADRENALIN 126 130adriamycin35ADULT AEROSOL MASK112adult aspirin regimen14ADVAIR DISKUS 130ADVAIR HFA 130ADVANCED ALLERGY COLLECTION 60ADVATE48ADVIL14ADVIL JUNIOR STRENGTH 14ADVIL LIQUI-GELS MINIS 14ADVIL MIGRAINE14ADYNOVATE48ADYPHREN 130ADYPHREN AMP 130

137

ADYPHREN AMP II 130ADYPHREN II 130ADZENYS ER 56ADZENYS XR-ODT 56AEMCOLO 21AERIVA CONCENTRATOR NEBULIZER112AFINITOR 35AFINITOR DISPERZ35afirmelle 99AFLURIA QUADRIVALENT109AFREZZA75AFSTYLA 48AGONEAZE 17AGRYLIN 48aif 2 drug preparation kit 14AIF 3 DRUG PREPARATION KIT 14AIMOVIG34airavite 77AIRDUO DIGIHALER130AIRDUO RESPICLICK 11314130AIRDUO RESPICLICK 23214130AIRDUO RESPICLICK 5514130AJOVY 34AKLIEF60AKOVAZ 50ak-poly-bac 123AKTEN 123AKYNZEO30ALA SCALP 60ala-cort 60ALA-QUIN 31ALAWAY 120albendazole41ALBENZA41albuterol sulfate130ALBUTEROL SULFATE 130albuterol sulfate er 130albuterol sulfate hfa130ALBUTEROL SULFATE HFA 130ALCAINE123alclometasone dipropionate 60ALCOHOL PREP PADS 112ALCORTIN A 31ALDACTAZIDE 50ALDACTONE 50ALDARA60ALDER 112ALDURAZYME 91ALECENSA35alendronate sodium 111ALEVAMAX60

ALEVE 14ALFERON N 105alfuzosin hcl er 94ALIMTA 35ALINIA41ALIQOPA 35aliskiren fumarate50ALKERAN 35ALKINDI SPRINKLE 94all day allergy d 126all day allergy d-12126allergy 24hour indooroutdoor 126allergy 24-hr 126allergy childrens 126allergy rel child (loratadine)126allergy relief126allergy relief cetirizine 126allergy relief d-12 126allergy reliefindooroutdoor 126allergy reliefnasal decongest 126allergy relief-d 126allopurinol34ALLZITAL9almotriptan malate 34ALOCRIL120ALOE VESTA CLEAR ANTIFUNGAL 31ALOGLIPTIN BENZOATE 72ALOGLIPTIN-METFORMIN HCL72ALOGLIPTIN-PIOGLITAZONE 72ALOMIDE120ALORA99alosetron hcl86ALOXI 30ALPHAGAN P 122ALPHANATE48ALPHANINE SD48alprazolam 47alprazolam er 47alprazolam intensol 47alprazolam xr 47ALPROLIX 48ALREX 120ALTABAX21ALTACAINE 123ALTACE 50altachlore 123ALTAFLUOR BENOX 123altafrin 123altavera 99ALTERNARIA 112ALTOPREV50

ALTRENO 60alum amp mag hydroxide-simeth 86alumina-magnesia-simethicone 86ALUNBRIG36ALVESCO 130alvimopan86alyacen 13599alyacen 77799alyq 133amabelz 99amantadine hcl42AMARYL 72AMBIEN 134AMBIEN CR 134ambrisentan 133amcinonide60 61AMELUZ 61AMERGE 34AMERICAN BEECH112AMERICAN COCKROACH112AMERICAN ELM112amethia 99amethyst 99AMICAR 48amikacin sulfate 21amiloride hcl50amiloride-hydrochlorothiazide 50aminoacetic acid 92aminoamrms 77aminocaproic acid 48AMINOPMRMS112aminoreliefrms 77amiodarone hcl 50AMITIZA86amitriptyline hcl 29AMLODIPINE BES+SYRSPEND SF 50amlodipine besylate 50amlodipine besylate-benazepril hcl 50amlodipine besylate-valsartan 50amlodipine-atorvastatin50amlodipine-olmesartan50amlodipine-valsartan-hctz 50ammonium lactate61amnesteem 61AMONDYS 4591amoxapine 29amoxicill-clarithro-lansopraz 86amoxicillin 21amoxicillin-potassium clavulanate21

138

amoxicillin-potassium clavulanate er21AMPHETAMINE ER56amphetamine sulfate56amphetamine-dextroamphetamine 56amphetamine-dextroamphetamine er 56ampicillin 21ampicillin-sulbactam sodium 21AMPYRA57AMRIX134AMZEEQ61ANACAINE61ANAFRANIL29anagrelide hcl48ana-lex 110ANALPRAM HC 110ANALPRAM HC SINGLES 110ANALPRAM-HC110ANASPAZ 86anastrozole 36ANCOBON31ANDEXXA112ANDRODERM 96ANDROGEL96ANDROGEL PUMP 96ANGELIQ 99ANIMI-377ANIMI-3VITAMIN D77ANNOVERA99ANODYNE LPT17ANORO ELLIPTA 130antacid 86antacid anti-gas max strength86antacid calcium 86antacid calcium rich 86antacid extra strength 86antacid maximum86antacid regular strength 86antacid ultra strength 86antacidantigas86antacidanti-gas86ANTARA 50ANTICOAGULANT SODIUM CITRATE26anti-diarrheal 86 87antihistamine amp nasal deconges 126ANTIVENIN LATRODECTUS MACTANS 112ANTIVENIN MICRURUS FULVIUS112

anucort-hc 110ANUSOL-HC110ANZEMET30APADAZ9apap-caff-dihydrocodeine 9APEXICON E 61APIDRA SOLOSTAR 75APIDRA VIAL75APLENZIN 29APOKYN 42APP SLIM RMS 112apraclonidine hcl 122aprepitant 30apri 100APRISO 110APRIZIO PAK 17APRIZIO PAK II 17APTENSIO XR56APTIOM 27APTIVUS44AQUAPHILIC 61AQUASOL A 77ARAKODA 41ARALAST NP130aranelle 100ARANESP (ALBUMIN FREE)48ARAVA105ARAZLO61ARCALYST 105ARESTIN 59ARICEPT 29ARIDA 61ARIDOL113ARIKAYCE21ARIMIDEX36aripiprazole 43ARISTADA 43ARISTADA INITIO 43ARIXTRA 26ARIZONA CYPRESS113armodafinil 135ARMONAIR DIGIHALER 130ARMOUR THYROID104ARNUITY ELLIPTA130AROMASIN36ARRANON 36arsenic trioxide36arthritis pain reliever9ARTHROTEC14artificial eye 123artificial tears123ARTISS 113ARZERRA36

ARZOL SILVER NIT APPLICATORS61ASACOL HD 110ASCENIV 105ascomp-codeine9ASCOR 77ASCORBIC ACID77ascorbic acid 77asenapine maleate43ashlyna100asilnasalrms 113ASMANEX (120 METERED DOSES) 131ASMANEX (14 METERED DOSES) 131ASMANEX (30 METERED DOSES) 131ASMANEX (60 METERED DOSES) 131ASMANEX (7 METERED DOSES) 131ASMANEX HFA 131ASPARLAS 36ASPARTAME113ASPARTAME (NUTRASWEET) 113aspirin 14aspirin adult low strength 14aspirin childrens 14aspirin ec14aspirin ec low dose 14aspirin ec low strength 14aspirin low dose 14aspirin-dipyridamole er43ASPIRIN-OMEPRAZOLE 43ASTAGRAF XL 105ASTERO 17ASTRAZENECA COVID-19 VACCINE 109ASTRINGYN 48ATABEX OB77ATACAND50ATACAND HCT 50atazanavir sulfate44ATELVIA 111atenolol 50ATENOLOL+SYRSPEND SF 50atenolol-chlorthalidone50ATGAM 105athletes foot (terbinafine) 31ATIVAN 47atomoxetine hcl56ATOPADERM 61

139

ATOPICLAIR61atorvastatin calcium 50atovaquone 41atovaquone-proguanil hcl41ATRALIN61ATRIPLA 44ATROPEN87atropine sulfate 87 123ATROPINE SULFATE 87 123ATROVENT HFA 131AUBAGIO57aubra100aubra eq100AUGMENTIN 21AUGMENTIN ES-600 21AUREOBASIDIUM113aurodryl allergy childrens 126aurophen childrens 9aurovela 1530 100aurovela 120 100aurovela 24 fe 100aurovela fe 1530 100aurovela fe 120 100AURYXIA 92AUSTEDO58AUSTRALIAN PINE 113AUTOLET LANCING DEVICE 73AUTOSOFT 30 INFUSION SET 113AUTOSOFT 90 INFUSION SET 113AUTOSOFT XC INFUSION SET 113AUVI-Q131AVAILNEX 113AVALIDE50AVAPRO 50AVAR CLEANSER61AVAR LS CLEANSER 61AVAR-E EMOLLIENT 61AVAR-E GREEN61AVAR-E LS 61AVASTIN36AVEED96AVEIDAOXIA 61aviane 100avidoxy21AVIDOXY DK 21AVITA61AVITENE113AVITENE FLOUR 113AVODART94AVONEX PEN57

AVONEX PREFILLED 57AVSOLA105AXONA 113AYGESTIN100ayuna 100AYVAKIT36azacitidine 36AZADROX61AZALGIA113AZASAN105AZASITE 120azathioprine 105azathioprine sodium105azelaic acid 61AZELAIC ACID-NIACINAMIDE61azela