2023 CIGNA COMPREHENSIVE DRUG LIST (Formulary)

Plan covered

Cigna Extra Rx (PDP)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT

ALL OF THE DRUGS WE COVER IN THIS PLAN.

2023 CIGNA

COMPREHENSIVE DRUG LIST

(Formulary)

HPMS Approved Formulary File Submission ID 00023074, Version Number 22

This formulary was updated on 12/01/2023. For more recent information or other questions, please contact Cigna Customer Service,

at 1-800-222-6700 (TTY users should call 711), 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer

your call during weekends from April 1 – September 30, or visit CignaMedicare.com. The Formulary, pharmacy network, and/or provider

network may change at any time.

Important Message About What You Pay for Insulin: You won’t pay more than $35 for a one-month supply of each insulin product

covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible. If your insulin is on a tier where

cost-sharing is lower than $35, you will pay the lower cost for your insulin.

Important Message About What You Pay for Vaccines: Our plan covers most Part D vaccines at no cost to you, even if you haven’t

paid your deductible. Call Customer Service for more information.

23_F_S5617_TR _V12

December 2023 INT_23_775008_C_Final_2l

December 2023

What is the Cigna Comprehensive Drug List?

A drug list is a list of covered drugs selected by Cigna in

consultation with a team of health care providers, which

represents the prescription therapies believed to be a

necessary part of a quality treatment program. Cigna will

generally cover the drugs listed in our drug list as long as the

drug is medically necessary, the prescription is filled at a Cigna

network pharmacy, and other plan rules are followed. For more

information on how to fill your prescriptions, please review your

Evidence of Coverage (EOC).

Can the Drug List (formulary) change?

Most changes in drug coverage happen on January 1, but we

may add or remove drugs on the drug list during the year, move

them to different cost-sharing tiers, or add new restrictions. We

must follow Medicare rules in making these changes.

Changes that can affect you this year. In the below cases,

you will be affected by coverage changes during the year:

• New generic drugs. We may immediately remove a brand

name drug on our drug list if we are replacing it with a new

generic drug that will appear on the same or lower cost-

sharing tier and with the same or fewer restrictions. Also,

when adding the new generic drug, we may decide to keep

the brand name drug on our drug list, but immediately move

it to a different cost-sharing tier or add new restrictions. If you

are currently taking that brand name drug, we may not tell

you in advance before we make that change, but we will later

provide you with information about the specific change(s) we

have made.

– If we make such a change, you or your prescriber can ask

us to make an exception and continue to cover the brand

name drug for you. The notice we provide you will also

include information on how to request an exception, and

you can also find information in the section entitled “How do

I request an exception to the Cigna Drug List?”

• Drugs removed from the market. If the Food and Drug

Administration (FDA) deems a drug on our drug list to be

unsafe or the drug’s manufacturer removes the drug from the

market, we will immediately remove the drug from our drug

list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect

customers currently taking a drug. For instance, we may

add a generic drug that is not new to the market to replace

a brand name drug currently on the drug list, or add new

restrictions to the brand name drug or move it to a different

cost-sharing tier or both. Or we may make changes based

on new clinical guidelines and/or studies. If we remove drugs

from our drug list, add prior authorization, quantity limits, and/

or step therapy restrictions on a drug or move a drug to a

higher cost-sharing tier, we must notify affected customers

of the change at least 30 days before the change becomes

effective, or at the time the customer requests a refill of the

drug, at which time the customer will receive a 30-day supply

of the drug.

– If we make these other changes, you or your prescriber

can ask us to make an exception and continue to cover the

brand name drug for you. The notice we provide you will

also include information on how to request an exception,

and you can find information in the section below titled

“How do I request an exception to the Cigna Drug List?”

Changes that will not affect you if you are currently taking

the drug. Generally, if you are taking a drug on our 2023 drug

list that was covered at the beginning of the year, we will not

discontinue or reduce coverage of the drug during the 2023

coverage year except as described above. This means these

drugs will remain available at the same cost-sharing and with

Note to existing customers: This formulary has changed since last year. Please review this document to make sure

that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna. When it refers to “plan” or “our plan,”

it means Cigna Extra Rx (PDP).

This document includes a list of the drugs (formulary) for our plans, which is current as of December 2023. For an

updated formulary, please contact us. Our contact information, along with the date we last updated the formulary,

appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy

network, and/or copayments/coinsurance may change on January 1, 2024, and from time to time during the year.

December 2023

no new restrictions for those customers taking them for the

remainder of the coverage year. You will not get direct notice

this year about changes that do not affect you. However, on

January 1 of the next year, such changes would affect you, and

it is important to check the drug list for the new benefit year for

any changes to drugs.

The enclosed drug list is current as of December 2023. To get

updated information about the drugs covered by Cigna, please

back cover pages. If there are significant changes made to the

printed drug list within the covered year, you may be notified by

mail identifying the changes. Drug lists located on our website

are reviewed and updated on a monthly basis.

How do I use the Drug List?

There are two ways to find your drug within the drug list:

Medical Condition

The drug list begins on page 8. The drugs in this drug list are

grouped into categories depending on the type of medical

conditions that they are used to treat. For example, drugs

used to treat a heart condition are listed under the category,

“CARDIOVASCULAR, HYPERTENSION / LIPIDS.” If you know

what your drug is used for, look for the category name in the list

that begins on page 8. Then look under the category name for

your drug.

Covered Drug Index

If you are not sure what category to look under, you should

look for your drug in the Covered Drugs Index that begins on

page 56. The Covered Drugs Index provides an alphabetical

list of all of the drugs included in this document. Both brand

name drugs and generic drugs are listed in the Index. Look in

the Index and find your drug. Next to your drug, you will see the

page number where you can find coverage information. Turn to

the page listed in the Covered Drug Index and find the name of

your drug in the drug name column of the list.

What are generic drugs?

Cigna covers both brand name drugs and generic drugs. A

generic drug is approved by the FDA as having the same active

ingredient as the brand name drug. Generally, generic drugs

cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits

on coverage. These requirements and limits may include:

• Prior Authorization: Cigna requires you or your doctor to

get prior authorization for certain drugs. This means that you

will need to get approval from Cigna before you fill these

prescriptions. If you don’t get approval, Cigna may not cover

the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount

of the drug that Cigna will cover. For example, Cigna allows

for 1 tablet per day for atorvastatin 40mg. This applies to

a standard one-month supply (for total quantity of 30 per

30 days) or three-month supply (for total quantity of 90 per

90 days).

• Step Therapy: In some cases, Cigna requires you to first try

certain drugs to treat your medical condition before we will

cover another drug for that condition. For example, if Drug A

and Drug B both treat your medical condition, Cigna may not

cover Drug B unless you try Drug A first. If Drug A does not

work for you, Cigna will then cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna limits

the amount of the drug that Cigna will cover to only a 30-day

supply or less, at one time. For example, customers who

have not had any recent fill of opioid pain medications within

the past 108 days (referred to as “opioid naïve”) are limited

to a maximum of 7 days’ supply of opioid pain medication.

Customers who have received a recent fill of an opioid pain

medication (not opioid naïve) are limited to up to a month’s

supply of that medication at one time. Other high cost drugs

may be subject to a non-extended day supply restriction,

as well.

You can find out if your drug has any additional requirements

or limits by looking in the drug list that begins on page 8. You

can also get more information about the restrictions applied to

specific covered drugs by visiting our website. We have posted

online documents that explain our prior authorization and step

therapy restrictions. You may also ask us to send you a copy.

Our contact information, along with the date we last updated the

drug list, appears on the front and back cover pages.

You can ask Cigna to make an exception to these restrictions

or limits or for a list of other, similar drugs that may treat

your health condition. See the section, “How do I request an

exception to the Cigna drug list?” on page 3 for information

about how to request an exception.

Options for Maintenance Medications

Taking the medications prescribed by your doctor (or other

prescriber) is important to your health.

We are committed to helping you control your chronic

conditions by making it easy for you to receive your

maintenance medications. There are several ways

we can work together to accomplish this goal:

December 2023

• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking

these medications every day as prescribed is important for

your overall health, and getting 90-day prescriptions of these

medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies

or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new

challenges with your maintenance medications.

How can I use my prescription drug coverage to save

money on my medications?

There may be opportunities for you to save money on your

medications using your Cigna coverage.

• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current

medications.

• Some plans may offer a $0 copay for Tier 1 and Tier 2 generic

drugs filled at a preferred retail and/or mail-order pharmacies.

Check the Drug Tier and Cost-share Tables on page 5 to see

if your plan offers these savings.

• Explore whether the ‘CMS Extra Help’ program may offer

additional financial support for your medications.

• If your medication is not covered in the Cigna drug list, talk

with your doctor about alternative medications which are

covered on the drug list.

What if my drug is not on the Drug List?

If your drug is not included in this drug list, you should first

contact Customer Service and ask if your drug is covered. If

you learn that Cigna does not cover your drug, you have

two options:

• You can ask Customer Service for a list of similar drugs that

are covered by Cigna. When you receive the list, show it to

your doctor and ask him or her to prescribe a similar drug that

is covered by Cigna.

• You can ask Cigna to make an exception and cover your

drug. See the next section for information about how to

request an exception.

How do I request an exception to the Cigna Drug List?

You can ask Cigna to make an exception to our coverage rules.

There are several types of exceptions that you can ask us

to make.

• You can ask us to cover a drug even if it is not on our drug

list. If approved, this drug will be covered at a pre-determined

cost-sharing level, and you would not be able to ask us to

provide the drug at a lower cost-sharing level.

• You can ask us to waive coverage restrictions or limits on

your drug. For example, for certain drugs, Cigna limits the

amount of the drug that we will cover. If your drug has a

quantity limit, you can ask us to waive the limit and cover

a greater amount.

• You can ask us to cover a formulary drug at a lower cost-

sharing level, unless the drug is on the specialty tier. If

approved, this would lower the amount you must pay for

your drug. This applies to the following circumstances:

– If the drug you’re taking is a brand name drug, you can

ask us to cover your drug at the cost-sharing amount

that applies to the lowest tier that contains brand name

alternatives for treating your condition.

– If the drug you’re taking is a generic drug, you can ask us

to cover your drug at the cost-sharing amount that applies

to the lowest tier that contains either brand or generic

alternatives for treating your condition.

– If the drug you’re taking is a biological product, you can

ask us to cover your drug at the cost-sharing amount that

applies to the lowest tier that contains biological product

alternatives for treating your condition.

Please note, if we grant your request to cover a drug that is

not on our drug list, you may not ask us to provide this drug

at a lower cost-sharing level.

Generally, Cigna will only approve your request for an exception

if the alternative drug is included in our drug list, the lower cost-

sharing drug or additional utilization restrictions would not be

as effective in treating your condition and/or would cause you

to have adverse medical effects.

You should contact us to ask us for an initial coverage decision

for a drug list, tiering or utilization restriction exception. When

you request a drug list, tiering or utilization restriction

exception you should submit a statement from your

prescriber or doctor supporting your request. Generally,

we must make our decision within 72 hours of getting your

prescriber’s supporting statement. You can request an

expedited (fast) exception if you or your doctor believe that your

health could be seriously harmed by waiting up to 72 hours for

a decision. If your request to expedite is granted, we must give

you a decision no later than 24 hours after we get a supporting

statement from your doctor or other prescriber.

December 2023

What do I do before I can talk to my doctor about changing

my drugs or requesting an exception?

As a new or existing customer in our plan you may be taking

drugs that are not on our drug list. Or, you may be taking a drug

that is on our drug list but your ability to get it is limited. For

example, you may need a prior authorization from us before

you can fill your prescription. You should talk to your doctor

to decide if you should switch to an appropriate drug that we

cover or request a drug list exception so that we will cover the

drug you take. While you talk to your doctor to determine the

right course of action for you, we may cover your drug up to a

30-day supply, in certain cases during the first 90 days you are

a customer of our plan.

For each of your drugs that is not on our drug list or if your

ability to get your drugs is limited, we will cover a temporary

30-day supply. If your prescription is written for fewer days,

we’ll allow refills to provide up to a maximum 30-day supply of

medication. After your first 30-day supply, we will not pay for

these drugs without a drug list exception, even if you have been

a customer of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a

drug that is not on our drug list or if your ability to get your drugs

is limited, but you are past the first 90 days of membership in

our plan, we will cover a 31-day emergency supply of that drug

while you pursue a drug list exception.

In order to accommodate unexpected transitions of our

customers that do not leave time for advanced planning, such

as level-of-care changes due to discharge from a hospital to a

nursing facility or to a home, Cigna will allow a one-time 31-day

supply (unless the prescription is written for fewer days).

Cigna’s Drug List

The comprehensive drug list that begins on page 8 provides

coverage information about all of the drugs covered by Cigna. If

you have trouble finding your drug in the list, turn to the Covered

Drug Index that begins on page 56.

The first column of the chart lists the drug name. Brand name

drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic

drugs are listed in lower-case italics (e.g., atorvastatin).

The information in the Requirements/Limits column tells you if

Cigna has any special requirements for coverage of your drug.

We provide quantity limits on certain drugs which are indicated

with a QL in the Covered Drugs by Category list on page 8

along with the amount dispensed per the days supplied. (For

example: atorvastatin 40mg QL 30/30; this means the drug

atorvastatin 40mg is limited to 30 tablets per 30 days. For

90-day supplies, this quantity limit would be expanded to

90 tablets per 90 days).

This plan offers additional prescription drug coverage in the

coverage gap. Please refer to your Evidence of Coverage

(EOC) to see this coverage and for more information.

To access a copy of your most recent EOC, go to

Cigna.com/member-resources.

What is a preferred network pharmacy?

If your plan has preferred network pharmacies, you will typically

save money by using these pharmacies. Your prescription

drug costs (like a copay or coinsurance) will typically be less

at a preferred network pharmacy because it has a preferred

agreement with your plan. If you need help finding a network

pharmacy, please call Customer Service at 1-800-222-6700

(TTY 711), or you can visit Cigna.com/member-resources for

the most current Pharmacy Directory.

For more information

For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage (EOC)

and other plan materials. To access a copy of your most recent EOC, go to Cigna.com/member-resources.

If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug

list, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE

(1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

December 2023

Drug Tier and Cost-Share Table

The following table represents the plan name, plan service

area, the drug tier number as it appears on the drug list, and the

cost-share amount for that tier number. Tier 1 is for Preferred

Generic drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred

Brand drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for

Specialty tier drugs. Tier 6 is for Select Care Drugs. Please refer

to the following chart. You may also refer to your Evidence of

Coverage (EOC) document for additional details.

Cigna is not always able to keep all generic medications in

the Preferred Generic and Generic drug tiers. Some generic

medications may be in Tier 3, Tier 4, Tier 5 or Tier 6. Keep in

mind that the name “Tier 3: Preferred Brand Drugs” is just a

description of the majority of the drugs in the tier. It does not

mean that there are only brand drugs in that tier.

Seniors Savings Model: For select insulin drugs, your copay

will be the same when you are in the deductible, initial coverage

and coverage gap phases of the Part D benefit. This does

not apply once you reach the catastrophic coverage phase.

For complete cost-share details on these select insulins,

please refer to Chapter 4 of your Evidence of Coverage (EOC).

To access a copy of your most recent EOC, go to

Cigna.com/member-resources. If you receive Extra Help,

you do not qualify for this program and your Low Income

Subsidy (LIS) copay level will apply.

For customers receiving Extra Help: Your Low Income

Subsidy (LIS) copay level will be based on how the Food and

Drug Administration (FDA) classifies certain drugs. Due to

this, a generic drug may receive a preferred brand copay, or a

preferred brand drug may receive a generic drug copay. Please

see your LIS Rider for additional information on these copay

levels. Or call Customer Service for further clarification regarding

a specific drug.

To locate your drug cost, please refer to the table(s) below to find your service area and the Prescription Drug plan

in which you are currently enrolled or would like to enroll. If you qualified for Extra Help with your drug costs, your

costs may be different from those described below. Please refer to your Evidence of Coverage (EOC) or call Customer

Service to find out what your costs are. Cigna uses preferred network pharmacies. See your Pharmacy Directory or

visit Cigna.com/member-resources to search for a preferred retail or mail-order pharmacy near you.

Cigna Extra Rx (PDP)

Preferred

Retail

Cost-Sharing

Standard

Retail

Cost-Sharing

Preferred

Mail-Order

Cost-Sharing

Standard

Mail-Order

Cost-Sharing

Long-term Care

31 days

Out-of-network

30 days*

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

COLORADO

Tier 1: Preferred Generic Drugs (GC) $4 / $8 / $12 $15 / $30 / $45 $4 / $8 / $0 $15 / $30 / $45 $15

Tier 2: Generic Drugs (GC) $10 / $20 / $30 $20 / $40 / $60 $10 / $20 / $2 $20 / $40 / $60 $20

Tier 3: Preferred Brand Drugs $45 / $90 / $135 $47 / $94 / $141 $45 / $90 / $135 $47 / $94 / $141 $47

Tier 4: Non-Preferred Drugs 48% 48% 48% 48% 48%

Tier 5: Specialty Tier 31% (30 days) 31% (30 days) 31% (30 days) 31% (30 days) 31%

Tier 6: Select Care Drugs $0 / $0 / $0 $11 / $22 / $33 $0 / $0 / $0 $11 / $22 / $33 $11

* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billed

charge and our typical Standard Retail pharmacy billed costs.

GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage

for more information about this coverage.

December 2023

* You will pay the copay or percentage of the drug cost shown above plus the difference between the Out-of-Network pharmacy billed

charge and our typical Standard Retail pharmacy billed costs.

GC: We provide additional coverage of the prescription drugs in this tier in the coverage gap. Please refer to our Evidence of Coverage

for more information about this coverage.

Cigna Extra Rx (PDP)

Preferred

Retail

Cost-Sharing

Standard

Retail

Cost-Sharing

Preferred

Mail-Order

Cost-Sharing

Standard

Mail-Order

Cost-Sharing

Long-term Care

31 days

Out-of-network

30 days*

30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days 30 / 60 / 90 Days

HAWAII

Tier 1: Preferred Generic Drugs (GC) $4 / $8 / $12 $15 / $30 / $45 $4 / $8 / $0 $15 / $30 / $45 $15

Tier 2: Generic Drugs (GC) $10 / $20 / $30 $20 / $40 / $60 $10 / $20 / $2 $20 / $40 / $60 $20

Tier 3: Preferred Brand Drugs $45 / $90 / $135 $47 / $94 / $141 $45 / $90 / $135 $47 / $94 / $141 $47

Tier 4: Non-Preferred Drugs 46% 46% 46% 46% 46%

Tier 5: Specialty Tier 31% (30 days) 31% (30 days) 31% (30 days) 31% (30 days) 31%

Tier 6: Select Care Drugs $0 / $0 / $0 $11 / $22 / $33 $0 / $0 / $0 $11 / $22 / $33 $11

PUERTO RICO

Tier 1: Preferred Generic Drugs (GC) $4 / $8 / $12 $15 / $30 / $45 $4 / $8 / $0 $15 / $30 / $45 $15

Tier 2: Generic Drugs (GC) $10 / $20 / $30 $20 / $40 / $60 $10 / $20 / $2 $20 / $40 / $60 $20

Tier 3: Preferred Brand Drugs $45 / $90 / $135 $47 / $94 / $141 $45 / $90 / $135 $47 / $94 / $141 $47

Tier 4: Non-Preferred Drugs 39% 39% 39% 39% 39%

Tier 5: Specialty Tier 31% (30 days) 31% (30 days) 31% (30 days) 31% (30 days) 31%

Tier 6: Select Care Drugs $0 / $0 / $0 $11 / $22 / $33 $0 / $0 / $0 $11 / $22 / $33 $11

ALL OTHER STATES

Tier 1: Preferred Generic Drugs (GC) $4 / $8 / $12 $15 / $30 / $45 $4 / $8 / $0 $15 / $30 / $45 $15

Tier 2: Generic Drugs (GC) $10 / $20 / $30 $20 / $40 / $60 $10 / $20 / $2 $20 / $40 / $60 $20

Tier 3: Preferred Brand Drugs $45 / $90 / $135 $47 / $94 / $141 $45 / $90 / $135 $47 / $94 / $141 $47

Tier 4: Non-Preferred Drugs 50% 50% 50% 50% 50%

Tier 5: Specialty Tier 31% (30 days) 31% (30 days) 31% (30 days) 31% (30 days) 31%

Tier 6: Select Care Drugs $0 / $0 / $0 $11 / $22 / $33 $0 / $0 / $0 $11 / $22 / $33 $11

December 2023

Drug List Key:

B/D – This prescription drug has a Part B versus D

administrative prior authorization requirement. This drug

may be covered under Medicare Part B or D depending

on circumstances.

GC – We provide additional coverage of the prescription

drugs in this tier in the coverage gap. Please refer to

our Evidence of Coverage for more information about

this coverage.

LA – Limited Availability. This prescription may be available

only at certain pharmacies. For more information consult

your Pharmacy Directory or call Customer Service at

1-800-222-6700 (TTY users should call 711), 8 a.m. –

8 p.m. local time, 7 days a week. Our automated phone

system may answer your call during weekends from April 1 –

September 30, or visit Cigna.com/member-resources.

NDS – Non-extended day supply medication. This drug is

only available as a 30-day supply or less.

PA – This drug requires prior authorization

QL – This drug has quantity limits

SSM – This select insulin is part of the senior savings model

ST – This drug has step therapy requirements

Generally all medications on the drug list are available

through mail-order, except when special circumstances

or situations prohibit mailing a particular medication to

your home.

Drug List Table of Contents:

The drugs on the drug list are grouped into categories depending on the type of medical conditions that they are used to

treat. If you know what your drug is used for, look for the category name in the list below. Then look under the category

name within the drug list for your drug.

Page

ANTI - INFECTIVES .....................................................................................................................................................................8

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ........................................................................................................13

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...........................................................................................................21

CARDIOVASCULAR, HYPERTENSION / LIPIDS ....................................................................................................................31

DERMATOLOGICALS/TOPICAL THERAPY ...........................................................................................................................35

DIAGNOSTICS / MISCELLANEOUS AGENTS ........................................................................................................................37

EAR, NOSE / THROAT MEDICATIONS .................................................................................................................................... 39

ENDOCRINE/DIABETES ...........................................................................................................................................................39

GASTROENTEROLOGY ...........................................................................................................................................................43

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ................................................................................................................... 45

MUSCULOSKELETAL / RHEUMATOLOGY ............................................................................................................................46

OBSTETRICS / GYNECOLOGY ...............................................................................................................................................47

OPHTHALMOLOGY ..................................................................................................................................................................50

RESPIRATORY AND ALLERGY ...............................................................................................................................................51

UROLOGICALS .........................................................................................................................................................................53

VITAMINS, HEMATINICS / ELECTROLYTES ..........................................................................................................................54

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET 4 PA

amphotericin b 4 PA

amphotericin b liposome 5 PA; NDS

caspofungin intravenous recon

soln 50 mg

5 PA; NDS

caspofungin intravenous recon

soln 70 mg

4 PA

clotrimazole mucous

membrane

CRESEMBA ORAL 4

uconazole in nacl (iso-osm) 4 PA

uconazole oral suspension for

reconstitution

uconazole oral tablet 2

ucytosine 5 NDS

griseofulvin microsize 4

griseofulvin ultramicrosize 4

itraconazole oral capsule 4 QL (120/30)

itraconazole oral solution 4

ketoconazole oral 3

nystatin oral suspension 3

nystatin oral tablet 2

posaconazole oral

tablet,delayed release (dr/ec)

5 QL (96/30); NDS

terbinane hcl oral 2

voriconazole intravenous 4 PA

voriconazole oral suspension

for reconstitution

5 NDS

voriconazole oral tablet 4

ANTIVIRALS

abacavir oral solution 3 QL (960/30)

abacavir oral tablet 4 QL (60/30)

abacavir-lamivudine 3 QL (30/30)

acyclovir oral capsule 2

acyclovir oral suspension 200

mg/5 ml

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

acyclovir oral tablet 2

acyclovir sodium intravenous

solution

4 B/D PA

adefovir 4

amantadine hcl 3

APRETUDE 4

APTIVUS 4 QL (120/30)

atazanavir oral capsule 150

mg, 300 mg

4 QL (30/30)

atazanavir oral capsule 200 mg 4 QL (60/30)

BARACLUDE ORAL

SOLUTION

4 QL (630/30)

BIKTARVY 5 NDS

CABENUVA 5 NDS

CIMDUO 4

COMPLERA 4 QL (30/30)

darunavir ethanolate 5 QL (60/30); NDS

DELSTRIGO 4

DESCOVY 5 QL (30/30); NDS

DOVATO 5 NDS

EDURANT 4 QL (30/30)

efavirenz oral capsule 200 mg 4 QL (120/30)

efavirenz oral capsule 50 mg 4 QL (180/30)

efavirenz oral tablet 4 QL (30/30)

efavirenz-emtricitabin-tenofov 5 QL (30/30); NDS

efavirenz-lamivu-tenofov disop

oral tablet 400-300-300 mg

4 QL (30/30)

efavirenz-lamivu-tenofov disop

oral tablet 600-300-300 mg

emtricitabine 3 QL (30/30)

emtricitabine-tenofovir (tdf) 5 QL (30/30); NDS

EMTRIVA ORAL SOLUTION 3 QL (680/28)

entecavir 4 QL (30/30)

EPCLUSA ORAL PELLETS IN

PACKET 150-37.5 MG

5 PA; QL (28/28);

NDS

EPCLUSA ORAL PELLETS IN

PACKET 200-50 MG

5 PA; QL (56/28);

NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lopinavir-ritonavir oral tablet

200-50 mg

4 QL (120/30)

maraviroc oral tablet 150 mg 5 QL (60/30); NDS

maraviroc oral tablet 300 mg 5 QL (120/30); NDS

MAVYRET ORAL PELLETS IN

PACKET

5 PA; QL (168/28);

NDS

MAVYRET ORAL TABLET 5 PA; QL (84/28);

NDS

nevirapine oral suspension 4 QL (1200/30)

nevirapine oral tablet 3 QL (60/30)

nevirapine oral tablet extended

release 24 hr 100 mg

4 QL (90/30)

nevirapine oral tablet extended

release 24 hr 400 mg

4 QL (30/30)

NORVIR ORAL POWDER IN

PACKET

ODEFSEY 5 QL (30/30); NDS

oseltamivir oral capsule 3

oseltamivir oral suspension for

reconstitution

PIFELTRO 4

PREVYMIS 5 QL (30/30); NDS

PREZCOBIX 4 QL (30/30)

PREZISTA ORAL

SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET

150 MG

4 QL (240/30)

PREZISTA ORAL TABLET

600 MG

5 QL (60/30); NDS

PREZISTA ORAL TABLET

75 MG

4 QL (480/30)

PREZISTA ORAL TABLET

800 MG

5 QL (30/30); NDS

RETROVIR INTRAVENOUS 4

REYATAZ ORAL POWDER IN

PACKET

5 QL (240/30); NDS

ribavirin oral capsule 3

ribavirin oral tablet 200 mg 3

rimantadine 4

ritonavir 3 QL (360/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

EPCLUSA ORAL TABLET

200-50 MG

5 PA; QL (56/28);

NDS

EPCLUSA ORAL TABLET

400-100 MG

5 PA; QL (28/28);

NDS

etravirine 5 QL (60/30); NDS

EVOTAZ 4 QL (30/30)

famciclovir 4 QL (60/30)

fosamprenavir 5 QL (120/30); NDS

FUZEON SUBCUTANEOUS

RECON SOLN

5 QL (60/30); NDS

GENVOYA 5 QL (30/30); NDS

HARVONI ORAL PELLETS IN

PACKET 33.75-150 MG

5 PA; QL (28/28);

NDS

HARVONI ORAL PELLETS IN

PACKET 45-200 MG

5 PA; QL (56/28);

NDS

HARVONI ORAL TABLET

45-200 MG

5 PA; QL (56/28);

NDS

HARVONI ORAL TABLET

90-400 MG

5 PA; QL (28/28);

NDS

INTELENCE ORAL TABLET

25 MG

4 QL (120/30)

ISENTRESS HD 5 NDS

ISENTRESS ORAL POWDER

IN PACKET

5 QL (60/30); NDS

ISENTRESS ORAL TABLET 5 QL (120/30); NDS

ISENTRESS ORAL TABLET,

CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET,

CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDS

lamivudine oral solution 3 QL (900/30)

lamivudine oral tablet 100 mg,

300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)

lamivudine-zidovudine 3 QL (60/30)

LEXIVA ORAL SUSPENSION 4 QL (1575/28)

lopinavir-ritonavir oral solution 4

lopinavir-ritonavir oral tablet

100-25 mg

4 QL (300/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

cefaclor oral suspension for

reconstitution 125 mg/5 ml, 250

mg/5 ml, 375 mg/5 ml

cefaclor oral tablet extended

release 12 hr

cefadroxil oral capsule 3

cefadroxil oral suspension for

reconstitution 250 mg/5 ml, 500

mg/5 ml

cefadroxil oral tablet 3

CEFAZOLIN IN DEXTROSE

(ISO-OS) INTRAVENOUS

PIGGYBACK 1 GRAM/50 ML,

2 GRAM/100 ML,

2 GRAM/50 ML

cefazolin injection recon soln

1 gram, 10 gram, 100 gram, 2

gram, 300 g, 500 mg

cefazolin intravenous recon

soln 1 gram

CEFAZOLIN INTRAVENOUS

RECON SOLN 2 GRAM,

3 GRAM

cefdinir 4

CEFEPIME IN DEXTROSE 5% 4

CEFEPIME IN DEXTROSE,

ISO-OSM

cefepime injection 4

cefepime intravenous 4 PA

cexime 4

cefotetan injection 4 PA

cefoxitin 4 PA

CEFOXITIN IN DEXTROSE,

ISO-OSM

4 PA

cefpodoxime 4

cefprozil 3

ceftazidime 4 PA

ceftriaxone 4

ceftriaxone in dextrose,iso-os 4

cefuroxime axetil oral tablet 3

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

RUKOBIA 5 NDS

SELZENTRY ORAL

SOLUTION

5 NDS

SELZENTRY ORAL TABLET

25 MG

4 QL (120/30)

SELZENTRY ORAL TABLET

75 MG

5 QL (60/30); NDS

STRIBILD 5 QL (30/30); NDS

SUNLENCA 5 LA; NDS

SYMTUZA 4

tenofovir disoproxil fumarate 4 QL (30/30)

TIVICAY ORAL TABLET 10 MG 4 QL (60/30)

TIVICAY ORAL TABLET

25 MG, 50 MG

5 QL (60/30); NDS

TIVICAY PD 4 QL (180/30)

TRIUMEQ 5 QL (30/30); NDS

TRIUMEQ PD 5 QL (300/30)

TRIZIVIR 5 QL (60/30); NDS

TROGARZO 5 NDS

valacyclovir oral tablet 1 gram 3 QL (120/30)

valacyclovir oral tablet 500 mg 3 QL (60/30)

valganciclovir oral recon soln 5 NDS

valganciclovir oral tablet 3

VEKLURY 5 QL (4/180); NDS

VEMLIDY 5 NDS

VIRACEPT ORAL TABLET

250 MG

4 QL (270/30)

VIRACEPT ORAL TABLET

625 MG

4 QL (120/30)

VIREAD ORAL POWDER 5 QL (240/30); NDS

VIREAD ORAL TABLET

150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

VOSEVI 5 PA; QL (28/28);

NDS

zidovudine oral capsule 4 QL (180/30)

zidovudine oral syrup 4 QL (1680/28)

zidovudine oral tablet 2 QL (60/30)

CEPHALOSPORINS

cefaclor oral capsule 4

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CAYSTON 5 PA; LA; QL (84/28);

NDS

chloramphenicol sod succinate 4

chloroquine phosphate 3

clindamycin hcl 2

CLINDAMYCIN IN 0.9% SOD

CHLOR

4 PA

clindamycin in 5% dextrose 4 PA

clindamycin palmitate hcl 4

clindamycin pediatric 4

clindamycin phosphate injection 4 PA

COARTEM 4 QL (24/30)

colistin (colistimethate na) 4 PA

cycloserine 4

dapsone oral 3

daptomycin 5 NDS

DAPTOMYCIN IN 0.9% SOD

CHLOR

5 NDS

emverm 4

ertapenem 4

ethambutol 4

FIRVANQ 4 QL (450/10)

gentamicin in nacl (iso-osm)

intravenous piggyback 100

mg/100 ml, 100 mg/50 ml, 120

mg/100 ml, 60 mg/50 ml, 80

mg/100 ml, 80 mg/50 ml

4 PA

gentamicin injection solution 40

mg/ml

4 PA

gentamicin sulfate (ped) (pf) 4 PA

hydroxychloroquine 3

imipenem-cilastatin 4

isoniazid oral solution 4

isoniazid oral tablet 2

ivermectin oral 3 PA

lincomycin 4 PA

linezolid in dextrose 5% 4 PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

cefuroxime sodium injection

recon soln 750 mg

4 PA

cefuroxime sodium intravenous 4 PA

cephalexin oral capsule 250

mg, 500 mg

cephalexin oral suspension for

reconstitution

tazicef 4 PA

TEFLARO 4 PA

ERYTHROMYCINS / OTHER MACROLIDES

azithromycin intravenous 4 PA

AZITHROMYCIN ORAL

PACKET

azithromycin oral suspension

for reconstitution

azithromycin oral tablet 2

clarithromycin 4

DIFICID ORAL SUSPENSION

FOR RECONSTITUTION

5 QL (136/10); NDS

DIFICID ORAL TABLET 5 QL (20/10); NDS

ery-tab oral tablet,delayed

release (dr/ec) 250 mg, 333 mg

erythrocin (as stearate) oral

tablet 250 mg

erythrocin intravenous recon

soln 500 mg

4 PA

erythromycin ethylsuccinate

oral suspension for

reconstitution 200 mg/5 ml

erythromycin oral 4

MISCELLANEOUS ANTIINFECTIVES

albendazole 5 NDS

amikacin injection solution

1,000 mg/4 ml, 500 mg/2 ml

4 PA

ARIKAYCE 4 PA; LA

atovaquone 4

atovaquone-proguanil 4

aztreonam 4 PA

bacitracin intramuscular 4

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VANCOMYCIN IN DEXTROSE

5% INTRAVENOUS

PIGGYBACK

vancomycin injection 4

vancomycin intravenous recon

soln 1,000 mg, 10 gram, 5

gram, 500 mg, 750 mg

VANCOMYCIN INTRAVENOUS

RECON SOLN 1.5 GRAM

vancomycin oral capsule 125

4 PA; QL (40/10)

vancomycin oral capsule 250

4 PA; QL (80/10)

vancomycin oral recon soln 25

mg/ml

4 QL (450/10)

VANCOMYCIN-DILUENT

COMBO NO.1

XIFAXAN ORAL TABLET

550 MG

5 PA; QL (90/30);

NDS

PENICILLINS

amoxicillin oral capsule 2

amoxicillin oral suspension for

reconstitution

amoxicillin oral tablet 2

amoxicillin oral tablet,chewable

125 mg, 250 mg

amoxicillin-pot clavulanate oral

suspension for reconstitution

200-28.5 mg/5 ml, 400-57 mg/5

ml, 600-42.9 mg/5 ml

amoxicillin-pot clavulanate oral

suspension for reconstitution

250-62.5 mg/5 ml

amoxicillin-pot clavulanate oral

tablet

amoxicillin-pot clavulanate oral

tablet extended release 12 hr

amoxicillin-pot clavulanate oral

tablet,chewable 200-28.5 mg

amoxicillin-pot clavulanate oral

tablet,chewable 400-57 mg

ampicillin oral capsule 500 mg 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

linezolid oral suspension for

reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)

LINEZOLID-0.9% SODIUM

CHLORIDE

4 PA

meoquine 3

meropenem 4

MEROPENEM-0.9% SODIUM

CHLORIDE

METRO I.V. 4 PA

metronidazole in nacl (iso-os) 4 PA

metronidazole oral tablet 2

neomycin 2

nitazoxanide 5 QL (20/10); NDS

paromomycin 4

paser 4

pentamidine inhalation 3 B/D PA; QL (1/28)

pentamidine injection 4

praziquantel 4

PRIFTIN 4

primaquine 4

pyrazinamide 4

pyrimethamine 5 PA; NDS

quinine sulfate 4 PA; QL (42/7)

rifabutin 4

rifampin 4

SIRTURO 4 PA; LA

SIVEXTRO INTRAVENOUS 5 PA; QL (6/28); NDS

SIVEXTRO ORAL 5 QL (6/28); NDS

streptomycin 4 PA

tigecycline 5 PA; NDS

tobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDS

tobramycin sulfate 4 PA

TRECATOR 3

VANCOMYCIN IN 0.9%

SODIUM CHL INTRAVENOUS

PIGGYBACK

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

SULFAS / RELATED AGENTS

sulfadiazine 4

sulfamethoxazole-trimethoprim

intravenous

4 PA

sulfamethoxazole-trimethoprim

oral suspension

sulfamethoxazole-trimethoprim

oral tablet

TETRACYCLINES

doxy-100 4 PA

doxycycline hyclate intravenous 4 PA

doxycycline hyclate oral

capsule

doxycycline hyclate oral tablet

100 mg, 20 mg

doxycycline monohydrate oral

capsule 100 mg, 50 mg

doxycycline monohydrate oral

suspension for reconstitution

doxycycline monohydrate oral

tablet

minocycline oral capsule 2

NUZYRA INTRAVENOUS 4 PA

NUZYRA ORAL 4

tetracycline 4

URINARY TRACT AGENTS

methenamine hippurate 4

nitrofurantoin macrocrystal oral

capsule 100 mg, 50 mg

nitrofurantoin monohyd/m-cryst 3

nitrofurantoin oral suspension

25 mg/5 ml

trimethoprim 2

VANCOMYCIN

vancomycin intravenous recon

soln 1.25 gram

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium injection 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ampicillin sodium 4 PA

ampicillin-sulbactam 4 PA

AUGMENTIN ORAL

SUSPENSION FOR

RECONSTITUTION

125-31.25 MG/5 ML

BICILLIN L-A 4 PA

dicloxacillin 2

NAFCILLIN IN DEXTROSE

ISO-OSM

4 PA

nafcillin injection 4 PA

nafcillin intravenous recon soln

2 gram

4 PA

oxacillin injection 4 PA

penicillin g potassium 4 PA

penicillin v potassium 2

pzerpen-g 4 PA

piperacillin-tazobactam 4

ZOSYN IN DEXTROSE (ISO-

OSM)

QUINOLONES

CIPRO ORAL SUSPENSION,

MICROCAPSULE RECON

ciprooxacin hcl oral tablet 100

ciprooxacin hcl oral tablet 250

mg, 500 mg, 750 mg

ciprooxacin in 5% dextrose 4 PA

ciprooxacin oral

suspension,microcapsule recon

500 mg/5 ml

levooxacin in d5w 4 PA

levooxacin intravenous 4 PA

levooxacin oral solution 4

levooxacin oral tablet 2

moxioxacin oral 4

MOXIFLOXACIN-SOD.ACE,

SUL-WATER

4 PA

moxioxacin-sod.chloride(iso) 4 PA

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

BENDEKA 5 B/D PA; NDS

BESPONSA 5 PA; NDS

bexarotene 5 PA; NDS

bicalutamide 3

BLENREP 4 PA

bleomycin 4 B/D PA

BLINCYTO INTRAVENOUS

KIT

4 B/D PA

BORTEZOMIB INJECTION 5 PA; NDS

BORTEZOMIB INTRAVENOUS

RECON SOLN

5 PA; NDS

BOSULIF ORAL TABLET

100 MG

5 PA; QL (90/30);

NDS

BOSULIF ORAL TABLET

400 MG, 500 MG

5 PA; QL (30/30);

NDS

BRAFTOVI ORAL CAPSULE

75 MG

5 PA; LA; QL

(180/30); NDS

BRUKINSA 5 PA; LA; NDS

BUSULFAN 5 B/D PA; NDS

CABOMETYX 5 PA; LA; QL (30/30);

NDS

CALQUENCE 5 PA; LA; QL (60/30);

NDS

CALQUENCE

(ACALABRUTINIB MAL)

5 PA; LA; QL (60/30);

NDS

CAPRELSA ORAL TABLET

100 MG

5 PA; LA; QL (60/30);

NDS

CAPRELSA ORAL TABLET

300 MG

5 PA; LA; QL (30/30);

NDS

carboplatin intravenous solution 4 B/D PA

carmustine intravenous recon

soln 100 mg

4 B/D PA

cisplatin intravenous solution 4 B/D PA

cladribine 4 B/D PA

clofarabine 4 B/D PA

COLUMVI 5 PA; QL (30/21);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

leucovorin calcium oral tablet

10 mg, 15 mg, 25 mg

leucovorin calcium oral tablet

5 mg

mesna 4 B/D PA

MESNEX ORAL 5 NDS

XGEVA 5 PA; QL (1.7/28);

NDS

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

abiraterone oral tablet 250 mg 4 PA; QL (120/30)

abiraterone oral tablet 500 mg 4 PA; QL (60/30)

ABRAXANE 5 PA; NDS

ADCETRIS 4 PA

ADSTILADRIN 5 PA; QL (4/90); NDS

AKEEGA 5 PA; QL (60/30);

NDS

ALECENSA 5 PA; QL (240/30);

NDS

ALIMTA 5 PA; NDS

ALIQOPA 5 PA; NDS

ALUNBRIG ORAL TABLET

180 MG, 90 MG

5 PA; QL (30/30);

NDS

ALUNBRIG ORAL TABLET

30 MG

5 PA; QL (60/30);

NDS

ALUNBRIG ORAL TABLETS,

DOSE PACK

5 PA; QL (60/365);

NDS

anastrozole 2

arsenic trioxide 4 B/D PA

AYVAKIT 5 PA; LA; QL (30/30);

NDS

azacitidine 4 B/D PA

azathioprine oral tablet 50 mg 2 B/D PA

azathioprine sodium 4 B/D PA

BALVERSA 5 PA; LA; NDS

BAVENCIO 5 PA; NDS

BELEODAQ 4 B/D PA

bendamustine intravenous

recon soln

5 B/D PA; NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

doxorubicin intravenous recon

soln 50 mg

4 B/D PA

doxorubicin intravenous

solution

4 B/D PA

doxorubicin, peg-liposomal 4 B/D PA

DROXIA 4

ELREXFIO 5 PA; NDS

ELZONRIS 5 PA; NDS

EMCYT 4

EMPLICITI 4 PA

ENHERTU 5 PA; NDS

epirubicin intravenous solution 4 B/D PA

EPKINLY 4 PA

ERBITUX 4 B/D PA

ERIVEDGE 5 PA; QL (30/30);

NDS

ERLEADA ORAL TABLET

240 MG

5 PA; LA; QL (30/30);

NDS

ERLEADA ORAL TABLET

60 MG

5 PA; QL (120/30);

NDS

erlotinib oral tablet 100 mg, 150

5 PA; QL (30/30);

NDS

erlotinib oral tablet 25 mg 5 PA; QL (60/30);

NDS

ETOPOPHOS 4 B/D PA

etoposide intravenous 3 B/D PA

everolimus (antineoplastic) oral

tablet

5 PA; QL (30/30);

NDS

everolimus (antineoplastic) oral

tablet for suspension 2 mg

5 PA; QL (150/30);

NDS

everolimus (antineoplastic) oral

tablet for suspension 3 mg, 5

5 PA; QL (56/28);

NDS

everolimus

(immunosuppressive)

5 B/D PA; NDS

EVOMELA 5 PA; NDS

exemestane 4

EXKIVITY 5 PA; LA; QL

(120/30); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

COMETRIQ ORAL CAPSULE

100 MG/DAY(80 MG X1-20 MG

X1)

5 PA; QL (56/28);

NDS

COMETRIQ ORAL CAPSULE

140 MG/DAY(80 MG X1-20 MG

X3)

5 PA; QL (112/28);

NDS

COMETRIQ ORAL CAPSULE

60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28);

NDS

COPIKTRA 5 PA; LA; QL (60/30);

NDS

COTELLIC 5 PA; LA; QL (63/28);

NDS

cyclophosphamide intravenous

recon soln

5 B/D PA; NDS

CYCLOPHOSPHAMIDE

INTRAVENOUS SOLUTION

5 B/D PA; NDS

cyclophosphamide oral capsule 3 B/D PA

cyclophosphamide oral tablet

25 mg

3 B/D PA

CYCLOPHOSPHAMIDE ORAL

TABLET 50 MG

3 B/D PA

cyclosporine intravenous 4 B/D PA

cyclosporine modied 4 B/D PA

cyclosporine oral capsule 4 B/D PA

CYRAMZA 5 PA; NDS

cytarabine 4 B/D PA

cytarabine (pf) 4 B/D PA

dacarbazine 4 B/D PA

dactinomycin 4 B/D PA

DANYELZA 4 PA

DARZALEX 5 PA; NDS

DARZALEX FASPRO 5 PA; NDS

daunorubicin intravenous

solution

4 B/D PA

DAURISMO ORAL TABLET

100 MG

5 PA; QL (30/30);

NDS

DAURISMO ORAL TABLET

25 MG

5 PA; QL (60/30);

NDS

decitabine 4 B/D PA

docetaxel 4 B/D PA

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

IFOSFAMIDE INTRAVENOUS

RECON SOLN 3 GRAM

4 B/D PA

ifosfamide intravenous solution 4 B/D PA

imatinib oral tablet 100 mg 5 PA; QL (180/30);

NDS

imatinib oral tablet 400 mg 5 PA; QL (60/30);

NDS

IMBRUVICA ORAL CAPSULE

140 MG

5 PA; QL (120/30);

NDS

IMBRUVICA ORAL CAPSULE

70 MG

5 PA; QL (30/30);

NDS

IMBRUVICA ORAL

SUSPENSION

5 PA; QL (180/30);

NDS

IMBRUVICA ORAL TABLET

140 MG, 280 MG, 420 MG

5 PA; QL (30/30);

NDS

IMFINZI 5 PA; NDS

IMJUDO 5 PA; LA; NDS

INFUGEM 5 B/D PA; NDS

INLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDS

INLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDS

INQOVI 5 PA; QL (5/28); NDS

INREBIC 5 PA; LA; QL

(120/30); NDS

IRESSA 5 PA; QL (30/30);

NDS

irinotecan 4 B/D PA

IXEMPRA 4 B/D PA

JAKAFI 5 PA; QL (60/30);

NDS

JAYPIRCA 5 PA; NDS

JEMPERLI 4 PA

JEVTANA 4 B/D PA

KADCYLA 5 PA; NDS

KANJINTI 5 PA; NDS

KEYTRUDA 5 PA; NDS

KIMMTRAK 4 PA

KISQALI 5 PA; QL (63/28);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

FARYDAK 5 PA; QL (6/21); NDS

FIRMAGON KIT W DILUENT

SYRINGE

4 B/D PA

oxuridine 4 B/D PA

udarabine 4 B/D PA

uorouracil intravenous 4 B/D PA

FOLOTYN 5 B/D PA; NDS

FOTIVDA 5 PA; LA; QL (21/28);

NDS

fulvestrant 5 B/D PA; NDS

FYARRO 4 PA; LA; NDS

GAVRETO 5 PA; LA; QL

(120/30); NDS

GAZYVA 5 PA; NDS

getinib 5 QL (30/30); NDS

gemcitabine intravenous recon

soln

4 B/D PA

gemcitabine intravenous

solution 1 gram/26.3 ml (38 mg/

ml), 2 gram/52.6 ml (38 mg/ml),

200 mg/5.26 ml (38 mg/ml)

4 B/D PA

GEMCITABINE

INTRAVENOUS SOLUTION

100 MG/ML

5 B/D PA; NDS

gengraf 4 B/D PA

GILOTRIF 5 PA; QL (30/30);

NDS

GLEOSTINE 4

HALAVEN 5 PA; NDS

hydroxyurea 2

IBRANCE 5 PA; QL (21/28);

NDS

ICLUSIG 5 PA; QL (30/30);

NDS

idarubicin 4 B/D PA

IDHIFA 5 PA; LA; QL (30/30);

NDS

ifosfamide intravenous recon

soln 1 gram

4 B/D PA

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

LORBRENA ORAL TABLET

25 MG

5 PA; QL (90/30);

NDS

LUMAKRAS ORAL TABLET

120 MG

5 PA; QL (240/30);

NDS

LUMAKRAS ORAL TABLET

320 MG

5 PA; QL (90/30);

NDS

LUMOXITI 5 PA; NDS

LUNSUMIO 5 PA; LA; NDS

LUPRON DEPOT 5 PA; NDS

LUPRON DEPOT (3 MONTH) 4 PA

LUPRON DEPOT (4 MONTH) 4 PA

LUPRON DEPOT (6 MONTH) 4 PA

LUPRON DEPOT-PED

(3 MONTH) INTRAMUSCULAR

SYRINGE KIT 11.25 MG

4 PA

LUPRON DEPOT-PED

(3 MONTH) INTRAMUSCULAR

SYRINGE KIT 30 MG

5 PA; NDS

LUPRON DEPOT-PED

INTRAMUSCULAR KIT

5 PA; NDS

LUPRON DEPOT-PED

INTRAMUSCULAR SYRINGE

KIT

4 PA

LYNPARZA 5 PA; QL (120/30);

NDS

LYSODREN 5 NDS

LYTGOBI 5 PA; LA; QL

(150/30); NDS

MARGENZA 5 PA; NDS

MARQIBO 4 B/D PA

MATULANE 5 NDS

megestrol oral suspension 400

mg/10 ml (10 ml), 400 mg/10

ml (40 mg/ml), 800 mg/20 ml

(20 ml)

4 PA

megestrol oral tablet 20 mg 4 PA

megestrol oral tablet 40 mg 3 PA

MEKINIST ORAL RECON

SOLN

5 PA; QL (1350/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

KISQALI FEMARA CO-PACK

ORAL TABLET 200 MG/

DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28);

NDS

KISQALI FEMARA CO-PACK

ORAL TABLET 400 MG/

DAY(200 MG X 2)-2.5 MG

5 PA; QL (70/28);

NDS

KISQALI FEMARA CO-PACK

ORAL TABLET 600 MG/

DAY(200 MG X 3)-2.5 MG

5 PA; QL (91/28);

NDS

KLISYRI 4 ST; QL (5/30)

KRAZATI 5 PA; LA; QL

(180/30); NDS

KYPROLIS 5 B/D PA; NDS

lapatinib 5 PA; QL (180/30);

NDS

lenalidomide oral capsule 10

mg, 15 mg, 25 mg, 5 mg

5 PA; LA; QL (28/28);

NDS

LENALIDOMIDE ORAL

CAPSULE 2.5 MG, 20 MG

5 PA; QL (28/28);

NDS

LENVIMA ORAL CAPSULE

10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30);

NDS

LENVIMA ORAL CAPSULE

12 MG/DAY (4 MG X 3),

18 MG/DAY (10 MG X 1-4 MG

X2), 24 MG/DAY(10 MG X

2-4 MG X 1)

5 PA; QL (90/30);

NDS

LENVIMA ORAL CAPSULE

14 MG/DAY(10 MG X 1-4 MG

X 1), 20 MG/DAY (10 MG X 2),

8 MG/DAY (4 MG X 2)

5 PA; QL (60/30);

NDS

letrozole 2

LEUKERAN 4

leuprolide (3 month) 4 PA

leuprolide subcutaneous kit 4 PA

LIBTAYO 5 PA; NDS

LONSURF ORAL TABLET

15-6.14 MG

5 PA; QL (100/28);

NDS

LONSURF ORAL TABLET

20-8.19 MG

5 PA; QL (80/28);

NDS

LORBRENA ORAL TABLET

100 MG

5 PA; QL (30/30);

NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ONIVYDE 4 PA

ONUREG 4 PA; QL (14/28)

OPDIVO 5 PA; NDS

OPDUALAG 4 PA

ORGOVYX 4 PA; LA; QL (30/28)

ORSERDU 5 PA; NDS

oxaliplatin 4 B/D PA

paclitaxel 4 B/D PA

PACLITAXEL PROTEIN-

BOUND

5 PA; NDS

PADCEV 4 PA

PEMAZYRE 5 PA; LA; QL (14/21);

NDS

pemetrexed disodium

intravenous recon soln

5 PA; NDS

PERJETA 5 PA; NDS

PHESGO 5 PA; NDS

PIQRAY 5 PA; NDS

POLIVY 5 PA; NDS

POMALYST 5 PA; LA; QL (21/28);

NDS

PORTRAZZA 4 B/D PA

POTELIGEO 5 PA; NDS

PROGRAF INTRAVENOUS 4 B/D PA

PROGRAF ORAL GRANULES

IN PACKET

4 B/D PA

PURIXAN 5 NDS

QINLOCK 5 PA; LA; QL (90/30);

NDS

RETEVMO ORAL CAPSULE

40 MG

5 PA; LA; QL

(180/30); NDS

RETEVMO ORAL CAPSULE

80 MG

5 PA; LA; QL

(120/30); NDS

REVLIMID ORAL CAPSULE

2.5 MG, 20 MG

5 PA; LA; QL (28/28);

NDS

REZLIDHIA 5 PA; LA; QL (60/30);

NDS

romidepsin intravenous recon

soln

5 PA; NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

MEKINIST ORAL TABLET

0.5 MG

5 PA; QL (90/30);

NDS

MEKINIST ORAL TABLET

2 MG

5 PA; QL (30/30);

NDS

MEKTOVI 5 PA; LA; QL

(180/30); NDS

melphalan hcl 5 B/D PA; NDS

mercaptopurine 4

methotrexate sodium (pf) 4 B/D PA

methotrexate sodium injection 4 B/D PA

methotrexate sodium oral 2

mitomycin intravenous 4 B/D PA

mitoxantrone 4 B/D PA

MONJUVI 4 PA

MVASI 5 PA; NDS

mycophenolate mofetil (hcl) 4 B/D PA

mycophenolate mofetil oral

capsule

3 B/D PA

mycophenolate mofetil oral

suspension for reconstitution

5 B/D PA; NDS

mycophenolate mofetil oral

tablet

4 B/D PA

mycophenolate sodium 4 B/D PA

MYLOTARG 5 PA; NDS

nelarabine 4 B/D PA

NERLYNX 5 PA; LA; NDS

nilutamide 5 NDS

NINLARO 5 PA; QL (3/28); NDS

NIPENT 4 B/D PA

NUBEQA 5 PA; LA; QL

(120/30); NDS

NULOJIX 5 B/D PA; NDS

octreotide acetate 4 PA

ODOMZO 5 PA; LA; QL (30/30);

NDS

OGIVRI 5 PA; NDS

OJJAARA 5 PA; QL (30/30);

NDS

ONCASPAR 4 B/D PA

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TAFINLAR ORAL CAPSULE 5 PA; QL (120/30);

NDS

TAFINLAR ORAL TABLET FOR

SUSPENSION

5 PA; QL (840/28);

NDS

TAGRISSO 5 PA; LA; QL (30/30);

NDS

TALVEY 4 PA

TALZENNA ORAL CAPSULE

0.1 MG, 0.35 MG, 0.5 MG,

0.75 MG, 1 MG

5 PA; QL (30/30);

NDS

TALZENNA ORAL CAPSULE

0.25 MG

5 PA; QL (90/30);

NDS

tamoxifen 2

TASIGNA ORAL CAPSULE

150 MG, 200 MG

5 PA; QL (112/28);

NDS

TASIGNA ORAL CAPSULE

50 MG

5 PA; QL (120/30);

NDS

TAZVERIK 4 PA; LA

TECENTRIQ 5 PA; NDS

TECVAYLI 4 PA

TEMODAR INTRAVENOUS 4 B/D PA

temsirolimus 4 B/D PA

TEPMETKO 5 PA; LA; QL (60/30);

NDS

THALOMID ORAL CAPSULE

100 MG, 50 MG

5 PA; QL (28/28);

NDS

THALOMID ORAL CAPSULE

150 MG, 200 MG

5 PA; QL (56/28);

NDS

thiotepa 4 PA

TIBSOVO 5 PA; NDS

TIVDAK 4 PA

topotecan intravenous recon

soln

5 B/D PA; NDS

topotecan intravenous solution 4 B/D PA

toremifene 5 NDS

TRAZIMERA 5 PA; NDS

TREANDA 5 B/D PA; NDS

TRELSTAR INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION

4 PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ROMIDEPSIN INTRAVENOUS

SOLUTION

5 PA; NDS

ROZLYTREK ORAL CAPSULE

100 MG

5 PA; QL (150/30);

NDS

ROZLYTREK ORAL CAPSULE

200 MG

5 PA; QL (90/30);

NDS

RUBRACA 5 PA; LA; QL

(120/30); NDS

RUXIENCE 5 PA; NDS

RYBREVANT 4 PA

RYDAPT 5 PA; QL (240/30);

NDS

RYLAZE 4 B/D PA

SANDIMMUNE ORAL

SOLUTION

4 B/D PA

SARCLISA 4 PA

SCEMBLIX ORAL TABLET

20 MG

5 PA; QL (600/30);

NDS

SCEMBLIX ORAL TABLET

40 MG

5 PA; QL (300/30);

NDS

SIGNIFOR 5 PA; NDS

SIMULECT 5 B/D PA; NDS

sirolimus 4 B/D PA

SOLTAMOX 4

SOMATULINE DEPOT 5 PA; NDS

sorafenib 5 PA; QL (120/30);

NDS

SPRYCEL ORAL TABLET

100 MG, 140 MG, 50 MG,

80 MG

5 PA; QL (30/30);

NDS

SPRYCEL ORAL TABLET

20 MG, 70 MG

5 PA; QL (60/30);

NDS

STIVARGA 5 PA; QL (84/28);

NDS

sunitinib malate 5 PA; QL (30/30);

NDS

SYNRIBO 5 PA; NDS

TABLOID 4

TABRECTA 5 PA; NDS

tacrolimus oral 3 B/D PA

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VOTRIENT 5 PA; QL (120/30);

NDS

VYXEOS 5 B/D PA; NDS

WELIREG 5 PA; LA; QL (90/30);

NDS

XALKORI 5 PA; QL (60/30);

NDS

XATMEP 4 PA

XOSPATA 5 PA; LA; NDS

XPOVIO ORAL TABLET

100 MG/WEEK (50 MG X 2),

40 MG/WEEK (40 MG X 1),

40MG TWICE WEEK (40 MG X

2), 60 MG/WEEK (60 MG X 1),

60MG TWICE WEEK (120 MG/

WEEK), 80 MG/WEEK (40 MG

X 2), 80MG TWICE WEEK

(160 MG/WEEK)

5 PA; LA; NDS

XTANDI ORAL CAPSULE 5 PA; QL (120/30);

NDS

XTANDI ORAL TABLET 40 MG 5 PA; QL (120/30);

NDS

XTANDI ORAL TABLET 80 MG 5 PA; QL (60/30);

NDS

YERVOY 5 PA; NDS

YONDELIS 5 PA; NDS

ZALTRAP 4 B/D PA

ZANOSAR 4 B/D PA

ZEJULA ORAL CAPSULE 5 PA; LA; QL (90/30);

NDS

ZEJULA ORAL TABLET 5 PA; LA; QL (30/30);

NDS

ZELBORAF 5 PA; QL (240/30);

NDS

ZEPZELCA 4 PA

ZIRABEV 5 PA; NDS

ZOLADEX 4 B/D PA

ZOLINZA 5 PA; QL (120/30);

NDS

ZYDELIG 5 PA; QL (60/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

tretinoin (antineoplastic) 5 NDS

TRIPTODUR 5 PA; QL (1/168);

NDS

TRODELVY 4 PA

TRUXIMA 5 PA; NDS

TUKYSA ORAL TABLET

150 MG

5 PA; LA; QL

(120/30); NDS

TUKYSA ORAL TABLET

50 MG

5 PA; LA; QL

(300/30); NDS

TURALIO ORAL CAPSULE

125 MG

5 PA; LA; QL

(120/30); NDS

UNITUXIN 5 PA; NDS

valrubicin 4 B/D PA

VANFLYTA 5 PA; QL (56/28);

NDS

VECTIBIX 5 PA; NDS

VELCADE 5 PA; NDS

VENCLEXTA ORAL TABLET

10 MG

4 PA; LA; QL (60/30)

VENCLEXTA ORAL TABLET

100 MG

5 PA; LA; QL

(120/30); NDS

VENCLEXTA ORAL TABLET

50 MG

5 PA; LA; QL (30/30);

NDS

VENCLEXTA STARTING PACK 5 PA; LA; QL

(84/365); NDS

VERZENIO 5 PA; LA; QL (60/30);

NDS

vinblastine 4 B/D PA

vincristine 4 B/D PA

vinorelbine 4 B/D PA

VITRAKVI ORAL CAPSULE

100 MG

5 PA; LA; QL (60/30);

NDS

VITRAKVI ORAL CAPSULE

25 MG

5 PA; LA; QL

(180/30); NDS

VITRAKVI ORAL SOLUTION 5 PA; LA; QL

(300/30); NDS

VIZIMPRO 5 PA; QL (30/30);

NDS

VONJO 5 PA; QL (120/30);

NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

DIACOMIT 5 LA; NDS

diazepam rectal 4

dilantin 4

divalproex oral capsule,

delayed rel sprinkle

divalproex oral tablet extended

release 24 hr

divalproex oral tablet,delayed

release (dr/ec)

EPIDIOLEX 5 PA; LA; NDS

epitol 2

EPRONTIA 4 PA

ethosuximide 4

felbamate 4

FINTEPLA 4 PA; LA; QL (360/30)

fosphenytoin 3

FYCOMPA ORAL

SUSPENSION

4 QL (720/30)

FYCOMPA ORAL TABLET

10 MG, 12 MG, 8 MG

4 QL (30/30)

FYCOMPA ORAL TABLET

2 MG, 4 MG, 6 MG

4 QL (60/30)

gabapentin oral capsule 100

mg, 300 mg

2 QL (360/30)

gabapentin oral capsule 400

2 QL (270/30)

gabapentin oral solution 4 QL (2160/30)

gabapentin oral tablet 600 mg 2 QL (180/30)

gabapentin oral tablet 800 mg 2 QL (120/30)

lacosamide intravenous 4 QL (1200/30)

lacosamide oral solution 4 QL (1200/30)

lacosamide oral tablet 100 mg,

150 mg, 200 mg

3 QL (60/30)

lacosamide oral tablet 50 mg 3 QL (120/30)

lamotrigine oral tablet 2

lamotrigine oral tablet extended

release 24hr

lamotrigine oral tablet,

chewable dispersible

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ZYKADIA 5 PA; QL (90/30);

NDS

ZYNLONTA 4 PA

ZYNYZ 5 PA; NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET

200 MG

4 QL (180/30)

APTIOM ORAL TABLET

400 MG

4 QL (90/30)

APTIOM ORAL TABLET

600 MG, 800 MG

4 QL (60/30)

BRIVIACT INTRAVENOUS 4

BRIVIACT ORAL SOLUTION 4 QL (600/30)

BRIVIACT ORAL TABLET 4 QL (60/30)

carbamazepine oral capsule, er

multiphase 12 hr

carbamazepine oral suspension 4

carbamazepine oral tablet 3

carbamazepine oral tablet

extended release 12 hr

carbamazepine oral

tablet,chewable

CELONTIN ORAL CAPSULE

300 MG

clobazam oral suspension 4 PA; QL (480/30)

clobazam oral tablet 10 mg 4 PA; QL (120/30)

clobazam oral tablet 20 mg 4 PA; QL (60/30)

clonazepam oral tablet 0.5 mg,

1 mg

2 QL (120/30)

clonazepam oral tablet 2 mg 2 QL (300/30)

clonazepam oral

tablet,disintegrating 0.125 mg,

0.25 mg

4 QL (90/30)

clonazepam oral

tablet,disintegrating 0.5 mg, 1

4 QL (120/30)

clonazepam oral

tablet,disintegrating 2 mg

4 QL (300/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

runamide oral tablet 3 PA

SPRITAM 4

subvenite 2

subvenite starter (blue) kit 2

subvenite starter (green) kit 2

subvenite starter (orange) kit 2

SYMPAZAN 5 PA; QL (60/30);

NDS

tiagabine 4

topiramate oral capsule,

sprinkle

2 PA

topiramate oral

capsule,extended release 24hr

4 PA

topiramate oral tablet 2 PA

TROKENDI XR 4 PA

valproate sodium 3

valproic acid 2

valproic acid (as sodium salt) 2

VALTOCO 4 PA; QL (10/30)

vigabatrin 5 PA; LA; QL

(180/30); NDS

vigadrone 5 PA; LA; QL

(180/30); NDS

XCOPRI MAINTENANCE

PACK ORAL TABLET 250MG/

DAY(150 MG X1-100MG

X1), 350 MG/DAY (200 MG

X1-150MG X1)

4 PA; QL (56/28)

XCOPRI ORAL TABLET

100 MG

4 PA; QL (120/30)

XCOPRI ORAL TABLET

150 MG, 200 MG

4 PA; QL (60/30)

XCOPRI ORAL TABLET 50 MG 4 PA; QL (240/30)

XCOPRI TITRATION PACK 4 PA; QL (56/365)

ZONISADE 5 PA; NDS

zonisamide 3 PA

ZTALMY 5 LA; QL (90/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lamotrigine oral

tablet,disintegrating

lamotrigine oral tablets,dose

pack

levetiracetam in nacl (iso-os)

intravenous piggyback 1,000

mg/100 ml, 1,500 mg/100 ml,

500 mg/100 ml

levetiracetam intravenous 3

levetiracetam oral solution 3

levetiracetam oral tablet 2

levetiracetam oral tablet

extended release 24 hr

methsuximide 3

NAYZILAM 4 PA; QL (10/30)

oxcarbazepine 3

phenobarbital oral elixir 4 PA; QL (1500/30)

phenobarbital oral tablet 3 PA; QL (120/30)

phenobarbital sodium injection

solution

phenytoin oral suspension 2

phenytoin oral tablet,chewable 3

phenytoin sodium extended

oral capsule 100 mg, 200 mg

phenytoin sodium extended

oral capsule 300 mg

phenytoin sodium intravenous

solution

pregabalin oral capsule 100

mg, 150 mg, 25 mg, 50 mg, 75

3 QL (120/30)

pregabalin oral capsule 200 mg 3 QL (90/30)

pregabalin oral capsule 225

mg, 300 mg

3 QL (60/30)

pregabalin oral solution 3 QL (900/30)

primidone oral tablet 125 mg 4

primidone oral tablet 250 mg,

50 mg

roweepra oral tablet 500 mg 2

runamide oral suspension 5 PA; NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

sumatriptan nasal spray,non-

aerosol 5 mg/actuation

4 QL (36/28)

sumatriptan succinate oral 2 QL (18/28)

SUMATRIPTAN SUCCINATE

SUBCUTANEOUS

CARTRIDGE

4 QL (8/28)

sumatriptan succinate

subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate

subcutaneous solution

4 QL (8/28)

UBRELVY 3 PA; QL (20/30)

MISCELLANEOUS NEUROLOGICAL THERAPY

ADLARITY 4 ST; QL (4/28)

AUBAGIO 5 PA; QL (30/30);

NDS

AUSTEDO ORAL TABLET

12 MG, 9 MG

5 PA; LA; QL

(120/30); NDS

AUSTEDO ORAL TABLET

6 MG

5 PA; LA; QL (60/30);

NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

12 MG

5 PA; LA; QL

(120/30); NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

24 MG

5 PA; LA; QL (60/30);

NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

6 MG

5 PA; LA; QL

(240/30); NDS

AUSTEDO XR TITRATION

KT(WK1-4)

5 PA; QL (84/365);

NDS

COPAXONE SUBCUTANEOUS

SYRINGE 20 MG/ML

5 PA; QL (30/30);

NDS

COPAXONE SUBCUTANEOUS

SYRINGE 40 MG/ML

5 PA; QL (12/28);

NDS

dalfampridine 3 PA; QL (60/30)

donepezil oral tablet 10 mg 2 QL (60/30)

donepezil oral tablet 5 mg 2 QL (30/30)

donepezil oral

tablet,disintegrating 10 mg

2 QL (60/30)

donepezil oral

tablet,disintegrating 5 mg

2 QL (30/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ANTIPARKINSONISM AGENTS

benztropine injection 4

benztropine oral 2 PA

bromocriptine 4

carbidopa 4

carbidopa-levodopa oral tablet 2

carbidopa-levodopa oral tablet

extended release

carbidopa-levodopa oral

tablet,disintegrating 10-100 mg

carbidopa-levodopa oral

tablet,disintegrating 25-100 mg,

25-250 mg

carbidopa-levodopa-

entacapone

entacapone 4

GOCOVRI 4 ST

NEUPRO 4

ONGENTYS 3

pramipexole oral tablet 2

rasagiline 4

ropinirole oral tablet 2

ropinirole oral tablet extended

release 24 hr

RYTARY 4 ST

selegiline hcl 3

MIGRAINE / CLUSTER HEADACHE THERAPY

AIMOVIG AUTOINJECTOR 3 PA; QL (1/30)

AJOVY AUTOINJECTOR 3 PA; QL (1.5/30)

AJOVY SYRINGE 3 PA; QL (1.5/30)

dihydroergotamine nasal 4 PA; QL (8/28)

ergotamine-caffeine 3

naratriptan 4 QL (18/28)

NURTEC ODT 3 PA; QL (16/30)

rizatriptan oral tablet 2 QL (36/28)

rizatriptan oral

tablet,disintegrating

4 QL (36/28)

sumatriptan nasal spray,non-

aerosol 20 mg/actuation

4 QL (18/28)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

cyclobenzaprine oral tablet 10

mg, 5 mg

3 PA

dantrolene oral 4

methocarbamol oral tablet 500

mg, 750 mg

3 PA

pyridostigmine bromide oral

syrup

pyridostigmine bromide oral

tablet 60 mg

pyridostigmine bromide oral

tablet extended release

tizanidine oral tablet 2

NARCOTIC ANALGESICS

acetaminophen-codeine oral

solution 120 mg-12 mg /5 ml (5

ml), 120-12 mg/5 ml

3 QL (4500/30); NDS

acetaminophen-codeine oral

tablet 300-15 mg, 300-30 mg

3 QL (360/30); NDS

acetaminophen-codeine oral

tablet 300-60 mg

3 QL (180/30); NDS

buprenorphine hcl injection 4 NDS

buprenorphine hcl sublingual 3 PA

endocet oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

endocet oral tablet 2.5-325 mg 4 QL (360/30); NDS

fentanyl citrate buccal lozenge

on a handle 1,200 mcg, 1,600

mcg, 400 mcg, 600 mcg, 800

mcg

5 PA; QL (120/30);

NDS

fentanyl citrate buccal lozenge

on a handle 200 mcg

4 PA; QL (120/30);

NDS

fentanyl transdermal patch 72

hour 100 mcg/hr, 12 mcg/hr, 25

mcg/hr, 50 mcg/hr, 75 mcg/hr

4 QL (10/30); NDS

hydrocodone-acetaminophen

oral solution 7.5-325 mg/15 ml

4 QL (5550/30); NDS

hydrocodone-acetaminophen

oral tablet 10-325 mg, 5-325

mg, 7.5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen oral

tablet 7.5-200 mg

4 QL (50/30); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ngolimod 5 PA; QL (30/30);

NDS

galantamine oral capsule,ext

rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)

galantamine oral tablet 3 QL (60/30)

GILENYA 5 PA; QL (30/30);

NDS

INGREZZA 5 PA; LA; QL (30/30);

NDS

INGREZZA INITIATION PACK 5 PA; LA; QL

(56/365); NDS

KESIMPTA PEN 5 PA; QL (1.2/28);

NDS

memantine oral

capsule,sprinkle,er 24hr

4 PA

memantine oral solution 4 PA; QL (300/30)

memantine oral tablet 10 mg 3 PA; QL (60/30)

memantine oral tablet 5 mg 3 PA; QL (90/30)

MEMANTINE ORAL TABLETS,

DOSE PACK

3 PA; QL (98/365)

NAMZARIC 3 PA

NUEDEXTA 5 PA; NDS

OCREVUS 4 PA

rivastigmine 4

rivastigmine tartrate 4 QL (60/30)

teriunomide 4 PA; QL (30/30)

tetrabenazine oral tablet 12.5

4 PA; QL (240/30)

tetrabenazine oral tablet 25 mg 4 PA; QL (120/30)

VUMERITY 5 PA; QL (120/30);

NDS

ZEPOSIA 5 PA; QL (30/30);

NDS

ZEPOSIA STARTER KIT (28-

DAY)

5 PA; QL (56/365);

NDS

ZEPOSIA STARTER PACK

(7-DAY)

5 PA; QL (14/365);

NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen oral tablet 2

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

XTAMPZA ER 4 PA; QL (90/30);

NDS

NON-NARCOTIC ANALGESICS

buprenorphine-naloxone

sublingual lm 12-3 mg

4 QL (60/30)

buprenorphine-naloxone

sublingual lm 2-0.5 mg

4 QL (360/30)

buprenorphine-naloxone

sublingual lm 4-1 mg, 8-2 mg

4 QL (90/30)

buprenorphine-naloxone

sublingual tablet 2-0.5 mg

2 QL (360/30)

buprenorphine-naloxone

sublingual tablet 8-2 mg

2 QL (90/30)

butorphanol nasal 4 QL (10/28)

celecoxib 3 QL (60/30)

DICLOFENAC EPOLAMINE 4 PA; QL (60/30)

diclofenac potassium oral tablet

50 mg

diclofenac sodium oral 2

diclofenac sodium topical drops 4 QL (300/28)

diclofenac sodium topical gel

3 QL (1000/28)

diunisal 2

EC-NAPROXEN ORAL

TABLET, DELAYED RELEASE

(DR/EC) 375 MG

EC-NAPROXEN ORAL

TABLET, DELAYED RELEASE

(DR/EC) 500 MG

etodolac oral capsule 3

etodolac oral tablet 3

etodolac oral tablet extended

release 24 hr

urbiprofen oral tablet 100 mg 2

ibu 1

ibuprofen oral suspension 4

ibuprofen oral tablet 400 mg,

600 mg, 800 mg

KLOXXADO 3

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

hydromorphone oral liquid 4 QL (2400/30); NDS

hydromorphone oral tablet 4 QL (180/30); NDS

INFUMORPH P/F 4 B/D PA; NDS

methadone injection solution 4 NDS

methadone intensol 4 QL (90/30); NDS

methadone oral concentrate 4 QL (90/30); NDS

methadone oral solution 10

mg/5 ml

4 QL (600/30); NDS

methadone oral solution 5 mg/5

4 QL (1200/30); NDS

methadone oral tablet 10 mg 2 QL (120/30); NDS

methadone oral tablet 5 mg 2 QL (240/30); NDS

morphine (pf) injection solution

0.5 mg/ml, 1 mg/ml

4 NDS

morphine concentrate oral

solution

3 QL (900/30); NDS

MORPHINE INJECTION

SOLUTION

4 NDS

MORPHINE INJECTION

SYRINGE 2 MG/ML, 4 MG/ML,

8 MG/ML

4 NDS

morphine intravenous solution

10 mg/ml, 4 mg/ml, 8 mg/ml

4 NDS

MORPHINE INTRAVENOUS

SYRINGE

4 NDS

morphine oral solution 3 QL (900/30); NDS

morphine oral tablet 3 QL (180/30); NDS

morphine oral tablet extended

release

3 QL (120/30); NDS

oxycodone oral concentrate 4 QL (180/30); NDS

oxycodone oral solution 4 QL (1200/30); NDS

oxycodone oral tablet 10 mg,

15 mg, 20 mg, 30 mg

3 QL (180/30); NDS

oxycodone oral tablet 5 mg 3 QL (360/30); NDS

oxycodone-acetaminophen oral

tablet 10-325 mg, 2.5-325 mg,

5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

oxymorphone oral tablet

extended release 12 hr

3 QL (90/30); NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

alprazolam oral

tablet,disintegrating 0.25 mg,

0.5 mg, 1 mg

3 QL (90/30)

alprazolam oral

tablet,disintegrating 2 mg

3 QL (150/30)

amitriptyline 2

amoxapine 3

aripiprazole oral solution 4

aripiprazole oral tablet 10 mg,

15 mg, 2 mg, 5 mg

4 QL (60/30)

aripiprazole oral tablet 20 mg,

30 mg

4 QL (30/30)

aripiprazole oral

tablet,disintegrating

4 QL (60/30)

ARISTADA INITIO 4 QL (4.8/365)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 1,064 MG/3.9 ML

4 QL (3.9/56)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 441 MG/1.6 ML

4 QL (1.6/28)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 662 MG/2.4 ML

4 QL (2.4/28)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 882 MG/3.2 ML

4 QL (3.2/28)

asenapine maleate sublingual

tablet 10 mg, 2.5 mg

4 QL (60/30)

asenapine maleate sublingual

tablet 5 mg

4 QL (90/30)

atomoxetine oral capsule 10

mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

atomoxetine oral capsule 100

mg, 60 mg, 80 mg

4 QL (30/30)

AUVELITY 4 ST; QL (60/30)

BELSOMRA 3 QL (30/30)

bupropion hcl oral tablet 100

2 QL (120/30)

bupropion hcl oral tablet 75 mg 2 QL (180/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

meloxicam oral tablet 15 mg 1

meloxicam oral tablet 7.5 mg 1 QL (60/30)

nabumetone 2

naloxone injection solution 2

naloxone injection syringe 1

mg/ml

naloxone nasal 3

naltrexone 3

naproxen oral suspension 4

naproxen oral tablet 1

naproxen oral tablet,delayed

release (dr/ec) 375 mg

naproxen oral tablet,delayed

release (dr/ec) 500 mg

naproxen sodium oral tablet

275 mg, 550 mg

naproxen-esomeprazole 4 PA; QL (60/30)

NUCYNTA ER 4 PA; QL (60/30)

oxaprozin 4

PENNSAID TOPICAL

SOLUTION IN METERED-

DOSE PUMP

4 PA; QL (224/28)

sulindac 2

tramadol oral tablet 50 mg 2 QL (240/30); NDS

tramadol-acetaminophen 2 QL (240/30); NDS

VIVITROL 5 NDS

ZIMHI 4

ZUBSOLV SUBLINGUAL

TABLET 0.7-0.18 MG,

1.4-0.36 MG, 11.4-2.9 MG,

2.9-0.71 MG, 5.7-1.4 MG

3 QL (30/30)

ZUBSOLV SUBLINGUAL

TABLET 8.6-2.1 MG

3 QL (60/30)

PSYCHOTHERAPEUTIC DRUGS

ABILIFY MAINTENA 4 QL (1/28)

alprazolam oral tablet 0.25 mg,

0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

dextroamphetamine sulfate oral

capsule, extended release

dextroamphetamine sulfate oral

tablet

dextroamphetamine-

amphetamine oral

capsule,extended release 24hr

4 QL (60/30)

dextroamphetamine-

amphetamine oral tablet 10 mg

3 QL (180/30)

dextroamphetamine-

amphetamine oral tablet 12.5

mg, 30 mg, 7.5 mg

3 QL (60/30)

dextroamphetamine-

amphetamine oral tablet 15 mg

3 QL (120/30)

dextroamphetamine-

amphetamine oral tablet 20 mg

3 QL (90/30)

dextroamphetamine-

amphetamine oral tablet 5 mg

3 QL (360/30)

diazepam injection 2

diazepam intensol 3 QL (360/30)

diazepam oral concentrate 3 QL (360/30)

diazepam oral solution 4 QL (1800/30)

diazepam oral tablet 2 QL (180/30)

doxepin oral capsule 3

doxepin oral concentrate 3

doxepin oral tablet 3 QL (30/30)

DRIZALMA SPRINKLE ORAL

CAPSULE, DELAYED REL

SPRINKLE 20 MG, 60 MG

4 QL (60/30)

DRIZALMA SPRINKLE ORAL

CAPSULE, DELAYED REL

SPRINKLE 30 MG

4 QL (120/30)

DRIZALMA SPRINKLE ORAL

CAPSULE, DELAYED REL

SPRINKLE 40 MG

4 QL (90/30)

duloxetine oral capsule,delayed

release(dr/ec) 20 mg, 60 mg

2 QL (60/30)

duloxetine oral capsule,delayed

release(dr/ec) 30 mg

2 QL (120/30)

EMSAM 4 QL (30/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

bupropion hcl oral tablet

extended release 24 hr 150 mg

3 QL (90/30)

bupropion hcl oral tablet

extended release 24 hr 300 mg

3 QL (30/30)

bupropion hcl oral tablet

sustained-release 12 hr 100 mg

2 QL (120/30)

bupropion hcl oral tablet

sustained-release 12 hr 150

mg, 200 mg

2 QL (60/30)

buspirone 2

CAPLYTA 4 QL (30/30)

chlorpromazine 4

citalopram oral solution 4

citalopram oral tablet 10 mg,

20 mg

1 QL (60/30)

citalopram oral tablet 40 mg 1 QL (30/30)

clomipramine 4

clorazepate dipotassium oral

tablet 15 mg

4 QL (180/30)

clorazepate dipotassium oral

tablet 3.75 mg

4 QL (90/30)

clorazepate dipotassium oral

tablet 7.5 mg

4 QL (360/30)

clozapine oral tablet 100 mg,

200 mg

clozapine oral tablet 25 mg, 50

clozapine oral

tablet,disintegrating

DAYVIGO 3 QL (30/30)

desipramine 4

desvenlafaxine succinate oral

tablet extended release 24 hr

100 mg

4 QL (120/30)

desvenlafaxine succinate oral

tablet extended release 24 hr

25 mg

4 QL (60/30)

desvenlafaxine succinate oral

tablet extended release 24 hr

50 mg

4 QL (90/30)

dexmethylphenidate oral tablet 3

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

INVEGA HAFYERA

INTRAMUSCULAR SYRINGE

1,092 MG/3.5 ML

4 QL (3.5/180)

INVEGA HAFYERA

INTRAMUSCULAR SYRINGE

1,560 MG/5 ML

4 QL (5/180)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

117 MG/0.75 ML

4 QL (0.75/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

156 MG/ML

4 QL (1/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

234 MG/1.5 ML

4 QL (1.5/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

39 MG/0.25 ML

4 QL (0.25/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

78 MG/0.5 ML

4 QL (0.5/28)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

273 MG/0.88 ML

4 QL (0.88/90)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

410 MG/1.32 ML

4 QL (1.32/90)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

546 MG/1.75 ML

4 QL (1.75/90)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

819 MG/2.63 ML

4 QL (2.63/90)

lithium carbonate 2

lithium citrate oral solution 8

meq/5 ml

lorazepam injection solution 4

lorazepam injection syringe 2

mg/ml

lorazepam intensol 3 QL (150/30)

lorazepam oral concentrate 3 QL (150/30)

lorazepam oral syringe 3 QL (150/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

escitalopram oxalate oral

solution

4 QL (600/30)

escitalopram oxalate oral tablet

10 mg, 5 mg

2 QL (60/30)

escitalopram oxalate oral tablet

20 mg

2 QL (30/30)

FANAPT ORAL TABLET 1 MG,

10 MG, 12 MG, 2 MG, 4 MG,

6 MG

4 PA; QL (60/30)

FANAPT ORAL TABLET 8 MG 4 PA; QL (90/30)

FANAPT ORAL TABLETS,

DOSE PACK

4 PA; QL (16/365)

FETZIMA ORAL CAPSULE,

EXT REL 24HR DOSE PACK

4 ST; QL (56/365)

FETZIMA ORAL CAPSULE,

EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

uoxetine oral capsule 10 mg 2 QL (120/30)

uoxetine oral capsule 20 mg,

40 mg

2 QL (90/30)

uoxetine oral solution 2

uphenazine decanoate 4

uphenazine hcl injection 4

uphenazine hcl oral

concentrate

uphenazine hcl oral elixir 4

uphenazine hcl oral tablet 3

uvoxamine oral tablet 100 mg,

25 mg

3 QL (90/30)

uvoxamine oral tablet 50 mg 3 QL (120/30)

guanfacine oral tablet extended

release 24 hr

4 QL (30/30)

haloperidol 2

haloperidol decanoate 4

haloperidol lactate injection 4

haloperidol lactate oral 2

HETLIOZ 5 PA; QL (30/30);

NDS

imipramine hcl 3

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

olanzapine-uoxetine 4

oxazepam 4 QL (120/30)

paliperidone oral tablet

extended release 24hr 1.5 mg,

9 mg

4 PA; QL (30/30)

paliperidone oral tablet

extended release 24hr 3 mg,

6 mg

4 PA; QL (60/30)

paroxetine hcl oral suspension 4 ST; QL (900/30)

paroxetine hcl oral tablet 10 mg 2 QL (180/30)

paroxetine hcl oral tablet 20

mg, 40 mg

2 QL (30/30)

paroxetine hcl oral tablet 30 mg 2 QL (60/30)

perphenazine 4

perphenazine-amitriptyline 4

PERSERIS 4 QL (1/28)

phenelzine 3

pimozide 4

protriptyline 4

quetiapine oral tablet 100 mg,

25 mg, 50 mg

2 QL (120/30)

quetiapine oral tablet 150 mg,

200 mg

2 QL (90/30)

quetiapine oral tablet 300 mg,

400 mg

2 QL (60/30)

quetiapine oral tablet extended

release 24 hr 150 mg, 200 mg

4 QL (30/30)

quetiapine oral tablet extended

release 24 hr 300 mg, 400 mg,

50 mg

4 QL (60/30)

QUILLICHEW ER ORAL

TABLET, CHEW, IR-ER.

BIPHASIC24HR 20 MG, 30 MG

4 PA; QL (60/30)

QUILLICHEW ER ORAL

TABLET, CHEW, IR-ER.

BIPHASIC24HR 40 MG

4 PA; QL (30/30)

REXULTI ORAL TABLET 4 QL (30/30)

RISPERDAL CONSTA 4 QL (2/28)

risperidone oral solution 4

risperidone oral syringe 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lorazepam oral tablet 0.5 mg,

1 mg

2 QL (90/30)

lorazepam oral tablet 2 mg 2 QL (150/30)

loxapine succinate 4

lurasidone oral tablet 120 mg,

20 mg, 40 mg, 60 mg

4 QL (30/30)

lurasidone oral tablet 80 mg 4 QL (60/30)

LYBALVI 4 PA; QL (30/30)

MARPLAN 4 QL (180/30)

metadate er 4

methylphenidate hcl oral tablet 3 QL (90/30)

methylphenidate hcl oral tablet

extended release

methylphenidate hcl oral tablet

extended release 24hr 18 mg,

18 mg (bx rating), 27 mg, 27

mg (bx rating), 36 mg, 36 mg

(bx rating), 54 mg, 54 mg (bx

rating)

mirtazapine oral tablet 2

mirtazapine oral

tablet,disintegrating

3 QL (30/30)

modanil oral tablet 100 mg 3 PA; QL (30/30)

modanil oral tablet 200 mg 3 PA; QL (60/30)

molindone 3

nefazodone 4

nortriptyline oral capsule 2

nortriptyline oral solution 3

NUPLAZID 4 PA; QL (30/30)

olanzapine intramuscular 4 QL (30/30)

olanzapine oral tablet 10 mg,

2.5 mg, 5 mg, 7.5 mg

4 QL (60/30)

olanzapine oral tablet 15 mg,

20 mg

4 QL (30/30)

olanzapine oral

tablet,disintegrating 10 mg, 5

4 QL (60/30)

olanzapine oral

tablet,disintegrating 15 mg, 20

4 QL (30/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

venlafaxine oral

capsule,extended release 24hr

150 mg, 37.5 mg

2 QL (60/30)

venlafaxine oral

capsule,extended release 24hr

75 mg

2 QL (90/30)

venlafaxine oral tablet 100 mg,

25 mg, 37.5 mg

2 QL (90/30)

venlafaxine oral tablet 50 mg,

75 mg

2 QL (120/30)

VERSACLOZ 4

VIIBRYD ORAL TABLETS,

DOSE PACK 10 MG (7)-

20 MG (23)

4 ST; QL (60/365)

vilazodone 4 ST; QL (30/30)

VRAYLAR ORAL CAPSULE 4 QL (30/30)

VRAYLAR ORAL CAPSULE,

DOSE PACK

4 QL (14/365)

XYREM 5 PA; LA; QL

(540/30); NDS

zaleplon oral capsule 10 mg 3 QL (60/30)

zaleplon oral capsule 5 mg 3 QL (30/30)

ziprasidone hcl oral capsule 20

4 QL (180/30)

ziprasidone hcl oral capsule 40

4 QL (120/30)

ziprasidone hcl oral capsule 60

mg, 80 mg

4 QL (60/30)

ziprasidone mesylate 4 QL (6/30)

zolpidem oral tablet 2 QL (30/30)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 210 MG,

300 MG

4 PA; QL (2/28)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 405 MG

4 PA; QL (1/28)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

risperidone oral tablet 0.25 mg,

0.5 mg, 4 mg

2 QL (120/30)

risperidone oral tablet 1 mg 2 QL (180/30)

risperidone oral tablet 2 mg 2 QL (90/30)

risperidone oral tablet 3 mg 2 QL (60/30)

risperidone oral

tablet,disintegrating 0.25 mg,

0.5 mg, 4 mg

4 QL (120/30)

risperidone oral

tablet,disintegrating 1 mg

4 QL (180/30)

risperidone oral

tablet,disintegrating 2 mg

4 QL (90/30)

risperidone oral

tablet,disintegrating 3 mg

4 QL (60/30)

SECUADO 4 QL (30/30)

sertraline oral concentrate 4

sertraline oral tablet 2 QL (60/30)

SODIUM OXYBATE 5 PA; QL (540/30);

NDS

SPRAVATO NASAL SPRAY,

NON-AEROSOL 56 MG

(28 MG X 2)

4 PA; QL (16/28)

SPRAVATO NASAL SPRAY,

NON-AEROSOL 84 MG

(28 MG X 3)

4 PA; QL (18/28)

tasimelteon 5 PA; QL (30/30);

NDS

temazepam oral capsule 15

mg, 30 mg

2 QL (60/365)

thioridazine 4

thiothixene 4

tranylcypromine 4

trazodone oral tablet 100 mg,

150 mg, 50 mg

trazodone oral tablet 300 mg 2

triuoperazine oral tablet 1 mg 3

triuoperazine oral tablet 10

mg, 2 mg, 5 mg

trimipramine 4

TRINTELLIX 4 ST; QL (30/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

betaxolol oral 3

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide 1

bumetanide injection 4

bumetanide oral tablet 0.5 mg,

1 mg

bumetanide oral tablet 2 mg 3

BYSTOLIC 4 ST

candesartan oral tablet 16 mg,

4 mg, 8 mg

3 QL (60/30)

candesartan oral tablet 32 mg 3 QL (30/30)

candesartan-hydrochlorothiazid 3

captopril 4

CAROSPIR 3

cartia xt 2

carvedilol 1

carvedilol phosphate 4

chlorothiazide sodium 4

chlorthalidone oral tablet 25

mg, 50 mg

clonidine 3 QL (4/28)

clonidine hcl oral tablet 1

diltiazem hcl intravenous 4

diltiazem hcl oral capsule,ext.

rel 24h degradable

diltiazem hcl oral

capsule,extended release 12 hr

diltiazem hcl oral

capsule,extended release 24 hr

120 mg, 180 mg, 240 mg, 300

mg, 420 mg

diltiazem hcl oral

capsule,extended release 24hr

120 mg, 180 mg, 240 mg, 300

diltiazem hcl oral tablet 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone intravenous

solution

4 B/D PA

amiodarone oral tablet 100 mg,

400 mg

amiodarone oral tablet 200 mg 2

dofetilide 4

ecainide 4

LIDOCAINE (PF)

INTRAVENOUS SOLUTION

lidocaine (pf) intravenous

syringe

mexiletine 4

MULTAQ 4 QL (60/30)

pacerone oral tablet 100 mg,

400 mg

pacerone oral tablet 200 mg 2

propafenone 4

quinidine sulfate oral tablet 2

sorine 2

sotalol af 2

sotalol oral 2

SOTYLIZE 4

ANTIHYPERTENSIVE THERAPY

acebutolol 2

aliskiren 4

amiloride 2

amiloride-hydrochlorothiazide 2

amlodipine 1

amlodipine-benazepril 2

amlodipine-valsartan 2

amlodipine-valsartan-hcthiazid 3

atenolol 1

atenolol-chlorthalidone 2

benazepril 1

benazepril-hydrochlorothiazide 2

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

losartan-hydrochlorothiazide

oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 3

metolazone 3

metoprolol succinate 1

metoprolol ta-hydrochlorothiaz 3

metoprolol tartrate oral tablet

100 mg, 25 mg, 50 mg

metyrosine 5 PA; NDS

minoxidil oral 2

moexipril 2

nadolol 4

nebivolol 4

nicardipine intravenous solution 4

nicardipine oral 4

nifedipine oral tablet extended

release

nifedipine oral tablet extended

release 24hr

nimodipine 4

nisoldipine 4

olmesartan 2

olmesartan-hydrochlorothiazide 2

ORENITRAM MONTH

1 TITRATION KT

5 PA; LA; NDS

ORENITRAM MONTH

2 TITRATION KT

5 PA; LA; NDS

ORENITRAM MONTH

3 TITRATION KT

5 PA; LA; NDS

orenitram oral tablet extended

release 0.125 mg

4 PA; NDS

orenitram oral tablet extended

release 0.25 mg, 1 mg, 2.5 mg,

5 mg

5 PA; NDS

perindopril erbumine 2

phenoxybenzamine 5 NDS

pindolol 3

prazosin 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

diltiazem hcl oral tablet

extended release 24 hr 120

mg, 180 mg, 240 mg, 300 mg,

360 mg

diltiazem hcl oral tablet

extended release 24 hr 420 mg

dilt-xr 2

doxazosin oral tablet 1 mg, 2

mg, 4 mg

2 QL (30/30)

doxazosin oral tablet 8 mg 2 QL (60/30)

EDARBI 3

EDARBYCLOR 3

enalapril maleate oral tablet 1

enalapril-hydrochlorothiazide 1

ethacrynate sodium 4

felodipine 2

fosinopril 2

fosinopril-hydrochlorothiazide 2

furosemide injection solution 4

furosemide oral solution 10 mg/

ml, 40 mg/5 ml (8 mg/ml)

FUROSEMIDE ORAL

SOLUTION 40 MG/4 ML

furosemide oral tablet 1

hydralazine injection 4

hydralazine oral 2

hydrochlorothiazide 1

indapamide 1

irbesartan 1 QL (30/30)

irbesartan-hydrochlorothiazide 1 QL (30/30)

isosorbide-hydralazine 3 QL (180/30)

KERENDIA 3 PA; QL (30/30)

labetalol oral 2

lisinopril 1

lisinopril-hydrochlorothiazide 1

losartan 1 QL (60/30)

losartan-hydrochlorothiazide

oral tablet 100-12.5 mg, 100-25

1 QL (30/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

COAGULATION THERAPY

aminocaproic acid oral 4

aspirin-dipyridamole 4

BRILINTA 3 QL (60/30)

cilostazol 2

clopidogrel oral tablet 300 mg 4

clopidogrel oral tablet 75 mg 1 QL (30/30)

dabigatran etexilate 4

dipyridamole oral 2

DOPTELET (10 TAB PACK) 5 PA; LA; NDS

DOPTELET (15 TAB PACK) 5 PA; LA; NDS

DOPTELET (30 TAB PACK) 5 PA; LA; NDS

ELIQUIS 3

ELIQUIS DVT-PE TREAT 30D

START

enoxaparin 4

fondaparinux subcutaneous

syringe 10 mg/0.8 ml, 5 mg/0.4

ml, 7.5 mg/0.6 ml

5 NDS

fondaparinux subcutaneous

syringe 2.5 mg/0.5 ml

HEPARIN (PORCINE) IN 5%

DEX

heparin (porcine) in nacl (pf) 4

heparin (porcine) injection

solution

HEPARIN(PORCINE) IN

0.45% NACL INTRAVENOUS

PARENTERAL SOLUTION

25,000 UNIT/250 ML,

25,000 UNIT/500 ML

heparin, porcine (pf) injection

syringe 5,000 unit/0.5 ml

jantoven 1

pentoxifylline 2

PRADAXA ORAL CAPSULE

110 MG

4 ST

prasugrel 3

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

propranolol oral

capsule,extended release 24 hr

propranolol oral solution 4

propranolol oral tablet 2

quinapril 1

quinapril-hydrochlorothiazide 2

ramipril 1

spironolactone 2

spironolacton-hydrochlorothiaz 2

taztia xt oral capsule,extended

release 24 hr 120 mg, 180 mg,

240 mg, 300 mg

telmisartan 2

terazosin oral capsule 1 mg, 2

mg, 5 mg

1 QL (30/30)

terazosin oral capsule 10 mg 1 QL (60/30)

tiadylt er 2

timolol maleate oral 2

torsemide oral 2

trandolapril 2

triamterene-hydrochlorothiazid 1

UPTRAVI ORAL 5 PA; LA; NDS

valsartan oral tablet 160 mg, 40

mg, 80 mg

2 QL (60/30)

valsartan oral tablet 320 mg 2 QL (30/30)

valsartan-hydrochlorothiazide 2 QL (30/30)

verapamil intravenous solution 4

verapamil oral capsule, 24 hr er

pellet ct

verapamil oral capsule,ext rel.

pellets 24 hr 120 mg, 180 mg

verapamil oral capsule,ext rel.

pellets 24 hr 240 mg

VERAPAMIL ORAL CAPSULE,

EXT REL. PELLETS 24 HR

360 MG

verapamil oral tablet 1

verapamil oral tablet extended

release

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lovastatin oral tablet 20 mg, 40

1 QL (60/30)

NEXLETOL 3 PA; QL (30/30)

NEXLIZET 3 PA; QL (30/30)

niacin oral tablet extended

release 24 hr

PRALUENT PEN 4 PA; QL (2/28)

pravastatin 1 QL (30/30)

prevalite 3

REPATHA PUSHTRONEX 3 PA; QL (3.5/28)

REPATHA SURECLICK 3 PA; QL (3/28)

REPATHA SYRINGE 3 PA; QL (3/28)

rosuvastatin 2 QL (30/30)

simvastatin 1 QL (30/30)

VASCEPA 3

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL TABLET 4 PA; QL (60/30)

digoxin injection solution 4

digoxin oral solution 4

digoxin oral tablet 125 mcg

(0.125 mg)

digoxin oral tablet 250 mcg

(0.25 mg)

digoxin oral tablet 62.5 mcg

(0.0625 mg)

ENTRESTO 3 QL (60/30)

LANOXIN PEDIATRIC 4

ranolazine 4 QL (60/30)

VERQUVO 3 PA; QL (30/30)

VYNDAMAX 4 PA

VYNDAQEL 4 PA

NITRATES

isosorbide dinitrate oral tablet 4

isosorbide mononitrate 2

nitroglycerin intravenous 4 B/D PA

nitroglycerin sublingual 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PROMACTA ORAL POWDER

IN PACKET 12.5 MG

5 PA; LA; QL

(360/30); NDS

PROMACTA ORAL POWDER

IN PACKET 25 MG

5 PA; LA; QL

(180/30); NDS

PROMACTA ORAL TABLET

12.5 MG, 25 MG, 50 MG

5 PA; LA; QL (30/30);

NDS

PROMACTA ORAL TABLET

75 MG

5 PA; LA; QL (60/30);

NDS

warfarin 1

XARELTO 3

XARELTO DVT-PE TREAT 30D

START

LIPID/CHOLESTEROL LOWERING AGENTS

atorvastatin 1 QL (30/30)

cholestyramine (with sugar) 3

cholestyramine light 3

cholestyramine-aspartame 3

colesevelam 3

colestipol oral granules 4

colestipol oral packet 4

colestipol oral tablet 3

ezetimibe 3 QL (30/30)

ezetimibe-simvastatin 4 QL (30/30)

fenobrate micronized oral

capsule 134 mg, 200 mg, 67

fenobrate nanocrystallized 3

fenobrate oral tablet 160 mg,

54 mg

fenobric acid (choline) oral

capsule,delayed release(dr/ec)

135 mg

fenobric acid (choline) oral

capsule,delayed release(dr/ec)

45 mg

gembrozil 1

icosapent ethyl 4

LIVALO 4 QL (30/30)

lovastatin oral tablet 10 mg 1 QL (30/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

DUPIXENT SYRINGE

SUBCUTANEOUS SYRINGE

200 MG/1.14 ML

5 PA; QL (4.56/28);

NDS

DUPIXENT SYRINGE

SUBCUTANEOUS SYRINGE

300 MG/2 ML

5 PA; QL (8/28); NDS

uorouracil topical cream 5% 3

uorouracil topical solution 3

glydo 3 QL (60/30)

imiquimod topical cream in

packet 5%

lidocaine (pf) injection solution 4

lidocaine hcl injection solution 4

lidocaine hcl laryngotracheal 3

lidocaine hcl mucous

membrane solution 4% (40 mg/

ml)

lidocaine topical adhesive

patch,medicated 5%

4 PA

lidocaine topical ointment 4 QL (50/30)

lidocaine viscous 2

lidocaine-prilocaine topical

cream

4 QL (30/30)

methoxsalen 4

PANRETIN 5 NDS

podolox 4

REGRANEX 5 PA; NDS

SANTYL 4

SILVER SULFADIAZINE 3

SSD 3

tacrolimus topical 4 PA; QL (100/30)

VALCHLOR 5 PA; NDS

ZTLIDO 4 PA; QL (90/30)

THERAPY FOR ACNE

adapalene topical gel 0.3% 4 QL (45/30)

claravis 4

clindamycin phosphate topical

gel

4 QL (120/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

nitroglycerin transdermal patch

24 hour

nitroglycerin translingual 4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 4 PA

calcipotriene scalp 3 QL (120/30)

calcipotriene topical cream 4 QL (120/30)

calcipotriene topical ointment 4 QL (120/30)

selenium sulde topical lotion 2

SKYRIZI INTRAVENOUS 5 PA; QL (1/28); NDS

SKYRIZI SUBCUTANEOUS

PEN INJECTOR

5 PA; QL (1/28); NDS

SKYRIZI SUBCUTANEOUS

SYRINGE 150 MG/ML

5 PA; QL (1/28); NDS

SKYRIZI SUBCUTANEOUS

WEARABLE INJECTOR

360 MG/2.4 ML (150 MG/ML)

5 PA; QL (2.4/28);

NDS

STELARA SUBCUTANEOUS

SOLUTION

5 PA; QL (0.5/28);

NDS

STELARA SUBCUTANEOUS

SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28);

NDS

STELARA SUBCUTANEOUS

SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

TALTZ AUTOINJECTOR 5 PA; LA; QL (4/28);

NDS

TALTZ SYRINGE 5 PA; QL (4/28); NDS

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate 2

DUPIXENT PEN

SUBCUTANEOUS PEN

INJECTOR 200 MG/1.14 ML

5 PA; QL (4.56/28);

NDS

DUPIXENT PEN

SUBCUTANEOUS PEN

INJECTOR 300 MG/2 ML

5 PA; QL (8/28); NDS

DUPIXENT SYRINGE

SUBCUTANEOUS SYRINGE

100 MG/0.67 ML

5 PA; QL (1.34/28);

NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

mupirocin 2 QL (44/30)

mupirocin calcium 4 QL (30/30)

sulfacetamide sodium (acne) 4

TOPICAL ANTIFUNGALS

ciclodan topical solution 4

ciclopirox topical cream 4 QL (90/28)

ciclopirox topical shampoo 4 QL (120/28)

ciclopirox topical solution 4 QL (6.6/28)

ciclopirox topical suspension 4 QL (60/28)

clotrimazole topical cream 2 QL (45/28)

clotrimazole topical solution 3 QL (30/28)

clotrimazole-betamethasone

topical cream

4 QL (45/28)

clotrimazole-betamethasone

topical lotion

4 QL (60/28)

econazole 4 QL (85/28)

JUBLIA 4 PA

ketoconazole topical cream 2 QL (60/28)

ketoconazole topical shampoo 2 QL (120/28)

nyamyc 3 QL (180/30)

nystatin topical cream 2 QL (30/28)

nystatin topical ointment 2 QL (30/28)

nystatin topical powder 3 QL (180/30)

nystatin-triamcinolone 4 QL (60/28)

nystop 3 QL (180/30)

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1% 2

alclometasone 3

betamethasone dipropionate 4

betamethasone valerate topical

cream

betamethasone valerate topical

lotion

betamethasone valerate topical

ointment

betamethasone, augmented

topical cream

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CLINDAMYCIN PHOSPHATE

TOPICAL GEL, ONCE DAILY

4 QL (120/30)

clindamycin phosphate topical

lotion

3 QL (120/30)

clindamycin phosphate topical

solution

4 QL (120/30)

clindamycin phosphate topical

swab

2 QL (60/30)

ery pads 4

erythromycin with ethanol

topical gel

erythromycin with ethanol

topical solution

erythromycin-benzoyl peroxide 4

isotretinoin oral capsule 10 mg,

20 mg, 30 mg, 40 mg

metronidazole topical 3

tazarotene topical cream 4 PA

tazarotene topical gel 0.05% 4 PA

TAZAROTENE TOPICAL GEL

0.1%

4 PA

TAZORAC TOPICAL CREAM

0.05%

4 PA

TAZORAC TOPICAL GEL 4 PA

tretinoin microspheres topical

gel 0.1%

4 PA

tretinoin microspheres topical

gel with pump 0.1%

4 PA

tretinoin topical cream 4 PA

tretinoin topical gel 0.01% 3 PA

tretinoin topical gel 0.025%,

0.05%

4 PA

TOPICAL ANESTHETICS

lidocaine hcl mucous

membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous

membrane solution 2%

TOPICAL ANTIBACTERIALS

gentamicin topical cream 4 QL (60/30)

gentamicin topical ointment 3

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

uticasone propionate topical

ointment

halobetasol propionate topical

cream

halobetasol propionate topical

ointment

hydrocortisone topical cream

1%, 2.5%

hydrocortisone topical lotion

2.5%

hydrocortisone topical ointment

1%, 2.5%

hydrocortisone valerate 4

mometasone topical 2

prednicarbate topical ointment 2

triamcinolone acetonide topical

cream 0.025%, 0.5%

triamcinolone acetonide topical

cream 0.1%

triamcinolone acetonide topical

lotion

triamcinolone acetonide topical

ointment 0.025%, 0.1%, 0.5%

triderm topical cream 0.1% 1

TOPICAL SCABICIDES / PEDICULICIDES

malathion 4

permethrin 3

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

LACTATED RINGERS

IRRIGATION

neomycin-polymyxin b gu 4

RINGER'S IRRIGATION 4

TIS-U-SOL PENTALYTE 4

MISCELLANEOUS AGENTS

acamprosate 4

anagrelide 3

CARBAGLU 5 PA; LA; NDS

carglumic acid 5 PA; NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

betamethasone, augmented

topical gel

betamethasone, augmented

topical lotion

betamethasone, augmented

topical ointment

clobetasol scalp 3 QL (100/28)

clobetasol topical cream 3 QL (120/28)

clobetasol topical foam 4 QL (100/28)

clobetasol topical gel 3 QL (120/28)

clobetasol topical lotion 4 QL (118/28)

clobetasol topical ointment 3 QL (120/28)

clobetasol topical shampoo 4 QL (236/28)

clobetasol topical spray,non-

aerosol

4 QL (125/28)

clobetasol-emollient topical

cream

3 QL (120/28)

clodan 4 QL (236/28)

desonide topical lotion 4

desonide topical ointment 4

desoximetasone topical cream 4

desoximetasone topical gel 4

desoximetasone topical

ointment

uocinolone and shower cap 4

uocinolone topical cream

0.01%

uocinolone topical cream

0.025%

uocinolone topical oil 4

uocinolone topical ointment 3

uocinolone topical solution 4

uocinonide topical cream

0.05%

3 QL (120/30)

uocinonide topical gel 4 QL (120/30)

uocinonide topical ointment 4 QL (120/30)

uocinonide topical solution 4 QL (120/30)

uticasone propionate topical

cream

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

levocarnitine oral solution 100

mg/ml

LEVOCARNITINE ORAL

TABLET

midodrine 3

nitisinone 5 NDS

pilocarpine hcl oral 4

PROLASTIN-C INTRAVENOUS

RECON SOLN

5 PA; LA; NDS

PROLASTIN-C INTRAVENOUS

SOLUTION

5 PA; NDS

riluzole 3

sevelamer carbonate oral

powder in packet 0.8 gram

4 QL (510/30)

sevelamer carbonate oral

powder in packet 2.4 gram

4 QL (150/30)

sevelamer carbonate oral tablet 3 QL (510/30)

sodium chloride 0.9%

intravenous parenteral solution

SODIUM CHLORIDE 0.9%

INTRAVENOUS PIGGYBACK

SODIUM CHLORIDE

IRRIGATION

sodium phenylbutyrate 5 PA; NDS

sodium polystyrene sulfonate

oral powder

sps (with sorbitol) 3

trientine oral capsule 250 mg 5 PA; QL (240/30);

NDS

TZIELD 4 PA; LA; QL (14/720)

VELPHORO 5 NDS

VELTASSA 4

WATER FOR IRRIGATION,

STERILE

XIAFLEX 4 PA

ZOLEDRONIC ACID-

MANNITOL-WATER

INTRAVENOUS PIGGYBACK

5 MG/100 ML

4 B/D PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CHEMET 4 PA

CLINIMIX 4.25%/D5W SULFIT

FREE

4 B/D PA

CUVRIOR 5 PA; QL (300/30);

NDS

D10%-0.45% SODIUM

CHLORIDE

d2.5%-0.45% sodium chloride 4

d5% and 0.9% sodium chloride 4

d5%-0.45% sodium chloride 4

deferasirox oral tablet,

dispersible

5 PA; NDS

DEXTROSE 10% AND 0.2%

NACL

dextrose 10% in water (d10w) 4

DEXTROSE 25% IN WATER

(D25W)

dextrose 5% in water (d5w)

intravenous parenteral solution

DEXTROSE 5% IN WATER

(D5W) INTRAVENOUS

PIGGYBACK

DEXTROSE 5%-LACTATED

RINGERS

dextrose 5%-0.2% sod chloride 4

dextrose 5%-0.3% sod.chloride 4

DEXTROSE 50% IN WATER

(D50W) INTRAVENOUS

PARENTERAL SOLUTION

dextrose 50% in water (d50w)

intravenous syringe

DEXTROSE 70% IN WATER

(D70W)

disulram 4

droxidopa oral capsule 100 mg 4 PA; QL (90/30)

droxidopa oral capsule 200 mg,

300 mg

4 PA; QL (180/30)

GLASSIA 5 PA; NDS

INCRELEX 4 PA; LA

levocarnitine (with sugar) 4

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

DEPO-MEDROL 4

dexamethasone intensol 4

dexamethasone oral elixir 2

dexamethasone oral solution 2

dexamethasone oral tablet 0.5

mg, 0.75 mg, 4 mg

dexamethasone oral tablet 1

mg, 1.5 mg, 2 mg, 6 mg

dexamethasone sodium phos

(pf) injection solution

dexamethasone sodium

phosphate injection solution

udrocortisone 2

hydrocortisone oral 3

MEDROL ORAL TABLET 2 MG 3

methylpred dp 2

methylprednisolone 2

methylprednisolone acetate 4

methylprednisolone sodium

succ injection recon soln 125

mg, 40 mg

methylprednisolone sodium

succ intravenous

prednisolone oral solution 4

prednisolone sodium

phosphate oral solution 15

mg/5 ml (3 mg/ml), 15 mg/5 ml

(5 ml), 25 mg/5 ml (5 mg/ml), 5

mg base/5 ml (6.7 mg/5 ml)

prednisone intensol 4

prednisone oral solution 4

prednisone oral tablet 2

prednisone oral tablets,dose

pack

SOLU-CORTEF ACT-O-VIAL

(PF)

triamcinolone acetonide

injection suspension 40 mg/ml

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

SMOKING DETERRENTS

bupropion hcl (smoking deter) 2 QL (60/30)

CHANTIX CONTINUING

MONTH BOX

CHANTIX ORAL TABLET 1 MG 4

CHANTIX STARTING MONTH

BOX

NICOTROL 4

NICOTROL NS 4

varenicline 4

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal 3 QL (60/30)

chlorhexidine gluconate

mucous membrane

ipratropium bromide nasal

spray,non-aerosol 21 mcg

(0.03%)

2 QL (30/30)

ipratropium bromide nasal

spray,non-aerosol 42 mcg

(0.06%)

3 QL (30/30)

oralone 4

periogard 2

triamcinolone acetonide dental 4

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) 2

ac otic oil 4

uocinolone acetonide oil 4

hydrocortisone-acetic acid 4

OTIC STEROID / ANTIBIOTIC

CIPRO HC 4

ciprooxacin-dexamethasone 3

neomycin-polymyxin-hc otic

(ear)

ENDOCRINE/DIABETES

ADRENAL HORMONES

cortisone 4

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

glipizide oral tablet extended

release 24hr 5 mg

2 QL (120/30)

glipizide-metformin oral tablet

2.5-250 mg

1 QL (240/30)

glipizide-metformin oral tablet

2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGEN HYPOKIT 3

GLUCAGON (HCL)

EMERGENCY KIT

glucagon emergency kit

(human)

GLYXAMBI 3 QL (30/30)

GVOKE 3

GVOKE HYPOPEN 1-PACK 3

GVOKE HYPOPEN 2-PACK 3

GVOKE PFS 1-PACK

SYRINGE

GVOKE PFS 2-PACK

SYRINGE

HUMALOG JUNIOR KWIKPEN

U-100

6 SSM

HUMALOG KWIKPEN

INSULIN

6 SSM

HUMALOG MIX 50-50 INSULN

U-100

6 SSM

HUMALOG MIX

50-50 KWIKPEN

6 SSM

HUMALOG MIX

75-25 KWIKPEN

6 SSM

HUMALOG MIX 75-25(U-100)

INSULN

6 SSM

HUMALOG U-100 INSULIN 6 SSM

HUMULIN

70/30 U-100 INSULIN

6 SSM

HUMULIN

70/30 U-100 KWIKPEN

6 SSM

HUMULIN N NPH INSULIN

KWIKPEN

6 SSM

HUMULIN N NPH

U-100 INSULIN

6 SSM

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ANTITHYROID AGENTS

methimazole oral tablet 10 mg,

5 mg

propylthiouracil 3

DIABETES THERAPY

acarbose oral tablet 100 mg 2 QL (90/30)

acarbose oral tablet 25 mg 2 QL (360/30)

acarbose oral tablet 50 mg 2 QL (180/30)

ALCOHOL PADS 6

ASSURE ID INSULIN SAFETY

SYRINGE 1 ML 29 GAUGE X

1/2"

6 QL (200/30)

BAQSIMI 3

BD SAFETYGLIDE INSULIN

SYRINGE SYRINGE 1 ML

31 GAUGE X 15/64"

6 QL (200/30)

BD ULTRA-FINE MICRO PEN

NEEDLE

6 QL (200/30)

BD ULTRA-FINE MINI PEN

NEEDLE

6 QL (200/30)

BD ULTRA-FINE NANO PEN

NEEDLE

6 QL (200/30)

BD ULTRA-FINE SHORT PEN

NEEDLE

6 QL (200/30)

BYDUREON BCISE 3 QL (4/28)

CYCLOSET 4 QL (180/30)

diazoxide 4

GAUZE PAD TOPICAL

BANDAGE 2 X 2 "

glimepiride oral tablet 1 mg 1 QL (240/30)

glimepiride oral tablet 2 mg 1 QL (120/30)

glimepiride oral tablet 4 mg 1 QL (60/30)

glipizide oral tablet 10 mg 1 QL (120/30)

glipizide oral tablet 5 mg 1 QL (240/30)

glipizide oral tablet extended

release 24hr 10 mg

2 QL (60/30)

glipizide oral tablet extended

release 24hr 2.5 mg

2 QL (240/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

metformin oral tablet 1,000 mg 1 QL (75/30)

metformin oral tablet 500 mg 1 QL (150/30)

metformin oral tablet 850 mg 1 QL (90/30)

metformin oral tablet extended

release 24 hr 500 mg

1 QL (120/30)

metformin oral tablet extended

release 24 hr 750 mg

1 QL (60/30)

MOUNJARO 3 QL (2/28)

nateglinide oral tablet 120 mg 2 QL (90/30)

nateglinide oral tablet 60 mg 2 QL (180/30)

NOVOFINE 32 6 QL (200/30)

NOVOFINE AUTOCOVER 6 QL (200/30)

NOVOFINE PLUS 6 QL (200/30)

OMNIPOD 5 G6 INTRO KIT

(GEN 5)

3 QL (1/365)

OMNIPOD 5 G6 PODS (GEN

3 QL (20/30)

OMNIPOD CLASSIC PODS

(GEN 3)

3 QL (20/30)

OMNIPOD DASH INTRO KIT

(GEN 4)

3 QL (1/365)

OMNIPOD DASH PODS (GEN

3 QL (20/30)

OMNIPOD GO PODS 3 QL (10/30)

OMNIPOD GO PODS

10 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

15 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

20 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

25 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

30 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

40 UNITS/DAY

3 QL (10/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

HUMULIN R REGULAR

U-100 INSULN

6 SSM

HUMULIN R U-500 (CONC)

INSULIN

5 B/D PA; NDS

HUMULIN R U-500 (CONC)

KWIKPEN

5 NDS

INSULIN SYRINGE-NEEDLE

U-100 SYRINGE 0.3 ML

29 GAUGE, 1 ML 29 GAUGE X

1/2", 1/2 ML 28 GAUGE

6 QL (200/30)

INVOKAMET 3 QL (60/30)

INVOKAMET XR 3 QL (60/30)

INVOKANA 3 QL (30/30)

JANUMET 3 QL (60/30)

JANUMET XR ORAL TABLET,

ER MULTIPHASE 24 HR

100-1,000 MG

3 QL (30/30)

JANUMET XR ORAL TABLET,

ER MULTIPHASE 24 HR

50-1,000 MG, 50-500 MG

3 QL (60/30)

JANUVIA 3 QL (30/30)

JARDIANCE 3 QL (30/30)

JENTADUETO 3 QL (60/30)

JENTADUETO XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 2.5-1,000 MG

3 QL (60/30)

JENTADUETO XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 5-1,000 MG

3 QL (30/30)

LANTUS SOLOSTAR

U-100 INSULIN

6 SSM

LANTUS U-100 INSULIN 6 SSM

LEVEMIR FLEXPEN 6 SSM

LEVEMIR U-100 INSULIN 6 SSM

LYUMJEV KWIKPEN

U-100 INSULIN

6 SSM

LYUMJEV KWIKPEN

U-200 INSULIN

6 SSM

LYUMJEV U-100 INSULIN 6 SSM

metformin oral solution 4 QL (765/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TRESIBA FLEXTOUCH U-100 6 SSM

TRESIBA FLEXTOUCH U-200 6 SSM

TRESIBA U-100 INSULIN 6 SSM

TRIJARDY XR ORAL TABLET,

IR - ER, BIPHASIC 24HR 10-5-

1,000 MG, 25-5-1,000 MG

3 QL (30/30)

TRIJARDY XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 12.5-2.5-1,000 MG,

5-2.5-1,000 MG

3 QL (60/30)

TRULICITY 3 QL (2/28)

VERSALON NONWOVEN ALL-

PURPOSE TOPICAL SPONGE

2 X 2 "

V-GO 20 3

V-GO 30 3

V-GO 40 3

VICTOZA 2-PAK 3 QL (9/30)

VICTOZA 3-PAK 3 QL (9/30)

XULTOPHY 100/3.6 3 QL (15/30)

MISCELLANEOUS HORMONES

ALDURAZYME 5 PA; NDS

cabergoline 3

calcitonin (salmon) nasal 3

calcitriol intravenous solution 1

mcg/ml

calcitriol oral capsule 2

calcitriol oral solution 3

CEREZYME INTRAVENOUS

RECON SOLN 400 UNIT

5 PA; NDS

CHORIONIC

GONADOTROPIN, HUMAN

INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg, 60

4 QL (60/30)

cinacalcet oral tablet 90 mg 4 QL (120/30)

danazol 4

desmopressin injection 4

desmopressin nasal spray with

pump

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

OZEMPIC SUBCUTANEOUS

PEN INJECTOR 0.25 MG OR

0.5 MG (2 MG/3 ML), 1 MG/

DOSE (4 MG/3 ML), 2 MG/

DOSE (8 MG/3 ML)

3 QL (3/28)

PEN NEEDLE, DIABETIC

NEEDLE 29 GAUGE X 1/2"

6 QL (200/30)

pioglitazone 1 QL (30/30)

repaglinide oral tablet 0.5 mg 4 QL (960/30)

repaglinide oral tablet 1 mg 4 QL (480/30)

repaglinide oral tablet 2 mg 4 QL (240/30)

RYBELSUS 3 QL (30/30)

SOLIQUA 100/33 3 QL (15/25)

SYNJARDY 3 QL (60/30)

SYNJARDY XR ORAL TABLET,

IR - ER, BIPHASIC 24HR

10-1,000 MG, 12.5-1,000 MG,

5-1,000 MG

3 QL (60/30)

SYNJARDY XR ORAL TABLET,

IR - ER, BIPHASIC 24HR

25-1,000 MG

3 QL (30/30)

TECHLITE INSULIN SYRINGE

SYRINGE 1 ML 29 GAUGE X

1/2", 1 ML 30 GAUGE X 1/2",

1 ML 31 GAUGE X 15/64",

1 ML 31 GAUGE X 5/16

6 QL (200/30)

TECHLITE INSULN SYR(HALF

UNIT) SYRINGE 0.3 ML

29 GAUGE X 1/2", 0.3 ML

30 GAUGE X 5/16", 0.3 ML

31 GAUGE X 15/64", 0.3 ML

31 GAUGE X 5/16", 0.5 ML

30 GAUGE X 1/2", 0.5 ML

30 GAUGE X 5/16", 0.5 ML

31 GAUGE X 15/64", 0.5 ML

31 GAUGE X 5/16"

6 QL (200/30)

TECHLITE PEN NEEDLE 6 QL (200/30)

TOUJEO MAX

U-300 SOLOSTAR

6 SSM

TOUJEO SOLOSTAR

U-300 INSULIN

6 SSM

TRADJENTA 3 QL (30/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

THYROID HORMONES

EUTHYROX 3

LEVO-T 3

levothyroxine oral tablet 2

LEVOXYL ORAL TABLET

100 MCG, 112 MCG, 125 MCG,

137 MCG, 150 MCG,

175 MCG, 200 MCG, 25 MCG,

50 MCG, 75 MCG, 88 MCG

liothyronine oral 2

SYNTHROID 4

UNITHROID 3

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

dicyclomine oral capsule 2

dicyclomine oral solution 4

dicyclomine oral tablet 2

diphenoxylate-atropine 4

glycopyrrolate (pf) 4

glycopyrrolate (pf) in water

injection

glycopyrrolate (pf) in water

intravenous syringe 0.4 mg/2

ml (0.2 mg/ml)

glycopyrrolate oral tablet 4

loperamide oral capsule 2

MISCELLANEOUS GASTROINTESTINAL AGENTS

alosetron 4 PA

aprepitant 4 B/D PA

balsalazide 4

betaine 5 NDS

budesonide oral 4

CLENPIQ 3

compro 4

constulose 2

CORTIFOAM 4

CREON 3

cromolyn oral 3

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

desmopressin nasal spray,non-

aerosol 10 mcg/spray (0.1 ml)

desmopressin oral 3

doxercalciferol 4

ELAPRASE 5 PA; NDS

FABRAZYME 5 NDS

KORLYM 5 PA; QL (120/30);

NDS

LUMIZYME 5 PA; NDS

miglustat 5 LA; NDS

NAGLAZYME 5 PA; NDS

NATPARA 5 PA; LA; QL (2/28);

NDS

pamidronate 4

paricalcitol oral 4

RAYALDEE 5 NDS

sapropterin 5 PA; NDS

SOMAVERT 5 PA; QL (30/30);

NDS

SYNAREL 4

testosterone cypionate 3

testosterone enanthate 4

testosterone transdermal gel 4 PA; QL (300/30)

testosterone transdermal gel in

metered-dose pump 12.5 mg/

1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel

in packet 1% (25 mg/2.5gram),

1% (50 mg/5 gram)

4 PA; QL (300/30)

TOLVAPTAN ORAL TABLET

15 MG

5 PA; QL (120/30);

NDS

tolvaptan oral tablet 30 mg 5 PA; QL (60/30);

NDS

zoledronic acid intravenous

solution

4 B/D PA

zoledronic acid-mannitol-

water intravenous piggyback 4

mg/100 ml

4 B/D PA

ZOLEDRONIC AC-MANNITOL-

0.9NACL

4 B/D PA

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PENTASA 4

prochlorperazine 4

prochlorperazine edisylate

injection solution 10 mg/2 ml (5

mg/ml)

prochlorperazine maleate 2

procto-med hc 3

proctosol hc topical 2

proctozone-hc 3

RECTIV 4

REMICADE 5 PA; QL (20/30);

NDS

SANCUSO 5 NDS

scopolamine base 4 QL (10/30)

SKYRIZI SUBCUTANEOUS

WEARABLE INJECTOR

180 MG/1.2 ML (150 MG/ML)

5 PA; QL (1.2/28);

NDS

SUCRAID 4 PA

sulfasalazine oral tablet 2

SULFASALAZINE ORAL

TABLET, DELAYED RELEASE

(DR/EC)

SUPREP BOWEL PREP KIT 4

SUTAB 4

TRULANCE 4

ursodiol oral capsule 300 mg 3

ursodiol oral tablet 4

VIOKACE 4

ZENPEP ORAL CAPSULE,

DELAYED RELEASE(DR/EC)

10,000-32,000 -42,000 UNIT,

15,000-47,000 -63,000 UNIT,

20,000-63,000- 84,000 UNIT,

25,000-79,000- 105,000 UNIT,

3,000-10,000 -14,000-UNIT,

40,000-126,000- 168,000 UNIT,

5,000-17,000- 24,000 UNIT

ULCER THERAPY

DEXILANT 4 ST; QL (30/30)

dexlansoprazole 4 ST; QL (30/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

dronabinol 4 B/D PA; QL (60/30)

enulose 2

GATTEX 30-VIAL 5 PA; NDS

GATTEX ONE-VIAL 5 PA; NDS

gavilyte-c 2

generlac 2

granisetron hcl oral 3 B/D PA

hydrocortisone rectal 3

hydrocortisone topical cream

with perineal applicator

lactulose oral solution 2

LINZESS 3 QL (30/30)

meclizine oral tablet 12.5 mg,

25 mg

mesalamine oral capsule (with

del rel tablets)

mesalamine oral

capsule,extended release 24hr

mesalamine oral tablet,delayed

release (dr/ec)

mesalamine rectal enema 4

mesalamine with cleansing

wipe

metoclopramide hcl oral

solution

metoclopramide hcl oral tablet 2

MOVANTIK 4 QL (30/30)

OCALIVA 4 PA; LA; QL (30/30)

ondansetron 2 B/D PA

ondansetron hcl (pf) 4

ondansetron hcl intravenous 4

ondansetron hcl oral solution 4 B/D PA

ondansetron hcl oral tablet 4

mg, 8 mg

2 B/D PA

palonosetron intravenous

solution 0.25 mg/5 ml

peg 3350-electrolytes 2

peg-electrolyte soln 2

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PROCRIT INJECTION

SOLUTION 10,000 UNIT/ML,

2,000 UNIT/ML, 20,000 UNIT/

ML, 3,000 UNIT/ML,

4,000 UNIT/ML, 40,000 UNIT/

4 PA

ZIEXTENZO 4 PA

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ABRYSVO 3 PA; QL (1/365)

ACTHIB (PF) 3

ADACEL(TDAP ADOLESN/

ADULT)(PF)

AREXVY (PF) 3 PA; QL (1/365)

ATGAM 4 B/D PA

BCG VACCINE, LIVE (PF) 4

BEXSERO 3

BOOSTRIX TDAP 3

BOTOX 4 PA

DAPTACEL (DTAP

PEDIATRIC) (PF)

DENGVAXIA (PF) 3

ENGERIX-B (PF) 3 B/D PA

ENGERIX-B PEDIATRIC (PF) 3 B/D PA

fomepizole 5 NDS

GARDASIL 9 (PF) 4

HAVRIX (PF) 3

HIBERIX (PF) 3

HIZENTRA 4 B/D PA

IMOVAX RABIES VACCINE

(PF)

INFANRIX (DTAP) (PF)

INTRAMUSCULAR SYRINGE

IPOL 3

IXIARO (PF) 4

JYNNEOS (PF)(STOCKPILE) 3 B/D PA

KINRIX (PF)

INTRAMUSCULAR SYRINGE

MENACTRA (PF)

INTRAMUSCULAR SOLUTION

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

esomeprazole magnesium oral

capsule,delayed release(dr/ec)

3 QL (60/30)

famotidine oral suspension 3

famotidine oral tablet 20 mg,

40 mg

lansoprazole oral

capsule,delayed release(dr/ec)

3 QL (60/30)

misoprostol 3

omeprazole oral

capsule,delayed release(dr/ec)

2 QL (60/30)

pantoprazole oral

tablet,delayed release (dr/ec)

1 QL (60/30)

sucralfate oral suspension 4

sucralfate oral tablet 2

TALICIA 4 QL (168/28)

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE 5 PA; NDS

ARCALYST 5 PA; NDS

AVONEX INTRAMUSCULAR

PEN INJECTOR KIT

5 PA; QL (1/28); NDS

AVONEX INTRAMUSCULAR

SYRINGE

5 PA; QL (1/28); NDS

AVONEX INTRAMUSCULAR

SYRINGE KIT

5 PA; QL (1/28); NDS

BESREMI 5 PA; LA; QL (2/28);

NDS

BETASERON

SUBCUTANEOUS KIT

5 PA; QL (14/28);

NDS

GENOTROPIN 5 PA; NDS

GENOTROPIN MINIQUICK 5 PA; NDS

MOZOBIL 5 B/D PA; NDS

NIVESTYM 5 PA; NDS

PEGASYS SUBCUTANEOUS

SOLUTION

5 PA; QL (4/28); NDS

PEGASYS SUBCUTANEOUS

SYRINGE

5 PA; QL (2/28); NDS

PLERIXAFOR 5 B/D PA; NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

colchicine oral tablet 3 QL (120/30)

febuxostat 4 ST

MITIGARE 3 QL (120/30)

probenecid 3

probenecid-colchicine 3

OSTEOPOROSIS THERAPY

alendronate oral tablet 10 mg 1 QL (30/30)

alendronate oral tablet 35 mg,

70 mg

1 QL (4/28)

FORTEO 5 PA; QL (2.4/28);

NDS

ibandronate oral 3 QL (1/28)

PROLIA 4 QL (1/180)

raloxifene 3 QL (30/30)

TYMLOS 5 PA; QL (1.56/30);

NDS

OTHER RHEUMATOLOGICALS

ADALIMUMAB-ADAZ 5 PA; QL (1.6/28);

NDS

BENLYSTA INTRAVENOUS 5 PA; NDS

CYLTEZO(CF) PEN 5 PA; QL (4/28); NDS

CYLTEZO(CF) PEN CROHN'S-

UC-HS

5 PA; QL (12/365);

NDS

CYLTEZO(CF) PEN

PSORIASIS-UV

5 PA; QL (8/365);

NDS

CYLTEZO(CF)

SUBCUTANEOUS SYRINGE

KIT 10 MG/0.2 ML,

20 MG/0.4 ML

5 PA; QL (2/28); NDS

CYLTEZO(CF)

SUBCUTANEOUS SYRINGE

KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

ENBREL MINI 5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS

SOLUTION

5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS

SYRINGE

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDS

HUMIRA PEN 5 PA; QL (4/28); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

MENQUADFI (PF) 3

MENVEO A-C-Y-W-135-DIP

(PF)

M-M-R II (PF) 3

PEDIARIX (PF) 3

PEDVAX HIB (PF) 3

PENTACEL (PF)

INTRAMUSCULAR KIT

15LF-48MCG-62DU

-10 MCG/0.5ML

PREHEVBRIO (PF) 3 B/D PA

PRIORIX (PF) 3

PRIVIGEN 5 B/D PA; NDS

PROQUAD (PF) 3

QUADRACEL (PF) 3

RABAVERT (PF) 3

RECOMBIVAX HB (PF) 3 B/D PA

ROTARIX 3

ROTATEQ VACCINE 3

SHINGRIX (PF) 3 QL (2/999)

STAMARIL (PF) 4

TDVAX 3

TENIVAC (PF) 3

TETANUS, DIPHTHERIA TOX

PED(PF)

TICE BCG 4 B/D PA

TICOVAC 3

TRUMENBA 3

TWINRIX (PF) 3

TYPHIM VI 3

VAQTA (PF) 3

VARIVAX (PF) 3

VARIZIG 4

YF-VAX (PF) 3

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet 100 mg,

300 mg

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

HYRIMOZ(CF) PEN 5 PA; QL (1.6/28);

NDS

HYRIMOZ(CF)

SUBCUTANEOUS SYRINGE

10 MG/0.1 ML

5 PA; QL (0.2/28);

NDS

HYRIMOZ(CF)

SUBCUTANEOUS SYRINGE

20 MG/0.2 ML

5 PA; QL (0.4/28);

NDS

HYRIMOZ(CF)

SUBCUTANEOUS SYRINGE

40 MG/0.4 ML

5 PA; QL (1.6/28);

NDS

leunomide 3 QL (30/30)

ORENCIA CLICKJECT 5 PA; QL (4/28); NDS

ORENCIA SUBCUTANEOUS

SYRINGE 125 MG/ML

5 PA; QL (4/28); NDS

ORENCIA SUBCUTANEOUS

SYRINGE 50 MG/0.4 ML

5 PA; QL (1.6/28);

NDS

ORENCIA SUBCUTANEOUS

SYRINGE 87.5 MG/0.7 ML

5 PA; QL (2.8/28);

NDS

penicillamine 5 NDS

RINVOQ 5 PA; QL (30/30);

NDS

XELJANZ ORAL SOLUTION 5 PA; QL (300/30);

NDS

XELJANZ ORAL TABLET 5 PA; QL (60/30);

NDS

XELJANZ XR 5 PA; QL (30/30);

NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

camila 3

deblitane 3

dotti 3 QL (8/28)

DUAVEE 4 PA

errin 3

estradiol oral 2

estradiol transdermal patch

semiweekly

3 QL (8/28)

estradiol transdermal patch

weekly

3 QL (4/28)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

HUMIRA PEN CROHNS-

UC-HS START

5 PA; QL (12/365);

NDS

HUMIRA PEN PSOR-UVEITS-

ADOL HS

5 PA; QL (8/365);

NDS

HUMIRA SUBCUTANEOUS

SYRINGE KIT 40 MG/0.8 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS

STARTER SUBCUTANEOUS

SYRINGE KIT 80 MG/0.8 ML

5 PA; QL (6/365);

NDS

HUMIRA(CF) PEDI CROHNS

STARTER SUBCUTANEOUS

SYRINGE KIT

80 MG/0.8 ML-40 MG/0.4 ML

5 PA; QL (4/365);

NDS

HUMIRA(CF) PEN CROHNS-

UC-HS

5 PA; QL (6/365);

NDS

HUMIRA(CF) PEN PEDIATRIC

5 PA; QL (4/180);

NDS

HUMIRA(CF) PEN PSOR-UV-

ADOL HS

5 PA; QL (6/365);

NDS

HUMIRA(CF) PEN

SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HUMIRA(CF) PEN

SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML

5 PA; QL (2/28); NDS

HUMIRA(CF)

SUBCUTANEOUS SYRINGE

KIT 10 MG/0.1 ML,

20 MG/0.2 ML

5 PA; QL (2/28); NDS

HUMIRA(CF)

SUBCUTANEOUS SYRINGE

KIT 40 MG/0.4 ML

5 PA; QL (4/28); NDS

HYRIMOZ PEN CROHN'S-UC

STARTER

5 PA; QL (4.8/365);

NDS

HYRIMOZ PEN PSORIASIS

STARTER

5 PA; QL (3.2/365);

NDS

HYRIMOZ(CF) PEDI CROHN

STARTER SUBCUTANEOUS

SYRINGE 80 MG/0.8 ML

5 PA; QL (3.2/365);

NDS

HYRIMOZ(CF) PEDI CROHN

STARTER SUBCUTANEOUS

SYRINGE 80 MG/0.8 ML-

40 MG/0.4 ML

5 PA; QL (2.4/365);

NDS

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

aubra eq 3

aurovela 1.5/30 (21) 3

aurovela 1/20 (21) 3

aurovela 24 fe 3

aurovela fe 1.5/30 (28) 3

aurovela fe 1-20 (28) 3

aviane 3

ayuna 3

azurette (28) 3

balziva (28) 3

blisovi 24 fe 3

blisovi fe 1.5/30 (28) 3

blisovi fe 1/20 (28) 3

briellyn 3

camrese 3

CAMRESE LO 3

charlotte 24 fe 3

chateal eq (28) 3

cryselle (28) 3

cyred eq 3

dasetta 1/35 (28) 3

dasetta 7/7/7 (28) 3

daysee 3

desog-e.estradiol/e.estradiol 3

desogestrel-ethinyl estradiol 3

dolishale 3

drospirenone-e.estradiol-lm.

fa oral tablet 3-0.02-0.451 mg

(24) (4)

DROSPIRENONE-E.

ESTRADIOL-LM.FA ORAL

TABLET 3-0.03-0.451 MG (21)

(7)

drospirenone-ethinyl estradiol 3

elinest 3

enpresse 3

enskyce 3

estarylla 3

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

estradiol vaginal 4

estradiol valerate 4

heather 3

hydroxyprogesterone caproate 5 NDS

incassia 3

JENCYCLA 3

lyza 3

medroxyprogesterone

intramuscular

medroxyprogesterone oral 2

NORA-BE 3

norethindrone (contraceptive) 3

norethindrone acetate 3

PREMARIN INJECTION 4

PREMARIN ORAL 3

PREMARIN VAGINAL 3

PREMPRO 3

progesterone micronized 3

sharobel 3

yuvafem 4

MISCELLANEOUS OB/GYN

clindamycin phosphate vaginal 3

metronidazole vaginal 4

mifepristone 4

terconazole 4

tranexamic acid oral 3

VANDAZOLE 4

ORAL CONTRACEPTIVES / RELATED AGENTS

armelle 3

altavera (28) 3

alyacen 1/35 (28) 3

alyacen 7/7/7 (28) 3

amethia 3

amethyst (28) 3

apri 3

aranelle (28) 3

ashlyna 3

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

levonorg-eth estrad triphasic 3

levora-28 3

lojaimiess 3

loryna (28) 3

low-ogestrel (28) 3

lo-zumandimine (28) 3

lutera (28) 3

marlissa (28) 3

merzee 3

microgestin 1.5/30 (21) 3

microgestin 1/20 (21) 3

microgestin fe 1.5/30 (28) 3

microgestin fe 1/20 (28) 3

mili 3

mono-linyah 3

necon 0.5/35 (28) 3

nikki (28) 3

noreth-ethinyl estradiol-iron 3

norethindrone ac-eth estradiol

oral tablet 1-20 mg-mcg, 1.5-30

mg-mcg

norethindrone-e.estradiol-iron 3

norgestimate-ethinyl estradiol 3

nortrel 0.5/35 (28) 3

nortrel 1/35 (21) 3

nortrel 1/35 (28) 3

nortrel 7/7/7 (28) 3

nylia 1/35 (28) 3

nylia 7/7/7 (28) 3

nymyo 3

ocella 3

philith 3

pimtrea (28) 3

portia 28 3

reclipsen (28) 3

RIVELSA 3

setlakin 3

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ethynodiol diac-eth estradiol 3

falmina (28) 3

nzala 3

gemmily 3

hailey 3

hailey 24 fe 3

hailey fe 1.5/30 (28) 3

hailey fe 1/20 (28) 3

iclevia 3

isibloom 3

jaimiess 3

jasmiel (28) 3

jolessa 3

joyeaux 3

juleber 3

junel 1.5/30 (21) 3

junel 1/20 (21) 3

junel fe 1.5/30 (28) 3

junel fe 1/20 (28) 3

junel fe 24 3

kaitlib fe 3

kalliga 3

kariva (28) 3

kelnor 1/35 (28) 3

kelnor 1-50 (28) 3

kurvelo (28) 3

l norgest/e.estradiol-e.estrad 3

larin 1.5/30 (21) 3

larin 1/20 (21) 3

larin 24 fe 3

larin fe 1.5/30 (28) 3

larin fe 1/20 (28) 3

LAYOLIS FE 3

leena 28 3

lessina 3

levonest (28) 3

levonorgestrel-ethinyl estrad 3

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE 4

bacitracin ophthalmic (eye) 4

bacitracin-polymyxin b 2

BESIVANCE 4

CILOXAN OPHTHALMIC

(EYE) OINTMENT

ciprooxacin hcl ophthalmic

(eye)

erythromycin ophthalmic (eye) 2

gentamicin ophthalmic (eye)

drops

moxioxacin ophthalmic (eye) 3

NATACYN 4

neomycin-bacitracin-polymyxin 2

neomycin-polymyxin-gramicidin 3

neo-polycin 2

ooxacin ophthalmic (eye) 2

polycin 2

polymyxin b sulf-trimethoprim 2

tobramycin ophthalmic (eye) 2

ANTIVIRALS

triuridine 4

ZIRGAN 3

BETA-BLOCKERS

carteolol 2

levobunolol ophthalmic (eye)

drops 0.5%

timolol maleate ophthalmic

(eye) drops

timolol maleate ophthalmic

(eye) gel forming solution

MISCELLANEOUS OPHTHALMOLOGICS

atropine ophthalmic (eye) drops 3

azelastine ophthalmic (eye) 4

cromolyn ophthalmic (eye) 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

simliya (28) 3

simpesse 3

sprintec (28) 3

sronyx 3

syeda 3

tarina 24 fe 3

tarina fe 1-20 eq (28) 3

taysofy 3

tilia fe 3

tri-estarylla 3

tri-legest fe 3

tri-linyah 3

tri-lo-estarylla 3

tri-lo-marzia 3

tri-lo-mili 3

tri-lo-sprintec 3

tri-mili 3

tri-nymyo 3

tri-sprintec (28) 3

trivora (28) 3

tri-vylibra 3

tri-vylibra lo 3

TYBLUME 3

tydemy 3

velivet triphasic regimen (28) 3

vestura (28) 3

vienva 3

viorele (28) 3

volnea (28) 3

vyfemla (28) 3

vylibra 3

wera (28) 3

wymzya fe 3

zovia 1-35 (28) 3

zumandimine (28) 3

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

travoprost 4

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc 3

neomycin-polymyxin

b-dexameth

neomycin-polymyxin-hc

ophthalmic (eye)

neo-polycin hc 4

TOBRADEX ST 3

tobramycin-dexamethasone 3

STEROIDS

dexamethasone sodium

phosphate ophthalmic (eye)

EYSUVIS 3 QL (16.6/30)

FLUOROMETHOLONE 3

INVELTYS 3

LOTEMAX OPHTHALMIC

(EYE) OINTMENT

LOTEMAX SM 4

loteprednol etabonate 4

PREDNISOLONE ACETATE 3

prednisolone sodium

phosphate ophthalmic (eye)

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC

(EYE) DROPS 0.1%

apraclonidine 4

brimonidine ophthalmic (eye)

drops 0.15%

brimonidine ophthalmic (eye)

drops 0.2%

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

desloratadine oral tablet 3 QL (30/30)

diphenhydramine hcl injection

solution 50 mg/ml

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CYSTARAN 5 PA; NDS

EYLEA 4 PA; QL (0.1/28)

olopatadine ophthalmic (eye) 4

OXERVATE 4 PA; QL (112/56)

PHOSPHOLINE IODIDE 4

pilocarpine hcl ophthalmic (eye)

drops 1%, 2%, 4%

RESTASIS 3 QL (60/30)

RESTASIS MULTIDOSE 3 QL (5.5/30)

sulfacetamide sodium

ophthalmic (eye) drops

sulfacetamide-prednisolone 2

XDEMVY 4 PA; QL (1/42)

XIIDRA 3 QL (60/30)

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

diclofenac sodium ophthalmic

(eye)

urbiprofen sodium 3

KETOROLAC OPHTHALMIC

(EYE) DROPS 0.4%

ketorolac ophthalmic (eye)

drops 0.5%

PROLENSA 3

ORAL DRUGS FOR GLAUCOMA

acetazolamide 3

acetazolamide sodium 4

methazolamide 4

OTHER GLAUCOMA DRUGS

brinzolamide 4

COMBIGAN 3

dorzolamide 2

dorzolamide-timolol 2

latanoprost 1

LUMIGAN OPHTHALMIC

(EYE) DROPS 0.01%

RHOPRESSA 4 ST

ROCKLATAN 4 ST

SIMBRINZA 4

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

budesonide inhalation 4 B/D PA; QL

(120/30)

COMBIVENT RESPIMAT 4 QL (8/30)

cromolyn inhalation 4 B/D PA

DALIRESP 4 PA; QL (30/30)

DULERA 4 ST; QL (13/30)

ESBRIET ORAL CAPSULE 5 PA; QL (270/30);

NDS

FLOVENT DISKUS

INHALATION BLISTER

WITH DEVICE 100 MCG/

ACTUATION, 50 MCG/

ACTUATION

3 QL (60/30)

FLOVENT DISKUS

INHALATION BLISTER

WITH DEVICE 250 MCG/

ACTUATION

3 QL (240/30)

FLOVENT HFA INHALATION

HFA AEROSOL INHALER

110 MCG/ACTUATION

3 QL (12/30)

FLOVENT HFA INHALATION

HFA AEROSOL INHALER

220 MCG/ACTUATION

3 QL (24/30)

FLOVENT HFA INHALATION

HFA AEROSOL INHALER

44 MCG/ACTUATION

3 QL (10.6/30)

unisolide 3 QL (50/30)

uticasone propionate nasal 2 QL (16/30)

formoterol fumarate 4 B/D PA; QL

(120/30)

HAEGARDA 5 PA; LA; NDS

icatibant 5 PA; QL (18/30);

NDS

INCRUSE ELLIPTA 3 QL (30/30)

ipratropium bromide inhalation 2 B/D PA

ipratropium-albuterol 2 B/D PA

KALYDECO ORAL GRANULES

IN PACKET 13.4 MG, 25 MG,

50 MG, 75 MG

5 PA; QL (56/28);

NDS

KALYDECO ORAL TABLET 5 PA; QL (60/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

EPINEPHRINE INJECTION

AUTO-INJECTOR

0.15 MG/0.15 ML,

0.3 MG/0.3 ML

3 QL (2/30)

epinephrine injection auto-

injector 0.15 mg/0.3 ml, 0.3

mg/0.3 ml

3 QL (2/30)

epinephrine injection solution 1

mg/ml

hydroxyzine hcl oral tablet 3 PA

levocetirizine oral tablet 2 QL (30/30)

promethazine oral 2 PA

PULMONARY AGENTS

acetylcysteine 4 B/D PA

ADEMPAS 5 PA; LA; QL (90/30);

NDS

ADVAIR DISKUS 3 QL (60/30)

ADVAIR HFA 3 QL (12/30)

albuterol sulfate inhalation

hfa aerosol inhaler 90 mcg/

actuation

3 QL (17/30)

albuterol sulfate inhalation

hfa aerosol inhaler 90 mcg/

actuation (nda020503)

3 QL (13.4/30)

albuterol sulfate inhalation

hfa aerosol inhaler 90 mcg/

actuation (nda020983)

3 QL (36/30)

albuterol sulfate inhalation

solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2

albuterol sulfate oral tablet 4

alyq 4 PA; QL (60/30)

ambrisentan 5 PA; LA; QL (30/30);

NDS

ANORO ELLIPTA 3 QL (60/30)

ARNUITY ELLIPTA 3 QL (30/30)

ATROVENT HFA 4 QL (25.8/30)

BREO ELLIPTA 3 QL (60/30)

breyna 4 QL (10.3/30)

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TRELEGY ELLIPTA 3 QL (60/30)

TRIKAFTA ORAL GRANULES

IN PACKET, SEQUENTIAL

5 PA; QL (56/28);

NDS

TRIKAFTA ORAL TABLETS,

SEQUENTIAL

5 PA; QL (84/28);

NDS

VENTAVIS 4 PA

VENTOLIN HFA 3 QL (36/30)

XOLAIR SUBCUTANEOUS

RECON SOLN

5 PA; LA; QL (8/28);

NDS

XOLAIR SUBCUTANEOUS

SYRINGE 150 MG/ML

5 PA; LA; QL (8/28);

NDS

XOLAIR SUBCUTANEOUS

SYRINGE 75 MG/0.5 ML

5 PA; LA; QL (1/28);

NDS

zarlukast 3 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

fesoterodine 4 ST; QL (30/30)

GEMTESA 4 QL (30/30)

MYRBETRIQ ORAL TABLET

EXTENDED RELEASE 24 HR

oxybutynin chloride oral syrup 2

oxybutynin chloride oral tablet 2

oxybutynin chloride oral tablet

extended release 24hr

2 QL (60/30)

solifenacin 3

tolterodine oral

capsule,extended release 24hr

4 ST

tolterodine oral tablet 4

TOVIAZ 4 ST; QL (30/30)

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin 2

dutasteride 2

nasteride oral tablet 5 mg 2 QL (30/30)

tamsulosin 2 QL (60/30)

MISCELLANEOUS UROLOGICALS

bethanechol chloride 3

CYSTAGON 4 LA

ELMIRON 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

montelukast oral granules in

packet

3 QL (30/30)

montelukast oral tablet 2 QL (30/30)

montelukast oral

tablet,chewable

2 QL (30/30)

NUCALA SUBCUTANEOUS

AUTO-INJECTOR

5 PA; LA; QL (3/28);

NDS

NUCALA SUBCUTANEOUS

SYRINGE 100 MG/ML

5 PA; LA; QL (3/28);

NDS

NUCALA SUBCUTANEOUS

SYRINGE 40 MG/0.4 ML

5 PA; LA; QL (0.4/28);

NDS

OFEV 5 PA; QL (60/30);

NDS

OPSUMIT 5 PA; LA; NDS

pirfenidone oral capsule 5 PA; QL (270/30);

NDS

pirfenidone oral tablet 267 mg 5 PA; QL (270/30);

NDS

pirfenidone oral tablet 534 mg,

801 mg

5 PA; QL (90/30);

NDS

PULMOZYME 5 B/D PA; QL

(150/30); NDS

roumilast 4 PA; QL (30/30)

RYALTRIS 4 ST

sajazir 5 PA; QL (18/30);

NDS

SEREVENT DISKUS 3 QL (60/30)

sildenal (pulm.hypertension)

oral tablet

3 PA; QL (90/30)

tadalal (pulm. hypertension) 4 PA; QL (60/30)

terbutaline 4

theo-24 4

theophylline oral tablet

extended release 12 hr 100 mg,

200 mg, 300 mg

theophylline oral tablet

extended release 12 hr 450 mg

theophylline oral tablet

extended release 24 hr 400 mg

theophylline oral tablet

extended release 24 hr 600 mg

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

POTASSIUM CHLORIDE

IN LR-D5 INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L

potassium chloride in water

intravenous piggyback 10

meq/100 ml, 10 meq/50 ml, 20

meq/100 ml, 20 meq/50 ml, 40

meq/100 ml

potassium chloride intravenous 4

potassium chloride oral

capsule, extended release

potassium chloride oral liquid 4

potassium chloride oral packet 3

potassium chloride oral tablet

extended release

potassium chloride oral

tablet,er particles/crystals

potassium chloride-0.45% nacl 4

POTASSIUM CHLORIDE-

D5-0.2%NACL INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L

POTASSIUM CHLORIDE-

D5-0.9%NACL

RINGER'S INTRAVENOUS 4

sodium bicarbonate

intravenous syringe

sodium chloride 0.45%

intravenous

sodium chloride 3% hypertonic 4

SODIUM CHLORIDE 5%

HYPERTONIC

sodium chloride intravenous 4

MISCELLANEOUS NUTRITION PRODUCTS

AMINOSYN II 15% 4 B/D PA

AMINOSYN-PF 7% (SULFITE-

FREE)

4 B/D PA

CLINIMIX 5%/D15W SULFITE

FREE

4 B/D PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

K-PHOS ORIGINAL 4

potassium citrate oral tablet

extended release

RENACIDIN 4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

calcium acetate(phosphat bind) 3 QL (360/30)

klor-con 2

KLOR-CON 10 1

KLOR-CON 8 1

klor-con m10 1

klor-con m20 1

lactated ringers intravenous 4

magnesium sulfate in d5w

intravenous piggyback 1

gram/100 ml

magnesium sulfate in water 4

magnesium sulfate injection 4

PHOSLYRA 4

POTASSIUM CHLORID-

D5-0.45%NACL

INTRAVENOUS PARENTERAL

SOLUTION 10 MEQ/L,

20 MEQ/L, 30 MEQ/L

potassium chlorid-

d5-0.45%nacl intravenous

parenteral solution 40 meq/l

POTASSIUM CHLORIDE IN

0.9%NACL INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L, 40 MEQ/L

potassium chloride in 5% dex

intravenous parenteral solution

10 meq/l

POTASSIUM CHLORIDE

IN 5% DEX INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L

December 2023

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 7.

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PNV-SELECT 3

potassium chloride oral

tablet,er particles/crystals 15

meq

PR NATAL 400 3

PR NATAL 400 EC 3

PR NATAL 430 3

PR NATAL 430 EC 3

PRENATAL PLUS (CALCIUM

CARB)

PRENATAL VITAMIN PLUS

LOW IRON

SE-NATAL 19 CHEWABLE 3

SE-NATAL-19 3

TARON-C DHA 3

TRINATAL RX 1 3

WESTAB PLUS 2

WESTGEL DHA 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CLINIMIX 4.25%/D10W SULF

FREE

4 B/D PA

CLINIMIX 5%-D20W(SULFITE-

FREE)

4 B/D PA

CLINIMIX 6%-D5W (SULFITE-

FREE)

4 B/D PA

CLINIMIX 8%-D10W(SULFITE-

FREE)

4 B/D PA

CLINIMIX 8%-D14W(SULFITE-

FREE)

4 B/D PA

CLINIMIX E 4.25%/D10W SUL

FREE

4 B/D PA

clinisol sf 15% 4 B/D PA

ELECTROLYTE-48 IN D5W 4

INTRALIPID INTRAVENOUS

EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PA

PERIKABIVEN 4 B/D PA

plenamine 4 B/D PA

premasol 10% 4 B/D PA

PROSOL 20% 4 B/D PA

TRAVASOL 10% 4 B/D PA

TROPHAMINE 10% 4 B/D PA

VITAMINS / HEMATINICS

BAL-CARE DHA 3

C-NATE DHA 3

COMPLETE NATAL DHA 3

ELITE-OB 3

uoride (sodium) oral tablet 1

uoride (sodium) oral

tablet,chewable 1 mg (2.2 mg

sod. uoride)

FOLIVANE-OB 3

ludent uoride oral

tablet,chewable 1 mg (2.2 mg

sod. uoride)

M-NATAL PLUS 3

PNV-DHA 3

PNV-OMEGA 3

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

abacavir-lamivudine .....................................8

abacavir oral solution

....................................8

abacavir oral tablet

......................................8

ABELCET

............................................... 8

ABILIFY MAINTENA

....................................26

abiraterone oral tablet 250 mg

...........................14

abiraterone oral tablet 500 mg

...........................14

ABRAXANE

............................................14

ABRYSVO

.............................................45

acamprosate

...........................................37

acarbose oral tablet 25 mg

..............................40

acarbose oral tablet 50 mg

..............................40

acarbose oral tablet 100 mg

.............................40

acebutolol

..............................................31

acetaminophen-codeine oral solution

120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml

..............24

acetaminophen-codeine oral tablet 300-15 mg,

300-30 mg

.............................................24

acetaminophen-codeine oral tablet 300-60 mg

...........24

acetazolamide

..........................................51

acetazolamide sodium

..................................51

acetic acid otic (ear)

....................................39

acetylcysteine

..........................................52

acitretin

................................................35

ACTHIB (PF)

...........................................45

ACTIMMUNE

..........................................45

acyclovir oral capsule

....................................8

acyclovir oral suspension 200 mg/5 ml

....................8

acyclovir oral tablet

......................................8

acyclovir sodium intravenous solution

..................... 8

ADACEL(TDAP ADOLESN/ADULT)(PF)

.................45

ADALIMUMAB-ADAZ

...................................46

adapalene topical gel 0.3%

..............................35

ADCETRIS

.............................................14

adefovir

.................................................8

ADEMPAS

.............................................52

ADLARITY

.............................................23

ADSTILADRIN

.........................................14

ADVAIR DISKUS

.......................................52

ADVAIR HFA

...........................................52

armelle

...............................................48

AIMOVIG AUTOINJECTOR

.............................23

AJOVY AUTOINJECTOR

...............................23

AJOVY SYRINGE

......................................23

AKEEGA

...............................................14

ala-cort topical cream 1%

...............................36

albendazole

............................................11

albuterol sulfate inhalation hfa aerosol inhaler

90 mcg/actuation

.......................................52

albuterol sulfate inhalation hfa aerosol inhaler

90 mcg/actuation (nda020503)

..........................52

albuterol sulfate inhalation hfa aerosol inhaler

90 mcg/actuation (nda020983)

..........................52

albuterol sulfate inhalation solution for nebulization

.......52

albuterol sulfate oral syrup

..............................52

albuterol sulfate oral tablet

..............................52

alclometasone

..........................................36

ALCOHOL PADS

.......................................40

ALDURAZYME

.........................................42

ALECENSA

............................................14

alendronate oral tablet 10 mg

...........................46

alendronate oral tablet 35 mg, 70 mg

....................46

alfuzosin

...............................................53

ALIMTA

................................................14

ALIQOPA

..............................................14

aliskiren

................................................31

allopurinol oral tablet 100 mg, 300 mg

...................46

alosetron

...............................................43

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1%

.......51

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg

.............26

alprazolam oral tablet 2 mg

.............................26

alprazolam oral tablet,disintegrating

0.25 mg, 0.5 mg, 1 mg

..................................26

alprazolam oral tablet,disintegrating 2 mg

................26

altavera (28)

...........................................48

ALUNBRIG ORAL TABLET 30 MG

......................14

ALUNBRIG ORAL TABLET 180 MG, 90 MG

..............14

ALUNBRIG ORAL TABLETS, DOSE PACK

..............14

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

alyacen 1/35 (28) .......................................48

alyacen 7/7/7 (28)

......................................48

alyq

....................................................52

amantadine hcl

..........................................8

ambrisentan

............................................52

amethia

................................................48

amethyst (28)

..........................................48

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

...11

amiloride

...............................................31

amiloride-hydrochlorothiazide

...........................31

aminocaproic acid oral

..................................33

AMINOSYN II 15%

.....................................54

AMINOSYN-PF 7% (SULFITE-FREE)

...................54

amiodarone intravenous solution

........................31

amiodarone oral tablet 100 mg, 400 mg

..................31

amiodarone oral tablet 200 mg

..........................31

amitriptyline

............................................26

amlodipine

.............................................31

amlodipine-benazepril

..................................31

amlodipine-valsartan

....................................31

amlodipine-valsartan-hcthiazid

..........................31

ammonium lactate

......................................35

amoxapine

.............................................26

amoxicillin oral capsule

.................................12

amoxicillin oral suspension for reconstitution

.............12

amoxicillin oral tablet

...................................12

amoxicillin oral tablet,chewable 125 mg, 250 mg

..........12

amoxicillin-pot clavulanate oral suspension for

reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml,

600-42.9 mg/5 ml

.......................................12

amoxicillin-pot clavulanate oral suspension for

reconstitution 250-62.5 mg/5 ml

.........................12

amoxicillin-pot clavulanate oral tablet

....................12

amoxicillin-pot clavulanate oral tablet,chewable

200-28.5 mg

...........................................12

amoxicillin-pot clavulanate oral tablet,chewable

400-57 mg

.............................................12

amoxicillin-pot clavulanate oral tablet extended

release 12 hr

...........................................12

amphotericin b

..........................................8

amphotericin b liposome

.................................8

ampicillin oral capsule 500 mg

...........................12

ampicillin sodium

.......................................13

ampicillin-sulbactam

....................................13

anagrelide

.............................................37

anastrozole

............................................14

ANORO ELLIPTA

.......................................52

apraclonidine

...........................................51

aprepitant

..............................................43

APRETUDE

............................................. 8

apri

....................................................48

APTIOM ORAL TABLET 200 MG

........................21

APTIOM ORAL TABLET 400 MG

........................21

APTIOM ORAL TABLET 600 MG, 800 MG

...............21

APTIVUS

...............................................8

aranelle (28)

...........................................48

ARCALYST

............................................45

AREXVY (PF)

..........................................45

ARIKAYCE

.............................................11

aripiprazole oral solution

................................26

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg

. . . . . . . . . 26

aripiprazole oral tablet 20 mg, 30 mg

....................26

aripiprazole oral tablet,disintegrating

.....................26

ARISTADA INITIO

......................................26

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 1,064 MG/3.9 ML

.............26

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 441 MG/1.6 ML

...............26

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 662 MG/2.4 ML

...............26

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 882 MG/3.2 ML

...............26

ARNUITY ELLIPTA

.....................................52

arsenic trioxide

.........................................14

asenapine maleate sublingual tablet 5 mg

................26

asenapine maleate sublingual tablet 10 mg, 2.5 mg

.......26

ashlyna

................................................48

aspirin-dipyridamole

....................................33

ASSURE ID INSULIN SAFETY SYRINGE 1 ML

29 GAUGE X 1/2"

......................................40

atazanavir oral capsule 150 mg, 300 mg

..................8

atazanavir oral capsule 200 mg

...........................8

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

atenolol ................................................31

atenolol-chlorthalidone

..................................31

ATGAM

................................................45

atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg

...26

atomoxetine oral capsule 100 mg, 60 mg, 80 mg

.........26

atorvastatin

............................................34

atovaquone

............................................11

atovaquone-proguanil

................................... 11

atropine ophthalmic (eye) drops

.........................50

ATROVENT HFA

.......................................52

AUBAGIO

..............................................23

aubra eq

...............................................48

AUGMENTIN ORAL SUSPENSION FOR

RECONSTITUTION 125-31.25 MG/5 ML

.................13

aurovela 1.5/30 (21)

....................................48

aurovela 1/20 (21)

......................................48

aurovela 24 fe

..........................................48

aurovela fe 1.5/30 (28)

..................................48

aurovela fe 1-20 (28)

...................................48

AUSTEDO ORAL TABLET 6 MG

........................23

AUSTEDO ORAL TABLET 12 MG, 9 MG

.................23

AUSTEDO XR ORAL TABLET EXTENDED

RELEASE 24 HR 6 MG

.................................23

AUSTEDO XR ORAL TABLET EXTENDED

RELEASE 24 HR 12 MG

................................23

AUSTEDO XR ORAL TABLET EXTENDED

RELEASE 24 HR 24 MG

................................23

AUSTEDO XR TITRATION KT(WK1-4)

..................23

AUVELITY

.............................................26

aviane

.................................................48

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

.......45

AVONEX INTRAMUSCULAR SYRINGE

.................45

AVONEX INTRAMUSCULAR SYRINGE KIT

.............45

ayuna

..................................................48

AYVAKIT

...............................................14

azacitidine

.............................................14

AZASITE

...............................................50

azathioprine oral tablet 50 mg

...........................14

azathioprine sodium

....................................14

azelastine nasal

........................................39

azelastine ophthalmic (eye)

.............................50

azithromycin intravenous

................................ 11

AZITHROMYCIN ORAL PACKET

........................11

azithromycin oral suspension for reconstitution

...........11

azithromycin oral tablet

.................................11

aztreonam

.............................................11

azurette (28)

...........................................48

bacitracin intramuscular ................................. 11

bacitracin ophthalmic (eye)

..............................50

bacitracin-polymyxin b

..................................50

baclofen oral tablet

.....................................24

BAL-CARE DHA

........................................55

balsalazide

.............................................43

BALVERSA

............................................14

balziva (28)

............................................48

BAQSIMI

...............................................40

BARACLUDE ORAL SOLUTION

.........................8

BAVENCIO

.............................................14

BCG VACCINE, LIVE (PF)

..............................45

BD SAFETYGLIDE INSULIN SYRINGE SYRINGE

1 ML 31 GAUGE X 15/64"

...............................40

BD ULTRA-FINE MICRO PEN NEEDLE

.................40

BD ULTRA-FINE MINI PEN NEEDLE

....................40

BD ULTRA-FINE NANO PEN NEEDLE

..................40

BD ULTRA-FINE SHORT PEN NEEDLE

.................40

BELEODAQ

............................................14

BELSOMRA

............................................26

benazepril

..............................................31

benazepril-hydrochlorothiazide

..........................31

bendamustine intravenous recon soln

....................14

BENDEKA

.............................................14

BENLYSTA INTRAVENOUS

.............................46

benztropine injection

....................................23

benztropine oral

........................................23

BESIVANCE

...........................................50

BESPONSA

............................................14

BESREMI

..............................................45

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

betaine ................................................43

betamethasone, augmented topical cream

...............36

betamethasone, augmented topical gel

..................37

betamethasone, augmented topical lotion

................37

betamethasone, augmented topical ointment

.............37

betamethasone dipropionate

............................36

betamethasone valerate topical cream

...................36

betamethasone valerate topical lotion

....................36

betamethasone valerate topical ointment

.................36

BETASERON SUBCUTANEOUS KIT

....................45

betaxolol oral

...........................................31

bethanechol chloride

....................................53

bexarotene

.............................................14

BEXSERO

.............................................45

bicalutamide

...........................................14

BICILLIN L-A

...........................................13

BIKTARVY

..............................................8

bisoprolol fumarate

.....................................31

bisoprolol-hydrochlorothiazide

...........................31

BLENREP

.............................................14

bleomycin

..............................................14

BLINCYTO INTRAVENOUS KIT

.........................14

blisovi 24 fe

............................................48

blisovi fe 1.5/30 (28)

....................................48

blisovi fe 1/20 (28)

......................................48

BOOSTRIX TDAP

......................................45

BORTEZOMIB INJECTION

.............................14

BORTEZOMIB INTRAVENOUS RECON SOLN

..........14

BOSULIF ORAL TABLET 100 MG

.......................14

BOSULIF ORAL TABLET 400 MG, 500 MG

..............14

BOTOX

................................................45

BRAFTOVI ORAL CAPSULE 75 MG

.....................14

BREO ELLIPTA

........................................52

breyna

.................................................52

briellyn

.................................................48

BRILINTA

..............................................33

brimonidine ophthalmic (eye) drops 0.2%

................51

brimonidine ophthalmic (eye) drops 0.15%

...............51

brinzolamide

...........................................51

BRIVIACT INTRAVENOUS

..............................21

BRIVIACT ORAL SOLUTION

............................21

BRIVIACT ORAL TABLET

...............................21

bromocriptine

..........................................23

BRUKINSA

............................................14

budesonide inhalation

...................................52

budesonide oral

........................................43

bumetanide injection

....................................31

bumetanide oral tablet 0.5 mg, 1 mg

.....................31

bumetanide oral tablet 2 mg

.............................31

buprenorphine hcl injection

..............................24

buprenorphine hcl sublingual

............................24

buprenorphine-naloxone sublingual lm 2-0.5 mg

.........25

buprenorphine-naloxone sublingual lm 4-1 mg, 8-2 mg

...25

buprenorphine-naloxone sublingual lm 12-3 mg

.........25

buprenorphine-naloxone sublingual tablet 2-0.5 mg

.......25

buprenorphine-naloxone sublingual tablet 8-2 mg

.........25

bupropion hcl oral tablet 75 mg

..........................26

bupropion hcl oral tablet 100 mg

.........................26

bupropion hcl oral tablet extended release

24 hr 150 mg

...........................................27

bupropion hcl oral tablet extended release

24 hr 300 mg

...........................................27

bupropion hcl oral tablet sustained-release

12 hr 100 mg

...........................................27

bupropion hcl oral tablet sustained-release

12 hr 150 mg, 200 mg

..................................27

bupropion hcl (smoking deter)

...........................39

buspirone

..............................................27

BUSULFAN

............................................14

butorphanol nasal

......................................25

BYDUREON BCISE

....................................40

BYSTOLIC

.............................................31

CABENUVA .............................................8

cabergoline

............................................42

CABOMETYX

..........................................14

calcipotriene scalp

......................................35

calcipotriene topical cream

..............................35

calcipotriene topical ointment

............................35

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

calcitonin (salmon) nasal ................................42

calcitriol intravenous solution 1 mcg/ml

...................42

calcitriol oral capsule

...................................42

calcitriol oral solution

...................................42

calcium acetate(phosphat bind)

..........................54

CALQUENCE

..........................................14

CALQUENCE (ACALABRUTINIB MAL)

..................14

camila

.................................................47

camrese

...............................................48

CAMRESE LO

.........................................48

candesartan-hydrochlorothiazid

.........................31

candesartan oral tablet 16 mg, 4 mg, 8 mg

...............31

candesartan oral tablet 32 mg

...........................31

CAPLYTA

..............................................27

CAPRELSA ORAL TABLET 100 MG

.....................14

CAPRELSA ORAL TABLET 300 MG

.....................14

captopril

...............................................31

CARBAGLU

............................................37

carbamazepine oral capsule, er multiphase 12 hr

.........21

carbamazepine oral suspension

.........................21

carbamazepine oral tablet

...............................21

carbamazepine oral tablet,chewable

.....................21

carbamazepine oral tablet extended release 12 hr

........21

carbidopa

..............................................23

carbidopa-levodopa-entacapone

.........................23

carbidopa-levodopa oral tablet

..........................23

carbidopa-levodopa oral tablet,disintegrating

10-100 mg

.............................................23

carbidopa-levodopa oral tablet,disintegrating

25-100 mg, 25-250 mg

..................................23

carbidopa-levodopa oral tablet extended release

.........23

carboplatin intravenous solution

.........................14

carglumic acid

..........................................37

carmustine intravenous recon soln 100 mg

...............14

CAROSPIR

............................................31

carteolol

...............................................50

cartia xt

................................................31

carvedilol

..............................................31

carvedilol phosphate

....................................31

caspofungin intravenous recon soln 50 mg

................8

caspofungin intravenous recon soln 70 mg

................8

CAYSTON

.............................................11

cefaclor oral capsule

....................................10

cefaclor oral suspension for reconstitution 1

25 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml

...................10

cefaclor oral tablet extended release 12 hr

...............10

cefadroxil oral capsule

..................................10

cefadroxil oral suspension for reconstitution

250 mg/5 ml, 500 mg/5 ml

...............................10

cefadroxil oral tablet

....................................10

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS

PIGGYBACK 1 GRAM/50 ML, 2 GRAM/100 ML,

2 GRAM/50 ML

.........................................10

cefazolin injection recon soln 1 gram, 10 gram,

100 gram, 2 gram, 300 g, 500 mg

.......................10

cefazolin intravenous recon soln 1 gram

.................10

CEFAZOLIN INTRAVENOUS RECON SOLN

2 GRAM, 3 GRAM

......................................10

cefdinir

.................................................10

CEFEPIME IN DEXTROSE 5%

..........................10

CEFEPIME IN DEXTROSE, ISO-OSM

...................10

cefepime injection

......................................10

cefepime intravenous

...................................10

cexime

................................................10

cefotetan injection

......................................10

cefoxitin

................................................10

CEFOXITIN IN DEXTROSE, ISO-OSM

..................10

cefpodoxime

...........................................10

cefprozil

...............................................10

ceftazidime

.............................................10

ceftriaxone

.............................................10

ceftriaxone in dextrose,iso-os

...........................10

cefuroxime axetil oral tablet

.............................10

cefuroxime sodium injection recon soln 750 mg

...........11

cefuroxime sodium intravenous

.......................... 11

celecoxib

...............................................25

CELONTIN ORAL CAPSULE 300 MG

...................21

cephalexin oral capsule 250 mg, 500 mg

.................11

cephalexin oral suspension for reconstitution

.............11

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT

...42

CHANTIX CONTINUING MONTH BOX

..................39

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

CHANTIX ORAL TABLET 1 MG .........................39

CHANTIX STARTING MONTH BOX

.....................39

charlotte 24 fe

..........................................48

chateal eq (28)

.........................................48

CHEMET

..............................................38

chloramphenicol sod succinate

..........................11

chlorhexidine gluconate mucous membrane

..............39

chloroquine phosphate

.................................. 11

chlorothiazide sodium

...................................31

chlorpromazine

.........................................27

chlorthalidone oral tablet 25 mg, 50 mg

..................31

cholestyramine-aspartame

..............................34

cholestyramine light

....................................34

cholestyramine (with sugar)

.............................34

CHORIONIC GONADOTROPIN, HUMAN

INTRAMUSCULAR

.....................................42

ciclodan topical solution

.................................36

ciclopirox topical cream

.................................36

ciclopirox topical shampoo

..............................36

ciclopirox topical solution

................................36

ciclopirox topical suspension

............................36

cilostazol

...............................................33

CILOXAN OPHTHALMIC (EYE) OINTMENT

.............50

CIMDUO

................................................ 8

cinacalcet oral tablet 30 mg, 60 mg

......................42

cinacalcet oral tablet 90 mg

.............................42

ciprooxacin-dexamethasone

...........................39

ciprooxacin hcl ophthalmic (eye)

........................50

ciprooxacin hcl oral tablet 100 mg

......................13

ciprooxacin hcl oral tablet 250 mg, 500 mg, 750 mg

. . . . . . 13

ciprooxacin in 5% dextrose

.............................13

ciprooxacin oral suspension,microcapsule recon

500 mg/5 ml

............................................13

CIPRO HC

.............................................39

CIPRO ORAL SUSPENSION, MICROCAPSULE

RECON

................................................13

cisplatin intravenous solution

............................14

citalopram oral solution

.................................27

citalopram oral tablet 10 mg, 20 mg

......................27

citalopram oral tablet 40 mg

.............................27

cladribine

..............................................14

claravis

................................................35

clarithromycin

..........................................11

CLENPIQ

..............................................43

clindamycin hcl

.........................................11

CLINDAMYCIN IN 0.9% SOD CHLOR

...................11

clindamycin in 5% dextrose

.............................11

clindamycin palmitate hcl

................................11

clindamycin pediatric

...................................11

clindamycin phosphate injection

.........................11

clindamycin phosphate topical gel

.......................35

CLINDAMYCIN PHOSPHATE TOPICAL GEL,

ONCE DAILY

...........................................36

clindamycin phosphate topical lotion

.....................36

clindamycin phosphate topical solution

...................36

clindamycin phosphate topical swab

.....................36

clindamycin phosphate vaginal

..........................48

CLINIMIX 4.25%/D5W SULFIT FREE

....................38

CLINIMIX 4.25%/D10W SULF FREE

....................55

CLINIMIX 5%/D15W SULFITE FREE

...................54

CLINIMIX 5%-D20W(SULFITE-FREE)

...................55

CLINIMIX 6%-D5W (SULFITE-FREE)

....................55

CLINIMIX 8%-D10W(SULFITE-FREE)

...................55

CLINIMIX 8%-D14W(SULFITE-FREE)

...................55

CLINIMIX E 4.25%/D10W SUL FREE

....................55

clinisol sf 15%

..........................................55

clobazam oral suspension

...............................21

clobazam oral tablet 10 mg

..............................21

clobazam oral tablet 20 mg

..............................21

clobetasol-emollient topical cream

.......................37

clobetasol scalp

........................................37

clobetasol topical cream

................................37

clobetasol topical foam

..................................37

clobetasol topical gel

...................................37

clobetasol topical lotion

.................................37

clobetasol topical ointment

..............................37

clobetasol topical shampoo

.............................37

clobetasol topical spray,non-aerosol

.....................37

clodan

.................................................37

clofarabine

.............................................14

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

clomipramine ...........................................27

clonazepam oral tablet 0.5 mg, 1 mg

.....................21

clonazepam oral tablet 2 mg

............................21

clonazepam oral tablet,disintegrating 0.5 mg, 1 mg

.......21

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg

..21

clonazepam oral tablet,disintegrating 2 mg

...............21

clonidine

...............................................31

clonidine hcl oral tablet

..................................31

clopidogrel oral tablet 75 mg

............................33

clopidogrel oral tablet 300 mg

...........................33

clorazepate dipotassium oral tablet 3.75 mg

..............27

clorazepate dipotassium oral tablet 7.5 mg

...............27

clorazepate dipotassium oral tablet 15 mg

................27

clotrimazole-betamethasone topical cream

...............36

clotrimazole-betamethasone topical lotion

................36

clotrimazole mucous membrane

..........................8

clotrimazole topical cream

...............................36

clotrimazole topical solution

.............................36

clozapine oral tablet 25 mg, 50 mg

.......................27

clozapine oral tablet 100 mg, 200 mg

....................27

clozapine oral tablet,disintegrating

.......................27

C-NATE DHA

..........................................55

COARTEM

.............................................11

colchicine oral tablet

....................................46

colesevelam

............................................34

colestipol oral granules

.................................34

colestipol oral packet

...................................34

colestipol oral tablet

....................................34

colistin (colistimethate na)

............................... 11

COLUMVI

..............................................14

COMBIGAN

............................................51

COMBIVENT RESPIMAT

...............................52

COMETRIQ ORAL CAPSULE 60 MG/DAY

(20 MG X 3/DAY)

.......................................15

COMETRIQ ORAL CAPSULE 100 MG/DAY

(80 MG X1-20 MG X1)

..................................15

COMETRIQ ORAL CAPSULE 140 MG/DAY

(80 MG X1-20 MG X3)

..................................15

COMPLERA

............................................8

COMPLETE NATAL DHA

...............................55

compro

................................................43

constulose

.............................................43

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

....23

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

....23

COPIKTRA

............................................15

CORLANOR ORAL TABLET

............................34

CORTIFOAM

...........................................43

cortisone

...............................................39

COTELLIC

.............................................15

CREON

................................................43

CRESEMBA ORAL

......................................8

cromolyn inhalation

.....................................52

cromolyn ophthalmic (eye)

..............................50

cromolyn oral

...........................................43

cryselle (28)

............................................48

CUVRIOR

..............................................38

cyclobenzaprine oral tablet 10 mg, 5 mg

.................24

cyclophosphamide intravenous recon soln

...............15

CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION

....15

cyclophosphamide oral capsule

.........................15

cyclophosphamide oral tablet 25 mg

.....................15

CYCLOPHOSPHAMIDE ORAL TABLET 50 MG

..........15

cycloserine

............................................. 11

CYCLOSET

............................................40

cyclosporine intravenous

................................15

cyclosporine modied

...................................15

cyclosporine oral capsule

...............................15

CYLTEZO(CF) PEN

....................................46

CYLTEZO(CF) PEN CROHN'S-UC-HS

..................46

CYLTEZO(CF) PEN PSORIASIS-UV

....................46

CYLTEZO(CF) SUBCUTANEOUS SYRINGE KIT

10 MG/0.2 ML, 20 MG/0.4 ML

...........................46

CYLTEZO(CF) SUBCUTANEOUS SYRINGE KIT

40 MG/0.8 ML

..........................................46

CYRAMZA

.............................................15

cyred eq

...............................................48

CYSTAGON

............................................53

CYSTARAN

............................................51

cytarabine

..............................................15

cytarabine (pf)

..........................................15

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

d2.5%-0.45% sodium chloride ...........................38

d5%-0.45% sodium chloride

.............................38

d5% and 0.9% sodium chloride

..........................38

D10%-0.45% SODIUM CHLORIDE

......................38

dabigatran etexilate

.....................................33

dacarbazine

............................................15

dactinomycin

...........................................15

dalfampridine

...........................................23

DALIRESP

.............................................52

danazol

................................................42

dantrolene oral

.........................................24

DANYELZA

............................................15

dapsone oral

...........................................11

DAPTACEL (DTAP PEDIATRIC) (PF)

....................45

daptomycin

............................................11

DAPTOMYCIN IN 0.9% SOD CHLOR

...................11

darunavir ethanolate

.....................................8

DARZALEX

............................................15

DARZALEX FASPRO

...................................15

dasetta 1/35 (28)

.......................................48

dasetta 7/7/7 (28)

.......................................48

daunorubicin intravenous solution

.......................15

DAURISMO ORAL TABLET 25 MG

......................15

DAURISMO ORAL TABLET 100 MG

.....................15

daysee

.................................................48

DAYVIGO

..............................................27

deblitane

...............................................47

decitabine

..............................................15

deferasirox oral tablet, dispersible

.......................38

DELSTRIGO

............................................8

DENGVAXIA (PF)

......................................45

DEPO-MEDROL

.......................................39

DESCOVY

..............................................8

desipramine

............................................27

desloratadine oral tablet

................................51

desmopressin injection

..................................42

desmopressin nasal spray,non-aerosol

10 mcg/spray (0.1 ml)

...................................43

desmopressin nasal spray with pump

....................42

desmopressin oral

......................................43

desog-e.estradiol/e.estradiol

............................48

desogestrel-ethinyl estradiol

.............................48

desonide topical lotion

..................................37

desonide topical ointment

...............................37

desoximetasone topical cream

..........................37

desoximetasone topical gel

.............................37

desoximetasone topical ointment

........................37

desvenlafaxine succinate oral tablet extended

release 24 hr 25 mg

....................................27

desvenlafaxine succinate oral tablet extended

release 24 hr 50 mg

....................................27

desvenlafaxine succinate oral tablet extended

release 24 hr 100 mg

...................................27

dexamethasone intensol

................................39

dexamethasone oral elixir

...............................39

dexamethasone oral solution

............................39

dexamethasone oral tablet 0.5 mg, 0.75 mg, 4 mg

........39

dexamethasone oral tablet 1 mg, 1.5 mg, 2 mg, 6 mg

.....39

dexamethasone sodium phos (pf) injection solution

.......39

dexamethasone sodium phosphate injection solution

.....39

dexamethasone sodium phosphate ophthalmic (eye)

.....51

DEXILANT

.............................................44

dexlansoprazole

........................................44

dexmethylphenidate oral tablet

..........................27

dextroamphetamine-amphetamine oral capsule,

extended release 24hr

..................................27

dextroamphetamine-amphetamine oral tablet 5 mg

.......27

dextroamphetamine-amphetamine oral tablet 10 mg

......27

dextroamphetamine-amphetamine oral tablet

12.5 mg, 30 mg, 7.5 mg

.................................27

dextroamphetamine-amphetamine oral tablet 15 mg

......27

dextroamphetamine-amphetamine oral tablet 20 mg

......27

dextroamphetamine sulfate oral capsule, extended

release

................................................27

dextroamphetamine sulfate oral tablet

...................27

dextrose 5%-0.2% sod chloride

..........................38

dextrose 5%-0.3% sod.chloride

..........................38

dextrose 5% in water (d5w) intravenous parenteral

solution

................................................38

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

DEXTROSE 5% IN WATER (D5W) INTRAVENOUS

PIGGYBACK

...........................................38

DEXTROSE 5%-LACTATED RINGERS

..................38

DEXTROSE 10% AND 0.2% NACL

......................38

dextrose 10% in water (d10w)

...........................38

DEXTROSE 25% IN WATER (D25W)

....................38

DEXTROSE 50% IN WATER (D50W) INTRAVENOUS

PARENTERAL SOLUTION

..............................38

dextrose 50% in water (d50w) intravenous syringe

........38

DEXTROSE 70% IN WATER (D70W)

....................38

DIACOMIT

.............................................21

diazepam injection

......................................27

diazepam intensol

......................................27

diazepam oral concentrate

..............................27

diazepam oral solution

..................................27

diazepam oral tablet

....................................27

diazepam rectal

........................................21

diazoxide

..............................................40

DICLOFENAC EPOLAMINE

............................25

diclofenac potassium oral tablet 50 mg

...................25

diclofenac sodium ophthalmic (eye)

......................51

diclofenac sodium oral

..................................25

diclofenac sodium topical drops

.........................25

diclofenac sodium topical gel 1%

........................25

dicloxacillin

.............................................13

dicyclomine oral capsule

................................43

dicyclomine oral solution

................................43

dicyclomine oral tablet

..................................43

DIFICID ORAL SUSPENSION FOR

RECONSTITUTION

....................................11

DIFICID ORAL TABLET

.................................11

diunisal

...............................................25

digoxin injection solution

................................34

digoxin oral solution

....................................34

digoxin oral tablet 62.5 mcg (0.0625 mg)

.................34

digoxin oral tablet 125 mcg (0.125 mg)

...................34

digoxin oral tablet 250 mcg (0.25 mg)

....................34

dihydroergotamine nasal

................................23

dilantin

.................................................21

diltiazem hcl intravenous

................................31

diltiazem hcl oral capsule,extended release 12 hr .........31

diltiazem hcl oral capsule,extended release

24hr 120 mg, 180 mg, 240 mg, 300 mg

..................31

diltiazem hcl oral capsule,extended release

24 hr 120 mg, 180 mg, 240 mg, 300 mg, 420 mg

.........31

diltiazem hcl oral capsule,ext.rel 24h degradable

.........31

diltiazem hcl oral tablet

..................................31

diltiazem hcl oral tablet extended release

24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

.........32

diltiazem hcl oral tablet extended release

24 hr 420 mg

...........................................32

dilt-xr

..................................................32

diphenhydramine hcl injection solution 50 mg/ml

..........51

diphenoxylate-atropine

..................................43

dipyridamole oral

.......................................33

disulram

..............................................38

divalproex oral capsule, delayed rel sprinkle

..............21

divalproex oral tablet,delayed release (dr/ec)

.............21

divalproex oral tablet extended release 24 hr

.............21

docetaxel

..............................................15

dofetilide

...............................................31

dolishale

...............................................48

donepezil oral tablet 5 mg

...............................23

donepezil oral tablet 10 mg

..............................23

donepezil oral tablet,disintegrating 5 mg

.................23

donepezil oral tablet,disintegrating 10 mg

................23

DOPTELET (10 TAB PACK)

.............................33

DOPTELET (15 TAB PACK)

.............................33

DOPTELET (30 TAB PACK)

.............................33

dorzolamide

............................................51

dorzolamide-timolol

.....................................51

dotti

...................................................47

DOVATO

................................................ 8

doxazosin oral tablet 1 mg, 2 mg, 4 mg

..................32

doxazosin oral tablet 8 mg

..............................32

doxepin oral capsule

....................................27

doxepin oral concentrate

................................27

doxepin oral tablet

......................................27

doxercalciferol

..........................................43

doxorubicin intravenous recon soln 50 mg

................15

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

doxorubicin intravenous solution .........................15

doxorubicin, peg-liposomal

..............................15

doxy-100

...............................................13

doxycycline hyclate intravenous

.........................13

doxycycline hyclate oral capsule

.........................13

doxycycline hyclate oral tablet 100 mg, 20 mg

............13

doxycycline monohydrate oral capsule 100 mg, 50 mg

....13

doxycycline monohydrate oral suspension for

reconstitution

...........................................13

doxycycline monohydrate oral tablet

.....................13

DRIZALMA SPRINKLE ORAL CAPSULE,

DELAYED REL SPRINKLE 20 MG, 60 MG

...............27

DRIZALMA SPRINKLE ORAL CAPSULE,

DELAYED REL SPRINKLE 30 MG

.......................27

DRIZALMA SPRINKLE ORAL CAPSULE,

DELAYED REL SPRINKLE 40 MG

.......................27

dronabinol

.............................................44

drospirenone-e.estradiol-lm.fa oral tablet

3-0.02-0.451 mg (24) (4)

................................48

DROSPIRENONE-E.ESTRADIOL-LM.FA ORAL

TABLET 3-0.03-0.451 MG (21) (7)

.......................48

drospirenone-ethinyl estradiol

...........................48

DROXIA

...............................................15

droxidopa oral capsule 100 mg

..........................38

droxidopa oral capsule 200 mg, 300 mg

..................38

DUAVEE

...............................................47

DULERA

...............................................52

duloxetine oral capsule,delayed release(dr/ec)

20 mg, 60 mg

..........................................27

duloxetine oral capsule,delayed release(dr/ec) 30 mg

.....27

DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR

200 MG/1.14 ML

.......................................35

DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR

300 MG/2 ML

..........................................35

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE

100 MG/0.67 ML

.......................................35

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE

200 MG/1.14 ML

.......................................35

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE

300 MG/2 ML

..........................................35

dutasteride

.............................................53

EC-NAPROXEN ORAL TABLET, DELAYED

RELEASE (DR/EC) 375 MG

.............................25

EC-NAPROXEN ORAL TABLET, DELAYED

RELEASE (DR/EC) 500 MG

.............................25

econazole

..............................................36

EDARBI

...............................................32

EDARBYCLOR

.........................................32

EDURANT

..............................................8

efavirenz-emtricitabin-tenofov

............................8

efavirenz-lamivu-tenofov disop oral tablet

400-300-300 mg

......................................... 8

efavirenz-lamivu-tenofov disop oral tablet

600-300-300 mg

......................................... 8

efavirenz oral capsule 50 mg

.............................8

efavirenz oral capsule 200 mg

............................ 8

efavirenz oral tablet

...................................... 8

ELAPRASE

............................................43

ELECTROLYTE-48 IN D5W

.............................55

elinest

.................................................48

ELIQUIS

...............................................33

ELIQUIS DVT-PE TREAT 30D START

...................33

ELITE-OB

..............................................55

ELMIRON

..............................................53

ELREXFIO

.............................................15

ELZONRIS

.............................................15

EMCYT

................................................15

EMPLICITI

.............................................15

EMSAM

................................................27

emtricitabine

............................................8

emtricitabine-tenofovir (tdf)

...............................8

EMTRIVA ORAL SOLUTION

.............................8

emverm

................................................ 11

enalapril-hydrochlorothiazide

............................32

enalapril maleate oral tablet

.............................32

ENBREL MINI

..........................................46

ENBREL SUBCUTANEOUS SOLUTION

.................46

ENBREL SUBCUTANEOUS SYRINGE

..................46

ENBREL SURECLICK

..................................46

endocet oral tablet 2.5-325 mg

..........................24

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg ....24

ENGERIX-B PEDIATRIC (PF)

...........................45

ENGERIX-B (PF)

.......................................45

ENHERTU

.............................................15

enoxaparin

.............................................33

enpresse

...............................................48

enskyce

................................................48

entacapone

............................................23

entecavir

................................................ 8

ENTRESTO

............................................34

enulose

................................................44

EPCLUSA ORAL PELLETS IN PACKET 150-37.5 MG

.....8

EPCLUSA ORAL PELLETS IN PACKET 200-50 MG

.......8

EPCLUSA ORAL TABLET 200-50 MG

....................9

EPCLUSA ORAL TABLET 400-100 MG

...................9

EPIDIOLEX

............................................21

epinephrine injection auto-injector

0.15 mg/0.3 ml, 0.3 mg/0.3 ml

...........................52

EPINEPHRINE INJECTION AUTO-INJECTOR

0.15 MG/0.15 ML, 0.3 MG/0.3 ML

.......................52

epinephrine injection solution 1 mg/ml

...................52

epirubicin intravenous solution

..........................15

epitol

..................................................21

EPKINLY

...............................................15

EPRONTIA

............................................21

ERBITUX

..............................................15

ergotamine-caffeine

....................................23

ERIVEDGE

............................................15

ERLEADA ORAL TABLET 60 MG

........................15

ERLEADA ORAL TABLET 240 MG

......................15

erlotinib oral tablet 25 mg

...............................15

erlotinib oral tablet 100 mg, 150 mg

......................15

errin

...................................................47

ertapenem

.............................................11

ery pads

...............................................36

ery-tab oral tablet,delayed release (dr/ec)

250 mg, 333 mg

........................................11

erythrocin (as stearate) oral tablet 250 mg

...............11

erythrocin intravenous recon soln 500 mg

................11

erythromycin-benzoyl peroxide

..........................36

erythromycin ethylsuccinate oral suspension for

reconstitution 200 mg/5 ml

..............................11

erythromycin ophthalmic (eye)

...........................50

erythromycin oral

.......................................11

erythromycin with ethanol topical gel

.....................36

erythromycin with ethanol topical solution

................36

ESBRIET ORAL CAPSULE

.............................52

escitalopram oxalate oral solution

.......................28

escitalopram oxalate oral tablet 10 mg, 5 mg

.............28

escitalopram oxalate oral tablet 20 mg

...................28

esomeprazole magnesium oral capsule,delayed

release(dr/ec)

..........................................45

estarylla

...............................................48

estradiol oral

...........................................47

estradiol transdermal patch semiweekly

..................47

estradiol transdermal patch weekly

......................47

estradiol vaginal

........................................48

estradiol valerate

.......................................48

ethacrynate sodium

.....................................32

ethambutol

.............................................11

ethosuximide

...........................................21

ethynodiol diac-eth estradiol

.............................49

etodolac oral capsule

...................................25

etodolac oral tablet

.....................................25

etodolac oral tablet extended release 24 hr

...............25

ETOPOPHOS

..........................................15

etoposide intravenous

..................................15

etravirine

................................................9

EUTHYROX

............................................43

everolimus (antineoplastic) oral tablet

....................15

everolimus (antineoplastic) oral tablet for

suspension 2 mg

.......................................15

everolimus (antineoplastic) oral tablet for

suspension 3 mg, 5 mg

.................................15

everolimus (immunosuppressive)

........................15

EVOMELA

.............................................15

EVOTAZ

................................................9

exemestane

............................................15

EXKIVITY

..............................................15

EYLEA

.................................................51

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

EYSUVIS ..............................................51

ezetimibe

..............................................34

ezetimibe-simvastatin

...................................34

FABRAZYME ..........................................43

falmina (28)

............................................49

famciclovir

..............................................9

famotidine oral suspension

..............................45

famotidine oral tablet 20 mg, 40 mg

......................45

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG,

2 MG, 4 MG, 6 MG

.....................................28

FANAPT ORAL TABLET 8 MG

..........................28

FANAPT ORAL TABLETS, DOSE PACK

.................28

FARYDAK

.............................................16

febuxostat

..............................................46

felbamate

..............................................21

felodipine

..............................................32

fenobrate micronized oral capsule 134 mg,

200 mg, 67 mg

.........................................34

fenobrate nanocrystallized

.............................34

fenobrate oral tablet 160 mg, 54 mg

....................34

fenobric acid (choline) oral capsule,delayed

release(dr/ec) 45 mg

....................................34

fenobric acid (choline) oral capsule,delayed

release(dr/ec) 135 mg

..................................34

fentanyl citrate buccal lozenge on a handle

1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg

......24

fentanyl citrate buccal lozenge on a handle 200 mcg

......24

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

..............24

fesoterodine

............................................53

FETZIMA ORAL CAPSULE, EXTENDED RELEASE

24 HR

.................................................28

FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE

PACK

.................................................28

nasteride oral tablet 5 mg

..............................53

ngolimod

..............................................24

FINTEPLA

.............................................21

nzala

.................................................49

FIRMAGON KIT W DILUENT SYRINGE

.................16

FIRVANQ

..............................................11

ac otic oil

.............................................39

ecainide

..............................................31

FLOVENT DISKUS INHALATION BLISTER WITH

DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION

...52

FLOVENT DISKUS INHALATION BLISTER WITH

DEVICE 250 MCG/ACTUATION

.........................52

FLOVENT HFA INHALATION HFA AEROSOL

INHALER 44 MCG/ACTUATION

.........................52

FLOVENT HFA INHALATION HFA AEROSOL

INHALER 110 MCG/ACTUATION

........................52

FLOVENT HFA INHALATION HFA AEROSOL

INHALER 220 MCG/ACTUATION

.......................52

oxuridine

..............................................16

uconazole in nacl (iso-osm)

.............................8

uconazole oral suspension for reconstitution

.............8

uconazole oral tablet

....................................8

ucytosine

..............................................8

udarabine

.............................................16

udrocortisone

.........................................39

unisolide

..............................................52

uocinolone acetonide oil

...............................39

uocinolone and shower cap

............................37

uocinolone topical cream 0.01%

........................37

uocinolone topical cream 0.025%

.......................37

uocinolone topical oil

..................................37

uocinolone topical ointment

............................37

uocinolone topical solution

.............................37

uocinonide topical cream 0.05%

........................37

uocinonide topical gel

..................................37

uocinonide topical ointment

............................37

uocinonide topical solution

.............................37

uoride (sodium) oral tablet

.............................55

uoride (sodium) oral tablet,chewable 1 mg

(2.2 mg sod. uoride)

...................................55

FLUOROMETHOLONE

.................................51

uorouracil intravenous

.................................16

uorouracil topical cream 5%

............................35

uorouracil topical solution

..............................35

uoxetine oral capsule 10 mg

...........................28

uoxetine oral capsule 20 mg, 40 mg

....................28

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

uoxetine oral solution ..................................28

uphenazine decanoate

.................................28

uphenazine hcl injection

...............................28

uphenazine hcl oral concentrate

........................28

uphenazine hcl oral elixir

...............................28

uphenazine hcl oral tablet

..............................28

urbiprofen oral tablet 100 mg

...........................25

urbiprofen sodium

.....................................51

uticasone propionate nasal

.............................52

uticasone propionate topical cream

.....................37

uticasone propionate topical ointment

...................37

uvoxamine oral tablet 50 mg

...........................28

uvoxamine oral tablet 100 mg, 25 mg

...................28

FOLIVANE-OB

.........................................55

FOLOTYN

.............................................16

fomepizole

.............................................45

fondaparinux subcutaneous syringe 2.5 mg/0.5 ml

........33

fondaparinux subcutaneous syringe

10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml

................33

formoterol fumarate

.....................................52

FORTEO

...............................................46

fosamprenavir

...........................................9

fosinopril

...............................................32

fosinopril-hydrochlorothiazide

...........................32

fosphenytoin

...........................................21

FOTIVDA

..............................................16

fulvestrant

..............................................16

furosemide injection solution

............................32

furosemide oral solution

10 mg/ml, 40 mg/5 ml (8 mg/ml)

.........................32

FUROSEMIDE ORAL SOLUTION 40 MG/4 ML

...........32

furosemide oral tablet

...................................32

FUZEON SUBCUTANEOUS RECON SOLN

..............9

FYARRO

...............................................16

FYCOMPA ORAL SUSPENSION

........................21

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG

...........21

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG

.........21

gabapentin oral capsule 100 mg, 300 mg ................21

gabapentin oral capsule 400 mg

.........................21

gabapentin oral solution

.................................21

gabapentin oral tablet 600 mg

...........................21

gabapentin oral tablet 800 mg

...........................21

galantamine oral capsule,ext rel. pellets 24 hr

............24

galantamine oral solution

................................24

galantamine oral tablet

..................................24

GARDASIL 9 (PF)

......................................45

GATTEX 30-VIAL

.......................................44

GATTEX ONE-VIAL

....................................44

GAUZE PAD TOPICAL BANDAGE 2 X 2 "

...............40

gavilyte-c

..............................................44

GAVRETO

.............................................16

GAZYVA

...............................................16

getinib

................................................16

gemcitabine intravenous recon soln

......................16

gemcitabine intravenous solution 1 gram/26.3 ml

(38 mg/ml), 2 gram/52.6 ml (38 mg/ml),

200 mg/5.26 ml (38 mg/ml)

..............................16

GEMCITABINE INTRAVENOUS SOLUTION

100 MG/ML

............................................16

gembrozil

.............................................34

gemmily

...............................................49

GEMTESA

.............................................53

generlac

...............................................44

gengraf

................................................16

GENOTROPIN

.........................................45

GENOTROPIN MINIQUICK

.............................45

gentamicin injection solution 40 mg/ml

...................11

gentamicin in nacl (iso-osm) intravenous piggyback

100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml,

60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml

................11

gentamicin ophthalmic (eye) drops

.......................50

gentamicin sulfate (ped) (pf)

............................. 11

gentamicin topical cream

................................36

gentamicin topical ointment

.............................36

GENVOYA

..............................................9

GILENYA

..............................................24

GILOTRIF

..............................................16

GLASSIA

..............................................38

GLEOSTINE

...........................................16

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

glimepiride oral tablet 1 mg ..............................40

glimepiride oral tablet 2 mg

..............................40

glimepiride oral tablet 4 mg

..............................40

glipizide-metformin oral tablet 2.5-250 mg

................40

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg

. . . . . . 40

glipizide oral tablet 5 mg

................................40

glipizide oral tablet 10 mg

...............................40

glipizide oral tablet extended release 24hr 2.5 mg

........40

glipizide oral tablet extended release 24hr 5 mg

..........40

glipizide oral tablet extended release 24hr 10 mg

.........40

GLUCAGEN HYPOKIT

.................................40

glucagon emergency kit (human)

........................40

GLUCAGON (HCL) EMERGENCY KIT

..................40

glycopyrrolate oral tablet

................................43

glycopyrrolate (pf)

......................................43

glycopyrrolate (pf) in water injection

......................43

glycopyrrolate (pf) in water intravenous syringe

0.4 mg/2 ml (0.2 mg/ml)

.................................43

glydo

..................................................35

GLYXAMBI

.............................................40

GOCOVRI

.............................................23

granisetron hcl oral

.....................................44

griseofulvin microsize

....................................8

griseofulvin ultramicrosize

................................ 8

guanfacine oral tablet extended release 24 hr

............28

GVOKE

................................................40

GVOKE HYPOPEN 1-PACK

............................40

GVOKE HYPOPEN 2-PACK

............................40

GVOKE PFS 1-PACK SYRINGE

. . . . . . . . . . . . . . . . . . . . . . . . . 40

GVOKE PFS 2-PACK SYRINGE

. . . . . . . . . . . . . . . . . . . . . . . . . 40

HAEGARDA ...........................................52

hailey

..................................................49

hailey 24 fe

............................................49

hailey fe 1.5/30 (28)

....................................49

hailey fe 1/20 (28)

......................................49

HALAVEN

..............................................16

halobetasol propionate topical cream

....................37

halobetasol propionate topical ointment

..................37

haloperidol

.............................................28

haloperidol decanoate

..................................28

haloperidol lactate injection

.............................28

haloperidol lactate oral

..................................28

HARVONI ORAL PELLETS IN PACKET 33.75-150 MG

....9

HARVONI ORAL PELLETS IN PACKET 45-200 MG

.......9

HARVONI ORAL TABLET 45-200 MG

....................9

HARVONI ORAL TABLET 90-400 MG

....................9

HAVRIX (PF)

...........................................45

heather

................................................48

HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS

PARENTERAL SOLUTION 25,000 UNIT/250 ML,

25,000 UNIT/500 ML

...................................33

HEPARIN (PORCINE) IN 5% DEX

.......................33

heparin (porcine) injection solution

.......................33

heparin (porcine) in nacl (pf)

.............................33

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

....33

HETLIOZ

..............................................28

HIBERIX (PF)

..........................................45

HIZENTRA

.............................................45

HUMALOG JUNIOR KWIKPEN U-100

...................40

HUMALOG KWIKPEN INSULIN

.........................40

HUMALOG MIX 50-50 INSULN U-100

...................40

HUMALOG MIX 50-50 KWIKPEN

. . . . . . . . . . . . . . . . . . . . . . . . 40

HUMALOG MIX 75-25 KWIKPEN

. . . . . . . . . . . . . . . . . . . . . . . . 40

HUMALOG MIX 75-25(U-100)INSULN

...................40

HUMALOG U-100 INSULIN

.............................40

HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

.........47

HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT

80 MG/0.8 ML-40 MG/0.4 ML

...........................47

HUMIRA(CF) PEN CROHNS-UC-HS

....................47

HUMIRA(CF) PEN PEDIATRIC UC

......................47

HUMIRA(CF) PEN PSOR-UV-ADOL HS

.................47

HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML

...........................47

HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML

...........................47

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT

10 MG/0.1 ML, 20 MG/0.2 ML

...........................47

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT

40 MG/0.4 ML

..........................................47

HUMIRA PEN

..........................................46

HUMIRA PEN CROHNS-UC-HS START

.................47

HUMIRA PEN PSOR-UVEITS-ADOL HS

.................47

HUMIRA SUBCUTANEOUS SYRINGE KIT

40 MG/0.8 ML

..........................................47

HUMULIN 70/30 U-100 INSULIN

........................40

HUMULIN 70/30 U-100 KWIKPEN

.......................40

HUMULIN N NPH INSULIN KWIKPEN

...................40

HUMULIN N NPH U-100 INSULIN

.......................40

HUMULIN R REGULAR U-100 INSULN

..................41

HUMULIN R U-500 (CONC) INSULIN

....................41

HUMULIN R U-500 (CONC) KWIKPEN

..................41

hydralazine injection

....................................32

hydralazine oral

........................................32

hydrochlorothiazide

.....................................32

hydrocodone-acetaminophen oral solution

7.5-325 mg/15 ml

.......................................24

hydrocodone-acetaminophen oral tablet

10-325 mg, 5-325 mg, 7.5-325 mg

.......................24

hydrocodone-ibuprofen oral tablet 7.5-200 mg

............24

hydrocortisone-acetic acid

..............................39

hydrocortisone oral

.....................................39

hydrocortisone rectal

...................................44

hydrocortisone topical cream 1%, 2.5%

..................37

hydrocortisone topical cream with perineal applicator

.....44

hydrocortisone topical lotion 2.5%

.......................37

hydrocortisone topical ointment 1%, 2.5%

................37

hydrocortisone valerate

.................................37

hydromorphone oral liquid

...............................25

hydromorphone oral tablet

..............................25

hydroxychloroquine

.....................................11

hydroxyprogesterone caproate

..........................48

hydroxyurea

............................................16

hydroxyzine hcl oral tablet

...............................52

HYRIMOZ(CF) PEDI CROHN STARTER

SUBCUTANEOUS SYRINGE 80 MG/0.8 ML

.............47

HYRIMOZ(CF) PEDI CROHN STARTER

SUBCUTANEOUS SYRINGE 80 MG/0.8 ML-

40 MG/0.4 ML

..........................................47

HYRIMOZ(CF) PEN

....................................47

HYRIMOZ(CF) SUBCUTANEOUS SYRINGE

10 MG/0.1 ML

..........................................47

HYRIMOZ(CF) SUBCUTANEOUS SYRINGE

20 MG/0.2 ML

..........................................47

HYRIMOZ(CF) SUBCUTANEOUS SYRINGE

40 MG/0.4 ML

..........................................47

HYRIMOZ PEN CROHN'S-UC STARTER

................47

HYRIMOZ PEN PSORIASIS STARTER

..................47

ibandronate oral ........................................46

IBRANCE

..............................................16

ibu

.....................................................25

ibuprofen oral suspension

...............................25

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

............25

icatibant

...............................................52

iclevia

..................................................49

ICLUSIG

...............................................16

icosapent ethyl

.........................................34

idarubicin

..............................................16

IDHIFA

.................................................16

ifosfamide intravenous recon soln 1 gram

................16

IFOSFAMIDE INTRAVENOUS RECON SOLN 3 GRAM

...16

ifosfamide intravenous solution

..........................16

imatinib oral tablet 100 mg

..............................16

imatinib oral tablet 400 mg

..............................16

IMBRUVICA ORAL CAPSULE 70 MG

. . . . . . . . . . . . . . . . . . . . 16

IMBRUVICA ORAL CAPSULE 140 MG

..................16

IMBRUVICA ORAL SUSPENSION

. . . . . . . . . . . . . . . . . . . . . . . 16

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG

...16

IMFINZI

................................................16

imipenem-cilastatin

.....................................11

imipramine hcl

..........................................28

imiquimod topical cream in packet 5%

...................35

IMJUDO

...............................................16

IMOVAX RABIES VACCINE (PF)

........................45

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

incassia ................................................48

INCRELEX

.............................................38

INCRUSE ELLIPTA

.....................................52

indapamide

............................................32

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

....45

INFUGEM

..............................................16

INFUMORPH P/F

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

INGREZZA

.............................................24

INGREZZA INITIATION PACK

...........................24

INLYTA ORAL TABLET 1 MG

............................16

INLYTA ORAL TABLET 5 MG

............................16

INQOVI

................................................16

INREBIC

...............................................16

INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML

29 GAUGE, 1 ML 29 GAUGE X 1/2", 1/2 ML 28 GAUGE

..41

INTELENCE ORAL TABLET 25 MG

......................9

INTRALIPID INTRAVENOUS EMULSION 20%, 30%

.....55

INVEGA HAFYERA INTRAMUSCULAR SYRINGE

1,092 MG/3.5 ML

.......................................28

INVEGA HAFYERA INTRAMUSCULAR SYRINGE

1,560 MG/5 ML

.........................................28

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

39 MG/0.25 ML

.........................................28

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

78 MG/0.5 ML

..........................................28

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

117 MG/0.75 ML

........................................28

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

156 MG/ML

............................................28

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

234 MG/1.5 ML

.........................................28

INVEGA TRINZA INTRAMUSCULAR SYRINGE

273 MG/0.88 ML

.......................................28

INVEGA TRINZA INTRAMUSCULAR SYRINGE

410 MG/1.32 ML

.......................................28

INVEGA TRINZA INTRAMUSCULAR SYRINGE

546 MG/1.75 ML

.......................................28

INVEGA TRINZA INTRAMUSCULAR SYRINGE

819 MG/2.63 ML

.......................................28

INVELTYS

.............................................51

INVOKAMET

...........................................41

INVOKAMET XR

.......................................41

INVOKANA

............................................41

IPOL

...................................................45

ipratropium-albuterol

....................................52

ipratropium bromide inhalation

..........................52

ipratropium bromide nasal spray,non-aerosol

21 mcg (0.03%)

........................................39

ipratropium bromide nasal spray,non-aerosol

42 mcg (0.06%)

........................................39

irbesartan

..............................................32

irbesartan-hydrochlorothiazide

..........................32

IRESSA

................................................16

irinotecan

..............................................16

ISENTRESS HD

.........................................9

ISENTRESS ORAL POWDER IN PACKET

................ 9

ISENTRESS ORAL TABLET

.............................9

ISENTRESS ORAL TABLET, CHEWABLE 25 MG

.........9

ISENTRESS ORAL TABLET, CHEWABLE 100 MG

........9

isibloom

................................................49

isoniazid oral solution

...................................11

isoniazid oral tablet

.....................................11

isosorbide dinitrate oral tablet

...........................34

isosorbide-hydralazine

..................................32

isosorbide mononitrate

..................................34

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

.....36

itraconazole oral capsule

.................................8

itraconazole oral solution

.................................8

ivermectin oral

.........................................11

IXEMPRA

..............................................16

IXIARO (PF)

...........................................45

jaimiess ................................................49

JAKAFI

................................................16

jantoven

...............................................33

JANUMET

.............................................41

JANUMET XR ORAL TABLET, ER MULTIPHASE

24 HR 50-1,000 MG, 50-500 MG

........................41

JANUMET XR ORAL TABLET, ER MULTIPHASE

24 HR 100-1,000 MG

...................................41

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

JANUVIA ..............................................41

JARDIANCE

...........................................41

jasmiel (28)

............................................49

JAYPIRCA

.............................................16

JEMPERLI

.............................................16

JENCYCLA

............................................48

JENTADUETO

.........................................41

JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG

..........................41

JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 5-1,000 MG

...........................41

JEVTANA

..............................................16

jolessa

.................................................49

joyeaux

................................................49

JUBLIA

................................................36

juleber

.................................................49

JULUCA

................................................9

junel 1.5/30 (21)

........................................49

junel 1/20 (21)

..........................................49

junel fe 1.5/30 (28)

......................................49

junel fe 1/20 (28)

.......................................49

junel fe 24

..............................................49

JYNNEOS (PF)(STOCKPILE)

...........................45

KABIVEN ..............................................55

KADCYLA

.............................................16

kaitlib fe

................................................49

kalliga

.................................................49

KALYDECO ORAL GRANULES IN PACKET 13.4 MG,

25 MG, 50 MG, 75 MG

..................................52

KALYDECO ORAL TABLET

.............................52

KANJINTI

..............................................16

kariva (28)

.............................................49

kelnor 1/35 (28)

........................................49

kelnor 1-50 (28)

........................................49

KERENDIA

............................................32

KESIMPTA PEN

........................................24

ketoconazole oral

........................................8

ketoconazole topical cream

.............................36

ketoconazole topical shampoo

..........................36

KETOROLAC OPHTHALMIC (EYE) DROPS 0.4%

.......51

ketorolac ophthalmic (eye) drops 0.5%

...................51

KEYTRUDA

............................................16

KIMMTRAK

............................................16

KINRIX (PF) INTRAMUSCULAR SYRINGE

..............45

KISQALI

...............................................16

KISQALI FEMARA CO-PACK ORAL TABLET

200 MG/DAY(200 MG X 1)-2.5 MG

......................17

KISQALI FEMARA CO-PACK ORAL TABLET

400 MG/DAY(200 MG X 2)-2.5 MG

......................17

KISQALI FEMARA CO-PACK ORAL TABLET

600 MG/DAY(200 MG X 3)-2.5 MG

......................17

KLISYRI

...............................................17

klor-con

................................................54

KLOR-CON 8

..........................................54

KLOR-CON 10

.........................................54

klor-con m10

...........................................54

klor-con m20

...........................................54

KLOXXADO

............................................25

KORLYM

...............................................43

K-PHOS ORIGINAL

....................................54

KRAZATI

...............................................17

kurvelo (28)

............................................49

KYPROLIS

.............................................17

labetalol oral ...........................................32

lacosamide intravenous

.................................21

lacosamide oral solution

................................21

lacosamide oral tablet 50 mg

............................21

lacosamide oral tablet 100 mg, 150 mg, 200 mg

..........21

lactated ringers intravenous

.............................54

LACTATED RINGERS IRRIGATION

.....................37

lactulose oral solution

...................................44

lamivudine oral solution

..................................9

lamivudine oral tablet 100 mg, 300 mg

....................9

lamivudine oral tablet 150 mg

............................9

lamivudine-zidovudine

...................................9

lamotrigine oral tablet

...................................21

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

lamotrigine oral tablet, chewable dispersible ..............21

lamotrigine oral tablet,disintegrating

.....................22

lamotrigine oral tablet extended release 24hr

.............21

lamotrigine oral tablets,dose pack

.......................22

LANOXIN PEDIATRIC

..................................34

lansoprazole oral capsule,delayed release(dr/ec)

.........45

LANTUS SOLOSTAR U-100 INSULIN

...................41

LANTUS U-100 INSULIN

...............................41

lapatinib

...............................................17

larin 1.5/30 (21)

........................................49

larin 1/20 (21)

..........................................49

larin 24 fe

..............................................49

larin fe 1.5/30 (28)

......................................49

larin fe 1/20 (28)

........................................49

latanoprost

.............................................51

LAYOLIS FE

...........................................49

leena 28

...............................................49

leunomide

............................................47

LENALIDOMIDE ORAL CAPSULE 2.5 MG, 20 MG

.......17

lenalidomide oral capsule 10 mg, 15 mg, 25 mg, 5 mg

....17

LENVIMA ORAL CAPSULE 10 MG/DAY

(10 MG X 1), 4 MG

.....................................17

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3),

18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY

(10 MG X 2-4 MG X 1)

..................................17

LENVIMA ORAL CAPSULE 14 MG/DAY(

10 MG X 1-4 MG X 1), 20 MG/DAY (10 MG X 2),

8 MG/DAY (4 MG X 2)

..................................17

lessina

.................................................49

letrozole

...............................................17

leucovorin calcium injection

.............................13

leucovorin calcium oral tablet 5 mg

......................14

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg

.......14

LEUKERAN

............................................17

leuprolide (3 month)

....................................17

leuprolide subcutaneous kit

.............................17

LEVEMIR FLEXPEN

....................................41

LEVEMIR U-100 INSULIN

..............................41

levetiracetam in nacl (iso-os) intravenous piggyback

1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml

.......22

levetiracetam intravenous

...............................22

levetiracetam oral solution

..............................22

levetiracetam oral tablet

.................................22

levetiracetam oral tablet extended release 24 hr

..........22

levobunolol ophthalmic (eye) drops 0.5%

.................50

levocarnitine oral solution 100 mg/ml

....................38

LEVOCARNITINE ORAL TABLET

.......................38

levocarnitine (with sugar)

................................38

levocetirizine oral tablet

.................................52

levooxacin in d5w

.....................................13

levooxacin intravenous

................................13

levooxacin oral solution

................................13

levooxacin oral tablet

..................................13

levonest (28)

...........................................49

levonorgestrel-ethinyl estrad

............................49

levonorg-eth estrad triphasic

............................49

levora-28

...............................................49

LEVO-T

................................................43

levothyroxine oral tablet

.................................43

LEVOXYL ORAL TABLET 100 MCG, 112 MCG,

125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG,

25 MCG, 50 MCG, 75 MCG, 88 MCG

....................43

LEXIVA ORAL SUSPENSION

............................9

LIBTAYO

...............................................17

lidocaine hcl injection solution

...........................35

lidocaine hcl laryngotracheal

............................35

lidocaine hcl mucous membrane jelly in applicator

........36

lidocaine hcl mucous membrane solution 2%

.............36

lidocaine hcl mucous membrane solution 4% (40 mg/ml)

..35

lidocaine (pf) injection solution

...........................35

LIDOCAINE (PF) INTRAVENOUS SOLUTION

...........31

lidocaine (pf) intravenous syringe

........................31

lidocaine-prilocaine topical cream

........................35

lidocaine topical adhesive patch,medicated 5%

...........35

lidocaine topical ointment

...............................35

lidocaine viscous

.......................................35

lincomycin

.............................................11

LINEZOLID-0.9% SODIUM CHLORIDE

..................12

linezolid in dextrose 5%

.................................11

linezolid oral suspension for reconstitution

...............12

linezolid oral tablet

......................................12

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

LINZESS ...............................................44

liothyronine oral

........................................43

lisinopril

................................................32

lisinopril-hydrochlorothiazide

............................32

lithium carbonate

.......................................28

lithium citrate oral solution 8 meq/5 ml

...................28

LIVALO

................................................34

l norgest/e.estradiol-e.estrad

............................49

lojaimiess

..............................................49

LONSURF ORAL TABLET 15-6.14 MG

..................17

LONSURF ORAL TABLET 20-8.19 MG

..................17

loperamide oral capsule

.................................43

lopinavir-ritonavir oral solution

............................9

lopinavir-ritonavir oral tablet 100-25 mg

...................9

lopinavir-ritonavir oral tablet 200-50 mg

...................9

lorazepam injection solution

.............................28

lorazepam injection syringe 2 mg/ml

.....................28

lorazepam intensol

.....................................28

lorazepam oral concentrate

.............................28

lorazepam oral syringe

..................................28

lorazepam oral tablet 0.5 mg, 1 mg

......................29

lorazepam oral tablet 2 mg

..............................29

LORBRENA ORAL TABLET 25 MG

......................17

LORBRENA ORAL TABLET 100 MG

.....................17

loryna (28)

.............................................49

losartan

................................................32

losartan-hydrochlorothiazide oral tablet 50-12.5 mg

.......32

losartan-hydrochlorothiazide oral tablet

100-12.5 mg, 100-25 mg

................................32

LOTEMAX OPHTHALMIC (EYE) OINTMENT

............51

LOTEMAX SM

.........................................51

loteprednol etabonate

...................................51

lovastatin oral tablet 10 mg

..............................34

lovastatin oral tablet 20 mg, 40 mg

.......................34

low-ogestrel (28)

.......................................49

loxapine succinate

......................................29

lo-zumandimine (28)

....................................49

ludent uoride oral tablet,chewable 1 mg (2.2 mg sod.

uoride)

................................................55

LUMAKRAS ORAL TABLET 120 MG

....................17

LUMAKRAS ORAL TABLET 320 MG

....................17

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01%

..........51

LUMIZYME

............................................43

LUMOXITI

.............................................17

LUNSUMIO

............................................17

LUPRON DEPOT

......................................17

LUPRON DEPOT (3 MONTH)

...........................17

LUPRON DEPOT (4 MONTH)

...........................17

LUPRON DEPOT (6 MONTH)

...........................17

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR

SYRINGE KIT 11.25 MG

................................17

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR

SYRINGE KIT 30 MG

...................................17

LUPRON DEPOT-PED INTRAMUSCULAR KIT

..........17

LUPRON DEPOT-PED INTRAMUSCULAR SYRINGE

KIT

....................................................17

lurasidone oral tablet 80 mg

.............................29

lurasidone oral tablet 120 mg, 20 mg, 40 mg, 60 mg

......29

lutera (28)

..............................................49

LYBALVI

...............................................29

LYNPARZA

............................................17

LYSODREN

............................................17

LYTGOBI

..............................................17

LYUMJEV KWIKPEN U-100 INSULIN

....................41

LYUMJEV KWIKPEN U-200 INSULIN

....................41

LYUMJEV U-100 INSULIN

..............................41

lyza

....................................................48

magnesium sulfate in d5w intravenous piggyback

1 gram/100 ml

..........................................54

magnesium sulfate injection

.............................54

magnesium sulfate in water

.............................54

malathion

..............................................37

maraviroc oral tablet 150 mg

.............................9

maraviroc oral tablet 300 mg

.............................9

MARGENZA

...........................................17

marlissa (28)

...........................................49

MARPLAN

.............................................29

MARQIBO

.............................................17

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

MATULANE ............................................17

matzim la

..............................................32

MAVYRET ORAL PELLETS IN PACKET

..................9

MAVYRET ORAL TABLET

...............................9

meclizine oral tablet 12.5 mg, 25 mg

.....................44

MEDROL ORAL TABLET 2 MG

..........................39

medroxyprogesterone intramuscular

.....................48

medroxyprogesterone oral

..............................48

meoquine

.............................................12

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml)

..........17

megestrol oral tablet 20 mg

.............................17

megestrol oral tablet 40 mg

.............................17

MEKINIST ORAL RECON SOLN

........................17

MEKINIST ORAL TABLET 0.5 MG

.......................18

MEKINIST ORAL TABLET 2 MG

.........................18

MEKTOVI

..............................................18

meloxicam oral tablet 7.5 mg

............................26

meloxicam oral tablet 15 mg

.............................26

melphalan hcl

..........................................18

memantine oral capsule,sprinkle,er 24hr

.................24

memantine oral solution

.................................24

memantine oral tablet 5 mg

.............................24

memantine oral tablet 10 mg

............................24

MEMANTINE ORAL TABLETS, DOSE PACK

.............24

MENACTRA (PF) INTRAMUSCULAR SOLUTION

........45

MENQUADFI (PF)

......................................46

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

........................46

mercaptopurine

.........................................18

meropenem

............................................12

MEROPENEM-0.9% SODIUM CHLORIDE

...............12

merzee

................................................49

mesalamine oral capsule,extended release 24hr

..........44

mesalamine oral capsule (with del rel tablets)

............44

mesalamine oral tablet,delayed release (dr/ec)

...........44

mesalamine rectal enema

...............................44

mesalamine with cleansing wipe

.........................44

mesna

.................................................14

MESNEX ORAL

........................................14

metadate er

............................................29

metformin oral solution

..................................41

metformin oral tablet 1,000 mg

..........................41

metformin oral tablet 500 mg

............................41

metformin oral tablet 850 mg

............................41

metformin oral tablet extended release 24 hr 500 mg

.....41

metformin oral tablet extended release 24 hr 750 mg

.....41

methadone injection solution

............................25

methadone intensol

.....................................25

methadone oral concentrate

.............................25

methadone oral solution 5 mg/5 ml

......................25

methadone oral solution 10 mg/5 ml

.....................25

methadone oral tablet 5 mg

.............................25

methadone oral tablet 10 mg

............................25

methazolamide

.........................................51

methenamine hippurate

.................................13

methimazole oral tablet 10 mg, 5 mg

.....................40

methocarbamol oral tablet 500 mg, 750 mg

..............24

methotrexate sodium injection

...........................18

methotrexate sodium oral

...............................18

methotrexate sodium (pf)

................................18

methoxsalen

...........................................35

methsuximide

..........................................22

methylphenidate hcl oral tablet

..........................29

methylphenidate hcl oral tablet extended release

.........29

methylphenidate hcl oral tablet extended release

24hr 18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx rating),

36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating)

.......29

methylpred dp

..........................................39

methylprednisolone

.....................................39

methylprednisolone acetate

.............................39

methylprednisolone sodium succ injection recon soln

125 mg, 40 mg

.........................................39

methylprednisolone sodium succ intravenous

............39

metoclopramide hcl oral solution

.........................44

metoclopramide hcl oral tablet

...........................44

metolazone

............................................32

metoprolol succinate

....................................32

metoprolol ta-hydrochlorothiaz

..........................32

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

......32

METRO I.V.

............................................12

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

metronidazole in nacl (iso-os) ...........................12

metronidazole oral tablet

................................12

metronidazole topical

...................................36

metronidazole vaginal

...................................48

metyrosine

.............................................32

mexiletine

..............................................31

microgestin 1.5/30 (21)

.................................49

microgestin 1/20 (21)

...................................49

microgestin fe 1.5/30 (28)

...............................49

microgestin fe 1/20 (28)

.................................49

midodrine

..............................................38

mifepristone

............................................48

miglustat

...............................................43

mili

....................................................49

minocycline oral capsule

................................13

minoxidil oral

...........................................32

mirtazapine oral tablet

..................................29

mirtazapine oral tablet,disintegrating

.....................29

misoprostol

............................................45

MITIGARE

.............................................46

mitomycin intravenous

..................................18

mitoxantrone

...........................................18

M-M-R II (PF)

..........................................46

M-NATAL PLUS

........................................55

modanil oral tablet 100 mg

.............................29

modanil oral tablet 200 mg

.............................29

moexipril

...............................................32

molindone

..............................................29

mometasone topical

....................................37

MONJUVI

..............................................18

mono-linyah

............................................49

montelukast oral granules in packet

......................53

montelukast oral tablet

..................................53

montelukast oral tablet,chewable

........................53

morphine concentrate oral solution

......................25

MORPHINE INJECTION SOLUTION

....................25

MORPHINE INJECTION SYRINGE 2 MG/ML,

4 MG/ML, 8 MG/ML

.....................................25

morphine intravenous solution 10 mg/ml, 4 mg/ml,

8 mg/ml

................................................25

MORPHINE INTRAVENOUS SYRINGE

..................25

morphine oral solution

..................................25

morphine oral tablet

....................................25

morphine oral tablet extended release

...................25

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml

.......25

MOUNJARO

...........................................41

MOVANTIK

............................................44

moxioxacin ophthalmic (eye)

...........................50

moxioxacin oral

.......................................13

MOXIFLOXACIN-SOD.ACE, SUL-WATER

...............13

moxioxacin-sod.chloride(iso)

...........................13

MOZOBIL

..............................................45

MULTAQ

...............................................31

mupirocin

..............................................36

mupirocin calcium

......................................36

MVASI

.................................................18

mycophenolate mofetil (hcl)

.............................18

mycophenolate mofetil oral capsule

......................18

mycophenolate mofetil oral suspension for reconstitution

..18

mycophenolate mofetil oral tablet

........................18

mycophenolate sodium

.................................18

MYLOTARG

............................................18

MYRBETRIQ ORAL TABLET EXTENDED RELEASE

24 HR

.................................................53

nabumetone ............................................26

nadolol

.................................................32

NAFCILLIN IN DEXTROSE ISO-OSM

...................13

nafcillin injection

........................................13

nafcillin intravenous recon soln 2 gram

...................13

NAGLAZYME

..........................................43

naloxone injection solution

..............................26

naloxone injection syringe 1 mg/ml

......................26

naloxone nasal

.........................................26

naltrexone

.............................................26

NAMZARIC

............................................24

naproxen-esomeprazole

................................26

naproxen oral suspension

...............................26

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

naproxen oral tablet ....................................26

naproxen oral tablet,delayed release (dr/ec) 375 mg

......26

naproxen oral tablet,delayed release (dr/ec) 500 mg

......26

naproxen sodium oral tablet 275 mg, 550 mg

.............26

naratriptan

.............................................23

NATACYN

..............................................50

nateglinide oral tablet 60 mg

............................41

nateglinide oral tablet 120 mg

...........................41

NATPARA

..............................................43

NAYZILAM

.............................................22

nebivolol

...............................................32

necon 0.5/35 (28)

.......................................49

nefazodone

............................................29

nelarabine

.............................................18

neomycin

..............................................12

neomycin-bacitracin-poly-hc

.............................51

neomycin-bacitracin-polymyxin

..........................50

neomycin-polymyxin b-dexameth

........................51

neomycin-polymyxin b gu

...............................37

neomycin-polymyxin-gramicidin

.........................50

neomycin-polymyxin-hc ophthalmic (eye)

................51

neomycin-polymyxin-hc otic (ear)

........................39

neo-polycin

............................................50

neo-polycin hc

..........................................51

NERLYNX

.............................................18

NEUPRO

..............................................23

nevirapine oral suspension

...............................9

nevirapine oral tablet

....................................9

nevirapine oral tablet extended release 24 hr 100 mg

......9

nevirapine oral tablet extended release 24 hr 400 mg

......9

NEXLETOL

............................................34

NEXLIZET

.............................................34

niacin oral tablet extended release 24 hr

.................34

nicardipine intravenous solution

.........................32

nicardipine oral

.........................................32

NICOTROL

............................................39

NICOTROL NS

.........................................39

nifedipine oral tablet extended release

...................32

nifedipine oral tablet extended release 24hr

..............32

nikki (28)

...............................................49

nilutamide

..............................................18

nimodipine

.............................................32

NINLARO

..............................................18

NIPENT

................................................18

nisoldipine

.............................................32

nitazoxanide

...........................................12

nitisinone

..............................................38

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

...13

nitrofurantoin monohyd/m-cryst

..........................13

nitrofurantoin oral suspension 25 mg/5 ml

................13

nitroglycerin intravenous

................................34

nitroglycerin sublingual

..................................34

nitroglycerin transdermal patch 24 hour

..................35

nitroglycerin translingual

................................35

NIVESTYM

............................................45

NORA-BE

..............................................48

noreth-ethinyl estradiol-iron

.............................49

norethindrone acetate

...................................48

norethindrone ac-eth estradiol oral tablet

1-20 mg-mcg, 1.5-30 mg-mcg

...........................49

norethindrone (contraceptive)

...........................48

norethindrone-e.estradiol-iron

...........................49

norgestimate-ethinyl estradiol

...........................49

nortrel 0.5/35 (28)

......................................49

nortrel 1/35 (21)

........................................49

nortrel 1/35 (28)

........................................49

nortrel 7/7/7 (28)

........................................49

nortriptyline oral capsule

................................29

nortriptyline oral solution

................................29

NORVIR ORAL POWDER IN PACKET

....................9

NOVOFINE 32

.........................................41

NOVOFINE AUTOCOVER

..............................41

NOVOFINE PLUS

......................................41

NUBEQA

..............................................18

NUCALA SUBCUTANEOUS AUTO-INJECTOR

...........53

NUCALA SUBCUTANEOUS SYRINGE 40 MG/0.4 ML

....53

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML

......53

NUCYNTA ER

..........................................26

NUEDEXTA

............................................24

NULOJIX

..............................................18

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

NUPLAZID .............................................29

NURTEC ODT

.........................................23

NUZYRA INTRAVENOUS

...............................13

NUZYRA ORAL

........................................13

nyamyc

................................................36

nylia 1/35 (28)

..........................................49

nylia 7/7/7 (28)

.........................................49

nymyo

.................................................49

nystatin oral suspension

.................................8

nystatin oral tablet

.......................................8

nystatin topical cream

...................................36

nystatin topical ointment

................................36

nystatin topical powder

..................................36

nystatin-triamcinolone

...................................36

nystop

.................................................36

OCALIVA ..............................................44

ocella

..................................................49

OCREVUS

.............................................24

octreotide acetate

......................................18

ODEFSEY

..............................................9

ODOMZO

..............................................18

OFEV

..................................................53

ooxacin ophthalmic (eye)

..............................50

OGIVRI

................................................18

OJJAARA

..............................................18

olanzapine-uoxetine

...................................29

olanzapine intramuscular

................................29

olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg

.......29

olanzapine oral tablet 15 mg, 20 mg

.....................29

olanzapine oral tablet,disintegrating 10 mg, 5 mg

.........29

olanzapine oral tablet,disintegrating 15 mg, 20 mg

........29

olmesartan

.............................................32

olmesartan-hydrochlorothiazide

.........................32

olopatadine ophthalmic (eye)

............................51

omeprazole oral capsule,delayed release(dr/ec)

..........45

OMNIPOD 5 G6 INTRO KIT (GEN 5)

....................41

OMNIPOD 5 G6 PODS (GEN 5)

.........................41

OMNIPOD CLASSIC PODS (GEN 3)

....................41

OMNIPOD DASH INTRO KIT (GEN 4)

...................41

OMNIPOD DASH PODS (GEN 4)

.......................41

OMNIPOD GO PODS

...................................41

OMNIPOD GO PODS 10 UNITS/DAY

....................41

OMNIPOD GO PODS 15 UNITS/DAY

....................41

OMNIPOD GO PODS 20 UNITS/DAY

....................41

OMNIPOD GO PODS 25 UNITS/DAY

....................41

OMNIPOD GO PODS 30 UNITS/DAY

....................41

OMNIPOD GO PODS 40 UNITS/DAY

....................41

ONCASPAR

............................................18

ondansetron

............................................44

ondansetron hcl intravenous

............................44

ondansetron hcl oral solution

............................44

ondansetron hcl oral tablet 4 mg, 8 mg

...................44

ondansetron hcl (pf)

....................................44

ONGENTYS

...........................................23

ONIVYDE

..............................................18

ONUREG

..............................................18

OPDIVO

...............................................18

OPDUALAG

............................................18

OPSUMIT

..............................................53

oralone

................................................39

ORENCIA CLICKJECT

.................................47

ORENCIA SUBCUTANEOUS SYRINGE

50 MG/0.4 ML

..........................................47

ORENCIA SUBCUTANEOUS SYRINGE

87.5 MG/0.7 ML

........................................47

ORENCIA SUBCUTANEOUS SYRINGE

125 MG/ML

............................................47

ORENITRAM MONTH 1 TITRATION KT

.................32

ORENITRAM MONTH 2 TITRATION KT

.................32

ORENITRAM MONTH 3 TITRATION KT

.................32

orenitram oral tablet extended release

0.25 mg, 1 mg, 2.5 mg, 5 mg

............................32

orenitram oral tablet extended release 0.125 mg

..........32

ORGOVYX

.............................................18

ORSERDU

.............................................18

oseltamivir oral capsule

..................................9

oseltamivir oral suspension for reconstitution

..............9

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

oxacillin injection .......................................13

oxaliplatin

..............................................18

oxaprozin

..............................................26

oxazepam

..............................................29

oxcarbazepine

.........................................22

OXERVATE

............................................51

oxybutynin chloride oral syrup

...........................53

oxybutynin chloride oral tablet

...........................53

oxybutynin chloride oral tablet extended release 24hr

.....53

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg

......................25

oxycodone oral concentrate

.............................25

oxycodone oral solution

.................................25

oxycodone oral tablet 5 mg

..............................25

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg

.......25

oxymorphone oral tablet extended release 12 hr

..........25

OZEMPIC SUBCUTANEOUS PEN INJECTOR

0.25 MG OR 0.5 MG (2 MG/3 ML), 1 MG/DOSE

(4 MG/3 ML), 2 MG/DOSE (8 MG/3 ML)

. . . . . . . . . . . . . . . . . . 42

pacerone oral tablet 100 mg, 400 mg ....................31

pacerone oral tablet 200 mg

.............................31

paclitaxel

...............................................18

PACLITAXEL PROTEIN-BOUND

........................18

PADCEV

...............................................18

paliperidone oral tablet extended release

24hr 1.5 mg, 9 mg

......................................29

paliperidone oral tablet extended release

24hr 3 mg, 6 mg

........................................29

palonosetron intravenous solution 0.25 mg/5 ml

..........44

pamidronate

............................................43

PANRETIN

.............................................35

pantoprazole oral tablet,delayed release (dr/ec)

..........45

paricalcitol oral

.........................................43

paromomycin

...........................................12

paroxetine hcl oral suspension

..........................29

paroxetine hcl oral tablet 10 mg

.........................29

paroxetine hcl oral tablet 20 mg, 40 mg

..................29

paroxetine hcl oral tablet 30 mg

.........................29

paser

..................................................12

PEDIARIX (PF)

.........................................46

PEDVAX HIB (PF)

......................................46

peg 3350-electrolytes

...................................44

PEGASYS SUBCUTANEOUS SOLUTION

...............45

PEGASYS SUBCUTANEOUS SYRINGE

................45

peg-electrolyte soln

.....................................44

PEMAZYRE

............................................18

pemetrexed disodium intravenous recon soln

.............18

penicillamine

...........................................47

penicillin g potassium

...................................13

penicillin v potassium

...................................13

PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2"

....42

PENNSAID TOPICAL SOLUTION IN

METERED-DOSE PUMP

...............................26

PENTACEL (PF) INTRAMUSCULAR KIT

15LF-48MCG-62DU -10 MCG/0.5ML

....................46

pentamidine inhalation

..................................12

pentamidine injection

...................................12

PENTASA

..............................................44

pentoxifylline

...........................................33

PERIKABIVEN

.........................................55

perindopril erbumine

....................................32

periogard

..............................................39

PERJETA

..............................................18

permethrin

.............................................37

perphenazine

..........................................29

perphenazine-amitriptyline

..............................29

PERSERIS

.............................................29

pzerpen-g

.............................................13

phenelzine

.............................................29

phenobarbital oral elixir

.................................22

phenobarbital oral tablet

................................22

phenobarbital sodium injection solution

..................22

phenoxybenzamine

.....................................32

phenytoin oral suspension

..............................22

phenytoin oral tablet,chewable

..........................22

phenytoin sodium extended oral capsule

100 mg, 200 mg

........................................22

phenytoin sodium extended oral capsule 300 mg

.........22

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

phenytoin sodium intravenous solution ...................22

PHESGO

..............................................18

philith

..................................................49

PHOSLYRA

............................................54

PHOSPHOLINE IODIDE

................................51

PIFELTRO

..............................................9

pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4%

.......51

pilocarpine hcl oral

......................................38

pimozide

...............................................29

pimtrea (28)

............................................49

pindolol

................................................32

pioglitazone

............................................42

piperacillin-tazobactam

.................................13

PIQRAY

................................................18

pirfenidone oral capsule

.................................53

pirfenidone oral tablet 267 mg

...........................53

pirfenidone oral tablet 534 mg, 801 mg

...................53

plenamine

..............................................55

PLERIXAFOR

..........................................45

PNV-DHA

..............................................55

PNV-OMEGA

..........................................55

PNV-SELECT

..........................................55

podolox

...............................................35

POLIVY

................................................18

polycin

.................................................50

polymyxin b sulf-trimethoprim

...........................50

POMALYST

............................................18

portia 28

...............................................49

PORTRAZZA

..........................................18

posaconazole oral tablet,delayed release (dr/ec)

..........8

POTASSIUM CHLORID-D5-0.45%NACL

INTRAVENOUS PARENTERAL SOLUTION

10 MEQ/L, 20 MEQ/L, 30 MEQ/L

........................54

potassium chlorid-d5-0.45%nacl intravenous

parenteral solution 40 meq/l

.............................54

potassium chloride-0.45% nacl

..........................54

POTASSIUM CHLORIDE-D5-0.2%NACL

INTRAVENOUS PARENTERAL SOLUTION 20 MEQ/L

...54

POTASSIUM CHLORIDE-D5-0.9%NACL

................54

POTASSIUM CHLORIDE IN 0.9%NACL

INTRAVENOUS PARENTERAL SOLUTION

20 MEQ/L, 40 MEQ/L

...................................54

potassium chloride in 5% dex intravenous

parenteral solution 10 meq/l

.............................54

POTASSIUM CHLORIDE IN 5% DEX INTRAVENOUS

PARENTERAL SOLUTION 20 MEQ/L

...................54

POTASSIUM CHLORIDE IN LR-D5 INTRAVENOUS

PARENTERAL SOLUTION 20 MEQ/L

...................54

potassium chloride intravenous

..........................54

potassium chloride in water intravenous piggyback 10

meq/100 ml, 10 meq/50 ml, 20 meq/100 ml,

20 meq/50 ml, 40 meq/100 ml

...........................54

potassium chloride oral capsule, extended release

........54

potassium chloride oral liquid

............................54

potassium chloride oral packet

..........................54

potassium chloride oral tablet,er particles/crystals

........54

potassium chloride oral tablet,er particles/crystals

15 meq

................................................55

potassium chloride oral tablet extended release

..........54

potassium citrate oral tablet extended release

............54

POTELIGEO

...........................................18

PRADAXA ORAL CAPSULE 110 MG

....................33

PRALUENT PEN

.......................................34

pramipexole oral tablet

..................................23

prasugrel

...............................................33

pravastatin

.............................................34

praziquantel

............................................12

prazosin

...............................................32

prednicarbate topical ointment

...........................37

PREDNISOLONE ACETATE

............................51

prednisolone oral solution

...............................39

prednisolone sodium phosphate ophthalmic (eye)

........51

prednisolone sodium phosphate oral solution

15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml),

25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

......39

prednisone intensol

.....................................39

prednisone oral solution

.................................39

prednisone oral tablet

...................................39

prednisone oral tablets,dose pack

.......................39

pregabalin oral capsule 100 mg, 150 mg, 25 mg,

50 mg, 75 mg

..........................................22

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

pregabalin oral capsule 200 mg .........................22

pregabalin oral capsule 225 mg, 300 mg

.................22

pregabalin oral solution

.................................22

PREHEVBRIO (PF)

.....................................46

PREMARIN INJECTION

................................48

PREMARIN ORAL

......................................48

PREMARIN VAGINAL

..................................48

premasol 10%

..........................................55

PREMPRO

.............................................48

PRENATAL PLUS (CALCIUM CARB)

....................55

PRENATAL VITAMIN PLUS LOW IRON

..................55

prevalite

...............................................34

PREVYMIS

.............................................9

PREZCOBIX

............................................9

PREZISTA ORAL SUSPENSION

.........................9

PREZISTA ORAL TABLET 75 MG

........................9

PREZISTA ORAL TABLET 150 MG

.......................9

PREZISTA ORAL TABLET 600 MG

.......................9

PREZISTA ORAL TABLET 800 MG

.......................9

PRIFTIN

...............................................12

primaquine

.............................................12

primidone oral tablet 125 mg

............................22

primidone oral tablet 250 mg, 50 mg

.....................22

PRIORIX (PF)

..........................................46

PRIVIGEN

.............................................46

PR NATAL 400

.........................................55

PR NATAL 400 EC

......................................55

PR NATAL 430

.........................................55

PR NATAL 430 EC

......................................55

probenecid

.............................................46

probenecid-colchicine

...................................46

prochlorperazine

.......................................44

prochlorperazine edisylate injection solution

10 mg/2 ml (5 mg/ml)

...................................44

prochlorperazine maleate

...............................44

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML,

2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML,

4,000 UNIT/ML, 40,000 UNIT/ML

........................45

procto-med hc

..........................................44

proctosol hc topical

.....................................44

proctozone-hc

..........................................44

progesterone micronized

................................48

PROGRAF INTRAVENOUS

.............................18

PROGRAF ORAL GRANULES IN PACKET

..............18

PROLASTIN-C INTRAVENOUS RECON SOLN

..........38

PROLASTIN-C INTRAVENOUS SOLUTION

.............38

PROLENSA

............................................51

PROLIA

................................................46

PROMACTA ORAL POWDER IN PACKET 12.5 MG

......34

PROMACTA ORAL POWDER IN PACKET 25 MG

........34

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG

....34

PROMACTA ORAL TABLET 75 MG

......................34

promethazine oral

......................................52

propafenone

...........................................31

propranolol oral capsule,extended release 24 hr

..........33

propranolol oral solution

................................33

propranolol oral tablet

...................................33

propylthiouracil

.........................................40

PROQUAD (PF)

........................................46

PROSOL 20%

..........................................55

protriptyline

............................................29

PULMOZYME

..........................................53

PURIXAN

..............................................18

pyrazinamide

...........................................12

pyridostigmine bromide oral syrup

.......................24

pyridostigmine bromide oral tablet 60 mg

.................24

pyridostigmine bromide oral tablet extended release

......24

pyrimethamine

.........................................12

QINLOCK ..............................................18

QUADRACEL (PF)

.....................................46

quetiapine oral tablet 100 mg, 25 mg, 50 mg

.............29

quetiapine oral tablet 150 mg, 200 mg

...................29

quetiapine oral tablet 300 mg, 400 mg

...................29

quetiapine oral tablet extended release

24 hr 150 mg, 200 mg

..................................29

quetiapine oral tablet extended release

24 hr 300 mg, 400 mg, 50 mg

...........................29

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

QUILLICHEW ER ORAL TABLET, CHEW, IR-ER.

BIPHASIC24HR 20 MG, 30 MG

.........................29

QUILLICHEW ER ORAL TABLET, CHEW, IR-ER.

BIPHASIC24HR 40 MG

.................................29

quinapril

...............................................33

quinapril-hydrochlorothiazide

............................33

quinidine sulfate oral tablet

..............................31

quinine sulfate

..........................................12

RABAVERT (PF) .......................................46

raloxifene

..............................................46

ramipril

................................................33

ranolazine

..............................................34

rasagiline

..............................................23

RAYALDEE

............................................43

reclipsen (28)

..........................................49

RECOMBIVAX HB (PF)

.................................46

RECTIV

................................................44

REGRANEX

...........................................35

REMICADE

............................................44

RENACIDIN

............................................54

repaglinide oral tablet 0.5 mg

............................42

repaglinide oral tablet 1 mg

.............................42

repaglinide oral tablet 2 mg

.............................42

REPATHA PUSHTRONEX

..............................34

REPATHA SURECLICK

.................................34

REPATHA SYRINGE

...................................34

RESTASIS

.............................................51

RESTASIS MULTIDOSE

................................51

RETEVMO ORAL CAPSULE 40 MG

.....................18

RETEVMO ORAL CAPSULE 80 MG

.....................18

RETROVIR INTRAVENOUS

.............................9

REVLIMID ORAL CAPSULE 2.5 MG, 20 MG

.............18

REXULTI ORAL TABLET

................................29

REYATAZ ORAL POWDER IN PACKET

. . . . . . . . . . . . . . . . . . . 9

REZLIDHIA

............................................18

RHOPRESSA

..........................................51

ribavirin oral capsule

..................................... 9

ribavirin oral tablet 200 mg

...............................9

rifabutin

................................................12

rifampin

................................................12

riluzole

.................................................38

rimantadine

.............................................9

RINGER'S INTRAVENOUS

.............................54

RINGER'S IRRIGATION

................................37

RINVOQ

...............................................47

RISPERDAL CONSTA

..................................29

risperidone oral solution

.................................29

risperidone oral syringe

.................................29

risperidone oral tablet 0.25 mg, 0.5 mg, 4 mg

.............30

risperidone oral tablet 1 mg

.............................30

risperidone oral tablet 2 mg

.............................30

risperidone oral tablet 3 mg

.............................30

risperidone oral tablet,disintegrating

0.25 mg, 0.5 mg, 4 mg

..................................30

risperidone oral tablet,disintegrating 1 mg

................30

risperidone oral tablet,disintegrating 2 mg

................30

risperidone oral tablet,disintegrating 3 mg

................30

ritonavir

.................................................9

rivastigmine

............................................24

rivastigmine tartrate

.....................................24

RIVELSA

..............................................49

rizatriptan oral tablet

....................................23

rizatriptan oral tablet,disintegrating

.......................23

ROCKLATAN

...........................................51

roumilast

..............................................53

romidepsin intravenous recon soln

.......................18

ROMIDEPSIN INTRAVENOUS SOLUTION

..............19

ropinirole oral tablet

.....................................23

ropinirole oral tablet extended release 24 hr

..............23

rosuvastatin

............................................34

ROTARIX

..............................................46

ROTATEQ VACCINE

...................................46

roweepra oral tablet 500 mg

.............................22

ROZLYTREK ORAL CAPSULE 100 MG

.................19

ROZLYTREK ORAL CAPSULE 200 MG

.................19

RUBRACA

.............................................19

runamide oral suspension

..............................22

runamide oral tablet

...................................22

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

RUKOBIA ..............................................10

RUXIENCE

............................................19

RYALTRIS

.............................................53

RYBELSUS

............................................42

RYBREVANT

...........................................19

RYDAPT

...............................................19

RYLAZE

...............................................19

RYTARY

...............................................23

sajazir .................................................53

SANCUSO

.............................................44

SANDIMMUNE ORAL SOLUTION

.......................19

SANTYL

...............................................35

sapropterin

.............................................43

SARCLISA

.............................................19

SCEMBLIX ORAL TABLET 20 MG

.......................19

SCEMBLIX ORAL TABLET 40 MG

.......................19

scopolamine base

......................................44

SECUADO

.............................................30

selegiline hcl

...........................................23

selenium sulde topical lotion

...........................35

SELZENTRY ORAL SOLUTION

.........................10

SELZENTRY ORAL TABLET 25 MG

.....................10

SELZENTRY ORAL TABLET 75 MG

.....................10

SE-NATAL-19

..........................................55

SE-NATAL 19 CHEWABLE

..............................55

SEREVENT DISKUS

...................................53

sertraline oral concentrate

...............................30

sertraline oral tablet

.....................................30

setlakin

................................................49

sevelamer carbonate oral powder in packet 0.8 gram

.....38

sevelamer carbonate oral powder in packet 2.4 gram

.....38

sevelamer carbonate oral tablet

.........................38

sharobel

...............................................48

SHINGRIX (PF)

........................................46

SIGNIFOR

.............................................19

sildenal (pulm.hypertension) oral tablet

.................53

SILVER SULFADIAZINE

................................35

SIMBRINZA

............................................51

simliya (28)

............................................50

simpesse

..............................................50

SIMULECT

.............................................19

simvastatin

.............................................34

sirolimus

...............................................19

SIRTURO

..............................................12

SIVEXTRO INTRAVENOUS

.............................12

SIVEXTRO ORAL

......................................12

SKYRIZI INTRAVENOUS

...............................35

SKYRIZI SUBCUTANEOUS PEN INJECTOR

............35

SKYRIZI SUBCUTANEOUS SYRINGE 150 MG/ML

.......35

SKYRIZI SUBCUTANEOUS WEARABLE INJECTOR

180 MG/1.2 ML (150 MG/ML)

...........................44

SKYRIZI SUBCUTANEOUS WEARABLE INJECTOR

360 MG/2.4 ML (150 MG/ML)

...........................35

sodium bicarbonate intravenous syringe

.................54

sodium chloride 0.9% intravenous parenteral solution

.....38

SODIUM CHLORIDE 0.9% INTRAVENOUS

PIGGYBACK

...........................................38

sodium chloride 0.45% intravenous

......................54

sodium chloride 3% hypertonic

..........................54

SODIUM CHLORIDE 5% HYPERTONIC

.................54

sodium chloride intravenous

.............................54

SODIUM CHLORIDE IRRIGATION

......................38

SODIUM OXYBATE

....................................30

sodium phenylbutyrate

..................................38

sodium polystyrene sulfonate oral powder

................38

solifenacin

.............................................53

SOLIQUA 100/33

.......................................42

SOLTAMOX

............................................19

SOLU-CORTEF ACT-O-VIAL (PF)

.......................39

SOMATULINE DEPOT

..................................19

SOMAVERT

............................................43

sorafenib

...............................................19

sorine

..................................................31

sotalol af

...............................................31

sotalol oral

.............................................31

SOTYLIZE

.............................................31

spironolactone

.........................................33

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

spironolacton-hydrochlorothiaz ..........................33

SPRAVATO NASAL SPRAY, NON-AEROSOL

56 MG (28 MG X 2)

.....................................30

SPRAVATO NASAL SPRAY, NON-AEROSOL

84 MG (28 MG X 3)

.....................................30

sprintec (28)

............................................50

SPRITAM

..............................................22

SPRYCEL ORAL TABLET 20 MG, 70 MG

................19

SPRYCEL ORAL TABLET 100 MG, 140 MG,

50 MG, 80 MG

.........................................19

sps (with sorbitol)

.......................................38

sronyx

.................................................50

SSD

...................................................35

STAMARIL (PF)

........................................46

STELARA SUBCUTANEOUS SOLUTION

................35

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML

...35

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML

......35

STIVARGA

.............................................19

streptomycin

...........................................12

STRIBILD

..............................................10

subvenite

..............................................22

subvenite starter (blue) kit

...............................22

subvenite starter (green) kit

.............................22

subvenite starter (orange) kit

............................22

SUCRAID

..............................................44

sucralfate oral suspension

..............................45

sucralfate oral tablet

....................................45

sulfacetamide-prednisolone

.............................51

sulfacetamide sodium (acne)

............................36

sulfacetamide sodium ophthalmic (eye) drops

............51

sulfadiazine

............................................13

sulfamethoxazole-trimethoprim intravenous

..............13

sulfamethoxazole-trimethoprim oral suspension

..........13

sulfamethoxazole-trimethoprim oral tablet

................13

sulfasalazine oral tablet

.................................44

SULFASALAZINE ORAL TABLET, DELAYED

RELEASE (DR/EC)

.....................................44

sulindac

................................................26

sumatriptan nasal spray,non-aerosol 5 mg/actuation

......23

sumatriptan nasal spray,non-aerosol 20 mg/actuation

.....23

sumatriptan succinate oral

..............................23

SUMATRIPTAN SUCCINATE SUBCUTANEOUS

CARTRIDGE

...........................................23

sumatriptan succinate subcutaneous pen injector

.........23

sumatriptan succinate subcutaneous solution

............23

sunitinib malate

.........................................19

SUNLENCA

............................................10

SUPREP BOWEL PREP KIT

............................44

SUTAB

................................................44

syeda

..................................................50

SYMPAZAN

............................................22

SYMTUZA

.............................................10

SYNAREL

.............................................43

SYNJARDY

............................................42

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG

.........42

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 25-1,000 MG

.....................................42

SYNRIBO

..............................................19

SYNTHROID

...........................................43

TABLOID ..............................................19

TABRECTA

............................................19

tacrolimus oral

.........................................19

tacrolimus topical

.......................................35

tadalal (pulm. hypertension)

............................53

TAFINLAR ORAL CAPSULE

............................19

TAFINLAR ORAL TABLET FOR SUSPENSION

..........19

TAGRISSO

.............................................19

TALICIA

................................................45

TALTZ AUTOINJECTOR

................................35

TALTZ SYRINGE

.......................................35

TALVEY

................................................19

TALZENNA ORAL CAPSULE 0.1 MG, 0.35 MG,

0.5 MG, 0.75 MG, 1 MG

................................19

TALZENNA ORAL CAPSULE 0.25 MG

...................19

tamoxifen

..............................................19

tamsulosin

.............................................53

tarina 24 fe

.............................................50

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

tarina fe 1-20 eq (28) ...................................50

TARON-C DHA

.........................................55

TASIGNA ORAL CAPSULE 50 MG

......................19

TASIGNA ORAL CAPSULE 150 MG, 200 MG

............19

tasimelteon

............................................30

taysofy

.................................................50

tazarotene topical cream

................................36

TAZAROTENE TOPICAL GEL 0.1%

.....................36

tazarotene topical gel 0.05%

............................36

tazicef

.................................................11

TAZORAC TOPICAL CREAM 0.05%

.....................36

TAZORAC TOPICAL GEL

...............................36

taztia xt oral capsule,extended release

24 hr 120 mg, 180 mg, 240 mg, 300 mg

..................33

TAZVERIK

.............................................19

TDVAX

................................................46

TECENTRIQ

...........................................19

TECHLITE INSULIN SYRINGE SYRINGE 1 ML

29 GAUGE X 1/2", 1 ML 30 GAUGE X 1/2", 1 ML

31 GAUGE X 15/64", 1 ML 31 GAUGE X 5/16

............42

TECHLITE INSULN SYR(HALF UNIT) SYRINGE 0.3 ML

29 GAUGE X 1/2", 0.3 ML 30 GAUGE X 5/16", 0.3 ML

31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML

30 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16", 0.5 ML

31 GAUGE X 15/64", 0.5 ML 31 GAUGE X 5/16"

.........42

TECHLITE PEN NEEDLE

...............................42

TECVAYLI

.............................................19

TEFLARO

..............................................11

telmisartan

.............................................33

temazepam oral capsule 15 mg, 30 mg

..................30

TEMODAR INTRAVENOUS

.............................19

temsirolimus

...........................................19

TENIVAC (PF)

..........................................46

tenofovir disoproxil fumarate

............................10

TEPMETKO

............................................19

terazosin oral capsule 1 mg, 2 mg, 5 mg

.................33

terazosin oral capsule 10 mg

............................33

terbinane hcl oral

.......................................8

terbutaline

.............................................53

terconazole

............................................48

teriunomide

...........................................24

testosterone cypionate

..................................43

testosterone enanthate

.................................43

testosterone transdermal gel

............................43

testosterone transdermal gel in metered-dose pump

12.5 mg/ 1.25 gram (1%)

................................43

testosterone transdermal gel in packet 1%

(25 mg/2.5gram), 1% (50 mg/5 gram)

....................43

TETANUS, DIPHTHERIA TOX PED(PF)

.................46

tetrabenazine oral tablet 12.5 mg

........................24

tetrabenazine oral tablet 25 mg

..........................24

tetracycline

.............................................13

THALOMID ORAL CAPSULE 100 MG, 50 MG

...........19

THALOMID ORAL CAPSULE 150 MG, 200 MG

..........19

theo-24

................................................53

theophylline oral tablet extended release

12 hr 100 mg, 200 mg, 300 mg

..........................53

theophylline oral tablet extended release 12 hr 450 mg

...53

theophylline oral tablet extended release 24 hr 400 mg

...53

theophylline oral tablet extended release 24 hr 600 mg

...53

thioridazine

............................................30

thiotepa

................................................19

thiothixene

.............................................30

tiadylt er

...............................................33

tiagabine

...............................................22

TIBSOVO

..............................................19

TICE BCG

.............................................46

TICOVAC

..............................................46

tigecycline

.............................................12

tilia fe

..................................................50

timolol maleate ophthalmic (eye) drops

..................50

timolol maleate ophthalmic (eye) gel forming solution

.....50

timolol maleate oral

.....................................33

TIS-U-SOL PENTALYTE

................................37

TIVDAK

................................................19

TIVICAY ORAL TABLET 10 MG

.........................10

TIVICAY ORAL TABLET 25 MG, 50 MG

..................10

TIVICAY PD

............................................10

tizanidine oral tablet

....................................24

TOBRADEX ST

........................................51

tobramycin-dexamethasone

.............................51

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

tobramycin in 0.225% nacl ..............................12

tobramycin ophthalmic (eye)

............................50

tobramycin sulfate

......................................12

tolterodine oral capsule,extended release 24hr

...........53

tolterodine oral tablet

...................................53

TOLVAPTAN ORAL TABLET 15 MG

.....................43

tolvaptan oral tablet 30 mg

..............................43

topiramate oral capsule,extended release 24hr

...........22

topiramate oral capsule, sprinkle

........................22

topiramate oral tablet

...................................22

topotecan intravenous recon soln

........................19

topotecan intravenous solution

..........................19

toremifene

.............................................19

torsemide oral

..........................................33

TOUJEO MAX U-300 SOLOSTAR

.......................42

TOUJEO SOLOSTAR U-300 INSULIN

...................42

TOVIAZ

................................................53

TRADJENTA

...........................................42

tramadol-acetaminophen

................................26

tramadol oral tablet 50 mg

..............................26

trandolapril

.............................................33

tranexamic acid oral

....................................48

tranylcypromine

........................................30

TRAVASOL 10%

.......................................55

travoprost

..............................................51

TRAZIMERA

...........................................19

trazodone oral tablet 100 mg, 150 mg, 50 mg

............30

trazodone oral tablet 300 mg

............................30

TREANDA

.............................................19

TRECATOR

............................................12

TRELEGY ELLIPTA

....................................53

TRELSTAR INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION

....................................19

TRESIBA FLEXTOUCH U-100

..........................42

TRESIBA FLEXTOUCH U-200

..........................42

TRESIBA U-100 INSULIN

...............................42

tretinoin (antineoplastic)

.................................20

tretinoin microspheres topical gel 0.1%

..................36

tretinoin microspheres topical gel with pump 0.1%

........36

tretinoin topical cream

..................................36

tretinoin topical gel 0.01%

...............................36

tretinoin topical gel 0.025%, 0.05%

......................36

triamcinolone acetonide dental

..........................39

triamcinolone acetonide injection suspension 40 mg/ml

...39

triamcinolone acetonide topical cream 0.1%

..............37

triamcinolone acetonide topical cream 0.025%, 0.5%

.....37

triamcinolone acetonide topical lotion

....................37

triamcinolone acetonide topical ointment

0.025%, 0.1%, 0.5%

....................................37

triamterene-hydrochlorothiazid

..........................33

triderm topical cream 0.1%

..............................37

trientine oral capsule 250 mg

............................38

tri-estarylla

.............................................50

triuoperazine oral tablet 1 mg

..........................30

triuoperazine oral tablet 10 mg, 2 mg, 5 mg

.............30

triuridine

..............................................50

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 10-5-1,000 MG, 25-5-1,000 MG

...................42

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG

...............42

TRIKAFTA ORAL GRANULES IN PACKET,

SEQUENTIAL

..........................................53

TRIKAFTA ORAL TABLETS, SEQUENTIAL

..............53

tri-legest fe

.............................................50

tri-linyah

...............................................50

tri-lo-estarylla

...........................................50

tri-lo-marzia

............................................50

tri-lo-mili

...............................................50

tri-lo-sprintec

...........................................50

trimethoprim

............................................13

tri-mili

..................................................50

trimipramine

............................................30

TRINATAL RX 1

........................................55

TRINTELLIX

...........................................30

tri-nymyo

...............................................50

TRIPTODUR

...........................................20

tri-sprintec (28)

.........................................50

TRIUMEQ

..............................................10

TRIUMEQ PD

..........................................10

trivora (28)

.............................................50

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

tri-vylibra ...............................................50

tri-vylibra lo

............................................50

TRIZIVIR

...............................................10

TRODELVY

............................................20

TROGARZO

...........................................10

TROKENDI XR

.........................................22

TROPHAMINE 10%

....................................55

TRULANCE

............................................44

TRULICITY

............................................42

TRUMENBA

...........................................46

TRUXIMA

..............................................20

TUKYSA ORAL TABLET 50 MG

.........................20

TUKYSA ORAL TABLET 150 MG

........................20

TURALIO ORAL CAPSULE 125 MG

.....................20

TWINRIX (PF)

..........................................46

TYBLUME

.............................................50

tydemy

.................................................50

TYMLOS

...............................................46

TYPHIM VI

.............................................46

TZIELD

................................................38

UBRELVY ..............................................23

UNITHROID

............................................43

UNITUXIN

.............................................20

UPTRAVI ORAL

........................................33

ursodiol oral capsule 300 mg

............................44

ursodiol oral tablet

......................................44

valacyclovir oral tablet 1 gram ...........................10

valacyclovir oral tablet 500 mg

..........................10

VALCHLOR

............................................35

valganciclovir oral recon soln

............................10

valganciclovir oral tablet

................................10

valproate sodium

.......................................22

valproic acid

............................................22

valproic acid (as sodium salt)

............................22

valrubicin

..............................................20

valsartan-hydrochlorothiazide

...........................33

valsartan oral tablet 160 mg, 40 mg, 80 mg

..............33

valsartan oral tablet 320 mg

.............................33

VALTOCO

..............................................22

VANCOMYCIN-DILUENT COMBO NO.1

.................12

VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS

PIGGYBACK

...........................................12

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS

PIGGYBACK

...........................................12

vancomycin injection

....................................12

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5

gram, 500 mg, 750 mg

..................................12

VANCOMYCIN INTRAVENOUS RECON SOLN

1.5 GRAM

.............................................12

vancomycin intravenous recon soln 1.25 gram

. . . . . . . . . . . . 13

vancomycin oral capsule 125 mg

........................12

vancomycin oral capsule 250 mg

........................12

vancomycin oral recon soln 25 mg/ml

....................12

VANDAZOLE

...........................................48

VANFLYTA

.............................................20

VAQTA (PF)

............................................46

varenicline

.............................................39

VARIVAX (PF)

..........................................46

VARIZIG

...............................................46

VASCEPA

..............................................34

VECTIBIX

..............................................20

VEKLURY

.............................................10

VELCADE

.............................................20

velivet triphasic regimen (28)

............................50

VELPHORO

............................................38

VELTASSA

.............................................38

VEMLIDY

..............................................10

VENCLEXTA ORAL TABLET 10 MG

.....................20

VENCLEXTA ORAL TABLET 50 MG

.....................20

VENCLEXTA ORAL TABLET 100 MG

....................20

VENCLEXTA STARTING PACK

.........................20

venlafaxine oral capsule,extended release 24hr 75 mg

....30

venlafaxine oral capsule,extended release

24hr 150 mg, 37.5 mg

..................................30

venlafaxine oral tablet 50 mg, 75 mg

.....................30

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg

...........30

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

VENTAVIS .............................................53

VENTOLIN HFA

........................................53

verapamil intravenous solution

..........................33

verapamil oral capsule, 24 hr er pellet ct

.................33

verapamil oral capsule,ext rel. pellets 24 hr 120 mg,

180 mg

................................................33

verapamil oral capsule,ext rel. pellets 24 hr 240 mg

.......33

VERAPAMIL ORAL CAPSULE, EXT REL. PELLETS

24 HR 360 MG

.........................................33

verapamil oral tablet

....................................33

verapamil oral tablet extended release

...................33

VERQUVO

.............................................34

VERSACLOZ

..........................................30

VERSALON NONWOVEN ALL-PURPOSE TOPICAL

SPONGE 2 X 2 "

.......................................42

VERZENIO

............................................20

vestura (28)

............................................50

V-GO 20

...............................................42

V-GO 30

...............................................42

V-GO 40

...............................................42

VICTOZA 2-PAK

........................................42

VICTOZA 3-PAK

........................................42

vienva

.................................................50

vigabatrin

..............................................22

vigadrone

..............................................22

VIIBRYD ORAL TABLETS, DOSE PACK 10 MG

(7)- 20 MG (23)

.........................................30

vilazodone

.............................................30

vinblastine

.............................................20

vincristine

..............................................20

vinorelbine

.............................................20

VIOKACE

..............................................44

viorele (28)

.............................................50

VIRACEPT ORAL TABLET 250 MG

......................10

VIRACEPT ORAL TABLET 625 MG

......................10

VIREAD ORAL POWDER

...............................10

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

.......10

VITRAKVI ORAL CAPSULE 25 MG

......................20

VITRAKVI ORAL CAPSULE 100 MG

....................20

VITRAKVI ORAL SOLUTION

............................20

VIVITROL

..............................................26

VIZIMPRO

.............................................20

volnea (28)

.............................................50

VONJO

................................................20

voriconazole intravenous

.................................8

voriconazole oral suspension for reconstitution

............8

voriconazole oral tablet

..................................8

VOSEVI

...............................................10

VOTRIENT

.............................................20

VRAYLAR ORAL CAPSULE

.............................30

VRAYLAR ORAL CAPSULE, DOSE PACK

...............30

VUMERITY

............................................24

vyfemla (28)

............................................50

vylibra

.................................................50

VYNDAMAX

...........................................34

VYNDAQEL

............................................34

VYXEOS

...............................................20

warfarin ................................................34

WATER FOR IRRIGATION, STERILE

....................38

WELIREG

..............................................20

wera (28)

..............................................50

WESTAB PLUS

........................................55

WESTGEL DHA

........................................55

wymzya fe

.............................................50

XALKORI ..............................................20

XARELTO

..............................................34

XARELTO DVT-PE TREAT 30D START

..................34

XATMEP

...............................................20

XCOPRI MAINTENANCE PACK ORAL TABLET

250MG/DAY(150 MG X1-100MG X1), 350 MG/DAY

(200 MG X1-150MG X1)

................................22

XCOPRI ORAL TABLET 50 MG

.........................22

XCOPRI ORAL TABLET 100 MG

........................22

XCOPRI ORAL TABLET 150 MG, 200 MG

...............22

XCOPRI TITRATION PACK

.............................22

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

XDEMVY ..............................................51

XELJANZ ORAL SOLUTION

............................47

XELJANZ ORAL TABLET

...............................47

XELJANZ XR

..........................................47

XGEVA

................................................14

XIAFLEX

...............................................38

XIFAXAN ORAL TABLET 550 MG

.......................12

XIIDRA

................................................51

XOLAIR SUBCUTANEOUS RECON SOLN

..............53

XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML

.....53

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML

.......53

XOSPATA

..............................................20

XPOVIO ORAL TABLET 100 MG/WEEK (50 MG X 2),

40 MG/WEEK (40 MG X 1), 40MG TWICE WEEK

(40 MG X 2), 60 MG/WEEK (60 MG X 1), 60MG

TWICE WEEK (120 MG/WEEK), 80 MG/WEEK

(40 MG X 2), 80MG TWICE WEEK (160 MG/WEEK)

......20

XTAMPZA ER

..........................................25

XTANDI ORAL CAPSULE

...............................20

XTANDI ORAL TABLET 40 MG

..........................20

XTANDI ORAL TABLET 80 MG

..........................20

XULTOPHY 100/3.6

....................................42

XYREM

................................................30

YERVOY ...............................................20

YF-VAX (PF)

...........................................46

YONDELIS

.............................................20

yuvafem

...............................................48

zarlukast ..............................................53

zaleplon oral capsule 5 mg

..............................30

zaleplon oral capsule 10 mg

.............................30

ZALTRAP

..............................................20

ZANOSAR

.............................................20

ZEJULA ORAL CAPSULE

...............................20

ZEJULA ORAL TABLET

.................................20

ZELBORAF

............................................20

ZENPEP ORAL CAPSULE, DELAYED RELEASE

(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000

-63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-

79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT,

40,000-126,000- 168,000 UNIT, 5,000-17,000-

24,000 UNIT

...........................................44

ZEPOSIA

..............................................24

ZEPOSIA STARTER KIT (28-DAY)

......................24

ZEPOSIA STARTER PACK (7-DAY)

.....................24

ZEPZELCA

............................................20

zidovudine oral capsule

.................................10

zidovudine oral syrup

...................................10

zidovudine oral tablet

...................................10

ZIEXTENZO

...........................................45

ZIMHI

..................................................26

ziprasidone hcl oral capsule 20 mg

......................30

ziprasidone hcl oral capsule 40 mg

......................30

ziprasidone hcl oral capsule 60 mg, 80 mg

...............30

ziprasidone mesylate

...................................30

ZIRABEV

..............................................20

ZIRGAN

...............................................50

ZOLADEX

.............................................20

zoledronic acid intravenous solution

.....................43

zoledronic acid-mannitol-water intravenous

piggyback 4 mg/100 ml

.................................43

ZOLEDRONIC ACID-MANNITOL-WATER

INTRAVENOUS PIGGYBACK 5 MG/100 ML

.............38

ZOLEDRONIC AC-MANNITOL-0.9NACL

.................43

ZOLINZA

..............................................20

zolpidem oral tablet

.....................................30

ZONISADE

............................................22

zonisamide

.............................................22

ZOSYN IN DEXTROSE (ISO-OSM)

.....................13

zovia 1-35 (28)

.........................................50

ZTALMY

...............................................22

ZTLIDO

................................................35

December 2023

DRUG PAGE DRUG PAGE

Covered Drugs Index

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG,

1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG

.....26

ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG

. . . . . . . . . . . . 26

zumandimine (28)

......................................50

ZYDELIG

..............................................20

ZYKADIA

..............................................21

ZYNLONTA

............................................21

ZYNYZ

................................................21

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION

210 MG, 300 MG

.......................................30

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 405 MG

........30

Notes

ACCEPTED 20_PDP_NDMLI

English – ATTENTION: If you speak English, language assistance services, free of charge are

available to you. Call (TTY 711).

Spanish – ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia

lingüística. Llame al(TTY 711).

Chinese – ὀព㸸ዴᯝᝍ౑⏝⦾㧓୰ᩥ㸪ᝍྍ௨ච㈝⋓ᚓㄒゝ᥼ຓ᭹ົࠋㄳ⮴㟁

(TTY 711)ࠋ

Tiếng Việt (Vietnamese) – CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí

dành cho bạn. Gọisố  (TTY: 711).

)

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RX5HOH77<

Korean – 㭒㦮: 䞲ῃ㠊⯒ ㌂㣿䞮㔲⓪ ἓ㤆, 㠎㠊㰖㤦㍲゚㓺⯒ ⶊ⬢⪲ 㧊㣿䞮㔺㑮㧞㔋┞┺.

 (TTY: 711) ⻞㦒⪲ 㩚䢪䟊㭒㕃㔲㡺.

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ȼɇɂɆȺɇɂȿȿɫɥɢɜɵɝɨɜɨɪɢɬɟɧɚɪɭɫɫɤɨɦɹɡɵɤɟɬɨɜɚɦɞɨɫɬɭɩɧɵɛɟɫɩɥɚɬɧɵɟ

ɭɫɥɭɝɢɩɟɪɟɜɨɞɚɁɜɨɧɢɬɟɬɟɥɟɬɚɣɩ

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$7(1d26HIDODSRUWXJXrVHQFRQWUDPVHGLVSRQtYHLVVHUYLoRVOLQJXtVWLFRVJUiWLV

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)مﻛﺑﻟاو مﺻﻟا فﺗﺎھ مﻗر 711.(

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

77<

Navajo – ti’go Diné Bizaad, saad

(TTY 711).

Urdu

لﺎﮐ ۔ ںﯾﮨ بﺎﯾﺗﺳد ںﯾﻣ تﻔﻣ تﺎﻣدﺧ ﯽﮐ ددﻣ ﯽﮐ نﺎﺑز وﮐ پآ وﺗ ،ںﯾﮨ ﮯﺗﻟوﺑ ودرا پآ رﮔا :رادرﺑﺧ

̭

:TTY) 

دﺷﺎﺑ ﯽﻣ مھارﻓ ﺎﻣﺷ یارﺑ نﺎﮕﯾار تروﺻﺑ ﯽﻧﺎﺑز تﻼﯾﮭﺳﺗ ،دﯾﻧﮐ ﯽﻣ وﮕﺗﻔﮔ ﯽﺳرﺎﻓ نﺎﺑز ﮫﺑ رﮔا :ﮫﺟوﺗ

Ωϳέϳ̴ΑαΎϣΗ77<711)



ΎΑ

1-800-222-6700

S5617_17_50212

1-800-222-6700

(01142020)

This formulary was updated on 12/01/2023. For more recent information or other questions, please contact Cigna Customer Service,

at 1-800-222-6700 (TTY users should call 711), 8 a.m. – 8 p.m. local time, 7 days a week. Our automated phone system may answer

your call during weekends from April 1 – September 30, or visit CignaMedicare.com. All Cigna products and services are provided

exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by

December 2023 967368 l

1-800-222-6700 (TTY 711)

8 a.m. – 8 p.m. local time, 7 days a week. Our

automated phone system may answer your call

during weekends from April 1 – September 30.

CignaMedicare.com