Preferred
Drug List (PDL)
Ohio
UnitedHealthcare
Community Plan – Medicaid
Effective Date: 7/1/2022
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o Online: UHC_Civ[email protected]
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Salt Lake City, UT 84130
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ိ ုိ
7/20/2021
INSIDE:
UnitedHealthcare Community Plan
List of Preferred Drugs
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this UnitedHealthcare Community Plan
List of Preferred Drugs. You can read all of the FAQ to learn more, or look for a question
and answer.
1
What drugs are on the Preferred Drug List? (We call the Preferred Drug List the
“Drug List” for short.)
The drugs on Preferred Drug List are the drugs covered by the UnitedHealthcare
Community Plan. These drugs are available at pharmacies within our network. A
pharmacy is in our network if we have an agreement with them to work with us and
provide you services. We refer to these pharmacies as “network pharmacies.”
UnitedHealthcare will cover all medically necessary drugs if:
·
your doctor or other prescriber says you need them to get better or stay healthy,
and
·
you fill the prescription at a UnitedHealthcare Community Plan network
pharmacy.
UnitedHealthcare may have additional steps to access certain drugs (see question <#5>
below).
You can also see an up-to-date drug list on our website at
<myuhc.com/CommunityPlan> or call Member Services at <1-800-895-2017> TTY 711.
2
Does the Drug List ever change?
Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug List
during the year. Generally, the Drug List will only change if:
·
a cheaper drug comes along that works as well as a drug on the Drug List now, or
·
we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
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·
Decide to require or not require prior approval for a drug. ( Prior approval is permission
from UnitedHealthcare Community Plan before you can get a drug.)
·
Add or change the amount of a drug you can get (called “quantity limits”).
·
Add or change step therapy restrictions on a drug. ( Step therapy means
you must try one drug before we will cover another drug.)
Questions 3, 4, and 7 below have more information on what happens
when the Drug List changes.
You can always check the up-to-date Drug List online at <myuhc.com/CommunityPlan>
You can also call Member Services to check the current Drug List at <1-800-895-2017>,
TTY 711>.
3
What happens when another drug comes along that works as well as
a drug on the Drug List now?
If you are taking a drug that is removed because another drug that works just as well is
available, we will tell you. You will get a letter letting you know about the change. We will
also tell you what alternate drugs are available to you. Contact your doctor or other
prescriber to make sure another drug will work for you.
4
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we
will take it off the Drug List right away. We will also send you a letter telling you that.
Contact your doctor or other prescriber and ask about your other options.
5
Are there any restrictions or limits on drug coverage? Or are there any
required actions to take in order to get certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get. In
some cases your doctor must do something before you can get the drug. For example:
·
Prior approval (or prior authorization): For some drugs, your doctor or
other prescriber must get approval from UnitedHealthcare before you
fill your prescription. If you don’t get approval, UnitedHealthcare may
not cover the drug.
·
Quantity limits: Sometimes UnitedHealthcare limits the amount of a
drug you can get.
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·
Step therapy: Sometimes UnitedHealthcare requires you to do step
therapy. This means you will have to try drugs in a certain order for your medical
condition. You might have to try one drug before we will cover another drug. If
your doctor thinks the first drug doesn’t work for you, then we will cover the
second.
You can find out if your drug has any additional requirements or limits by looking in
the tables below. You can also get more information by visiting our website at
<myuhc.com/CommunityPlan>. We have posted online documents that explain our prior
authorization and step therapy restrictions. You may also call Member Services and ask
us to send you information about our prior authorization and step therapy restrictions.
6
How will you know if the drug you want has limitations or if there are
required actions to take to get the drug?
The Preferred Drug List has a column labeled “Requirements and
Limits.”
7
What happens if we change our rules on how we cover some drugs?
For example, if we add prior authorization (approval), quantity limits,
and/or step therapy restrictions on a drug.
We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions
on a drug. We will tell you before the restriction is added.. This gives you time to talk to
your doctor or other prescriber about what to do next.
8
How can you find a drug on the Drug List?
There are two ways to find a drug:
·
You can search by medical condition.
To search by medical condition, find the section labeled “List of drugs by medical
condition”. The drugs in this section are grouped into categories depending on
the type of medical conditions they are used to treat.
For example, if you have a heart condition, you should look in the category,
Cardiovascular Agents. That is where you will find drugs that treat heart
conditions.
·
You can also search for drugs alphabetically.
To search alphabetically, go to the <Index of Covered Drugs> and find the name of your
drug. The page number where you can find the drug will be next to it.
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9
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services and ask about it. If you
learn that UnitedHealthcare does not prefer the drug, you can do one of these things:
·
Ask Member Services for a list of drugs that are similar to the one you want to take.
Then show the list to your doctor or other prescriber. He or she can prescribe a drug on
the Drug List that is like the one you want to take. Or
·
You can ask the health plan to make an exception to cover your drug. Please see
question 11 for more information about exceptions.
10
What if you just joined UnitedHealthcare Community Plan and can’t
find your drug on the Drug List or have a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the first
90 days you are a member of UnitedHealthcare. This will give you time to talk to your
doctor or other prescriber. He or she can help you decide if there is a similar drug on the
Drug List you can take instead, or whether to request an exception.
11Can you ask for an exception to cover your drug?
Yes. Your doctor can ask UnitedHealthcare Community Plan to make an exception to
cover a drug that is not on the Drug List.
Your doctor can also ask us to change the rules on your drug.
·
For example, we may limit the amount of a drug we will cover. If your drug has a limit,
your doctor can ask us to change the limit and cover more.
·
Other examples: Your doctor can ask us to drop step therapy restrictions or prior
approval requirements.
12
How long does it take to get an exception?
First, we must receive some information from your doctor supporting your request for an
exception. After we receive the information, we will give you a decision on your
exception request within the timeframes required by the state, generally within 24 hours.
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13
How can you ask for an exception?
To ask for an exception, you can do one of two things:
-
Call Member Services. A Member Services representative
will work with you and your doctor to help ask for an exception.
-
Call your doctor and ask them to request an exception by calling the Prior
Notification Service at <1-800-310-6826>, or they can fax a request to<866-940-
7328>.
14
What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs.
They usually cost less than the brand name drug and usually don’t have well-known
names. Generic drugs are approved by the Food and Drug Administration (FDA). In
most instances UnitedHealthcare covers generic drugs first. If your doctor feels a brand
name drug is medically necessary, you will need to ask your doctor to submit for prior
approval.
15
What are OTC drugs?
OTC stands for “over-the-counter.” UnitedHealthcare prefers some OTC drugs when
they are written as prescriptions by your provider.
You can read the UnitedHealthcare Community Plan Drug List to see what OTC drugs
are preferred.
16
Does UnitedHealthcare cover OTC non-drug products?
UnitedHealthcare covers some OTC non-drug products when they are written as
prescriptions by your provider.
You can read the UnitedHealthcare Community Plan Drug List to see what OTC non-
drug products are covered.
17
What is a Specialty Pharmacy Medication?
A specialty pharmacy medication is a drug that generally has one or more of the
following characteristics:
It’s used by a small number of people
It treats rare, chronic, and/or potentially life-threatening diseases
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It has special storage or handling requirements such as needing to be
refrigerated
It may need close monitoring, ongoing clinical support and management, and
complete patient education and engagement
It’s a high cost medication
It may not be available at retail pharmacies
It may be oral, injectable, or inhaled
Specialty pharmacy medications are available through our specialty pharmacy network.
If you have questions, call Member Services at <1-800-895-2017, TTY 711>.
List of Preferred Drugs
The List of Preferred Drugs gives you information about the drugs covered by
UnitedHealthcare Community Plan. If you have trouble finding your drug in the list, turn
to the Index.
The first column of the chart lists the generic name of the drug. The second column of
the chart lists brand name drugs. Brand name drugs are capitalized (e.g., CRESTOR).
The third column in the list tells you if the preferred drug covered is the brand or generic
version.
The information in the “Requirements & Limits” column tells you if UnitedHealthcare has
any rules for covering your drug.
Utilization Management Restrictions
PA - Prior approval (or prior authorization)
For some drugs, your doctor or other prescriber must get approval from
UnitedHealthcare Community Plan before you fill your prescription. If you don’t
get approval, UnitedHealthcare may not cover the drug.
QL - Quantity limits
Sometimes UnitedHealthcare Community Plan limits the amount of a drug you
can get.
ST - Step therapy
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Sometimes UnitedHealthcare Community Plan requires you to do step therapy.
This means you will have to try drugs in a certain order for your medical
condition. You might have to try one drug before we will cover another drug. If
your doctor thinks the first drug doesn’t work for you, then your doctor can ask for
approval to cover the second.
Other special requirements for coverage
SP – Specialty Pharmacy
Drug needs to be accessed through a network Specialty Pharmacy.
Specialty Pharmacy Drugs may require extra handling, provider coordination or
patient education that can’t be done at a network retail pharmacy.
Drug Tiers
The drugs listed in the PDL have different tiers. The tiers are listed in the grid below.
Tier Name Drug Tier
Tier 1 Generic
Tier 2 Brand
OTC = Over the Counter
PA = Prior Authorization required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
* = Available without PA for participating Behavioral Health Prescribers
[You can find information on what the symbols and abbreviations in this table mean by
looking in the footnotes]
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注意：如果您說中文 ，您可獲得免費語言協助服務。請致電：
。 或聽障專線 。
UnitedHealthcare Community Plan of Ohio
Table of Contents
Analgesics.....................................................................................................................................................................................................................4
Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions....................................................................................................10
Anesthetics................................................................................................................................................................................................................. 16
Anesthetics - Drugs for Numbing................................................................................................................................................................................17
Anti-Addiction/Substance Abuse Treatment Agents...................................................................................................................................................18
Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence......................................................................................... 19
Antiandrogens - Hormone Suppressants....................................................................................................................................................................19
Antibacterials.............................................................................................................................................................................................................. 20
Antibacterials - Drugs to Treat Bacterial Infections.....................................................................................................................................................24
Anticonvulsants...........................................................................................................................................................................................................26
Anticonvulsants - Drugs to Treat Seizures..................................................................................................................................................................28
Antidementia Agents...................................................................................................................................................................................................29
Antidepressants.......................................................................................................................................................................................................... 30
Antiemetics................................................................................................................................................................................................................. 32
Antiemetics - Drugs to Treat Nausea and Vomiting....................................................................................................................................................34
Antifungals.................................................................................................................................................................................................................. 34
Antifungals - Drugs to Treat Fungal Infections............................................................................................................................................................35
Antigout Agents...........................................................................................................................................................................................................36
Anti-HIV Agents, Other - HIV Drugs............................................................................................................................................................................37
Anti-inflammatory Agents - Drugs to Treat Inflammation............................................................................................................................................ 37
Antimigraine Agents....................................................................................................................................................................................................37
Antimigraine Agents - Drugs to Treat Migraines......................................................................................................................................................... 37
Antimyasthenic Agents............................................................................................................................................................................................... 38
Antimycobacterials......................................................................................................................................................................................................39
Antineoplastics............................................................................................................................................................................................................39
Antineoplastics - Drugs to Treat Cancer.....................................................................................................................................................................43
Antineoplastics, Other - Chemotherapy Agents..........................................................................................................................................................43
Antiparasitics...............................................................................................................................................................................................................43
Antiparasitics - Drugs to Treat Parasitic Infections..................................................................................................................................................... 44
Antiparkinson Agents..................................................................................................................................................................................................45
Antipsychotics.............................................................................................................................................................................................................47
Antispasmodics, Urinary - Bladder Control Drugs...................................................................................................................................................... 48
Antispasticity Agents...................................................................................................................................................................................................49
Antivirals..................................................................................................................................................................................................................... 49
Antivirals - Drugs to Treat Viral Infections...................................................................................................................................................................52
Anxiolytics...................................................................................................................................................................................................................53
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs................................................................................................. 53
1
Bipolar Agents.............................................................................................................................................................................................................54
Blood Formation Modifiers - Blood Formation Drugs..................................................................................................................................................54
Blood Glucose Regulators.......................................................................................................................................................................................... 54
Blood Glucose Regulators - Drugs to Regulate Blood Sugar..................................................................................................................................... 59
Blood Products and Modifiers.....................................................................................................................................................................................60
Blood Products and Modifiers - Drugs to Treat Blood Disorders................................................................................................................................ 61
Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders........................................................................................................62
Cardiovascular Agents................................................................................................................................................................................................62
Cardiovascular Agents - Drugs to Treat Heart and Circulation Conditions.................................................................................................................70
Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs...................................................................................................................................70
Central Nervous System Agents.................................................................................................................................................................................71
Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis............................................................................................................................................... 74
Dental and Oral Agents...............................................................................................................................................................................................74
Dental and Oral Agents - Drugs to Treat Mouth and Throat Conditions..................................................................................................................... 74
Dermatological Agents................................................................................................................................................................................................75
Dermatological Agents - Drugs to Treat Skin Conditions............................................................................................................................................83
Diabetes - Glucose Monitoring....................................................................................................................................................................................86
Diabetic/Endocrine Blood: Glucose Monitoring...........................................................................................................................................................92
Electrolytes/Minerals/Metals/Vitamins........................................................................................................................................................................ 92
Enzyme Inhibitors - Chemotherapy Agents.............................................................................................................................................................. 106
Estrogens - Hormone Replacement/Modifying Drugs...............................................................................................................................................106
Gastrointestinal Agents.............................................................................................................................................................................................106
Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions................................................................................................ 111
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment...........................................................................................................................126
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment.......................................................................................................... 126
Genitourinary Agents................................................................................................................................................................................................ 127
Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...................................................................................................... 129
Glycemic Agents - Diabetic Drugs............................................................................................................................................................................ 129
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)...............................................................................................................................130
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) - Drugs to Regulate Hormones............................................................................. 131
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary).............................................................................................................................. 131
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones............................................................................ 132
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)................................................................................................................... 132
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones..................................................................132
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)....................................................................................................132
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones.................................................. 141
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)............................................................................................................................... 142
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones..................................................................142
Hormonal Agents, Suppressant (Adrenal)................................................................................................................................................................ 142
Hormonal Agents, Suppressant (Pituitary)................................................................................................................................................................142
2
Hormonal Agents, Suppressant (Thyroid).................................................................................................................................................................143
Immune Suppressants - Immune System Drugs...................................................................................................................................................... 143
Immunological Agents...............................................................................................................................................................................................143
Immunological Agents - Drugs that Stimulate or Suppress the Immune System..................................................................................................... 148
Inflammatory Bowel Disease Agents........................................................................................................................................................................ 149
Metabolic Bone Disease Agents...............................................................................................................................................................................150
Miscellaneous Therapeutic Agents...........................................................................................................................................................................151
Molecular Target Inhibitors - Chemotherapy Agents................................................................................................................................................ 163
Monoclonal Antibodies - Chemotherapy Agents.......................................................................................................................................................164
Multiple Sclerosis Agents - Multiple Sclerosis Drugs................................................................................................................................................ 164
Ophthalmic Agents....................................................................................................................................................................................................165
Ophthalmic Agents - Drugs to Treat Eye Conditions................................................................................................................................................ 169
Otic Agents............................................................................................................................................................................................................... 173
Otic Agents - Drugs to Treat Ear Conditions.............................................................................................................................................................174
Respiratory Tract/Pulmonary Agents........................................................................................................................................................................174
Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions....................................................................... 181
Sedatives/Hypnotics - Drugs for Sedation and Sleep...............................................................................................................................................198
Skeletal Muscle Relaxants........................................................................................................................................................................................198
Sleep Disorder Agents..............................................................................................................................................................................................199
Sleep Disorder Agents - Drugs for Sedation and Sleep............................................................................................................................................200
Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies........................................................... 201
Vaccines................................................................................................................................................................................................................... 207
Vitamins.................................................................................................................................................................................................................... 207
3
Preferred Agents Non-Preferred Agents
Analgesics
Nonsteroidal Anti-inflammatory Drugs
ADVIL (brand for cvs ibuprofen) - Tier 2; QL
ADVIL JUNIOR STRENGTH (brand for cvs ibuprofen junior strength) -
Tier 2; QL
ADVIL LIQUI-GELS MINIS (brand for cvs ibuprofen) - Tier 2; QL
ADVIL MIGRAINE (brand for cvs ibuprofen) - Tier 2; QL
ALEVE ORAL TABLET (brand for all day pain relief) - Tier 2; QL
all day pain relief (generic for MEDIPROXEN) - Tier 1; QL
all day relief (generic for MEDIPROXEN) - Tier 1; QL
celecoxib oral (generic for CELEBREX) - Tier 1; QL
diclofenac potassium oral tablet (generic for CATAFLAM) - Tier 1; QL
diclofenac sodium er - Tier 1; QL
ANAPROX DS (brand for naproxen sodium) - Tier 2; PA; QL
ARTHROTEC (brand for diclofenac-misoprostol) - Tier 2; PA; QL
CAMBIA - Tier 2; PA; QL
CATAFLAM (brand for diclofenac potassium) - Tier 2; PA; QL
CELEBREX (brand for celecoxib) - Tier 2; PA; QL
DAYPRO (brand for oxaprozin) - Tier 2; PA; QL
DICLOFENAC (brand for diclofenac) - Tier 2; PA; QL
DICLOFENAC PATCH 1.3% (brand for diclofenac epolamine) - Tier 2;
PA; QL
diclofenac potassium oral capsule (generic for ZIPSOR) - Tier 1; PA; QL
diclofenac sodium external solution (generic for PENNSAID) - Tier 1; PA;
QL
diclofenac sodium external gel 1 % (generic for ASPERCREME
ARTHRITIS PAIN) - Tier 1; QL
diclofenac sodium oral - Tier 1; QL
diflunisal oral - Tier 1; QL
etodolac (generic for LODINE) - Tier 1; QL
etodolac er - Tier 1; QL
fenoprofen calcium oral tablet (generic for NALFON) - Tier 1; QL
flurbiprofen oral tablet 100 mg - Tier 1; QL
ibuprofen (generic for IBU) - Tier 1; QL
ibu-200 (generic for ADVIL) - Tier 1; QL
ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL
JUNIOR STRENGTH) - Tier 1; QL
diclofenac-misoprostol (generic for ARTHROTEC) - Tier 1; PA; QL
DUEXIS (brand for ibuprofen-famotidine) - Tier 2; PA; QL
EC-NAPROSYN (brand for ec-naproxen) - Tier 2; PA; QL
ec-naproxen (generic for EC-NAPROSYN) - Tier 1; PA; QL
ELYXYB - Tier 2; PA; QL
FELDENE (brand for piroxicam) - Tier 2; PA; QL
fenoprofen calcium oral capsule 400 mg (generic for NALFON) - Tier 1;
PA
FLECTOR (brand for diclofenac epolamine) - Tier 2; PA; QL
ibuprofen-famotidine (generic for DUEXIS) - Tier 1; PA; QL
KETOROLAC TROMETHAMINE NASAL (brand for ketorolac
tromethamine) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
4
Preferred Agents Non-Preferred Agents
ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier
1; QL
ibuprofen ib oral tablet 200 mg (generic for ADVIL) - Tier 1; QL
ibuprofen ib oral tablet chewable 100 mg (generic for ADVIL JUNIOR
STRENGTH) - Tier 1; QL
ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS
ADVIL) - Tier 1; QL
ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR
STRENGTH) - Tier 1; QL
ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1; QL
ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) -
Tier 1; QL
LICART - Tier 2; PA
LODINE (brand for etodolac) - Tier 2; PA; QL
LOFENA (brand for diclofenac potassium) - Tier 2; PA; QL
meloxicam oral capsule - Tier 1; PA; QL
NALFON ORAL CAPSULE (brand for fenoprofen calcium) - Tier 2; PA
NALFON ORAL TABLET (brand for fenoprofen calcium) - Tier 2; PA; QL
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG,
750 MG (brand for naproxen sodium er) - Tier 2; PA
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG
(brand for naproxen sodium er) - Tier 2; PA; QL
NAPROSYN (brand for naproxen) - Tier 2; PA; QL
ibuprofen oral capsule 200 mg (generic for ADVIL) - Tier 1; QL
ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS
ADVIL) - Tier 1; QL
ibuprofen oral tablet 200 mg (generic for ADVIL) - Tier 1; QL
ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier
1; QL
INDOCIN - Tier 2; QL
indomethacin er - Tier 1; QL
indomethacin oral capsule 25 mg, 50 mg - Tier 1; QL
INFANTS ADVIL (brand for cvs ibuprofen infants) - Tier 2; QL
infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; QL
ketoprofen er - Tier 1; QL
naproxen oral tablet delayed release (generic for EC-NAPROSYN) - Tier
1; PA; QL
naproxen sodium er oral tablet extended release 24 hour 375 mg (generic
for NAPRELAN) - Tier 1; PA
naproxen sodium er oral tablet extended release 24 hour 500 mg (generic
for NAPRELAN) - Tier 1; PA; QL
NAPROXEN SODIUM ER ORAL TABLET EXTENDED RELEASE 24
HOUR 750 MG (brand for naproxen sodium er) - Tier 2; PA
naproxen-esomeprazole (generic for VIMOVO) - Tier 1; PA; QL
PENNSAID (brand for diclofenac sodium) - Tier 2; PA; QL
RELAFEN (brand for nabumetone) - Tier 2; PA; QL
RELAFEN DS - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
5
Preferred Agents Non-Preferred Agents
ketorolac tromethamine oral - Tier 1; QL
meclofenamate sodium oral - Tier 1; QL
mediproxen (generic for MEDIPROXEN) - Tier 1; QL
mefenamic acid oral - Tier 1; QL
meloxicam oral tablet (generic for MOBIC) - Tier 1; QL
MOTRIN CHILDRENS (brand for cvs ibuprofen junior strength) - Tier
2; QL
MOTRIN IB (brand for cvs ibuprofen) - Tier 2; QL
MOTRIN INFANTS DROPS (brand for cvs ibuprofen infants) - Tier 2;
QL
nabumetone oral (generic for RELAFEN) - Tier 1; QL
naproxen oral suspension (generic for NAPROSYN) - Tier 1; QL
SPRIX (brand for ketorolac tromethamine) - Tier 2; PA
VIMOVO (brand for naproxen-esomeprazole) - Tier 2; PA; QL
ZIPSOR (brand for diclofenac potassium) - Tier 2; PA; QL
ZORVOLEX (brand for diclofenac) - Tier 2; PA; QL
naproxen oral tablet (generic for NAPROSYN) - Tier 1; QL
naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier
1; QL
naproxen sodium oral tablet 275 mg - Tier 1; QL
naproxen sodium oral tablet 550 mg (generic for ANAPROX DS) - Tier
1; QL
oxaprozin (generic for DAYPRO) - Tier 1; QL
piroxicam oral (generic for FELDENE) - Tier 1; QL
sulindac oral - Tier 1; QL
Opioid Analgesics, Long-acting
BUTRANS (brand for buprenorphine) - Tier 2; PA; QL
morphine sulfate er (generic for MS CONTIN) - Tier 1; PA; QL
BELBUCA - Tier 2; PA; QL
buprenorphine (generic for BUTRANS) - Tier 1; PA; QL
CONZIP (brand for tramadol hcl er) - Tier 2; PA; QL
fentanyl - Tier 1; PA; QL
hydrocodone bitartrate er oral capsule extended release 12 hour - Tier 1;
PA; QL
hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent 100 mg,
120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg (generic for HYSINGLA ER)
- Tier 1; PA; QL
hydromorphone hcl er oral tablet extended release 24 hour 12 mg, 16 mg,
32 mg, 8 mg - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
6
Preferred Agents Non-Preferred Agents
HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-DETERRENT 100
MG, 120 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG (brand for
hydrocodone bitartrate er) - Tier 2; PA; QL
levorphanol tartrate oral - Tier 1; PA; QL
methadone hcl intensol (generic for METHADONE HCL INTENSOL) - Tier
1; PA; QL
methadone hcl oral concentrate (generic for METHADONE HCL
INTENSOL) - Tier 1; PA; QL
methadone hcl oral solution - Tier 1; PA; QL
methadone hcl oral tablet - Tier 1; PA; QL
methadone hcl oral tablet soluble (generic for METHADOSE) - Tier 1; PA;
QL
methadose oral concentrate 10 mg/ml (generic for METHADONE HCL
INTENSOL) - Tier 1; PA; QL
methadose oral tablet soluble (generic for METHADOSE) - Tier 1; PA; QL
methadose sugar-free (generic for METHADONE HCL INTENSOL) - Tier
1; PA; QL
morphine sulfate (pf) intravenous solution 1 mg/ml - Tier 1; PA
morphine sulfate er beads - Tier 1; PA; QL
MS CONTIN (brand for morphine sulfate er) - Tier 2; PA; QL
NUCYNTA ER - Tier 2; PA; QL
OXYCODONE HCL ER (brand for oxycodone hcl er) - Tier 2; PA; QL
OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL
oxymorphone hcl er - Tier 1; PA; QL
ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG - Tier
2; PA; QL
ROXYBOND ORAL TABLET ABUSE-DETERRENT 5 MG - Tier 2; PA
tramadol hcl er (biphasic) - Tier 1; PA; QL
TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR
(brand for tramadol hcl er) - Tier 2; PA; QL
tramadol hcl er oral tablet extended release 24 hour - Tier 1; PA; QL
XTAMPZA ER - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
7
Preferred Agents Non-Preferred Agents
Opioid Analgesics, Short-acting
acetaminophen-codeine - Tier 1; QL
acetaminophen-codeine #2 - Tier 1; QL
acetaminophen-codeine #3 - Tier 1; QL
acetaminophen-codeine #4 - Tier 1; QL
ALLZITAL - Tier 2; QL
ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL
bac (generic for BAC) - Tier 1; QL
BUPAP (brand for butalbital-acetaminophen) - Tier 2
butalbital-acetaminophen oral tablet 50-300 mg (generic for BUPAP) -
Tier 1
butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON)
- Tier 1; QL
ACTIQ (brand for fentanyl citrate) - Tier 2; PA; QL
APADAZ (brand for benzhydrocodone-acetaminophen) - Tier 2; PA; QL
apap-caff-dihydrocodeine (generic for TREZIX) - Tier 1; PA; QL
BENZHYDROCODONE-ACETAMINOPHEN (brand for
benzhydrocodone-acetaminophen) - Tier 2; PA; QL
butalbital-acetaminophen capsule 50-300 mg oral - Tier 1; PA; QL
BUTALBITAL-ACETAMINOPHEN CAPSULE 50-300 MG ORAL - Tier 2;
PA; QL
butalbital-apap-caff-cod oral capsule 50-300-40-30 mg (generic for
FIORICET/CODEINE) - Tier 1; PA; QL
butalbital-apap-caffeine oral capsule 50-300-40 mg (generic for
FIORICET) - Tier 1; PA
butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL
butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for
ESGIC) - Tier 1; QL
butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL
butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1;
QL
butalbital-aspirin-caffeine - Tier 1; QL
butorphanol tartrate nasal - Tier 1; QL
codeine sulfate - Tier 1; QL
endocet (generic for ENDOCET) - Tier 1; QL
ESGIC ORAL CAPSULE (brand for butalbital-apap-caffeine) - Tier 2;
QL
DILAUDID ORAL (brand for hydromorphone hcl) - Tier 2; PA; QL
ESGIC ORAL TABLET (brand for butalbital-apap-caffeine) - Tier 2; PA;
QL
fentanyl citrate buccal lozenge on a handle (generic for ACTIQ) - Tier 1;
PA; QL
FENTANYL CITRATE BUCCAL TABLET (brand for fentanyl citrate) - Tier
2; PA
FENTORA (brand for fentanyl citrate) - Tier 2; PA
FIORICET (brand for butalbital-apap-caffeine) - Tier 2; PA
FIORICET/CODEINE (brand for butalbital-apap-caff-cod) - Tier 2; PA; QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 7.5-300 mg - Tier 1;
PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
8
Preferred Agents Non-Preferred Agents
hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1;
QL
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-
325 mg - Tier 1; QL
hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL
hydromorphone hcl rectal - Tier 1; QL
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml -
Tier 1; QL
morphine sulfate oral - Tier 1; QL
morphine sulfate rectal - Tier 1; QL
oxycodone hcl oral capsule - Tier 1; QL
oxycodone hcl oral concentrate 100 mg/5ml - Tier 1; QL
hydrocodone-acetaminophen oral tablet 5-300 mg (generic for XODOL) -
Tier 1; PA; QL
hydrocodone-ibuprofen - Tier 1; PA; QL
LORTAB - Tier 2; PA; QL
meperidine hcl oral - Tier 1; PA; QL
NUCYNTA - Tier 2; PA; QL
oxymorphone hcl - Tier 1; PA; QL
pentazocine-naloxone hcl - Tier 1; PA; QL
PERCOCET (brand for oxycodone-acetaminophen) - Tier 2; PA; QL
QDOLO (brand for tramadol hcl) - Tier 2; PA; QL
SEGLENTIS - Tier 2; PA; QL
oxycodone hcl oral solution - Tier 1; QL
OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 5-325 MG/5ML
- Tier 2; QL
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325
mg, 7.5-325 mg (generic for ENDOCET) - Tier 1; QL
TENCON (brand for butalbital-acetaminophen) - Tier 2; QL
tramadol hcl oral tablet (generic for ULTRAM) - Tier 1; QL
tramadol-acetaminophen (generic for ULTRACET) - Tier 1; QL
ZEBUTAL (brand for butalbital-apap-caffeine) - Tier 2; QL
TRAMADOL HCL ORAL SOLUTION (brand for tramadol hcl) - Tier 2; PA;
QL
TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL
ULTRACET (brand for tramadol-acetaminophen) - Tier 2; PA; QL
ULTRAM (brand for tramadol hcl) - Tier 2; PA; QL
VTOL LQ - Tier 2; PA
Opioid Dependence Treatments -
Antidotes/Deterrents/Protectants
buprenorphine hcl sublingual - Tier 1; PA; QL; GE; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
9
Preferred Agents Non-Preferred Agents
Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and
Joint Conditions
Analgesics - Miscellaneous Analgesics
8 hour arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1;
QL
8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; QL
8 hour pain relief oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; QL
8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL
8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL
8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL
8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1; QL
acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL
acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1; QL
acetaminophen rapid tabs child - Tier 1; PA
EXCEDRIN EXTRA STRENGTH TABLET 250-250-65 MG ORAL (brand
for cvs headache relief) - Tier 2; PA
EXCEDRIN TENSION HEADACHE (brand for ra tension headache) - Tier
2; PA
menstrual pain relief (generic for PAMPRIN MAX PAIN FORMULA) - Tier
1; PA
PANADOL EXTRA (brand for ra tension headache) - Tier 2; PA
rapid melts junior oral tablet dispersible 160 mg - Tier 1; PA
tension headache (generic for EXCEDRIN TENSION HEADACHE) - Tier
1; PA
acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1;
QL
acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier
1; QL
acetaminophen childrens oral suspension 160 mg/5ml (generic for
PANADOL CHILDRENS) - Tier 1; QL
acetaminophen childrens oral tablet chewable 160 mg (generic for
MAPAP CHILDRENS) - Tier 1; QL
acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; QL
acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
10
Preferred Agents Non-Preferred Agents
acetaminophen ex st oral tablet 500 mg (generic for PANADOL
EXTRA STRENGTH) - Tier 1; QL
acetaminophen extra strength (generic for PANADOL EXTRA
STRENGTH) - Tier 1; QL
acetaminophen infants (generic for PANADOL CHILDRENS) - Tier 1;
QL
acetaminophen oral liquid 160 mg/5ml (generic for LITTLE REMEDIES
FOR FEVER) - Tier 1; QL
acetaminophen oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1
acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650
mg/20.3ml - Tier 1; QL
acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic
for PANADOL CHILDRENS) - Tier 1; QL
acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1;
QL
acetaminophen oral tablet 500 mg (generic for PANADOL EXTRA
STRENGTH) - Tier 1; QL
acetaminophen oral tablet chewable 160 mg (generic for MAPAP
CHILDRENS) - Tier 1; QL
acetaminophen rectal suppository 120 mg (generic for FEVERALL
CHILDRENS) - Tier 1; QL
acetaminophen rectal suppository 650 mg (generic for FEVERALL
ADULTS) - Tier 1; QL
apra (generic for MEDI-TABS CHILDRENS) - Tier 1; QL
arthritis pain oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; QL
arthritis pain relief oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; QL
arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1; QL
aurophen childrens (generic for PANADOL CHILDRENS) - Tier 1; QL
betatemp childrens (generic for PANADOL CHILDRENS) - Tier 1; QL
childrens acetaminophen (generic for PANADOL CHILDRENS) - Tier
1; QL
childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL
childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
11
Preferred Agents Non-Preferred Agents
childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier
1; QL
childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL
ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL
EXCEDRIN EXTRA STRENGTH TABLET 250-250-65 MG ORAL
(brand for cvs headache relief) - Tier 2
EXCEDRIN MIGRAINE (brand for cvs headache relief) - Tier 2
fever reducer/pain reliever (generic for PANADOL CHILDRENS) - Tier
1; QL
fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier
1; QL
feverall adults (generic for FEVERALL ADULTS) - Tier 1; QL
feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; QL
FEVERALL INFANTS - Tier 2; QL
FEVERALL JUNIOR STRENGTH - Tier 2; QL
headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier
1
headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1
headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH)
- Tier 1
infants pain & fever (generic for PANADOL CHILDRENS) - Tier 1; QL
infants pain relief drops (generic for PANADOL CHILDRENS) - Tier 1;
QL
infants pain/fever (generic for PANADOL CHILDRENS) - Tier 1; QL
liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) -
Tier 1; QL
liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier
1; QL
mapap acetaminophen extra str (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1
mapap arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL
mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; QL
mapap oral capsule - Tier 1; QL
migraine formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier
1
migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
12
Preferred Agents Non-Preferred Agents
mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; QL
m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL
non-aspirin (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL
non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; QL
non-aspirin childrens (generic for MAPAP CHILDRENS) - Tier 1; QL
non-aspirin extra strength (generic for PANADOL EXTRA
STRENGTH) - Tier 1; QL
non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1; QL
non-aspirin pain relief (generic for PHARBETOL) - Tier 1; QL
pain & fever child (generic for PANADOL CHILDRENS) - Tier 1; QL
pain & fever childrens (generic for MAPAP CHILDRENS) - Tier 1; QL
pain & fever childrens oral suspension 160 mg/5ml (generic for
PANADOL CHILDRENS) - Tier 1; QL
pain & fever infants (generic for PANADOL CHILDRENS) - Tier 1; QL
pain relief childrens oral tablet chewable 160 mg (generic for MAPAP
CHILDRENS) - Tier 1; QL
pain relief extra st (generic for PANADOL EXTRA STRENGTH) - Tier
1; QL
pain relief extra strength (generic for PANADOL EXTRA STRENGTH)
- Tier 1; QL
CHILDRENS) - Tier 1; QL
pain relief oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1
pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL
pain relief oral tablet 500 mg (generic for PANADOL EXTRA
STRENGTH) - Tier 1; QL
pain relief oral tablet extended release 650 mg (generic for TYLENOL
8 HOUR) - Tier 1; QL
pain relief regular st (generic for PHARBETOL) - Tier 1; QL
pain relief regular strength (generic for PHARBETOL) - Tier 1; QL
pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA
STR) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
13
Preferred Agents Non-Preferred Agents
pain relieve child dye-free (generic for PANADOL CHILDRENS) - Tier
1; QL
pain reliever (generic for PANADOL EXTRA STRENGTH) - Tier 1; QL
pain reliever childrens oral suspension 160 mg/5ml (generic for
PANADOL CHILDRENS) - Tier 1; QL
pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1
pain reliever ex st oral tablet 500 mg (generic for PANADOL EXTRA
STRENGTH) - Tier 1; QL
pain reliever ex st oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; QL
pain reliever extra strength oral tablet 250-250-65 mg (generic for
EXCEDRIN EXTRA STRENGTH) - Tier 1
pain reliever extra strength oral tablet 500 mg (generic for PANADOL
EXTRA STRENGTH) - Tier 1; QL
pain reliever infants oral suspension 160 mg/5ml (generic for
PANADOL CHILDRENS) - Tier 1; QL
pain reliever oral tablet (generic for PHARBETOL) - Tier 1; QL
pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier
1
pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1
PANADOL CHILDRENS (brand for acetaminophen) - Tier 2; QL
PANADOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;
QL
PANADOL INFANTS (brand for acetaminophen) - Tier 2; QL
PHARBETOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;
QL
PHARBETOL ORAL TABLET 325 MG (brand for acetaminophen) -
Tier 2; QL
sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL
sb pain reliever childrens (generic for PANADOL CHILDRENS) - Tier
1; QL
TYLENOL FOR CHILDREN + ADULTS (brand for acetaminophen) -
Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
14
Preferred Agents Non-Preferred Agents
TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for
acetaminophen) - Tier 2; QL
TYLENOL ORAL TABLET 325 MG, 500 MG (brand for
acetaminophen) - Tier 2; QL
TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for
acetaminophen) - Tier 2; QL
TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for
8 hour arthritis pain reliever) - Tier 2; QL
Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory
Drugs
salsalate oral - Tier 1; QL aspirin tri-buffered (generic for BUFFERIN) - Tier 1; PA
BUFFERIN (brand for sm aspirin tri-buffered) - Tier 2; PA
DICLONA - Tier 2; PA; QL
tri-buffered aspirin (generic for BUFFERIN) - Tier 1; PA
Opioid Analgesics, Short-acting
OXAYDO ORAL TABLET 5 MG (brand for oxycodone hcl) - Tier 2; QL
oxycodone hcl oral tablet (generic for OXAYDO) - Tier 1; QL
OXAYDO ORAL TABLET 7.5 MG - Tier 2; PA; QL
ROXICODONE (brand for oxycodone hcl) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
15
Preferred Agents Non-Preferred Agents
Anesthetics
Local Anesthetics
anecream external cream (generic for ANECREAM) - Tier 1; QL
blue tube/ aloe (generic for ANECREAM) - Tier 1; QL
lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QL
lidocaine external ointment 5 % - Tier 1; QL
lidocaine external patch 5 % (generic for LIDODERM) - Tier 1; QL
lidocaine hcl mouth/throat - Tier 1
lidocaine hcl urethral/mucosal external gel - Tier 1; QL
lidocaine viscous hcl - Tier 1; QL
lidocaine-prilocaine external cream - Tier 1; QL
LMX 4 (brand for blue tube/ aloe) - Tier 2; QL
premium lidocaine - Tier 1; QL
AGONEAZE (brand for lidocaine-prilocaine) - Tier 2; PA; QL
ANODYNE LPT (brand for lidocaine-prilocaine) - Tier 2; PA; QL
ASTERO - Tier 2; PA
burn relief external gel - Tier 1; PA
LDO PLUS - Tier 2; PA
LIDO BDK (brand for lidocaine-prilocaine) - Tier 2; PA; QL
lidocaine hcl external cream 3 % - Tier 1; PA; QL
lidocaine hcl external cream 4 % (generic for ASPERCREME
LIDOCAINE) - Tier 1; PA
lidocaine hcl external solution - Tier 1; PA
lidocaine maximum strength (generic for ASPERCREME LIDOCAINE) -
Tier 1; PA
lidocaine pain relieving external cream 4 % (generic for ASPERCREME
LIDOCAINE) - Tier 1; PA
lidocaine plus (generic for ASPERCREME LIDOCAINE) - Tier 1; PA
lidocaine-prilocaine external kit (generic for LIDO BDK) - Tier 1; PA; QL
LIDODERM (brand for lidocaine) - Tier 2; PA; QL
lidopin external cream 3 % - Tier 1; PA; QL
LIDOPRIL (brand for lidocaine-prilocaine) - Tier 2; PA; QL
LIDOPRIL XR (brand for lidocaine-prilocaine) - Tier 2; PA; QL
LIDO-PRILO CAINE PACK (brand for lidocaine-prilocaine) - Tier 2; PA;
QL
LIVIXIL PAK (brand for lidocaine-prilocaine) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
16
Preferred Agents Non-Preferred Agents
pain relief external cream 4 % (generic for ASPERCREME LIDOCAINE) -
Tier 1; PA
pain relieving + lidocaine (generic for ASPERCREME LIDOCAINE) - Tier
1; PA
pain relieving external cream 4 % (generic for ASPERCREME
LIDOCAINE) - Tier 1; PA
PRILOLID (brand for lidocaine-prilocaine) - Tier 2; PA; QL
PRILOVIX (brand for lidocaine-prilocaine) - Tier 2; PA; QL
PRILOVIX LITE (brand for lidocaine-prilocaine) - Tier 2; PA; QL
PRILOVIX LITE PLUS (brand for lidocaine-prilocaine) - Tier 2; PA; QL
PRILOVIX PLUS (brand for lidocaine-prilocaine) - Tier 2; PA; QL
PRILOVIX ULTRALITE (brand for lidocaine-prilocaine) - Tier 2; PA; QL
PRILOVIX ULTRALITE PLUS (brand for lidocaine-prilocaine) - Tier 2; PA;
QL
RELADOR PAK (brand for lidocaine-prilocaine) - Tier 2; PA; QL
RELADOR PAK PLUS (brand for lidocaine-prilocaine) - Tier 2; PA; QL
SYNERA - Tier 2; PA
VEXATROL (brand for lidocaine-prilocaine) - Tier 2; PA; QL
XOLIDO XP - Tier 2; PA
ZTLIDO - Tier 2; PA; QL
Anesthetics - Drugs for Numbing
Local Anesthetics
cough drops mouth/throat lozenge 5.4 mg (generic for CEPACOL SORE
THROAT) - Tier 1; PA
ELEMAR PATCH - Tier 2; PA
GEBAUERS PAIN EASE - Tier 2; PA
GEBAUERS SPRAY AND STRETCH - Tier 2; PA
ZERUVIA - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
17
Preferred Agents Non-Preferred Agents
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium - Tier 1; QL
disulfiram oral tablet 250 mg - Tier 1; QL
disulfiram oral tablet 500 mg - Tier 1
naltrexone hcl oral - Tier 1
VIVITROL - Tier 2; QL
Opioid Dependence
buprenorphine hcl-naloxone hcl (generic for SUBOXONE) - Tier 1; QL
SUBLOCADE - Tier 2; QL
SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; QL
ZUBSOLV - Tier 2; QL
LUCEMYRA - Tier 2; PA; QL
Opioid Reversal Agents
KLOXXADO - Tier 2; QL
naloxone hcl injection - Tier 1; QL
naloxone hcl nasal (generic for NARCAN) - Tier 1; QL
NARCAN (brand for naloxone hcl) - Tier 2; QL
ZIMHI - Tier 2; QL
Smoking Cessation Agents
bupropion hcl er (smoking det) - Tier 1
habitrol (generic for HABITROL) - Tier 1; QL
NICODERM CQ (brand for cvs nicotine) - Tier 2; QL
nicotine step 1 (generic for HABITROL) - Tier 1; QL
nicotine step 2 (generic for NICODERM CQ) - Tier 1; QL
nicotine step 3 (generic for NICODERM CQ) - Tier 1; QL
nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for
NICODERM CQ) - Tier 1; QL
nicotine transdermal patch 24 hour 21 mg/24hr (generic for
HABITROL) - Tier 1; QL
nicotine transdermal system (generic for HABITROL) - Tier 1; QL
NICOTROL - Tier 2; QL
APO-VARENICLINE - Tier 2; PA; QL
nicotine transdermal kit 21-14-7 mg/24hr - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
18
Preferred Agents Non-Preferred Agents
NICOTROL NS - Tier 2; QL
varenicline tartrate - Tier 1; QL
Anti-Addiction/Substance Abuse Treatment Agents - Drugs for
Overdose or Deterrence
Smoking Cessation Agents - Deterrents
mini nicotine (generic for KLS QUIT2) - Tier 1; QL
NICORETTE (brand for cvs nicotine) - Tier 2; QL
NICORETTE MINI (brand for cvs nicotine) - Tier 2; QL
NICORETTE STARTER KIT (brand for cvs nicotine) - Tier 2; QL
nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1;
QL
nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1;
QL
nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) -
Tier 1; QL
nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) -
Tier 1; QL
nicotine mini (generic for KLS QUIT2) - Tier 1; QL
nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1; QL
nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1; QL
nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1;
QL
nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1;
QL
nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; QL
nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; QL
quit2 (generic for KLS QUIT2) - Tier 1; QL
quit4 (generic for KLS QUIT4) - Tier 1; QL
THRIVE (brand for cvs nicotine) - Tier 2; QL
Antiandrogens - Hormone Suppressants
Antineoplastics - Drugs to Treat Cancer
ORGOVYX - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
19
Preferred Agents Non-Preferred Agents
Antibacterials
Aminoglycosides
ARIKAYCE - Tier 2; PA; SP; QL
neomycin sulfate oral - Tier 1; QL
paromomycin sulfate oral (generic for HUMATIN) - Tier 1; QL
HUMATIN (brand for paromomycin sulfate) - Tier 2; PA; QL
Antibacterials, Other
CLEOCIN VAGINAL SUPPOSITORY - Tier 2; QL
clindamycin hcl oral (generic for CLEOCIN) - Tier 1; QL
clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL
clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL
CLINDESSE - Tier 2; QL
linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1;
PA; QL
linezolid oral tablet (generic for ZYVOX) - Tier 1; PA
methenamine hippurate (generic for HIPREX) - Tier 1; QL
metronidazole external (generic for METROGEL) - Tier 1; QL
metronidazole oral tablet - Tier 1; QL
metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL
CLEOCIN ORAL (brand for clindamycin hcl) - Tier 2; PA; QL
CLEOCIN VAGINAL CREAM (brand for clindamycin phosphate) - Tier 2;
PA; QL
colistimethate sodium (cba) (generic for COLY-MYCIN M) - Tier 1; PA
COLY-MYCIN M (brand for colistimethate sodium (cba)) - Tier 2; PA
FIRVANQ (brand for vancomycin hcl) - Tier 2; PA; QL
FLAGYL (brand for metronidazole) - Tier 2; PA; QL
fosfomycin tromethamine (generic for MONUROL) - Tier 1; PA
HIPREX (brand for methenamine hippurate) - Tier 2; PA; QL
MACROBID (brand for nitrofurantoin monohyd macro) - Tier 2; PA; QL
MACRODANTIN (brand for nitrofurantoin macrocrystal) - Tier 2; PA; QL
METROCREAM (brand for metronidazole) - Tier 2; PA; QL
MONUROL (brand for fosfomycin tromethamine) - Tier 2
nitrofurantoin - Tier 1; QL
nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL
nitrofurantoin monohydrate macrocrystals (generic for MACROBID) -
Tier 1; QL
NORITATE - Tier 2
rosadan external cream (generic for ROSADAN) - Tier 1; QL
rosadan external gel (generic for ROSADAN) - Tier 1; QL
trimethoprim oral - Tier 1; QL
vancomycin hcl oral capsule (generic for VANCOCIN) - Tier 1; QL
XIFAXAN - Tier 2; ST; QL
METROGEL (brand for metronidazole) - Tier 2; PA; QL
METROLOTION (brand for metronidazole) - Tier 2; PA; QL
metronidazole oral capsule (generic for FLAGYL) - Tier 1; PA; QL
NUVESSA - Tier 2; PA; QL
SIVEXTRO ORAL - Tier 2; PA; QL
SOLOSEC - Tier 2; PA; QL
tinidazole oral tablet 250 mg - Tier 1; PA
tinidazole oral tablet 500 mg - Tier 1; PA; QL
VANCOCIN (brand for vancomycin hcl) - Tier 2; PA; QL
vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-% - Tier 1;
PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
20
Preferred Agents Non-Preferred Agents
vancomycin hcl oral solution reconstituted (generic for FIRVANQ) - Tier 1;
PA; QL
vandazole (generic for VANDAZOLE) - Tier 1; PA; QL
XENLETA ORAL - Tier 2; PA; QL
ZYVOX ORAL SUSPENSION RECONSTITUTED (brand for linezolid) -
Tier 2; PA; QL
ZYVOX ORAL TABLET (brand for linezolid) - Tier 2; PA
Beta-lactam, Cephalosporins
cefaclor er - Tier 1; QL
cefaclor oral capsule - Tier 1; QL
cefaclor oral suspension reconstituted 250 mg/5ml - Tier 1; QL
cefadroxil - Tier 1; QL
cefdinir - Tier 1; QL
cefprozil - Tier 1; QL
cefuroxime axetil - Tier 1; QL
cephalexin oral capsule 250 mg, 500 mg - Tier 1; QL
cephalexin oral suspension reconstituted - Tier 1; QL
cephalexin oral tablet 250 mg - Tier 1
cephalexin oral tablet 500 mg - Tier 1; QL
cefazolin sodium-dextrose intravenous solution 2-4 gm/100ml-% - Tier 1;
PA
cefixime (generic for SUPRAX) - Tier 1; PA; QL
cefpodoxime proxetil - Tier 1; PA; QL
cephalexin oral capsule 750 mg - Tier 1; PA
SUPRAX ORAL CAPSULE (brand for cefixime) - Tier 2; PA; QL
SUPRAX ORAL SUSPENSION RECONSTITUTED 200 MG/5ML (brand
for cefixime) - Tier 2; PA; QL
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML - Tier 2;
PA
SUPRAX ORAL TABLET CHEWABLE - Tier 2; PA
Beta-lactam, Penicillins
amoxicillin - Tier 1; QL
amoxicillin-potassium clavulanate (generic for AUGMENTIN) - Tier 1;
QL
amoxicillin-potassium clavulanate er - Tier 1; QL
ampicillin - Tier 1; QL
dicloxacillin sodium - Tier 1; QL
penicillin v potassium - Tier 1; QL
AUGMENTIN (brand for amoxicillin-pot clavulanate) - Tier 2; PA; QL
AUGMENTIN ES-600 (brand for amoxicillin-pot clavulanate) - Tier 2; PA;
QL
Carbapenems
RECARBRIO - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
21
Preferred Agents Non-Preferred Agents
Macrolides
azithromycin oral (generic for ZITHROMAX) - Tier 1; QL
clarithromycin er - Tier 1; QL
clarithromycin oral - Tier 1; QL
DIFICID - Tier 2; QL
E.E.S. 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL
E.E.S. GRANULES (brand for erythromycin ethylsuccinate) - Tier 2; PA;
QL
ERYPED 200 (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL
ERYPED 400 (brand for erythromycin ethylsuccinate) - Tier 2; PA; QL
ERY-TAB (brand for erythromycin) - Tier 2; PA; QL
ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2; PA;
QL
erythromycin base (generic for ERY-TAB) - Tier 1; PA; QL
erythromycin ethylsuccinate oral (generic for E.E.S. 400) - Tier 1; PA; QL
erythromycin oral (generic for ERY-TAB) - Tier 1; PA; QL
ZITHROMAX ORAL (brand for azithromycin) - Tier 2; PA; QL
ZITHROMAX TRI-PAK (brand for azithromycin) - Tier 2; PA; QL
ZITHROMAX Z-PAK (brand for azithromycin) - Tier 2; PA; QL
Quinolones
CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL; AL
ciprofloxacin hcl oral (generic for CIPRO) - Tier 1; QL
levofloxacin oral (generic for LEVAQUIN) - Tier 1; QL
BAXDELA ORAL - Tier 2; PA; QL
CIPRO ORAL TABLET (brand for ciprofloxacin hcl) - Tier 2; PA; QL
moxifloxacin hcl oral - Tier 1; PA; QL
ofloxacin oral - Tier 1; PA; QL
Sulfonamides
sulfadiazine oral - Tier 1; QL
sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1;
QL
sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL
BACTRIM (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL
BACTRIM DS (brand for sulfamethoxazole-trimethoprim) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
22
Preferred Agents Non-Preferred Agents
Tetracyclines
avidoxy - Tier 1; QL
doxycycline hyclate oral capsule (generic for VIBRAMYCIN) - Tier 1;
QL
doxycycline hyclate oral tablet 100 mg (generic for LYMEPAK) - Tier 1;
QL
doxycycline hyclate oral tablet 50 mg (generic for TARGADOX) - Tier 1
doxycycline monohydrate oral capsule 100 mg (generic for
MONDOXYNE NL) - Tier 1; QL
doxycycline monohydrate oral capsule 50 mg - Tier 1; QL
doxycycline monohydrate oral suspension reconstituted (generic for
VIBRAMYCIN) - Tier 1; AL
doxycycline monohydrate oral tablet 100 mg, 50 mg - Tier 1; QL
ACTICLATE (brand for doxycycline hyclate) - Tier 2; PA; QL
coremino (generic for COREMINO) - Tier 1; PA
demeclocycline hcl - Tier 1; PA; QL
DORYX (brand for doxycycline hyclate) - Tier 2; PA; QL
DORYX MPC - Tier 2; PA
doxycycline (generic for ORACEA) - Tier 1; PA
doxycycline hyclate oral tablet 150 mg, 75 mg (generic for ACTICLATE) -
Tier 1; PA; QL
doxycycline hyclate oral tablet 20 mg - Tier 1; PA
doxycycline hyclate oral tablet delayed release 100 mg - Tier 1; PA; QL
doxycycline hyclate oral tablet delayed release 150 mg, 75 mg - Tier 1;
PA
LYMEPAK (brand for doxycycline hyclate) - Tier 2; QL
minocycline hcl oral capsule 100 mg (generic for MINOCIN) - Tier 1;
QL
minocycline hcl oral capsule 50 mg - Tier 1; QL
minocycline hcl oral capsule 75 mg - Tier 1
mondoxyne nl (generic for MONDOXYNE NL) - Tier 1; QL
TARGADOX (brand for doxycycline hyclate) - Tier 2
tetracycline hcl oral - Tier 1; QL
VIBRAMYCIN ORAL SYRUP - Tier 2
doxycycline hyclate oral tablet delayed release 200 mg, 50 mg (generic
for DORYX) - Tier 1; PA; QL
DOXYCYCLINE HYCLATE ORAL TABLET DELAYED RELEASE 80 MG
(brand for doxycycline hyclate) - Tier 2; PA; QL
doxycycline monohydrate oral capsule 150 mg, 75 mg - Tier 1; PA
doxycycline monohydrate oral tablet 150 mg - Tier 1; PA
doxycycline monohydrate oral tablet 75 mg - Tier 1; PA; QL
MINOCYCLINE HCL ER ORAL CAPSULE EXTENDED RELEASE 24
HOUR (brand for minocycline hcl er) - Tier 2; PA; QL
minocycline hcl er oral tablet extended release 24 hour (generic for
COREMINO) - Tier 1; PA
minocycline hcl oral tablet 100 mg - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
23
Preferred Agents Non-Preferred Agents
minocycline hcl oral tablet 50 mg, 75 mg - Tier 1; PA
MINOLIRA - Tier 2; PA; QL
NUZYRA ORAL - Tier 2; PA; QL
ORACEA (brand for doxycycline) - Tier 2; PA
SOLODYN (brand for minocycline hcl er) - Tier 2; PA
VIBRAMYCIN ORAL CAPSULE (brand for doxycycline hyclate) - Tier 2;
PA; QL
VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED (brand for
doxycycline monohydrate) - Tier 2; PA; AL
XIMINO (brand for minocycline hcl er) - Tier 2; PA; QL
Antibacterials - Drugs to Treat Bacterial Infections
Antibacterials, Other - Antibiotics
antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL
antibiotic pain/scar (generic for NEOSPORIN + PAIN RELIEF MAX
ST) - Tier 1
antibiotic/pain relief external ointment 1 % (generic for NEOSPORIN +
PAIN RELIEF MAX ST) - Tier 1
antiseptic (generic for BETADINE) - Tier 1
BETADINE EXTERNAL SOLUTION 10 % (brand for cvs povidone-
iodine) - Tier 2
first aid antibiotic external ointment 1 % (generic for NEOSPORIN +
PAIN RELIEF MAX ST) - Tier 1
first aid antibiotic external ointment 3.5-400-5000 , 3.5-400-5000 mg-
unit (generic for NEOSPORIN ORIGINAL) - Tier 1; QL
alcohol prep pads external 70 % - Tier 1; PA; QL
FEM PH - Tier 2; PA
iodine tincture external tincture 2 % - Tier 1; PA
LUGOLS STRONG IODINE - Tier 2; PA
NEO-SYNALAR EXTERNAL KIT - Tier 2; PA
SUTAB - Tier 2; PA
TRIMO-SAN VAGINAL GEL 0.025-0.01 % - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
24
Preferred Agents Non-Preferred Agents
first aid antiseptic external solution 10 % (generic for BETADINE) -
Tier 1
medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier
1; QL
methenamine mandelate oral - Tier 1
NEOSPORIN + PAIN RELIEF MAX ST (brand for cvs antibiotic
pain/scar) - Tier 2
NEOSPORIN ORIGINAL (brand for cvs antibiotic) - Tier 2; QL
povidone iodine (generic for BETADINE) - Tier 1
povidone-iodine external solution (generic for BETADINE) - Tier 1
qc triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL
SCRUB CARE POVIDONE-IODINE (brand for cvs povidone-iodine) -
Tier 2
triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL
triple antibiotic max st (generic for NEOSPORIN + PAIN RELIEF MAX
ST) - Tier 1
triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1;
QL
triple antibiotic pain relief (generic for NEOSPORIN + PAIN RELIEF
MAX ST) - Tier 1
triple antibiotic plus (generic for NEOSPORIN + PAIN RELIEF MAX
ST) - Tier 1
triple antibiotic plus max st (generic for NEOSPORIN + PAIN RELIEF
MAX ST) - Tier 1
triple antibiotic/pain (generic for NEOSPORIN + PAIN RELIEF MAX
ST) - Tier 1
triple antibiotic+pain relief (generic for NEOSPORIN + PAIN RELIEF
MAX ST) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
25
Preferred Agents Non-Preferred Agents
Anticonvulsants
Anticonvulsants, Other
EPIDIOLEX - Tier 2; PA; SP; QL
EPRONTIA - Tier 2; QL; AL
FYCOMPA - Tier 2; ST; QL
lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL
lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1; QL
levetiracetam oral (generic for KEPPRA) - Tier 1; QL
roweepra (generic for ROWEEPRA) - Tier 1; QL
topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL
valproic acid oral - Tier 1; QL
BRIVIACT ORAL - Tier 2; PA; QL
ELEPSIA XR - Tier 2; PA; QL
felbamate (generic for FELBATOL) - Tier 1; PA; QL
FELBATOL (brand for felbamate) - Tier 2; PA; QL
FINTEPLA - Tier 2; PA; QL
KEPPRA ORAL (brand for levetiracetam) - Tier 2; PA; QL
KEPPRA XR (brand for levetiracetam er) - Tier 2; PA; QL
LAMICTAL (brand for lamotrigine) - Tier 2; PA; QL
LAMICTAL ODT (brand for lamotrigine) - Tier 2; PA; QL
LAMICTAL STARTER (brand for lamotrigine starter kit-blue) - Tier 2; PA;
QL
LAMICTAL XR (brand for lamotrigine er) - Tier 2; PA; QL
lamotrigine er (generic for LAMICTAL XR) - Tier 1; PA; QL
lamotrigine oral kit (generic for LAMICTAL ODT) - Tier 1; PA; QL
lamotrigine oral tablet dispersible (generic for LAMICTAL ODT) - Tier 1;
PA; QL
lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT-
BLUE) - Tier 1; PA; QL
lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT-
GREEN) - Tier 1; PA; QL
lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT-
ORANGE) - Tier 1; PA; QL
levetiracetam er (generic for KEPPRA XR) - Tier 1; PA; QL
QUDEXY XR (brand for topiramate er) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
26
Preferred Agents Non-Preferred Agents
SPRITAM - Tier 2; PA; QL
subvenite (generic for SUBVENITE) - Tier 1; PA; QL
subvenite starter kit-blue (generic for SUBVENITE STARTER KIT-BLUE)
- Tier 1; PA; QL
subvenite starter kit-green (generic for SUBVENITE STARTER KIT-
GREEN) - Tier 1; PA; QL
subvenite starter kit-orange (generic for SUBVENITE STARTER KIT-
ORANGE) - Tier 1; PA; QL
TOPAMAX (brand for topiramate) - Tier 2; PA; QL
TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; PA; QL
topiramate er (generic for QUDEXY XR) - Tier 1; PA; QL
topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) - Tier
1; PA; QL
TROKENDI XR - Tier 2; PA; QL
XCOPRI - Tier 2; PA; QL
XCOPRI (250 MG DAILY DOSE) - Tier 2; PA; QL
XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL
Calcium Channel Modifying Agents
ethosuximide oral (generic for ZARONTIN) - Tier 1; QL CELONTIN - Tier 2; PA; QL
ZARONTIN (brand for ethosuximide) - Tier 2; PA; QL
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clobazam oral suspension (generic for ONFI) - Tier 1; QL
clobazam oral tablet (generic for ONFI) - Tier 1; PA; QL
DIASTAT ACUDIAL (brand for diazepam) - Tier 2; QL
DIASTAT PEDIATRIC (brand for diazepam) - Tier 2; QL
gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL
gabapentin oral solution 250 mg/5ml (generic for NEURONTIN) - Tier
1; QL
gabapentin oral tablet (generic for NEURONTIN) - Tier 1; QL
NAYZILAM - Tier 2; QL
phenobarbital oral - Tier 1; QL
primidone oral (generic for MYSOLINE) - Tier 1; QL
VALTOCO 10 MG DOSE - Tier 2; QL
diazepam rectal (generic for DIASTAT ACUDIAL) - Tier 1; PA; QL
GABITRIL (brand for tiagabine hcl) - Tier 2; PA; QL
MYSOLINE (brand for primidone) - Tier 2; PA; QL
NEURONTIN (brand for gabapentin) - Tier 2; PA; QL
ONFI (brand for clobazam) - Tier 2; PA; QL
SABRIL (brand for vigabatrin) - Tier 2; PA; SP; QL
SYMPAZAN - Tier 2; PA; QL
tiagabine hcl (generic for GABITRIL) - Tier 1; PA; QL
vigabatrin (generic for SABRIL) - Tier 1; PA; SP; QL
vigadrone (generic for VIGADRONE) - Tier 1; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
27
Preferred Agents Non-Preferred Agents
VALTOCO 15 MG DOSE - Tier 2; QL
VALTOCO 20 MG DOSE - Tier 2; QL
VALTOCO 5 MG DOSE - Tier 2; QL
Sodium Channel Agents
BANZEL (brand for rufinamide) - Tier 2; QL
carbamazepine er (generic for CARBATROL) - Tier 1; QL
carbamazepine oral (generic for EPITOL) - Tier 1; QL
DILANTIN ORAL CAPSULE 30 MG - Tier 2; QL
epitol (generic for EPITOL) - Tier 1; QL
oxcarbazepine (generic for TRILEPTAL) - Tier 1; QL
phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL
phenytoin oral suspension 125 mg/5ml (generic for DILANTIN) - Tier 1;
QL
phenytoin oral tablet chewable (generic for PHENYTOIN INFATABS) -
Tier 1; QL
phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL
APTIOM - Tier 2; PA; QL
CARBATROL (brand for carbamazepine er) - Tier 2; PA; QL
DILANTIN INFATABS (brand for phenytoin) - Tier 2; PA; QL
DILANTIN ORAL CAPSULE 100 MG (brand for phenytoin sodium
extended) - Tier 2; PA; QL
DILANTIN ORAL SUSPENSION (brand for phenytoin) - Tier 2; PA; QL
lacosamide oral (generic for VIMPAT) - Tier 1; PA; ST; QL
OXTELLAR XR - Tier 2; PA; QL
PHENYTEK (brand for phenytoin sodium extended) - Tier 2; PA; QL
rufinamide (generic for BANZEL) - Tier 1; PA; QL
TEGRETOL (brand for carbamazepine) - Tier 2; PA; QL
TEGRETOL-XR (brand for carbamazepine er) - Tier 2; PA; QL
VIMPAT ORAL (brand for lacosamide) - Tier 2; ST; QL
zonisamide oral (generic for ZONEGRAN) - Tier 1; QL
TRILEPTAL (brand for oxcarbazepine) - Tier 2; PA; QL
ZONEGRAN (brand for zonisamide) - Tier 2; PA; QL
Anticonvulsants - Drugs to Treat Seizures
Anticonvulsants, Other
DIACOMIT - Tier 2; PA; SP; QL
Gamma-Aminobutyric Acid (GABA) Augmenting Agents - Seizure
Control Drugs
ZTALMY - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
28
Preferred Agents Non-Preferred Agents
Antidementia Agents
Antidementia Agents, Other
ergoloid mesylates oral - Tier 1; QL NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY PACK - Tier 2;
PA; QL
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24 HOUR - Tier 2;
PA; QL; AL
Cholinesterase Inhibitors
donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1;
QL
donepezil hcl oral tablet dispersible - Tier 1; QL
EXELON (brand for rivastigmine) - Tier 2; QL
galantamine hydrobromide er (generic for RAZADYNE ER) - Tier 1;
QL
galantamine hydrobromide oral tablet - Tier 1; QL; AL
rivastigmine tartrate - Tier 1; QL; AL
ADLARITY - Tier 2; PA
ARICEPT (brand for donepezil hcl) - Tier 2; PA; QL
donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; PA; QL
galantamine hydrobromide oral solution - Tier 1; PA; QL
RAZADYNE ER (brand for galantamine hydrobromide er) - Tier 2; PA; QL
rivastigmine (generic for EXELON) - Tier 1; PA; QL
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl oral tablet (generic for NAMENDA) - Tier 1; QL memantine hcl er (generic for NAMENDA XR) - Tier 1; PA; QL
memantine hcl oral solution 2 mg/ml - Tier 1; PA; QL
NAMENDA (brand for memantine hcl) - Tier 2; PA; QL
NAMENDA TITRATION PAK (brand for memantine hcl) - Tier 2; PA; QL
NAMENDA XR (brand for memantine hcl er) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
29
Preferred Agents Non-Preferred Agents
Antidepressants
Antidepressants, Other
bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; PA; QL
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300
mg (generic for WELLBUTRIN XL) - Tier 1; PA; QL
bupropion hcl oral - Tier 1; PA; QL
chlordiazepoxide-amitriptyline - Tier 1; PA
mirtazapine oral (generic for REMERON) - Tier 1; PA; QL
perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50
mg - Tier 1; PA
perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; PA; QL
APLENZIN - Tier 2; PA; QL
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24
HOUR 450 MG (brand for bupropion hcl er (xl)) - Tier 2; PA; QL
FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 6-50 mg - Tier
1; PA; QL
olanzapine-fluoxetine hcl oral capsule 3-25 mg (generic for SYMBYAX) -
Tier 1; PA; QL; AL
olanzapine-fluoxetine hcl oral capsule 6-25 mg (generic for SYMBYAX) -
Tier 1; PA; QL
REMERON (brand for mirtazapine) - Tier 2; PA; QL
REMERON SOLTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG
(brand for mirtazapine) - Tier 2; PA; QL
SPRAVATO (56 MG DOSE) - Tier 2; PA; QL
SPRAVATO (84 MG DOSE) - Tier 2; PA; QL
SYMBYAX ORAL CAPSULE 3-25 MG (brand for olanzapine-fluoxetine
hcl) - Tier 2; PA; QL; AL
SYMBYAX ORAL CAPSULE 6-25 MG (brand for olanzapine-fluoxetine
hcl) - Tier 2; PA; QL
WELLBUTRIN SR (brand for bupropion hcl er (sr)) - Tier 2; PA; QL
WELLBUTRIN XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL
Monoamine Oxidase Inhibitors
tranylcypromine sulfate (generic for PARNATE) - Tier 1; PA; QL EMSAM - Tier 2; PA; QL
MARPLAN - Tier 2; PA; QL
NARDIL (brand for phenelzine sulfate) - Tier 2; PA; QL
PARNATE (brand for tranylcypromine sulfate) - Tier 2; PA; QL
phenelzine sulfate oral (generic for NARDIL) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
30
Preferred Agents Non-Preferred Agents
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitors)
citalopram hydrobromide oral solution - Tier 1; PA; QL
citalopram hydrobromide oral tablet (generic for CELEXA) - Tier 1; PA;
QL
escitalopram oxalate oral (generic for LEXAPRO) - Tier 1; PA; QL
fluoxetine hcl oral (generic for PROZAC) - Tier 1; PA; QL
fluvoxamine maleate - Tier 1; PA; QL
nefazodone hcl - Tier 1; PA; QL
paroxetine hcl (generic for PAXIL) - Tier 1; PA; QL
sertraline hcl oral concentrate (generic for ZOLOFT) - Tier 1; PA; QL
sertraline hcl oral tablet (generic for ZOLOFT) - Tier 1; PA; QL
trazodone hcl oral - Tier 1; PA; QL
venlafaxine hcl - Tier 1; PA; QL
CELEXA (brand for citalopram hydrobromide) - Tier 2; PA; QL
CITALOPRAM HYDROBROMIDE ORAL CAPSULE - Tier 2; PA; QL
DESVENLAFAXINE ER - Tier 2; PA; QL
desvenlafaxine succinate er (generic for PRISTIQ) - Tier 1; PA; QL
EFFEXOR XR (brand for venlafaxine hcl er) - Tier 2; PA; QL
FETZIMA - Tier 2; PA; QL
FETZIMA TITRATION - Tier 2; PA; QL
fluoxetine hcl (pmdd) - Tier 1; PA; QL
fluvoxamine maleate er - Tier 1; PA; QL
LEXAPRO (brand for escitalopram oxalate) - Tier 2; PA; QL
paroxetine hcl er (generic for PAXIL CR) - Tier 1; PA; QL
paroxetine mesylate - Tier 1; PA; QL
venlafaxine hcl er (generic for EFFEXOR XR) - Tier 1; PA; QL PAXIL (brand for paroxetine hcl) - Tier 2; PA; QL
PAXIL CR (brand for paroxetine hcl er) - Tier 2; PA; QL
PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG - Tier 2; PA; QL
PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; QL
PROZAC (brand for fluoxetine hcl) - Tier 2; PA; QL
SERTRALINE HCL ORAL CAPSULE - Tier 2; PA; QL
TRINTELLIX - Tier 2; PA; QL
VIIBRYD (brand for vilazodone hcl) - Tier 2; PA; QL
VIIBRYD STARTER PACK - Tier 2; PA; QL
vilazodone hcl (generic for VIIBRYD) - Tier 1; PA; QL
ZOLOFT (brand for sertraline hcl) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
31
Preferred Agents Non-Preferred Agents
Tricyclics
amitriptyline hcl oral - Tier 1; PA; QL
amoxapine - Tier 1; PA; QL
desipramine hcl oral (generic for NORPRAMIN) - Tier 1; PA; QL
doxepin hcl oral capsule - Tier 1; PA; QL
doxepin hcl oral concentrate - Tier 1; PA; QL
imipramine hcl oral - Tier 1; PA; QL
imipramine pamoate - Tier 1; PA; QL
nortriptyline hcl oral (generic for PAMELOR) - Tier 1; PA; QL
protriptyline hcl - Tier 1; PA; QL
trimipramine maleate oral - Tier 1; PA; QL
ANAFRANIL (brand for clomipramine hcl) - Tier 2; PA; QL
clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; PA; QL
NORPRAMIN (brand for desipramine hcl) - Tier 2; PA; QL
PAMELOR (brand for nortriptyline hcl) - Tier 2; PA; QL
Antiemetics
Antiemetics, Other
BONINE (brand for cvs motion sickness relief) - Tier 2
compro (generic for COMPRO) - Tier 1; PA; QL
DICLEGIS (brand for doxylamine-pyridoxine) - Tier 2; QL
driminate (generic for DRIMINATE) - Tier 1
meclizine hcl oral tablet (generic for TRAVEL-EASE) - Tier 1; QL
meclizine hcl oral tablet chewable (generic for ANTIVERT) - Tier 1
metoclopramide hcl oral solution - Tier 1; QL
metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL
motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1
motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier
1
ANTIVERT (brand for cvs motion sickness relief) - Tier 2; PA
BONJESTA - Tier 2; PA; QL
doxylamine-pyridoxine (generic for DICLEGIS) - Tier 1; PA; QL
GIMOTI - Tier 2; PA; QL
metoclopramide hcl oral tablet dispersible - Tier 1; PA; QL
REGLAN (brand for metoclopramide hcl) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
32
Preferred Agents Non-Preferred Agents
motion sickness relief oral tablet chewable 25 mg (generic for
ANTIVERT) - Tier 1
motion-time (generic for ANTIVERT) - Tier 1
perphenazine oral - Tier 1; PA; QL
prochlorperazine (generic for COMPRO) - Tier 1; PA; QL
prochlorperazine maleate oral - Tier 1; PA; QL
promethazine hcl oral - Tier 1; QL
promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL
promethegan (generic for PROMETHEGAN) - Tier 1; QL
scopolamine (generic for TRANSDERM-SCOP) - Tier 1; QL
TRANSDERM-SCOP (brand for scopolamine) - Tier 2; QL
travel ease (generic for ANTIVERT) - Tier 1
trimethobenzamide hcl oral - Tier 1; QL
Emetogenic Therapy Adjuncts
aprepitant oral capsule 125 mg, 40 mg - Tier 1; QL
dronabinol (generic for MARINOL) - Tier 1; QL
EMEND ORAL (brand for aprepitant) - Tier 2; QL
EMEND TRI-PACK (brand for aprepitant) - Tier 2; QL
ondansetron hcl oral solution - Tier 1; QL
ondansetron hcl oral tablet 4 mg, 8 mg - Tier 1; QL
ondansetron odt - Tier 1; QL
AKYNZEO ORAL - Tier 2; PA; QL
ANZEMET - Tier 2; PA; QL
aprepitant oral (generic for EMEND TRI-PACK) - Tier 1; PA; QL
aprepitant oral capsule 80 & 125 mg (generic for EMEND TRI-PACK) -
Tier 1; PA; QL
aprepitant oral capsule 80 mg (generic for EMEND) - Tier 1; PA; QL
granisetron hcl oral - Tier 1; PA; QL
MARINOL (brand for dronabinol) - Tier 2; PA; QL
SANCUSO - Tier 2; PA; QL
VARUBI (180 MG DOSE) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
33
Preferred Agents Non-Preferred Agents
Antiemetics - Drugs to Treat Nausea and Vomiting
Antiemetics, Other - Nausea and Vomiting Drugs
anti-nausea (generic for EMETROL) - Tier 1
EMETROL (brand for anti-nausea) - Tier 2
nausea control (generic for EMETROL) - Tier 1
nausea relief (generic for EMETROL) - Tier 1
Antifungals
3 day (generic for MONISTAT 3) - Tier 1
clotrimazole mouth/throat troche 10 mg - Tier 1; QL
fluconazole oral (generic for DIFLUCAN) - Tier 1; QL
flucytosine oral capsule 250 mg (generic for ANCOBON) - Tier 1; QL
flucytosine oral capsule 500 mg (generic for ANCOBON) - Tier 1
griseofulvin microsize oral - Tier 1; QL
griseofulvin ultramicrosize - Tier 1; QL
GYNAZOLE-1 - Tier 2; QL
ketoconazole oral - Tier 1; QL
miconazole 3 - Tier 1; QL
miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for
MONISTAT 3 COMBO PACK APP) - Tier 1; QL
ANCOBON ORAL CAPSULE 250 MG (brand for flucytosine) - Tier 2; PA;
QL
ANCOBON ORAL CAPSULE 500 MG (brand for flucytosine) - Tier 2; PA
CRESEMBA ORAL - Tier 2; PA; QL
DIFLUCAN (brand for fluconazole) - Tier 2; PA; QL
itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL
miconazole 1 (generic for MONISTAT 1 COMBO PACK) - Tier 1; PA
miconazole 1 combo pack (generic for MONISTAT 1 COMBO PACK) -
Tier 1; PA
NOXAFIL ORAL SUSPENSION - Tier 2; PA
NOXAFIL ORAL TABLET DELAYED RELEASE (brand for posaconazole)
- Tier 2; PA; QL
miconazole 3 combo pack app (generic for MONISTAT 3 COMBO
PACK APP) - Tier 1; QL
miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for
MONISTAT 3 COMBO PACK APP) - Tier 1; QL
miconazole 7 day treatment (generic for MONISTAT 7 SIMPLY CURE)
- Tier 1; QL
miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY
CURE) - Tier 1; QL
miconazole 7 vaginal suppository 100 mg - Tier 1
miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) -
Tier 1; QL
nystatin mouth/throat - Tier 1; QL
ORAVIG - Tier 2; PA; QL
posaconazole (generic for NOXAFIL) - Tier 1; PA; QL
SPORANOX (brand for itraconazole) - Tier 2; PA; QL
SPORANOX PULSEPAK (brand for itraconazole) - Tier 2; PA; QL
TOLSURA - Tier 2; PA; QL
VFEND ORAL SUSPENSION RECONSTITUTED (brand for
voriconazole) - Tier 2; PA
VFEND ORAL TABLET (brand for voriconazole) - Tier 2; PA; QL
voriconazole oral suspension reconstituted (generic for VFEND) - Tier 1;
PA
voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
34
Preferred Agents Non-Preferred Agents
nystatin oral - Tier 1; QL
terbinafine hcl oral - Tier 1; QL
terconazole - Tier 1; QL
Antifungals - Drugs to Treat Fungal Infections
Antifungals - Fungal Infection Drugs
3 day vaginal (generic for GYNE-LOTRIMIN 3) - Tier 1
3-day vaginal vaginal cream 2 % (generic for GYNE-LOTRIMIN 3) -
Tier 1
ALOE VESTA CLEAR ANTIFUNGAL - Tier 2
antifungal external cream (generic for CAVILON) - Tier 1
antifungal external powder (generic for DESENEX) - Tier 1; QL
antifungal foot care (generic for LAMISIL AT) - Tier 1; QL
antifungal miconazole (generic for CAVILON) - Tier 1
atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) -
Tier 1
athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; QL
AZOLEN TINCTURE - Tier 2; PA
CORTI-SAV - Tier 2; PA
FUNGOID TINCTURE - Tier 2; PA
hydrocortisone-iodoquinol (generic for DERMAZENE) - Tier 1; PA
iodoquinol-hc-aloe polysacch - Tier 1; PA
KETODAN EXTERNAL KIT - Tier 2; PA
LAMISIL AT JOCK ITCH CREAM 1 % EXTERNAL (brand for athletes foot
(terbinafine)) - Tier 2; PA; QL
LOPROX EXTERNAL KIT 0.77 % - Tier 2; PA
LOPROX EXTERNAL KIT 0.77 % (SUSP) - Tier 2; PA; QL
tioconazole 1 vaginal ointment 6.5 % (generic for MONISTAT 1-DAY) -
Tier 1; PA; QL
athletes foot external aerosol powder 2 % (generic for CRUEX
PRESCRIPTION STRENGTH) - Tier 1
athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1; QL
athletes foot external powder 2 % (generic for DESENEX) - Tier 1; QL
athletes foot powder spray external aerosol powder 2 % (generic for
CRUEX PRESCRIPTION STRENGTH) - Tier 1
athletes foot spray external aerosol 2 % (generic for LOTRIMIN AF) -
Tier 1
CAVILON (brand for antifungal) - Tier 2
clotrimazole 3 (generic for GYNE-LOTRIMIN 3) - Tier 1
clotrimazole 7 (generic for GYNE-LOTRIMIN) - Tier 1; QL
clotrimazole vaginal (generic for GYNE-LOTRIMIN) - Tier 1; QL
tioconazole-1 (generic for MONISTAT 1-DAY) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
35
Preferred Agents Non-Preferred Agents
clotrimazole vaginal cream 1 % (generic for GYNE-LOTRIMIN) - Tier
1; QL
CRUEX PRESCRIPTION STRENGTH (brand for athletes foot powder
spray) - Tier 2
DESENEX EXTERNAL POWDER (brand for antifungal) - Tier 2; QL
DESENEX JOCK ITCH (brand for athletes foot powder spray) - Tier 2
foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; QL
GYNE-LOTRIMIN (brand for clotrimazole) - Tier 2; QL
GYNE-LOTRIMIN 3 (brand for 3 day vaginal) - Tier 2
jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1; QL
LAMISIL AT EXTERNAL CREAM (brand for athletes foot (terbinafine))
- Tier 2; QL
LAMISIL AT JOCK ITCH CREAM 1 % EXTERNAL (brand for athletes
foot (terbinafine)) - Tier 2; QL
micaderm (generic for CAVILON) - Tier 1
MICATIN (brand for antifungal) - Tier 2
miconazole antifungal (generic for CAVILON) - Tier 1
miconazole nitrate external (generic for CAVILON) - Tier 1
miconazorb af (generic for DESENEX) - Tier 1; QL
MICOTRIN AP (brand for antifungal) - Tier 2; QL
MYCOZYL AP (brand for antifungal) - Tier 2; QL
terbinafine hcl external (generic for LAMISIL AT) - Tier 1; QL
terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT)
- Tier 1; QL
ZEASORB-AF (brand for antifungal) - Tier 2; QL
Antigout Agents
allopurinol oral (generic for ZYLOPRIM) - Tier 1; QL
colchicine oral tablet (generic for COLCRYS) - Tier 1; PA; QL
colchicine-probenecid - Tier 1; PA; QL
probenecid - Tier 1; QL
COLCHICINE ORAL CAPSULE (brand for colchicine) - Tier 2; PA; QL
COLCRYS (brand for colchicine) - Tier 2; PA; QL
febuxostat (generic for ULORIC) - Tier 1; PA; QL
GLOPERBA - Tier 2; PA; QL
MITIGARE (brand for colchicine) - Tier 2; PA; QL
ULORIC (brand for febuxostat) - Tier 2; PA; QL
ZYLOPRIM (brand for allopurinol) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
36
Preferred Agents Non-Preferred Agents
Anti-HIV Agents, Other - HIV Drugs
Antivirals - Drugs to Treat Viral Infections
VOCABRIA - Tier 2; PA; QL
Anti-inflammatory Agents - Drugs to Treat Inflammation
Glucocorticoids - Drugs to Treat Inflammation
anucort-hc (generic for ANUSOL-HC) - Tier 1; PA
ANUSOL-HC RECTAL (brand for anucort-hc) - Tier 2; PA
HEMMOREX-HC (brand for anucort-hc) - Tier 2; PA
hydrocortisone acetate rectal (generic for ANUSOL-HC) - Tier 1; PA
PROCTOCORT RECTAL (brand for hydrocortisone acetate) - Tier 2; PA
Antimigraine Agents
Ergot Alkaloids
ergotamine-caffeine (generic for CAFERGOT) - Tier 1; QL CAFERGOT (brand for ergotamine-caffeine) - Tier 2; PA; QL
dihydroergotamine mesylate injection - Tier 1; PA; QL
dihydroergotamine mesylate nasal (generic for MIGRANAL) - Tier 1; PA;
QL
ERGOMAR - Tier 2; PA
MIGERGOT - Tier 2; PA; QL
MIGRANAL (brand for dihydroergotamine mesylate) - Tier 2; PA; QL
QULIPTA - Tier 2; PA; QL
Prophylactic
AIMOVIG - Tier 2; ST; QL
AJOVY - Tier 2; ST; QL
timolol maleate oral - Tier 1; QL
EMGALITY - Tier 2; PA; QL
EMGALITY (300 MG DOSE) - Tier 2; PA; QL
Antimigraine Agents - Drugs to Treat Migraines
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist -
Migraine Drugs
NURTEC - Tier 2; PA; QL UBRELVY - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
37
Preferred Agents Non-Preferred Agents
Ergot Alkaloids - Migraine Drugs
TRUDHESA - Tier 2; PA; QL
Serotonin (5-HT) Receptor Agonists - Migraine Drugs
naratriptan hcl (generic for AMERGE) - Tier 1; QL
rizatriptan benzoate (generic for MAXALT) - Tier 1; QL
sumatriptan nasal (generic for IMITREX) - Tier 1; QL
sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL
sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL)
- Tier 1; QL
sumatriptan succinate subcutaneous (generic for IMITREX
STATDOSE SYSTEM) - Tier 1; QL
almotriptan malate - Tier 1; PA; QL
AMERGE (brand for naratriptan hcl) - Tier 2; PA; QL
eletriptan hydrobromide (generic for RELPAX) - Tier 1; PA; QL
FROVA (brand for frovatriptan succinate) - Tier 2; PA; QL
frovatriptan succinate (generic for FROVA) - Tier 1; PA; QL
IMITREX (brand for sumatriptan) - Tier 2; PA; QL
IMITREX STATDOSE REFILL (brand for sumatriptan succinate refill) -
Tier 2; PA; QL
IMITREX STATDOSE SYSTEM (brand for sumatriptan succinate) - Tier 2;
PA; QL
MAXALT (brand for rizatriptan benzoate) - Tier 2; PA; QL
ONZETRA XSAIL - Tier 2; PA; QL
RELPAX (brand for eletriptan hydrobromide) - Tier 2; PA; QL
REYVOW - Tier 2; PA; QL
sumatriptan-naproxen sodium (generic for TREXIMET) - Tier 1; PA; QL
TOSYMRA - Tier 2; PA; QL
TREXIMET (brand for sumatriptan-naproxen sodium) - Tier 2; PA; QL
ZEMBRACE SYMTOUCH - Tier 2; PA; QL
ZOLMITRIPTAN NASAL SOLUTION 2.5 MG (brand for zolmitriptan) - Tier
2; PA; QL
zolmitriptan nasal solution 5 mg (generic for ZOMIG) - Tier 1; PA; QL
zolmitriptan oral (generic for ZOMIG) - Tier 1; PA; QL
ZOMIG (brand for zolmitriptan) - Tier 2; PA; QL
Antimyasthenic Agents
Parasympathomimetics
pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL
pyridostigmine bromide oral tablet (generic for MESTINON) - Tier 1;
QL
MESTINON (brand for pyridostigmine bromide) - Tier 2; PA; QL
pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1;
PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
38
Preferred Agents Non-Preferred Agents
Antimycobacterials
Antimycobacterials, Other
dapsone oral - Tier 1; QL
rifabutin (generic for MYCOBUTIN) - Tier 1; QL
MYCOBUTIN (brand for rifabutin) - Tier 2; PA; QL
Antituberculars
cycloserine oral - Tier 1; QL
ethambutol hcl oral tablet 100 mg - Tier 1
ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1;
QL
isoniazid oral - Tier 1; QL
PASER - Tier 2; QL
PRIFTIN - Tier 2; QL
pyrazinamide oral - Tier 1; QL
rifampin oral - Tier 1; QL
SIRTURO - Tier 2; QL
TRECATOR - Tier 2; QL
MYAMBUTOL (brand for ethambutol hcl) - Tier 2; PA; QL
PRETOMANID - Tier 2; PA; QL
Antineoplastics
Alkylating Agents
cyclophosphamide injection solution reconstituted 500 mg - Tier 1
cyclophosphamide oral capsule - Tier 1
CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2
LEUKERAN - Tier 2
MATULANE - Tier 2; SP; QL
MYLERAN - Tier 2
temozolomide (generic for TEMODAR) - Tier 1; PA; SP; QL
TEMODAR ORAL (brand for temozolomide) - Tier 2; PA; SP; QL
VALCHLOR - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
39
Preferred Agents Non-Preferred Agents
Antiandrogens
abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL
bicalutamide (generic for CASODEX) - Tier 1; QL
ERLEADA - Tier 2; PA; SP; QL
flutamide (generic for EULEXIN) - Tier 1; QL
NUBEQA - Tier 2; PA; SP; QL
CASODEX (brand for bicalutamide) - Tier 2; PA; QL
EULEXIN (brand for flutamide) - Tier 2; PA; QL
NILANDRON (brand for nilutamide) - Tier 2; PA; QL
nilutamide (generic for NILANDRON) - Tier 1; PA; QL
XTANDI - Tier 2; PA; SP; QL
YONSA - Tier 2; PA; SP; QL
ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL
Antiangiogenic Agents
lenalidomide (generic for REVLIMID) - Tier 1; PA; SP; QL
POMALYST - Tier 2; PA; SP; QL
REVLIMID (brand for lenalidomide) - Tier 2; PA; SP; QL
THALOMID - Tier 2; PA; SP; QL
Antiestrogens/Modifiers
tamoxifen citrate oral - Tier 1; QL
toremifene citrate (generic for FARESTON) - Tier 1; QL
EMCYT - Tier 2; PA; QL
FARESTON (brand for toremifene citrate) - Tier 2; PA; QL
SOLTAMOX - Tier 2; PA; QL
Antimetabolites
hydroxyurea oral (generic for HYDREA) - Tier 1; QL
mercaptopurine oral - Tier 1; QL
ONUREG - Tier 2; PA; SP; QL
TABLOID - Tier 2; SP; QL
HYDREA (brand for hydroxyurea) - Tier 2; PA; QL
PEMETREXED DISODIUM INTRAVENOUS SOLUTION - Tier 2; PA
pemetrexed disodium intravenous solution reconstituted 1000 mg, 750 mg
- Tier 1; PA
PEMETREXED INTRAVENOUS SOLUTION 1 GM/40ML, 100 MG/4ML -
Tier 2; PA
PURIXAN - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
40
Preferred Agents Non-Preferred Agents
Antineoplastics, Other
IDHIFA - Tier 2; PA; SP; QL
LONSURF - Tier 2; PA; SP; QL
NINLARO - Tier 2; PA; SP; QL
XPOVIO (60 MG TWICE WEEKLY) - Tier 2; PA; SP; QL
ZOLINZA - Tier 2; PA; SP; QL
PEMAZYRE - Tier 2; PA; SP; QL
SYNRIBO - Tier 2; PA; SP; QL
TAZVERIK - Tier 2; PA; QL
XPOVIO (100 MG ONCE WEEKLY) - Tier 2; PA; SP; QL
XPOVIO (40 MG ONCE WEEKLY) - Tier 2; PA; SP; QL
XPOVIO (40 MG TWICE WEEKLY) - Tier 2; PA; SP; QL
XPOVIO (60 MG ONCE WEEKLY) - Tier 2; PA; SP; QL
XPOVIO (80 MG ONCE WEEKLY) - Tier 2; PA; SP; QL
XPOVIO (80 MG TWICE WEEKLY) - Tier 2; PA; SP; QL
Aromatase Inhibitors, 3rd Generation
anastrozole oral (generic for ARIMIDEX) - Tier 1; QL
exemestane (generic for AROMASIN) - Tier 1; QL
letrozole oral (generic for FEMARA) - Tier 1; QL
ARIMIDEX (brand for anastrozole) - Tier 2; PA; QL
AROMASIN (brand for exemestane) - Tier 2; PA; QL
FEMARA (brand for letrozole) - Tier 2; PA; QL
Enzyme Inhibitors
etoposide oral - Tier 1; QL
HYCAMTIN ORAL - Tier 2; PA; SP; QL
Molecular Target Inhibitors
BALVERSA - Tier 2; PA; SP; QL
COTELLIC - Tier 2; PA; SP; QL
DAURISMO - Tier 2; PA; SP; QL
ERIVEDGE - Tier 2; PA; SP; QL
everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg (generic for
AFINITOR) - Tier 1; PA; SP; QL
everolimus oral tablet soluble (generic for AFINITOR DISPERZ) - Tier
1; PA; SP; QL
IBRANCE - Tier 2; PA; SP; QL
INQOVI - Tier 2; PA; SP; QL
JAKAFI - Tier 2; PA; SP; QL
KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; QL
AFINITOR (brand for everolimus) - Tier 2; PA; SP; QL
AFINITOR DISPERZ (brand for everolimus) - Tier 2; PA; SP; QL
BRAFTOVI - Tier 2; PA; SP; QL
COPIKTRA - Tier 2; PA; SP; QL
EXKIVITY - Tier 2; PA; SP; QL
INREBIC - Tier 2; PA; SP; QL
KISQALI (200 MG DOSE) - Tier 2; PA; QL
KISQALI (400 MG DOSE) - Tier 2; PA; QL
KISQALI (600 MG DOSE) - Tier 2; PA; QL
KOSELUGO - Tier 2; PA; SP; QL
LYNPARZA - Tier 2; PA
MEKTOVI - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
41
Preferred Agents Non-Preferred Agents
KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; QL
KISQALI FEMARA(200 MG DOSE) - Tier 2; PA; SP; QL
MEKINIST - Tier 2; PA; SP; QL
NEXAVAR (brand for sorafenib tosylate) - Tier 2; PA; SP; QL
ODOMZO - Tier 2; PA; SP; QL
PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; QL
PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; QL
PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; QL
ROZLYTREK - Tier 2; PA; SP; QL
RUBRACA - Tier 2; PA; SP; QL
RYDAPT - Tier 2; PA; QL
STIVARGA - Tier 2; PA; SP; QL
sorafenib tosylate (generic for NEXAVAR) - Tier 1; PA; SP; QL
SUTENT (brand for sunitinib malate) - Tier 2; PA; SP; QL
TALZENNA - Tier 2; PA; SP; QL
VONJO - Tier 2; PA; SP; QL
sunitinib malate (generic for SUTENT) - Tier 1; PA; SP; QL
TAFINLAR - Tier 2; PA; SP; QL
TEPMETKO - Tier 2; PA; SP; QL
TIBSOVO - Tier 2; PA; SP; QL
VENCLEXTA - Tier 2; PA; SP; QL
VENCLEXTA STARTING PACK - Tier 2; PA; SP; QL
VERZENIO - Tier 2; PA; SP; QL
VITRAKVI - Tier 2; PA; SP; QL
ZEJULA - Tier 2; PA; SP; QL
ZELBORAF - Tier 2; PA; SP; QL
ZYDELIG - Tier 2; PA; SP; QL
Retinoids
bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL
PANRETIN - Tier 2; PA
tretinoin oral - Tier 1; SP; QL
TARGRETIN (brand for bexarotene) - Tier 2; PA; SP; QL
Treatment Adjuncts
leucovorin calcium oral - Tier 1; QL
MESNEX ORAL - Tier 2; SP; QL
dexrazoxane hcl (generic for TOTECT) - Tier 1; PA
KHAPZORY - Tier 2; PA
leucovorin calcium injection solution 500 mg/50ml - Tier 1; PA
levoleucovorin calcium pf intravenous solution 250 mg/25ml - Tier 1; PA
TOTECT (brand for dexrazoxane hcl) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
42
Preferred Agents Non-Preferred Agents
Antineoplastics - Drugs to Treat Cancer
Alkylating Agents - Chemotherapy Agents
melphalan (generic for ALKERAN) - Tier 1 ALKERAN ORAL (brand for melphalan) - Tier 2; PA
WELIREG - Tier 2; PA; SP; QL
Antimetabolites - Chemotherapy Agents
capecitabine (generic for XELODA) - Tier 1; SP; QL XELODA (brand for capecitabine) - Tier 2; PA; SP; QL
Antineoplastics, Other - Chemotherapy Agents
BESREMI - Tier 2; PA; SP; QL
Molecular Target Inhibitors - Chemotherapy Agents
SCEMBLIX - Tier 2; PA; SP; QL VIJOICE - Tier 2; PA; SP; QL
Monoclonal Antibodies - Chemotherapy Agents
ALYMSYS - Tier 2; PA
Antineoplastics, Other - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
ZYKADIA - Tier 2; PA; SP; QL LUMAKRAS - Tier 2; PA; SP; QL
Antiparasitics
Anthelmintics
albendazole oral - Tier 1; QL
ivermectin oral (generic for STROMECTOL) - Tier 1; QL
praziquantel oral (generic for BILTRICIDE) - Tier 1; QL
BILTRICIDE (brand for praziquantel) - Tier 2; PA; QL
EMVERM - Tier 2; PA; QL
STROMECTOL (brand for ivermectin) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
43
Preferred Agents Non-Preferred Agents
Antiprotozoals
atovaquone (generic for MEPRON) - Tier 1; QL
atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; QL
chloroquine phosphate oral - Tier 1; QL
COARTEM - Tier 2
hydroxychloroquine sulfate oral (generic for PLAQUENIL) - Tier 1; QL
mefloquine hcl - Tier 1; QL
nitazoxanide oral (generic for ALINIA) - Tier 1; PA; QL
pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1
primaquine phosphate - Tier 1
pyrimethamine tablet 25 mg oral (generic for DARAPRIM) - Tier 1; SP;
QL
quinine sulfate oral (generic for QUALAQUIN) - Tier 1
ALINIA ORAL TABLET (brand for nitazoxanide) - Tier 2; PA; QL
BENZNIDAZOLE - Tier 2; PA; QL
DARAPRIM (brand for pyrimethamine) - Tier 2; PA; SP; QL
KRINTAFEL - Tier 2; PA; QL
MALARONE (brand for atovaquone-proguanil hcl) - Tier 2; PA; QL
MEPRON (brand for atovaquone) - Tier 2; PA; QL
NEBUPENT (brand for pentamidine isethionate) - Tier 2; PA
PLAQUENIL (brand for hydroxychloroquine sulfate) - Tier 2; PA; QL
pyrimethamine tablet 25 mg oral (generic for DARAPRIM) - Tier 1; PA;
SP; QL
QUALAQUIN (brand for quinine sulfate) - Tier 2; PA
Antiparasitics - Drugs to Treat Parasitic Infections
Antiprotozoals - Protozoal Infection Drugs
LAMPIT - Tier 2; PA; QL
Pediculicides/Scabicides - Scabies and Lice Drugs
lice killing (generic for RID) - Tier 1
lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier 1
lice killing max strength (generic for RID LICE KILLING SHAMPOO) -
Tier 1
lice killing maximum strength (generic for RID LICE KILLING
SHAMPOO) - Tier 1
lice maximum strength (generic for RID LICE KILLING SHAMPOO) -
Tier 1
lice treatment external shampoo 0.33-4 % (generic for RID LICE
KILLING SHAMPOO) - Tier 1
RID LICE KILLING SHAMPOO (brand for cvs lice killing) - Tier 2
lice solution combination kit (generic for CVS LICE SOLUTION) - Tier 1;
PA; QL
stop lice complete treatment (generic for CVS LICE SOLUTION) - Tier 1;
PA; QL
sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier
1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
44
Preferred Agents Non-Preferred Agents
Antiparkinson Agents
Anticholinergics
benztropine mesylate oral - Tier 1; QL
trihexyphenidyl hcl - Tier 1; QL
Antiparkinson Agents, Other
amantadine hcl oral - Tier 1; QL
entacapone (generic for COMTAN) - Tier 1; QL
carbidopa-levodopa-entacapone (generic for STALEVO 100) - Tier 1; PA;
QL
COMTAN (brand for entacapone) - Tier 2; PA; QL
GOCOVRI - Tier 2; PA; QL
NOURIANZ - Tier 2; PA; QL
ONGENTYS - Tier 2; PA; QL
OSMOLEX ER - Tier 2; PA; QL
STALEVO 100 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA;
QL
STALEVO 125 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA;
QL
STALEVO 150 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA;
QL
STALEVO 200 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA;
QL
STALEVO 50 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL
STALEVO 75 (brand for carbidopa-levodopa-entacapone) - Tier 2; PA; QL
TASMAR (brand for tolcapone) - Tier 2; PA; QL
tolcapone (generic for TASMAR) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
45
Preferred Agents Non-Preferred Agents
Dopamine Agonists
bromocriptine mesylate oral (generic for PARLODEL) - Tier 1; QL
pramipexole dihydrochloride - Tier 1; QL
ropinirole hcl - Tier 1; QL
APOKYN (brand for apomorphine hcl) - Tier 2; PA; SP; QL
apomorphine hcl subcutaneous (generic for APOKYN) - Tier 1; PA; SP;
QL
KYNMOBI - Tier 2; PA; SP; QL
MIRAPEX ER (brand for pramipexole dihydrochloride er) - Tier 2; PA; QL
NEUPRO - Tier 2; PA; QL
PARLODEL (brand for bromocriptine mesylate) - Tier 2; PA; QL
pramipexole dihydrochloride er (generic for MIRAPEX ER) - Tier 1; PA;
QL
ropinirole hcl er - Tier 1; PA; QL
Dopamine Precursors and/or L-Amino Acid Decarboxylase
Inhibitors
carbidopa-levodopa er - Tier 1; QL
carbidopa-levodopa oral tablet (generic for DHIVY) - Tier 1; QL
carbidopa oral (generic for LODOSYN) - Tier 1; PA; QL
carbidopa-levodopa oral tablet dispersible - Tier 1; PA; QL
DHIVY (brand for carbidopa-levodopa) - Tier 2; PA; QL
DUOPA - Tier 2; PA
INBRIJA - Tier 2; PA; SP; QL
LODOSYN (brand for carbidopa) - Tier 2; PA; QL
RYTARY - Tier 2; PA; QL
SINEMET (brand for carbidopa-levodopa) - Tier 2; PA; QL
Monoamine Oxidase B (MAO-B) Inhibitors
selegiline hcl oral - Tier 1; QL AZILECT (brand for rasagiline mesylate) - Tier 2; PA; QL
rasagiline mesylate oral (generic for AZILECT) - Tier 1; PA; QL
XADAGO - Tier 2; PA; QL
ZELAPAR - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
46
Preferred Agents Non-Preferred Agents
Antipsychotics
1st Generation/Typical
fluphenazine decanoate injection - Tier 1; PA
fluphenazine hcl injection - Tier 1; PA
fluphenazine hcl oral concentrate - Tier 1; PA
fluphenazine hcl oral elixir - Tier 1; PA
fluphenazine hcl oral tablet - Tier 1; PA; QL
haloperidol decanoate intramuscular (generic for HALDOL
DECANOATE) - Tier 1; PA; QL
haloperidol lactate oral - Tier 1; PA; QL
haloperidol oral - Tier 1; PA; QL
loxapine succinate - Tier 1; PA; QL
molindone hcl - Tier 1; PA; QL
pimozide - Tier 1; QL
chlorpromazine hcl oral - Tier 1; PA; QL
HALDOL DECANOATE (brand for haloperidol decanoate) - Tier 2; PA; QL
thioridazine hcl oral - Tier 1; PA; QL
thiothixene - Tier 1; PA; QL
trifluoperazine hcl - Tier 1; PA; QL
2nd Generation/Atypical
ABILIFY MAINTENA - Tier 2; PA; QL
aripiprazole oral tablet (generic for ABILIFY) - Tier 1; PA; QL
ARISTADA - Tier 2; PA; QL
ARISTADA INITIO - Tier 2; PA; QL
FANAPT - Tier 2; PA; ST; QL; AL
FANAPT TITRATION PACK - Tier 2; PA; ST; QL; AL
GEODON ORAL (brand for ziprasidone hcl) - Tier 2; PA; QL; AL
INVEGA (brand for paliperidone er) - Tier 2; PA; QL
INVEGA HAFYERA - Tier 2; PA; QL
INVEGA SUSTENNA - Tier 2; PA; QL
INVEGA TRINZA - Tier 2; PA; QL
LATUDA - Tier 2; PA; ST; QL
ABILIFY (brand for aripiprazole) - Tier 2; PA; QL
ABILIFY MYCITE MAINTENANCE KIT - Tier 2; PA; QL
ABILIFY MYCITE STARTER KIT - Tier 2; PA; QL
aripiprazole oral solution - Tier 1; PA; QL
aripiprazole oral tablet dispersible - Tier 1; PA; QL; AL
asenapine maleate (generic for SAPHRIS) - Tier 1; PA; ST; QL; AL
CAPLYTA - Tier 2; PA; QL
LYBALVI - Tier 2; PA; QL; AL
NUPLAZID - Tier 2; PA; QL
paliperidone er (generic for INVEGA) - Tier 1; PA; QL
REXULTI - Tier 2; PA; QL
SECUADO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
47
Preferred Agents Non-Preferred Agents
olanzapine oral (generic for ZYPREXA) - Tier 1; PA; QL; AL
PERSERIS - Tier 2; PA; QL
quetiapine fumarate (generic for SEROQUEL) - Tier 1; PA; QL
quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; PA; QL
RISPERDAL CONSTA - Tier 2; PA; QL; AL
RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; PA;
QL
RISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; PA; QL;
AL
risperidone oral solution (generic for RISPERDAL) - Tier 1; PA; QL
risperidone oral tablet (generic for RISPERDAL) - Tier 1; PA; QL; AL
risperidone oral tablet dispersible - Tier 1; PA; QL; AL
SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA; QL
SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL
VRAYLAR - Tier 2; PA; QL
ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA; QL; AL
ZYPREXA RELPREVV - Tier 2; PA; QL
ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; QL; AL
SAPHRIS (brand for asenapine maleate) - Tier 2; PA; ST; QL; AL
ziprasidone hcl (generic for GEODON) - Tier 1; PA; QL; AL
Treatment-Resistant
clozapine (generic for CLOZARIL) - Tier 1; PA; QL
CLOZARIL (brand for clozapine) - Tier 2; PA; QL
VERSACLOZ - Tier 2; PA; QL
Antispasmodics, Urinary - Bladder Control Drugs
Genitourinary Agents - Drugs to Treat Bladder, Genital and
Kidney Conditions
GEMTESA - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
48
Preferred Agents Non-Preferred Agents
Antispasticity Agents
baclofen oral tablet - Tier 1; QL
dantrolene sodium oral (generic for DANTRIUM) - Tier 1; QL
tizanidine hcl oral tablet (generic for ZANAFLEX) - Tier 1; QL
baclofen intrathecal solution prefilled syringe (generic for GABLOFEN) -
Tier 1; PA
DANTRIUM ORAL (brand for dantrolene sodium) - Tier 2; PA; QL
FLEQSUVY - Tier 2; PA; QL
GABLOFEN INTRATHECAL SOLUTION PREFILLED SYRINGE 50
MCG/ML (brand for baclofen) - Tier 2; PA
LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/5ML - Tier 2;
PA
LYVISPAH - Tier 2; PA
tizanidine hcl oral capsule 2 mg (generic for ZANAFLEX) - Tier 1; PA; QL
tizanidine hcl oral capsule 4 mg, 6 mg (generic for ZANAFLEX) - Tier 1;
PA
ZANAFLEX ORAL CAPSULE 2 MG (brand for tizanidine hcl) - Tier 2; PA;
QL
ZANAFLEX ORAL CAPSULE 4 MG, 6 MG (brand for tizanidine hcl) - Tier
2; PA
ZANAFLEX ORAL TABLET (brand for tizanidine hcl) - Tier 2; PA; QL
Antivirals
Anti-cytomegalovirus (CMV) Agents
VALCYTE ORAL SOLUTION RECONSTITUTED (brand for
valganciclovir hcl) - Tier 2
valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL
PREVYMIS ORAL - Tier 2; PA; QL
VALCYTE ORAL TABLET (brand for valganciclovir hcl) - Tier 2; PA; QL
valganciclovir hcl oral solution reconstituted (generic for VALCYTE) - Tier
1; PA
ZIRGAN - Tier 2; PA; QL
Anti-hepatitis B (HBV) Agents
adefovir dipivoxil (generic for HEPSERA) - Tier 1; SP; QL
BARACLUDE ORAL SOLUTION - Tier 2; SP; QL
entecavir (generic for BARACLUDE) - Tier 1; SP; QL
lamivudine oral tablet 100 mg (generic for EPIVIR HBV) - Tier 1; SP;
QL
VEMLIDY - Tier 2; SP; QL
BARACLUDE ORAL TABLET (brand for entecavir) - Tier 2; PA; SP; QL
EPIVIR HBV (brand for lamivudine) - Tier 2; PA; SP; QL
HEPSERA (brand for adefovir dipivoxil) - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
49
Preferred Agents Non-Preferred Agents
Anti-hepatitis C (HCV) Agents
MAVYRET - Tier 2; PA; SP; QL
ribavirin oral - Tier 1; QL
SOFOSBUVIR-VELPATASVIR (brand for sofosbuvir-velpatasvir) - Tier
2; PA; SP; QL
EPCLUSA ORAL PACKET - Tier 2; PA; SP; QL
EPCLUSA ORAL TABLET 200-50 MG - Tier 2; PA
EPCLUSA ORAL TABLET 400-100 MG (brand for sofosbuvir-velpatasvir)
- Tier 2; PA; SP; QL
HARVONI ORAL PACKET - Tier 2; PA
HARVONI ORAL TABLET 45-200 MG - Tier 2; PA; QL
HARVONI ORAL TABLET 90-400 MG (brand for ledipasvir-sofosbuvir) -
Tier 2; PA; SP; QL
LEDIPASVIR-SOFOSBUVIR (brand for ledipasvir-sofosbuvir) - Tier 2; PA;
SP; QL
SOVALDI ORAL PACKET - Tier 2; PA
SOVALDI ORAL TABLET 200 MG - Tier 2; PA; QL
SOVALDI ORAL TABLET 400 MG - Tier 2; PA; SP; QL
VIEKIRA PAK - Tier 2; PA; SP; QL
VOSEVI - Tier 2; PA; SP; QL
ZEPATIER - Tier 2; PA; SP; QL
Antiherpetic Agents
acyclovir external (generic for ZOVIRAX) - Tier 1; QL
acyclovir oral (generic for ZOVIRAX) - Tier 1; QL
DENAVIR - Tier 2
valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL
famciclovir oral - Tier 1; PA; QL
SITAVIG - Tier 2; PA; QL
VALTREX (brand for valacyclovir hcl) - Tier 2; PA; QL
ZOVIRAX (brand for acyclovir) - Tier 2; PA; QL
Anti-HIV Agents, Integrase Inhibitors (INSTI)
BIKTARVY ORAL TABLET 30-120-15 MG - Tier 2
BIKTARVY ORAL TABLET 50-200-25 MG - Tier 2; QL
DOVATO - Tier 2; QL
GENVOYA - Tier 2; QL
ISENTRESS - Tier 2; QL
ISENTRESS HD - Tier 2; QL
JULUCA - Tier 2; QL
TIVICAY - Tier 2; QL
TIVICAY PD - Tier 2; QL
STRIBILD - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
50
Preferred Agents Non-Preferred Agents
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA - Tier 2; QL
DELSTRIGO - Tier 2; QL
efavirenz (generic for SUSTIVA) - Tier 1; QL
efavirenz-emtricitab-tenofovir (generic for ATRIPLA) - Tier 1; QL
PIFELTRO - Tier 2; QL
SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; QL
SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; QL
EDURANT - Tier 2; PA; QL
efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; PA; QL
etravirine (generic for INTELENCE) - Tier 1; PA; QL
INTELENCE (brand for etravirine) - Tier 2; PA; QL
nevirapine - Tier 1; PA; QL
nevirapine er - Tier 1; PA; QL
SUSTIVA (brand for efavirenz) - Tier 2; PA; QL
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir sulfate oral tablet (generic for ZIAGEN) - Tier 1; QL
abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL
CIMDUO - Tier 2; QL
DESCOVY - Tier 2; QL
emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; QL
EMTRIVA (brand for emtricitabine) - Tier 2; QL
ODEFSEY - Tier 2; QL
tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL
TRIUMEQ - Tier 2; QL
TRIUMEQ PD - Tier 2; QL
TRUVADA (brand for emtricitabine-tenofovir df) - Tier 2; QL
VIREAD ORAL POWDER - Tier 2; QL
abacavir sulfate oral solution (generic for ZIAGEN) - Tier 1; PA; QL
COMBIVIR (brand for lamivudine-zidovudine) - Tier 2; PA; QL
emtricitabine (generic for EMTRIVA) - Tier 1; PA; QL
EPIVIR (brand for lamivudine) - Tier 2; PA; QL
EPZICOM (brand for abacavir sulfate-lamivudine) - Tier 2; PA; QL
lamivudine oral solution (generic for EPIVIR) - Tier 1; PA; QL
lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1; PA;
QL
lamivudine-zidovudine (generic for COMBIVIR) - Tier 1; PA; QL
RETROVIR ORAL (brand for zidovudine) - Tier 2; PA; QL
stavudine - Tier 1; PA; QL
TRIZIVIR - Tier 2; PA; QL
VIREAD ORAL TABLET 150 MG, 200 MG - Tier 2; QL
zidovudine (generic for RETROVIR) - Tier 1; QL
VIREAD ORAL TABLET 250 MG - Tier 2; PA; QL
VIREAD ORAL TABLET 300 MG (brand for tenofovir disoproxil fumarate)
- Tier 2; PA; QL
ZIAGEN (brand for abacavir sulfate) - Tier 2; PA; QL
Anti-HIV Agents, Other
RUKOBIA - Tier 2; PA; QL FUZEON - Tier 2; PA; QL
maraviroc (generic for SELZENTRY) - Tier 1; PA; QL
SELZENTRY (brand for maraviroc) - Tier 2; PA; QL
TYBOST - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
51
Preferred Agents Non-Preferred Agents
Anti-HIV Agents, Protease Inhibitors (PI)
atazanavir sulfate (generic for REYATAZ) - Tier 1; QL
EVOTAZ - Tier 2; QL
KALETRA ORAL TABLET (brand for lopinavir-ritonavir) - Tier 2; QL
lopinavir-ritonavir oral solution (generic for KALETRA) - Tier 1; QL
NORVIR ORAL TABLET (brand for ritonavir) - Tier 2; QL
PREZCOBIX - Tier 2; QL
REYATAZ ORAL PACKET - Tier 2; QL
APTIVUS - Tier 2; PA; QL
fosamprenavir calcium (generic for LEXIVA) - Tier 1; PA; QL
KALETRA ORAL SOLUTION (brand for lopinavir-ritonavir) - Tier 2; PA;
QL
LEXIVA (brand for fosamprenavir calcium) - Tier 2; PA; QL
lopinavir-ritonavir oral tablet (generic for KALETRA) - Tier 1; PA; QL
NORVIR ORAL PACKET - Tier 2; PA; QL
NORVIR ORAL SOLUTION - Tier 2; PA; QL
REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA;
QL
ritonavir (generic for NORVIR) - Tier 1; PA; QL
SYMTUZA - Tier 2; PA; QL
VIRACEPT - Tier 2; PA; QL
Anti-influenza Agents
oseltamivir phosphate oral (generic for TAMIFLU) - Tier 1; QL
RELENZA DISKHALER - Tier 2; QL
rimantadine hcl - Tier 1; QL
TAMIFLU (brand for oseltamivir phosphate) - Tier 2; PA; QL
XOFLUZA (40 MG DOSE) - Tier 2; PA; QL
XOFLUZA (80 MG DOSE) - Tier 2; PA; QL
Antivirals - Drugs to Treat Viral Infections
TPOXX ORAL - Tier 2; PA
Anti-Cytomegalovirus (CMV) Agents - Miscellaneous Antiviral
Drugs
LIVTENCITY - Tier 2; PA; QL
Anti-HIV Agents, Protease Inhibitors - HIV Drugs
PREZISTA - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
52
Preferred Agents Non-Preferred Agents
Antivirals
LAGEVRIO - Tier 2; QL
PAXLOVID - Tier 2; QL
Anxiolytics
Anxiolytics, Other
buspirone hcl oral - Tier 1; QL
hydroxyzine hcl oral - Tier 1; QL
hydroxyzine pamoate oral (generic for VISTARIL) - Tier 1; QL
meprobamate - Tier 1; QL
IGALMI - Tier 2; PA; QL
VISTARIL (brand for hydroxyzine pamoate) - Tier 2; PA; QL
Benzodiazepines
alprazolam oral tablet (generic for XANAX) - Tier 1; QL
chlordiazepoxide hcl - Tier 1; QL
clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL
clorazepate dipotassium (generic for TRANXENE-T) - Tier 1; QL
diazepam intensol (generic for DIAZEPAM INTENSOL) - Tier 1; QL
diazepam oral (generic for DIAZEPAM INTENSOL) - Tier 1; QL
lorazepam intensol (generic for LORAZEPAM INTENSOL) - Tier 1; QL
lorazepam oral concentrate 2 mg/ml (generic for LORAZEPAM
INTENSOL) - Tier 1; QL
lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL
midazolam hcl oral - Tier 1; QL
oxazepam - Tier 1; QL
alprazolam er (generic for XANAX XR) - Tier 1; PA; QL
alprazolam intensol - Tier 1; PA; QL
alprazolam oral tablet dispersible - Tier 1; PA; QL
alprazolam xr (generic for XANAX XR) - Tier 1; PA; QL
ATIVAN ORAL (brand for lorazepam) - Tier 2; PA; QL
clonazepam oral tablet dispersible - Tier 1; PA; QL
KLONOPIN (brand for clonazepam) - Tier 2; PA; QL
LOREEV XR - Tier 2; PA; QL
TRANXENE-T (brand for clorazepate dipotassium) - Tier 2; PA; QL
VALIUM (brand for diazepam) - Tier 2; PA; QL
XANAX (brand for alprazolam) - Tier 2; PA; QL
XANAX XR (brand for alprazolam er) - Tier 2; PA; QL
Attention Deficit Hyperactivity Disorder Agents, Non-
amphetamines - ADHD Drugs
Central Nervous System Agents - Drugs to Treat Nerve
Conditions
QELBREE - Tier 2; ST; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
53
Preferred Agents Non-Preferred Agents
Bipolar Agents
Mood Stabilizers
divalproex sodium er (generic for DEPAKOTE ER) - Tier 1; QL
divalproex sodium oral (generic for DEPAKOTE) - Tier 1; QL
EQUETRO - Tier 2; PA; QL
lithium carbonate er (generic for LITHOBID) - Tier 1; PA; QL
lithium carbonate oral - Tier 1; PA; QL
DEPAKOTE (brand for divalproex sodium) - Tier 2; PA; QL
DEPAKOTE ER (brand for divalproex sodium er) - Tier 2; PA; QL
DEPAKOTE SPRINKLES (brand for divalproex sodium) - Tier 2; PA; QL
LITHOBID (brand for lithium carbonate er) - Tier 2; PA; QL
Blood Formation Modifiers - Blood Formation Drugs
Blood Products and Modifiers - Drugs to Treat Blood Disorders
EMPAVELI - Tier 2; PA; SP; QL
Blood Glucose Regulators
Antidiabetic Agents
acarbose oral (generic for PRECOSE) - Tier 1; QL
BYETTA 10 MCG PEN - Tier 2; QL
BYETTA 5 MCG PEN - Tier 2; QL
FARXIGA - Tier 2; QL
glimepiride (generic for AMARYL) - Tier 1; QL
glipizide er (generic for GLUCOTROL XL) - Tier 1; QL
glipizide ir - Tier 1; QL
glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL
glipizide-metformin hcl - Tier 1; QL
glyburide micronized (generic for GLYNASE) - Tier 1; QL
glyburide oral - Tier 1; QL
glyburide-metformin - Tier 1; QL
ACTOPLUS MET (brand for pioglitazone hcl-metformin hcl) - Tier 2; PA;
QL
ACTOS (brand for pioglitazone hcl) - Tier 2; PA; QL
ADLYXIN - Tier 2; PA; QL
ADLYXIN STARTER PACK - Tier 2; PA; QL
ALOGLIPTIN BENZOATE (brand for alogliptin benzoate) - Tier 2; PA; QL
ALOGLIPTIN-METFORMIN HCL (brand for alogliptin-metformin hcl) - Tier
2; PA; QL
ALOGLIPTIN-PIOGLITAZONE (brand for alogliptin-pioglitazone) - Tier 2;
PA; QL
AMARYL (brand for glimepiride) - Tier 2; PA; QL
BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
54
Preferred Agents Non-Preferred Agents
INVOKAMET - Tier 2; QL
INVOKANA - Tier 2; QL
JANUMET - Tier 2; QL
JANUMET XR - Tier 2; QL
JANUVIA - Tier 2; QL
JARDIANCE - Tier 2; QL
JENTADUETO - Tier 2; QL
metformin hcl er - Tier 1; QL
metformin hcl oral tablet 1000 mg, 500 mg, 850 mg - Tier 1; QL
miglitol - Tier 1; QL
nateglinide - Tier 1; QL
pioglitazone hcl (generic for ACTOS) - Tier 1; QL
CYCLOSET - Tier 2; PA; QL
DUETACT (brand for pioglitazone hcl-glimepiride) - Tier 2; PA; QL
GLUCOTROL XL (brand for glipizide er) - Tier 2; PA; QL
GLUMETZA (brand for metformin hcl er (mod)) - Tier 2; PA; QL
GLYNASE (brand for glyburide micronized) - Tier 2; PA; QL
GLYXAMBI - Tier 2; PA; QL
INVOKAMET XR - Tier 2; PA; QL
JENTADUETO XR - Tier 2; PA; QL
KAZANO (brand for alogliptin-metformin hcl) - Tier 2; PA; QL
KOMBIGLYZE XR - Tier 2; PA; QL
metformin hcl er (mod) (generic for GLUMETZA) - Tier 1; PA; QL
metformin hcl er (osm) - Tier 1; PA; QL
pioglitazone hcl-metformin hcl (generic for ACTOPLUS MET) - Tier 1;
QL
repaglinide - Tier 1; QL
SYNJARDY - Tier 2; QL
TRADJENTA - Tier 2; QL
TRULICITY - Tier 2; QL
VICTOZA - Tier 2; QL
metformin hcl oral solution (generic for RIOMET) - Tier 1; PA; QL
metformin hcl oral tablet 625 mg - Tier 1; PA; QL
NESINA (brand for alogliptin benzoate) - Tier 2; PA; QL
ONGLYZA - Tier 2; PA; QL
OSENI (brand for alogliptin-pioglitazone) - Tier 2; PA; QL
OZEMPIC - Tier 2; PA; QL
OZEMPIC (2 MG/DOSE) - Tier 2; PA; QL
pioglitazone hcl-glimepiride (generic for DUETACT) - Tier 1; PA; QL
PRECOSE (brand for acarbose) - Tier 2; PA; QL
QTERN - Tier 2; PA; QL
RIOMET (brand for metformin hcl) - Tier 2; PA; QL
RYBELSUS - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
55
Preferred Agents Non-Preferred Agents
SEGLUROMET - Tier 2; PA; QL
SOLIQUA - Tier 2; PA; QL
STEGLATRO - Tier 2; PA; QL
STEGLUJAN - Tier 2; PA; QL
SYMLINPEN 120 - Tier 2; PA; QL
SYMLINPEN 60 - Tier 2; PA; QL
SYNJARDY XR - Tier 2; PA; QL
TRIJARDY XR - Tier 2; PA
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000
MG, 10-500 MG - Tier 2; PA
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000
MG, 5-1000 MG, 5-500 MG - Tier 2; PA; QL
XULTOPHY - Tier 2; PA; QL
Glycemic Agents
BAQSIMI ONE PACK - Tier 2; QL
BAQSIMI TWO PACK - Tier 2; QL
GLUCAGEN HYPOKIT - Tier 2; QL
GLUCAGON EMERGENCY KIT 1 MG INJECTION - Tier 2; QL
GVOKE HYPOPEN 1-PACK - Tier 2; QL
GVOKE HYPOPEN 2-PACK - Tier 2; QL
GVOKE PFS - Tier 2; QL
PROGLYCEM (brand for diazoxide) - Tier 2; QL
diazoxide oral (generic for PROGLYCEM) - Tier 1; PA; QL
GLUCAGON EMERGENCY INJECTION SOLUTION RECONSTITUTED -
Tier 2; PA; QL
glucagon emergency kit 1 mg injection - Tier 1; PA; QL
GVOKE KIT - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
56
Preferred Agents Non-Preferred Agents
Insulins
APIDRA SOLOSTAR - Tier 2; QL
APIDRA VIAL - Tier 2; QL
HUMALOG (brand for insulin lispro) - Tier 2; QL
HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen)
- Tier 2; QL
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-
INJECTOR 100 UNIT/ML (brand for insulin lispro (1 unit dial)) - Tier 2;
QL
HUMALOG MIX 50/50 - Tier 2; QL
HUMALOG MIX 50/50 KWIKPEN - Tier 2; QL
HUMALOG MIX 75/25 - Tier 2; QL
ADMELOG (brand for insulin lispro) - Tier 2; PA; QL
ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; PA;
QL
AFREZZA - Tier 2; PA; QL
BASAGLAR KWIKPEN (brand for insulin glargine solostar) - Tier 2; PA;
QL
FIASP - Tier 2; PA; QL
FIASP FLEXTOUCH - Tier 2; PA; QL
FIASP PENFILL - Tier 2; PA; QL
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR
200 UNIT/ML - Tier 2; PA; QL
HUMULIN R VIAL - Tier 2; PA; QL
HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro)
- Tier 2; QL
HUMULIN 70/30 KWIKPEN - Tier 2; QL
HUMULIN 70/30 VIAL - Tier 2; QL
HUMULIN N KWIKPEN - Tier 2; QL
HUMULIN N VIAL - Tier 2; QL
HUMULIN R U-500 KWIKPEN - Tier 2; QL
HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; QL
INSULIN ASP PROT & ASP FLEXPEN (brand for insulin asp prot &
asp flexpen) - Tier 2; QL
INSULIN ASPART (brand for insulin aspart) - Tier 2; QL
INSULIN GLARGINE (brand for insulin glargine) - Tier 2; PA; QL
INSULIN GLARGINE SOLOSTAR (brand for insulin glargine solostar) -
Tier 2; PA; QL
INSULIN GLARGINE-YFGN (brand for insulin glargine-yfgn) - Tier 2; PA;
QL
LYUMJEV - Tier 2; PA; QL
LYUMJEV KWIKPEN - Tier 2; PA; QL
NOVOLIN 70/30 RELION - Tier 2; PA; QL
NOVOLIN R FLEXPEN - Tier 2; PA; QL
NOVOLIN R FLEXPEN RELION - Tier 2; PA; QL
NOVOLIN R RELION - Tier 2; PA; QL
SEMGLEE (YFGN) (brand for insulin glargine-yfgn) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
57
Preferred Agents Non-Preferred Agents
INSULIN ASPART FLEXPEN (brand for insulin aspart flexpen) - Tier
2; QL
INSULIN ASPART PENFILL (brand for insulin aspart penfill) - Tier 2;
QL
INSULIN ASPART PROT & ASPART (brand for insulin aspart prot &
aspart) - Tier 2; QL
INSULIN LISPRO (brand for insulin lispro) - Tier 2; QL
INSULIN LISPRO (1 UNIT DIAL) (brand for insulin lispro (1 unit dial)) -
Tier 2; QL
INSULIN LISPRO JUNIOR KWIKPEN (brand for insulin lispro junior
kwikpen) - Tier 2; QL
INSULIN LISPRO PROT & LISPRO (brand for insulin lispro prot &
lispro) - Tier 2; QL
LANTUS SOLOSTAR (brand for insulin glargine solostar) - Tier 2; QL
LANTUS U-100 VIAL (brand for insulin glargine) - Tier 2; QL
LEVEMIR U-100 FLEXTOUCH - Tier 2; QL
LEVEMIR U-100 VIAL - Tier 2; QL
NOVOLIN 70/30 FLEXPEN - Tier 2; QL
NOVOLIN 70/30 FLEXPEN RELION - Tier 2; QL
NOVOLIN 70/30 VIAL - Tier 2; QL
NOVOLIN N FLEXPEN - Tier 2; QL
NOVOLIN N FLEXPEN RELION - Tier 2; QL
NOVOLIN N RELION - Tier 2; QL
NOVOLIN N VIAL - Tier 2; QL
NOVOLIN R VIAL - Tier 2; QL
NOVOLOG 70/30 FLEXPEN RELION (brand for insulin asp prot & asp
flexpen) - Tier 2; QL
NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; QL
NOVOLOG FLEXPEN RELION (brand for insulin aspart flexpen) - Tier
2; QL
NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp
flexpen) - Tier 2; QL
NOVOLOG MIX 70/30 RELION (brand for insulin aspart prot & aspart)
- Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
58
Preferred Agents Non-Preferred Agents
NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) -
Tier 2; QL
NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; QL
NOVOLOG RELION (brand for insulin aspart) - Tier 2; QL
NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; QL
TOUJEO MAX SOLOSTAR - Tier 2; QL
TOUJEO SOLOSTAR - Tier 2; QL
TRESIBA - Tier 2; ST; QL
TRESIBA FLEXTOUCH - Tier 2; ST; QL
Blood Glucose Regulators - Drugs to Regulate Blood Sugar
Antidiabetic Agents - Diabetic Drugs
MOUNJARO - Tier 2; PA
Glycemic Agents - Diabetic Drugs
glucose oral tablet chewable 4 gm (generic for TRUEPLUS
GLUCOSE) - Tier 1; QL
glutose 5 - Tier 1
soft glucose (generic for TRUEPLUS GLUCOSE) - Tier 1; QL
TRUEPLUS GLUCOSE ON THE GO (brand for cvs glucose) - Tier 2;
QL
TRUEPLUS GLUCOSE ORAL TABLET CHEWABLE (brand for cvs
glucose) - Tier 2; QL
glucose liquid shot oral liquid - Tier 1; PA
GLUCOSE NURSETTE - Tier 2; PA
glucose oral tablet chewable 4-6 gm-mg (generic for DEX4) - Tier 1; PA
GOOD START 5% GLUCOSE WATER - Tier 2; PA
TRUEPLUS GLUCOSE ORAL GEL - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
59
Preferred Agents Non-Preferred Agents
Blood Products and Modifiers
Anticoagulants
ELIQUIS - Tier 2; QL
ELIQUIS DVT/PE STARTER PACK - Tier 2; QL
enoxaparin sodium (generic for LOVENOX) - Tier 1; QL
heparin sodium (porcine) - Tier 1
heparin sodium (porcine) pf - Tier 1
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5
mg (generic for JANTOVEN) - Tier 1; QL
jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1
PRADAXA - Tier 2; QL
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL
warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1
ARIXTRA SUBCUTANEOUS SOLUTION 10 MG/0.8ML, 7.5 MG/0.6ML
(brand for fondaparinux sodium) - Tier 2; PA; QL
ARIXTRA SUBCUTANEOUS SOLUTION 2.5 MG/0.5ML, 5 MG/0.4ML
(brand for fondaparinux sodium) - Tier 2; PA
fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 7.5 mg/0.6ml
(generic for ARIXTRA) - Tier 1; PA; QL
fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml, 5 mg/0.4ml
(generic for ARIXTRA) - Tier 1; PA
FRAGMIN - Tier 2; PA
LOVENOX (brand for enoxaparin sodium) - Tier 2; PA; QL
SAVAYSA - Tier 2; PA; QL
XARELTO ORAL SUSPENSION RECONSTITUTED - Tier 2; PA; QL
XARELTO ORAL TABLET - Tier 2; QL
XARELTO STARTER PACK - Tier 2; QL
ZONTIVITY - Tier 2; PA; QL
Blood Products and Modifiers, Other
anagrelide hcl (generic for AGRYLIN) - Tier 1
DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2
DROXIA ORAL CAPSULE 400 MG - Tier 2; QL
EPOGEN - Tier 2; PA; SP; QL
NEUPOGEN - Tier 2; PA; SP; QL
PROMACTA ORAL TABLET - Tier 2; SP; QL
RETACRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML,
3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML - Tier 2; PA; SP; QL
RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA; SP
ZIEXTENZO - Tier 2; PA; SP
AGRYLIN (brand for anagrelide hcl) - Tier 2; PA
ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QL
FULPHILA - Tier 2; PA; SP; QL
GRANIX - Tier 2; PA; SP; QL
LEUKINE - Tier 2; PA; SP; QL
MOZOBIL - Tier 2; PA; SP; QL
MULPLETA - Tier 2; PA; SP; QL
NEULASTA - Tier 2; PA; SP; QL
NEULASTA ONPRO - Tier 2; PA; SP; QL
NIVESTYM - Tier 2; PA; SP; QL
OXBRYTA ORAL TABLET - Tier 2; PA; QL
OXBRYTA ORAL TABLET SOLUBLE - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
60
Preferred Agents Non-Preferred Agents
PROCRIT - Tier 2; PA; SP; QL
PROMACTA ORAL PACKET - Tier 2; PA; SP; QL
PYRUKYND - Tier 2; PA; SP; QL
PYRUKYND TAPER PACK - Tier 2; PA; SP; QL
RELEUKO - Tier 2; PA; SP
SIKLOS - Tier 2; PA; QL
UDENYCA - Tier 2; PA; SP; QL
ZARXIO - Tier 2; PA; SP; QL
Hemostasis Agents
AMICAR ORAL SOLUTION (brand for aminocaproic acid) - Tier 2; QL
aminocaproic acid oral tablet (generic for AMICAR) - Tier 1; QL
tranexamic acid oral (generic for LYSTEDA) - Tier 1; QL
AMICAR ORAL TABLET (brand for aminocaproic acid) - Tier 2; PA; QL
aminocaproic acid oral solution (generic for AMICAR) - Tier 1; PA; QL
LYSTEDA (brand for tranexamic acid) - Tier 2; PA; QL
Platelet Modifying Agents
aspirin-dipyridamole er - Tier 1; QL
BRILINTA - Tier 2; QL
cilostazol - Tier 1; QL
clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QL
dipyridamole oral - Tier 1; QL
prasugrel hcl (generic for EFFIENT) - Tier 1; QL
CABLIVI - Tier 2; PA; SP; QL
DOPTELET - Tier 2; PA; SP; QL
EFFIENT (brand for prasugrel hcl) - Tier 2; PA; QL
PLAVIX (brand for clopidogrel bisulfate) - Tier 2; PA; QL
TAVALISSE - Tier 2; PA; SP; QL
Blood Products and Modifiers - Drugs to Treat Blood Disorders
Hemostasis Agents - Drugs to Stop Bleeding
NUWIQ INTRAVENOUS KIT 1000 UNIT, 2000 UNIT, 250 UNIT, 2500
UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT - Tier 2; PA
THROMBOGEN - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
61
Preferred Agents Non-Preferred Agents
Blood Products/Modifiers/Volume Expanders - Drugs to Treat
Blood Disorders
Blood Formation Modifiers - Blood Formation Drugs
MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 100
MCG/0.3ML, 200 MCG/0.3ML, 50 MCG/0.3ML, 75 MCG/0.3ML - Tier
2; PA; QL
MIRCERA INJECTION SOLUTION PREFILLED SYRINGE 150
MCG/0.3ML, 30 MCG/0.3ML - Tier 2; PA
Hemostasis Agents - Drugs to Stop Bleeding
ADYNOVATE - Tier 2; PA
ELOCTATE - Tier 2; PA
ESPEROCT - Tier 2; PA
HEMLIBRA - Tier 2; PA; SP; QL
IDELVION - Tier 2; PA
COAGADEX INTRAVENOUS SOLUTION RECONSTITUTED 500 UNIT -
Tier 2; PA
MONSELS FERRIC SUBSULFATE - Tier 2; PA
RECOTHROM - Tier 2; PA
RECOTHROM SPRAY KIT - Tier 2; PA
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine (generic for CATAPRES-TTS-1) - Tier 1; QL
clonidine hcl oral - Tier 1; QL
guanfacine hcl - Tier 1; QL
methyldopa - Tier 1; QL
midodrine hcl - Tier 1; QL
CATAPRES-TTS-1 (brand for clonidine) - Tier 2; PA; QL
CATAPRES-TTS-2 (brand for clonidine) - Tier 2; PA; QL
CATAPRES-TTS-3 (brand for clonidine) - Tier 2; PA; QL
droxidopa (generic for NORTHERA) - Tier 1; PA; SP; QL
NEXICLON XR - Tier 2; PA; QL
NORTHERA (brand for droxidopa) - Tier 2; PA; SP; QL
Alpha-adrenergic Blocking Agents
doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL
prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL
CARDURA (brand for doxazosin mesylate) - Tier 2; PA; QL
DIBENZYLINE (brand for phenoxybenzamine hcl) - Tier 2; PA; QL
MINIPRESS (brand for prazosin hcl) - Tier 2; PA; QL
phenoxybenzamine hcl oral (generic for DIBENZYLINE) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
62
Preferred Agents Non-Preferred Agents
Angiotensin II Receptor Antagonists
irbesartan (generic for AVAPRO) - Tier 1; QL
losartan potassium oral (generic for COZAAR) - Tier 1; QL
olmesartan medoxomil oral (generic for BENICAR) - Tier 1; QL
valsartan oral tablet (generic for DIOVAN) - Tier 1; QL
ATACAND (brand for candesartan cilexetil) - Tier 2; PA; QL
AVAPRO (brand for irbesartan) - Tier 2; PA; QL
BENICAR (brand for olmesartan medoxomil) - Tier 2; PA; QL
candesartan cilexetil (generic for ATACAND) - Tier 1; PA; QL
COZAAR (brand for losartan potassium) - Tier 2; PA; QL
DIOVAN (brand for valsartan) - Tier 2; PA; QL
EDARBI - Tier 2; PA; QL
MICARDIS (brand for telmisartan) - Tier 2; PA; QL
telmisartan (generic for MICARDIS) - Tier 1; PA; QL
VALSARTAN ORAL SOLUTION - Tier 2; PA; QL
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL
captopril oral - Tier 1; QL
enalapril maleate oral tablet (generic for VASOTEC) - Tier 1; QL
EPANED (brand for enalapril maleate) - Tier 2; QL
fosinopril sodium - Tier 1; QL
lisinopril oral (generic for ZESTRIL) - Tier 1; QL
moexipril hcl - Tier 1; QL
perindopril erbumine - Tier 1; QL
quinapril hcl (generic for ACCUPRIL) - Tier 1; QL
ramipril (generic for ALTACE) - Tier 1; QL
trandolapril (generic for MAVIK) - Tier 1; QL
ACCUPRIL (brand for quinapril hcl) - Tier 2; PA; QL
ALTACE (brand for ramipril) - Tier 2; PA; QL
enalapril maleate oral solution (generic for EPANED) - Tier 1; PA; QL
LOTENSIN (brand for benazepril hcl) - Tier 2; PA; QL
QBRELIS - Tier 2; PA; QL
VASOTEC (brand for enalapril maleate) - Tier 2; PA; QL
ZESTRIL (brand for lisinopril) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
63
Preferred Agents Non-Preferred Agents
Antiarrhythmics
amiodarone hcl oral tablet 200 mg (generic for PACERONE) - Tier 1;
QL
disopyramide phosphate (generic for NORPACE) - Tier 1; QL
dofetilide (generic for TIKOSYN) - Tier 1; QL
flecainide acetate - Tier 1; QL
mexiletine hcl oral - Tier 1; QL
NORPACE CR - Tier 2; QL
PACERONE ORAL TABLET 200 MG (brand for amiodarone hcl) - Tier
2; QL
propafenone hcl - Tier 1; QL
propafenone hcl er (generic for RYTHMOL SR) - Tier 1; QL
quinidine gluconate er - Tier 1; QL
amiodarone hcl oral tablet 100 mg, 400 mg (generic for PACERONE) -
Tier 1; PA; QL
BETAPACE (brand for sotalol hcl) - Tier 2; PA; QL
BETAPACE AF (brand for sotalol hcl (af)) - Tier 2; PA; QL
MULTAQ - Tier 2; PA; QL
NORPACE (brand for disopyramide phosphate) - Tier 2; PA; QL
PACERONE ORAL TABLET 100 MG, 400 MG (brand for amiodarone hcl)
- Tier 2; PA; QL
RYTHMOL SR (brand for propafenone hcl er) - Tier 2; PA; QL
SOTYLIZE - Tier 2; PA; QL
TIKOSYN (brand for dofetilide) - Tier 2; PA; QL
quinidine sulfate - Tier 1; QL
sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL
sotalol hcl oral (generic for BETAPACE) - Tier 1; QL
Beta-adrenergic Blocking Agents
acebutolol hcl oral - Tier 1; QL
atenolol oral (generic for TENORMIN) - Tier 1; QL
betaxolol hcl oral - Tier 1; QL
bisoprolol fumarate oral - Tier 1; QL
BYSTOLIC (brand for nebivolol hcl) - Tier 2; QL
carvedilol (generic for COREG) - Tier 1; QL
HEMANGEOL - Tier 2; QL
labetalol hcl oral - Tier 1; QL
metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL
metoprolol tartrate oral (generic for LOPRESSOR) - Tier 1; QL
nadolol oral (generic for CORGARD) - Tier 1; QL
pindolol - Tier 1; QL
carvedilol phosphate er (generic for COREG CR) - Tier 1; PA; QL
COREG (brand for carvedilol) - Tier 2; PA; QL
COREG CR (brand for carvedilol phosphate er) - Tier 2; PA; QL
CORGARD (brand for nadolol) - Tier 2; PA; QL
INDERAL LA (brand for propranolol hcl er) - Tier 2; PA; QL
INDERAL XL - Tier 2; PA; QL
INNOPRAN XL - Tier 2; PA; QL
KAPSPARGO SPRINKLE - Tier 2; PA; QL
LOPRESSOR (brand for metoprolol tartrate) - Tier 2; PA; QL
nebivolol hcl (generic for BYSTOLIC) - Tier 1; PA; QL
TENORMIN (brand for atenolol) - Tier 2; PA; QL
TOPROL XL (brand for metoprolol succinate er) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
64
Preferred Agents Non-Preferred Agents
propranolol hcl er (generic for INDERAL LA) - Tier 1; QL
propranolol hcl oral - Tier 1; QL
Calcium Channel Blocking Agents, Dihydropyridines
amlodipine besylate oral (generic for NORVASC) - Tier 1; QL
felodipine er - Tier 1; QL
nicardipine hcl oral - Tier 1; QL
nifedipine er (generic for AFEDITAB CR) - Tier 1; QL
nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1;
QL
nifedipine oral - Tier 1; QL
isradipine - Tier 1; PA; QL
KATERZIA - Tier 2; PA; QL
nimodipine oral - Tier 1; PA; QL
nisoldipine er (generic for SULAR) - Tier 1; PA; QL
NORLIQVA - Tier 2; PA; QL
NORVASC (brand for amlodipine besylate) - Tier 2; PA; QL
NYMALIZE - Tier 2; PA; QL
PROCARDIA XL (brand for nifedipine er osmotic release) - Tier 2; PA; QL
SULAR (brand for nisoldipine er) - Tier 2; PA; QL
Calcium Channel Blocking Agents, Nondihydropyridines
cartia xt (generic for CARTIA XT) - Tier 1; QL
diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL
diltiazem hcl er coated beads oral capsule extended release 24 hour
(generic for CARDIZEM CD) - Tier 1; QL
diltiazem hcl er oral capsule extended release 12 hour - Tier 1; QL
diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180
mg - Tier 1; QL
diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL
dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg - Tier 1;
QL
taztia xt (generic for TAZTIA XT) - Tier 1; QL
tiadylt er (generic for TAZTIA XT) - Tier 1; QL
CALAN SR (brand for verapamil hcl er) - Tier 2; PA; QL
CARDIZEM (brand for diltiazem hcl) - Tier 2; PA; QL
CARDIZEM CD (brand for diltiazem hcl er coated beads) - Tier 2; PA; QL
CARDIZEM LA (brand for diltiazem hcl er coated beads) - Tier 2; PA; QL
diltiazem hcl er coated beads oral tablet extended release 24 hour
(generic for MATZIM LA) - Tier 1; PA; QL
diltiazem hcl er oral capsule extended release 24 hour 240 mg - Tier 1;
PA; QL
dilt-xr oral capsule extended release 24 hour 240 mg - Tier 1; PA; QL
matzim la (generic for MATZIM LA) - Tier 1; PA; QL
TIAZAC (brand for diltiazem hcl er beads) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
65
Preferred Agents Non-Preferred Agents
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180
mg, 240 mg, 360 mg (generic for VERELAN) - Tier 1; QL
verapamil hcl er oral tablet extended release (generic for CALAN SR) -
Tier 1; QL
verapamil hcl oral - Tier 1; QL
verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg,
300 mg (generic for VERELAN PM) - Tier 1; PA; QL
VERELAN (brand for verapamil hcl er) - Tier 2; PA; QL
VERELAN PM (brand for verapamil hcl er) - Tier 2; PA; QL
Cardiovascular Agents, Other
acetazolamide er - Tier 1; QL
acetazolamide oral - Tier 1; QL
amiloride-hydrochlorothiazide - Tier 1; QL
amlodipine besylate-benazepril hcl (generic for LOTREL) - Tier 1; QL
amlodipine besylate-valsartan (generic for EXFORGE) - Tier 1; QL
amlodipine-olmesartan (generic for AZOR) - Tier 1; QL
atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL
benazepril-hydrochlorothiazide (generic for LOTENSIN HCT) - Tier 1;
QL
bisoprolol-hydrochlorothiazide (generic for ZIAC) - Tier 1; QL
DEMSER (brand for metyrosine) - Tier 2; QL
digitek (generic for DIGITEK) - Tier 1; QL
ACCURETIC (brand for quinapril-hydrochlorothiazide) - Tier 2; PA; QL
ALDACTAZIDE (brand for spironolactone-hctz) - Tier 2; PA; QL
aliskiren fumarate (generic for TEKTURNA) - Tier 1; PA; QL
amlodipine-atorvastatin (generic for CADUET) - Tier 1; PA; QL
ATACAND HCT (brand for candesartan cilexetil-hctz) - Tier 2; PA; QL
AVALIDE (brand for irbesartan-hydrochlorothiazide) - Tier 2; PA; QL
AZOR (brand for amlodipine-olmesartan) - Tier 2; PA; QL
BENICAR HCT (brand for olmesartan medoxomil-hctz) - Tier 2; PA; QL
BIDIL (brand for isosorb dinitrate-hydralazine) - Tier 2; PA; QL
CADUET (brand for amlodipine-atorvastatin) - Tier 2; PA; QL
candesartan cilexetil-hctz (generic for ATACAND HCT) - Tier 1; PA; QL
CORLANOR - Tier 2; PA; QL
digox (generic for DIGITEK) - Tier 1; QL
digoxin oral solution - Tier 1; QL
digoxin oral tablet 125 mcg, 250 mcg (generic for DIGITEK) - Tier 1;
QL
enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL
ENTRESTO - Tier 2; PA; QL
fosinopril sodium-hctz - Tier 1; QL
irbesartan-hydrochlorothiazide (generic for AVALIDE) - Tier 1; QL
lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL
losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL
metoprolol-hydrochlorothiazide - Tier 1; QL
olmesartan medoxomil-hctz (generic for BENICAR HCT) - Tier 1; QL
DIOVAN HCT (brand for valsartan-hydrochlorothiazide) - Tier 2; PA; QL
EDARBYCLOR - Tier 2; PA; QL
EXFORGE (brand for amlodipine besylate-valsartan) - Tier 2; PA; QL
EXFORGE HCT - Tier 2; PA; QL
HYZAAR (brand for losartan potassium-hctz) - Tier 2; PA; QL
isosorb dinitrate-hydralazine (generic for BIDIL) - Tier 1; PA; QL
KERENDIA - Tier 2; PA; QL
LANOXIN ORAL TABLET 125 MCG, 250 MCG (brand for digoxin) - Tier
2; PA; QL
LOTENSIN HCT (brand for benazepril-hydrochlorothiazide) - Tier 2; PA;
QL
LOTREL (brand for amlodipine besy-benazepril hcl) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
66
Preferred Agents Non-Preferred Agents
olmesartan-amlodipine-hctz (generic for TRIBENZOR) - Tier 1; QL
pentoxifylline er - Tier 1; QL
quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL
ranolazine er (generic for RANEXA) - Tier 1; QL
spironolactone-hctz (generic for ALDACTAZIDE) - Tier 1; QL
telmisartan-amlodipine - Tier 1; QL
trandolapril-verapamil hcl er - Tier 1; QL
triamterene-hctz (generic for MAXZIDE) - Tier 1; QL
valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1; QL
VECAMYL - Tier 2; QL
MAXZIDE (brand for triamterene-hctz) - Tier 2; PA; QL
MAXZIDE-25 (brand for triamterene-hctz) - Tier 2; PA; QL
metyrosine (generic for DEMSER) - Tier 1; PA; QL
MICARDIS HCT (brand for telmisartan-hctz) - Tier 2; PA; QL
RANEXA (brand for ranolazine er) - Tier 2; PA; QL
TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA; QL
TEKTURNA HCT - Tier 2; PA; QL
telmisartan-hctz (generic for MICARDIS HCT) - Tier 1; PA; QL
TENORETIC 100 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL
TENORETIC 50 (brand for atenolol-chlorthalidone) - Tier 2; PA; QL
TRIBENZOR (brand for olmesartan-amlodipine-hctz) - Tier 2; PA; QL
VASERETIC (brand for enalapril-hydrochlorothiazide) - Tier 2; PA; QL
ZESTORETIC (brand for lisinopril-hydrochlorothiazide) - Tier 2; PA; QL
ZIAC (brand for bisoprolol-hydrochlorothiazide) - Tier 2; PA; QL
Diuretics, Loop
bumetanide oral (generic for BUMEX) - Tier 1; QL
ethacrynic acid (generic for EDECRIN) - Tier 1; QL
furosemide oral (generic for LASIX) - Tier 1; QL
SOAANZ ORAL TABLET 20 MG (brand for torsemide) - Tier 2; QL
torsemide (generic for SOAANZ) - Tier 1; QL
BUMEX (brand for bumetanide) - Tier 2; PA; QL
EDECRIN (brand for ethacrynic acid) - Tier 2; PA; QL
LASIX (brand for furosemide) - Tier 2; PA; QL
SOAANZ ORAL TABLET 40 MG, 60 MG - Tier 2; PA; QL
Diuretics, Potassium-sparing
amiloride hcl oral - Tier 1; QL
eplerenone (generic for INSPRA) - Tier 1; QL
spironolactone oral (generic for ALDACTONE) - Tier 1; QL
triamterene oral (generic for DYRENIUM) - Tier 1; QL
ALDACTONE (brand for spironolactone) - Tier 2; PA; QL
CAROSPIR - Tier 2; PA; QL
DYRENIUM (brand for triamterene) - Tier 2; PA; QL
INSPRA (brand for eplerenone) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
67
Preferred Agents Non-Preferred Agents
Diuretics, Thiazide
chlorthalidone - Tier 1; QL
DIURIL - Tier 2; QL
hydrochlorothiazide oral - Tier 1; QL
indapamide - Tier 1; QL
metolazone - Tier 1; QL
THALITONE - Tier 2; QL
Dyslipidemics, Fibric Acid Derivatives
fenofibrate oral tablet 145 mg, 48 mg (generic for TRICOR) - Tier 1;
QL
gemfibrozil oral (generic for LOPID) - Tier 1; QL
ANTARA (brand for fenofibrate micronized) - Tier 2; PA; QL
fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67
mg - Tier 1; PA; QL
FENOFIBRATE MICRONIZED ORAL CAPSULE 30 MG, 90 MG (brand
for fenofibrate micronized) - Tier 2; PA; QL
fenofibrate oral capsule (generic for LIPOFEN) - Tier 1; PA; QL
fenofibrate oral tablet 120 mg, 40 mg (generic for FENOGLIDE) - Tier 1;
PA; QL
fenofibrate oral tablet 160 mg, 54 mg - Tier 1; PA; QL
fenofibric acid oral capsule delayed release (generic for TRILIPIX) - Tier
1; PA; QL
FENOGLIDE (brand for fenofibrate) - Tier 2; PA; QL
LIPOFEN (brand for fenofibrate) - Tier 2; PA; QL
LOPID (brand for gemfibrozil) - Tier 2; PA; QL
TRICOR (brand for fenofibrate) - Tier 2; PA; QL
TRILIPIX (brand for fenofibric acid) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
68
Preferred Agents Non-Preferred Agents
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL
lovastatin oral - Tier 1; QL
pravastatin sodium - Tier 1; QL
rosuvastatin calcium (generic for CRESTOR) - Tier 1; QL
simvastatin oral (generic for ZOCOR) - Tier 1; QL
ALTOPREV - Tier 2; PA; QL
CRESTOR (brand for rosuvastatin calcium) - Tier 2; PA; QL
EZALLOR SPRINKLE - Tier 2; PA; QL
fluvastatin sodium - Tier 1; PA; QL
fluvastatin sodium er (generic for LESCOL XL) - Tier 1; PA; QL
LESCOL XL (brand for fluvastatin sodium er) - Tier 2; PA; QL
LIPITOR (brand for atorvastatin calcium) - Tier 2; PA; QL
LIVALO - Tier 2; PA; QL
ZOCOR (brand for simvastatin) - Tier 2; PA; QL
ZYPITAMAG - Tier 2; PA; QL
Dyslipidemics, Other
cholestyramine light (generic for PREVALITE) - Tier 1; QL
cholestyramine oral (generic for QUESTRAN) - Tier 1; QL
colestipol hcl oral tablet (generic for COLESTID) - Tier 1; QL
ezetimibe (generic for ZETIA) - Tier 1; QL
omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL
PRALUENT - Tier 2; PA; SP; QL
prevalite (generic for PREVALITE) - Tier 1; QL
REPATHA - Tier 2; PA; SP; QL
colesevelam hcl (generic for WELCHOL) - Tier 1; PA; QL
COLESTID (brand for colestipol hcl) - Tier 2; PA; QL
COLESTID FLAVORED (brand for colestipol hcl) - Tier 2; PA; QL
colestipol hcl oral granules (generic for COLESTID) - Tier 1; PA; QL
colestipol hcl oral packet (generic for COLESTID) - Tier 1; PA; QL
ezetimibe-simvastatin (generic for VYTORIN) - Tier 1; PA; QL
icosapent ethyl (generic for VASCEPA) - Tier 1; PA; QL
JUXTAPID - Tier 2; PA; SP; QL
LOVAZA (brand for omega-3-acid ethyl esters) - Tier 2; PA; QL
NEXLETOL - Tier 2; PA; QL
NEXLIZET - Tier 2; PA; QL
niacin er (antihyperlipidemic) (generic for NIASPAN) - Tier 1; PA; QL
NIASPAN (brand for niacin er (antihyperlipidemic)) - Tier 2; PA; QL
QUESTRAN (brand for cholestyramine) - Tier 2; PA; QL
QUESTRAN LIGHT (brand for cholestyramine light) - Tier 2; PA; QL
VASCEPA (brand for icosapent ethyl) - Tier 2; PA; QL
VYTORIN (brand for ezetimibe-simvastatin) - Tier 2; PA; QL
WELCHOL (brand for colesevelam hcl) - Tier 2; PA; QL
ZETIA (brand for ezetimibe) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
69
Preferred Agents Non-Preferred Agents
Vasodilators, Direct-acting Arterial
hydralazine hcl oral - Tier 1; QL
minoxidil oral - Tier 1; QL
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate (generic for ISORDIL TITRADOSE) - Tier 1; QL
isosorbide mononitrate - Tier 1; QL
isosorbide mononitrate er - Tier 1; QL
NITRO-BID - Tier 2; QL
nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL
nitroglycerin transdermal (generic for NITRO-DUR) - Tier 1; QL
nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QL
NITROSTAT TABLET SUBLINGUAL 0.4 MG SUBLINGUAL (brand for
nitroglycerin) - Tier 2; QL
RECTIV - Tier 2; DX2RX
GONITRO - Tier 2; PA; QL
ISORDIL TITRADOSE (brand for isosorbide dinitrate) - Tier 2; PA; QL
NITRO-DUR (brand for nitroglycerin) - Tier 2; PA; QL
NITROLINGUAL (brand for nitroglycerin) - Tier 2; PA; QL
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.6 MG
(brand for nitroglycerin) - Tier 2; PA; QL
NITROSTAT TABLET SUBLINGUAL 0.4 MG SUBLINGUAL (brand for
nitroglycerin) - Tier 2; PA; QL
Cardiovascular Agents - Drugs to Treat Heart and Circulation
Conditions
Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs
CAMZYOS - Tier 2; PA; SP; QL
isoxsuprine hcl oral tablet 10 mg - Tier 1; PA
Dyslipidemics, Fibric Acid Derivatives - Cholesterol Control Drugs
fenofibric acid oral tablet (generic for FIBRICOR) - Tier 1; PA; QL
FIBRICOR (brand for fenofibric acid) - Tier 2; PA; QL
Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs
Cardiovascular Agents - Drugs to Treat Heart and Circulation
Conditions
VERQUVO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
70
Preferred Agents Non-Preferred Agents
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Non-
amphetamines
atomoxetine hcl (generic for STRATTERA) - Tier 1; QL
clonidine hcl er (generic for KAPVAY) - Tier 1; QL
CONCERTA (brand for methylphenidate hcl er (osm)) - Tier 2; QL
dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; QL
dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; QL; AL
FOCALIN XR (brand for dexmethylphenidate hcl er) - Tier 2; QL; AL
guanfacine hcl er (generic for INTUNIV) - Tier 1; QL
methylphenidate hcl er - Tier 1; QL
methylphenidate hcl er (cd) - Tier 1; QL
methylphenidate hcl er (la) (generic for RITALIN LA) - Tier 1; QL
methylphenidate hcl er (osm) oral tablet extended release 18 mg, 27
mg, 36 mg (generic for CONCERTA) - Tier 1; QL
ADHANSIA XR - Tier 2; PA; QL
APTENSIO XR (brand for methylphenidate hcl er (xr)) - Tier 2; PA
COTEMPLA XR-ODT - Tier 2; PA; QL
DAYTRANA - Tier 2; PA; QL; AL
FOCALIN (brand for dexmethylphenidate hcl) - Tier 2; PA; QL
INTUNIV (brand for guanfacine hcl er) - Tier 2; PA; QL
JORNAY PM - Tier 2; PA; QL
KAPVAY (brand for clonidine hcl er) - Tier 2; PA; QL
METHYLIN (brand for methylphenidate hcl) - Tier 2; PA; QL
methylphenidate hcl er (osm) oral tablet extended release 72 mg (generic
for RELEXXII) - Tier 1; PA; QL
methylphenidate hcl er (xr) (generic for APTENSIO XR) - Tier 1; PA
methylphenidate hcl er (osm) tablet extended release 54 mg oral
(generic for CONCERTA) - Tier 1; QL
methylphenidate hcl oral solution (generic for METHYLIN) - Tier 1; QL
methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; QL
QUILLICHEW ER - Tier 2; QL
QUILLIVANT XR - Tier 2; QL
RITALIN LA (brand for methylphenidate hcl er (la)) - Tier 2; QL
methylphenidate hcl oral tablet chewable - Tier 1; PA
relexxii (generic for RELEXXII) - Tier 1; PA; QL
RITALIN (brand for methylphenidate hcl) - Tier 2; PA; QL
STRATTERA (brand for atomoxetine hcl) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
71
Preferred Agents Non-Preferred Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1;
QL
amphetamine-dextroamphetamine er (generic for ADDERALL XR) -
Tier 1; QL
dextroamphetamine sulfate (generic for PROCENTRA) - Tier 1; QL
dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1; QL
PROCENTRA (brand for dextroamphetamine sulfate) - Tier 2; QL
VYVANSE ORAL CAPSULE - Tier 2; QL
ADDERALL (brand for amphetamine-dextroamphetamine) - Tier 2; PA;
QL
ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2; PA;
QL
ADZENYS XR-ODT - Tier 2; PA; QL
amphetamine sulfate (generic for EVEKEO) - Tier 1; PA; QL
AZSTARYS - Tier 2; PA; QL; AL
DESOXYN (brand for methamphetamine hcl) - Tier 2; PA; QL
DEXEDRINE (brand for dextroamphetamine sulfate er) - Tier 2; PA; QL
DYANAVEL XR - Tier 2; PA; QL
EVEKEO (brand for amphetamine sulfate) - Tier 2; PA; QL
EVEKEO ODT - Tier 2; PA; QL
methamphetamine hcl (generic for DESOXYN) - Tier 1; PA; QL
MYDAYIS - Tier 2; PA; QL
VYVANSE ORAL TABLET CHEWABLE - Tier 2; PA; QL; AL
ZENZEDI (brand for dextroamphetamine sulfate) - Tier 2; PA; QL
Central Nervous System, Other
AUSTEDO - Tier 2; PA; SP; QL
caffeine citrate oral - Tier 1; QL
INGREZZA - Tier 2; PA; SP; QL
riluzole (generic for RILUTEK) - Tier 1; QL
tetrabenazine (generic for XENAZINE) - Tier 1; PA; SP; QL
XENAZINE (brand for tetrabenazine) - Tier 2; PA; SP; QL
EXSERVAN - Tier 2; PA; QL
FIRDAPSE - Tier 2; PA; SP; QL
GRALISE - Tier 2; PA; QL
HORIZANT - Tier 2; PA; QL
NUEDEXTA - Tier 2; PA; QL
RADICAVA ORS - Tier 2; PA; SP; QL
RADICAVA ORS STARTER KIT - Tier 2; PA; SP; QL
RILUTEK (brand for riluzole) - Tier 2; PA; QL
TIGLUTIK - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
72
Preferred Agents Non-Preferred Agents
Fibromyalgia Agents
duloxetine hcl oral (generic for CYMBALTA) - Tier 1; PA; QL
pregabalin (generic for LYRICA) - Tier 1; QL
CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL
DRIZALMA SPRINKLE - Tier 2; PA; QL
LYRICA (brand for pregabalin) - Tier 2; PA; QL
LYRICA CR (brand for pregabalin er) - Tier 2; PA; QL
pregabalin er (generic for LYRICA CR) - Tier 1; PA; QL
SAVELLA - Tier 2; PA; QL
SAVELLA TITRATION PACK - Tier 2; PA; QL
Multiple Sclerosis Agents
AUBAGIO - Tier 2; SP; QL
AVONEX PEN - Tier 2; SP; QL
AVONEX PREFILLED - Tier 2; SP; QL
BETASERON - Tier 2; SP; QL
COPAXONE (brand for glatiramer acetate) - Tier 2; SP; QL
dalfampridine er (generic for AMPYRA) - Tier 1; SP; QL
dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; SP; QL
dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1; SP;
QL
GILENYA ORAL CAPSULE 0.5 MG - Tier 2; SP; QL
REBIF - Tier 2; SP; QL
REBIF REBIDOSE - Tier 2; SP; QL
AMPYRA (brand for dalfampridine er) - Tier 2; PA; SP; QL
BAFIERTAM - Tier 2; PA
EXTAVIA - Tier 2; PA; SP; QL
glatiramer acetate (generic for GLATOPA) - Tier 1; PA; SP; QL
glatopa (generic for GLATOPA) - Tier 1; PA; SP; QL
KESIMPTA - Tier 2; PA; SP; QL
MAVENCLAD (10 TABS) - Tier 2; PA; SP; QL
MAVENCLAD (4 TABS) - Tier 2; PA; SP; QL
MAVENCLAD (5 TABS) - Tier 2; PA; SP; QL
MAVENCLAD (6 TABS) - Tier 2; PA; SP; QL
MAVENCLAD (7 TABS) - Tier 2; PA; SP; QL
MAVENCLAD (8 TABS) - Tier 2; PA; SP; QL
REBIF REBIDOSE TITRATION PACK - Tier 2; SP; QL
REBIF TITRATION PACK - Tier 2; SP; QL
MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL
MAYZENT - Tier 2; PA; SP; QL
MAYZENT STARTER PACK - Tier 2; PA; SP; QL
PLEGRIDY - Tier 2; PA; SP; QL
PLEGRIDY STARTER PACK - Tier 2; PA; SP; QL
TECFIDERA (brand for dimethyl fumarate) - Tier 2; PA; SP; QL
VUMERITY - Tier 2; PA; SP; QL
ZEPOSIA - Tier 2; PA; SP; QL
ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA; SP; QL
ZEPOSIA STARTER KIT - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
73
Preferred Agents Non-Preferred Agents
Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis
Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,
Cough, Cold and Lung Conditions
BRONCHITOL - Tier 2; PA; QL
Dental and Oral Agents
cevimeline hcl (generic for EVOXAC) - Tier 1; QL
chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier
1; QL
oralone (generic for ORALONE) - Tier 1; QL
periogard (generic for PERIOGARD) - Tier 1; QL
pilocarpine hcl oral (generic for SALAGEN) - Tier 1; QL
triamcinolone acetonide mouth/throat (generic for ORALONE) - Tier 1;
QL
EVOXAC (brand for cevimeline hcl) - Tier 2; PA; QL
PERIDEX (brand for chlorhexidine gluconate) - Tier 2; PA; QL
SALAGEN (brand for pilocarpine hcl) - Tier 2; PA; QL
Dental and Oral Agents - Drugs to Treat Mouth and Throat
Conditions
ANBESOL MAXIMUM STRENGTH MOUTH/THROAT GEL (brand for cvs
oral anesthetic max str) - Tier 2; PA
AQUORAL (brand for cvs dry mouth) - Tier 2; PA; QL
BABY ANBESOL (brand for cvs baby teething oral pain) - Tier 2; PA
baby teething oral pain (generic for BABY ANBESOL) - Tier 1; PA
cherry cough drops (generic for DENTIVA) - Tier 1; PA
cherry menthol drops (generic for DENTIVA) - Tier 1; PA
dry mouth (generic for AQUORAL) - Tier 1; PA; QL
honey lemon drops (generic for DENTIVA) - Tier 1; PA
HURRICAINE MOUTH/THROAT GEL (brand for cvs oral anesthetic max
str) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
74
Preferred Agents Non-Preferred Agents
instant oral pain relief max (generic for ANBESOL MAXIMUM
STRENGTH) - Tier 1; PA
LOLLICAINE (brand for cvs oral anesthetic max str) - Tier 2; PA
menthol drops (generic for DENTIVA) - Tier 1; PA
MOUTH KOTE REMINT (brand for cvs dry mouth) - Tier 2; PA; QL
MUCOSITISRX - Tier 2; PA
oral anesthetic max str (generic for ANBESOL MAXIMUM STRENGTH) -
Tier 1; PA
oral pain relief mouth/throat gel 20 % (generic for ANBESOL MAXIMUM
STRENGTH) - Tier 1; PA
SALIVAMAX - Tier 2; PA
sore throat mouth/throat lozenge 6-10 mg (generic for DENTIVA) - Tier 1;
PA
XEROSTOMIA RELIEF SPRAY (brand for cvs dry mouth) - Tier 2; PA; QL
ZILACTIN BABY - Tier 2; PA
Dermatological Agents
Acne and Rosacea Agents
accutane (generic for ACCUTANE) - Tier 1; PA; QL
acitretin - Tier 1; QL
adapalene external gel 0.1 % (generic for DIFFERIN) - Tier 1; QL
amnesteem (generic for ACCUTANE) - Tier 1; PA; QL
AVITA (brand for tretinoin) - Tier 2; QL
AZELEX - Tier 2; QL
benzoyl peroxide-erythromycin (generic for BENZAMYCIN) - Tier 1;
QL
claravis (generic for ACCUTANE) - Tier 1; PA; QL
clindamycin phosphate-benzoyl peroxide (generic for ACANYA) - Tier
1; QL
isotretinoin oral (generic for ABSORICA) - Tier 1; PA; QL
ABSORICA (brand for isotretinoin) - Tier 2; PA; QL
ABSORICA LD - Tier 2; PA; QL
ACANYA (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL
adapalene external cream (generic for DIFFERIN) - Tier 1; PA; QL
adapalene external gel 0.3 % (generic for DIFFERIN) - Tier 1; PA; QL
adapalene-benzoyl peroxide external gel (generic for EPIDUO) - Tier 1;
PA; QL
AKLIEF - Tier 2; PA; QL
ALTRENO - Tier 2; PA; QL
ARAZLO - Tier 2; PA; SP; QL; AL
ATRALIN (brand for tretinoin) - Tier 2; PA; QL
azelaic acid external (generic for FINACEA) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
75
Preferred Agents Non-Preferred Agents
myorisan (generic for ACCUTANE) - Tier 1; PA; QL
neuac external gel (generic for NEUAC) - Tier 1; QL
TAZORAC EXTERNAL CREAM 0.05 % - Tier 2; QL
TAZORAC EXTERNAL GEL 0.1 % - Tier 2; QL
tretinoin external (generic for ATRALIN) - Tier 1; QL
tretinoin microsphere (generic for RETIN-A MICRO) - Tier 1; QL
tretinoin microsphere pump (generic for RETIN-A MICRO) - Tier 1; QL
zenatane (generic for ACCUTANE) - Tier 1; PA; QL
BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL
clindamycin-tretinoin (generic for VELTIN) - Tier 1; PA; QL
DIFFERIN (brand for adapalene) - Tier 2; PA; QL
EPIDUO (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL
EPIDUO FORTE (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL
FABIOR (brand for tazarotene) - Tier 2; PA; QL
FINACEA (brand for azelaic acid) - Tier 2; PA; QL
MIRVASO - Tier 2; PA; QL
ONEXTON - Tier 2; PA; QL
RETIN-A (brand for tretinoin) - Tier 2; PA; QL
RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) -
Tier 2; PA; QL
RETIN-A MICRO PUMP (brand for tretinoin microsphere) - Tier 2; PA; QL
RHOFADE - Tier 2; PA; QL
tazarotene external cream (generic for TAZORAC) - Tier 1; PA; QL
TAZAROTENE EXTERNAL FOAM (brand for tazarotene) - Tier 2; PA; QL
TAZORAC EXTERNAL CREAM 0.1 % (brand for tazarotene) - Tier 2; PA;
QL
TAZORAC EXTERNAL GEL 0.05 % - Tier 2; PA; QL
TWYNEO - Tier 2; PA; QL
VELTIN (brand for clindamycin-tretinoin) - Tier 2; PA; QL
ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL
Dermatitis and Pruitus Agents
ala-cort (generic for AVEENO ANTI-ITCH MAX ST) - Tier 1; QL
amcinonide external cream - Tier 1
amcinonide external lotion - Tier 1
ammonium lactate external (generic for AL12) - Tier 1; QL
anti-dandruff (generic for SELSUN BLUE) - Tier 1
betamethasone valerate external cream - Tier 1; QL
betamethasone valerate external lotion - Tier 1
betamethasone valerate external ointment - Tier 1; QL
clobetasol prop emollient base - Tier 1; QL
clobetasol propionate e - Tier 1; QL
clobetasol propionate emulsion (generic for TOVET) - Tier 1; QL
clobetasol propionate external (generic for CLOBEX) - Tier 1; QL
alclometasone dipropionate - Tier 1; PA; QL
APEXICON E - Tier 2; PA; QL
betamethasone dipropionate aug (generic for DIPROLENE) - Tier 1; PA;
QL
betamethasone dipropionate external cream - Tier 1; PA; QL
betamethasone dipropionate external lotion - Tier 1; PA
betamethasone dipropionate external ointment - Tier 1; PA; QL
betamethasone valerate external foam (generic for LUXIQ) - Tier 1; PA;
QL
BRYHALI - Tier 2; PA; QL
CAPEX - Tier 2; PA; QL
CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
76
Preferred Agents Non-Preferred Agents
clodan external shampoo (generic for CLODAN) - Tier 1; QL
dandruff shampoo external lotion (generic for SELSUN BLUE) - Tier 1
DERMA-SMOOTHE/FS BODY (brand for fluocinolone acetonide body)
- Tier 2; QL
DERMA-SMOOTHE/FS SCALP (brand for fluocinolone acetonide
scalp) - Tier 2; QL
desonide external cream (generic for DESOWEN) - Tier 1; QL
desonide external ointment - Tier 1; QL
diflorasone diacetate external cream (generic for PSORCON) - Tier 1;
QL
diflorasone diacetate external ointment - Tier 1
doxepin hcl external (generic for PRUDOXIN) - Tier 1; QL
CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL
clocortolone pivalate (generic for CLODERM) - Tier 1; PA; QL
CLODERM (brand for clocortolone pivalate) - Tier 2; PA; QL
CORDRAN EXTERNAL CREAM 0.05 % (brand for flurandrenolide) - Tier
2; PA; QL
CORDRAN EXTERNAL LOTION (brand for flurandrenolide) - Tier 2; PA;
QL
CORDRAN EXTERNAL OINTMENT (brand for flurandrenolide) - Tier 2;
PA
CORDRAN EXTERNAL TAPE - Tier 2; PA; QL
cortisone maximum strength external gel (generic for CORTIZONE-10) -
Tier 1; PA
ELIDEL (brand for pimecrolimus) - Tier 2; ST; QL
fluocinolone acetonide external cream 0.01 % - Tier 1; QL
fluocinolone acetonide external solution (generic for SYNALAR) - Tier
1; QL
fluocinonide emulsified base - Tier 1; QL
fluocinonide external cream 0.05 % - Tier 1; QL
fluocinonide external gel - Tier 1; QL
fluocinonide external ointment - Tier 1; QL
fluocinonide external solution - Tier 1; QL
flurandrenolide external cream (generic for CORDRAN) - Tier 1; QL
flurandrenolide external lotion (generic for NOLIX) - Tier 1; QL
flurandrenolide external ointment (generic for CORDRAN) - Tier 1
desonide external gel (generic for DESRX) - Tier 1; PA; QL
desonide external lotion - Tier 1; PA; QL
DESOWEN (brand for desonide) - Tier 2; PA; QL
desoximetasone external (generic for TOPICORT) - Tier 1; PA; QL
desrx (generic for DESRX) - Tier 1; PA; QL
DIPROLENE (brand for betamethasone dipropionate aug) - Tier 2; PA;
QL
EUCRISA - Tier 2; PA; QL
fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS BODY) -
Tier 1; PA; QL
fluocinolone acetonide external cream 0.025 % (generic for SYNALAR) -
Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
77
Preferred Agents Non-Preferred Agents
fluticasone propionate external cream - Tier 1; QL
fluticasone propionate external ointment - Tier 1; QL
hydrocortisone anti-itch external cream 0.5 % - Tier 1; QL
hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL
hydrocortisone external cream 1 % (generic for AVEENO ANTI-ITCH
MAX ST) - Tier 1; QL
hydrocortisone external lotion 2.5 % - Tier 1; QL
hydrocortisone external ointment 0.5 % - Tier 1
hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH
RELIEF MAX STR) - Tier 1; QL
hydrocortisone external ointment 2.5 % - Tier 1; QL
instacort 5 - Tier 1; QL
fluocinolone acetonide external ointment (generic for SYNALAR) - Tier 1;
PA; QL
fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS SCALP)
- Tier 1; PA; QL
fluocinonide external cream 0.1 % (generic for VANOS) - Tier 1; PA; QL
fluticasone propionate external lotion - Tier 1; PA; QL
halcinonide (generic for HALOG) - Tier 1; PA; QL
halobetasol propionate external cream - Tier 1; PA; QL
HALOBETASOL PROPIONATE EXTERNAL FOAM (brand for
halobetasol propionate) - Tier 2; PA; QL
halobetasol propionate external ointment - Tier 1; PA; QL
HALOG (brand for halcinonide) - Tier 2; PA; QL
LAC-HYDRIN FIVE - Tier 2; QL
mometasone furoate external - Tier 1; QL
prednicarbate - Tier 1
selenium sulfide external lotion - Tier 1; QL
selenium sulfide external shampoo 2.25 % - Tier 1
tacrolimus external (generic for PROTOPIC) - Tier 1; PA; QL
tovet external foam (generic for TOVET) - Tier 1; QL
triamcinolone acetonide external cream (generic for TRIDERM) - Tier
1; QL
triamcinolone acetonide external lotion 0.025 % - Tier 1
triamcinolone acetonide external lotion 0.1 % - Tier 1; QL
hydrocortisone butyr lipo base (generic for LOCOID LIPOCREAM) - Tier
1; PA; QL
hydrocortisone butyrate (generic for LOCOID) - Tier 1; PA; QL
hydrocortisone valerate - Tier 1; PA; QL
IMPEKLO - Tier 2; PA; QL
KENALOG EXTERNAL (brand for triamcinolone acetonide) - Tier 2; PA;
QL
LEXETTE (brand for halobetasol propionate) - Tier 2; PA; QL
LOCOID (brand for hydrocortisone butyrate) - Tier 2; PA; QL
LOCOID LIPOCREAM (brand for hydrocortisone butyr lipo base) - Tier 2;
PA; QL
LUXIQ (brand for betamethasone valerate) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
78
Preferred Agents Non-Preferred Agents
triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier
1; QL
triamcinolone acetonide external ointment 0.05 % (generic for
TRITOCIN) - Tier 1
triamcinolone in absorbase (generic for TRITOCIN) - Tier 1
TRIANEX (brand for triamcinolone acetonide) - Tier 2
triderm (generic for TRIDERM) - Tier 1; QL
tritocin (generic for TRITOCIN) - Tier 1
nolix (generic for NOLIX) - Tier 1; PA; QL
OLUX (brand for clobetasol propionate) - Tier 2; PA; QL
OLUX-E (brand for clobetasol propionate emulsion) - Tier 2; PA; QL
PANDEL - Tier 2; PA
pimecrolimus (generic for ELIDEL) - Tier 1; PA; ST; QL
PROTOPIC (brand for tacrolimus) - Tier 2; PA; QL
PRUDOXIN (brand for doxepin hcl) - Tier 2; PA; QL
PSORCON (brand for diflorasone diacetate) - Tier 2; PA; QL
selenium sulfide external shampoo 2.3 % - Tier 1; PA
SYNALAR (brand for fluocinolone acetonide) - Tier 2; PA; QL
TEMOVATE (brand for clobetasol propionate) - Tier 2; PA; QL
TEXACORT - Tier 2; PA
TOPICORT (brand for desoximetasone) - Tier 2; PA; QL
TOPICORT SPRAY (brand for desoximetasone) - Tier 2; PA; QL
triamcinolone acetonide external aerosol solution (generic for KENALOG)
- Tier 1; PA; QL
TRIDESILON (brand for desonide) - Tier 2; PA; QL
ULTRAVATE - Tier 2; PA; QL
VANOS (brand for fluocinonide) - Tier 2; PA; QL
ZONALON (brand for doxepin hcl) - Tier 2; PA; QL
Dermatological Agents, Other
calcipotriene external cream (generic for DOVONEX) - Tier 1; QL
calcipotriene external ointment (generic for CALCITRENE) - Tier 1; QL
calcipotriene external solution - Tier 1; QL
calcipotriene-betameth diprop external ointment (generic for
TACLONEX) - Tier 1; QL
calcitriol external (generic for VECTICAL) - Tier 1; QL
clotrimazole-betamethasone - Tier 1; QL
CONDYLOX - Tier 2
fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL
fluorouracil external solution - Tier 1
imiquimod external cream 5 % - Tier 1; QL
methoxsalen rapid - Tier 1
AMELUZ - Tier 2; PA
ANALPRAM HC (brand for hydrocort-pramoxine (perianal)) - Tier 2; PA
ANALPRAM HC SINGLES (brand for hydrocort-pramoxine (perianal)) -
Tier 2; PA
ANALPRAM-HC (brand for hydrocortisone ace-pramoxine) - Tier 2; PA
CALCIPOTRIENE EXTERNAL FOAM (brand for calcipotriene) - Tier 2;
PA; QL
calcipotriene-betameth diprop external suspension (generic for
TACLONEX) - Tier 1; PA; QL
CALCITRENE (brand for calcipotriene) - Tier 2; PA; QL
CARAC (brand for fluorouracil) - Tier 2; PA; QL
diclofenac sodium external gel 3 % - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
79
Preferred Agents Non-Preferred Agents
nystatin-triamcinolone - Tier 1; QL
podofilox external - Tier 1; QL
silver sulfadiazine external (generic for SSD) - Tier 1; QL
ssd (generic for SSD) - Tier 1; QL
DOVONEX (brand for calcipotriene) - Tier 2; PA; QL
DUOBRII - Tier 2; PA; QL
EFUDEX (brand for fluorouracil) - Tier 2; PA; QL
ENSTILAR - Tier 2; PA; QL
EPIFOAM - Tier 2; PA
FLUOROURACIL EXTERNAL CREAM 0.5 % (brand for fluorouracil) -
Tier 2; PA; QL
hydrocortisone ace-pramoxine external (generic for ANALPRAM-HC) -
Tier 1; PA
hydrocort-pramoxine (perianal) (generic for ANALPRAM HC) - Tier 1; PA
imiquimod external cream 3.75 % (generic for ZYCLARA) - Tier 1; PA; QL
imiquimod pump (generic for ZYCLARA) - Tier 1; PA; QL
LEVULAN KERASTICK - Tier 2; PA
NEO-SYNALAR EXTERNAL CREAM - Tier 2; PA; QL
PRAMOSONE (brand for hydrocortisone ace-pramoxine) - Tier 2; PA
PROCORT - Tier 2; PA
PROCTOFOAM HC - Tier 2; PA; QL
QBREXZA - Tier 2; PA; QL
SILVADENE (brand for silver sulfadiazine) - Tier 2; PA; QL
SORILUX (brand for calcipotriene) - Tier 2; PA; QL
TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL
VECTICAL (brand for calcitriol) - Tier 2; PA; QL
VEREGEN - Tier 2; PA; QL
XERESE - Tier 2; PA; QL
ZYCLARA (brand for imiquimod) - Tier 2; PA; QL
ZYCLARA PUMP (brand for imiquimod) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
80
Preferred Agents Non-Preferred Agents
Pediculicides/Scabicides
lice killing (generic for NIX CREME RINSE) - Tier 1
lice treatment creme rinse (generic for NIX CREME RINSE) - Tier 1
lice treatment external liquid 1 % (generic for NIX CREME RINSE) -
Tier 1
lice treatment external lotion 1 % - Tier 1
NATROBA (brand for spinosad) - Tier 2; QL
permethrin external - Tier 1; QL
ivermectin external (generic for SOOLANTRA) - Tier 1; PA; QL
lindane - Tier 1; PA; QL
malathion (generic for OVIDE) - Tier 1; PA; QL
OVIDE (brand for malathion) - Tier 2; PA; QL
SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL
spinosad (generic for NATROBA) - Tier 1; PA; QL
Topical Anti-infectives
ciclodan (generic for CICLODAN) - Tier 1; QL
ciclopirox external gel - Tier 1
ciclopirox external shampoo (generic for LOPROX) - Tier 1
ciclopirox external solution (generic for CICLODAN) - Tier 1; QL
ciclopirox olamine external cream (generic for LOPROX) - Tier 1; QL
ciclopirox olamine suspension 0.77 % external (generic for LOPROX) -
Tier 1
ciclopirox olamine suspension 0.77 % external (generic for LOPROX) -
Tier 1; QL
clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1;
QL
ACZONE (brand for dapsone) - Tier 2; PA; QL
AMZEEQ - Tier 2; PA; QL
CENTANY (brand for mupirocin) - Tier 2; PA; QL
CENTANY AT - Tier 2; PA
ciclopirox treatment - Tier 1; PA
CLEOCIN-T (brand for clindamycin phosphate) - Tier 2; PA; QL
clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; PA; QL
clindacin-p (generic for CLINDACIN ETZ) - Tier 1; PA; QL
CLINDAGEL (brand for clindamycin phosphate) - Tier 2; PA; QL
clindamycin phosphate external foam (generic for EVOCLIN) - Tier 1; PA;
QL
clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier
1; QL
clindamycin phosphate external solution - Tier 1; QL
clotrimazole external cream 1 % (generic for DESENEX) - Tier 1; QL
clotrimazole external solution 1 % - Tier 1; QL
econazole nitrate external - Tier 1; QL
erythromycin external (generic for ERYGEL) - Tier 1; QL
gentamicin sulfate external - Tier 1; QL
ketoconazole external cream - Tier 1; QL
ketoconazole external shampoo - Tier 1; QL
mupirocin calcium - Tier 1; QL
mupirocin external (generic for CENTANY) - Tier 1; QL
clindamycin phosphate external swab (generic for CLINDACIN ETZ) - Tier
1; PA; QL
dapsone external (generic for ACZONE) - Tier 1; PA; QL
ERTACZO - Tier 2; PA
ery - Tier 1; PA; QL
ERYGEL (brand for erythromycin) - Tier 2; PA; QL
EVOCLIN (brand for clindamycin phosphate) - Tier 2; PA; QL
EXTINA (brand for ketoconazole) - Tier 2; PA
JUBLIA - Tier 2; PA; QL
KERYDIN (brand for tavaborole) - Tier 2; PA; QL
ketoconazole external foam (generic for KETODAN) - Tier 1; PA
ketodan external foam (generic for KETODAN) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
81
Preferred Agents Non-Preferred Agents
nyamyc (generic for NYAMYC) - Tier 1; QL
nystatin external (generic for NYAMYC) - Tier 1; QL
nystop (generic for NYAMYC) - Tier 1; QL
sulfacetamide sodium (acne) (generic for KLARON) - Tier 1; QL
SULFAMYLON EXTERNAL CREAM - Tier 2
KLARON (brand for sulfacetamide sodium (acne)) - Tier 2; PA; QL
LOPROX EXTERNAL CREAM (brand for ciclopirox olamine) - Tier 2; PA;
QL
LOPROX EXTERNAL SHAMPOO (brand for ciclopirox) - Tier 2; PA
LOPROX EXTERNAL SUSPENSION (brand for ciclopirox olamine) - Tier
2; PA
LULICONAZOLE (brand for luliconazole) - Tier 2; PA; QL
LUZU (brand for luliconazole) - Tier 2; PA; QL
mafenide acetate external (generic for SULFAMYLON) - Tier 1; PA
MENTAX (brand for butenafine hcl) - Tier 2; PA
MICONAZOLE-ZINC OXIDE-PETROLAT (brand for miconazole-zinc
oxide-petrolat) - Tier 2; PA; QL
naftifine hcl - Tier 1; PA
NAFTIN - Tier 2; PA
oxiconazole nitrate (generic for OXISTAT) - Tier 1; PA; QL
OXISTAT EXTERNAL CREAM (brand for oxiconazole nitrate) - Tier 2;
PA; QL
OXISTAT EXTERNAL LOTION - Tier 2; PA
SULFAMYLON EXTERNAL PACKET (brand for mafenide acetate) - Tier
2; PA
tavaborole (generic for KERYDIN) - Tier 1; PA; QL
VUSION (brand for miconazole-zinc oxide-petrolat) - Tier 2; PA; QL
XEPI - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
82
Preferred Agents Non-Preferred Agents
Dermatological Agents - Drugs to Treat Skin Conditions
advanced healing external ointment (generic for FLANDERS
BUTTOCKS) - Tier 1
alum sulfate-ca acetate (generic for DOMEBORO) - Tier 1
astringent solution (generic for DOMEBORO) - Tier 1
AVAR CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2
baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) -
Tier 1; QL
beauty 360 pure glycerin - Tier 1
beauty 360 soothing bath (generic for AVEENO BABY BATH
TREATMENT) - Tier 1
benzoin - Tier 1
americerin (generic for AMERICERIN) - Tier 1; PA
ana-lex (generic for ANA-LEX) - Tier 1; PA; QL
AQUA-NU (brand for cvs advanced healing) - Tier 2; PA
AQUAPHILIC (brand for cvs advanced healing) - Tier 2; PA
AQUAPHOR ADV PROTECT HEALING (brand for cvs advanced healing)
- Tier 2; PA
AQUAPHOR ADV THERAPY HEALING (brand for cvs advanced healing)
- Tier 2; PA
AQUAPHOR ADVANCED THERAPY BABY (brand for cvs advanced
healing) - Tier 2; PA
AVAR LS CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2;
PA
benzoin compound (generic for STERI-STRIP COMPOUND
BENZOIN) - Tier 1
boro-packs (generic for DOMEBORO) - Tier 1
boudreauxs butt paste ointment 40 % external (generic for
BOUDREAUXS BUTT PASTE) - Tier 1; QL
BOUDREAUXS BUTT PASTE OINTMENT 40 % EXTERNAL (brand
for cvs diaper rash) - Tier 2; QL
bp 10-1 - Tier 1
diaper rash external ointment (generic for BOUDREAUXS BUTT
PASTE) - Tier 1; QL
DR SMITHS ADULT BARRIER - Tier 2; QL
DR SMITHS DIAPER QUICK RELIEF - Tier 2; QL
AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2; PA
AVAR-E GREEN (brand for sss 10-5) - Tier 2; PA
AVAR-E LS (brand for sulfacetamide sodium-sulfur) - Tier 2; PA
BASLE (brand for beta care) - Tier 2; PA
BOUDREAUXS BABY BUTT SMOOTH (brand for cvs advanced healing)
- Tier 2; PA
bp cleansing wash - Tier 1; PA
CLODAN EXTERNAL KIT - Tier 2; PA
dibucaine (perianal) (generic for NUPERCAINAL) - Tier 1; PA
hydrocerin (generic for AMERICERIN) - Tier 1; PA
hydrocortisone acetate external ointment - Tier 1; PA
LANAPHILIC (brand for cvs advanced healing) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
83
Preferred Agents Non-Preferred Agents
flanders buttocks (generic for FLANDERS BUTTOCKS) - Tier 1
glycerin external - Tier 1
glycerin external liquid 99.5 % - Tier 1
hydrocortisone acetate external cream (generic for GYNECORT 10) -
Tier 1
hydrolatum (generic for FLANDERS BUTTOCKS) - Tier 1
lidocaine-hydrocort (perianal) (generic for LIDOCORT) - Tier 1
ointment base (generic for FLANDERS BUTTOCKS) - Tier 1
renewal soothing bath (generic for AVEENO BABY BATH
TREATMENT) - Tier 1
sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1
LIDOCAINE-HYDROCORTISONE ACE RECTAL GEL - Tier 2; PA
lidocaine-hydrocortisone ace rectal kit 2-2 % (generic for ANA-LEX) - Tier
1; PA; QL
lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-2.5 % - Tier 1; PA
lidocaine-hydrocortisone ace rectal kit 3-1 % - Tier 1; PA; QL
LIDOCORT (brand for lidocaine-hydrocort (perianal)) - Tier 2; PA
minerin creme (generic for AMERICERIN) - Tier 1; PA
NEUAC EXTERNAL KIT - Tier 2; PA
NUPERCAINAL (brand for dibucaine (perianal)) - Tier 2; PA
NUTRASEB - Tier 2; PA
PLEXION CLEANSER (brand for sulfacetamide sodium-sulfur) - Tier 2;
PA
sulfacetamide sodium-sulfur external cream 10-2 % (generic for
AVAR-E LS) - Tier 1
sulfacetamide sodium-sulfur external cream 10-5 % (generic for
AVAR-E EMOLLIENT) - Tier 1
sulfacetamide sodium-sulfur external liquid 10-5 % (generic for AVAR
CLEANSER) - Tier 1
sulfacetamide sodium-sulfur external liquid 9.8-4.8 % (generic for
PLEXION CLEANSER) - Tier 1
sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for
SUMADAN WASH) - Tier 1; QL
sulfacetamide sodium-sulfur external suspension 8-4 % (generic for
SULFACLEANSE 8/4) - Tier 1
PROMISEB - Tier 2; PA
PROSILK EXTERNAL - Tier 2; PA
salicylic acid-cleanser - Tier 1; PA
SORBIDON HYDRATE (brand for hydrocerin) - Tier 2; PA
sss 10-5 external foam - Tier 1; PA
sulfacetamide sodium-sulfur external liquid 10-2 % (generic for AVAR LS
CLEANSER) - Tier 1; PA
sulfacetamide sodium-sulfur external pad 10-4 % (generic for SUMAXIN) -
Tier 1; PA
sulfacetamide-sulfur in urea - Tier 1; PA
SULFACLEANSE 8/4 (brand for sulfacetamide sodium-sulfur) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
84
Preferred Agents Non-Preferred Agents
sulfacetamide sodium-sulfur liquid 9-4 % external - Tier 1
sulfacetamide sod-sulfur wash external liquid 9-4 % - Tier 1
sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for
SUMADAN WASH) - Tier 1; QL
sulfamez wash - Tier 1
zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT
PASTE) - Tier 1; QL
SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2; PA;
QL
SUMADAN XLT - Tier 2; PA
SUMAXIN (brand for sulfacetamide sodium-sulfur) - Tier 2; PA
SUMAXIN CP - Tier 2; PA; QL
SYNALAR (CREAM) - Tier 2; PA; QL
SYNALAR (OINTMENT) - Tier 2; PA; QL
TOVET EXTERNAL KIT - Tier 2; PA; QL
TRI-LUMA - Tier 2; PA
urea hydrating - Tier 1; PA
VANICREAM EXTERNAL OINTMENT (brand for cvs advanced healing) -
Tier 2; PA
Dermatological Agents - Skin Agents
ABREVA (brand for docosanol) - Tier 2; QL
calamine external lotion , 8-8 % - Tier 1
calamine-zinc oxide external lotion - Tier 1
cerovel (generic for CEROVEL) - Tier 1; QL
DERMELEVE ADVANCED FORMULA - Tier 2
docosanol external (generic for ABREVA) - Tier 1; QL
gormel - Tier 1; QL
gormel 10 (generic for NUTRAPLUS) - Tier 1; QL
hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1
hydrocortisone plus external cream 1 % (generic for CORTIZONE-10
INTENSIVE HEALING) - Tier 1
CIBINQO - Tier 2; PA; SP; QL
CLINDACIN ETZ EXTERNAL KIT - Tier 2; PA
CLINDACIN PAC - Tier 2; PA
cold sore treatment external liquid 0.13-3 % - Tier 1; PA
DERMACINRX UREA (brand for urea) - Tier 2; PA
FORDAGEL - Tier 2; PA; QL
hemorrhoidal rectal ointment 0.25-3-14-71.9 % - Tier 1; PA
NUTRIARX CREAMPAK (brand for sanadermrx skin repair) - Tier 2; PA;
QL
OPZELURA - Tier 2; PA; QL
RESORCINOL-SULFUR - Tier 2; PA
ROSADAN EXTERNAL KIT - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
85
Preferred Agents Non-Preferred Agents
hydrocortisone/aloe (generic for CORTIZONE-10 INTENSIVE
HEALING) - Tier 1
hydrocortisone/aloe max str (generic for CORTIZONE-10 INTENSIVE
HEALING) - Tier 1
hydrocortisone-aloe (generic for CORTIZONE-10 INTENSIVE
HEALING) - Tier 1
hydrocortisone-aloe max st (generic for CORTIZONE-10 INTENSIVE
HEALING) - Tier 1
moisturel - Tier 1
NUTRAPLUS (brand for gormel 10) - Tier 2; QL
qc anti-itch aloe (generic for CORTIZONE-10 INTENSIVE HEALING) -
Tier 1
SANADERMRX SKIN REPAIR (brand for sanadermrx skin repair) - Tier 2;
PA; QL
SYNALAR TS - Tier 2; PA; QL
TRIADIME-80 (brand for sanadermrx skin repair) - Tier 2; PA; QL
TRIHEAL-80 (brand for sanadermrx skin repair) - Tier 2; PA; QL
TRIVIX (brand for sanadermrx skin repair) - Tier 2; PA; QL
uredeb (generic for UREDEB) - Tier 1; PA
VTAMA - Tier 2; PA; QL
XERAC AC - Tier 2; PA
xurea (generic for UREDEB) - Tier 1; PA
ZILXI - Tier 2; PA; QL
urea 20 intensive hydrating - Tier 1; QL
urea external cream 39 % (generic for UREDEB) - Tier 1
urea external cream 40 % - Tier 1; QL
urea external cream 41 % (generic for DERMACINRX UREA) - Tier 1
urea external lotion (generic for CEROVEL) - Tier 1; QL
ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL
ureacin-20 - Tier 1; QL
UREMEZ-40 - Tier 2; QL
Diabetes - Glucose Monitoring
ACCU-CHEK AVIVA DEVICE (brand for element compact control 2) -
Tier 2; QL
ACCU-CHEK GUIDE CONTROL (brand for element compact control
2) - Tier 2; QL
ACCU-CHEK SMARTVIEW CONTROL (brand for element compact
control 2) - Tier 2; QL
ACCUTREND GLUCOSE CONTROL (brand for element compact
control 2) - Tier 2; QL
BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier
2; QL
BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL
ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for cvs glucose meter
test strips) - Tier 2; PA; QL
ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite
device/lancets) - Tier 2; PA; QL
ACCU-CHEK GUIDE TEST STRIPS (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
ACCU-CHEK LINKASSIST - Tier 2; PA
ACCU-CHEK SMARTVIEW (brand for cvs glucose meter test strips) - Tier
2; PA; QL
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite
device/lancets) - Tier 2; PA; QL
ACCU-CHEK SPIRIT COMBO PACK - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
86
Preferred Agents Non-Preferred Agents
BD ULTRA-FINE PEN NEEDLES (brand for aum mini insulin pen
needle) - Tier 2; QL
CARETOUCH CONTROL SOL LEVEL 2 (brand for element compact
control 2) - Tier 2; QL
CHEMSTRIP 10 MD - Tier 2
CHEMSTRIP 10/SG - Tier 2
CHEMSTRIP 2 GP - Tier 2
CHEMSTRIP 5 OB - Tier 2
CHEMSTRIP 7 - Tier 2
CHEMSTRIP 9 - Tier 2
CHEMSTRIP K (brand for ketone test) - Tier 2; QL
CHEMSTRIP UGK - Tier 2; QL
ACCUTREND GLUCOSE (brand for cvs glucose meter test strips) - Tier
2; PA; QL
ADVANCED GLUCOSE TEST (brand for cvs glucose meter test strips) -
Tier 2; PA; QL
AUM MINI INSULIN PEN NEEDLE 32G X 4 MM , 32G X 5 MM , 32G X 6
MM (brand for aum mini insulin pen needle) - Tier 2; PA; QL
AUM READYGARD DUO PEN NEEDLE (brand for aum mini insulin pen
needle) - Tier 2; PA; QL
BLOOD GLUCOSE TEST IN VITRO STRIP (brand for cvs glucose meter
test strips) - Tier 2; PA; QL
BLOOD GLUCOSE TEST STRIPS (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
DEXCOM G6 RECEIVER - Tier 2; QL
DEXCOM G6 SENSOR (brand for freestyle libre 3 sensor) - Tier 2; QL
DIASTIX - Tier 2
EASYMAX 15 LEVEL 2 CONTROL (brand for element compact
control 2) - Tier 2; QL
EASYMAX 15 LEVEL 2-3 CONTROL (brand for element compact
control 2) - Tier 2; QL
GLUCOSE CONTROL SOLUTIONS (brand for element compact
control 2) - Tier 2; QL
FREESTYLE LIBRE 14 DAY READER - Tier 2; PA; QL
FREESTYLE LIBRE 14 DAY SENSOR (brand for freestyle libre 3
sensor) - Tier 2; PA; QL
CARETOUCH MONITOR SYSTEM (brand for blood glucose monitor
system) - Tier 2; PA; QL
CARETOUCH TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
CHEMSTRIP MICRAL - Tier 2; PA
COMFORT TOUCH LANCETS 31G (brand for advanced mobile lancet) -
Tier 2; PA; QL
COMFORT TOUCH PLUS LANCETS 30G (brand for advanced mobile
lancet) - Tier 2; PA; QL
CONTOUR MONITOR (brand for blood glucose monitor system) - Tier 2;
PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
87
Preferred Agents Non-Preferred Agents
FREESTYLE LIBRE 2 READER - Tier 2; PA; QL
FREESTYLE LIBRE 2 SENSOR (brand for freestyle libre 3 sensor) -
Tier 2; PA; QL
FREESTYLE LIBRE READER - Tier 2; PA; QL
GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION (brand for
element compact control 2) - Tier 2; QL
KETO-DIASTIX - Tier 2; QL
KETONE CARE - Tier 2; QL
KETONE TEST (brand for ketone test) - Tier 2; QL
KETOSTIX (brand for ketone test) - Tier 2; QL
LANCETS (brand for advanced mobile lancet) - Tier 2; QL
CONTOUR MONITOR (brand for diatrue plus blood glucose) - Tier 2; PA;
QL
CONTOUR NEXT EZ KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; PA; QL
CONTOUR NEXT GEN MONITOR (brand for blood glucose monitor
system) - Tier 2; PA; QL
CONTOUR NEXT LINK KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; PA; QL
CONTOUR NEXT MONITOR KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; PA; QL
CONTOUR NEXT ONE KIT (brand for diatrue plus blood glucose) - Tier
2; PA; QL
MEDISENSE GLUCOSE KETONE CONTR (brand for element
compact control 2) - Tier 2; QL
MEDISENSE HI/MID/LOW CONTROL (brand for element compact
control 2) - Tier 2; QL
NEUTEK 2TEK CONTROL (brand for element compact control 2) -
Tier 2; QL
ONETOUCH ULTRA TEST STRIPS (brand for cvs glucose meter test
strips) - Tier 2; QL
ONETOUCH ULTRA 2 KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; QL
ONETOUCH ULTRA CONTROL (brand for element compact control
2) - Tier 2; QL
CONTOUR NEXT TEST STRIPS (brand for cvs glucose meter test strips)
- Tier 2; PA; QL
CONTOUR TEST STRIPS (brand for cvs glucose meter test strips) - Tier
2; PA; QL
D-CARE BLOOD GLUCOSE (brand for cvs glucose meter test strips) -
Tier 2; PA; QL
D-CARE GLUCOMETER (brand for blood glucose monitor system) - Tier
2; PA; QL
EASY TOUCH TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
EASYMAX 15 TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
88
Preferred Agents Non-Preferred Agents
ONETOUCH ULTRA MINI KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; QL
ONETOUCH VERIO KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; QL
ONETOUCH VERIO FLEX SYSTEM (brand for blood glucose monitor
system) - Tier 2; QL
ONETOUCH VERIO IN VITRO SOLUTION (brand for element
compact control 2) - Tier 2; QL
ONETOUCH VERIO TEST STRIPS (brand for cvs glucose meter test
strips) - Tier 2; QL
ONETOUCH VERIO IQ SYSTEM (brand for blood glucose monitor
system) - Tier 2; QL
EASYMAX NG BLOOD GLUCOSE (brand for blood glucose monitor
system) - Tier 2; PA; QL
BLOOD GLUCOSE TEST STRIPS (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
EASYMAX V BLOOD GLUCOSE (brand for diatrue plus blood glucose) -
Tier 2; PA; QL
ENLITE GLUCOSE SENSOR (brand for freestyle libre 3 sensor) - Tier 2;
PA; QL
FORTISCARE G1 TEST STRIP (brand for cvs glucose meter test strips) -
Tier 2; PA; QL
FORTISCARE T1 GLUCOSE SYSTEM (brand for diatrue plus blood
glucose) - Tier 2; PA; QL
ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood
glucose monitor system) - Tier 2; QL
PRECISION GLUCOSE KETONE CONTR (brand for element
compact control 2) - Tier 2; QL
QUINTET CONTROL HIGH/NORMAL (brand for element compact
control 2) - Tier 2; QL
RELION TRUE MET AIR GLUC METER (brand for blood glucose
monitor system) - Tier 2; QL
RELION TRUE METRIX TEST STRIPS (brand for cvs glucose meter
test strips) - Tier 2; ST; QL
SAFE-T-LANCE (brand for advanced mobile lancet) - Tier 2; QL
FORTISCARE TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
FREESTYLE LIBRE 3 SENSOR (brand for freestyle libre 3 sensor) - Tier
2; PA; QL
FREESTYLE PRECISION NEO SYSTEM (brand for blood glucose
monitor system) - Tier 2; PA; QL
FREESTYLE PRECISION NEO TEST (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
GLUCOCARD EXPRESSION TEST (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
GLUCOCARD SHINE TEST (brand for cvs glucose meter test strips) -
Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
89
Preferred Agents Non-Preferred Agents
TRUE METRIX AIR GLUCOSE METER KIT (brand for blood glucose
monitor system) - Tier 2; QL
TRUE METRIX BLOOD GLUCOSE TEST STRIP IN VITRO (brand for
cvs glucose meter test strips) - Tier 2; ST; QL
TRUE METRIX GO GLUCOSE METER (brand for blood glucose
monitor system) - Tier 2; QL
TRUE METRIX METER KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; QL
TRUECONTROL GLUCOSE CONT LEV 0 (brand for element
compact control 2) - Tier 2; QL
TRUECONTROL GLUCOSE CONT LEV 1 (brand for element
compact control 2) - Tier 2; QL
GLUCOCARD VITAL TEST (brand for cvs glucose meter test strips) - Tier
2; PA; QL
GLUCOSE METER TEST STRIPS (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
GUARDIAN REAL-TIME REPLACE PED - Tier 2; PA; QL
GUARDIAN SENSOR (3) (brand for freestyle libre 3 sensor) - Tier 2; PA;
QL
INSULIN PEN NEEDLES (brand for pen needles) - Tier 2; PA; QL
INSULIN PEN NEEDLES 32G X 4 MM , 32G X 5 MM , 32G X 6 MM
(brand for aum mini insulin pen needle) - Tier 2; PA; QL
LANCETS (brand for advanced mobile lancet) - Tier 2; PA; QL
TRUEPLUS LANCETS 30G (brand for advanced mobile lancet) - Tier
2; QL
TRUEPLUS SAFETY LANCETS 28G (brand for advanced mobile
lancet) - Tier 2; QL
MICRODOT TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
MM EASY TOUCH GLUCOSE METER (brand for blood glucose monitor
system) - Tier 2; PA; QL
NEUTEK 2TEK TEST (brand for cvs glucose meter test strips) - Tier 2;
PA; QL
ONETOUCH ULTRA MINI KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; PA; QL
OPTIUMEZ TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
PENLET II BLOOD SAMPLER (brand for select-lite device/lancets) - Tier
2; PA; QL
PRECISION XTRA (brand for blood glucose monitor system) - Tier 2; PA;
QL
PRECISION XTRA BLOOD GLUCOSE (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
PRECISION XTRA KETONE - Tier 2; PA; QL
PREMIUM BLOOD GLUCOSE TEST (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
QUINTET AC BLOOD GLUCOSE (brand for diatrue plus blood glucose) -
Tier 2; PA; QL
QUINTET AC BLOOD GLUCOSE TEST (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
90
Preferred Agents Non-Preferred Agents
QUINTET BLOOD GLUCOSE SYSTEM (brand for diatrue plus blood
glucose) - Tier 2; PA; QL
QUINTET BLOOD GLUCOSE TEST (brand for cvs glucose meter test
strips) - Tier 2; PA; QL
RELION ULTIMA GLUCOSE SYSTEM (brand for blood glucose monitor
system) - Tier 2; PA; QL
RELION ULTIMA TEST (brand for cvs glucose meter test strips) - Tier 2;
PA; QL
SAFE-T-LANCE (brand for advanced mobile lancet) - Tier 2; PA; QL
TRUE FOCUS BLOOD GLUCOSE STRIP (brand for cvs glucose meter
test strips) - Tier 2; PA; QL
TRUE METRIX AIR GLUCOSE METER DEVICE (brand for diatrue plus
blood glucose) - Tier 2; PA; QL
TRUE METRIX BLOOD GLUCOSE TEST STRIP IN VITRO (brand for cvs
glucose meter test strips) - Tier 2; PA; QL
TRUE METRIX METER KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; PA; QL
TRUEPLUS LANCETS 30G (brand for advanced mobile lancet) - Tier 2;
PA; QL
TRUEPLUS SAFETY LANCETS 28G (brand for advanced mobile lancet)
- Tier 2; PA; QL
TRUETRACK BLOOD GLUCOSE DEVICE (brand for diatrue plus blood
glucose) - Tier 2; PA; QL
TRUETRACK TEST (brand for cvs glucose meter test strips) - Tier 2; PA;
QL
UNISTRIP1 GENERIC (brand for cvs glucose meter test strips) - Tier 2;
PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
91
Preferred Agents Non-Preferred Agents
Diabetic/Endocrine Blood: Glucose Monitoring
GENTLE-LET PLATFORMS (brand for lancet transporter case) - Tier 2;
PA; QL
LANCETS (brand for lancet transporter case) - Tier 2; PA; QL
ONETOUCH SURESOFT LANCING DEVICE (brand for lancet
transporter case) - Tier 2; PA; QL
PENLET II REPLACEMENT CAP (brand for lancet transporter case) -
Tier 2; PA; QL
PSS SELECT PLATFORMS (brand for lancet transporter case) - Tier 2;
PA; QL
Electrolytes/Minerals/Metals/Vitamins
Electrolyte/Mineral Replacement
CARBAGLU (brand for carglumic acid) - Tier 2; SP; QL
carglumic acid (generic for CARBAGLU) - Tier 1; SP; QL
cavarest (generic for CAVAREST) - Tier 1
DENTA 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL
DENTAGEL (brand for sf) - Tier 2
easygel - Tier 1
klor-con (generic for KLOR-CON) - Tier 1; QL
klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL
klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL
klor-con m15 (generic for KLOR-CON M15) - Tier 1; QL
klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL
potassium chloride crys er (generic for KLOR-CON M10) - Tier 1; QL
anticavity fluoride rinse mouth/throat solution 0.05 % (generic for ACT
ANTICAVITY FLUORIDE RINSE) - Tier 1; PA
CLINPRO 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA
ENDARI - Tier 2; PA; QL
FLUORIDEX (brand for sodium fluoride 5000 ppm) - Tier 2; PA
FLUORIDEX ENHANCED WHITENING (brand for sodium fluoride 5000
ppm) - Tier 2; PA
FLUORIDEX SENSITIVITY RELIEF - Tier 2; PA
FLUORIMAX 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA
FLUORIMAX 5000 SENSITIVE - Tier 2; PA
JUST RIGHT 5000 (brand for sodium fluoride 5000 ppm) - Tier 2; PA
K-TAB (brand for potassium chloride er) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
92
Preferred Agents Non-Preferred Agents
potassium chloride er (generic for K-TAB) - Tier 1; QL
potassium chloride oral packet (generic for KLOR-CON) - Tier 1; QL
potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml
(20%) - Tier 1; QL
potassium citrate er oral tablet extended release 10 meq (1080 mg)
(generic for UROCIT-K 10) - Tier 1; QL
potassium citrate er oral tablet extended release 15 meq (1620 mg)
(generic for UROCIT-K 15) - Tier 1
potassium citrate er oral tablet extended release 5 meq (540 mg)
(generic for UROCIT-K 5) - Tier 1
PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2
PREVIDENT 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL
PREVIDENT 5000 BOOSTER PLUS (brand for sodium fluoride 5000
ppm) - Tier 2; PA
PREVIDENT 5000 ENAMEL PROTECT (brand for sodium fluoride 5000
enamel) - Tier 2; PA
PREVIDENT 5000 ORTHO DEFENSE (brand for sodium fluoride 5000
ppm) - Tier 2; PA
PREVIDENT 5000 SENSITIVE (brand for sodium fluoride 5000 enamel) -
Tier 2; PA
PREVIDENT MOUTH/THROAT (brand for sodium fluoride) - Tier 2; PA
sodium fluoride 5000 enamel (generic for PREVIDENT 5000 ENAMEL
PROTECT) - Tier 1; PA
PREVIDENT DENTAL (brand for sf) - Tier 2
sf (generic for CAVAREST) - Tier 1
sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL
sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1;
QL
sodium fluoride 5000 ppm dental cream (generic for DENTA 5000
PLUS) - Tier 1; QL
sodium fluoride 5000 ppm dental gel (generic for CAVAREST) - Tier 1
sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1;
QL
sodium fluoride dental gel (generic for CAVAREST) - Tier 1
sodium fluoride oral solution 1.1 (0.5 f) mg/ml - Tier 1; QL
sodium fluoride 5000 ppm dental paste (generic for CLINPRO 5000) - Tier
1; PA
sodium fluoride 5000 sensitive (generic for PREVIDENT 5000 ENAMEL
PROTECT) - Tier 1; PA
sodium fluoride mouth/throat (generic for PREVIDENT) - Tier 1; PA
UROCIT-K 10 (brand for potassium citrate er) - Tier 2; PA; QL
UROCIT-K 15 (brand for potassium citrate er) - Tier 2; PA
UROCIT-K 5 (brand for potassium citrate er) - Tier 2; PA
sodium fluoride oral tablet chewable (generic for NAFRINSE) - Tier 1;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
93
Preferred Agents Non-Preferred Agents
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body
Fluid Deficiency Drugs
BPROTECTED PEDIA IRON (brand for fe-vite iron) - Tier 2; QL
cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM)
- Tier 1; QL
calcium 500/vitamin d3 - Tier 1
calcium 600/vit d/minerals oral tablet 600-200 mg-unit - Tier 1; QL
calcium 600/vit d/minerals oral tablet chewable 600-400 mg-unit - Tier
1
calcium 600/vitamin d - Tier 1; QL
calcium 600/vitamin d-3 - Tier 1; QL
calcium 600+d oral tablet 600-400 mg-unit - Tier 1; QL
calcium 600+d tablet 600-200 mg-unit oral 600-200 mg-unit - Tier 1;
QL
abatron af (generic for ABATRON AF) - Tier 1; PA
BENTIVITE - Tier 2; PA; QL
calcium 500 +d3 (generic for OS-CAL EXTRA D3) - Tier 1; PA
calcium 500/d oral tablet chewable - Tier 1; PA
calcium 600+d oral capsule 600-500 mg-unit - Tier 1; PA
calcium 600+d3 oral capsule 600-500 mg-unit - Tier 1; PA
calcium citrate malate-vit d - Tier 1; PA
calcium citrate+d3 petites oral tablet 200-6.25 mg-mcg (generic for
CITRACAL PETITES/VITAMIN D) - Tier 1; PA
calcium citrate-vitamin d oral tablet 200-125 mg-unit - Tier 1; PA
calcium cit-vit d-3 petites (generic for CITRACAL PETITES/VITAMIN D) -
Tier 1; PA
calcium carb-cholecalciferol oral tablet 600-400 mg-unit - Tier 1; QL
calcium carbonate+vitamin d - Tier 1; QL
calcium carbonate-vitamin d3 - Tier 1; QL
calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1
calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1
calcium citrate +d3 (generic for CALCITRATE) - Tier 1
calcium citrate oral tablet 950 (200 ca) mg - Tier 1
calcium citrate plus vit d - Tier 1; QL
calcium citrate+d oral tablet 315-250 mg-unit (generic for
CALCITRATE) - Tier 1
calcium citrate+d3 oral tablet (generic for ADVANCED
CALCIUM/D/MAGNESIUM) - Tier 1; QL
calcium high potency - Tier 1; PA
calcium oral tablet 600 mg - Tier 1; PA
calcium-vitamin d oral tablet chewable 250-400 mg-unit (generic for
CALTRATE GUMMY BITES) - Tier 1; PA
calcium-vitamin d3 oral capsule 600-500 mg-unit - Tier 1; PA
CALTRATE GUMMY BITES (brand for cvs calcium-vitamin d) - Tier 2; PA
CENTRATEX - Tier 2; PA
citrus calcium/vitamin d (generic for CITRACAL PETITES/VITAMIN D) -
Tier 1; PA
coral calcium oral capsule 185-50-100 mg-mg-unit - Tier 1; PA
CORVITE 150 ORAL TABLET (brand for corvite fe) - Tier 2; PA
CORVITE FE (brand for corvite fe) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
94
Preferred Agents Non-Preferred Agents
calcium citrate+d3 w/magne (generic for ADVANCED
CALCIUM/D/MAGNESIUM) - Tier 1; QL
calcium citrate-vit d - Tier 1; QL
calcium citrate-vitamin d oral tablet 315-200 mg-unit - Tier 1; QL
calcium high potency/vitamin d - Tier 1; QL
calcium plus vitamin d (generic for OYSCO 500+D) - Tier 1; QL
calcium plus vitamin d3 - Tier 1; QL
calcium/minerals/vitamin d - Tier 1
calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5
mg - Tier 1
calcium-vitamin d oral tablet 600-400 mg-unit - Tier 1; QL
calcium-vitamin d3 oral tablet 600-400 mg-unit - Tier 1; QL
fe c tab (generic for ICAR-C) - Tier 1; PA
FERIVA 21/7 - Tier 2; PA
FERIVAFA - Tier 2; PA
FERRALET 90 - Tier 2; PA; QL
FERRAPLUS 90 - Tier 2; PA
FERRO-PLEX - Tier 2; PA; QL
ferrous sulfate oral syrup - Tier 1; PA; QL
FLORIVA ORAL LIQUID - Tier 2; PA
FOLIVANE-F - Tier 2; PA
HEMATOGEN FA - Tier 2; PA
HEMATRON-AF (brand for tl-hem 150) - Tier 2; PA
HEMAX (brand for tl-hem 150) - Tier 2; PA
CHROMAGEN (brand for iron complex) - Tier 2
EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ - Tier
2; QL
electrolyte solution (generic for ORALYTE FREEZER POPS) - Tier 1;
QL
ENFAMIL ENFALYTE (brand for cvs electrolyte solution) - Tier 2; QL
EZFE 200 - Tier 2
ferate (generic for FERATE) - Tier 1
FER-IN-SOL (brand for fe-vite iron) - Tier 2; QL
ferocon (generic for TRICON) - Tier 1
ferosul (generic for FEROSUL) - Tier 1; QL
ferotrinsic (generic for TRICON) - Tier 1
HEMOCYTE PLUS - Tier 2; PA
high potency iron - Tier 1; PA
ICAR-C (brand for fe c tab) - Tier 2; PA
INTEGRA F - Tier 2; PA
iron 100/c (generic for ICAR-C) - Tier 1; PA
iron oral tablet 200 (65 fe) mg (generic for FEOSOL) - Tier 1; PA
iron oral tablet 27 mg - Tier 1; PA
iron oral tablet extended release 142 (45 fe) mg (generic for SLOW FE) -
Tier 1; PA
iron slow release oral tablet extended release 160 (50 fe) mg - Tier 1; PA
IROSPAN 24/6 - Tier 2; PA
kelp oral tablet 0.15 mg - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
95
Preferred Agents Non-Preferred Agents
ferretts - Tier 1
ferrex 150 capsule 150 mg oral (generic for FERREX 150) - Tier 1
FERREX 150 CAPSULE 150 MG ORAL (brand for polysaccharide iron
complex) - Tier 2
FERRIC X-150 (brand for polysaccharide iron complex) - Tier 2
ferrous fumarate oral tablet 324 (106 fe) mg (generic for FERROCITE)
- Tier 1
ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) -
Tier 1
ferrous gluconate oral tablet 324 (37.5 fe) mg - Tier 1
ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; QL
ferrous sulfate oral elixir - Tier 1
K-PHOS-NEUTRAL (brand for phosphorous) - Tier 2; PA; QL
k-tan plus (generic for K-TAN PLUS) - Tier 1; PA
liquid calcium with d3 oral capsule 600-500 mg-unit - Tier 1; PA
MAG-200 (brand for kp mag-oxide magnesium) - Tier 2; PA
mag-g - Tier 1; PA
MAGNEBIND 300 - Tier 2; PA
magnesium oral capsule 500 mg - Tier 1; PA
magnesium oxide oral tablet 200 mg (generic for MAG-OXIDE) - Tier 1;
PA
mag-oxide (generic for MAG-OXIDE) - Tier 1; PA
mag-oxide magnesium (generic for MAG-OXIDE) - Tier 1; PA
NIFEREX (brand for corvite fe) - Tier 2; PA
ferrous sulfate oral solution 75 (15 fe) mg/ml (generic for
BPROTECTED PEDIA IRON) - Tier 1; QL
ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier
1; QL
ferrous sulfate oral tablet delayed release - Tier 1; QL
fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; QL
foltrin (generic for TRICON) - Tier 1
GALZIN ORAL CAPSULE 25 MG - Tier 2
GALZIN ORAL CAPSULE 50 MG - Tier 2; QL
HEMATOGEN (brand for iron complex) - Tier 2
hi cal (generic for OYSCO 500+D) - Tier 1; QL
iferex 150 (generic for FERREX 150) - Tier 1
NUFERA (brand for corvite fe) - Tier 2; PA
NU-MAG - Tier 2; PA
ORACIT - Tier 2; PA
OS-CAL EXTRA D3 (brand for gnp calcium 500 +d3) - Tier 2; PA
PHOS-NAK - Tier 2; PA
phosphorus supplement - Tier 1; PA
phosphorus w/sod & potassium - Tier 1; PA
purevit dualfe plus (generic for K-TAN PLUS) - Tier 1; PA
se-tan plus (generic for K-TAN PLUS) - Tier 1; PA
SLOW FE (brand for gnp iron) - Tier 2; PA
slow release iron oral tablet extended release 143 (45 fe) mg - Tier 1; PA
SLOW-MAG - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
96
Preferred Agents Non-Preferred Agents
iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1
iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1
iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL
iron supplement - Tier 1
iron supplement childrens (generic for BPROTECTED PEDIA IRON) -
Tier 1; QL
K-PHOS - Tier 2; QL
K-PHOS NO 2 - Tier 2
magnesium oral tablet 500 mg - Tier 1
magnesium oxide oral tablet 400 (240 mg) mg (generic for
MAGNESIUM-OXIDE) - Tier 1
magnesium oxide oral tablet 500 mg - Tier 1
SLOWMAG MG MUSCLE/HEART - Tier 2; PA
tl-hem 150 (generic for ABATRON AF) - Tier 1; PA
zinc gluconate oral tablet 100 mg - Tier 1; PA
magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1
NU-IRON (brand for polysaccharide iron complex) - Tier 2
oralyte freezer pops (generic for ORALYTE FREEZER POPS) - Tier 1;
QL
OS-CAL CALCIUM + D3 (brand for calcium plus vitamin d) - Tier 2; QL
oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL
oyster shell calcium + d oral tablet 500-400 mg-unit - Tier 1
oyster shell calcium + d3 - Tier 1
oyster shell calcium plus d (generic for OYSCO 500+D) - Tier 1; QL
oyster shell calcium w/d (generic for OYSCO 500+D) - Tier 1; QL
oyster shell calcium/vit d (generic for OYSCO 500+D) - Tier 1; QL
oyster shell calcium/vit d3 - Tier 1
oyster shell calcium/vitamin d oral tablet 500-200 mg-unit (generic for
OYSCO 500+D) - Tier 1; QL
oyster shell calcium-vit d - Tier 1; QL
ped electrolyte freeze pop (generic for ORALYTE FREEZER POPS) -
Tier 1; QL
PEDIALYTE FREEZER POPS (brand for cvs electrolyte solution) -
Tier 2; QL
PEDIALYTE ORAL SOLUTION (brand for cvs electrolyte solution) -
Tier 2; QL
PEDIALYTE SINGLES (brand for cvs electrolyte solution) - Tier 2; QL
pediatric electrolyte oral solution (generic for ORALYTE FREEZER
POPS) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
97
Preferred Agents Non-Preferred Agents
PHOSPHA 250 NEUTRAL (brand for phosphorous) - Tier 2; QL
phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1;
QL
phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL)
- Tier 1; QL
PHOSPHO-TRIN K500 - Tier 2; QL
poly-iron 150 (generic for FERREX 150) - Tier 1
poly-iron 150 forte (generic for IFEREX 150 FORTE) - Tier 1
polysaccharide iron complex (generic for FERREX 150) - Tier 1
polysaccharide iron forte (generic for IFEREX 150 FORTE) - Tier 1
polysaccharide-iron complex (generic for FERREX 150) - Tier 1
potassium citrate-citric acid - Tier 1
REHYDRALYTE (brand for cvs electrolyte solution) - Tier 2; QL
sod citrate-citric acid - Tier 1
TRICON (brand for ferocon) - Tier 2
WILZIN - Tier 2
zinc gluconate oral tablet 50 mg - Tier 1; QL
zinc oral tablet 50 mg - Tier 1; QL
Electrolyte/Mineral/Metal Modifiers
CHEMET - Tier 2
deferasirox oral tablet (generic for JADENU) - Tier 1; SP; QL
deferasirox oral tablet soluble (generic for EXJADE) - Tier 1; SP; QL
deferiprone (generic for FERRIPROX) - Tier 1; SP; QL
FERRIPROX ORAL SOLUTION - Tier 2; SP; QL
SAMSCA (brand for tolvaptan) - Tier 2; SP; QL
trientine hcl (generic for SYPRINE) - Tier 1; SP; QL
deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA; SP;
QL
deferasirox oral packet (generic for JADENU SPRINKLE) - Tier 1; PA; SP;
QL
EXJADE (brand for deferasirox) - Tier 2; PA; SP; QL
FERRIPROX ORAL TABLET (brand for deferiprone) - Tier 2; PA; SP; QL
FERRIPROX TWICE-A-DAY - Tier 2; PA; SP; QL
JADENU (brand for deferasirox) - Tier 2; PA; SP; QL
JADENU SPRINKLE (brand for deferasirox) - Tier 2; PA; SP; QL
JYNARQUE ORAL TABLET (brand for tolvaptan) - Tier 2; PA; SP; QL
JYNARQUE ORAL TABLET THERAPY PACK 15 MG, 45 & 15 MG, 60 &
30 MG, 90 & 30 MG - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
98
Preferred Agents Non-Preferred Agents
JYNARQUE ORAL TABLET THERAPY PACK 30 & 15 MG - Tier 2; PA
SYPRINE (brand for trientine hcl) - Tier 2; PA; SP; QL
tolvaptan oral tablet 30 mg (generic for JYNARQUE) - Tier 1; PA; SP; QL
Phosphate Binders
calcium acetate (phos binder) (generic for CALPHRON) - Tier 1; QL
calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1;
QL
PHOSLYRA - Tier 2; QL
sevelamer carbonate (generic for RENVELA) - Tier 1; QL
sevelamer hcl (generic for RENAGEL) - Tier 1; QL
AURYXIA - Tier 2; PA; QL
FOSRENOL (brand for lanthanum carbonate) - Tier 2; PA; QL
lanthanum carbonate (generic for FOSRENOL) - Tier 1; PA; QL
RENAGEL (brand for sevelamer hcl) - Tier 2; PA; QL
RENVELA (brand for sevelamer carbonate) - Tier 2; PA; QL
VELPHORO - Tier 2; PA; QL
Potassium Binders
sodium polystyrene sulfonate - Tier 1
sps - Tier 1; QL
LOKELMA - Tier 2; PA; QL
VELTASSA - Tier 2; PA; QL
Vitamins
a-25 - Tier 1; QL
ACTIVITE (brand for vp-vite rx) - Tier 2; PA; QL
animal shapes kids first (generic for FLINTSTONES MULTIVITAMIN) -
Tier 1; QL
aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier 1
b complex - Tier 1; QL
b complex vitamins - Tier 1; QL
b complex-c oral capsule - Tier 1
b-complex oral tablet - Tier 1
b-complex with b-12 - Tier 1
b-complex/b-12 oral - Tier 1
b-plex - Tier 1
ACTIFLOVIT EAR HEALTH (brand for b complex formula 1 (lipotrop)) -
Tier 2; PA
b complex formula 1 (lipotrop) (generic for CVS BALANCED B50) - Tier 1;
PA
b complex plus c (generic for ALLBEE/C) - Tier 1; PA
b complex-folic acid - Tier 1; PA
b-100 complex cr (generic for ENDUR-B) - Tier 1; PA
balance b-100 (generic for CVS BALANCED B50) - Tier 1; PA
balance b-50 (generic for BIG 100 (BIOTIN)) - Tier 1; PA
balanced b100 - Tier 1; PA
balanced b-100 cr (generic for ENDUR-B) - Tier 1; PA
balanced b-100 oral tablet (generic for BIG 100 (BIOTIN)) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
99
Preferred Agents Non-Preferred Agents
BPROTECTED PEDIA D-VITE (brand for aqueous vitamin d) - Tier 2
childrens chewable vitamins (generic for FLINTSTONES
MULTIVITAMIN) - Tier 1; QL
childrens chewables/ex c (generic for FLINTSTONES/EXTRA C) - Tier
1; QL
childrens vitamins/extra c (generic for FLINTSTONES/EXTRA C) - Tier
1; QL
classic prenatal - Tier 1; QL
COMPLETE NATAL DHA - Tier 2; QL
CO-NATAL FA (brand for neonatal complete) - Tier 2; QL
d3 high potency oral capsule 25 mcg (1000 ut) (generic for
PRONUTRIENTS VITAMIN D3) - Tier 1
balanced b50 (generic for CVS BALANCED B50) - Tier 1; PA
balanced b-50 oral tablet (generic for BIG 100 (BIOTIN)) - Tier 1; PA
balanced b-50 tr (generic for ENDUR-B) - Tier 1; PA
b-complex/vitamin c cr - Tier 1; PA
beta carotene oral - Tier 1; PA
bp vit 3 (generic for TALIVA) - Tier 1; PA
brewers yeast oral tablet 487.5 mg - Tier 1; PA
b-stress - Tier 1; PA
calcium-folic acid plus d - Tier 1; PA
CENTRUM SPECIALIST PRENATAL - Tier 2; PA
CITRANATAL 90 DHA - Tier 2; PA; QL
CITRANATAL ASSURE - Tier 2; PA; QL
d3 oral capsule 10 mcg (400 unit), 50 mcg (2000 ut) - Tier 1; QL
d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D
5000) - Tier 1
d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS
VITAMIN D3) - Tier 1
d3 super strength - Tier 1; QL
d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1
d3-50 (generic for D3-50) - Tier 1; QL
DECARA ORAL CAPSULE 1.25 MG (50000 UT) (brand for vitamin d3)
- Tier 2; QL
DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2
DIALYVITE (brand for vp-vite rx) - Tier 2; PA; QL
CITRANATAL B-CALM - Tier 2; PA
CITRANATAL BLOOM - Tier 2; PA
CITRANATAL DHA - Tier 2; PA; QL
CITRANATAL HARMONY - Tier 2; PA
C-NATE DHA (brand for virt-nate dha) - Tier 2; PA
cod liver oil oral capsule , 1250-135 unit, 4000-200 unit - Tier 1; PA
cod liver oil oral oil - Tier 1; PA
COMPLETENATE - Tier 2; PA; QL
complex b-100-inositol - Tier 1; PA
CONCEPT DHA (brand for virt-c dha) - Tier 2; PA
CONCEPT OB - Tier 2; PA
DIALYVITE 800/ZINC - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
100
Preferred Agents Non-Preferred Agents
DIALYVITE 800 ORAL TABLET (brand for full spectrum b/vitamin c) -
Tier 2; QL
DIALYVITE VITAMIN D 5000 (brand for cvs d3) - Tier 2
DIALYVITE/ZINC - Tier 2
D-VI-SOL (brand for aqueous vitamin d) - Tier 2
d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1
ELDERTONIC - Tier 2
ENFAMIL EXPECTA - Tier 2; QL
fabb (generic for VIRT-GARD) - Tier 1
flintstones multivitamin (generic for FLINTSTONES MULTIVITAMIN) -
Tier 1; QL
FOLGARD RX (brand for fabb) - Tier 2
DIALYVITE 800-ZINC 15 - Tier 2; PA
ELITE-OB - Tier 2; PA
ENBRACE HR - Tier 2; PA
FLORIVA ORAL TABLET CHEWABLE - Tier 2; PA
FLORIVA PLUS (brand for multi-vitamin/fluoride) - Tier 2; PA; QL
FOLITE - Tier 2; PA; QL
FOLIVANE-OB - Tier 2; PA
foltabs 800 - Tier 1; PA
FOLTANX (brand for l-methylfolate-b6-b12) - Tier 2; PA
FOLTRATE (brand for vitamin b12-folic acid) - Tier 2; PA
inner ear plus (generic for CVS BALANCED B50) - Tier 1; PA
lipoflavovit (generic for CVS BALANCED B50) - Tier 1; PA
full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; QL
HYLAVITE - Tier 2
little ones childrens (generic for FLINTSTONES MULTIVITAMIN) - Tier
1; QL
M-NATAL PLUS (brand for prenatal) - Tier 2; QL
MULTI-MAC - Tier 2; QL
multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QL
multi-vitamin/fluoride/iron - Tier 1; QL
mynephrocaps oral capsule 1 mg (generic for MYNEPHRON) - Tier 1
MYNEPHRON (brand for triphrocaps) - Tier 2
NEONATAL COMPLETE ORAL TABLET 29-1 MG (brand for neonatal
complete) - Tier 2; QL
l-methylfolate-b6-b12 (generic for FOLTANX) - Tier 1; PA
LORID (brand for vp-vite rx) - Tier 2; PA; QL
mega multiple/chelated mineral (generic for CVS BALANCED B50) - Tier
1; PA
MEPHYTON (brand for phytonadione) - Tier 2; PA; QL
multi-vitamin hp/minerals - Tier 1; PA
NEONATAL COMPLETE ORAL TABLET 27-1 MG (brand for prenatal) -
Tier 2; PA; QL
NEONATAL PLUS TABLET 27-1 MG ORAL (brand for prenatal) - Tier 2;
PA; QL
nephronex oral tablet (generic for NEPHRONEX) - Tier 1; PA; QL
NEPHRO-VITE RX (brand for vp-vite rx) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
101
Preferred Agents Non-Preferred Agents
NEONATAL PLUS TABLET 27-1 MG ORAL (brand for prenatal) - Tier
2; QL
NEONATAL VITAMIN (brand for cvs prenatal) - Tier 2; QL
NEPHPLEX RX - Tier 2
nephro vitamins (generic for DIALYVITE 800) - Tier 1; QL
NEPHRO-VITE (brand for full spectrum b/vitamin c) - Tier 2; QL
niacin er oral capsule extended release 250 mg - Tier 1; QL
niacin er oral capsule extended release 500 mg - Tier 1
niacin er oral tablet extended release (generic for SLO-NIACIN) - Tier
1
niacin oral tablet 100 mg, 250 mg, 50 mg - Tier 1
NIVA-PLUS (brand for prenatal) - Tier 2; QL
NESTABS - Tier 2; PA
NESTABS DHA - Tier 2; PA
NESTABS ONE - Tier 2; PA; QL
niacin flush free oral capsule 400-100 mg - Tier 1; PA
NICOMIDE (brand for nicotinamide) - Tier 2; PA
nicotinamide oral (generic for NICOMIDE) - Tier 1; PA
no flush niacin oral capsule - Tier 1; PA
OB COMPLETE - Tier 2; PA
OB COMPLETE ONE - Tier 2; PA
OB COMPLETE PETITE - Tier 2; PA
OB COMPLETE PREMIER - Tier 2; PA
OB COMPLETE/DHA - Tier 2; PA
ONE VITE WOMENS (brand for cvs prenatal) - Tier 2; QL
phytonadione oral (generic for MEPHYTON) - Tier 1; QL
PRENATABS RX (brand for thrivite rx) - Tier 2; QL
prenatal formula oral tablet 28-0.8 mg - Tier 1; QL
prenatal gummy oral tablet chewable 0.4-25 mg (generic for ONE A
DAY PRENATAL) - Tier 1; QL
prenatal multi+dha - Tier 1; QL
prenatal multivitamins - Tier 1; QL
prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier
1; QL
prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1;
QL
OBSTETRIX DHA - Tier 2; PA
one daily womens health oral tablet (generic for ONE-A-DAY WOMENS
FORMULA) - Tier 1; PA
ONE VITE WOMENS PLUS (brand for prenatal) - Tier 2; PA; QL
pnv-dha (generic for ZATEAN-PN DHA) - Tier 1; PA
pnv-dha+docusate - Tier 1; PA
pnv-omega - Tier 1; PA
pnv-select - Tier 1; PA
POLY-VI-FLOR ORAL SUSPENSION - Tier 2; PA
POLY-VI-FLOR ORAL TABLET CHEWABLE 0.25 MG - Tier 2; PA; QL
POLY-VI-FLOR ORAL TABLET CHEWABLE 0.5 MG, 1 MG - Tier 2; PA
POLY-VI-FLOR/IRON - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
102
Preferred Agents Non-Preferred Agents
prenatal oral tablet 28-0.8 mg - Tier 1; QL
prenatal plus vitamin/mineral (generic for NEONATAL PLUS) - Tier 1;
QL
prenatal vitamin plus low iron (generic for NEONATAL PLUS) - Tier 1;
QL
prenatal vitamins oral tablet 28-0.8 mg - Tier 1; QL
prenatal/iron - Tier 1; QL
PRENATVITE RX - Tier 2; QL
PRONUTRIENTS VITAMIN D3 (brand for cvs d3) - Tier 2
QUFLORA PEDIATRIC ORAL SOLUTION 0.5 MG/ML (brand for
multi-vitamin/fluoride) - Tier 2; QL
PREMESISRX - Tier 2; PA
PRENAISSANCE - Tier 2; PA
PRENAISSANCE PLUS - Tier 2; PA
prenatal 19 - Tier 1; PA; QL
prenatal gummy oral tablet chewable 0.18-25 mg (generic for ALIVE
DAILY SUP PRENATAL GUMMI) - Tier 1; PA; QL
prenatal plus (generic for NEONATAL PLUS) - Tier 1; PA; QL
prenatal/folic acid+dha - Tier 1; PA
PRENATE - Tier 2; PA
PRENATE AM - Tier 2; PA
PRENATE DHA - Tier 2; PA
PRENATE ELITE - Tier 2; PA
radiance platinum vitamin d3 (generic for RADIANCE PLATINUM
VITAMIN D3) - Tier 1
RENAL (brand for triphrocaps) - Tier 2
RENAL MULTIVITAMIN FORMULA (brand for full spectrum b/vitamin
c) - Tier 2; QL
renal-vite (generic for DIALYVITE 800) - Tier 1; QL
rena-vite (generic for DIALYVITE 800) - Tier 1; QL
SLO-NIACIN (brand for niacin er) - Tier 2
stress formula/zinc (b-compl) - Tier 1
stress formula/zinc oral tablet - Tier 1
super b/c - Tier 1
thiamine mononitrate oral - Tier 1; QL
PRENATE ENHANCE - Tier 2; PA
PRENATE ESSENTIAL - Tier 2; PA
PRENATE MINI - Tier 2; PA
PRENATE PIXIE - Tier 2; PA
PRENATE RESTORE - Tier 2; PA
PRIMACARE - Tier 2; PA; QL
QUFLORA FE - Tier 2; PA
QUFLORA FE PEDIATRIC - Tier 2; PA; QL
QUFLORA GUMMIES - Tier 2; PA; QL
QUFLORA PEDIATRIC ORAL SOLUTION 0.25 MG/ML (brand for multi-
vitamin/fluoride) - Tier 2; PA; QL
RELNATE DHA (brand for virt-nate dha) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
103
Preferred Agents Non-Preferred Agents
THRIVITE RX (brand for thrivite rx) - Tier 2; QL
TRINATAL RX 1 (brand for trinatal rx 1) - Tier 2; QL
triphrocaps (generic for MYNEPHRON) - Tier 1
tri-vite pediatric (generic for BPROTECTED PEDIA TRI-VITE) - Tier 1;
QL
VINATE ONE (brand for trinatal rx 1) - Tier 2; QL
virt-caps (generic for MYNEPHRON) - Tier 1
virt-gard (generic for VIRT-GARD) - Tier 1
vitachew vitamin d3 (generic for KIDS FIRST VITAMIN D3 GUMMIES)
- Tier 1
VITAFOL FE+ - Tier 2; QL
VITAL-D RX - Tier 2
risanoid plus (generic for CVS BALANCED B50) - Tier 1; PA
SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG - Tier 2; PA
SELECT-OB ORAL TABLET CHEWABLE 29-1 MG - Tier 2; PA; QL
SELECT-OB+DHA - Tier 2; PA
SE-NATAL 19 - Tier 2; PA; QL
super b complex/c (generic for ALLBEE/C) - Tier 1; PA
SUPER B-50 B COMPLEX (brand for b-100 high potency balanced) - Tier
2; PA
SUPERVITE - Tier 2; PA
TALIVA (brand for bp vit 3) - Tier 2; PA
TARON-C DHA - Tier 2; PA
TARON-PREX - Tier 2; PA
vitamin a oral capsule 2400 mcg (8000 ut), 3 mg (10000 ut) - Tier 1;
QL
vitamin b complex-c - Tier 1
vitamin b-1 oral tablet 100 mg - Tier 1; QL
vitamin d (cholecalciferol) oral tablet 10 mcg (400 unit) - Tier 1; QL
vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for
VITAMIN D-1000 MAX ST) - Tier 1
vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS
VITAMIN D3) - Tier 1
vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier
1
TRISTART DHA - Tier 2; PA
TRISTART ONE - Tier 2; PA; QL
TRI-VI-FLOR ORAL SUSPENSION 0.25 MG/ML (brand for tri-vi-floro) -
Tier 2; PA; QL
TRI-VI-FLOR ORAL SUSPENSION 0.5 MG/ML (brand for tri-vi-floro) -
Tier 2; PA
TRI-VI-FLORO ORAL SUSPENSION 0.25 MG/ML (brand for tri-vi-floro) -
Tier 2; PA; QL
TRI-VI-FLORO ORAL SUSPENSION 0.5 MG/ML (brand for tri-vi-floro) -
Tier 2; PA
virt-c dha (generic for CONCEPT DHA) - Tier 1; PA
virt-nate dha (generic for VIVA DHA) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
104
Preferred Agents Non-Preferred Agents
vitamin d oral tablet chewable 10 mcg (400 unit) (generic for
HEALTHY KIDS VITAMIN D3) - Tier 1
vitamin d3 gummies (generic for KIDS FIRST VITAMIN D3 GUMMIES)
- Tier 1
vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1;
QL
vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE
VITAMIN D 5000) - Tier 1
vitamin d-3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE
VITAMIN D 5000) - Tier 1
vitamin d3 oral capsule 25 mcg (1000 ut) (generic for
PRONUTRIENTS VITAMIN D3) - Tier 1
virt-pn dha (generic for ZATEAN-PN DHA) - Tier 1; PA
VITAFOL GUMMIES - Tier 2; PA
VITAFOL STRIPS - Tier 2; PA; QL
VITAFOL ULTRA - Tier 2; PA
VITAFOL-NANO - Tier 2; PA
VITAFOL-OB - Tier 2; PA; QL
VITAFOL-OB+DHA - Tier 2; PA; QL
VITAFOL-ONE - Tier 2; PA
VITAMEZ (brand for bp vit 3) - Tier 2; PA
vitamin k (phytonadione) - Tier 1; PA; QL
VITASURE (brand for vp-vite rx) - Tier 2; PA; QL
VITATHELY WITH GINGER (brand for prenatal) - Tier 2; PA; QL
vitamin d3 oral capsule 250 mcg (10000 ut) (generic for IS-D 10,000) -
Tier 1
vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; QL
vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; QL
vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D-
VITE) - Tier 1
vitamin d3 oral liquid 125 mcg/ml - Tier 1
vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1; QL
vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE
PLATINUM VITAMIN D3) - Tier 1
vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000
MAX ST) - Tier 1
VIVA DHA (brand for virt-nate dha) - Tier 2; PA
WESCAP-C DHA (brand for virt-c dha) - Tier 2; PA
WESCAP-PN DHA (brand for pnv-dha) - Tier 2; PA
WESNATE DHA (brand for virt-nate dha) - Tier 2; PA
WESTAB MAX - Tier 2; PA
WESTGEL DHA - Tier 2; PA
XVITE (brand for vp-vite rx) - Tier 2; PA; QL
ZATEAN-PN DHA (brand for pnv-dha) - Tier 2; PA
ZELDANA (brand for antioxidant formula) - Tier 2; PA
ZE-PLUS (brand for antioxidant formula) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
105
Preferred Agents Non-Preferred Agents
vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000
MAX ST) - Tier 1
vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) -
Tier 1; QL
vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for
HEALTHY KIDS VITAMIN D3) - Tier 1
vitamin d3 oral tablet chewable 25 mcg, 25 mcg (1000 ut) (generic for
KIDS FIRST VITAMIN D3 GUMMIES) - Tier 1
vitamin d-400 - Tier 1; QL
vitamin-b complex - Tier 1
vp-vite rx (generic for NEPHRONEX) - Tier 1; PA; QL
weekly-d (generic for D3-50) - Tier 1; QL
wescaps (generic for MYNEPHRON) - Tier 1
westab mini (generic for VIRT-GARD) - Tier 1
WESTAB PLUS (brand for prenatal) - Tier 2; QL
womens prenatal+dha - Tier 1; QL
Enzyme Inhibitors - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
TRUSELTIQ (100MG DAILY DOSE) - Tier 2; PA; SP; QL
TRUSELTIQ (125MG DAILY DOSE) - Tier 2; PA; SP; QL
TRUSELTIQ (50MG DAILY DOSE) - Tier 2; PA; SP; QL
TRUSELTIQ (75MG DAILY DOSE) - Tier 2; PA; SP; QL
Estrogens - Hormone Replacement/Modifying Drugs
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers) - Drugs to Regulate Hormones
MYFEMBREE - Tier 2; PA; QL
NEXTSTELLIS - Tier 2; PA; QL
Gastrointestinal Agents
VOQUEZNA TRIPLE PAK - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
106
Preferred Agents Non-Preferred Agents
Anti-Constipation Agents
AMITIZA (brand for lubiprostone) - Tier 2; ST; QL
constulose - Tier 1; QL
enulose - Tier 1; QL
generlac - Tier 1; QL
lactulose encephalopathy - Tier 1; QL
lactulose oral solution - Tier 1; QL
LINZESS ORAL CAPSULE 145 MCG, 290 MCG - Tier 2; ST; QL
MOVANTIK - Tier 2; ST; QL
KRISTALOSE (brand for lactulose) - Tier 2; PA; QL
lactulose oral packet (generic for KRISTALOSE) - Tier 1; PA; QL
LINZESS ORAL CAPSULE 72 MCG - Tier 2; PA; QL
LUBIPROSTONE (brand for lubiprostone) - Tier 2; PA; ST; QL
MOTEGRITY - Tier 2; PA; QL
RELISTOR - Tier 2; PA; QL
SYMPROIC - Tier 2; PA; QL
TRULANCE - Tier 2; PA; QL
ZELNORM - Tier 2; PA; QL
Anti-Constipation AgentsOther
IBSRELA - Tier 2; PA; QL
Anti-Diarrheal Agents
anti-diarrheal oral liquid 1 mg/5ml - Tier 1
anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1
diamode (generic for IMODIUM A-D) - Tier 1
diphenoxylate-atropine oral liquid - Tier 1
diphenoxylate-atropine oral tablet (generic for LOMOTIL) - Tier 1; QL
IMODIUM A-D ORAL TABLET (brand for anti-diarrheal) - Tier 2
loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QL
loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1
meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1
MOTOFEN - Tier 2; QL
alosetron hcl (generic for LOTRONEX) - Tier 1; PA; QL
anti-diarrheal oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1;
PA
IMODIUM A-D ORAL LIQUID (brand for anti-diarrheal) - Tier 2; PA
LOMOTIL (brand for diphenoxylate-atropine) - Tier 2; PA; QL
loperamide hcl oral liquid 1 mg/7.5ml (generic for IMODIUM A-D) - Tier 1;
PA
loperamide hcl oral suspension (generic for IMODIUM A-D) - Tier 1; PA
LOTRONEX (brand for alosetron hcl) - Tier 2; PA; QL
MYTESI - Tier 2; PA; QL
opium - Tier 1; PA; QL
VIBERZI - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
107
Preferred Agents Non-Preferred Agents
XERMELO - Tier 2; PA; SP; QL
Antispasmodics, Gastrointestinal
CUVPOSA (brand for glycopyrrolate) - Tier 2; QL
dicyclomine hcl oral capsule - Tier 1; QL
dicyclomine hcl oral solution - Tier 1
dicyclomine hcl oral tablet - Tier 1; QL
glycopyrrolate oral tablet 1 mg (generic for ROBINUL) - Tier 1
glycopyrrolate oral tablet 2 mg (generic for ROBINUL-FORTE) - Tier 1
methscopolamine bromide oral - Tier 1
chlordiazepoxide-clidinium (generic for LIBRAX) - Tier 1; PA; QL
DARTISLA ODT - Tier 2; PA; QL
GLYCATE (brand for glycopyrrolate) - Tier 2; PA
glycopyrrolate oral solution (generic for CUVPOSA) - Tier 1; PA; QL
GLYCOPYRROLATE ORAL TABLET 1.5 MG (brand for glycopyrrolate) -
Tier 2; PA
LIBRAX (brand for chlordiazepoxide-clidinium) - Tier 2; PA; QL
ROBINUL (brand for glycopyrrolate) - Tier 2; PA
ROBINUL-FORTE (brand for glycopyrrolate) - Tier 2; PA
Gastrointestinal Agents, Other
amoxicill-clarithro-lansopraz - Tier 1; QL
gavilyte-g (generic for GAVILYTE-G) - Tier 1; QL
gavilyte-n with flavor pack (generic for GAVILYTE-N WITH FLAVOR
PACK) - Tier 1; QL
OMECLAMOX-PAK - Tier 2
peg 3350-kcl-na bicarb-nacl (generic for GAVILYTE-N WITH FLAVOR
PACK) - Tier 1; QL
peg-3350/electrolytes (generic for GAVILYTE-G) - Tier 1; QL
PYLERA - Tier 2
ursodiol oral capsule 300 mg - Tier 1; QL
ursodiol oral tablet (generic for URSO 250) - Tier 1
CHENODAL - Tier 2; PA; SP; QL
CLENPIQ - Tier 2; PA; QL
GATTEX - Tier 2; PA; SP; QL
gavilyte-c - Tier 1; PA
GOLYTELY (brand for peg-3350/electrolytes) - Tier 2; PA; QL
HELIDAC THERAPY - Tier 2; PA; QL
MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA; QL
MYALEPT - Tier 2; PA; SP; QL
OCALIVA - Tier 2; PA; SP; QL
OSMOPREP - Tier 2; PA; QL
peg-3350/electrolytes/ascorbat (generic for MOVIPREP) - Tier 1; PA; QL
peg-kcl-nacl-nasulf-na asc-c (generic for MOVIPREP) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
108
Preferred Agents Non-Preferred Agents
PLENVU - Tier 2; PA; QL
RELTONE (brand for ursodiol) - Tier 2; PA; QL
SUPREP BOWEL PREP KIT - Tier 2; PA; QL
TALICIA - Tier 2; PA
URSO 250 (brand for ursodiol) - Tier 2; PA
URSO FORTE (brand for ursodiol) - Tier 2; PA
URSODIOL ORAL CAPSULE 200 MG, 400 MG (brand for ursodiol) - Tier
2; PA; QL
Histamine2 (H2) Receptor Antagonists
acid controller (generic for PEPCID AC) - Tier 1; QL
acid reducer oral tablet (generic for PEPCID AC) - Tier 1; QL
acid reducer oral tablet 200 mg (generic for TAGAMET HB) - Tier 1;
QL
cimetidine hcl - Tier 1; QL
cimetidine oral (generic for TAGAMET HB) - Tier 1; QL
famotidine oral suspension reconstituted 40 mg/5ml - Tier 1; QL; AL
famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL
famotidine oral tablet 20 mg, 40 mg (generic for PEPCID) - Tier 1; QL
famotidine orig st (generic for PEPCID AC) - Tier 1; QL
heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier
1; QL
nizatidine - Tier 1; PA; QL
PEPCID (brand for famotidine) - Tier 2; PA; QL
heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL
heartburn relief oral tablet 200 mg (generic for TAGAMET HB) - Tier 1;
QL
Irritable Bowel Syndrome Agents
BYLVAY - Tier 2; PA; SP; QL; AL
BYLVAY (PELLETS) - Tier 2; PA; SP; QL; AL
Protectants
misoprostol oral (generic for CYTOTEC) - Tier 1; QL
sucralfate oral (generic for CARAFATE) - Tier 1; QL
CARAFATE (brand for sucralfate) - Tier 2; PA; QL
CYTOTEC (brand for misoprostol) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
109
Preferred Agents Non-Preferred Agents
Proton Pump Inhibitors
acid reducer oral capsule delayed release - Tier 1; QL
lansoprazole oral capsule delayed release 15 mg (generic for
PREVACID 24HR) - Tier 1; QL
lansoprazole oral capsule delayed release 30 mg (generic for
PREVACID) - Tier 1; QL
NEXIUM ORAL PACKET (brand for esomeprazole magnesium) - Tier
2; QL
omeprazole magnesium oral capsule delayed release - Tier 1; QL
omeprazole oral capsule delayed release 10 mg, 20 mg, 20.6 (20
base) mg, 40 mg - Tier 1; QL
pantoprazole sodium oral tablet delayed release (generic for
PROTONIX) - Tier 1; QL
acid reducer oral tablet delayed release (generic for PRILOSEC OTC) -
Tier 1; PA; QL
ACIPHEX (brand for rabeprazole sodium) - Tier 2; PA; QL
DEXILANT (brand for dexlansoprazole) - Tier 2; PA; QL
DEXLANSOPRAZOLE (brand for dexlansoprazole) - Tier 2; PA; QL
esomeprazole magnesium oral capsule delayed release (generic for
NEXIUM) - Tier 1; PA; QL
esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1; PA;
QL
lansoprazole oral tablet delayed release dispersible 15 mg, 30 mg
(generic for PREVACID SOLUTAB) - Tier 1; PA; QL
PROTONIX ORAL PACKET (brand for pantoprazole sodium) - Tier 2;
QL
NEXIUM ORAL CAPSULE DELAYED RELEASE (brand for
esomeprazole magnesium) - Tier 2; PA; QL
omeprazole magnesium oral tablet delayed release (generic for
PRILOSEC OTC) - Tier 1; PA; QL
omeprazole oral tablet delayed release 20 mg - Tier 1; PA; QL
omeprazole-sod bicarbonate (generic for ZEGERID) - Tier 1; PA; QL
omeprazole-sodium bicarb oral capsule 20-1100 mg (generic for
ZEGERID) - Tier 1; PA; QL
omeprazole-sodium bicarbonate (generic for ZEGERID) - Tier 1; PA; QL
pantoprazole sodium oral packet (generic for PROTONIX) - Tier 1; PA;
QL
PREVACID (brand for lansoprazole) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
110
Preferred Agents Non-Preferred Agents
PREVACID 24HR (brand for cvs lansoprazole) - Tier 2; PA; QL
PREVACID SOLUTAB (brand for cvs lansoprazole) - Tier 2; PA; QL
PRILOSEC - Tier 2; PA; QL
PRILOSEC OTC (brand for acid reducer) - Tier 2; PA; QL
PROTONIX ORAL TABLET DELAYED RELEASE (brand for pantoprazole
sodium) - Tier 2; PA; QL
RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE - Tier 2; PA; QL
rabeprazole sodium oral tablet delayed release (generic for ACIPHEX) -
Tier 1; PA; QL
ZEGERID (brand for cvs omeprazole-sod bicarbonate) - Tier 2; PA; QL
Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and
Stomach Conditions
Antispasmodics, Gastrointestinal - Bowel Treatment Drugs
DONNATAL (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA
pb-hyoscy-atropine-scopolamine (generic for DONNATAL) - Tier 1; PA
phenobarbital-belladonna alk (generic for DONNATAL) - Tier 1; PA
PHENOHYTRO (brand for pb-hyoscy-atropine-scopolamine) - Tier 2; PA
Antispasmodics, Gastrointestinal - Stomach and Intestine Drugs
belladonna alkaloids-opium - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
111
Preferred Agents Non-Preferred Agents
Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal
Drugs
abatinex (generic for ABATINEX) - Tier 1
acid gone (generic for ACID GONE) - Tier 1
acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1
acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1
acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier
1
acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) -
Tier 1
acidophilus/l-sporogenes (generic for FLORANEX) - Tier 1
ACTIPHLORA (brand for cvs adult 50+ probiotic) - Tier 2; QL
adult 50+ probiotic (generic for ACTIPHLORA) - Tier 1; QL
adult probiotic (generic for ACTIPHLORA) - Tier 1; QL
alvimopan (generic for ENTEREG) - Tier 1; PA
antacid antigas multi-sympt - Tier 1; PA
dairy aid (generic for LACTAID) - Tier 1; PA
dairy relief fast acting oral tablet 9000 unit (generic for LACTAID FAST
ACT) - Tier 1; PA
dairy relief oral tablet 3000 unit (generic for LACTAID) - Tier 1; PA
ENTEREG (brand for alvimopan) - Tier 2; PA
ENZADYNE - Tier 2; PA
LACTAID (brand for cvs dairy relief) - Tier 2; PA
LACTAID FAST ACT ORAL TABLET (brand for cvs dairy relief fast
acting) - Tier 2; PA
advanced antacid (generic for MINTOX) - Tier 1; QL
advanced antacid max st (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
almacone double strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
alum & mag hydroxide-simeth (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
alumina-magnesia-simethicone (generic for MINTOX) - Tier 1; QL
antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for
MINTOX) - Tier 1; QL
antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for
ALMACONE DOUBLE STRENGTH) - Tier 1; QL
lactase enzyme (generic for LACTAID) - Tier 1; PA
lactase enzyme ultra str (generic for LACTAID FAST ACT) - Tier 1; PA
lactase fast acting (generic for LACTAID FAST ACT) - Tier 1; PA
lactose fast acting relief oral tablet (generic for LACTAID FAST ACT) -
Tier 1; PA
surelac (generic for LACTAID) - Tier 1; PA
TITRALAC - Tier 2; PA
ultra dairy digestive (generic for LACTAID FAST ACT) - Tier 1; PA
VOQUEZNA DUAL PAK - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
112
Preferred Agents Non-Preferred Agents
antacid & gas relief (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; QL
antacid advanced (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; QL
antacid advanced max st (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
antacid anti-gas (generic for MINTOX) - Tier 1; QL
antacid anti-gas ex st oral suspension 400-400-40 mg/5ml (generic for
ALMACONE DOUBLE STRENGTH) - Tier 1; QL
antacid anti-gas max strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
antacid anti-gas reg strength (generic for MINTOX) - Tier 1; QL
antacid calcium (generic for CAL-GEST ANTACID) - Tier 1
antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1
antacid extra strength oral suspension (generic for ALMACONE
DOUBLE STRENGTH) - Tier 1; QL
antacid extra strength oral tablet chewable 160-105 mg (generic for
ACID GONE) - Tier 1
antacid extra strength oral tablet chewable 750 mg (generic for CVS
CHEWY NOT CHALKY FLAVOR) - Tier 1
antacid fast relief (generic for MINTOX) - Tier 1; QL
antacid i (generic for MINTOX) - Tier 1; QL
antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL
antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier
1
antacid liquid (generic for MINTOX) - Tier 1; QL
antacid m (generic for MINTOX) - Tier 1; QL
antacid maximum (generic for TUMS ULTRA 1000) - Tier 1
antacid maximum strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
antacid maximum strength oral tablet chewable 1000 mg (generic for
TUMS ULTRA 1000) - Tier 1
antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml
(generic for MINTOX) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
113
Preferred Agents Non-Preferred Agents
antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA
1000) - Tier 1
antacid oral tablet chewable 500 mg (generic for CAL-GEST
ANTACID) - Tier 1
antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT
CHALKY FLAVOR) - Tier 1
antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; QL
antacid plus anti-gas relief (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
antacid regular strength oral suspension (generic for MINTOX) - Tier 1;
QL
antacid regular strength oral tablet chewable (generic for CAL-GEST
ANTACID) - Tier 1
antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS
ULTRA 1000) - Tier 1
antacid/anti-gas (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; QL
antacid/anti-gas max st (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
antacid/antigas oral suspension 200-200-20 mg/5ml (generic for
MINTOX) - Tier 1; QL
antacid/gas relief max st (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) -
Tier 1
anti-diarrheal anti-gas (generic for IMODIUM MULTI-SYMPTOM
RELIEF) - Tier 1
anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) -
Tier 1
anti-diarrheal/anti-gas (generic for IMODIUM MULTI-SYMPTOM
RELIEF) - Tier 1
anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH)
- Tier 1
BACICAP (brand for cvs adult 50+ probiotic) - Tier 2; QL
biotinex (generic for ABATINEX) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
114
Preferred Agents Non-Preferred Agents
bismatrol oral tablet chewable (generic for SOOTHE) - Tier 1; QL
bismuth (generic for SOOTHE) - Tier 1; QL
bismuth subsalicylate oral (generic for SOOTHE) - Tier 1; QL
calcium antacid (generic for CAL-GEST ANTACID) - Tier 1
calcium antacid ex st (generic for CVS CHEWY NOT CHALKY
FLAVOR) - Tier 1
calcium antacid extra strength (generic for CVS CHEWY NOT
CHALKY FLAVOR) - Tier 1
calcium antacid ultra max st oral tablet chewable 1000 mg (generic for
TUMS ULTRA 1000) - Tier 1
calcium carbonate antacid oral suspension - Tier 1; QL
calcium carbonate antacid oral tablet - Tier 1
calcium carbonate antacid oral tablet chewable (generic for CAL-
GEST ANTACID) - Tier 1
cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1
chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY
FLAVOR) - Tier 1
childrens soothe - Tier 1
comfort gel (generic for MINTOX) - Tier 1; QL
comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml
(generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL
DERMACINRX PROBISOL (brand for cvs adult 50+ probiotic) - Tier 2;
QL
DERMACINRX PROBITRAN (brand for cvs adult 50+ probiotic) - Tier
2; QL
diarrhea (generic for SOOTHE) - Tier 1
diarrhea relief (generic for SOOTHE) - Tier 1
digestive probiotic oral capsule (generic for ACTIPHLORA) - Tier 1;
QL
digestive probiotic oral capsule 250 mg (generic for FLORASTOR) -
Tier 1
diotame instydose (generic for SOOTHE) - Tier 1
enema (generic for FLEET ENEMA) - Tier 1
enema disposable (generic for FLEET ENEMA) - Tier 1
enema ready-to-use (generic for FLEET ENEMA) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
115
Preferred Agents Non-Preferred Agents
enema rectal enema 16-6 gm/133ml, 19-7 gm/118ml (generic for
FLEET ENEMA) - Tier 1
everyday care probiotic (generic for ACTIPHLORA) - Tier 1; QL
FLEET ENEMA (brand for cvs enema disposable) - Tier 2
FLEET PEDIATRIC (brand for enema pediatric) - Tier 2
FLORANEX ONE (brand for cvs adult 50+ probiotic) - Tier 2; QL
floranex tablet oral (generic for FLORANEX) - Tier 1
FLORANEX TABLET ORAL (brand for acidophilus/l-sporogenes) - Tier
2
foaming antacid oral tablet chewable 80-20 mg - Tier 1
freeze dried acidophilus (generic for ABATINEX) - Tier 1
gas relief antiflatuent (generic for GAS-X ULTRA STRENGTH) - Tier 1
gas relief drops infants (generic for MYLICON INFANTS GAS RELIEF)
- Tier 1
gas relief extra strength (generic for GAS-X EXTRA STRENGTH) -
Tier 1
gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier 1
gas relief infants (generic for MYLICON INFANTS GAS RELIEF) - Tier
1
gas relief infants drops (generic for MYLICON INFANTS GAS RELIEF)
- Tier 1
gas relief infants oral suspension (generic for MYLICON INFANTS
GAS RELIEF) - Tier 1
gas relief oral capsule 125 mg (generic for GAS-X EXTRA
STRENGTH) - Tier 1
gas relief oral capsule 180 mg (generic for GAS-X ULTRA
STRENGTH) - Tier 1
gas relief oral tablet chewable - Tier 1
gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA
STRENGTH) - Tier 1
gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier
1
gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1
GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for eq gas relief)
- Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
116
Preferred Agents Non-Preferred Agents
GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for
cvs gas relief extra strength) - Tier 2
GAS-X ULTRA STRENGTH (brand for cvs gas relief ultra strength) -
Tier 2
GAVISCON - Tier 2
GAVISCON EXTRA RELIEF FORMULA (brand for cvs heartburn relief
ex st) - Tier 2
GAVISCON EXTRA STRENGTH (brand for antacid extra strength) -
Tier 2
GELUSIL - Tier 2
geri-lanta (generic for MINTOX) - Tier 1; QL
geri-mox (generic for MINTOX) - Tier 1; QL
goodsense milk of magnesia (generic for PHILLIPS MILK OF
MAGNESIA) - Tier 1
heartburn antacid (generic for ACID GONE) - Tier 1
heartburn antacid ex st (generic for ACID GONE) - Tier 1
heartburn relief ex st (generic for GAVISCON EXTRA RELIEF
FORMULA) - Tier 1
heartburn relief oral tablet chewable 160-105 mg (generic for ACID
GONE) - Tier 1
high potency probiotic (generic for ACTIPHLORA) - Tier 1; QL
IMODIUM MULTI-SYMPTOM RELIEF (brand for gnp anti-
diarrheal/anti-gas) - Tier 2
infant gas relief (generic for MYLICON INFANTS GAS RELIEF) - Tier
1
infants gas relief (generic for MYLICON INFANTS GAS RELIEF) - Tier
1
infants simethicone (generic for MYLICON INFANTS GAS RELIEF) -
Tier 1
lactobacillus oral tablet (generic for FLORANEX) - Tier 1
lacto-pectin (generic for ACTIPHLORA) - Tier 1; QL
long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1
loperamide-simethicone (generic for IMODIUM MULTI-SYMPTOM
RELIEF) - Tier 1
MAALOX CHILDRENS (brand for childrens pepto) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
117
Preferred Agents Non-Preferred Agents
MAALOX MAX ORAL SUSPENSION (brand for alum & mag
hydroxide-simeth) - Tier 2; QL
MAALOX MULTI SYMPTOM MAX ST (brand for alum & mag
hydroxide-simeth) - Tier 2; QL
mag-al plus (generic for MINTOX) - Tier 1; QL
mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier
1; QL
mega probiotic (generic for ACTIPHLORA) - Tier 1; QL
meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier
1; QL
milk of magnesia (generic for PHILLIPS MILK OF MAGNESIA) - Tier 1
milk of magnesia concentrate - Tier 1
mintox maximum strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; QL
mintox plus - Tier 1
mood support probiotic (generic for ACTIPHLORA) - Tier 1; QL
MYLICON INFANTS GAS RELIEF (brand for cvs gas relief infants) -
Tier 2
NEWFLORA PROBIOTIC (brand for acidophilus) - Tier 2
PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for cvs
anti-diarrheal) - Tier 2
PHAZYME (brand for cvs gas relief extra strength) - Tier 2
PHAZYME ULTRA STRENGTH (brand for cvs gas relief ultra strength)
- Tier 2
PHILLIPS MILK OF MAGNESIA ORAL SUSPENSION 400 MG/5ML
(brand for cvs milk of magnesia) - Tier 2
pink bismuth maximum strength (generic for SOOTHE MAXIMUM
STRENGTH) - Tier 1
pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) -
Tier 1
pink bismuth oral tablet 262 mg (generic for SOOTHE) - Tier 1
pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier
1; QL
pink-bismuth (generic for SOOTHE) - Tier 1; QL
PRIMIDAR (brand for cvs adult 50+ probiotic) - Tier 2; QL
PROBINATE (brand for cvs adult 50+ probiotic) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
118
Preferred Agents Non-Preferred Agents
probiotic adult 50+ (generic for ACTIPHLORA) - Tier 1; QL
probiotic blend (generic for ACTIPHLORA) - Tier 1; QL
probiotic colon care (generic for ACTIPHLORA) - Tier 1; QL
probiotic complex (generic for ACTIPHLORA) - Tier 1; QL
probiotic maximum strength (generic for ACTIPHLORA) - Tier 1; QL
probiotic oral capsule (generic for ACTIPHLORA) - Tier 1; QL
probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1
probiotic pearls ex st (generic for ACTIPHLORA) - Tier 1; QL
PRODIGEN (brand for cvs adult 50+ probiotic) - Tier 2; QL
PROVAD (brand for cvs adult 50+ probiotic) - Tier 2; QL
quad-probiotic (generic for ACTIPHLORA) - Tier 1; QL
1
REJUVAFLOR (brand for acidophilus) - Tier 2
RESTORA (brand for cvs adult 50+ probiotic) - Tier 2; QL
RISAQUAD (brand for cvs adult 50+ probiotic) - Tier 2; QL
RISAQUAD-2 (brand for cvs adult 50+ probiotic) - Tier 2; QL
saccharomyces boulardii (generic for FLORASTOR) - Tier 1
saline enema (generic for FLEET ENEMA) - Tier 1
senior probiotic (generic for ACTIPHLORA) - Tier 1; QL
simeped (generic for MYLICON INFANTS GAS RELIEF) - Tier 1
simethicone drops infants (generic for MYLICON INFANTS GAS
RELIEF) - Tier 1
simethicone oral (generic for GAS-X EXTRA STRENGTH) - Tier 1
simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) -
Tier 1
smooth antacid ex st oral tablet chewable 750 mg (generic for CVS
CHEWY NOT CHALKY FLAVOR) - Tier 1
smooth antacid extra st (generic for CVS CHEWY NOT CHALKY
FLAVOR) - Tier 1
smooth antacid extra strength (generic for CVS CHEWY NOT
CHALKY FLAVOR) - Tier 1
sodium bicarbonate oral tablet - Tier 1
soothe maximum strength (generic for SOOTHE MAXIMUM
STRENGTH) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
119
Preferred Agents Non-Preferred Agents
soothe oral suspension (generic for SOOTHE) - Tier 1
soothe oral tablet (generic for SOOTHE) - Tier 1
soothe oral tablet chewable (generic for SOOTHE) - Tier 1; QL
stomach relief extra strength (generic for SOOTHE MAXIMUM
STRENGTH) - Tier 1
stomach relief max st oral suspension 525 mg/15ml (generic for
SOOTHE MAXIMUM STRENGTH) - Tier 1
stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic
for SOOTHE MAXIMUM STRENGTH) - Tier 1
stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527
mg/30ml (generic for SOOTHE) - Tier 1
stomach relief oral tablet 262 mg (generic for SOOTHE) - Tier 1
stomach relief oral tablet chewable 262 mg (generic for SOOTHE) -
Tier 1; QL
stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) -
Tier 1
stomach relief ultra (generic for SOOTHE MAXIMUM STRENGTH) -
Tier 1
TUMS (brand for antacid) - Tier 2
TUMS CHEWY BITES (brand for antacid) - Tier 2
TUMS E-X 750 (brand for antacid) - Tier 2
TUMS EXTRA STRENGTH 750 (brand for antacid) - Tier 2
TUMS LASTING EFFECTS (brand for antacid) - Tier 2
TUMS SMOOTHIES (brand for antacid) - Tier 2
TUMS ULTRA 1000 (brand for antacid maximum) - Tier 2
VISBIOME HIGH POTENCY ORAL CAPSULE (brand for cvs adult
50+ probiotic) - Tier 2; QL
womens 50 billion (generic for ACTIPHLORA) - Tier 1; QL
ZELAC (brand for cvs adult 50+ probiotic) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
120
Preferred Agents Non-Preferred Agents
Laxatives - Bowel Treatment Drugs
clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;
QL
daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1
enema mineral oil (generic for FLEET OIL) - Tier 1
EVAC (brand for cvs natural fiber supplement) - Tier 2
fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1
fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1
fiber oral powder 28.3 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; QL
fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1
fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1
fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1
fiber therapy oral powder 28.3 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; QL
FLEET OIL (brand for cvs mineral oil enema) - Tier 2
gavilax oral powder (generic for CLEARLAX) - Tier 1; QL
gentlelax (generic for CLEARLAX) - Tier 1; QL
glycolax (generic for CLEARLAX) - Tier 1; QL
konsyl daily fiber oral powder 28.3 % (generic for METAMUCIL
SMOOTH TEXTURE) - Tier 1; QL
laxaclear (generic for CLEARLAX) - Tier 1; QL
laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
121
Preferred Agents Non-Preferred Agents
mineral oil enema (generic for FLEET OIL) - Tier 1
mineral oil heavy oral - Tier 1
mineral oil oral oil - Tier 1
mineral oil rectal enema (generic for FLEET OIL) - Tier 1
MIRALAX ORAL POWDER (brand for gavilax) - Tier 2; QL
mm clearlax (generic for CLEARLAX) - Tier 1; QL
natural daily fiber (generic for METAMUCIL) - Tier 1
natural fiber laxative oral powder 58.6 % (generic for METAMUCIL
SMOOTH TEXTURE) - Tier 1
natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1
natural fiber oral powder 28.3 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; QL
natural fiber oral powder 48.57 % (generic for METAMUCIL) - Tier 1
natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1
natural fiber supplement (generic for EVAC) - Tier 1
natural vegetable (generic for HYDROCIL) - Tier 1
natural vegetable fiber (generic for METAMUCIL) - Tier 1
natura-lax (generic for CLEARLAX) - Tier 1; QL
peg 3350 oral powder (generic for CLEARLAX) - Tier 1; QL
polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1;
QL
polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) -
Tier 1; QL
purelax oral powder (generic for CLEARLAX) - Tier 1; QL
smooth lax oral powder (generic for CLEARLAX) - Tier 1; QL
sorbitol oral - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
122
Preferred Agents Non-Preferred Agents
Laxatives - Drugs to treat Constipation
AVEDANA GLYCERIN (ADULT) (brand for cvs glycerin adult) - Tier 2
chocolate laxative pieces (generic for EX-LAX) - Tier 1
chocolated laxative (generic for EX-LAX) - Tier 1
citroma (generic for CITROMA) - Tier 1; QL
CITRUCEL (brand for cvs soluble fiber therapy) - Tier 2
COLACE (brand for cvs stool softener) - Tier 2; QL
col-rite oral capsule 250 mg - Tier 1; QL
docu (generic for DOCU LIQUID) - Tier 1; QL
docu liquid (generic for DOCU LIQUID) - Tier 1; QL
docusate calcium (generic for SURFAK) - Tier 1
docusate mini (generic for DOCUSOL MINI) - Tier 1; QL
docusate sodium oral capsule (generic for COLACE) - Tier 1; QL
EX-LAX (brand for chocolated laxative) - Tier 2; PA
senna oral capsule - Tier 1; PA
senna-extra (generic for SENOKOT EXTRA STRENGTH) - Tier 1; PA
SENOKOT EXTRA STRENGTH (brand for cvs senna-extra) - Tier 2; PA
docusate sodium oral liquid 100 mg/10ml, 50 mg/5ml (generic for
DOCU LIQUID) - Tier 1; QL
docusate sodium oral syrup - Tier 1
docusate sodium oral tablet (generic for DOK) - Tier 1
DOCUSOL MINI (brand for docusate mini) - Tier 2; QL
docuzen (generic for SENEXON-S) - Tier 1
dok oral tablet (generic for DOK) - Tier 1
dss (generic for COLACE) - Tier 1; QL
easy-lax plus (generic for SENEXON-S) - Tier 1
ENEMEEZ MINI (brand for docusate mini) - Tier 2; QL
EX-LAX MAXIMUM STRENGTH (brand for cvs laxative pills max st) -
Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
123
Preferred Agents Non-Preferred Agents
fiber laxative + calcium (generic for FIBERCON) - Tier 1
fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1
fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1
fiber oral tablet 625 mg (generic for FIBERCON) - Tier 1
fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1
fiber therapy oral tablet 625 mg (generic for FIBERCON) - Tier 1
fiber-caps (generic for FIBERCON) - Tier 1
fiber-lax (generic for FIBERCON) - Tier 1
geri-kot (generic for SENOKOT) - Tier 1
glycerin (adult) rectal suppository 2 gm (generic for AVEDANA
GLYCERIN (ADULT)) - Tier 1
glycerin (infants & children) rectal suppository 1 gm - Tier 1
glycerin adult rectal suppository 2 gm (generic for AVEDANA
GLYCERIN (ADULT)) - Tier 1
glycerin child rectal suppository 1 gm, 1.2 gm - Tier 1
glycerin childrens - Tier 1
glycerin pediatric rectal suppository 1.2 gm - Tier 1
laxacin (generic for SENEXON-S) - Tier 1
laxative max str (generic for EX-LAX MAXIMUM STRENGTH) - Tier 1
laxative maximum strength oral tablet 25 mg (generic for EX-LAX
MAXIMUM STRENGTH) - Tier 1
laxative oral tablet chewable 15 mg (generic for EX-LAX) - Tier 1
laxative pills max st (generic for EX-LAX MAXIMUM STRENGTH) -
Tier 1
laxative pills oral tablet 25 mg (generic for EX-LAX MAXIMUM
STRENGTH) - Tier 1
laxative regular strength (generic for SENNA SMOOTH) - Tier 1
magnesium citrate oral solution (generic for CITROMA) - Tier 1; QL
mm stool softener laxative (generic for COLACE) - Tier 1; QL
natural laxative (generic for SENOKOT) - Tier 1
natural senna laxative (generic for SENOKOT) - Tier 1
natural vegetable laxative oral tablet 8.6 mg (generic for SENOKOT) -
Tier 1
p col-rite (generic for SENEXON-S) - Tier 1
PEDIA-LAX ORAL LIQUID - Tier 2
PERDIEM OVERNIGHT RELIEF (brand for laxative pills) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
124
Preferred Agents Non-Preferred Agents
qc chocolated laxative (generic for EX-LAX) - Tier 1
sb docusate sodium/senna (generic for SENEXON-S) - Tier 1
senexon-s (generic for SENEXON-S) - Tier 1
senna lax (generic for SENOKOT) - Tier 1
senna laxative (generic for SENOKOT) - Tier 1
senna oral liquid - Tier 1
senna oral syrup - Tier 1
senna oral tablet (generic for SENOKOT) - Tier 1
senna plus oral tablet (generic for SENEXON-S) - Tier 1
senna s (generic for SENEXON-S) - Tier 1
senna smooth (generic for SENNA SMOOTH) - Tier 1
senna-docusate sodium (generic for SENEXON-S) - Tier 1
senna-lax (generic for SENOKOT) - Tier 1
senna-plus (generic for SENEXON-S) - Tier 1
senna-s (generic for SENEXON-S) - Tier 1
senna-tabs (generic for SENOKOT) - Tier 1
senna-time (generic for SENOKOT) - Tier 1
senna-time s (generic for SENEXON-S) - Tier 1
sennazon - Tier 1
SENOKOT (brand for cvs senna) - Tier 2
SENOKOT S (brand for cvs senna plus) - Tier 2
silace oral liquid (generic for DOCU LIQUID) - Tier 1; QL
silace oral syrup - Tier 1
soluble fiber therapy (generic for CITRUCEL) - Tier 1
stimulant laxative oral tablet 8.6-50 mg (generic for SENEXON-S) -
Tier 1
stool softener laxative oral capsule (generic for COLACE) - Tier 1; QL
stool softener oral capsule 100 mg (generic for COLACE) - Tier 1; QL
stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1
stool softener oral capsule 250 mg - Tier 1; QL
stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier
1
stool softener oral tablet 100 mg (generic for DOK) - Tier 1
stool softener pls laxative (generic for SENEXON-S) - Tier 1
stool softener plus laxative (generic for SENEXON-S) - Tier 1
stool softener/laxative (generic for SENEXON-S) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
125
Preferred Agents Non-Preferred Agents
stool softener/laxative oral tablet (generic for SENEXON-S) - Tier 1
vegetable lax+stool softener (generic for SENEXON-S) - Tier 1
vegetable laxative (generic for SENOKOT) - Tier 1
Genetic or Enzyme Disorder: Replacement, Modifiers, Treatment
VOXZOGO - Tier 2; PA; SP; QL
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers,
Treatment
BUPHENYL (brand for sodium phenylbutyrate) - Tier 2; SP; QL
CREON - Tier 2; QL
cromolyn sodium oral (generic for GASTROCROM) - Tier 1; QL
CYSTADANE (brand for betaine) - Tier 2; SP; QL
CYSTAGON - Tier 2; SP; QL
NITYR - Tier 2; DX2RX; SP; QL
PROCYSBI ORAL CAPSULE DELAYED RELEASE - Tier 2; SP; QL
RAVICTI - Tier 2; SP; QL
sapropterin dihydrochloride (generic for KUVAN) - Tier 1; SP; QL
ZENPEP - Tier 2; QL
betaine (generic for CYSTADANE) - Tier 1; PA; SP; QL
CARNITOR ORAL SOLUTION (brand for levocarnitine) - Tier 2; PA; QL
CARNITOR ORAL TABLET (brand for levocarnitine) - Tier 2; PA
CARNITOR SF (brand for levocarnitine) - Tier 2; PA; QL
CERDELGA - Tier 2; PA; SP; QL
CHOLBAM - Tier 2; PA; SP; QL
EVRYSDI - Tier 2; PA; SP; QL
GALAFOLD - Tier 2; PA; SP; QL
GASTROCROM (brand for cromolyn sodium) - Tier 2; PA; QL
GIVLAARI - Tier 2; PA
KEVEYIS - Tier 2; PA; SP; QL
KUVAN (brand for sapropterin dihydrochloride) - Tier 2; PA; SP; QL
levocarnitine oral solution (generic for CARNITOR) - Tier 1; PA; QL
levocarnitine oral tablet (generic for CARNITOR) - Tier 1; PA
levocarnitine sf (generic for CARNITOR) - Tier 1; PA; QL
miglustat (generic for ZAVESCA) - Tier 1; PA; SP; QL
nitisinone (generic for ORFADIN) - Tier 1; DX2RX; SP; QL
ORFADIN (brand for nitisinone) - Tier 2; DX2RX; SP; QL
PALYNZIQ - Tier 2; PA; SP; QL
PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES
10500-35500 UNIT, 16800-56800 UNIT, 21000-54700 UNIT, 37000-
97300 UNIT, 4200-14200 UNIT - Tier 2; PA; QL
PANCREAZE ORAL CAPSULE DELAYED RELEASE PARTICLES 2600-
8800 UNIT - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
126
Preferred Agents Non-Preferred Agents
PERTZYE - Tier 2; PA; QL
PROCYSBI ORAL PACKET - Tier 2; PA; SP; QL
sodium phenylbutyrate oral (generic for BUPHENYL) - Tier 1; PA; SP; QL
STRENSIQ - Tier 2; PA; SP; QL
TEGSEDI - Tier 2; PA; SP; QL
VIOKACE - Tier 2; PA; QL
VYNDAMAX - Tier 2; PA; SP; QL
VYNDAQEL - Tier 2; PA; SP; QL
ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl - Tier 1; QL
GELNIQUE - Tier 2; QL
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR - Tier
2; QL
oxybutynin chloride er (generic for DITROPAN XL) - Tier 1; QL
oxybutynin chloride oral - Tier 1; QL
OXYTROL - Tier 2; QL
OXYTROL FOR WOMEN - Tier 2; QL
solifenacin succinate (generic for VESICARE) - Tier 1; QL
TOVIAZ - Tier 2; QL
darifenacin hydrobromide er - Tier 1; PA; QL
DETROL (brand for tolterodine tartrate) - Tier 2; PA; QL
DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL
DITROPAN XL (brand for oxybutynin chloride er) - Tier 2; PA; QL
MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER - Tier 2; PA;
QL; AL
tolterodine tartrate (generic for DETROL) - Tier 1; PA; QL
tolterodine tartrate er (generic for DETROL LA) - Tier 1; PA; QL
trospium chloride - Tier 1; PA; QL
trospium chloride er - Tier 1; PA; QL
VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL
VESICARE LS - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
127
Preferred Agents Non-Preferred Agents
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL
dutasteride oral (generic for AVODART) - Tier 1; QL
finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL
tadalafil oral tablet 5 mg (generic for CIALIS) - Tier 1; PA; QL; GE
tamsulosin hcl (generic for FLOMAX) - Tier 1; QL
terazosin hcl - Tier 1; QL
AVODART (brand for dutasteride) - Tier 2; PA; QL
CARDURA XL - Tier 2; PA; QL
CIALIS ORAL TABLET 5 MG (brand for tadalafil) - Tier 2; PA; QL; GE
dutasteride-tamsulosin hcl (generic for JALYN) - Tier 1; PA; QL
FLOMAX (brand for tamsulosin hcl) - Tier 2; PA; QL
JALYN (brand for dutasteride-tamsulosin hcl) - Tier 2; PA; QL
PROSCAR (brand for finasteride) - Tier 2; PA; QL
RAPAFLO (brand for silodosin) - Tier 2; PA; QL
silodosin (generic for RAPAFLO) - Tier 1; PA; QL
UROXATRAL (brand for alfuzosin hcl er) - Tier 2; PA; QL
Genitourinary Agents, Other
bethanechol chloride oral - Tier 1
ELMIRON - Tier 2; QL
LITHOSTAT - Tier 2
penicillamine oral (generic for CUPRIMINE) - Tier 1; SP; QL
THIOLA (brand for tiopronin) - Tier 2; SP; QL
CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL
DEPEN TITRATABS (brand for penicillamine) - Tier 2; PA; SP; QL
THIOLA EC - Tier 2; PA; SP; QL
tiopronin (generic for THIOLA) - Tier 1; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
128
Preferred Agents Non-Preferred Agents
Genitourinary Agents - Drugs to Treat Bladder, Genital and
Kidney Conditions
Genitourinary Agents, Other - Miscellaneous Bladder, Genital,
and Kidney Conditions Drugs
azo (generic for PHENAZO) - Tier 1
phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL
phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1
phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier
1; QL
phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier
1; QL
urin ds (generic for UTIRA-C) - Tier 1; QL
urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1
UROGESIC-BLUE (brand for me/naphos/mb/hyo1) - Tier 2
URO-MP (brand for uro-mp) - Tier 2
UTIRA-C (brand for urin ds) - Tier 2; QL
me/naphos/mb/hyo1 (generic for UROGESIC-BLUE) - Tier 1; PA
OPTIONS GYNOL II CONTRACEPTIVE - Tier 2; PA
PHEXXI - Tier 2; PA; QL
PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; PA; QL
URELLE (brand for uro-458) - Tier 2; PA
URIMAR-T - Tier 2; PA
URO-458 (brand for uro-458) - Tier 2; PA
VCF VAGINAL CONTRACEPTIVE VAGINAL FILM - Tier 2; PA
vcf vaginal contraceptive vaginal gel - Tier 1; PA
VILEVEV MB (brand for uro-458) - Tier 2; PA
VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM - Tier 2
VILAMIT MB (brand for uro-mp) - Tier 2
Glycemic Agents - Diabetic Drugs
Blood Glucose Regulators - Drugs to Regulate Blood Sugar
ZEGALOGUE - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
129
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
CORTEF ORAL TABLET 10 MG, 5 MG (brand for hydrocortisone) -
Tier 2; QL
dexamethasone intensol - Tier 1
dexamethasone oral elixir - Tier 1; QL
dexamethasone oral solution - Tier 1; QL
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 2 mg - Tier 1
dexamethasone oral tablet 1.5 mg, 4 mg, 6 mg - Tier 1; QL
fludrocortisone acetate oral - Tier 1; QL
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) -
Tier 1; QL
MEDROL ORAL TABLET 2 MG - Tier 2
methylprednisolone oral (generic for MEDROL) - Tier 1; QL
ACTHAR - Tier 2; PA; SP; QL
ALKINDI SPRINKLE - Tier 2; PA; QL
CORTEF ORAL TABLET 20 MG (brand for hydrocortisone) - Tier 2; PA;
QL
CORTROPHIN - Tier 2; PA; SP; QL
dexamethasone oral tablet therapy pack (generic for HIDEX 6-DAY) - Tier
1; PA
EMFLAZA - Tier 2; PA; SP; QL
HEMADY - Tier 2; PA; QL
HIDEX 6-DAY (brand for dexamethasone) - Tier 2; PA
MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG (brand for
methylprednisolone) - Tier 2; PA; QL
prednisolone oral - Tier 1; QL
prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml -
Tier 1; QL
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml -
Tier 1
prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml
(generic for PEDIAPRED) - Tier 1; QL
prednisolone sodium phosphate oral tablet dispersible 10 mg, 30 mg
(generic for ORAPRED ODT) - Tier 1
prednisolone sodium phosphate oral tablet dispersible 15 mg (generic
for ORAPRED ODT) - Tier 1; QL
prednisone intensol - Tier 1; QL
MEDROL ORAL TABLET THERAPY PACK (brand for
methylprednisolone) - Tier 2; PA; QL
MILLIPRED - Tier 2; PA; QL
ORAPRED ODT ORAL TABLET DISPERSIBLE 10 MG, 30 MG (brand for
prednisolone sodium phosphate) - Tier 2; PA
ORAPRED ODT ORAL TABLET DISPERSIBLE 15 MG (brand for
prednisolone sodium phosphate) - Tier 2; PA; QL
PEDIAPRED (brand for prednisolone sodium phosphate) - Tier 2; PA; QL
RAYOS - Tier 2; PA; QL
TAPERDEX 12-DAY - Tier 2; PA; QL
TAPERDEX 6-DAY (brand for dexamethasone) - Tier 2; PA
TAPERDEX 7-DAY - Tier 2; PA; QL
prednisone oral solution - Tier 1; QL
prednisone oral tablet - Tier 1; QL
prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL
prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) -
Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
130
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) -
Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) -
Hormone Replacement/Modifying Drugs
HEXATRIONE - Tier 2; PA
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin ace spray refrig - Tier 1; QL
desmopressin acetate injection (generic for DDAVP) - Tier 1
desmopressin acetate oral (generic for DDAVP) - Tier 1; QL
desmopressin acetate pf (generic for DDAVP PF) - Tier 1
desmopressin acetate spray - Tier 1; QL
EGRIFTA SV - Tier 2; DX2RX; SP; QL
INCRELEX - Tier 2; PA; SP; QL
NORDITROPIN FLEXPRO - Tier 2; PA; SP; QL
OMNITROPE - Tier 2; PA; SP; QL
CHORIONIC GONADOTROPIN INTRAMUSCULAR (brand for chorionic
gonadotropin) - Tier 2; PA
DDAVP INJECTION (brand for desmopressin acetate) - Tier 2; PA
DDAVP ORAL (brand for desmopressin acetate) - Tier 2; PA; QL
DDAVP PF (brand for desmopressin acetate pf) - Tier 2; PA
DESMOPRESSIN ACETATE NASAL (brand for desmopressin acetate) -
Tier 2; PA; QL
GENOTROPIN - Tier 2; PA; SP; QL
GENOTROPIN MINIQUICK - Tier 2; PA; SP; QL
HUMATROPE - Tier 2; PA; SP; QL
NOCDURNA - Tier 2; PA; QL
NOVAREL (brand for chorionic gonadotropin) - Tier 2; PA
NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP; QL
NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP; QL
NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP; QL
PREGNYL (brand for chorionic gonadotropin) - Tier 2; PA
SAIZEN - Tier 2; PA; SP; QL
SAIZENPREP - Tier 2; PA; SP; QL
SEROSTIM - Tier 2; PA; SP; QL
STIMATE (brand for desmopressin acetate) - Tier 2; PA; QL
ZOMACTON - Tier 2; PA; SP; QL
ZORBTIVE - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
131
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -
Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -
Hormone Replacement/Modifying Drugs
OVIDREL - Tier 2; PA
SKYTROFA - Tier 2; PA; SP; QL
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
KORLYM - Tier 2; PA; SP; QL
methergine (generic for METHERGINE) - Tier 1; QL
methylergonovine maleate oral (generic for METHERGINE) - Tier 1;
QL
CERVIDIL - Tier 2; PA
PREPIDIL - Tier 2; PA
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins) - Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins) - Hormone Replacement/Modifying Drugs
MIFEPREX (brand for mifepristone) - Tier 2; PA
mifepristone (generic for MIFEPREX) - Tier 1; PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
oxandrolone oral - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
132
Preferred Agents Non-Preferred Agents
Androgens
ANDRODERM - Tier 2; PA; QL
danazol oral - Tier 1; ST; QL
testosterone cypionate intramuscular (generic for DEPO-
TESTOSTERONE) - Tier 1; QL
testosterone enanthate intramuscular - Tier 1; QL
testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO
PUMP) - Tier 1; PA; QL
testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%)
(generic for ANDROGEL) - Tier 1; PA; QL
ANDROGEL (brand for testosterone) - Tier 2; PA; QL
ANDROGEL PUMP (brand for testosterone) - Tier 2; PA; QL
DEPO-TESTOSTERONE (brand for testosterone cypionate) - Tier 2; PA;
QL
FORTESTA (brand for testosterone) - Tier 2; PA
JATENZO - Tier 2; PA; QL
METHITEST - Tier 2; PA; QL
methyltestosterone oral - Tier 1; PA; QL
NATESTO - Tier 2; PA; QL
TESTIM (brand for testosterone) - Tier 2; PA; QL
testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) (generic for
ANDROGEL PUMP) - Tier 1; PA; QL
testosterone transdermal gel 10 mg/act (2%) (generic for FORTESTA) -
Tier 1; PA
testosterone transdermal gel 20.25 mg/1.25gm (1.62%) - Tier 1; PA; QL
testosterone transdermal gel 40.5 mg/2.5gm (1.62%) (generic for
ANDROGEL) - Tier 1; PA; QL
testosterone transdermal solution - Tier 1; PA; QL
TLANDO - Tier 2; PA; QL
VOGELXO (brand for testosterone) - Tier 2; PA; QL
VOGELXO PUMP (brand for testosterone) - Tier 2; PA; QL
XYOSTED - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
133
Preferred Agents Non-Preferred Agents
Estrogens
afirmelle (generic for AFIRMELLE) - Tier 1; QL
altavera (generic for ALTAVERA) - Tier 1; QL
alyacen 1/35 (generic for DASETTA 1/35) - Tier 1; QL
alyacen 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL
amabelz (generic for AMABELZ) - Tier 1; QL
amethia (generic for AMETHIA) - Tier 1; QL
amethyst (generic for AMETHYST) - Tier 1; QL
ANNOVERA - Tier 2; QL
apri (generic for APRI) - Tier 1; QL
aranelle - Tier 1; QL
ashlyna (generic for AMETHIA) - Tier 1; QL
aubra (generic for AFIRMELLE) - Tier 1; QL
ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL
ALORA (brand for estradiol) - Tier 2; PA; QL
ANGELIQ - Tier 2; PA; QL
BIJUVA - Tier 2; PA; QL
CLIMARA (brand for estradiol) - Tier 2; PA; QL
DELESTROGEN INTRAMUSCULAR OIL 10 MG/ML - Tier 2; PA; QL
DELESTROGEN INTRAMUSCULAR OIL 40 MG/ML (brand for estradiol
valerate) - Tier 2; PA; QL
DEPO-ESTRADIOL - Tier 2; PA; QL
DIVIGEL - Tier 2; PA; QL
DUAVEE - Tier 2; PA; QL
ELESTRIN - Tier 2; PA
aubra eq (generic for AFIRMELLE) - Tier 1; QL
aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL
aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL
aurovela 24 fe - Tier 1; QL
aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL
aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL
aviane (generic for AFIRMELLE) - Tier 1; QL
ayuna (generic for ALTAVERA) - Tier 1; QL
azurette (generic for AZURETTE) - Tier 1; QL
BALCOLTRA - Tier 2; QL
balziva (generic for BALZIVA) - Tier 1; QL
BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; QL
ESTRACE (brand for estradiol) - Tier 2; PA; QL
estradiol vaginal tablet (generic for YUVAFEM) - Tier 1; PA; QL
estradiol valerate intramuscular oil 40 mg/ml (generic for
DELESTROGEN) - Tier 1; PA; QL
EVAMIST - Tier 2; PA; QL
fayosim (generic for FAYOSIM) - Tier 1; PA; QL
FEMRING - Tier 2; PA; QL
levonorgest-eth est & eth est (generic for FAYOSIM) - Tier 1; PA; QL
MENOSTAR - Tier 2; PA; QL
MINIVELLE (brand for estradiol) - Tier 2; PA; QL
PREFEST - Tier 2; PA; QL
rivelsa (generic for FAYOSIM) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
134
Preferred Agents Non-Preferred Agents
blisovi 24 fe - Tier 1; QL
blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL
blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL
briellyn (generic for BALZIVA) - Tier 1; QL
camrese (generic for AMETHIA) - Tier 1; QL
camrese lo (generic for CAMRESE LO) - Tier 1; QL
caziant - Tier 1; QL
charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL
chateal (generic for ALTAVERA) - Tier 1; QL
chateal eq (generic for ALTAVERA) - Tier 1; QL
CLIMARA PRO - Tier 2; QL
COMBIPATCH - Tier 2; QL
TAYTULLA (brand for norethin ace-eth estrad-fe) - Tier 2; PA; QL
VAGIFEM (brand for estradiol) - Tier 2; PA; QL
VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL
yuvafem (generic for YUVAFEM) - Tier 1; PA; QL
cryselle-28 - Tier 1; QL
cyred (generic for APRI) - Tier 1; QL
cyred eq (generic for APRI) - Tier 1; QL
dasetta 1/35 (generic for DASETTA 1/35) - Tier 1; QL
dasetta 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL
daysee (generic for AMETHIA) - Tier 1; QL
delyla (generic for AFIRMELLE) - Tier 1; QL
desogestrel-ethinyl estradiol (generic for APRI) - Tier 1; QL
dolishale (generic for AMETHYST) - Tier 1; QL
dotti (generic for DOTTI) - Tier 1; QL
drospiren-eth estrad-levomefol (generic for BEYAZ) - Tier 1; QL
drospirenone-ethinyl estradiol (generic for JASMIEL) - Tier 1; QL
elinest - Tier 1; QL
eluryng (generic for ELURYNG) - Tier 1; QL
emoquette (generic for APRI) - Tier 1; QL
enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL
enskyce (generic for APRI) - Tier 1; QL
estarylla (generic for ESTARYLLA) - Tier 1; QL
estradiol oral (generic for ESTRACE) - Tier 1; QL
estradiol transdermal (generic for CLIMARA) - Tier 1; QL
estradiol vaginal cream (generic for ESTRACE) - Tier 1; QL
estradiol-norethindrone acet (generic for AMABELZ) - Tier 1; QL
ESTRING - Tier 2; QL
ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
135
Preferred Agents Non-Preferred Agents
etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL
falmina (generic for AFIRMELLE) - Tier 1; QL
femynor (generic for ESTARYLLA) - Tier 1; QL
fyavolv (generic for FYAVOLV) - Tier 1; QL
gemmily (generic for GEMMILY) - Tier 1; QL
GENERESS FE (brand for norethin-eth estradiol-fe) - Tier 2; QL
hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL
hailey 24 fe - Tier 1; QL
hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL
hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL
iclevia (generic for ICLEVIA) - Tier 1; QL
introvale (generic for ICLEVIA) - Tier 1; QL
isibloom (generic for APRI) - Tier 1; QL
jaimiess (generic for AMETHIA) - Tier 1; QL
jasmiel (generic for JASMIEL) - Tier 1; QL
jinteli (generic for FYAVOLV) - Tier 1; QL
jolessa (generic for ICLEVIA) - Tier 1; QL
juleber (generic for APRI) - Tier 1; QL
junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL
junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL
junel fe (generic for AUROVELA FE 1.5/30) - Tier 1; QL
kaitlib fe (generic for KAITLIB FE) - Tier 1; QL
kalliga (generic for APRI) - Tier 1; QL
kariva (generic for AZURETTE) - Tier 1; QL
kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL
kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL
kurvelo (generic for ALTAVERA) - Tier 1; QL
larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL
larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL
larin 24 fe - Tier 1; QL
larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL
larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL
larissia (generic for AFIRMELLE) - Tier 1; QL
layolis fe (generic for KAITLIB FE) - Tier 1; QL
leena - Tier 1; QL
lessina (generic for AFIRMELLE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
136
Preferred Agents Non-Preferred Agents
levonest (generic for ENPRESSE-28) - Tier 1; QL
levonorgest-eth estrad 91-day (generic for AMETHIA) - Tier 1; QL
levonorgestrel-ethinyl estrad (generic for AFIRMELLE) - Tier 1; QL
levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL
levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL
lillow (generic for ALTAVERA) - Tier 1; QL
LO LOESTRIN FE - Tier 2; QL
LOESTRIN 1.5/30 (21) (brand for norethindrone acet-ethinyl est) - Tier
2; QL
LOESTRIN 1/20 (21) (brand for norethindrone acet-ethinyl est) - Tier
2; QL
LOESTRIN FE 1.5/30 (brand for norethin ace-eth estrad-fe) - Tier 2;
QL
LOESTRIN FE 1/20 (brand for norethin ace-eth estrad-fe) - Tier 2; QL
lojaimiess (generic for CAMRESE LO) - Tier 1; QL
loryna (generic for JASMIEL) - Tier 1; QL
LOSEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2;
QL
low-ogestrel - Tier 1; QL
lo-zumandimine (generic for JASMIEL) - Tier 1; QL
lutera (generic for AFIRMELLE) - Tier 1; QL
lyllana (generic for DOTTI) - Tier 1; QL
marlissa (generic for ALTAVERA) - Tier 1; QL
MENEST - Tier 2; QL
merzee (generic for GEMMILY) - Tier 1; QL
microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL
microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL
microgestin 24 fe - Tier 1; QL
microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL
microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL
mili (generic for ESTARYLLA) - Tier 1; QL
mimvey (generic for AMABELZ) - Tier 1; QL
MINASTRIN 24 FE (brand for norethin ace-eth estrad-fe) - Tier 2; QL
MIRCETTE (brand for desogestrel-ethinyl estradiol) - Tier 2; QL
mono-linyah (generic for ESTARYLLA) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
137
Preferred Agents Non-Preferred Agents
NATAZIA - Tier 2; QL
necon 0.5/35 (28) - Tier 1; QL
nikki (generic for JASMIEL) - Tier 1; QL
norethin ace-eth estrad-fe (generic for AUROVELA FE 1.5/30) - Tier 1;
QL
norethindrone acet-ethinyl est (generic for AUROVELA 1.5/30) - Tier 1;
QL
norethindrone-eth estradiol (generic for FYAVOLV) - Tier 1; QL
norethin-eth estradiol-fe (generic for KAITLIB FE) - Tier 1; QL
norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL
norgestimate-ethinyl estradiol triphasic (generic for TRI FEMYNOR) -
Tier 1; QL
nortrel 0.5/35 (28) - Tier 1; QL
nortrel 1/35 (21) (generic for DASETTA 1/35) - Tier 1; QL
nortrel 1/35 (28) (generic for DASETTA 1/35) - Tier 1; QL
nortrel 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL
NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; QL
nylia 1/35 (generic for DASETTA 1/35) - Tier 1; QL
nylia 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL
nymyo (generic for ESTARYLLA) - Tier 1; QL
ocella (generic for OCELLA) - Tier 1; QL
philith (generic for BALZIVA) - Tier 1; QL
pimtrea (generic for AZURETTE) - Tier 1; QL
pirmella 1/35 (generic for DASETTA 1/35) - Tier 1; QL
pirmella 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL
portia-28 (generic for ALTAVERA) - Tier 1; QL
PREMARIN ORAL - Tier 2; QL
PREMARIN VAGINAL - Tier 2; QL
PREMPHASE - Tier 2; QL
PREMPRO - Tier 2; QL
previfem (generic for ESTARYLLA) - Tier 1; QL
QUARTETTE (brand for levonorgest-eth est & eth est) - Tier 2; QL
reclipsen (generic for APRI) - Tier 1; QL
SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; QL
SEASONIQUE (brand for levonorgest-eth estrad 91-day) - Tier 2; QL
setlakin (generic for ICLEVIA) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
138
Preferred Agents Non-Preferred Agents
simliya (generic for AZURETTE) - Tier 1; QL
simpesse (generic for AMETHIA) - Tier 1; QL
sprintec 28 (generic for ESTARYLLA) - Tier 1; QL
sronyx (generic for AFIRMELLE) - Tier 1; QL
syeda (generic for OCELLA) - Tier 1; QL
tarina 24 fe - Tier 1; QL
tarina fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL
tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL
taysofy (generic for GEMMILY) - Tier 1; QL
tilia fe - Tier 1; QL
tri femynor (generic for TRI FEMYNOR) - Tier 1; QL
tri-estarylla (generic for TRI FEMYNOR) - Tier 1; QL
tri-legest fe - Tier 1; QL
tri-linyah (generic for TRI FEMYNOR) - Tier 1; QL
tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; QL
tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; QL
tri-lo-mili (generic for TRI-LO-ESTARYLLA) - Tier 1; QL
tri-lo-sprintec (generic for TRI-LO-ESTARYLLA) - Tier 1; QL
tri-mili (generic for TRI FEMYNOR) - Tier 1; QL
tri-nymyo (generic for TRI FEMYNOR) - Tier 1; QL
tri-sprintec (generic for TRI FEMYNOR) - Tier 1; QL
trivora (28) (generic for ENPRESSE-28) - Tier 1; QL
tri-vylibra (generic for TRI FEMYNOR) - Tier 1; QL
tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; QL
tyblume - Tier 1; QL
tydemy (generic for TYDEMY) - Tier 1; QL
velivet - Tier 1; QL
vestura (generic for JASMIEL) - Tier 1; QL
vienva (generic for AFIRMELLE) - Tier 1; QL
viorele (generic for AZURETTE) - Tier 1; QL
volnea (generic for AZURETTE) - Tier 1; QL
vyfemla (generic for BALZIVA) - Tier 1; QL
vylibra (generic for ESTARYLLA) - Tier 1; QL
wera - Tier 1; QL
wymzya fe (generic for WYMZYA FE) - Tier 1; QL
xulane - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
139
Preferred Agents Non-Preferred Agents
YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2; QL
YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2; QL
zafemy - Tier 1; QL
zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL
zumandimine (generic for OCELLA) - Tier 1; QL
Progestins
camila (generic for CAMILA) - Tier 1; QL
CRINONE - Tier 2
deblitane (generic for CAMILA) - Tier 1; QL
DEPO-SUBQ PROVERA 104 - Tier 2; ST; QL
ELLA - Tier 2; QL
errin (generic for CAMILA) - Tier 1; QL
heather (generic for CAMILA) - Tier 1; QL
incassia (generic for CAMILA) - Tier 1; QL
jencycla (generic for CAMILA) - Tier 1; QL
lyleq (generic for CAMILA) - Tier 1; QL
lyza (generic for CAMILA) - Tier 1; QL
AYGESTIN (brand for norethindrone acetate) - Tier 2; PA; QL
DEPO-PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA;
QL
ENDOMETRIN - Tier 2; PA
PROVERA (brand for medroxyprogesterone acetate) - Tier 2; PA; QL
medroxyprogesterone acetate intramuscular (generic for DEPO-
PROVERA) - Tier 1; QL
medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1;
QL
megestrol acetate oral suspension 40 mg/ml, 625 mg/5ml - Tier 1; QL
megestrol acetate oral tablet 20 mg - Tier 1
megestrol acetate oral tablet 40 mg - Tier 1; QL
nora-be (generic for CAMILA) - Tier 1; QL
norethindrone acetate oral (generic for AYGESTIN) - Tier 1; QL
norethindrone oral (generic for CAMILA) - Tier 1; QL
norlyda (generic for CAMILA) - Tier 1; QL
norlyroc (generic for CAMILA) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
140
Preferred Agents Non-Preferred Agents
progesterone intramuscular - Tier 1
progesterone oral (generic for PROMETRIUM) - Tier 1; QL
PROMETRIUM (brand for progesterone) - Tier 2; QL
sharobel (generic for CAMILA) - Tier 1; QL
SLYND - Tier 2; QL
tulana (generic for CAMILA) - Tier 1; QL
Selective Estrogen Receptor Modifying Agents
raloxifene hcl (generic for EVISTA) - Tier 1; QL EVISTA (brand for raloxifene hcl) - Tier 2; PA; QL
OSPHENA - Tier 2; PA; QL; GE
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers) - Drugs to Regulate Hormones
Estrogens - Hormone Replacement/Modifying Drugs
TWIRLA - Tier 2; QL COVARYX (brand for est estrogens-methyltest) - Tier 2; PA; QL
COVARYX HS (brand for est estrogens-methyltest hs) - Tier 2; PA; QL
EEMT (brand for est estrogens-methyltest) - Tier 2; PA; QL
est estrogens-methyltest (generic for COVARYX) - Tier 1; PA; QL
est estrogens-methyltest ds (generic for COVARYX) - Tier 1; PA; QL
est estrogens-methyltest hs (generic for COVARYX HS) - Tier 1; PA; QL
Progestins - Hormone Replacement/Modifying Drugs
aftera (generic for AFTERA) - Tier 1; QL; GE
econtra ez (generic for AFTERA) - Tier 1; QL; GE
econtra one-step (generic for AFTERA) - Tier 1; QL; GE
levonorgestrel (generic for AFTERA) - Tier 1; QL; GE
my choice (generic for AFTERA) - Tier 1; QL; GE
my way (generic for AFTERA) - Tier 1; QL; GE
new day (generic for AFTERA) - Tier 1; QL; GE
opcicon one-step (generic for AFTERA) - Tier 1; QL; GE
option 2 (generic for AFTERA) - Tier 1; QL; GE
PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; QL; GE
react (generic for AFTERA) - Tier 1; QL; GE
take action (generic for AFTERA) - Tier 1; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
141
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
euthyrox (generic for EUTHYROX) - Tier 1; QL
levo-t (generic for EUTHYROX) - Tier 1; QL
levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL
levoxyl (generic for EUTHYROX) - Tier 1; QL
liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL
unithroid (generic for EUTHYROX) - Tier 1; QL
CYTOMEL (brand for liothyronine sodium) - Tier 2; PA; QL
LEVOTHYROXINE SODIUM ORAL CAPSULE (brand for levothyroxine
sodium) - Tier 2; PA; QL
SYNTHROID (brand for levothyroxine sodium) - Tier 2; PA; QL
THYQUIDITY - Tier 2; PA; QL
TIROSINT (brand for levothyroxine sodium) - Tier 2; PA; QL
TIROSINT-SOL - Tier 2; PA; QL
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) -
Drugs to Replace Thyroid Hormones
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) -
Thyroid Replacement Drugs
ARMOUR THYROID - Tier 2; QL
np thyroid - Tier 1; QL
Hormonal Agents, Suppressant (Adrenal)
LYSODREN - Tier 2; PA; QL ISTURISA - Tier 2; PA; SP; QL
RECORLEV - Tier 2; PA; SP; QL
Hormonal Agents, Suppressant (Pituitary)
cabergoline - Tier 1; QL
leuprolide acetate injection - Tier 1; PA; SP; QL
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 3.75 MG - Tier
2; PA; ST; SP; QL
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT 7.5 MG - Tier
2; PA; SP; QL
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 11.25 MG -
Tier 2; PA; ST; SP; QL
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT 22.5 MG - Tier
2; PA; SP; QL
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2;
PA; SP; QL
ELIGARD - Tier 2; PA; SP; QL
FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL
LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL
LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP; QL
MYCAPSSA - Tier 2; PA; SP; QL
SANDOSTATIN (brand for octreotide acetate) - Tier 2; PA; SP; QL
SYNAREL - Tier 2; PA
TRIPTODUR - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
142
Preferred Agents Non-Preferred Agents
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2;
PA; SP; QL
octreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QL
ORIAHNN - Tier 2; PA; QL
ORILISSA - Tier 2; ST; QL
SIGNIFOR - Tier 2; PA; SP; QL
SOMAVERT - Tier 2; PA; SP; QL
ZOLADEX - Tier 2; ST
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole oral - Tier 1; QL
propylthiouracil oral - Tier 1; QL
Immune Suppressants - Immune System Drugs
Immunological Agents - Drugs that Stimulate or Suppress the
Immune System
LUPKYNIS - Tier 2; PA; QL
Immunological Agents
Angioedema Agents
HAEGARDA - Tier 2; PA; SP; QL
RUCONEST - Tier 2; PA; SP; QL
TAKHZYRO - Tier 2; PA; SP; QL
BERINERT - Tier 2; PA; SP; QL
CINRYZE - Tier 2; PA; SP; QL
FIRAZYR (brand for icatibant acetate) - Tier 2; PA; SP; QL
icatibant acetate (generic for SAJAZIR) - Tier 1; PA; SP; QL
sajazir (generic for SAJAZIR) - Tier 1; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
143
Preferred Agents Non-Preferred Agents
Immunoglobulins
ATGAM - Tier 2; PA
CYTOGAM - Tier 2; PA
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5 GM/10ML, 20
GM/400ML - Tier 2; PA
GAMASTAN - Tier 2; PA
GAMMAPLEX INTRAVENOUS SOLUTION 20 GM/400ML - Tier 2; PA
GAMUNEX-C INJECTION SOLUTION 40 GM/400ML - Tier 2; PA
HYPERRHO S/D - Tier 2; PA
MICRHOGAM ULTRA-FILTERED PLUS - Tier 2; PA
RHOGAM ULTRA-FILTERED PLUS - Tier 2; PA
RHOPHYLAC - Tier 2; PA
WINRHO SDF - Tier 2; PA
Immunological Agents, Other
ARCALYST - Tier 2; SP; QL
KINERET - Tier 2; PA; SP; QL
OTEZLA - Tier 2; PA; SP; QL
RIDAURA - Tier 2; QL
SYNAGIS - Tier 2; PA; SP; QL
TALTZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2; PA;
ST; SP; QL
TALTZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;
PA; SP; QL
XELJANZ - Tier 2; PA; SP; QL
XOLAIR - Tier 2; PA; SP; QL
ACTEMRA ACTPEN - Tier 2; PA; SP; QL
ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL
ADBRY - Tier 2; PA; SP; QL
BENLYSTA SUBCUTANEOUS - Tier 2; PA; SP; QL
COSENTYX - Tier 2; PA; SP; QL
DUPIXENT - Tier 2; PA; SP; QL
ILARIS - Tier 2; PA; SP; QL
ILUMYA - Tier 2; PA; SP; QL
KEVZARA - Tier 2; PA; SP; QL
OLUMIANT ORAL TABLET 1 MG, 2 MG - Tier 2; PA; SP; QL
OLUMIANT ORAL TABLET 4 MG - Tier 2; PA
ORALAIR - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
144
Preferred Agents Non-Preferred Agents
ORALAIR ADULT STARTER PACK - Tier 2; PA; QL
ORENCIA CLICKJECT - Tier 2; PA; SP; QL
ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL
RINVOQ - Tier 2; PA; SP; QL
SILIQ - Tier 2; PA; SP; QL
SKYRIZI (150 MG DOSE) - Tier 2; PA; SP; QL
SKYRIZI PEN - Tier 2; PA; SP; QL
SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;
PA; SP; QL
STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL
TREMFYA - Tier 2; PA; SP; QL
XELJANZ XR - Tier 2; PA; SP; QL
Immunostimulants
ACTIMMUNE - Tier 2; PA; SP; QL
INTRON A - Tier 2; PA; SP; QL
PEGASYS - Tier 2; PA; SP; QL
Immunosuppressants
AZASAN (brand for azathioprine) - Tier 2
azathioprine oral tablet 100 mg, 75 mg (generic for AZASAN) - Tier 1
azathioprine oral tablet 50 mg (generic for IMURAN) - Tier 1; QL
cyclosporine modified oral capsule 100 mg, 25 mg (generic for
GENGRAF) - Tier 1; QL
cyclosporine modified oral capsule 50 mg - Tier 1
cyclosporine modified oral solution (generic for GENGRAF) - Tier 1;
QL
cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL
ENBREL - Tier 2; PA; SP; QL
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (generic for
ZORTRESS) - Tier 1
ARAVA (brand for leflunomide) - Tier 2; PA; QL
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.5
MG, 1 MG - Tier 2; PA; QL
ASTAGRAF XL ORAL CAPSULE EXTENDED RELEASE 24 HOUR 5 MG
- Tier 2; PA
CELLCEPT (brand for mycophenolate mofetil) - Tier 2; PA; QL
CIMZIA - Tier 2; PA; SP; QL
ENSPRYNG - Tier 2; PA; SP; QL
ENVARSUS XR - Tier 2; PA; QL
IMURAN (brand for azathioprine) - Tier 2; PA; QL
MYFORTIC (brand for mycophenolate sodium) - Tier 2; PA; QL
NEORAL (brand for cyclosporine modified) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
145
Preferred Agents Non-Preferred Agents
gengraf (generic for GENGRAF) - Tier 1; QL
HUMIRA PEN-PEDIATRIC UC START - Tier 2; PA; SP; QL
HUMIRA PEN-PSOR/UVEIT STARTER - Tier 2; PA; SP; QL
HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML, 40
MG/0.8ML - Tier 2; PA; SP; QL
HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML - Tier
2; PA; SP; QL
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10
MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML, 80
MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML - Tier 2; PA; SP; QL
leflunomide oral (generic for ARAVA) - Tier 1; QL
methotrexate oral - Tier 1; QL
OTREXUP - Tier 2; PA; QL
PROGRAF ORAL CAPSULE 0.5 MG, 5 MG (brand for tacrolimus) - Tier
2; PA
PROGRAF ORAL CAPSULE 1 MG (brand for tacrolimus) - Tier 2; PA; QL
PROGRAF ORAL PACKET - Tier 2; PA
RAPAMUNE ORAL SOLUTION (brand for sirolimus) - Tier 2; PA; QL
RAPAMUNE ORAL TABLET 0.5 MG, 1 MG (brand for sirolimus) - Tier 2;
PA; QL
RAPAMUNE ORAL TABLET 2 MG (brand for sirolimus) - Tier 2; PA
RASUVO - Tier 2; PA; QL
REDITREX - Tier 2; PA; QL
SANDIMMUNE ORAL (brand for cyclosporine) - Tier 2; PA; QL
methotrexate sodium (pf) - Tier 1
methotrexate sodium injection - Tier 1
methotrexate sodium oral - Tier 1; QL
mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL
mycophenolate sodium (generic for MYFORTIC) - Tier 1; QL
sirolimus oral solution (generic for RAPAMUNE) - Tier 1; QL
sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1;
QL
sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1
tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1
tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QL
ZORTRESS ORAL TABLET 1 MG (brand for everolimus) - Tier 2
SIMPONI - Tier 2; PA; SP; QL
TREXALL - Tier 2; PA
XATMEP - Tier 2; PA; QL
ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG (brand for
everolimus) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
146
Preferred Agents Non-Preferred Agents
Vaccines
ACTHIB - Tier 2
ADACEL - Tier 2; QL
BEXSERO - Tier 2; QL
BOOSTRIX - Tier 2; QL
DAPTACEL - Tier 2; QL
DIPHTHERIA-TETANUS TOXOIDS DT - Tier 2; QL
ENGERIX-B - Tier 2; QL
GARDASIL 9 - Tier 2; QL
HAVRIX - Tier 2; QL
HIBERIX - Tier 2
INFANRIX - Tier 2; QL
IPOL - Tier 2
MENACTRA - Tier 2; QL
MENQUADFI - Tier 2; QL
MENVEO - Tier 2; QL
M-M-R II - Tier 2; QL
PEDIARIX - Tier 2; QL
PEDVAX HIB - Tier 2
PENTACEL - Tier 2; QL
PREHEVBRIO - Tier 2; QL
PROQUAD - Tier 2; QL
QUADRACEL INTRAMUSCULAR SUSPENSION - Tier 2; QL
RECOMBIVAX HB - Tier 2; QL
ROTARIX - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
147
Preferred Agents Non-Preferred Agents
ROTATEQ - Tier 2
SHINGRIX - Tier 2; QL; AL
TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL
TENIVAC - Tier 2; QL
TETANUS-DIPHTHERIA TOXOIDS TD (brand for tetanus-diphtheria
toxoids td) - Tier 2; QL
TRUMENBA - Tier 2; QL
TWINRIX - Tier 2; QL
VAQTA - Tier 2; QL
VARIVAX - Tier 2; QL
VAXNEUVANCE - Tier 2; QL
Immunological Agents - Drugs that Stimulate or Suppress the
Immune System
Vaccines
MODERNA COVID-19 VACCINE (brand for moderna covid-19 vaccine) -
Tier 2; PA; QL
PFIZER-BIONTECH COVID-19 VACC - Tier 2; PA; QL
SPIKEVAX COVID-19 VACCINE (brand for moderna covid-19 vaccine) -
Tier 2; PA; QL
AFLURIA QUADRIVALENT - Tier 2; QL
DENGVAXIA - Tier 2; QL
FLUAD QUADRIVALENT - Tier 2; QL
FLUARIX QUADRIVALENT - Tier 2; QL
FLUBLOK QUADRIVALENT - Tier 2; QL
FLUCELVAX QUADRIVALENT - Tier 2; QL
FLULAVAL QUADRIVALENT - Tier 2; QL
FLUZONE HIGH-DOSE QUADRIVALENT - Tier 2; QL
FLUZONE QUADRIVALENT - Tier 2; QL
HEPLISAV-B - Tier 2; QL; AL
HYPERTET - Tier 2; QL
NOVAVAX - Tier 2; QL
PFIZER COVID-19 VAC-TRIS 5-11Y - Tier 2; QL
PNEUMOVAX 23 - Tier 2; QL
PREVNAR 13 - Tier 2; QL
PREVNAR 20 - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
148
Preferred Agents Non-Preferred Agents
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium (generic for COLAZAL) - Tier 1; QL
LIALDA (brand for mesalamine) - Tier 2; QL
mesalamine er oral capsule extended release 24 hour (generic for
APRISO) - Tier 1; QL
mesalamine oral capsule delayed release 400 mg (generic for
DELZICOL) - Tier 1; QL
mesalamine rectal enema - Tier 1; QL
mesalamine-cleanser (generic for ROWASA) - Tier 1; QL
PENTASA (brand for mesalamine er) - Tier 2; QL
SFROWASA - Tier 2; QL
sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL
APRISO (brand for mesalamine er) - Tier 2; PA; QL
ASACOL HD (brand for mesalamine) - Tier 2; PA; QL
AZULFIDINE (brand for sulfasalazine) - Tier 2; PA; QL
AZULFIDINE EN-TABS (brand for sulfasalazine) - Tier 2; PA; QL
CANASA (brand for mesalamine) - Tier 2; PA; QL
COLAZAL (brand for balsalazide disodium) - Tier 2; PA; QL
DELZICOL (brand for mesalamine) - Tier 2; PA; QL
DIPENTUM - Tier 2; PA; QL
mesalamine er oral capsule extended release (generic for PENTASA) -
Tier 1; PA; QL
mesalamine oral tablet delayed release (generic for ASACOL HD) - Tier
1; PA; QL
mesalamine rectal suppository (generic for CANASA) - Tier 1; PA; QL
ROWASA (brand for mesalamine-cleanser) - Tier 2; PA; QL
Glucocorticoids
budesonide er (generic for UCERIS) - Tier 1; QL
budesonide oral - Tier 1; QL
hydrocortisone (perianal) (generic for PROCTO-MED HC) - Tier 1; QL
hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA)
- Tier 1; QL
procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL
procto-pak (generic for PROCTO-PAK) - Tier 1; QL
proctosol hc (generic for PROCTO-MED HC) - Tier 1; QL
proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL
ANUSOL-HC EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2;
PA; QL
CORTENEMA (brand for hydrocortisone) - Tier 2; PA; QL
CORTIFOAM - Tier 2; PA; QL
ORTIKOS - Tier 2; PA; QL
PROCTOCORT EXTERNAL (brand for hydrocortisone (perianal)) - Tier 2;
PA; QL
TARPEYO - Tier 2; PA; QL
UCERIS (brand for budesonide er) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
149
Preferred Agents Non-Preferred Agents
Metabolic Bone Disease Agents
alendronate sodium oral tablet 10 mg, 35 mg - Tier 1; QL
alendronate sodium oral tablet 70 mg (generic for FOSAMAX) - Tier 1;
QL
calcitonin (salmon) nasal (generic for MIACALCIN) - Tier 1; QL
calcitriol oral (generic for ROCALTROL) - Tier 1; QL
cinacalcet hcl (generic for SENSIPAR) - Tier 1; QL
doxercalciferol oral - Tier 1
ibandronate sodium oral (generic for BONIVA) - Tier 1; QL
paricalcitol oral (generic for ZEMPLAR) - Tier 1
TERIPARATIDE (RECOMBINANT) - Tier 2; SP; QL
ACTONEL (brand for risedronate sodium) - Tier 2; PA; QL
alendronate sodium oral solution - Tier 1; PA; QL
ATELVIA (brand for risedronate sodium) - Tier 2; PA; QL
BONIVA (brand for ibandronate sodium) - Tier 2; PA; QL
FORTEO - Tier 2; PA; SP; QL
FOSAMAX (brand for alendronate sodium) - Tier 2; PA; QL
FOSAMAX PLUS D - Tier 2; PA; QL
NATPARA - Tier 2; PA; SP; QL
RAYALDEE - Tier 2; PA; QL
risedronate sodium (generic for ACTONEL) - Tier 1; PA; QL
ROCALTROL (brand for calcitriol) - Tier 2; PA; QL
SENSIPAR (brand for cinacalcet hcl) - Tier 2; PA; QL
TYMLOS - Tier 2; PA; SP; QL
ZEMPLAR ORAL (brand for paricalcitol) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
150
Preferred Agents Non-Preferred Agents
Miscellaneous Therapeutic Agents
ACE AEROSOL CLOUD ENHANCER (brand for adult aerosol mask) -
Tier 2; QL
acne (generic for CLEARSKIN) - Tier 1
acne control cleanser (generic for CLEARSKIN) - Tier 1
acne medication 10 external lotion - Tier 1; QL
acne medication 5 external lotion - Tier 1
ADULT AEROSOL MASK (brand for adult aerosol mask) - Tier 2; QL
adv acne spot treatment (generic for DERMACINRX ATRIX ANTIBAC
WASH) - Tier 1
advanced acne spot treat (generic for CLEAN & CLEAR ACNE
SCRUB) - Tier 1
ACCU-CHEK TENDER 1 INFUSION - Tier 2; PA
ACUNOL (brand for bhi hemorrhoid relief) - Tier 2; PA
AEROCHAMBER PLUS FLO-VU (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
AEROCHAMBER PLUS FLO-VU LARGE (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
AEROCHAMBER PLUS FLO-VU SMALL (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
AEROCHAMBER PLUS FLO-VU W/MASK (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
ALEVAMAX (brand for calicylic) - Tier 2; PA
algal-900 dha (generic for ALGAL-900 DHA) - Tier 1; PA
AERIVA CONCENTRATOR NEBULIZER (brand for aeriva
concentrator nebulizer) - Tier 2
ALCOHOL PREP PADS PAD , 70 % (brand for alcohol prep) - Tier 2;
QL
antibiotic (generic for BACITRAYCIN PLUS) - Tier 1; QL
antifungal (tolnaftate) (generic for TINACTIN) - Tier 1
antifungal tolnaftate (generic for TINACTIN) - Tier 1
arthritis pain relieving - Tier 1; QL
aspirin adults (generic for BAYER ASPIRIN) - Tier 1; QL
aspirin childrens (generic for BAYER LOW DOSE) - Tier 1; QL
aspirin ec (generic for BAYER ASPIRIN) - Tier 1; QL
amino action (generic for PRE PROTEIN) - Tier 1; PA
aminoamrms - Tier 1; PA
aminoreliefrms - Tier 1; PA
ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; PA; QL
anti-fungal external powder (generic for LOTRIMIN AF) - Tier 1; PA
ARNICARE ARNICA EXTERNAL OINTMENT (brand for calendula) - Tier
2; PA
atabex dha 200 - Tier 1; PA
ATOPICLAIR (brand for calicylic) - Tier 2; PA
AUM MINI INSULIN PEN NEEDLE 32G X 8 MM , 33G X 4 MM , 33G X 5
MM , 33G X 6 MM (brand for aum mini insulin pen needle) - Tier 2; PA;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
151
Preferred Agents Non-Preferred Agents
aspirin ec oral tablet 325 mg (generic for BAYER ASPIRIN) - Tier 1;
QL
aspirin oral (generic for BAYER ASPIRIN) - Tier 1; QL
ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for adult
aspirin regimen) - Tier 2; QL
aspirin rectal - Tier 1
athletes foot (tolnaftate) external aerosol powder 1 % (generic for
ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1
athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) -
Tier 1
athletes foot powder spray external aerosol powder 1 % (generic for
ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1
AUM SAFETY PEN NEEDLE (brand for ra pen needles) - Tier 2; PA; QL
AVENOC (brand for calendula) - Tier 2; PA
AZALGIA - Tier 2; PA
bee pollen oral capsule 580 mg - Tier 1; PA
BENSAL HP - Tier 2; PA
BENZEPRO FOAMING CLOTHS (brand for bpo foaming cloths) - Tier 2;
PA
BETASEPT SURGICAL SCRUB - Tier 2; PA
BLUESTAR - Tier 2; PA
BREATHE COMFORT CHAMBER/ADULT (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
athletes foot spray (generic for TINACTIN) - Tier 1
bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1; QL
bacitracin zinc external - Tier 1; QL
bacitracin zinc first aid - Tier 1; QL
bacitracin zinc-aloe - Tier 1; QL
BAYER ASPIRIN (brand for aspirin) - Tier 2; QL
BAYER LOW DOSE ORAL TABLET CHEWABLE (brand for aspirin) -
Tier 2; QL
BENZAC AC WASH (brand for benzoyl peroxide wash) - Tier 2; QL
BINAXNOW COVID-19 AG HOME TEST (brand for covid-19 at-home
test) - Tier 2; QL
bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1
BREATHE COMFORT CHAMBER/CHILD (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
BREXAFEMME - Tier 2; PA; QL
CALENDULA EXTERNAL OINTMENT (brand for calendula) - Tier 2; PA
calicylic (generic for ATOPICLAIR) - Tier 1; PA
CAMINO PRO COMPLETE/GLYTACTIN - Tier 2; PA
co q-10 oral capsule 50 mg - Tier 1; PA
co-enzyme q10 (generic for PRONUTRIENTS COQ10) - Tier 1; PA
coenzyme q10 oral capsule 100 mg (generic for PRONUTRIENTS
COQ10) - Tier 1; PA
coenzyme q-10 oral capsule 100 mg (generic for PRONUTRIENTS
COQ10) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
152
Preferred Agents Non-Preferred Agents
bisacodyl laxative (generic for EX-LAX ULTRA) - Tier 1
bisacodyl oral tablet delayed release 5 mg (generic for EX-LAX
ULTRA) - Tier 1
bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; QL
bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1
BREATHE COMFORT HUMIDIFIER (brand for cvs cool mist
humidifer) - Tier 2; QL
BREATHE EASE NEB MASK/CHILD (brand for adult aerosol mask) -
Tier 2; QL
BREATHE EASE NEB MASK/INFANT (brand for adult aerosol mask) -
Tier 2; QL
coenzyme q-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) -
Tier 1; PA
coenzyme q10 oral capsule 50 mg - Tier 1; PA
coenzyme q10 oral tablet 200 mg (generic for VITALINE COQ10) - Tier 1;
PA
COLCIGEL (brand for rapid gel rx) - Tier 2; PA
COLD-EEZE (brand for eql zinc cold relief) - Tier 2; PA
COLD-EEZE NATURAL MULTI-SYMP MOUTH/THROAT (brand for eql
zinc cold relief) - Tier 2; PA
COLD-EEZE PLUS DEFENSE MOUTH/THROAT (brand for eql zinc cold
relief) - Tier 2; PA
COLD-EEZE SUGAR FREE (brand for eql zinc cold relief) - Tier 2; PA
BUBBLES THE FISH II PEDI MASK (brand for adult aerosol mask) -
Tier 2; QL
calamine external lotion - Tier 1
capsaicin external cream (generic for DERMACINRX PENETRAL) -
Tier 1; QL
capsaicin hp (generic for ZOSTRIX HP) - Tier 1; QL
capsaicin pain relief (generic for ZOSTRIX HP) - Tier 1; QL
capzix (generic for ZOSTRIX HP) - Tier 1; QL
CARESTART COVID-19 HOME TEST (brand for covid-19 at-home
test) - Tier 2; QL
CARETOUCH 2 CPAP HOSE HANGER (brand for adult aerosol
mask) - Tier 2; QL
CONTOUR CONTROL SOLUTION (brand for control) - Tier 2; PA; QL
coq10 oral capsule 100 mg (generic for PRONUTRIENTS COQ10) - Tier
1; PA
coq10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - Tier 1; PA
coq-10 oral capsule 200 mg (generic for Q-SORB CO Q-10) - Tier 1; PA
coq-10 oral capsule 50 mg - Tier 1; PA
cure-all (generic for ATOPICLAIR) - Tier 1; PA
DEXERYL (brand for calicylic) - Tier 2; PA
DIALYVITE OMEGA-3 CONCENTRATE (brand for fish oil) - Tier 2; PA
EASYMAX CONTROL (brand for control) - Tier 2; PA; QL
ECZEMOL (brand for bhi hemorrhoid relief) - Tier 2; PA
ELETONE (brand for calicylic) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
153
Preferred Agents Non-Preferred Agents
CARETOUCH CPAP & BIPAP HOSE (brand for adult aerosol mask) -
Tier 2; QL
CARETOUCH CPAP MASK WIPES (brand for adult aerosol mask) -
Tier 2; QL
CARETOUCH CPAP PRE-WASH SOLN (brand for adult aerosol
mask) - Tier 2; QL
CARETOUCH CPAP TUBE BRUSH (brand for adult aerosol mask) -
Tier 2; QL
CARETOUCH UNIVERSL CPAP FILTER (brand for adult aerosol
mask) - Tier 2; QL
CASTIVA WARMING - Tier 2; QL
CAYA - Tier 2; QL
EPSOLAY - Tier 2; PA; QL
estro vital nutrients ex st (generic for HCU EASY) - Tier 1; PA
evening primrose oil oral capsule 500 mg - Tier 1; PA
fa-8 - Tier 1; PA
FEMCAP - Tier 2; PA; QL
fish oil half-the-size (generic for OVEGA-3) - Tier 1; PA
fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH OIL
CONC) - Tier 1; PA
fish oil oral capsule 500 mg (generic for OVEGA-3) - Tier 1; PA
FLEXICHAMBER (brand for breathe comfort chamber/adult) - Tier 2; PA;
QL
FLEXICHAMBER ADULT MASK/SMALL - Tier 2; PA
childrens aspirin oral tablet chewable 81 mg (generic for BAYER LOW
DOSE) - Tier 1; QL
c-lax laxative (generic for EX-LAX ULTRA) - Tier 1
CLEARDETECT COVID-19 AG HOME (brand for covid-19 at-home
test) - Tier 2; QL
clearskin (generic for CLEARSKIN) - Tier 1
CLINITEST RAPID COVID-19 TEST (brand for covid-19 at-home test)
- Tier 2; QL
COMIRNATY (brand for pfizer-biont covid-19 vac-tris) - Tier 2; QL
COMPRESSOR NEBULIZER (brand for aeriva concentrator nebulizer)
- Tier 2
CONDOMS - Tier 2; QL
FLEXICHAMBER CHILD MASK/LARGE - Tier 2; PA
FLEXICHAMBER CHILD MASK/SMALL - Tier 2; PA
FLUID ADMINISTRATION SET (brand for fluid administration set) - Tier
2; PA
FORTISCARE CONTROL (brand for control) - Tier 2; PA; QL
GENADUR EXTERNAL (brand for liquid bandage) - Tier 2; PA
GLUCOSE CONTROL SOLUTION IN VITRO LIQUID (brand for control) -
Tier 2; PA; QL
GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION HIGH (brand
for diatrue control level 3) - Tier 2; PA; QL
GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION LOW (brand for
diatrue control level 1) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
154
Preferred Agents Non-Preferred Agents
COOL MIST HUMIDIFER (brand for cvs cool mist humidifer) - Tier 2;
QL
corn & callus remover (generic for COMPOUND W) - Tier 1
COVID-19 AT-HOME TEST (brand for covid-19 at-home test) - Tier 2;
QL
COVID-19 SPECIMEN COLLECTION - Tier 2
daily acne wash (generic for DERMACINRX ATRIX ANTIBAC WASH)
- Tier 1
DERMACINRX ATRIX ANTIBAC WASH (brand for cvs adv acne spot
treatment) - Tier 2
DERMACINRX ATRIX CLARIFY TONER (brand for cvs adv acne spot
treatment) - Tier 2
GLUCOSE CONTROL SOLUTION IN VITRO SOLUTION NORMAL
(brand for control) - Tier 2; PA; QL
GLYTACTIN COMPLETE 10PE - Tier 2; PA
G-PREPROTEIN - Tier 2; PA
GUARDIAN LINK 3 TRANSMITTER - Tier 2; PA; QL
HALUCORT - Tier 2; PA
HCU EASY (brand for sm estro vital nutrients ex st) - Tier 2; PA
HIBICLENS - Tier 2; PA
HPR PLUS EXTERNAL CREAM (brand for calicylic) - Tier 2; PA
HUMATROPEN FOR 12MG (brand for inject-ease) - Tier 2; PA
HUMATROPEN FOR 24MG (brand for inject-ease) - Tier 2; PA
HUMATROPEN FOR 6MG (brand for inject-ease) - Tier 2; PA
DERMACINRX PENETRAL (brand for capsaicin) - Tier 2; QL
DEXCOM G6 TRANSMITTER - Tier 2; QL
DIATRUST COVID-19 HOME TEST (brand for covid-19 at-home test)
- Tier 2; QL
double antibiotic (generic for POLYSPORIN) - Tier 1
DROPSAFE ALCOHOL PREP (brand for alcohol prep) - Tier 2; QL
DRYSOL - Tier 2; QL
EASIVENT (brand for breathe comfort chamber/adult) - Tier 2; QL
EASIVENT MASK LARGE (brand for breathe comfort chamber/adult) -
Tier 2; QL
EASIVENT MASK MEDIUM (brand for breathe comfort chamber/adult)
- Tier 2; QL
HYLAFEM - Tier 2; PA
HYLATOPIC PLUS (brand for bromi-lotion) - Tier 2; PA
ICHTHAMMOL DRAWING SALVE (brand for calendula) - Tier 2; PA
IMUBOLIC - Tier 2; PA
INSPIRACHAMBER/LARGE (brand for breathe comfort chamber/adult) -
Tier 2; PA; QL
INSPIRACHAMBER/MEDIUM (brand for breathe comfort chamber/adult) -
Tier 2; PA; QL
INSPIRACHAMBER/MOUTHPIECE (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
INSPIRACHAMBER/SMALL (brand for breathe comfort chamber/adult) -
Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
155
Preferred Agents Non-Preferred Agents
EASIVENT MASK SMALL (brand for breathe comfort chamber/adult) -
Tier 2; QL
EBASE CONTROLLER KIT (brand for adult aerosol mask) - Tier 2; QL
ED-SPAZ (brand for hyoscyamine sulfate) - Tier 2; QL
ELLUME COVID-19 HOME TEST (brand for covid-19 at-home test) -
Tier 2; QL
enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL
enteric fish oil (generic for VITEYES OMEGA-3 VISION SUPPORT) -
Tier 1; QL
EX-LAX ULTRA (brand for bisacodyl ec) - Tier 2
fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL
FILTER AIR PP (brand for adult aerosol mask) - Tier 2; QL
INSULIN PEN NEEDLES 29G X 12.7MM (brand for sure comfort pen
needles) - Tier 2; PA; QL
INSULIN PEN NEEDLES 29G X 12MM , 31G X 6 MM (brand for 1st tier
unifine pentips) - Tier 2; PA; QL
INSULIN PEN NEEDLES 29G X 5MM , 29G X 8MM , 31G X 4 MM - Tier
2; PA; QL
INSULIN PEN NEEDLES 31G X 5 MM , 31G X 8 MM (brand for ra pen
needles) - Tier 2; PA; QL
INSULIN PEN NEEDLES 32G X 8 MM , 33G X 4 MM , 33G X 5 MM , 33G
X 6 MM (brand for aum mini insulin pen needle) - Tier 2; PA; QL
INSULIN SYRINGES 27G X 1/2" 0.5 ML, 27G X 1/2" 1 ML (brand for
insulin syringe) - Tier 2; PA; QL
fish oil concentrate oral capsule 1000 mg (generic for SEA-OMEGA) -
Tier 1; QL
fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1; QL
fish oil oral capsule delayed release 1000 mg (generic for VITEYES
OMEGA-3 VISION SUPPORT) - Tier 1; QL
fish oil oral capsule delayed release 1200 mg - Tier 1; QL
FLEET BISACODYL - Tier 2; QL
FLOWFLEX COVID-19 AG HOME TEST (brand for covid-19 at-home
test) - Tier 2; QL
folic acid oral tablet 1 mg - Tier 1; QL
folic acid oral tablet 400 mcg, 800 mcg - Tier 1
INSULIN SYRINGES 28G X 5/16" 1 ML - Tier 2; PA; QL
INSULIN SYRINGES 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML, 30G X 1/2"
1 ML, 31G X 5/16" 1 ML (brand for careone insulin syringe) - Tier 2; PA;
QL
INSULIN SYRINGES 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML (brand
for global easy glide insulin syr) - Tier 2; PA; QL
INSULIN SYRINGES 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML (brand for
mm insulin syringe/needle) - Tier 2; PA; QL
kelp-b6-lecithin-vinegar - Tier 1; PA
KERALYT EXTERNAL GEL 6 % (brand for salicylic acid) - Tier 2; PA; QL
KERALYT EXTERNAL SHAMPOO (brand for salicylic acid) - Tier 2; PA
korean ginseng oral capsule 250 mg, 350 mg - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
156
Preferred Agents Non-Preferred Agents
foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER
SPRAY) - Tier 1
FORMULA 3 THE TREATMENT (brand for tinaspore) - Tier 2
FORMULA 7 THE SOLUTION (brand for tinaspore) - Tier 2
fungi-guard (generic for TINACTIN) - Tier 1
gentle laxative oral tablet delayed release 5 mg (generic for EX-LAX
ULTRA) - Tier 1
gentle laxative rectal suppository 10 mg (generic for THE MAGIC
BULLET) - Tier 1; QL
gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1
genuine aspirin (generic for BAYER ASPIRIN) - Tier 1; QL
l-arginine oral capsule - Tier 1; PA
lecithin oral capsule - Tier 1; PA
LEVSIN ORAL (brand for hyoscyamine sulfate) - Tier 2; PA; QL
LEVSIN/SL (brand for hyoscyamine sulfate) - Tier 2; PA; QL
LIVMARLI - Tier 2; PA; SP; QL
l-lysine hcl oral tablet 500 mg - Tier 1; PA
l-lysine oral tablet 1000 mg, 500 mg - Tier 1; PA
LTXF PRIM CNV PIN MICRODRIP (brand for fluid administration set) -
Tier 2; PA
LTXF PRIM IV SET/CNVT PIN (brand for fluid administration set) - Tier 2;
PA
h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1;
QL
hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL
hyoscyamine sulfate oral (generic for ANASPAZ) - Tier 1; QL
hyoscyamine sulfate sl (generic for LEVSIN/SL) - Tier 1; QL
hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL
hyosyne - Tier 1; QL
IHEALTH COVID-19 RAPID TEST (brand for covid-19 at-home test) -
Tier 2; QL
INDICAID COVID-19 RAPID TEST (brand for covid-19 at-home test) -
Tier 2; QL
INSPIREASE (brand for breathe comfort chamber/adult) - Tier 2; QL
LTXF SECONDARY/CNV PIN/32INC (brand for fluid administration set) -
Tier 2; PA
lysine hcl oral tablet 1000 mg - Tier 1; PA
MACRILEN - Tier 2; PA; SP; QL
METOPIRONE - Tier 2; PA
MIMYX (brand for calicylic) - Tier 2; PA
MINILINK REAL-TIME TRANSMITTER - Tier 2; PA; QL
MODERNA COVID-19 VAC (BOOSTER) - Tier 2; PA
MODERNA COVID-19 VACC 6M-5Y - Tier 2; PA
MORCIN - Tier 2; PA
MSUD EASY (brand for sm estro vital nutrients ex st) - Tier 2; PA
INSPIREASE RESERVOIR BAGS - Tier 2; QL
INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (brand for
global inject ease insulin syr) - Tier 2; QL
INSULIN SYRINGES 29G X 1/2" 0.3 ML (brand for eql insulin syringe)
- Tier 2; QL
INSULIN SYRINGES 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X
5/16" 1 ML (brand for ra insulin syringe) - Tier 2; QL
INSULIN SYRINGES 29G X 5/16" 1 ML - Tier 2; QL
INSULIN SYRINGES 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML (brand
for mm insulin syringe/needle) - Tier 2; QL
INTELISWAB COVID-19 RAPID TEST (brand for covid-19 at-home
test) - Tier 2; QL
natural fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH
OIL CONC) - Tier 1; PA
NEOSALUS EXTERNAL CREAM (brand for calicylic) - Tier 2; PA
NEOSALUS EXTERNAL LOTION (brand for bromi-lotion) - Tier 2; PA
NERVE PAIN RELIEF (brand for calendula) - Tier 2; PA
NEURAGEN PN (brand for calendula) - Tier 2; PA
NICAPRIN (brand for proleva) - Tier 2; PA
NIVATOPIC PLUS (brand for calicylic) - Tier 2; PA
NORDIPEN 5 INJECTION DEVICE (brand for inject-ease) - Tier 2; PA
NORDIPEN DELIVERY SYSTEM (brand for inject-ease) - Tier 2; PA
NUVAIL - Tier 2; PA
NYVEPRIA - Tier 2; PA; SP
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
157
Preferred Agents Non-Preferred Agents
jock itch max st (generic for ODOR EATERS FOOT/SNEAKER
SPRAY) - Tier 1
jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER
SPRAY) - Tier 1
laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA)
- Tier 1
laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) -
Tier 1; QL
LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL
magnesium oxide oral tablet 400 mg - Tier 1
MASK VORTEX/CHILD/FROG - Tier 2; QL
MASK VORTEX/TODDLER/LADYBUG - Tier 2; QL
omega-3 fish oil oral capsule 1200 mg (generic for THERAGRAN-M FISH
OIL CONC) - Tier 1; PA
omega-3 fish oil oral capsule 300 mg (generic for FISH OIL PEARLS) -
Tier 1; PA
omega-3 oral capsule 1400 mg - Tier 1; PA
OMNITROPE PEN 5 INJ DEVICE (brand for inject-ease) - Tier 2; PA
ONETOUCH SOLUTIONS STARTER KIT - Tier 2; PA; QL
ONETOUCH VERIO IN VITRO SOLUTION HIGH (brand for diatrue
control level 3) - Tier 2; PA; QL
ORLADEYO - Tier 2; PA; SP; QL
OVACE PLUS WASH (brand for sodium sulfacetamide wash) - Tier 2; PA
OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2; PA
medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1
MICOTRIN AL (brand for tinaspore) - Tier 2
MINI COMPRESSOR (brand for aeriva concentrator nebulizer) - Tier 2
MYCOZYL AL (brand for tinaspore) - Tier 2
natural fish oil oral capsule 1000 mg (generic for SEA-OMEGA) - Tier
1; QL
NEBULIZER MASK ADULT (brand for adult aerosol mask) - Tier 2; QL
NEBULIZER MASK CHILD (brand for adult aerosol mask) - Tier 2; QL
NEODOT THERMOMETER - Tier 2; QL
NEUTROGENA OIL-FREE ACNE WASH (brand for cvs adv acne spot
treatment) - Tier 2
NULEV (brand for hyoscyamine sulfate) - Tier 2; QL
PALFORZIA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (120 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (160 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (200 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (240 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (3 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (300 MG MAINTENANCE) - Tier 2; PA; SP; QL
PALFORZIA (300 MG TITRATION) - Tier 2; PA; SP; QL
PALFORZIA (40 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (6 MG DAILY DOSE) - Tier 2; PA; SP; QL
PALFORZIA (80 MG DAILY DOSE) - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
158
Preferred Agents Non-Preferred Agents
odorless coated fish oil (generic for VITEYES OMEGA-3 VISION
SUPPORT) - Tier 1; QL
omega-3 fish oil oral capsule 1000 mg (generic for SEA-OMEGA) -
Tier 1; QL
omega-3 fish oil oral capsule delayed release 1200 mg - Tier 1; QL
omega-3 oral capsule 1000 mg (generic for SEA-OMEGA) - Tier 1; QL
OMNIFLEX DIAPHRAGM - Tier 2; QL
OMNIPOD 5 G6 INTRO (GEN 5) - Tier 2; QL
OMNIPOD 5 G6 POD (GEN 5) - Tier 2; QL
ON/GO COVID-19 ANTIGEN TEST (brand for covid-19 at-home test) -
Tier 2; QL
PALFORZIA INITIAL ESCALATION - Tier 2; PA; SP; QL
PARADIGM REAL-TIME TRANSMITTER - Tier 2; PA; QL
PARI TREK S COMBO PACK (brand for adult mask) - Tier 2; PA
PFIZER COVID-19 VAC-TRIS 6M-4Y - Tier 2; PA
PKU EASY (brand for sm estro vital nutrients ex st) - Tier 2; PA
PKU EASY MICROTABS - Tier 2; PA
PLEXION NS (brand for sodium sulfacetamide) - Tier 2; PA; QL
podocon-25 - Tier 1; PA
pre protein oral tablet (generic for PRE PROTEIN) - Tier 1; PA
PREPROTEIN - Tier 2; PA
PREPROTEIN 20 - Tier 2; PA
PRID (brand for calendula) - Tier 2; PA
ON/GO ONE COVID-19 HOME TEST (brand for covid-19 at-home
test) - Tier 2; QL
ONELAX (brand for bisacodyl) - Tier 2; QL
OSCIMIN (brand for hyoscyamine sulfate) - Tier 2; QL
PANOXYL (brand for bp wash) - Tier 2
PARI ALTERA NEBULIZER HANDSET (brand for adult aerosol mask)
- Tier 2; QL
PARI ALTERA NEBULIZER SYSTEM (brand for aeriva concentrator
nebulizer) - Tier 2
PARI BABY CONVERSION KIT (brand for adult aerosol mask) - Tier
2; QL
PROLEVA (brand for proleva) - Tier 2; PA
PRONUTRIENTS COQ10 (brand for co-enzyme q10) - Tier 2; PA
proteinex oral tablet (generic for PRE PROTEIN) - Tier 1; PA
PRUCLAIR (brand for calicylic) - Tier 2; PA
PRUMYX (brand for calicylic) - Tier 2; PA
PSORIZIDE FORTE (brand for bhi hemorrhoid relief) - Tier 2; PA
PSORIZIDE ULTRA (brand for bhi hemorrhoid relief) - Tier 2; PA
pure l-arginine hcl - Tier 1; PA
RAPID GEL RX (brand for rapid gel rx) - Tier 2; PA
REMIGEN (brand for calicylic) - Tier 2; PA
salicylic acid external foam (generic for SALVAX) - Tier 1; PA
salicylic acid external shampoo (generic for KERALYT) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
159
Preferred Agents Non-Preferred Agents
PARI ERAPID NEBULIZER HANDSET (brand for adult aerosol mask)
- Tier 2; QL
PARI ERAPID NEBULIZER SYSTEM (brand for aeriva concentrator
nebulizer) - Tier 2
PARI LC PLUS NEB SET PED MASK (brand for aeriva concentrator
nebulizer) - Tier 2
PARI LC PLUS NEBULIZER (brand for aeriva concentrator nebulizer)
- Tier 2
PARI LC PLUS VIOS PRO NEB (brand for aeriva concentrator
nebulizer) - Tier 2
PARI LC SPRINT NEBULIZER SET (brand for aeriva concentrator
nebulizer) - Tier 2
salicylic acid wart remover (generic for VIRASAL) - Tier 1; PA; QL
SALVAX (brand for salicylic acid) - Tier 2; PA
sam-e.p.a. (generic for OVEGA-3) - Tier 1; PA
SCARCIN EXTERNAL LIQUID - Tier 2; PA
SEVENFACT - Tier 2; PA
sodium sulfacetamide external shampoo 9.8 % (generic for PLEXION NS)
- Tier 1; PA; QL
sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1;
PA
SOLUTION TRANSFER DEVICE (brand for fluid administration set) - Tier
2; PA
soya lecithin - Tier 1; PA
PARI PRONEB MAX LC PLUS (brand for aeriva concentrator
nebulizer) - Tier 2
PARI PRONEB MAX LC SPRINT (brand for aeriva concentrator
nebulizer) - Tier 2
PARI SINUS AEROSOL SYSTEM (brand for aeriva concentrator
nebulizer) - Tier 2
PARI SMARTMASK BABY/ELBOW (brand for adult aerosol mask) -
Tier 2; QL
PARI TREK S W/12V DC ADAPTOR (brand for aeriva concentrator
nebulizer) - Tier 2
PARI VIOS PRO LC PLUS SYSTEM (brand for aeriva concentrator
nebulizer) - Tier 2
SPEEDGEL RX (brand for rapid gel rx) - Tier 2; PA
STRATA CTX - Tier 2; PA
STRATA MARK - Tier 2; PA
STRATA XRT - Tier 2; PA
sulfacetamide sodium (cleans) (generic for OVACE PLUS WASH) - Tier
1; PA
sulfacetamide sodium external (generic for OVACE PLUS WASH) - Tier
1; PA
TAVNEOS - Tier 2; PA; SP; QL
TETRIX (brand for calicylic) - Tier 2; PA
tolnaftate external powder (generic for LOTRIMIN AF) - Tier 1; PA
TRANZGEL (brand for rapid gel rx) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
160
Preferred Agents Non-Preferred Agents
PARI VIOS PRO LC SPRINT SYSTEM (brand for aeriva concentrator
nebulizer) - Tier 2
PARI VORTEX ADULT MASK (brand for adult aerosol mask) - Tier 2;
QL
PEDIATRIC COMPRESSOR NEBULIZER (brand for aeriva
concentrator nebulizer) - Tier 2
PFIZER-BIONT COVID-19 VAC-TRIS (brand for pfizer-biont covid-19
vac-tris) - Tier 2; QL
poly bacitracin (generic for POLYSPORIN) - Tier 1
POLYSPORIN (brand for cvs poly bacitracin) - Tier 2
PREMIUM CONDOMS LUBRICATED - Tier 2; QL
TRAUMEEL EXTERNAL (brand for calendula) - Tier 2; PA
TYLACTIN COMPLETE 15 PE - Tier 2; PA
TYR EASY (brand for sm estro vital nutrients ex st) - Tier 2; PA
ultra energy (generic for HCU EASY) - Tier 1; PA
ULTRA HERS RX - Tier 2; PA
ULTRA HIS - Tier 2; PA
ULTRA PCOS - Tier 2; PA
UNISTRIP CONTROL (brand for diatrue control level 1) - Tier 2; PA; QL
VIRASAL (brand for salicylic acid wart remover) - Tier 2; PA; QL
VORTEX HOLD CHMBR/MASK/CHILD (brand for adult mask) - Tier 2;
PA
PRONEB ULTRA FILTER SET (brand for adult aerosol mask) - Tier 2;
QL
qc gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1
QUICKVUE AT-HOME COVID-19 TEST (brand for covid-19 at-home
test) - Tier 2; QL
REPLACEMENT FILTERS (brand for adult aerosol mask) - Tier 2; QL
salicylic acid external gel (generic for KERALYT) - Tier 1; QL
sea-omega (generic for SEA-OMEGA) - Tier 1; QL
ST JOSEPH LOW DOSE ORAL TABLET CHEWABLE (brand for
aspirin) - Tier 2; QL
sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1;
QL
VORTEX HOLD CHMBR/MASK/TODDLER (brand for adult mask) - Tier
2; PA
VORTEX VALVED HOLDING CHAMBER (brand for breathe comfort
chamber/adult) - Tier 2; PA; QL
XERALUX (brand for calicylic) - Tier 2; PA
XYZMUNE - Tier 2; PA
ZEEL ARTHIRITIS PAIN RELIEF EXTERNAL (brand for calendula) - Tier
2; PA
ZOKINVY - Tier 2; PA; SP; QL
ZYVEXOL (brand for proleva) - Tier 2; PA
ZYVIT (brand for proleva) - Tier 2; PA
the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL
TINACTIN EXTERNAL AEROSOL (brand for athletes foot spray) - Tier
2
TINACTIN EXTERNAL CREAM (brand for antifungal (tolnaftate)) - Tier
2
tinaspore (generic for FORMULA 3 THE TREATMENT) - Tier 1
tolnaftate antifungal (generic for TINACTIN) - Tier 1
tolnaftate external cream (generic for TINACTIN) - Tier 1
TUBING/WING TIP (brand for adult aerosol mask) - Tier 2; QL
ULTRASONIC MINI NEBULIZER (brand for aeriva concentrator
nebulizer) - Tier 2
VAPORIZER WARM STEAM - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
161
Preferred Agents Non-Preferred Agents
VIOS AEROSOL DELIVERY SYSTEM (brand for aeriva concentrator
nebulizer) - Tier 2
VIOS LC PLUS (brand for aeriva concentrator nebulizer) - Tier 2
VIOS LC PLUS DELUXE (brand for aeriva concentrator nebulizer) -
Tier 2
VIOS LC PLUS PEDIATRIC (brand for aeriva concentrator nebulizer) -
Tier 2
VIOS LC SPRINT (brand for aeriva concentrator nebulizer) - Tier 2
VIOS LC SPRINT PEDIATRIC (brand for aeriva concentrator
nebulizer) - Tier 2
wart remover external liquid 17 % (generic for COMPOUND W) - Tier
1
wart remover maximum strength external liquid (generic for
COMPOUND W) - Tier 1
WIDE-SEAL DIAPHRAGM 60 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 65 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 70 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 75 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 80 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 85 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 90 - Tier 2; QL
WIDE-SEAL DIAPHRAGM 95 - Tier 2; QL
womans laxative (generic for EX-LAX ULTRA) - Tier 1
womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1
womens laxative (generic for EX-LAX ULTRA) - Tier 1
ZOSTRIX HP (brand for capsaicin) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
162
Preferred Agents Non-Preferred Agents
Molecular Target Inhibitors - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
ALECENSA - Tier 2; PA; SP; QL
ALUNBRIG - Tier 2; PA; SP; QL
BOSULIF - Tier 2; PA; SP; QL
BRUKINSA - Tier 2; PA; SP; QL
CABOMETYX - Tier 2; PA; SP; QL
CALQUENCE - Tier 2; PA; SP; QL
CAPRELSA - Tier 2; PA; SP; QL
COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; QL
COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; QL
COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; QL
erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; QL
GAVRETO - Tier 2; PA; SP; QL
AYVAKIT - Tier 2; PA; SP; QL
FOTIVDA - Tier 2; PA; SP; QL
GLEEVEC (brand for imatinib mesylate) - Tier 2; PA; SP; QL
lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; QL
LORBRENA - Tier 2; PA; SP; QL
NERLYNX - Tier 2; PA; SP; QL
TAGRISSO - Tier 2; PA; SP; QL
TARCEVA (brand for erlotinib hcl) - Tier 2; PA; SP; QL
TUKYSA - Tier 2; PA; SP; QL
VIZIMPRO - Tier 2; PA; SP; QL
XOSPATA - Tier 2; PA; SP; QL
GILOTRIF - Tier 2; PA; SP; QL
ICLUSIG - Tier 2; PA; SP; QL
imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; QL
IMBRUVICA - Tier 2; PA; SP; QL
INLYTA - Tier 2; PA; SP; QL
IRESSA - Tier 2; PA; SP; QL
LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; QL
LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; QL
LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; QL
LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; QL
LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; QL
LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
163
Preferred Agents Non-Preferred Agents
LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL
LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL
QINLOCK - Tier 2; PA
RETEVMO - Tier 2; PA
SPRYCEL - Tier 2; PA; SP; QL
TABRECTA - Tier 2; PA
TASIGNA - Tier 2; PA; SP; QL
TURALIO - Tier 2; PA; SP; QL
TYKERB (brand for lapatinib ditosylate) - Tier 2; PA; SP; QL
VOTRIENT - Tier 2; PA; SP; QL
XALKORI - Tier 2; PA; SP; QL
Monoclonal Antibodies - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
BESPONSA - Tier 2; PA
MARGENZA - Tier 2; PA
RITUXAN - Tier 2; PA
TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG -
Tier 2; PA
Multiple Sclerosis Agents - Multiple Sclerosis Drugs
Central Nervous System Agents - Drugs to Treat Nerve
Conditions
PONVORY - Tier 2; PA; SP; QL
PONVORY STARTER PACK - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
164
Preferred Agents Non-Preferred Agents
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL
TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; ST; QL
bimatoprost ophthalmic - Tier 1; PA; QL
LUMIGAN - Tier 2; PA; QL
travoprost (bak free) (generic for TRAVATAN Z) - Tier 1; PA; ST; QL
VYZULTA - Tier 2; PA; QL
XALATAN (brand for latanoprost) - Tier 2; PA; QL
XELPROS - Tier 2; PA; QL
ZIOPTAN - Tier 2; PA; QL
Ophthalmic Agents, Other
atropine sulfate ophthalmic ointment - Tier 1
atropine sulfate ophthalmic solution 1 % (generic for ISOPTO
ATROPINE) - Tier 1; QL
bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier
1; QL
COMBIGAN (brand for brimonidine tartrate-timolol) - Tier 2; PA; QL
cyclopentolate hcl ophthalmic solution 0.5 %, 2 % (generic for
CYCLOGYL) - Tier 1
cyclopentolate hcl ophthalmic solution 1 % (generic for CYCLOGYL) -
Tier 1; QL
dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL
dorzolamide hcl-timolol mal pf (generic for COSOPT PF) - Tier 1; QL
altafrin (generic for ALTAFRIN) - Tier 1; PA
BEOVU INTRAVITREAL SOLUTION PREFILLED SYRINGE - Tier 2; PA
BLEPHAMIDE S.O.P. - Tier 2; PA
brimonidine tartrate-timolol (generic for COMBIGAN) - Tier 1; PA; QL
CEQUA - Tier 2; PA; QL
COSOPT (brand for dorzolamide hcl-timolol mal) - Tier 2; PA; QL
COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA; QL
CYCLOGYL OPHTHALMIC SOLUTION 0.5 %, 2 % (brand for
cyclopentolate hcl) - Tier 2; PA
CYCLOGYL OPHTHALMIC SOLUTION 1 % (brand for cyclopentolate
hcl) - Tier 2; PA; QL
cyclosporine ophthalmic (generic for RESTASIS) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
165
Preferred Agents Non-Preferred Agents
neomycin-polymyxin-dexameth ophthalmic ointment (generic for
MAXITROL) - Tier 1; QL
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
(generic for MAXITROL) - Tier 1; QL
neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL
RESTASIS (brand for cyclosporine) - Tier 2; PA; ST; QL
ROCKLATAN - Tier 2; QL
sulfacetamide-prednisolone - Tier 1
TOBRADEX (brand for tobramycin-dexamethasone) - Tier 2; QL
CYSTADROPS - Tier 2; PA; SP; QL
CYSTARAN - Tier 2; PA; SP; QL
ISOPTO ATROPINE (brand for atropine sulfate) - Tier 2; PA; QL
LACRISERT - Tier 2; PA
MAXITROL (brand for neomycin-polymyxin-dexameth) - Tier 2; PA; QL
neomycin-polymyxin-hc ophthalmic - Tier 1; PA; QL
OXERVATE - Tier 2; PA; SP; QL
phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1; PA
PRED-G - Tier 2; PA
PRED-G S.O.P. - Tier 2; PA
RESTASIS MULTIDOSE (brand for cyclosporine) - Tier 2; PA; QL
TOBRADEX ST - Tier 2; PA; QL
tobramycin-dexamethasone (generic for TOBRADEX) - Tier 1; PA; QL
TYRVAYA - Tier 2; PA; QL
XIIDRA - Tier 2; PA; QL
ZYLET - Tier 2; PA; QL
Ophthalmic Anti-allergy Agents
azelastine hcl ophthalmic - Tier 1
cromolyn sodium ophthalmic - Tier 1; QL
olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; QL
PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % (brand for
olopatadine hcl) - Tier 2; QL
ALOCRIL - Tier 2; PA
ALOMIDE - Tier 2; PA
bepotastine besilate (generic for BEPREVE) - Tier 1; PA; QL
BEPREVE (brand for bepotastine besilate) - Tier 2; PA; QL
epinastine hcl - Tier 1; PA
ZERVIATE - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
166
Preferred Agents Non-Preferred Agents
Ophthalmic Anti-Infectives
ak-poly-bac (generic for POLYCIN) - Tier 1; QL
bacitracin-polymyxin b ophthalmic (generic for POLYCIN) - Tier 1; QL
CILOXAN - Tier 2
ciprofloxacin hcl ophthalmic - Tier 1; QL
erythromycin ophthalmic - Tier 1; QL
gentamicin sulfate ophthalmic - Tier 1; QL
moxifloxacin hcl ophthalmic solution (generic for VIGAMOX) - Tier 1;
QL
NATACYN - Tier 2
neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1
neomycin-polymyxin-gramicidin - Tier 1; QL
neo-polycin (generic for NEO-POLYCIN) - Tier 1
AZASITE - Tier 2; PA; QL
bacitracin ophthalmic - Tier 1; PA; QL
BESIVANCE - Tier 2; PA; QL
BLEPH-10 (brand for sulfacetamide sodium) - Tier 2; PA; QL
gatifloxacin ophthalmic (generic for ZYMAXID) - Tier 1; PA; QL
gentak - Tier 1; PA; QL
KLARITY-A - Tier 2; PA; QL
levofloxacin ophthalmic - Tier 1; PA
moxifloxacin hcl (2x day) - Tier 1; PA; QL
OCUFLOX (brand for ofloxacin) - Tier 2; PA; QL
POLYTRIM (brand for polymyxin b-trimethoprim) - Tier 2; PA; QL
sulfacetamide sodium ophthalmic ointment - Tier 1; PA; QL
ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL
polycin (generic for POLYCIN) - Tier 1; QL
polymyxin b-trimethoprim (generic for POLYTRIM) - Tier 1; QL
sulfacetamide sodium ophthalmic solution (generic for BLEPH-10) -
Tier 1; QL
tobramycin ophthalmic - Tier 1; QL
TOBREX - Tier 2; QL
trifluridine - Tier 1; QL
VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL
ZYMAXID (brand for gatifloxacin) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
167
Preferred Agents Non-Preferred Agents
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic - Tier 1
diclofenac sodium ophthalmic - Tier 1; QL
DUREZOL (brand for difluprednate) - Tier 2; QL
fluorometholone (generic for FML LIQUIFILM) - Tier 1; QL
flurbiprofen sodium - Tier 1; QL
FML - Tier 2; QL
FML FORTE - Tier 2; QL
ketorolac tromethamine ophthalmic solution 0.4 % (generic for
ACULAR LS) - Tier 1
ketorolac tromethamine ophthalmic solution 0.5 % (generic for
ACULAR) - Tier 1; QL
PRED MILD - Tier 2; QL
ACULAR (brand for ketorolac tromethamine) - Tier 2; PA; QL
ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA
ACUVAIL - Tier 2; PA; QL
ALREX - Tier 2; PA; QL
bromfenac sodium (once-daily) - Tier 1; PA
BROMSITE - Tier 2; PA; QL
difluprednate (generic for DUREZOL) - Tier 1; PA; QL
EYSUVIS - Tier 2; PA; QL
FLAREX - Tier 2; PA; QL
FML LIQUIFILM (brand for fluorometholone) - Tier 2; PA; QL
ILEVRO - Tier 2; PA; QL
INVELTYS - Tier 2; PA; QL
prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1;
QL
prednisolone acetate p-f (generic for PRED FORTE) - Tier 1; QL
prednisolone sodium phosphate ophthalmic - Tier 1
LOTEMAX (brand for loteprednol etabonate) - Tier 2; PA; QL
LOTEMAX SM - Tier 2; PA; QL
loteprednol etabonate (generic for LOTEMAX) - Tier 1; PA; QL
MAXIDEX - Tier 2; PA
NEVANAC - Tier 2; PA; QL
PRED FORTE (brand for prednisolone acetate) - Tier 2; PA; QL
PROLENSA - Tier 2; PA; QL
Ophthalmic Beta-Adrenergic Blocking Agents
betaxolol hcl ophthalmic - Tier 1; QL
carteolol hcl - Tier 1; QL
levobunolol hcl - Tier 1; QL
timolol maleate (once-daily) (generic for ISTALOL) - Tier 1; QL
timolol maleate ophthalmic (generic for TIMOPTIC) - Tier 1; QL
BETIMOL - Tier 2; PA; QL
BETOPTIC-S - Tier 2; PA; QL
ISTALOL (brand for timolol maleate (once-daily)) - Tier 2; PA; QL
timolol maleate ocudose (generic for TIMOPTIC OCUDOSE) - Tier 1; PA;
QL
timolol maleate pf (generic for TIMOPTIC OCUDOSE) - Tier 1; PA; QL
TIMOPTIC (brand for timolol maleate) - Tier 2; PA; QL
TIMOPTIC OCUDOSE (brand for timolol maleate ocudose) - Tier 2; PA;
QL
TIMOPTIC-XE (brand for timolol maleate) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
168
Preferred Agents Non-Preferred Agents
Ophthalmic Intraocular Pressure Lowering Agents, Other
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % - Tier 2; PA; QL
ALPHAGAN P OPHTHALMIC SOLUTION 0.15 % (brand for
brimonidine tartrate) - Tier 2; QL
AZOPT (brand for brinzolamide) - Tier 2; PA; ST; QL
brimonidine tartrate ophthalmic solution 0.2 % - Tier 1; QL
DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC (brand for
dorzolamide hcl) - Tier 2; QL
dorzolamide hcl solution 2 % ophthalmic (generic for TRUSOPT) - Tier
1; QL
methazolamide oral - Tier 1; QL
PHOSPHOLINE IODIDE - Tier 2
pilocarpine hcl ophthalmic - Tier 1; QL
apraclonidine hcl - Tier 1; PA; QL
brimonidine tartrate ophthalmic solution 0.15 % (generic for ALPHAGAN
P) - Tier 1; PA; QL
brinzolamide (generic for AZOPT) - Tier 1; PA; ST; QL
IOPIDINE - Tier 2; PA; QL
TRUSOPT (brand for dorzolamide hcl) - Tier 2; PA; QL
VUITY - Tier 2; PA; QL
RHOPRESSA - Tier 2; QL
SIMBRINZA - Tier 2; QL
Ophthalmic Agents - Drugs to Treat Eye Conditions
Ophthalmic Agents, Other - Miscellaneous Eye Drugs
altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1
altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1; QL
altalube (generic for ALTALUBE) - Tier 1; QL
artificial eye (generic for ALTALUBE) - Tier 1; QL
artificial tears ophthalmic ointment (generic for ALTALUBE) - Tier 1;
QL
artificial tears ophthalmic solution (generic for GENTEAL TEARS) -
Tier 1
artificial tears ophthalmic solution 1.4 % - Tier 1
astringent eye drops (generic for VISINE-AC) - Tier 1; QL
BIOLLE TEARS (brand for cvs lubricant eye drops (pf)) - Tier 2
artificial tears ophthalmic solution 0.5-0.6 %, 5-6 mg/ml (generic for
STYE) - Tier 1; PA
artificial tears ophthalmic solution 1-0.3 % (generic for MOISTURE EYES)
- Tier 1; PA
BYOOVIZ - Tier 2; PA
ISOPTO TEARS - Tier 2; PA
lubricant eye ophthalmic solution 1-0.3 % (generic for MOISTURE EYES)
- Tier 1; PA
lubricating/dry eye (generic for REFRESH OPTIVE) - Tier 1; PA
PAREMYD - Tier 2; PA
REFRESH OPTIVE OPHTHALMIC SOLUTION (brand for cvs
lubricating/dry eye) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
169
Preferred Agents Non-Preferred Agents
carboxymethylcellulose sodium ophthalmic solution (generic for
ULTRA FRESH) - Tier 1; QL
dry eye relief ophthalmic gel 0.4-0.3 % (generic for GENTEAL TEARS
SEVERE DAY/NIGHT) - Tier 1; QL
dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL
eye drops advanced relief - Tier 1; QL
eye drops long lasting (generic for SYSTANE) - Tier 1; QL
eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE
COMFORT) - Tier 1
eye drops ophthalmic solution 0.05-0.1-1-1 % - Tier 1; QL
eye drops ophthalmic solution 0.05-0.25 % (generic for VISINE-AC) -
Tier 1; QL
REFRESH OPTIVE PF - Tier 2; PA
REFRESH RELIEVA (brand for cvs lubricating/dry eye) - Tier 2; PA
REFRESH RELIEVA PF OPHTHALMIC SOLUTION 0.5-0.9 % - Tier 2;
PA
stye ophthalmic solution (generic for STYE) - Tier 1; PA
eye lubricant (generic for ALTALUBE) - Tier 1; QL
for sty relief (generic for ALTALUBE) - Tier 1; QL
GENTEAL SEVERE - Tier 2; QL
GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) -
Tier 2
GENTEAL TEARS NIGHT-TIME (brand for artificial eye) - Tier 2; QL
GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.2-0.3 % (brand
for sm artificial tears) - Tier 2
GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2
GENTEAL TEARS SEVERE DAY/NIGHT (brand for dry eye relief) -
Tier 2; QL
HYPOTEARS (brand for artificial eye) - Tier 2; QL
lubricant drops fast act (generic for SYSTANE) - Tier 1; QL
lubricant drops long last (generic for SYSTANE) - Tier 1; QL
lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; QL
lubricant drops ophthalmic solution (generic for SYSTANE BALANCE)
- Tier 1; QL
lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for
SYSTANE HYDRATION PF) - Tier 1; QL
lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE
TEARS) - Tier 1
lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for
SYSTANE) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
170
Preferred Agents Non-Preferred Agents
lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA
FRESH) - Tier 1; QL
lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE
BALANCE) - Tier 1; QL
lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1
lubricant eye nighttime (generic for ALTALUBE) - Tier 1; QL
lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) -
Tier 1; QL
lubricant eye pm (generic for ALTALUBE) - Tier 1; QL
lubricant pm (generic for ALTALUBE) - Tier 1; QL
lubricating eye drop (generic for BIOLLE TEARS) - Tier 1
lubricating eye drops (generic for SYSTANE) - Tier 1; QL
lubricating eye/overnight (generic for ALTALUBE) - Tier 1; QL
lubricating plus (generic for BIOLLE TEARS) - Tier 1
lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1
lubricating tears (generic for SYSTANE) - Tier 1; QL
lubricating tears eye drops (generic for GENTEAL TEARS) - Tier 1
MURO 128 OPHTHALMIC OINTMENT (brand for cvs sod chloride
hypertonicity) - Tier 2
MURO 128 OPHTHALMIC SOLUTION 5 % (brand for cvs sodium
chloride) - Tier 2; QL
natural tears pf (generic for GENTEAL TEARS MODERATE PF) - Tier
1
nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL
polyvinyl alcohol ophthalmic - Tier 1
pure & gentle lubricant - Tier 1
REFRESH LACRI-LUBE (brand for artificial eye) - Tier 2; QL
REFRESH P.M. (brand for artificial eye) - Tier 2; QL
REFRESH PLUS (brand for cvs lubricant eye drops (pf)) - Tier 2
REFRESH TEARS (brand for carboxymethylcellulose sodium) - Tier 2;
QL
relief eye drops (generic for VISINE-AC) - Tier 1; QL
restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1
restore pm (generic for ALTALUBE) - Tier 1; QL
sod chloride hypertonicity (generic for ALTACHLORE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
171
Preferred Agents Non-Preferred Agents
sodium chloride (hypertonic) ophthalmic ointment (generic for
ALTACHLORE) - Tier 1
sodium chloride (hypertonic) ophthalmic solution (generic for
ALTACHLORE) - Tier 1; QL
sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE)
- Tier 1
sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) -
Tier 1; QL
SYSTANE (brand for cvs lubricant drops fast act) - Tier 2; QL
SYSTANE BALANCE (brand for cvs lubricant drops) - Tier 2; QL
SYSTANE COMPLETE (brand for cvs lubricant drops) - Tier 2; QL
SYSTANE CONTACTS (brand for sm artificial tears) - Tier 2
SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) -
Tier 2; QL
SYSTANE NIGHTTIME (brand for artificial eye) - Tier 2; QL
SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops
(pf)) - Tier 2; QL
SYSTANE ULTRA (brand for cvs lubricant drops fast act) - Tier 2; QL
SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2;
QL
ultra fresh (generic for ULTRA FRESH) - Tier 1; QL
ultra fresh pm (generic for ALTALUBE) - Tier 1; QL
ultra lubricant drop (generic for SYSTANE) - Tier 1; QL
ultra lubricating eye drops (generic for SYSTANE) - Tier 1; QL
ultra lubricating eye drops pf (generic for SYSTANE HYDRATION PF)
- Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
172
Preferred Agents Non-Preferred Agents
Ophthalmic Anti-allergy Agents - Allergy, Infection and
Inflammation Drugs
CYCLOMYDRIL - Tier 2
NAPHCON-A (brand for allergy eye) - Tier 2
redness relief ophthalmic solution 0.012-0.2 % (generic for CLEAR
EYES REDNESS RELIEF) - Tier 1; QL
VISINE (brand for allergy eye) - Tier 2
eye allergy relief (generic for OPCON-A) - Tier 1; PA
Ophthalmic Antibiotics - Drugs to treat Eye Infections
BETADINE OPHTHALMIC PREP (brand for povidone-iodine) - Tier 2; PA
POVIDONE-IODINE OPHTHALMIC (brand for povidone-iodine) - Tier 2;
PA
Ophthalmic Anti-Inflammatories - Allergy, Infection and
Inflammation Drugs
ALAWAY (brand for cvs allergy eye drops) - Tier 2; QL
ALAWAY CHILDRENS ALLERGY (brand for cvs allergy eye drops) -
Tier 2; QL
allergy eye drops (generic for ALAWAY) - Tier 1; QL
CLARITIN EYE (brand for cvs allergy eye drops) - Tier 2; QL
eye itch relief ophthalmic solution 0.025 % (generic for ALAWAY) -
Tier 1; QL
ketotifen fumarate ophthalmic (generic for ALAWAY) - Tier 1; QL
ZADITOR (brand for cvs allergy eye drops) - Tier 2; QL
Otic Agents
acetic acid otic - Tier 1
CIPRO HC - Tier 2; QL
CIPRODEX (brand for ciprofloxacin-dexamethasone) - Tier 2; QL
CORTISPORIN-TC - Tier 2; QL
flac (generic for FLAC) - Tier 1; QL
fluocinolone acetonide otic (generic for FLAC) - Tier 1; QL
neomycin-polymyxin-hc otic - Tier 1; QL
ofloxacin otic - Tier 1; QL
CETRAXAL (brand for ciprofloxacin hcl) - Tier 2; PA; QL
ciprofloxacin hcl otic (generic for CETRAXAL) - Tier 1; PA; QL
ciprofloxacin-dexamethasone (generic for CIPRODEX) - Tier 1; PA; QL
CIPROFLOXACIN-FLUOCINOLONE PF (brand for ciprofloxacin-
fluocinolone pf) - Tier 2; PA; QL
DERMOTIC (brand for fluocinolone acetonide) - Tier 2; PA; QL
hydrocortisone-acetic acid (generic for ACETASOL HC) - Tier 1; PA; QL
OTOVEL (brand for ciprofloxacin-fluocinolone pf) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
173
Preferred Agents Non-Preferred Agents
Otic Agents - Drugs to Treat Ear Conditions
Otic Agents - Drugs for the Ear
CLEARCANAL EARWAX SOFTENER (brand for cvs ear drops) - Tier
2
ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1
ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1
ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) -
Tier 1
ear wax removal system (generic for CLEARCANAL EARWAX
SOFTENER) - Tier 1
earwax removal (generic for CLEARCANAL EARWAX SOFTENER) -
Tier 1
earwax removal drops (generic for CLEARCANAL EARWAX
SOFTENER) - Tier 1
earwax removal kit otic solution 6.5 % (generic for CLEARCANAL
EARWAX SOFTENER) - Tier 1
Respiratory Tract/Pulmonary Agents
Antihistamines
all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1;
QL
allergy (cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL
allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1;
QL
allergy childrens oral liquid (generic for RA DIPHEDRYL ALLERGY) -
Tier 1; QL
allergy medication (generic for BANOPHEN) - Tier 1; QL
allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL
allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; QL
allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL
all day allergy relief (generic for ZYRTEC ALLERGY) - Tier 1; PA; QL
allergy relief oral capsule 10 mg (generic for ZYRTEC ALLERGY) - Tier 1;
PA; QL
azelastine-fluticasone (generic for DYMISTA) - Tier 1; PA; QL
BENADRYL ALLERGY CHILDRENS LIQUID 12.5 MG/5ML ORAL (brand
for allergy childrens) - Tier 2; PA; QL
carbinoxamine maleate oral tablet 6 mg (generic for RYVENT) - Tier 1;
PA; QL
cetirizine hcl oral tablet chewable (generic for WAL-ZYR CHILDRENS) -
Tier 1; PA; QL
CLARINEX (brand for desloratadine) - Tier 2; PA; QL
desloratadine oral tablet (generic for CLARINEX) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
174
Preferred Agents Non-Preferred Agents
allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER-
TEC) - Tier 1; QL
allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
QL
allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL
allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA
DIPHEDRYL ALLERGY) - Tier 1; QL
allergy relief childrens oral tablet chewable 12.5 mg (generic for
BENADRYL ALLERGY CHILDRENS) - Tier 1; QL
allergy relief max st (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
QL
allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL
desloratadine oral tablet dispersible 5 mg - Tier 1; PA; QL
DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA; QL
KARBINAL ER - Tier 2; PA; QL
levocetirizine dihydrochloride oral (generic for XYZAL ALLERGY 24HR) -
Tier 1; PA; QL
PATANASE (brand for olopatadine hcl) - Tier 2; PA; QL
RYCLORA - Tier 2; PA; QL
ryvent (generic for RYVENT) - Tier 1; PA; QL
ZYRTEC ALLERGY ORAL CAPSULE (brand for allergy relief) - Tier 2;
PA; QL
allergy relief oral liquid 12.5 mg/5ml, 25 mg/10ml (generic for RA
DIPHEDRYL ALLERGY) - Tier 1; QL
allergy relief oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1;
QL
allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; QL
allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL
ALLERGY CHILDRENS) - Tier 1; QL
allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL
allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER-
TEC) - Tier 1; QL
aller-tec (generic for KLS ALLER-TEC) - Tier 1; QL
anti-hist allergy (generic for BANOPHEN) - Tier 1; QL
azelastine hcl nasal - Tier 1; QL
banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL
banophen oral tablet (generic for BANOPHEN) - Tier 1; QL
BENADRYL ALLERGY CHILDRENS LIQUID 12.5 MG/5ML ORAL
(brand for allergy childrens) - Tier 2; QL
BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE
(brand for cvs allergy relief childrens) - Tier 2; QL
BENADRYL ALLERGY ORAL TABLET (brand for allergy relief) - Tier
2; QL
BENADRYL ALLERGY ULTRATABS (brand for allergy relief) - Tier 2;
QL
carbinoxamine maleate oral solution - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
175
Preferred Agents Non-Preferred Agents
carbinoxamine maleate oral tablet 4 mg - Tier 1; QL
cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS)
- Tier 1; QL
cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1; QL
childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; QL
clemastine fumarate oral tablet 2.68 mg - Tier 1; QL
complete allergy (generic for BANOPHEN) - Tier 1; QL
complete allergy medicine oral capsule (generic for BANOPHEN) -
Tier 1; QL
complete allergy relief (generic for BANOPHEN) - Tier 1; QL
cyproheptadine hcl oral - Tier 1; QL
DAYHIST ALLERGY 12 HOUR RELIEF (brand for clemastine
fumarate) - Tier 2; QL
diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL
diphen (generic for BANOPHEN) - Tier 1; QL
diphenhist (generic for BANOPHEN) - Tier 1; QL
diphenhydramine hcl oral (generic for BANOPHEN) - Tier 1; QL
geri-dryl (generic for BANOPHEN) - Tier 1; QL
h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier
1; QL
indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; QL
liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
QL
m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL
NARAMIN (brand for allergy childrens) - Tier 2; QL
olopatadine hcl nasal (generic for PATANASE) - Tier 1; QL
pharbedryl (generic for BANOPHEN) - Tier 1; QL
siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL
total allergy (generic for BANOPHEN) - Tier 1; QL
total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
QL
ZYRTEC ALLERGY ORAL TABLET (brand for all day allergy) - Tier 2;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
176
Preferred Agents Non-Preferred Agents
Anti-inflammatories, Inhaled Corticosteroids
ASMANEX (120 METERED DOSES) - Tier 2; QL
ASMANEX (14 METERED DOSES) - Tier 2; QL
ASMANEX (30 METERED DOSES) - Tier 2; QL
ASMANEX (60 METERED DOSES) - Tier 2; QL
budesonide inhalation (generic for PULMICORT) - Tier 1; QL
FLOVENT DISKUS - Tier 2; QL
FLOVENT HFA (brand for fluticasone propionate hfa) - Tier 2; QL
flunisolide nasal - Tier 1; QL
fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL
PULMICORT FLEXHALER - Tier 2; QL
ALVESCO - Tier 2; PA; QL
ARMONAIR DIGIHALER - Tier 2; PA; QL
ARNUITY ELLIPTA - Tier 2; PA; QL
ASMANEX HFA - Tier 2; PA; QL
BECONASE AQ - Tier 2; PA; QL
FLUTICASONE PROPIONATE HFA (brand for fluticasone propionate hfa)
- Tier 2; PA; QL
mometasone furoate nasal - Tier 1; PA; QL
OMNARIS - Tier 2; PA; QL
PULMICORT SUSPENSION (brand for budesonide) - Tier 2; PA; QL
QNASL - Tier 2; PA; QL
QNASL CHILDRENS - Tier 2; PA; QL
QVAR REDIHALER - Tier 2; PA; QL
XHANCE - Tier 2; PA; QL
ZETONNA - Tier 2; PA; QL
Antileukotrienes
montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL
zafirlukast (generic for ACCOLATE) - Tier 1; ST; QL
ACCOLATE (brand for zafirlukast) - Tier 2; PA; ST; QL
SINGULAIR (brand for montelukast sodium) - Tier 2; PA; QL
zileuton er - Tier 1; PA; QL
ZYFLO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
177
Preferred Agents Non-Preferred Agents
Bronchodilators, Anticholinergic
ATROVENT HFA - Tier 2; QL
INCRUSE ELLIPTA - Tier 2; QL
ipratropium bromide inhalation - Tier 1; QL
ipratropium bromide nasal - Tier 1; QL
SPIRIVA HANDIHALER - Tier 2; QL
SPIRIVA RESPIMAT - Tier 2; QL
LONHALA MAGNAIR REFILL KIT - Tier 2; PA; QL
LONHALA MAGNAIR STARTER KIT - Tier 2; PA; QL
TUDORZA PRESSAIR - Tier 2; PA; QL
YUPELRI - Tier 2; PA; QL
Bronchodilators, Sympathomimetic
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%,
0.63 mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml - Tier 1; QL
ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5%
INHALATION - Tier 2; QL
albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier
1; QL
albuterol sulfate oral syrup - Tier 1; QL
albuterol sulfate oral tablet 2 mg - Tier 1
albuterol sulfate oral tablet 4 mg - Tier 1; QL
epinephrine solution auto-injector 0.15 mg/0.3ml injection (generic for
EPIPEN JR 2-PAK) - Tier 1; QL
ADRENALIN INJECTION SOLUTION 1 MG/ML - Tier 2; PA; QL
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
(generic for PROAIR HFA) - Tier 1; PA; QL
ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE)
MCG/ACT INHALATION (brand for albuterol sulfate hfa) - Tier 2; PA; QL
arformoterol tartrate (generic for BROVANA) - Tier 1; PA; QL
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.15 MG/0.15ML, 0.3
MG/0.3ML (brand for epinephrine) - Tier 2; PA; QL
BROVANA (brand for arformoterol tartrate) - Tier 2; PA; QL
epinephrine injection solution auto-injector 0.15 mg/0.15ml (generic for
AUVI-Q) - Tier 1; PA; QL
epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for
AUVI-Q) - Tier 1; QL
PROAIR HFA (brand for albuterol sulfate hfa) - Tier 2; QL
SEREVENT DISKUS - Tier 2; QL
STRIVERDI RESPIMAT - Tier 2; QL
SYMJEPI - Tier 2; QL
terbutaline sulfate oral - Tier 1; QL
VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; QL
epinephrine solution auto-injector 0.15 mg/0.3ml injection (generic for
EPIPEN JR 2-PAK) - Tier 1; PA; QL
epinephrine solution auto-injector 0.3 mg/0.3ml injection (generic for
AUVI-Q) - Tier 1; PA; QL
EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL
EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL
formoterol fumarate inhalation (generic for PERFOROMIST) - Tier 1; PA;
QL
levalbuterol hcl inhalation (generic for XOPENEX) - Tier 1; PA; QL
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT (brand for
levalbuterol tartrate) - Tier 2; PA; QL
PERFOROMIST (brand for formoterol fumarate) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
178
Preferred Agents Non-Preferred Agents
PROAIR DIGIHALER - Tier 2; PA; QL
PROAIR RESPICLICK - Tier 2; PA; QL
PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL
XOPENEX NEB (brand for levalbuterol hcl) - Tier 2; PA; QL
XOPENEX CONCENTRATE (brand for levalbuterol hcl) - Tier 2; PA; QL
XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL
Cystic Fibrosis Agents
KALYDECO - Tier 2; PA; SP; QL
ORKAMBI - Tier 2; PA; SP; QL
PULMOZYME - Tier 2; SP; QL
SYMDEKO - Tier 2; PA; SP; QL
tobramycin inhalation nebulization solution 300 mg/4ml (generic for
BETHKIS) - Tier 1; PA; SP; QL
tobramycin nebulization solution 300 mg/5ml inhalation (generic for
KITABIS PAK) - Tier 1; PA; SP; QL
TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML
INHALATION (brand for tobramycin) - Tier 2; PA; SP; QL
TRIKAFTA - Tier 2; PA; SP; QL
BETHKIS (brand for tobramycin) - Tier 2; PA; SP; QL
CAYSTON - Tier 2; PA; SP; QL
KITABIS PAK (brand for tobramycin) - Tier 2; PA; SP; QL
TOBI NEBULIZER (brand for tobramycin) - Tier 2; PA; SP; QL
TOBI PODHALER - Tier 2; PA; SP; QL
Mast Cell Stabilizers
cromolyn sodium inhalation - Tier 1; QL
Phosphodiesterase Inhibitors, Airways Disease
THEO-24 - Tier 2; QL
theophylline - Tier 1; QL
theophylline er - Tier 1; QL
DALIRESP - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
179
Preferred Agents Non-Preferred Agents
Pulmonary Antihypertensives
alyq (generic for ALYQ) - Tier 1; PA; SP; QL
ambrisentan (generic for LETAIRIS) - Tier 1; PA; SP; QL
sildenafil citrate oral suspension reconstituted (generic for REVATIO) -
Tier 1; PA; SP; QL
sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1; PA;
SP; QL
tadalafil (pah) (generic for ALYQ) - Tier 1; PA; SP; QL
TRACLEER (brand for bosentan) - Tier 2; PA; SP; QL
ADCIRCA (brand for tadalafil (pah)) - Tier 2; PA; SP; QL
ADEMPAS - Tier 2; PA; SP; QL
bosentan (generic for TRACLEER) - Tier 1; PA; SP; QL
LETAIRIS (brand for ambrisentan) - Tier 2; PA; SP; QL
OPSUMIT - Tier 2; PA; SP; QL
ORENITRAM - Tier 2; PA; SP; QL
REMODULIN (brand for treprostinil) - Tier 2; PA
REVATIO INTRAVENOUS (brand for sildenafil citrate) - Tier 2; PA
REVATIO ORAL (brand for sildenafil citrate) - Tier 2; PA; SP; QL
sildenafil citrate intravenous (generic for REVATIO) - Tier 1; PA
treprostinil (generic for REMODULIN) - Tier 1; PA
TYVASO - Tier 2; PA
TYVASO DPI MAINTENANCE KIT - Tier 2; PA
TYVASO DPI TITRATION KIT - Tier 2; PA
TYVASO REFILL - Tier 2; PA
TYVASO STARTER - Tier 2; PA
UPTRAVI ORAL - Tier 2; PA; SP; QL
VENTAVIS INHALATION SOLUTION 20 MCG/ML - Tier 2; PA
Pulmonary Fibrosis Agents
ESBRIET (brand for pirfenidone) - Tier 2; PA; SP; QL
OFEV - Tier 2; PA; SP; QL
pirfenidone (generic for ESBRIET) - Tier 1; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
180
Preferred Agents Non-Preferred Agents
Respiratory Tract Agents, Other
acetylcysteine inhalation solution 10 % - Tier 1; QL
acetylcysteine inhalation solution 20 % - Tier 1
FASENRA PEN - Tier 2; PA; QL
NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;
PA; SP; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100
MG/ML - Tier 2; PA; SP; QL
promethazine vc - Tier 1; QL
promethazine-phenylephrine - Tier 1; QL
CLARINEX-D 12 HOUR - Tier 2; PA; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40
MG/0.4ML - Tier 2; PA
ribavirin inhalation (generic for VIRAZOLE) - Tier 1; PA
VIRAZOLE (brand for ribavirin) - Tier 2; PA
Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,
Cough, Cold and Lung Conditions
4-WAY FAST ACTING (brand for cvs sinus relief ext st) - Tier 2
4-WAY MENTHOL (brand for cvs sinus relief ext st) - Tier 2
AFRIN SALINE NASAL MIST (brand for altamist spray) - Tier 2
altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1
altarussin (generic for DIABETIC TUSSIN EX) - Tier 1
AYR (brand for altamist spray) - Tier 2
AYR SALINE NASAL DROPS - Tier 2
BABY AYR SALINE (brand for altamist spray) - Tier 2
chest congestion relief (generic for DIABETIC TUSSIN EX) - Tier 1
CORICIDIN HBP COUGH/COLD (brand for cough & cold) - Tier 2
cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1
AYR SALINE NASAL (brand for saline) - Tier 2; PA
AYR SALINE NASAL NO-DRIP (brand for saline) - Tier 2; PA
cold & flu oral liquid 10-5-325 mg/15ml (generic for THERAFLU
EXPRESSMAX) - Tier 1; PA
cold & flu relief daytime (generic for MUCINEX FAST-MAX CONG
HEADACHE) - Tier 1; PA
cold max (generic for MAPAP COLD FORMULA MULTI-SYMPT) - Tier 1;
PA
cold max daytime (generic for MAPAP COLD FORMULA MULTI-SYMPT)
- Tier 1; PA
cold multi-symptom daytime (generic for MAPAP COLD FORMULA
MULTI-SYMPT) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
181
Preferred Agents Non-Preferred Agents
cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier
1
cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH)
- Tier 1
cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1
deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier
1
ed bron gp - Tier 1
ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1
guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1
hydrocodone bit-homatrop mbr (generic for HYCODAN) - Tier 1; QL
hydromet (generic for HYCODAN) - Tier 1; QL
cold relief oral tablet 12.5-500 mg - Tier 1; PA
cold/flu daytime relief (generic for MUCINEX FAST-MAX CONG
HEADACHE) - Tier 1; PA
cold/flu relief daytime (generic for MUCINEX FAST-MAX CONG
HEADACHE) - Tier 1; PA
COMTREX COLD & COUGH MAX ST (brand for cold multi-symptom
daytime) - Tier 2; PA
cough & sore throat nighttime (generic for CORICIDIN HBP NIGHTTIME
COLD) - Tier 1; PA
cough/sore throat daytime oral liquid 1000-30 mg/30ml - Tier 1; PA
cough/sore throat nighttime oral liquid 30-12.5-1000 mg/30ml (generic for
CORICIDIN HBP NIGHTTIME COLD) - Tier 1; PA
maxi-tuss pe max - Tier 1
medifin 400 (generic for XPECT) - Tier 1
MUCINEX MAXIMUM STRENGTH (brand for cvs mucus extended
release) - Tier 2; QL
mucus er maximum str (generic for EQ MUCUS ER) - Tier 1; QL
mucus er oral tablet extended release 12 hour 1200 mg (generic for
EQ MUCUS ER) - Tier 1; QL
mucus extended release oral tablet extended release 12 hour 1200 mg
(generic for EQ MUCUS ER) - Tier 1; QL
mucus relief 12 hour max st (generic for EQ MUCUS ER) - Tier 1; QL
mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1
day time cold & flu oral capsule (generic for MUCINEX FAST-MAX CONG
HEADACHE) - Tier 1; PA
day time cold & flu relief (generic for THERAFLU EXPRESSMAX) - Tier 1;
PA
day time cold/flu (generic for MUCINEX FAST-MAX CONG HEADACHE)
- Tier 1; PA
daytime (generic for MUCINEX FAST-MAX CONG HEADACHE) - Tier 1;
PA
daytime cold & flu oral liquid (generic for THERAFLU EXPRESSMAX) -
Tier 1; PA
daytime cold & flu relief (generic for THERAFLU EXPRESSMAX) - Tier 1;
PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
182
Preferred Agents Non-Preferred Agents
mucus relief er oral tablet extended release 12 hour 1200 mg (generic
for EQ MUCUS ER) - Tier 1; QL
mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL
mucus relief max strength oral tablet extended release 12 hour 1200
mg (generic for EQ MUCUS ER) - Tier 1; QL
mucus relief oral tablet 400 mg (generic for XPECT) - Tier 1
mucus relief oral tablet extended release 12 hour 1200 mg (generic for
EQ MUCUS ER) - Tier 1; QL
mucus-er oral tablet extended release 12 hour 1200 mg (generic for
EQ MUCUS ER) - Tier 1; QL
nasal decongestant pe max st (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1
daytime cold/flu ms relief (generic for MUCINEX FAST-MAX CONG
HEADACHE) - Tier 1; PA
daytime cold/flu oral capsule 10-5-325 mg (generic for MUCINEX FAST-
MAX CONG HEADACHE) - Tier 1; PA
daytime cold/flu oral liquid 10-5-325 mg/15ml (generic for THERAFLU
EXPRESSMAX) - Tier 1; PA
daytime cold/flu relief (generic for MUCINEX FAST-MAX CONG
HEADACHE) - Tier 1; PA
daytime cold/flu relief oral liquid 325-10-5 mg/15ml (generic for
THERAFLU EXPRESSMAX) - Tier 1; PA
daytime liquid (generic for MUCINEX FAST-MAX CONG HEADACHE) -
Tier 1; PA
nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE
SINUS CONGESTION) - Tier 1
nasal four (generic for 4-WAY FAST ACTING) - Tier 1
nasal four spray (generic for 4-WAY FAST ACTING) - Tier 1
NASAL MOIST NASAL SOLUTION (brand for altamist spray) - Tier 2
nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) -
Tier 1
nasal spray fast acting (generic for 4-WAY FAST ACTING) - Tier 1
nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1
NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for cvs sinus relief
ext st) - Tier 2
flu/cold/daytime (generic for THERAFLU SEVERE COLD) - Tier 1; PA
flu/severe cold & cough day (generic for WAL-FLU SEVERE COLD &
COUGH) - Tier 1; PA
flu/severe cold daytime oral liquid 10-5-325 mg/15ml (generic for
THERAFLU EXPRESSMAX) - Tier 1; PA
flu/severe cold daytime oral packet 20-10-500 mg (generic for THERAFLU
SEVERE COLD) - Tier 1; PA
HYCODAN (brand for hydrocodone bit-homatrop mbr) - Tier 2; PA; QL
mapap cold formula multi-sympt (generic for MAPAP COLD FORMULA
MULTI-SYMPT) - Tier 1; PA
mucinex fast-max cong headache (generic for MUCINEX FAST-MAX
CONG HEADACHE) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
183
Preferred Agents Non-Preferred Agents
non-pseudo sinus decongestant (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1
nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1
nose drops nasal decongest (generic for 4-WAY FAST ACTING) - Tier
1
nose drops nasal solution 1 % (generic for 4-WAY FAST ACTING) -
Tier 1
OCEAN FOR KIDS (brand for altamist spray) - Tier 2
OCEAN NASAL SPRAY (brand for altamist spray) - Tier 2
pharbinex (generic for XPECT) - Tier 1
phenylephrine hcl oral (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1
MUCINEX SINUS-MAX SEV CONG/PN ORAL CAPSULE (brand for cold
& flu relief daytime) - Tier 2; PA
multi symptom flu/severe cold (generic for THERAFLU SEVERE COLD) -
Tier 1; PA
night time cold/flu relief oral liquid 15-6.25-500 mg/15ml (generic for
CORICIDIN HBP NIGHTTIME COLD) - Tier 1; PA
nighttime cold medicine (generic for CORICIDIN HBP NIGHTTIME COLD)
- Tier 1; PA
nighttime cold/flu relief oral liquid 15-6.25-500 mg/15ml (generic for
CORICIDIN HBP NIGHTTIME COLD) - Tier 1; PA
severe allergy - Tier 1; PA
severe cold/cough (generic for THERAFLU EXPRESSMAX) - Tier 1; PA
pseudoephedrine-bromphen-dm - Tier 1; QL
refenesen 400 (generic for XPECT) - Tier 1
saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1
saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1
sb mucus relief (generic for XPECT) - Tier 1
siltussin sa (generic for DIABETIC TUSSIN EX) - Tier 1
sinus pe decongestant (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1
sinus relief ext st (generic for 4-WAY FAST ACTING) - Tier 1
sinus relief extra strength (generic for 4-WAY FAST ACTING) - Tier 1
sinus/congestion relief pe (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1
severe cold/cough daytime (generic for WAL-FLU SEVERE COLD &
COUGH) - Tier 1; PA
severe cold/flu daytime (generic for THERAFLU EXPRESSMAX) - Tier 1;
PA
THERAFLU EXPRESSMAX (brand for cvs daytime cold/flu relief) - Tier 2;
PA
THERAFLU EXPRESSMAX SEV CLD/CG ORAL TABLET 10-5-325 MG
(brand for cold multi-symptom daytime) - Tier 2; PA
THERAFLU SEVERE COLD (brand for eql flu/severe cold daytime) - Tier
2; PA
THERAFLU SEVERE COLD/CGH DAY (brand for cold multi-symptom
daytime) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
184
Preferred Agents Non-Preferred Agents
SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for cvs
nasal decongestant pe) - Tier 2
SUDAFED PE SINUS CONGESTION (brand for cvs nasal
decongestant pe) - Tier 2
tab tussin (generic for XPECT) - Tier 1
tussin chest congestion oral syrup 100 mg/5ml (generic for DIABETIC
TUSSIN EX) - Tier 1
tussin cough long acting (generic for WAL-TUSSIN COUGH) - Tier 1
tussin cough long-acting (generic for WAL-TUSSIN COUGH) - Tier 1
tussin cough oral syrup (generic for WAL-TUSSIN COUGH) - Tier 1
tussin maximum strength oral syrup 15 mg/5ml (generic for WAL-
TUSSIN COUGH) - Tier 1
tussin mucus+chest congestion oral syrup (generic for DIABETIC
TUSSIN EX) - Tier 1
tussin oral syrup 100 mg/5ml (generic for DIABETIC TUSSIN EX) -
Tier 1
XPECT (brand for chest congestion relief) - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
185
Preferred Agents Non-Preferred Agents
Antihistamines - Allergy Drugs
12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL
all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL
all day allergy-d oral tablet extended release 12 hour 5-120 mg
(generic for KLS ALLER-TEC D) - Tier 1; QL
allergy complete-d (generic for KLS ALLER-TEC D) - Tier 1; QL
allergy relief d oral tablet extended release 12 hour (generic for KLS
ALLER-TEC D) - Tier 1; QL
allergy relief oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLER-TEC D) - Tier 1; QL
allergy relief/nasal decongest oral tablet extended release 12 hour
(generic for KLS ALLER-TEC D) - Tier 1; QL
ALAHIST CF - Tier 2; PA; QL
ALAHIST DM (brand for polytussin dm) - Tier 2; PA; QL
despec dm - Tier 1; PA
despec dm-g - Tier 1; PA
polytussin dm (generic for ALAHIST DM) - Tier 1; PA; QL
rymed - Tier 1; PA; QL
tussin cf cough & cold oral syrup 5-10-100 mg/5ml - Tier 1; PA
allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLER-TEC D) - Tier 1; QL
aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL
cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL
cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier
1; QL
desgen dm oral liquid (generic for DESGEN DM) - Tier 1
ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; QL
nohist-lq (generic for ED A-HIST) - Tier 1; QL
robafen cf multi-symptom cold (generic for DESGEN DM) - Tier 1
ROBITUSSIN PEAK COLD MULTI-SYM (brand for goodsense tussin
cf) - Tier 2
tussin adult multi-symptom (generic for DESGEN DM) - Tier 1
tussin cf multi-symptom cold (generic for DESGEN DM) - Tier 1
tussin cf oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier
1
tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1
ZYRTEC-D ALLERGY & CONGESTION (brand for 12 hour allergy-d) -
Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
186
Preferred Agents Non-Preferred Agents
Antihistamines - Drugs to Treat Allergies
aller-chlor (generic for CHLOR-TRIMETON) - Tier 1; QL
allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL
allergy 4 hour (generic for CHLOR-TRIMETON) - Tier 1; QL
allergy childrens oral syrup (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; QL
allergy oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1; QL
allergy rel child (loratadine) (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; QL
allergy relief (loratadine) (generic for KLS ALLERCLEAR) - Tier 1; QL
allergy relief 4-hour (generic for CHLOR-TRIMETON) - Tier 1; QL
allergy relief childrens oral syrup 5 mg/5ml (generic for CLARITIN
ALLERGY CHILDRENS) - Tier 1; QL
24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; PA; QL
ALLEGRA ALLERGY (brand for 24hr allergy relief) - Tier 2; PA; QL
aller-ease (generic for ALLEGRA ALLERGY) - Tier 1; PA; QL
aller-fex (generic for KLS ALLER-FEX) - Tier 1; PA; QL
allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; PA; QL
allergy relief childrens oral tablet chewable 5 mg (generic for CLARITIN) -
Tier 1; PA; QL
allergy relief oral capsule 10 mg (generic for CLARITIN) - Tier 1; PA; QL
allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1;
PA; QL
allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - Tier 1;
PA; QL
allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier
1; QL
allergy relief oral tablet 4 mg (generic for CHLOR-TRIMETON) - Tier 1;
QL
allergy relief oral tablet dispersible 10 mg (generic for CLARITIN
REDITABS) - Tier 1; QL
allergy relief oral tablet extended release 12 mg (generic for CHLOR-
TRIMETON ALLERGY) - Tier 1; QL
childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) -
Tier 1; QL
chlor-pheniramine (generic for CHLOR-TRIMETON) - Tier 1; QL
allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS ALLER-
FEX) - Tier 1; PA; QL
CLARITIN CHILDRENS (brand for cvs allergy relief childrens) - Tier 2;
PA; QL
CLARITIN ORAL CAPSULE (brand for goodsense allergy relief) - Tier 2;
PA; QL
CLARITIN ORAL TABLET CHEWABLE 5 MG (brand for cvs allergy relief
childrens) - Tier 2; PA; QL
CLARITIN REDITABS ORAL TABLET DISPERSIBLE 5 MG - Tier 2; PA;
QL
fexofenadine hcl oral (generic for ALLEGRA ALLERGY) - Tier 1; PA; QL
HISTEX PD (brand for triprolidine hcl) - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
187
Preferred Agents Non-Preferred Agents
chlorpheniramine maleate er (generic for CHLOR-TRIMETON
ALLERGY) - Tier 1; QL
chlorpheniramine maleate oral (generic for CHLOR-TRIMETON) - Tier
1; QL
chlortabs (generic for CHLOR-TRIMETON) - Tier 1; QL
CHLOR-TRIMETON (brand for aller-chlor) - Tier 2; QL
CHLOR-TRIMETON ALLERGY (brand for chlorpheniramine maleate
er) - Tier 2; QL
CLARITIN ALLERGY CHILDRENS (brand for allergy childrens) - Tier
2; QL
CLARITIN ORAL TABLET (brand for allergy relief) - Tier 2; QL
loratadine childrens oral tablet chewable (generic for CLARITIN) - Tier 1;
PA; QL
loratadine oral capsule (generic for CLARITIN) - Tier 1; PA; QL
pediaclear pd childrens - Tier 1; PA
triprolidine hcl oral (generic for HISTEX PD) - Tier 1; PA
CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand
for cvs allergy relief) - Tier 2; QL
ed chlorped jr (generic for CHLOR-TRIMETON) - Tier 1; QL
loradamed (generic for KLS ALLERCLEAR) - Tier 1; QL
loratadine allergy relief oral tablet 10 mg (generic for KLS
ALLERCLEAR) - Tier 1; QL
loratadine allergy relief oral tablet dispersible 10 mg (generic for
CLARITIN REDITABS) - Tier 1; QL
loratadine childrens oral solution 5 mg/5ml (generic for CLARITIN
ALLERGY CHILDRENS) - Tier 1; QL
loratadine childrens oral syrup (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; QL
loratadine oral syrup (generic for CLARITIN ALLERGY CHILDRENS) -
Tier 1; QL
loratadine oral tablet (generic for KLS ALLERCLEAR) - Tier 1; QL
loratadine oral tablet dispersible 10 mg (generic for CLARITIN
REDITABS) - Tier 1; QL
pharbechlor (generic for CHLOR-TRIMETON) - Tier 1; QL
TRIAMINIC ALLERCHEWS (brand for cvs allergy relief) - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
188
Preferred Agents Non-Preferred Agents
Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung
Drugs
24 hour nasal allergy (generic for KLS ALLER-CORT) - Tier 1; QL
aller-cort (generic for KLS ALLER-CORT) - Tier 1; QL
allergy spray 24 hour nasal aerosol (generic for KLS ALLER-CORT) -
Tier 1; QL
NASACORT ALLERGY 24HR (brand for allergy spray 24 hour) - Tier
2; QL
NASACORT ALLERGY 24HR CHILDREN (brand for allergy spray 24
hour) - Tier 2; QL
nasal allergy 24 hour (generic for KLS ALLER-CORT) - Tier 1; QL
nasal allergy nasal aerosol 55 mcg/act (generic for KLS ALLER-
CORT) - Tier 1; QL
nasal allergy spray (generic for KLS ALLER-CORT) - Tier 1; QL
Bronchodilators, Sympathomimetic - Asthma/Lung Drugs
ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; QL
ADVAIR HFA - Tier 2; QL
ANORO ELLIPTA - Tier 2; QL
COMBIVENT RESPIMAT - Tier 2; QL
DULERA - Tier 2; QL
fluticasone-salmeterol aerosol powder breath activated 100-50
mcg/act inhalation (generic for WIXELA INHUB) - Tier 1; QL
fluticasone-salmeterol aerosol powder breath activated 250-50
mcg/act inhalation (generic for WIXELA INHUB) - Tier 1; QL
fluticasone-salmeterol aerosol powder breath activated 500-50
mcg/act inhalation (generic for WIXELA INHUB) - Tier 1; QL
ipratropium-albuterol - Tier 1; QL
AIRDUO DIGIHALER - Tier 2; PA; QL
AIRDUO RESPICLICK 113/14 (brand for fluticasone-salmeterol) - Tier 2;
PA; QL
AIRDUO RESPICLICK 232/14 (brand for fluticasone-salmeterol) - Tier 2;
PA; QL
AIRDUO RESPICLICK 55/14 (brand for fluticasone-salmeterol) - Tier 2;
PA; QL
asthmanefrin refill - Tier 1; PA
BEVESPI AEROSPHERE - Tier 2; PA; QL
BREO ELLIPTA (brand for fluticasone furoate-vilanterol) - Tier 2; PA; QL
BREZTRI AEROSPHERE - Tier 2; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
189
Preferred Agents Non-Preferred Agents
STIOLTO RESPIMAT - Tier 2; QL
SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; QL
BUDESONIDE-FORMOTEROL FUMARATE (brand for budesonide-
formoterol fumarate) - Tier 2; PA; QL
DUAKLIR PRESSAIR - Tier 2; PA; QL
FLUTICASONE FUROATE-VILANTEROL (brand for fluticasone furoate-
vilanterol) - Tier 2; PA; QL
fluticasone-salmeterol aerosol powder breath activated 100-50 mcg/act
inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL
fluticasone-salmeterol aerosol powder breath activated 250-50 mcg/act
inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL
fluticasone-salmeterol aerosol powder breath activated 500-50 mcg/act
inhalation (generic for WIXELA INHUB) - Tier 1; PA; QL
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER
BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14
MCG/ACT (brand for fluticasone-salmeterol) - Tier 2; PA; QL
S2 (RACEPINEPHRINE) - Tier 2; PA
TRELEGY ELLIPTA - Tier 2; PA; QL
wixela inhub (generic for WIXELA INHUB) - Tier 1; PA; QL
Mast Cell Stabilizers - Drugs for the Lungs
cromolyn sodium nasal (generic for NASALCROM) - Tier 1; QL
NASALCROM (brand for cromolyn sodium) - Tier 2; QL
Respiratory Tract Agents, Other - Asthma/Lung Drugs
12 hour decongestant (generic for GILTUSS SEVERE SINUS) - Tier 1
12 hour nasal decongestant (generic for GILTUSS SEVERE SINUS) -
Tier 1
12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) -
Tier 1
12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1
adult tussin cough & chest (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1
ADVIL COLD/SINUS (brand for cvs cold & sinus relief) - Tier 2
AFRIN NODRIP ORIGINAL (brand for 12 hour decongestant) - Tier 2
ALAVERT ALLERGY/SINUS (brand for allergy relief d-12) - Tier 2; QL
allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL
12hr allergy & congestion (generic for ALLEGRA-D ALLERGY &
CONGESTION) - Tier 1; PA; QL
ALLEGRA-D ALLERGY & CONGESTION (brand for 12hr allergy &
congestion) - Tier 2; PA; QL
allergy relief d (generic for ALLEGRA-D ALLERGY & CONGESTION) -
Tier 1; PA; QL
allergy-d allergy & conges (generic for ALLEGRA-D ALLERGY &
CONGESTION) - Tier 1; PA; QL
antihistamine & nasal deconges (generic for ALLEGRA-D ALLERGY &
CONGESTION) - Tier 1; PA; QL
benzonatate oral capsule 150 mg - Tier 1; PA
capcof - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
190
Preferred Agents Non-Preferred Agents
allerclear d-24hr (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
allergy & congestion (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
QL
allergy relief d-24 (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
allergy relief nasal decong (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
allergy relief/nasal decong (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
CUROSURF INTRATRACHEAL SUSPENSION 120 MG/1.5ML - Tier 2;
PA
fexofenadine/pse er (generic for ALLEGRA-D ALLERGY &
CONGESTION) - Tier 1; PA; QL
fexofenadine-pseudoephed er (generic for ALLEGRA-D ALLERGY &
CONGESTION) - Tier 1; PA; QL
HISTEX-AC - Tier 2; PA; QL
hydrocodone polst-cpm polst er - Tier 1; PA; QL
HYPERSAL (brand for sodium chloride) - Tier 2; PA
MAR-COF CG EXPECTORANT (brand for trymine cg) - Tier 2; PA; QL
maxi-tuss cd - Tier 1; PA; QL
M-END PE - Tier 2; PA; QL
allergy relief/nasal decongest oral tablet extended release 24 hour
(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; QL
allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLERCLEAR D-12HR) - Tier 1; QL
allergy relief-d oral tablet extended release 24 hour 10-240 mg
(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; QL
allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL
allergy/congestion relief (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1;
QL
anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1
NINJACOF-XG - Tier 2; PA; QL
poly-tussin ac - Tier 1; PA; QL
PONARIS (brand for sesame oil nasal spray) - Tier 2; PA
sesame oil nasal spray (generic for PONARIS) - Tier 1; PA
trymine cg (generic for MAR-COF CG EXPECTORANT) - Tier 1; PA; QL
TUSNEL C - Tier 2; PA; QL
aprodine - Tier 1
benzonatate oral capsule 100 mg (generic for TESSALON PERLES) -
Tier 1; QL
benzonatate oral capsule 200 mg - Tier 1; QL
chest congest/cough child (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1
chest congestion relief dm oral syrup (generic for ROBAFEN DM
COUGH CLEAR) - Tier 1; QL
childrens cold & allergy - Tier 1
childrens cough (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
191
Preferred Agents Non-Preferred Agents
childrens mucus relief cough (generic for DELSYM CGH/CHEST
CONG DM CHILD) - Tier 1
CLARITIN-D 12 HOUR (brand for allergy relief d-12) - Tier 2; QL
CLARITIN-D 24 HOUR (brand for allergy relief d-24) - Tier 2; QL
cold & allergy - Tier 1
cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1
cold & cough childrens oral liquid 2.5-1-5 mg/5ml (generic for
DIMAPHEN DM COLD/COUGH) - Tier 1; QL
cold & cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for
DIMAPHEN DM COLD/COUGH) - Tier 1; QL
cold & sinus relief oral tablet 30-200 mg (generic for ADVIL
COLD/SINUS) - Tier 1
cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL
cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) -
Tier 1; QL
cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for
DIMAPHEN DM COLD/COUGH) - Tier 1; QL
cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM
COLD/COUGH) - Tier 1; QL
cough & chest congestion (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1
cough childrens (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1
cough dm (generic for DELSYM) - Tier 1; QL
cough dm childrens (generic for DELSYM) - Tier 1; QL
cough dm er (generic for DELSYM) - Tier 1; QL
cough/chest congestion dm (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; QL
DELSYM CGH/CHEST CONG DM CHILD (brand for childrens cough)
- Tier 2
DELSYM COUGH CHILDRENS (brand for cough dm) - Tier 2; QL
DELSYM COUGH/CHEST CONGEST DM (brand for childrens cough)
- Tier 2
DELSYM ORAL SUSPENSION EXTENDED RELEASE (brand for
cough dm) - Tier 2; QL
dextromethorphan polistirex er (generic for DELSYM) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
192
Preferred Agents Non-Preferred Agents
dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM
COUGH CLEAR) - Tier 1; QL
dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH)
- Tier 1; QL
dm maximum adult (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1
ENDACOF-DM (brand for cold & cough childrens) - Tier 2; QL
g tussin ac - Tier 1; QL
geri-tussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1;
QL
giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1
guaiatussin ac - Tier 1; QL
guaicon dms (generic for ROBAFEN DM COUGH CLEAR) - Tier 1; QL
guaifenesin ac - Tier 1; QL
guaifenesin-codeine - Tier 1; QL
guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; QL
ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1
ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL
COLD/SINUS) - Tier 1
ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL
COLD/SINUS) - Tier 1
long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier
1
long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier
1
lorata-d (generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier
1; QL
lorata-dine d (generic for EQ ALLERGY RELIEF NASAL DECONG) -
Tier 1; QL
loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL
loratadine-d (generic for EQ ALLERGY RELIEF NASAL DECONG) -
Tier 1; QL
loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
193
Preferred Agents Non-Preferred Agents
loratadine-d 24hr (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; QL
maxi-tuss ac - Tier 1; QL
maxi-tuss gmx (generic for DIABETIC TUSSIN DM MAX ST) - Tier 1
m-clear wc - Tier 1; QL
meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier
1; QL
MUCINEX CHILDRENS FREEFROM ORAL LIQUID 5-100 MG/5ML
(brand for childrens cough) - Tier 2
MUCINEX CHILDRENS STUFFY NOSE (brand for 12 hour
decongestant) - Tier 2
MUCINEX COUGH CHILDRENS (brand for childrens cough) - Tier 2
MUCINEX D (brand for cvs mucus d extended release) - Tier 2
MUCINEX D MAX STRENGTH (brand for cvs mucus d max st er) -
Tier 2
MUCINEX DM (brand for cvs mucus dm extended release) - Tier 2; QL
MUCINEX FAST-MAX DM MAX (brand for childrens cough) - Tier 2
MUCINEX SINUS-MAX CLEAR & COOL (brand for 12 hour
decongestant) - Tier 2
MUCINEX SINUS-MAX SINUS/ALLRGY (brand for 12 hour
decongestant) - Tier 2
mucus & cough relief child (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1
mucus & cough relief childrens (generic for DELSYM CGH/CHEST
CONG DM CHILD) - Tier 1
mucus d (generic for MUCINEX D) - Tier 1
mucus d extended release (generic for MUCINEX D) - Tier 1
mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier
1
mucus dm (generic for MUCINEX DM) - Tier 1; QL
mucus dm extended release oral tablet extended release 12 hour 30-
600 mg (generic for MUCINEX DM) - Tier 1; QL
mucus relief cough children (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
194
Preferred Agents Non-Preferred Agents
mucus relief cough childrens (generic for DELSYM CGH/CHEST
CONG DM CHILD) - Tier 1
mucus relief d max strength (generic for MUCINEX D MAX
STRENGTH) - Tier 1
mucus relief d oral tablet extended release 12 hour 60-600 mg
(generic for MUCINEX D) - Tier 1
mucus relief dm max oral liquid (generic for DELSYM CGH/CHEST
CONG DM CHILD) - Tier 1
mucus relief dm oral liquid 20-400 mg/20ml (generic for DELSYM
CGH/CHEST CONG DM CHILD) - Tier 1
mucus relief dm oral tablet extended release 12 hour 30-600 mg
(generic for MUCINEX DM) - Tier 1; QL
mucus-d (generic for MUCINEX D) - Tier 1
mucus-dm (generic for MUCINEX DM) - Tier 1; QL
nasal decongestant 12 hour (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1
nasal decongestant 12hr (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1
nasal decongestant max st (generic for SUDOGEST) - Tier 1; QL
nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier
1; QL
nasal decongestant oral tablet extended release 12 hour 120 mg
(generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1
nasal decongestant spray (generic for GILTUSS SEVERE SINUS) -
Tier 1
nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) -
Tier 1
nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1
nasal relief moisturizing (generic for GILTUSS SEVERE SINUS) - Tier
1
nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1
nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1
nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier
1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
195
Preferred Agents Non-Preferred Agents
nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS)
- Tier 1
nasal spray moisturizing (generic for GILTUSS SEVERE SINUS) - Tier
1
nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1
nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1
no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1
no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1
promethazine vc/codeine - Tier 1; QL
promethazine-codeine - Tier 1; QL
promethazine-dm - Tier 1; QL
promethazine-phenyleph-codeine - Tier 1; QL
pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1
pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION
12HR) - Tier 1
pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier
1; QL
pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1
ROBITUSSIN 12 HOUR COUGH (brand for cough dm) - Tier 2; QL
ROBITUSSIN 12 HOUR COUGH CHILD (brand for cough dm) - Tier 2;
QL
ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400
MG/20ML (brand for childrens cough) - Tier 2
rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL
rynex pe - Tier 1
rynex pse - Tier 1
siltussin-dm alcohol free (generic for ROBAFEN DM COUGH CLEAR)
- Tier 1; QL
sinus 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) -
Tier 1
sinus 12-hour (generic for SUDAFED SINUS CONGESTION 12HR) -
Tier 1
sinus congestion max strength (generic for SUDOGEST) - Tier 1; QL
sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
196
Preferred Agents Non-Preferred Agents
sodium chloride inhalation nebulization solution 0.9 %, 10 %, 3 % -
Tier 1
sodium chloride inhalation nebulization solution 7 % (generic for
HYPERSAL) - Tier 1
SUDAFED (brand for cvs nasal decongestant) - Tier 2; QL
SUDAFED CHILDRENS - Tier 2; QL
SUDAFED SINUS CONGESTION (brand for cvs nasal decongestant)
- Tier 2; QL
SUDAFED SINUS CONGESTION 12HR (brand for 12 hour
decongestant) - Tier 2
sudogest 12 hour (generic for SUDAFED SINUS CONGESTION
12HR) - Tier 1
sudogest maximum strength (generic for SUDOGEST) - Tier 1; QL
sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL
suphedrine 12hour (generic for SUDAFED SINUS CONGESTION
12HR) - Tier 1
suphedrine maximum strength (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1
suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; QL
suphedrine oral tablet extended release 12 hour 120 mg (generic for
SUDAFED SINUS CONGESTION 12HR) - Tier 1
tussin cf oral liquid 30-10-100 mg/5ml - Tier 1
tussin cough dm sugar free (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; QL
tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for
ROBAFEN DM COUGH CLEAR) - Tier 1; QL
tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for
DIABETIC TUSSIN DM MAX ST) - Tier 1
tussin dm cough/chest cong (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; QL
tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for
ROBAFEN DM COUGH CLEAR) - Tier 1; QL
tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1
tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
197
Preferred Agents Non-Preferred Agents
tussin dm max oral liquid 20-400 mg/20ml (generic for DELSYM
CGH/CHEST CONG DM CHILD) - Tier 1
tussin dm max st (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1
tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM
COUGH CLEAR) - Tier 1; QL
Sedatives/Hypnotics - Drugs for Sedation and Sleep
Sleep Disorders, Other - Miscellaneous Sedation and Sleep
Drugs
XYWAV - Tier 2; PA; QL
Skeletal Muscle Relaxants
chlorzoxazone oral tablet 500 mg - Tier 1; QL
cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL
methocarbamol oral - Tier 1; QL
AMRIX (brand for cyclobenzaprine hcl er) - Tier 2; PA; QL
carisoprodol oral (generic for SOMA) - Tier 1; PA; QL
carisoprodol-aspirin-codeine - Tier 1; PA; QL
chlorzoxazone oral tablet 375 mg, 750 mg (generic for LORZONE) - Tier
1; PA
cyclobenzaprine hcl er (generic for AMRIX) - Tier 1; PA; QL
cyclobenzaprine hcl oral tablet 7.5 mg (generic for FEXMID) - Tier 1; PA
FEXMID (brand for cyclobenzaprine hcl) - Tier 2; PA
LORZONE (brand for chlorzoxazone) - Tier 2; PA
metaxalone oral tablet 400 mg - Tier 1; PA
metaxalone oral tablet 800 mg (generic for SKELAXIN) - Tier 1; PA; QL
NORGESIC (brand for orphenadrine-aspirin-caffeine) - Tier 2; PA; QL
NORGESIC FORTE (brand for norgesic forte) - Tier 2; PA; QL
orphenadrine citrate er - Tier 1; PA; QL
orphenadrine-aspirin-caffeine (generic for NORGESIC) - Tier 1; PA; QL
ORPHENGESIC FORTE (brand for norgesic forte) - Tier 2; PA; QL
SOMA (brand for carisoprodol) - Tier 2; PA; QL
VANADOM (brand for carisoprodol) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
198
Preferred Agents Non-Preferred Agents
Sleep Disorder Agents
Sleep Promoting Agents
estazolam - Tier 1; QL
flurazepam hcl - Tier 1; QL
temazepam oral capsule 15 mg, 30 mg (generic for RESTORIL) - Tier
1; QL
triazolam (generic for HALCION) - Tier 1; QL
zaleplon - Tier 1; QL
zolpidem tartrate oral (generic for AMBIEN) - Tier 1; QL
AMBIEN (brand for zolpidem tartrate) - Tier 2; PA; QL
AMBIEN CR (brand for zolpidem tartrate er) - Tier 2; PA
BELSOMRA - Tier 2; PA
DAYVIGO - Tier 2; PA; QL
doxepin hcl oral tablet (generic for SILENOR) - Tier 1; PA; QL
EDLUAR - Tier 2; PA; QL
eszopiclone oral tablet 1 mg (generic for LUNESTA) - Tier 1; PA; QL
eszopiclone oral tablet 2 mg, 3 mg (generic for LUNESTA) - Tier 1; PA
HALCION (brand for triazolam) - Tier 2; PA; QL
HETLIOZ - Tier 2; PA; SP; QL
HETLIOZ LQ - Tier 2; PA; SP; QL; AL
LUNESTA ORAL TABLET 1 MG (brand for eszopiclone) - Tier 2; PA; QL
LUNESTA ORAL TABLET 2 MG, 3 MG (brand for eszopiclone) - Tier 2;
PA
ramelteon (generic for ROZEREM) - Tier 1; PA; QL
RESTORIL ORAL CAPSULE 15 MG, 30 MG, 7.5 MG (brand for
temazepam) - Tier 2; PA; QL
RESTORIL ORAL CAPSULE 22.5 MG (brand for temazepam) - Tier 2;
PA
ROZEREM (brand for ramelteon) - Tier 2; PA; QL
SILENOR (brand for doxepin hcl) - Tier 2; PA; QL
temazepam oral capsule 22.5 mg (generic for RESTORIL) - Tier 1; PA
temazepam oral capsule 7.5 mg (generic for RESTORIL) - Tier 1; PA; QL
zolpidem tartrate er (generic for AMBIEN CR) - Tier 1; PA
zolpidem tartrate sublingual - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
199
Preferred Agents Non-Preferred Agents
Wakefulness Promoting Agents
armodafinil (generic for NUVIGIL) - Tier 1; QL
modafinil (generic for PROVIGIL) - Tier 1; QL
NUVIGIL (brand for armodafinil) - Tier 2; PA; QL
PROVIGIL (brand for modafinil) - Tier 2; PA; QL
SUNOSI - Tier 2; PA; QL
WAKIX - Tier 2; PA; QL
XYREM - Tier 2; PA; SP; QL
Sleep Disorder Agents - Drugs for Sedation and Sleep
Sleep Disorders, Other - Drugs for Sleeping
night time sleep aid (generic for SIMPLY SLEEP) - Tier 1; PA; QL
nighttime sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1;
PA
nighttime sleep aid oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier
1; PA
nighttime sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier
1; PA; QL
QUVIVIQ - Tier 2; PA; QL
rest simply (generic for SIMPLY SLEEP) - Tier 1; PA; QL
SIMPLY SLEEP (brand for cvs sleep aid) - Tier 2; PA; QL
sleep aid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; PA;
QL
sleep aid max st (generic for UNISOM SLEEPGELS) - Tier 1; PA
sleep aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier
1; PA
sleep aid nighttime oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier
1; PA; QL
sleep aid oral capsule 50 mg (generic for UNISOM SLEEPGELS) - Tier 1;
PA
sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; PA; QL
sleep ii (generic for SIMPLY SLEEP) - Tier 1; PA; QL
sleep tabs (generic for SIMPLY SLEEP) - Tier 1; PA; QL
sleepaid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; PA; QL
sleep-aid max st (generic for UNISOM SLEEPGELS) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
200
Preferred Agents Non-Preferred Agents
sleep-aid nighttime oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier
1; PA
sleep-aid nighttime oral capsule 50 mg (generic for UNISOM
SLEEPGELS) - Tier 1; PA
sleep-aid oral capsule (generic for UNISOM SLEEPGELS) - Tier 1; PA
sleeptime oral capsule (generic for WAL-SLEEP Z) - Tier 1; PA
z-sleep oral capsule 25 mg (generic for WAL-SLEEP Z) - Tier 1; PA
Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat
Vitamin, Mineral and Body Fluid Deficiencies
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body
Fluid Deficiency Drugs
adc/f (0.5mg/ml) - Tier 1
animal shapes complete (generic for CEROVITE JR) - Tier 1; QL
ascorbic acid oral tablet 500 mg (generic for PUREWAY-C) - Tier 1;
QL
biocel (generic for LYSIPLEX PLUS) - Tier 1; QL
b-plex plus (generic for LYSIPLEX PLUS) - Tier 1; QL
BPROTECTED PEDIA POLY-VITE/FE (brand for pc pediatric poly-
vita/fe drop) - Tier 2; QL
calcium 600 oral tablet 1500 (600 ca) mg - Tier 1; QL
calcium 600+d tablet 600-200 mg-unit oral 600-200 mg-unit - Tier 1;
QL
calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL
ACEROLA C 500 - Tier 2; PA
ACTITROM (brand for c 1000-bioflavonoids-rose hips) - Tier 2; PA
ACTITROM-D (brand for c 1000-bioflavonoids-rose hips) - Tier 2; PA
ACTIVE FE - Tier 2; PA
ADRENAL C FORMULA (brand for bioflex) - Tier 2; PA
airshield (generic for CVS AIRSHIELD) - Tier 1; PA; QL
AIRSHIELD IMMUNITY SUPPORT (brand for cvs daily gummies) - Tier 2;
PA; QL
ascorbic acid oral powder (generic for CYTO C) - Tier 1; PA
b complex formula 1 (w/ fa) (generic for BIG 100) - Tier 1; PA
BACMIN (brand for b-plex plus) - Tier 2; PA; QL
balanced b-100 oral tablet (generic for BIG 100) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
201
Preferred Agents Non-Preferred Agents
calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1; QL
calcium fast dissolution - Tier 1; QL
calcium high potency - Tier 1; QL
calcium oral tablet 1500 (600 ca) mg - Tier 1; QL
calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1; QL
calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier
1
CENTRUM FLAVOR BURST KIDS (brand for cvs gummy dinos) - Tier
2; QL
CENTRUM KIDS (brand for cvs gummy dinos) - Tier 2; QL
cerovite jr (generic for CEROVITE JR) - Tier 1; QL
chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL
balanced b-50 oral tablet (generic for BIG 100) - Tier 1; PA
bioflex (generic for ESTER-C) - Tier 1; PA
biotin forte oral tablet 5 mg - Tier 1; PA
biotin high potency - Tier 1; PA; QL
biotin oral capsule 2500 mcg (generic for HARD NAILS) - Tier 1; PA
biotin oral capsule 5000 mcg (generic for MERIBIN) - Tier 1; PA
biotin oral tablet 1000 mcg - Tier 1; PA; QL
biotin oral tablet 5 mg - Tier 1; PA
BPROTECTED PEDIA POLY-VITE (brand for poly-vite pediatric) - Tier 2;
PA; QL
c 1000-bioflavonoids-rose hips (generic for ACTITROM) - Tier 1; PA
c complex (generic for ESTER-C) - Tier 1; PA
chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1;
QL
chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL
childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL
childrens chewables/iron (generic for LAND BEFORE TIME
MULTIVITAMIN) - Tier 1; QL
childrens complete oral tablet chewable 18 mg (generic for CEROVITE
JR) - Tier 1; QL
childrens vitamins/iron (generic for LAND BEFORE TIME
MULTIVITAMIN) - Tier 1; QL
CORVITE 150 ORAL TABLET 150-1.25 MG - Tier 2
calcium soft chews oral tablet chewable 500-100-40 - Tier 1; PA
cal-mag aspartate - Tier 1; PA
CENTRUM ADULTS ORAL TABLET CHEWABLE (brand for cvs daily
gummies) - Tier 2; PA; QL
CENTRUM FLAVOR BURST (brand for cvs daily gummies) - Tier 2; PA;
QL
CENTRUM FLAVOR BURST ADULT (brand for cvs daily gummies) - Tier
2; PA; QL
CENTRUM FRESH/FRUITY 50+ (brand for cvs daily gummies) - Tier 2;
PA; QL
CENTRUM FRESH/FRUITY ADULT (brand for cvs daily gummies) - Tier
2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
202
Preferred Agents Non-Preferred Agents
daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; QL
daily vitamin formula+iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; QL
DIALYVITE 3000 - Tier 2
DIALYVITE 5000 - Tier 2
effer-k oral tablet effervescent 25 meq - Tier 1; QL
ergocalciferol oral capsule (generic for DRISDOL) - Tier 1; QL
fruity c - Tier 1; QL
gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1;
QL
CENTRUM MULTI + OMEGA 3 (brand for cvs daily gummies) - Tier 2;
PA; QL
CENTRUM SILVER ORAL TABLET CHEWABLE (brand for cvs daily
gummies) - Tier 2; PA; QL
CENTRUM VITAMINTS (brand for cvs daily gummies) - Tier 2; PA; QL
CHOICEFUL MULTIVITAMIN ORAL TABLET CHEWABLE (brand for cvs
daily gummies) - Tier 2; PA; QL
cod liver oil oral capsule 1250-133 unit - Tier 1; PA
CORAL CALCIUM ORAL TABLET 1000 (390 CA) MG - Tier 2; PA
CORVITA (brand for b-plex plus) - Tier 2; PA; QL
crush vitamin c drops (generic for CRUSH VITAMIN C DROPS) - Tier 1;
PA
gummy multivitamin kids (generic for CENTRUM FLAVOR BURST
KIDS) - Tier 1; QL
klor-con/ef - Tier 1; QL
k-prime - Tier 1; QL
lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL
multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; QL
MULTIVITAMIN CHILDRENS GUMMIES (brand for cvs gummy dinos)
- Tier 2; QL
multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) -
Tier 1; QL
nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL
daflonex-xl (generic for ACTITROM) - Tier 1; PA
daily gummies (generic for CVS AIRSHIELD) - Tier 1; PA; QL
daily gummies adult (generic for CVS AIRSHIELD) - Tier 1; PA; QL
DERMACINRX DOTREMIN - Tier 2; PA; QL
DERMACINRX MULTITAM (brand for b-plex plus) - Tier 2; PA; QL
DERMACINRX RIBOTIN-E (brand for b-plex plus) - Tier 2; PA; QL
DIALYVITE SUPREME D (brand for b-plex plus) - Tier 2; PA; QL
DRISDOL (brand for ergocalciferol) - Tier 2; PA; QL
effervescent formula (generic for GERM DEFENSE PM) - Tier 1; PA
ELFOLATE (brand for l-methylfolate) - Tier 2; PA
ester-c oral tablet (generic for ESTER-C) - Tier 1; PA
flexgen (generic for ESTER-C) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
203
Preferred Agents Non-Preferred Agents
one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; QL
one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) -
Tier 1; QL
oyster shell calcium 500 + d - Tier 1; QL
oyster shell calcium oral tablet 500 mg - Tier 1; QL
oyster shell calcium/d oral tablet 250-125 mg-unit - Tier 1; QL
oyster shell calcium/vitamin d oral tablet 250-125 mg-unit - Tier 1; QL
pot & sod cit-cit ac - Tier 1
stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE)
- Tier 1; QL
TARON FORTE - Tier 2
FOLAMAX (brand for b-plex plus) - Tier 2; PA; QL
FOLIFLEX (brand for b-plex plus) - Tier 2; PA; QL
FOLITIN-Z (brand for b-plex plus) - Tier 2; PA; QL
glutamine oral capsule - Tier 1; PA
HARD NAILS (brand for ra biotin) - Tier 2; PA
HONEY BEARS (brand for multivitamin gummies childrens) - Tier 2; PA;
QL
HONEY BEARS W/IRON-ZINC - Tier 2; PA; QL
l-carnitine - Tier 1; PA
liquid calcium/vitamin d - Tier 1; PA
l-lysine oral tablet 500 mg - Tier 1; PA
l-methylfolate (generic for ELFOLATE) - Tier 1; PA
tricitrates - Tier 1
tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; QL
tri-vite/fluoride oral solution 0.5 mg/ml - Tier 1
vit c/rose hips - Tier 1; QL
vita s forte (generic for LYSIPLEX PLUS) - Tier 1; QL
vitacel (generic for LYSIPLEX PLUS) - Tier 1; QL
vitachew multiple vitamin (generic for CENTRUM FLAVOR BURST
KIDS) - Tier 1; QL
vitamin c cr oral tablet extended release 500 mg (generic for ENDUR-
C) - Tier 1; QL
vitamin c er oral tablet extended release 1500 mg - Tier 1; QL
vitamin c oral tablet 1000 mg, 250 mg - Tier 1; QL
l-methylfolate calcium oral (generic for ELFOLATE) - Tier 1; PA
l-tyrosine oral capsule - Tier 1; PA
m2 magnesium - Tier 1; PA
magnesium oral capsule 300 mg - Tier 1; PA
magnesium oral tablet 250 mg, 30 mg - Tier 1; PA
mens daily gummies (generic for CVS AIRSHIELD) - Tier 1; PA; QL
MERIBIN (brand for biotin) - Tier 2; PA
natural magnesium - Tier 1; PA
NUTRICAP (brand for b-plex plus) - Tier 2; PA; QL
OBSTETRIX EC - Tier 2; PA
OBTREX - Tier 2; PA
ONEVITE (brand for b-plex plus) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
204
Preferred Agents Non-Preferred Agents
vitamin c oral tablet 500 mg (generic for PUREWAY-C) - Tier 1; QL
vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; QL
vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN
C) - Tier 1; QL
vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; QL
vitamin c/rose hips oral tablet 1000 mg - Tier 1; QL
vitamin c/rose hips oral tablet 500 mg (generic for PUREWAY-C) - Tier
1; QL
vitamin c-rose hips oral tablet (generic for PUREWAY-C) - Tier 1; QL
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit
(generic for DRISDOL) - Tier 1; QL
vitamins acd-fluoride - Tier 1; QL
PERIDIN-C (brand for bioflex) - Tier 2; PA
POLY-VI-SOL (brand for poly-vite pediatric) - Tier 2; PA; QL
POLY-VITE PEDIATRIC (brand for poly-vite pediatric) - Tier 2; PA; QL
prenatal gummy oral tablet chewable 0.4-113.5 mg - Tier 1; PA
PRO HERS RX - Tier 2; PA
PRO HIS RX - Tier 2; PA
PRO PCOS RX - Tier 2; PA
PROTECT IRON - Tier 2; PA; QL
PROTEINEX ORAL LIQUID - Tier 2; PA
PROTEINEX P100 - Tier 2; PA
PROTEINEX P18 - Tier 2; PA
PROTEINEX-18 - Tier 2; PA
vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL
zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL
pure l-tyrosine - Tier 1; PA
spectravite adult 50+ oral tablet chewable (generic for CVS AIRSHIELD) -
Tier 1; PA; QL
spectravite women oral tablet chewable (generic for CVS AIRSHIELD) -
Tier 1; PA; QL
STROVITE FORTE ORAL TABLET (brand for b-plex plus) - Tier 2; PA;
QL
STROVITE ONE (brand for b-plex plus) - Tier 2; PA; QL
SYSTANE ICAPS AREDS2 ORAL TABLET CHEWABLE (brand for cvs
daily gummies) - Tier 2; PA; QL
THRIVITE 19 (brand for b-plex plus) - Tier 2; PA; QL
totalday multiple (generic for ENDUR-VM) - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
205
Preferred Agents Non-Preferred Agents
TROMBONEX (brand for c 1000-bioflavonoids-rose hips) - Tier 2; PA
TROMBONEX-D (brand for c 1000-bioflavonoids-rose hips) - Tier 2; PA
UDAMIN SP (brand for b-plex plus) - Tier 2; PA; QL
ultra-mega (generic for ENDUR-VM) - Tier 1; PA
urosex (generic for ALLERWELL ALLERGY FORMULA) - Tier 1; PA
vasoflex forte (generic for ACTITROM) - Tier 1; PA
vasoflex hd (generic for ESTER-C) - Tier 1; PA
VASOFLEX ORAL CAPSULE (brand for c 1000-bioflavonoids-rose hips) -
Tier 2; PA
vasoflex oral tablet (generic for ESTER-C) - Tier 1; PA
VENEXA (brand for b-plex plus) - Tier 2; PA; QL
VENEXA FE (brand for b-plex plus) - Tier 2; PA; QL
VENTRIXYL (brand for b-plex plus) - Tier 2; PA; QL
VENTRIXYL FE (brand for b-plex plus) - Tier 2; PA; QL
vitamin b-2 oral tablet 100 mg, 25 mg - Tier 1; PA
vitamin c cr oral tablet extended release (generic for ESTER-C) - Tier 1;
PA
vitamin c drops mouth/throat lozenge 60 mg (generic for CRUSH
VITAMIN C DROPS) - Tier 1; PA
vitamin c er oral capsule extended release - Tier 1; PA
vitamin c/bioflavonoids (generic for ESTER-C) - Tier 1; PA
VITAROCA PLUS (brand for b-plex plus) - Tier 2; PA; QL
VITRAMYN (brand for b-plex plus) - Tier 2; PA; QL
VITRANOL FE (brand for b-plex plus) - Tier 2; PA; QL
VITREXYL (brand for b-plex plus) - Tier 2; PA; QL
VITREXYL + IRON (brand for b-plex plus) - Tier 2; PA; QL
womens daily gummies (generic for CVS AIRSHIELD) - Tier 1; PA; QL
zinc oral lozenge - Tier 1; PA
zinc sulfate oral tablet 220 (50 zn) mg - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
206
Preferred Agents Non-Preferred Agents
Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs
b-1 - Tier 1; QL
b6 - Tier 1; QL
cyanocobalamin injection solution 1000 mcg/ml (generic for DODEX) -
Tier 1
DODEX (brand for cyanocobalamin) - Tier 2
e - Tier 1
e-400-clear - Tier 1; QL
natural vitamin e - Tier 1; QL
pyridoxine hcl oral - Tier 1; QL
thiamine hcl oral - Tier 1; QL
vitamin b1 - Tier 1; QL
vitamin b-1 oral tablet 250 mg - Tier 1; QL
aqueous vitamin e (generic for SOLUVITA E) - Tier 1; PA
b12 - Tier 1; PA
b-12 oral liquid 1000 mcg/15ml - Tier 1; PA
b-12 oral tablet 1000 mcg, 500 mcg - Tier 1; PA
b12 quick dissolve - Tier 1; PA
b-12 sublingual tablet sublingual 5000 mcg - Tier 1; PA
NASCOBAL - Tier 2; PA; QL
soluvita e (generic for SOLUVITA E) - Tier 1; PA
vitamin b-12 oral tablet 100 mcg, 1000 mcg, 250 mcg, 500 mcg - Tier 1;
PA
vitamin b12 oral tablet 1000 mcg - Tier 1; PA
vitamin b12 oral tablet extended release 2000 mcg - Tier 1; PA
vitamin b-12 er oral tablet extended release 1000 mcg - Tier 1
vitamin b12 oral tablet extended release 1000 mcg - Tier 1
vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1
vitamin b-6 - Tier 1; QL
vitamin b-6 er - Tier 1; QL
vitamin e natural - Tier 1
vitamin e oral capsule 134 mg (200 unit), 45 mg (100 unit), 450 mg
(1000 ut), 90 mg (200 unit) - Tier 1
vitamin e oral capsule 180 mg (400 unit), 268 mg (400 unit) - Tier 1;
QL
vitamin b-12 oral tablet extended release 2000 mcg - Tier 1; PA
vitamin b12 sublingual liquid 3000 mcg/ml - Tier 1; PA
vitamin b-12 sublingual tablet sublingual 2500 mcg, 5000 mcg - Tier 1; PA
vitamin e oral solution 6.75 mg/0.3ml (generic for SOLUVITA E) - Tier 1;
PA
Vaccines
Immunological Agents - Drugs that Stimulate or Suppress the
Immune System
JANSSEN COVID-19 VACCINE - Tier 2; QL
Vitamins
Electrolytes/Minerals/Metals/Vitamins
pantothenic acid - Tier 1; PA
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
207
Prior Authorization / Class Criteria
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; DX2RX: Diagnosis Required; GE: Gender Limit; PA: Prior Auth
Required; QL: Quantity Limit; SP: Specialty Medication; ST: Step Therapy
208
Index of Drugs
12 hour allergy-d........................................ 186
12 hour decongestant................................ 190
12 hour nasal decongestant.......................190
12 hour nasal relief spray...........................190
12 hour nasal spray....................................190
12hr allergy & congestion...........................190
24 hour nasal allergy..................................189
24hr allergy relief........................................187
3 day............................................................ 34
3 day vaginal................................................ 35
3-day vaginal vaginal cream 2 %................. 35
4-WAY FAST ACTING............................... 181
4-WAY MENTHOL..................................... 181
8 hour arthritis pain reliever..........................10
8 hour arthritis relief..................................... 10
8 hour pain relief oral tablet extended
release 650 mg............................................ 10
8 hour pain reliever...................................... 10
8 hr arthritis pain relief..................................10
8hr arthritis pain relief...................................10
8hr muscle aches & pain..............................10
a-25.............................................................. 99
abacavir sulfate oral solution........................51
abacavir sulfate oral tablet........................... 51
abacavir sulfate-lamivudine..........................51
abatinex......................................................112
abatron af..................................................... 94
ABILIFY........................................................47
ABILIFY MAINTENA.................................... 47
ABILIFY MYCITE MAINTENANCE KIT....... 47
ABILIFY MYCITE STARTER KIT.................47
abiraterone acetate...................................... 40
ABREVA.......................................................85
ABSORICA...................................................75
ABSORICA LD............................................. 75
acamprosate calcium................................... 18
ACANYA...................................................... 75
acarbose oral............................................... 54
ACCOLATE................................................177
ACCU-CHEK AVIVA DEVICE......................86
ACCU-CHEK AVIVA PLUS TEST STRIPS..86
ACCU-CHEK FASTCLIX LANCET KIT........86
ACCU-CHEK GUIDE CONTROL.................86
ACCU-CHEK GUIDE TEST STRIPS........... 86
ACCU-CHEK LINKASSIST.......................... 86
ACCU-CHEK SMARTVIEW......................... 86
ACCU-CHEK SMARTVIEW CONTROL...... 86
ACCU-CHEK SOFTCLIX LANCET
DEVICE KIT................................................. 86
ACCU-CHEK SPIRIT COMBO PACK..........86
ACCU-CHEK TENDER 1 INFUSION.........151
ACCUPRIL................................................... 63
ACCURETIC................................................ 66
accutane.......................................................75
ACCUTREND GLUCOSE............................ 86
ACCUTREND GLUCOSE CONTROL......... 87
ACE AEROSOL CLOUD ENHANCER.......151
acebutolol hcl oral........................................ 64
ACEROLA C 500....................................... 201
acetaminophen 8 hour................................. 10
acetaminophen 8 hours................................10
acetaminophen 8hr arth pain....................... 10
acetaminophen 8hr musc ache.................... 10
acetaminophen childrens oral suspension
160 mg/5ml.................................................. 10
acetaminophen childrens oral tablet
chewable 160 mg......................................... 10
acetaminophen er........................................ 10
acetaminophen ex st oral liquid 500
mg/15ml....................................................... 10
acetaminophen ex st oral tablet 500 mg...... 10
acetaminophen extra strength......................11
acetaminophen infants................................. 11
acetaminophen oral liquid 160 mg/5ml........ 11
acetaminophen oral liquid 500 mg/15ml...... 11
acetaminophen oral solution 160 mg/5ml,
325 mg/10.15ml, 650 mg/20.3ml..................11
acetaminophen oral suspension 160
mg/5ml, 650 mg/20.3ml................................11
acetaminophen oral tablet 325 mg...............11
acetaminophen oral tablet 500 mg...............11
acetaminophen oral tablet chewable 160
mg................................................................ 11
acetaminophen rapid tabs child................... 11
acetaminophen rectal suppository 120 mg.. 11
acetaminophen rectal suppository 650 mg.. 11
acetaminophen-codeine.................................8
acetaminophen-codeine #2............................8
acetaminophen-codeine #3............................8
acetaminophen-codeine #4............................8
acetazolamide er..........................................66
acetazolamide oral....................................... 66
acetic acid otic............................................173
acetylcysteine inhalation solution 10 %......181
acetylcysteine inhalation solution 20 %......181
acid controller.............................................109
acid gone....................................................112
acid reducer oral capsule delayed release.110
acid reducer oral tablet...............................109
acid reducer oral tablet 200 mg..................109
acid reducer oral tablet delayed release.... 110
acidophilus lactobacillus oral......................112
acidophilus oral capsule , 10 mg...............112
acidophilus probiotic oral capsule 10 mg... 112
acidophilus probiotic oral tablet , 0.5 mg...112
acidophilus/l-sporogenes........................... 112
ACIPHEX................................................... 110
acitretin.........................................................75
acne........................................................... 151
acne control cleanser................................. 151
acne medication 10 external lotion.............151
acne medication 5 external lotion...............151
ACTEMRA ACTPEN.................................. 144
209
ACTEMRA SUBCUTANEOUS...................144
ACTHAR.................................................... 130
ACTHIB...................................................... 147
ACTICLATE................................................. 23
ACTIFLOVIT EAR HEALTH.........................99
ACTIMMUNE............................................. 145
ACTIPHLORA............................................ 112
ACTIQ............................................................ 8
ACTITROM................................................ 201
ACTITROM-D.............................................201
ACTIVE FE.................................................201
ACTIVELLA................................................134
ACTIVITE..................................................... 99
ACTONEL.................................................. 150
ACTOPLUS MET......................................... 54
ACTOS.........................................................54
ACULAR.....................................................168
ACULAR LS............................................... 168
ACUNOL.................................................... 151
ACUVAIL....................................................168
acyclovir external......................................... 50
acyclovir oral................................................ 50
ACZONE...................................................... 81
ADACEL.....................................................147
adapalene external cream............................75
adapalene external gel 0.1 %.......................75
adapalene external gel 0.3 %.......................75
adapalene-benzoyl peroxide external gel.... 75
ADBRY.......................................................144
adc/f (0.5mg/ml)......................................... 201
ADCIRCA................................................... 180
ADDERALL.................................................. 72
ADDERALL XR............................................ 72
adefovir dipivoxil...........................................49
ADEMPAS..................................................180
ADHANSIA XR.............................................71
ADLARITY....................................................29
ADLYXIN......................................................54
ADLYXIN STARTER PACK......................... 54
ADMELOG................................................... 57
ADMELOG SOLOSTAR...............................57
ADRENAL C FORMULA............................ 201
ADRENALIN INJECTION SOLUTION 1
MG/ML....................................................... 178
adult 50+ probiotic......................................112
ADULT AEROSOL MASK..........................151
adult probiotic.............................................112
adult tussin cough & chest......................... 190
adv acne spot treatment.............................151
ADVAIR DISKUS....................................... 189
ADVAIR HFA..............................................189
advanced acne spot treat...........................151
advanced antacid....................................... 112
advanced antacid max st........................... 112
ADVANCED GLUCOSE TEST.................... 87
advanced healing external ointment .......... 83
ADVIL.............................................................4
ADVIL COLD/SINUS..................................190
ADVIL JUNIOR STRENGTH..........................4
ADVIL LIQUI-GELS MINIS.............................4
ADVIL MIGRAINE.......................................... 4
ADYNOVATE............................................... 62
ADZENYS XR-ODT..................................... 72
AERIVA CONCENTRATOR NEBULIZER. 151
AEROCHAMBER PLUS FLO-VU.............. 151
AEROCHAMBER PLUS FLO-VU LARGE. 151
AEROCHAMBER PLUS FLO-VU SMALL..151
AEROCHAMBER PLUS FLO-VU W/MASK
....................................................................151
AFINITOR.................................................... 41
AFINITOR DISPERZ....................................41
afirmelle......................................................134
AFLURIA QUADRIVALENT....................... 148
AFREZZA.....................................................57
AFRIN NODRIP ORIGINAL....................... 190
AFRIN SALINE NASAL MIST.................... 181
aftera.......................................................... 141
AGONEAZE................................................. 16
AGRYLIN..................................................... 60
AIMOVIG......................................................37
AIRDUO DIGIHALER.................................189
AIRDUO RESPICLICK 113/14...................189
AIRDUO RESPICLICK 232/14...................189
AIRDUO RESPICLICK 55/14.....................189
airshield......................................................201
AIRSHIELD IMMUNITY SUPPORT........... 201
AJOVY......................................................... 37
AKLIEF.........................................................75
ak-poly-bac.................................................167
AKYNZEO ORAL......................................... 33
ala-cort......................................................... 76
ALAHIST CF.............................................. 186
ALAHIST DM..............................................186
ALAVERT ALLERGY/SINUS..................... 190
ALAWAY.................................................... 173
ALAWAY CHILDRENS ALLERGY.............173
albendazole oral...........................................43
albuterol sulfate hfa aerosol solution 108
(90 base) mcg/act inhalation...................... 178
ALBUTEROL SULFATE HFA AEROSOL
SOLUTION 108 (90 BASE) MCG/ACT
INHALATION..............................................178
albuterol sulfate inhalation nebulization
solution (2.5 mg/3ml) 0.083%, 0.63
mg/3ml, 1.25 mg/3ml, 2.5 mg/0.5ml...........178
ALBUTEROL SULFATE NEBULIZATION
SOLUTION (5 MG/ML) 0.5% INHALATION
....................................................................178
albuterol sulfate nebulization solution (5
mg/ml) 0.5% inhalation...............................178
albuterol sulfate oral syrup......................... 178
albuterol sulfate oral tablet 2 mg................ 178
albuterol sulfate oral tablet 4 mg................ 178
alclometasone dipropionate......................... 76
alcohol prep pads external 70 %..................24
ALCOHOL PREP PADS PAD , 70 %........151
ALDACTAZIDE............................................ 66
210
ALDACTONE............................................... 67
ALECENSA................................................ 163
alendronate sodium oral solution............... 150
alendronate sodium oral tablet 10 mg, 35
mg.............................................................. 150
alendronate sodium oral tablet 70 mg........150
ALEVAMAX................................................151
ALEVE ORAL TABLET.................................. 4
alfuzosin hcl er........................................... 128
algal-900 dha............................................. 151
ALINIA ORAL TABLET................................ 44
aliskiren fumarate.........................................66
ALKERAN ORAL..........................................43
ALKINDI SPRINKLE.................................. 130
all day allergy d.......................................... 186
all day allergy oral tablet 10 mg................. 174
all day allergy relief.................................... 174
all day allergy-d oral tablet extended
release 12 hour 5-120 mg.......................... 186
all day pain relief............................................ 4
all day relief.................................................... 4
ALLEGRA ALLERGY................................. 187
ALLEGRA-D ALLERGY & CONGESTION.190
aller-chlor................................................... 187
allerclear.....................................................187
allerclear d-12hr......................................... 190
allerclear d-24hr......................................... 190
aller-cort..................................................... 189
aller-ease................................................... 187
aller-fex...................................................... 187
allergy & congestion...................................191
allergy (cetirizine)....................................... 174
allergy 24hour indoor/outdoor.................... 174
allergy 24-hr............................................... 187
allergy 4 hour............................................. 187
allergy childrens oral liquid.........................174
allergy childrens oral syrup........................ 187
allergy complete-d......................................186
allergy eye drops........................................173
allergy medication...................................... 174
allergy oral capsule 25 mg......................... 174
allergy oral liquid 12.5 mg/5ml................... 174
allergy oral tablet 25 mg.............................174
allergy oral tablet 4 mg...............................187
allergy rel child (loratadine)........................ 187
allergy relief (cetirizine) oral tablet 10 mg.. 174
allergy relief (loratadine).............................187
allergy relief 4-hour.................................... 187
allergy relief adult....................................... 175
allergy relief cetirizine.................................175
allergy relief childrens oral liquid 12.5
mg/5ml....................................................... 175
allergy relief childrens oral syrup 5 mg/5ml 187
allergy relief childrens oral tablet chewable
12.5 mg...................................................... 175
allergy relief childrens oral tablet chewable
5 mg........................................................... 187
allergy relief d.............................................191
allergy relief d oral tablet extended release
12 hour....................................................... 186
allergy relief d-12........................................191
allergy relief d-24........................................191
allergy relief max st.................................... 175
allergy relief nasal decong......................... 191
allergy relief oral capsule 10 mg........ 175, 187
allergy relief oral capsule 25 mg................ 175
allergy relief oral liquid 12.5 mg/5ml, 25
mg/10ml..................................................... 175
allergy relief oral tablet 10 mg............ 175, 187
allergy relief oral tablet 180 mg.................. 187
allergy relief oral tablet 25 mg.................... 175
allergy relief oral tablet 4 mg...................... 187
allergy relief oral tablet 60 mg.................... 187
allergy relief oral tablet chewable 12.5 mg.175
allergy relief oral tablet dispersible 10 mg..187
allergy relief oral tablet extended release
12 hour 5-120 mg.......................................186
allergy relief oral tablet extended release
12 mg......................................................... 187
allergy relief(cetirizine)............................... 175
allergy relief/indoor/outdoor oral tablet 10
mg.............................................................. 175
allergy relief/indoor/outdoor oral tablet 180
mg.............................................................. 187
allergy relief/nasal decong......................... 191
allergy relief/nasal decongest oral tablet
extended release 12 hour.......................... 186
allergy relief/nasal decongest oral tablet
extended release 24 hour.......................... 191
allergy relief-d oral tablet extended release
12 hour 5-120 mg...............................186, 191
allergy relief-d oral tablet extended release
24 hour 10-240 mg.....................................191
allergy relief-d12.........................................191
allergy spray 24 hour nasal aerosol........... 189
allergy/congestion relief............................. 191
allergy-d allergy & conges..........................191
aller-tec...................................................... 175
aller-tec d................................................... 186
allopurinol oral..............................................36
ALLZITAL....................................................... 8
almacone double strength..........................112
almotriptan malate........................................38
ALOCRIL....................................................166
ALOE VESTA CLEAR ANTIFUNGAL.......... 35
ALOGLIPTIN BENZOATE............................54
ALOGLIPTIN-METFORMIN HCL.................54
ALOGLIPTIN-PIOGLITAZONE.................... 54
ALOMIDE................................................... 166
ALORA....................................................... 134
alosetron hcl...............................................107
ALPHAGAN P OPHTHALMIC SOLUTION
0.1 %.......................................................... 169
ALPHAGAN P OPHTHALMIC SOLUTION
0.15 %........................................................ 169
alprazolam er............................................... 53
211
alprazolam intensol...................................... 53
alprazolam oral tablet...................................53
alprazolam oral tablet dispersible.................53
alprazolam xr................................................53
ALREX....................................................... 168
ALTACE....................................................... 63
altachlore ophthalmic ointment.................. 169
altachlore ophthalmic solution....................169
altafrin........................................................ 165
altalube.......................................................169
altamist spray............................................. 181
altarussin....................................................181
altarussin dm..............................................191
altavera...................................................... 134
ALTOPREV.................................................. 69
ALTRENO.................................................... 75
alum & mag hydroxide-simeth....................112
alum sulfate-ca acetate................................ 83
alumina-magnesia-simethicone................. 112
ALUNBRIG.................................................163
ALVESCO.................................................. 177
alvimopan...................................................112
alyacen 1/35...............................................134
alyacen 7/7/7..............................................134
ALYMSYS.................................................... 43
alyq.............................................................180
amabelz......................................................134
amantadine hcl oral......................................45
AMARYL...................................................... 54
AMBIEN..................................................... 199
AMBIEN CR............................................... 199
ambrisentan............................................... 180
amcinonide external cream.......................... 76
amcinonide external lotion........................... 76
AMELUZ.......................................................79
AMERGE......................................................38
americerin.................................................... 83
amethia...................................................... 134
amethyst.....................................................134
AMICAR ORAL SOLUTION......................... 61
AMICAR ORAL TABLET..............................61
amiloride hcl oral.......................................... 67
amiloride-hydrochlorothiazide...................... 66
amino action...............................................151
aminoamrms.............................................. 151
aminocaproic acid oral solution....................61
aminocaproic acid oral tablet....................... 61
aminoreliefrms............................................151
amiodarone hcl oral tablet 100 mg, 400 mg.64
amiodarone hcl oral tablet 200 mg...............64
AMITIZA..................................................... 107
amitriptyline hcl oral..................................... 32
amlodipine besylate oral.............................. 65
amlodipine besylate-benazepril hcl.............. 66
amlodipine besylate-valsartan......................66
amlodipine-atorvastatin................................ 66
amlodipine-olmesartan.................................66
ammonium lactate external.......................... 76
amnesteem.................................................. 75
amoxapine....................................................32
amoxicill-clarithro-lansopraz.......................108
amoxicillin.....................................................21
amoxicillin-potassium clavulanate................21
amoxicillin-potassium clavulanate er............21
amphetamine sulfate....................................72
amphetamine-dextroamphetamine.............. 72
amphetamine-dextroamphetamine er.......... 72
ampicillin...................................................... 21
AMPYRA...................................................... 73
AMRIX........................................................198
AMZEEQ...................................................... 81
ANAFRANIL................................................. 32
anagrelide hcl...............................................60
ana-lex......................................................... 83
ANALPRAM HC........................................... 79
ANALPRAM HC SINGLES...........................79
ANALPRAM-HC........................................... 79
ANAPROX DS................................................4
ANASPAZ.................................................. 151
anastrozole oral............................................41
ANBESOL MAXIMUM STRENGTH
MOUTH/THROAT GEL................................ 74
ANCOBON ORAL CAPSULE 250 MG.........34
ANCOBON ORAL CAPSULE 500 MG.........34
ANDRODERM............................................133
ANDROGEL............................................... 133
ANDROGEL PUMP....................................133
anecream external cream............................ 16
anefrin spray.............................................. 191
ANGELIQ................................................... 134
animal shapes complete............................ 201
animal shapes kids first................................99
ANNOVERA............................................... 134
ANODYNE LPT............................................16
ANORO ELLIPTA.......................................189
antacid & anti-gas oral suspension 200-
200-20 mg/5ml........................................... 112
antacid & anti-gas oral suspension 400-
400-40 mg/5ml........................................... 112
antacid & gas relief.....................................112
antacid advanced....................................... 113
antacid advanced max st........................... 113
antacid anti-gas..........................................113
antacid anti-gas ex st oral suspension 400-
400-40 mg/5ml........................................... 113
antacid anti-gas max strength.................... 113
antacid antigas multi-sympt........................113
antacid anti-gas reg strength......................113
antacid calcium.......................................... 113
antacid calcium rich....................................113
antacid extra strength oral suspension...... 113
antacid extra strength oral tablet chewable
160-105 mg................................................ 113
antacid extra strength oral tablet chewable
750 mg....................................................... 113
antacid fast relief........................................ 113
antacid i......................................................113
212
antacid iii.................................................... 113
antacid kids................................................ 113
antacid liquid.............................................. 113
antacid m....................................................113
antacid maximum....................................... 113
antacid maximum strength......................... 113
antacid maximum strength oral tablet
chewable 1000 mg..................................... 113
antacid multi-symptom oral tablet chewable
675-135-60 mg...........................................113
antacid oral suspension 200-200-20
mg/5ml, 400-400-40 mg/10ml.................... 113
antacid oral tablet chewable 1000 mg........113
antacid oral tablet chewable 500 mg..........114
antacid oral tablet chewable 750 mg..........114
antacid plus antigas................................... 114
antacid plus anti-gas relief......................... 114
antacid regular strength oral suspension... 114
antacid regular strength oral tablet
chewable.................................................... 114
antacid ultra strength oral tablet chewable
1000 mg..................................................... 114
antacid/anti-gas..........................................114
antacid/anti-gas max st.............................. 114
antacid/antigas oral suspension 200-200-
20 mg/5ml.................................................. 114
antacid/gas relief max st............................ 114
ANTARA.......................................................68
antibiotic............................................... 24, 151
antibiotic pain/scar....................................... 24
antibiotic/pain relief external ointment 1 %...24
anticavity fluoride rinse mouth/throat
solution 0.05 %.............................................92
anti-dandruff................................................. 76
anti-diarr/ant-gas........................................ 114
anti-diarrheal anti-gas................................ 114
anti-diarrheal oral liquid 1 mg/5ml.............. 107
anti-diarrheal oral liquid 1 mg/7.5ml........... 107
anti-diarrheal oral suspension 262 mg/15ml
....................................................................114
anti-diarrheal oral tablet 2 mg.................... 107
anti-diarrheal/anti-gas................................ 114
antifungal (tolnaftate)................................. 151
antifungal external cream.............................35
antifungal external powder........................... 35
anti-fungal external powder........................151
antifungal foot care.......................................35
antifungal miconazole.................................. 35
antifungal tolnaftate....................................151
anti-gas oral capsule 180 mg..................... 114
anti-hist allergy........................................... 175
antihistamine & nasal deconges................ 191
anti-nausea.................................................. 34
antiseptic...................................................... 24
ANTIVERT................................................... 32
anucort-hc.................................................... 37
ANUSOL-HC EXTERNAL.......................... 149
ANUSOL-HC RECTAL.................................37
ANZEMET.................................................... 33
APADAZ.........................................................8
apap-caff-dihydrocodeine...............................8
APEXICON E............................................... 76
APIDRA SOLOSTAR................................... 57
APIDRA VIAL............................................... 57
APLENZIN....................................................30
APOKYN...................................................... 46
apomorphine hcl subcutaneous................... 46
APO-VARENICLINE.................................... 18
apra.............................................................. 11
apraclonidine hcl........................................ 169
aprepitant oral.............................................. 33
aprepitant oral capsule 125 mg, 40 mg........33
aprepitant oral capsule 80 & 125 mg........... 33
aprepitant oral capsule 80 mg......................33
apri............................................................. 134
APRISO......................................................149
aprodine..................................................... 191
APTENSIO XR............................................. 71
APTIOM....................................................... 28
APTIVUS......................................................52
AQUA-NU.....................................................83
AQUAPHILIC............................................... 83
AQUAPHOR ADV PROTECT HEALING..... 83
AQUAPHOR ADV THERAPY HEALING..... 83
AQUAPHOR ADVANCED THERAPY
BABY............................................................83
aqueous vitamin d........................................ 99
aqueous vitamin e...................................... 207
AQUORAL....................................................74
aranelle...................................................... 134
ARANESP (ALBUMIN FREE)...................... 60
ARAVA....................................................... 145
ARAZLO.......................................................75
ARCALYST................................................ 144
arformoterol tartrate................................... 178
ARICEPT......................................................29
ARIKAYCE................................................... 20
ARIMIDEX....................................................41
aripiprazole oral solution.............................. 47
aripiprazole oral tablet..................................47
aripiprazole oral tablet dispersible................47
ARISTADA................................................... 47
ARISTADA INITIO........................................47
ARIXTRA SUBCUTANEOUS SOLUTION
10 MG/0.8ML, 7.5 MG/0.6ML.......................60
ARIXTRA SUBCUTANEOUS SOLUTION
2.5 MG/0.5ML, 5 MG/0.4ML.........................60
armodafinil..................................................200
ARMONAIR DIGIHALER........................... 177
ARMOUR THYROID.................................. 142
ARNICARE ARNICA EXTERNAL
OINTMENT................................................ 151
ARNUITY ELLIPTA.................................... 177
AROMASIN.................................................. 41
arthritis pain oral tablet extended release
650 mg......................................................... 11
213
arthritis pain relief oral tablet extended
release 650 mg............................................ 11
arthritis pain reliever oral..............................11
arthritis pain relieving................................. 151
ARTHROTEC.................................................4
artificial eye................................................ 169
artificial tears ophthalmic ointment.............169
artificial tears ophthalmic solution ............ 169
artificial tears ophthalmic solution 0.5-0.6
%, 5-6 mg/ml.............................................. 169
artificial tears ophthalmic solution 1.4 %.... 169
artificial tears ophthalmic solution 1-0.3 %.169
ASACOL HD.............................................. 149
ascomp-codeine.............................................8
ascorbic acid oral powder.......................... 201
ascorbic acid oral tablet 500 mg................ 201
asenapine maleate.......................................47
ashlyna.......................................................134
ASMANEX (120 METERED DOSES)........ 177
ASMANEX (14 METERED DOSES).......... 177
ASMANEX (30 METERED DOSES).......... 177
ASMANEX (60 METERED DOSES).......... 177
ASMANEX HFA......................................... 177
aspirin adults.............................................. 151
aspirin childrens......................................... 151
aspirin ec....................................................151
aspirin ec oral tablet 325 mg...................... 151
aspirin oral..................................................152
ASPIRIN ORAL TABLET DELAYED
RELEASE 81 MG.......................................152
aspirin rectal...............................................152
aspirin tri-buffered........................................ 15
aspirin-dipyridamole er.................................61
ASTAGRAF XL ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 0.5 MG,
1 MG.......................................................... 145
ASTAGRAF XL ORAL CAPSULE
EXTENDED RELEASE 24 HOUR 5 MG....145
ASTERO...................................................... 16
asthmanefrin refill.......................................189
astringent eye drops...................................169
astringent solution........................................ 83
atabex dha 200.......................................... 152
ATACAND.................................................... 63
ATACAND HCT............................................66
atazanavir sulfate......................................... 52
ATELVIA.................................................... 150
atenolol oral..................................................64
atenolol-chlorthalidone................................. 66
ATGAM...................................................... 144
atheletes foot................................................35
athletes foot (terbinafine)............................. 35
athletes foot (tolnaftate) external aerosol
powder 1 %................................................ 152
athletes foot (tolnaftate) external cream 1
%................................................................ 152
athletes foot external aerosol powder 2 %... 35
athletes foot external cream 1 %..................35
athletes foot external powder 2 %................35
athletes foot powder spray external aerosol
powder 1 %................................................ 152
athletes foot powder spray external aerosol
powder 2 %.................................................. 35
athletes foot spray......................................152
athletes foot spray external aerosol 2 %...... 35
ATIVAN ORAL............................................. 53
atomoxetine hcl............................................ 71
ATOPICLAIR..............................................152
atorvastatin calcium oral.............................. 69
atovaquone.................................................. 44
atovaquone-proguanil hcl.............................44
ATRALIN...................................................... 75
atropine sulfate ophthalmic ointment......... 165
atropine sulfate ophthalmic solution 1 %....165
ATROVENT HFA....................................... 178
AUBAGIO.....................................................73
aubra.......................................................... 134
aubra eq..................................................... 134
AUGMENTIN................................................21
AUGMENTIN ES-600...................................21
AUM MINI INSULIN PEN NEEDLE 32G X
4 MM , 32G X 5 MM , 32G X 6 MM..............87
AUM MINI INSULIN PEN NEEDLE 32G X
8 MM , 33G X 4 MM , 33G X 5 MM , 33G X
6 MM.......................................................... 152
AUM READYGARD DUO PEN NEEDLE.....87
AUM SAFETY PEN NEEDLE.................... 152
aurophen childrens.......................................11
aurovela 1.5/30.......................................... 134
aurovela 1/20............................................. 134
aurovela 24 fe............................................ 134
aurovela fe 1.5/30...................................... 134
aurovela fe 1/20......................................... 134
AURYXIA..................................................... 99
AUSTEDO....................................................72
AUVI-Q INJECTION SOLUTION AUTO-
INJECTOR 0.15 MG/0.15ML, 0.3
MG/0.3ML.................................................. 178
AVALIDE...................................................... 66
AVAPRO...................................................... 63
AVAR CLEANSER....................................... 83
AVAR LS CLEANSER..................................83
AVAR-E EMOLLIENT.................................. 83
AVAR-E GREEN.......................................... 83
AVAR-E LS.................................................. 83
AVEDANA GLYCERIN (ADULT)............... 123
AVENOC.................................................... 152
aviane.........................................................134
avidoxy......................................................... 23
AVITA...........................................................75
AVODART..................................................128
AVONEX PEN..............................................73
AVONEX PREFILLED..................................73
AYGESTIN................................................. 140
AYR............................................................181
AYR SALINE NASAL................................. 181
AYR SALINE NASAL DROPS................... 181
214
AYR SALINE NASAL NO-DRIP................. 181
ayuna......................................................... 134
AYVAKIT.................................................... 163
AZALGIA.................................................... 152
AZASAN.....................................................145
AZASITE.................................................... 167
azathioprine oral tablet 100 mg, 75 mg......145
azathioprine oral tablet 50 mg....................145
azelaic acid external.....................................75
azelastine hcl nasal....................................175
azelastine hcl ophthalmic........................... 166
azelastine-fluticasone.................................175
AZELEX....................................................... 75
AZILECT...................................................... 46
azithromycin oral.......................................... 22
azo............................................................. 129
AZOLEN TINCTURE....................................35
AZOPT....................................................... 169
AZOR........................................................... 66
AZSTARYS.................................................. 72
AZULFIDINE.............................................. 149
AZULFIDINE EN-TABS..............................149
azurette...................................................... 134
b complex.....................................................99
b complex formula 1 (lipotrop)......................99
b complex formula 1 (w/ fa)........................201
b complex plus c.......................................... 99
b complex vitamins.......................................99
b complex-c oral capsule............................. 99
b complex-folic acid......................................99
b-1.............................................................. 207
b-100 complex cr..........................................99
b12............................................................. 207
b-12 oral liquid 1000 mcg/15ml.................. 207
b-12 oral tablet 1000 mcg, 500 mcg...........207
b12 quick dissolve......................................207
b-12 sublingual tablet sublingual 5000 mcg
....................................................................207
b6............................................................... 207
BABY ANBESOL..........................................74
BABY AYR SALINE................................... 181
baby basics diaper rash............................... 83
baby teething oral pain.................................74
bac................................................................. 8
BACICAP................................................... 114
bacitracin external...................................... 152
bacitracin ophthalmic................................. 167
bacitracin zinc external...............................152
bacitracin zinc first aid................................152
bacitracin zinc-aloe.................................... 152
bacitracin-polymyxin b ophthalmic............. 167
bacitra-neomycin-polymyxin-hc..................165
baclofen intrathecal solution prefilled
syringe..........................................................49
baclofen oral tablet.......................................49
BACMIN..................................................... 201
BACTRIM..................................................... 22
BACTRIM DS............................................... 22
BAFIERTAM.................................................73
balance b-100.............................................. 99
balance b-50................................................ 99
balanced b100..............................................99
balanced b-100 cr........................................ 99
balanced b-100 oral tablet ..................99, 201
balanced b50................................................99
balanced b-50 oral tablet ..................100, 201
balanced b-50 tr......................................... 100
BALCOLTRA..............................................134
balsalazide disodium..................................149
BALVERSA.................................................. 41
balziva........................................................ 134
banophen oral capsule 25 mg....................175
banophen oral tablet.................................. 175
BANZEL....................................................... 28
BAQSIMI ONE PACK...................................56
BAQSIMI TWO PACK.................................. 56
BARACLUDE ORAL SOLUTION................. 49
BARACLUDE ORAL TABLET......................49
BASAGLAR KWIKPEN................................ 57
BASLE..........................................................83
BAXDELA ORAL..........................................22
BAYER ASPIRIN........................................152
BAYER LOW DOSE ORAL TABLET
CHEWABLE............................................... 152
b-complex oral tablet ................................100
b-complex with b-12................................... 100
b-complex/b-12 oral................................... 100
b-complex/vitamin c cr............................... 100
BD AUTOSHIELD DUO PEN NEEDLES..... 87
BD ULTRA-FINE INSULIN SYRINGES....... 87
BD ULTRA-FINE PEN NEEDLES................87
beauty 360 pure glycerin..............................83
beauty 360 soothing bath.............................83
BECONASE AQ......................................... 177
bee pollen oral capsule 580 mg................. 152
BELBUCA...................................................... 6
belladonna alkaloids-opium........................111
BELSOMRA............................................... 199
BENADRYL ALLERGY CHILDRENS
LIQUID 12.5 MG/5ML ORAL......................175
BENADRYL ALLERGY CHILDRENS
ORAL TABLET CHEWABLE......................175
BENADRYL ALLERGY ORAL TABLET.....175
BENADRYL ALLERGY ULTRATABS........ 175
benazepril hcl oral........................................ 63
benazepril-hydrochlorothiazide.................... 66
BENICAR..................................................... 63
BENICAR HCT.............................................66
BENLYSTA SUBCUTANEOUS................. 144
BENSAL HP............................................... 152
BENTIVITE...................................................94
BENZAC AC WASH...................................152
BENZAMYCIN..............................................75
BENZEPRO FOAMING CLOTHS.............. 152
BENZHYDROCODONE-
ACETAMINOPHEN........................................8
BENZNIDAZOLE..........................................44
215
benzoin.........................................................83
benzoin compound.......................................83
benzonatate oral capsule 100 mg.............. 191
benzonatate oral capsule 150 mg.............. 191
benzonatate oral capsule 200 mg.............. 191
benzoyl peroxide-erythromycin.................... 76
benztropine mesylate oral............................ 45
BEOVU INTRAVITREAL SOLUTION
PREFILLED SYRINGE.............................. 165
bepotastine besilate................................... 166
BEPREVE.................................................. 166
BERINERT................................................. 143
BESIVANCE...............................................167
BESPONSA............................................... 164
BESREMI..................................................... 43
beta carotene oral...................................... 100
BETADINE EXTERNAL SOLUTION 10 %...24
BETADINE OPHTHALMIC PREP..............173
betaine....................................................... 126
betamethasone dipropionate aug.................76
betamethasone dipropionate external
cream........................................................... 76
betamethasone dipropionate external lotion 76
betamethasone dipropionate external
ointment....................................................... 76
betamethasone valerate external cream......76
betamethasone valerate external foam........76
betamethasone valerate external lotion....... 76
betamethasone valerate external ointment.. 76
BETAPACE.................................................. 64
BETAPACE AF............................................ 64
BETASEPT SURGICAL SCRUB............... 152
BETASERON............................................... 73
betatemp childrens.......................................11
betaxolol hcl ophthalmic.............................168
betaxolol hcl oral.......................................... 64
bethanechol chloride oral........................... 128
BETHKIS....................................................179
BETIMOL................................................... 168
BETOPTIC-S..............................................168
BEVESPI AEROSPHERE..........................189
bexarotene................................................... 42
BEXSERO..................................................147
BEYAZ....................................................... 134
bicalutamide................................................. 40
BIDIL............................................................ 66
BIJUVA.......................................................134
BIKTARVY ORAL TABLET 30-120-15 MG..50
BIKTARVY ORAL TABLET 50-200-25 MG..50
BILTRICIDE................................................. 43
bimatoprost ophthalmic.............................. 165
BINAXNOW COVID-19 AG HOME TEST..152
biocel..........................................................202
bioflex.........................................................202
BIOLLE TEARS..........................................169
biotin forte oral tablet 5 mg.........................202
biotin high potency..................................... 202
biotin oral capsule 2500 mcg..................... 202
biotin oral capsule 5000 mcg..................... 202
biotin oral tablet 1000 mcg......................... 202
biotin oral tablet 5 mg.................................202
biotinex.......................................................114
bisacodyl ec............................................... 152
bisacodyl laxative....................................... 152
bisacodyl oral tablet delayed release 5 mg 153
bisacodyl rectal.......................................... 153
bismatrol oral tablet chewable....................114
bismuth.......................................................115
bismuth subsalicylate oral.......................... 115
bisoprolol fumarate oral................................64
bisoprolol-hydrochlorothiazide..................... 66
BLEPH-10.................................................. 167
BLEPHAMIDE S.O.P................................. 165
blisovi 24 fe................................................ 134
blisovi fe 1.5/30.......................................... 135
blisovi fe 1/20............................................. 135
BLOOD GLUCOSE TEST IN VITRO
STRIP...........................................................87
BLOOD GLUCOSE TEST STRIPS........87, 89
blue tube/ aloe..............................................16
BLUESTAR................................................ 153
BONINE....................................................... 32
BONIVA......................................................150
BONJESTA.................................................. 32
BOOSTRIX.................................................147
boro-packs................................................... 83
bosentan.................................................... 180
BOSULIF....................................................163
BOUDREAUXS BABY BUTT SMOOTH...... 83
boudreauxs butt paste ointment 40 %
external........................................................ 83
BOUDREAUXS BUTT PASTE OINTMENT
40 % EXTERNAL......................................... 83
bp 10-1......................................................... 83
bp cleansing wash........................................83
bp vit 3........................................................100
bp wash external liquid 2.5 %.................... 153
b-plex......................................................... 100
b-plex plus..................................................202
BPROTECTED PEDIA D-VITE.................. 100
BPROTECTED PEDIA IRON.......................94
BPROTECTED PEDIA POLY-VITE........... 202
BPROTECTED PEDIA POLY-VITE/FE..... 202
BRAFTOVI................................................... 41
BREATHE COMFORT CHAMBER/ADULT153
BREATHE COMFORT CHAMBER/CHILD 153
BREATHE COMFORT HUMIDIFIER......... 153
BREATHE EASE NEB MASK/CHILD........ 153
BREATHE EASE NEB MASK/INFANT...... 153
BREO ELLIPTA..........................................189
brewers yeast oral tablet 487.5 mg............ 100
BREXAFEMME.......................................... 153
BREZTRI AEROSPHERE..........................189
briellyn........................................................135
BRILINTA..................................................... 61
brimonidine tartrate ophthalmic solution
0.15 %........................................................ 169
216
brimonidine tartrate ophthalmic solution 0.2
%................................................................ 169
brimonidine tartrate-timolol.........................165
brinzolamide...............................................169
BRIVIACT ORAL..........................................26
bromfenac sodium (once-daily)..................168
bromocriptine mesylate oral......................... 46
BROMSITE................................................ 168
BRONCHITOL..............................................74
BROVANA..................................................178
BRUKINSA.................................................163
BRYHALI......................................................76
b-stress...................................................... 100
BUBBLES THE FISH II PEDI MASK..........153
budesonide er............................................ 149
budesonide inhalation................................ 177
budesonide oral..........................................149
BUDESONIDE-FORMOTEROL
FUMARATE............................................... 189
BUFFERIN................................................... 15
bumetanide oral........................................... 67
BUMEX........................................................ 67
BUPAP........................................................... 8
BUPHENYL................................................126
buprenorphine................................................ 6
buprenorphine hcl sublingual......................... 9
buprenorphine hcl-naloxone hcl................... 18
bupropion hcl er (smoking det).....................18
bupropion hcl er (sr)..................................... 30
bupropion hcl er (xl) oral tablet extended
release 24 hour 150 mg, 300 mg................. 30
BUPROPION HCL ER (XL) ORAL TABLET
EXTENDED RELEASE 24 HOUR 450 MG..30
bupropion hcl oral.........................................30
burn relief external gel..................................16
buspirone hcl oral.........................................53
butalbital-acetaminophen capsule 50-300
mg oral........................................................... 8
BUTALBITAL-ACETAMINOPHEN
CAPSULE 50-300 MG ORAL.........................8
butalbital-acetaminophen oral tablet 50-
300 mg........................................................... 8
butalbital-acetaminophen oral tablet 50-
325 mg........................................................... 8
butalbital-apap-caff-cod oral capsule 50-
300-40-30 mg.................................................8
butalbital-apap-caff-cod oral capsule 50-
325-40-30 mg.................................................8
butalbital-apap-caffeine oral capsule 50-
300-40 mg...................................................... 8
butalbital-apap-caffeine oral capsule 50-
325-40 mg...................................................... 8
butalbital-apap-caffeine oral tablet................. 8
butalbital-asa-caff-codeine............................. 8
butalbital-aspirin-caffeine............................... 8
butorphanol tartrate nasal.............................. 8
BUTRANS...................................................... 6
BYDUREON BCISE AUTOINJECTOR........ 54
BYETTA 10 MCG PEN................................ 54
BYETTA 5 MCG PEN.................................. 54
BYLVAY..................................................... 109
BYLVAY (PELLETS).................................. 109
BYOOVIZ................................................... 169
BYSTOLIC................................................... 64
c 1000-bioflavonoids-rose hips.................. 202
c complex................................................... 202
cabergoline.................................................142
CABLIVI....................................................... 61
CABOMETYX.............................................163
CADUET...................................................... 66
CAFERGOT................................................. 37
caffeine citrate oral.......................................72
cal mag zinc +d3.......................................... 94
calamine external lotion ........................... 153
calamine external lotion , 8-8 %.................. 85
calamine-zinc oxide external lotion.............. 85
CALAN SR................................................... 65
calcipotriene external cream........................ 79
CALCIPOTRIENE EXTERNAL FOAM.........79
calcipotriene external ointment.................... 79
calcipotriene external solution......................79
calcipotriene-betameth diprop external
ointment....................................................... 79
calcipotriene-betameth diprop external
suspension................................................... 79
calcitonin (salmon) nasal............................150
CALCITRENE.............................................. 79
calcitriol external.......................................... 79
calcitriol oral............................................... 150
calcium 500 +d3...........................................94
calcium 500/d oral tablet chewable.............. 94
calcium 500/vitamin d3.................................94
calcium 600 oral tablet 1500 (600 ca) mg.. 202
calcium 600/vit d/minerals oral tablet 600-
200 mg-unit.................................................. 94
calcium 600/vit d/minerals oral tablet
chewable 600-400 mg-unit...........................94
calcium 600/vitamin d...................................94
calcium 600/vitamin d-3............................... 94
calcium 600+d oral capsule 600-500 mg-
unit............................................................... 94
calcium 600+d oral tablet 600-400 mg-unit..94
calcium 600+d tablet 600-200 mg-unit oral
600-200 mg-unit................................... 94, 202
calcium 600+d3 oral capsule 600-500 mg-
unit............................................................... 94
calcium acetate (phos binder)...................... 99
calcium acetate oral tablet 667 mg.............. 99
calcium antacid.......................................... 115
calcium antacid ex st..................................115
calcium antacid extra strength................... 115
calcium antacid ultra max st oral tablet
chewable 1000 mg..................................... 115
calcium carb-cholecalciferol oral tablet
600-400 mg-unit........................................... 94
calcium carbonate antacid oral suspension115
217
calcium carbonate antacid oral tablet.........115
calcium carbonate antacid oral tablet
chewable.................................................... 115
calcium carbonate oral tablet 1500 (600
ca) mg........................................................ 202
calcium carbonate oral tablet chewable
1250 (500 ca) mg....................................... 202
calcium carbonate+vitamin d........................94
calcium carbonate-vitamin d3...................... 94
calcium cit plus vit d-3.................................. 94
calcium citrate + d3 maximum......................94
calcium citrate +d3....................................... 94
calcium citrate malate-vit d...........................94
calcium citrate oral tablet 950 (200 ca) mg.. 94
calcium citrate plus vit d............................... 94
calcium citrate+d oral tablet 315-250 mg-
unit............................................................... 94
calcium citrate+d3 oral tablet ..................... 94
calcium citrate+d3 petites oral tablet 200-
6.25 mg-mcg................................................ 94
calcium citrate+d3 w/magne.........................94
calcium citrate-vit d...................................... 95
calcium citrate-vitamin d oral tablet 200-
125 mg-unit.................................................. 95
calcium citrate-vitamin d oral tablet 315-
200 mg-unit.................................................. 95
calcium cit-vit d-3 petites..............................95
calcium fast dissolution.............................. 202
calcium high potency............................95, 202
calcium high potency/vitamin d.................... 95
calcium oral tablet 1500 (600 ca) mg......... 202
calcium oral tablet 600 mg........................... 95
calcium oyster shell oral tablet 1250 (500
ca) mg........................................................ 202
calcium plus vitamin d.................................. 95
calcium plus vitamin d3................................ 95
calcium soft chews oral tablet chewable
500-100-40 ................................................202
calcium soft chews oral tablet chewable
500-200-40 mg-unt-mcg.............................202
calcium/minerals/vitamin d........................... 95
calcium-folic acid plus d............................. 100
calcium-magnesium-zinc oral tablet 333-
133-5 mg, 333.33-133.33-5 mg....................95
calcium-vitamin d oral tablet 600-400 mg-
unit............................................................... 95
calcium-vitamin d oral tablet chewable 250-
400 mg-unit.................................................. 95
calcium-vitamin d3 oral capsule 600-500
mg-unit......................................................... 95
calcium-vitamin d3 oral tablet 600-400 mg-
unit............................................................... 95
CALENDULA EXTERNAL OINTMENT......153
cal-gest antacid.......................................... 115
calicylic.......................................................153
cal-mag aspartate...................................... 202
CALQUENCE.............................................163
CALTRATE GUMMY BITES........................ 95
CAMBIA......................................................... 4
camila.........................................................140
CAMINO PRO COMPLETE/GLYTACTIN.. 153
camrese..................................................... 135
camrese lo..................................................135
CAMZYOS................................................... 70
CANASA.................................................... 149
candesartan cilexetil.....................................63
candesartan cilexetil-hctz.............................66
capcof.........................................................191
capecitabine................................................. 43
CAPEX......................................................... 76
CAPLYTA.....................................................47
CAPRELSA................................................ 163
capsaicin external cream........................... 153
capsaicin hp............................................... 153
capsaicin pain relief....................................153
captopril oral.................................................63
capzix......................................................... 153
CARAC.........................................................79
CARAFATE................................................ 109
CARBAGLU................................................. 92
carbamazepine er........................................ 28
carbamazepine oral......................................28
CARBATROL............................................... 28
carbidopa oral.............................................. 46
carbidopa-levodopa er................................. 46
carbidopa-levodopa oral tablet.....................46
carbidopa-levodopa oral tablet dispersible...46
carbidopa-levodopa-entacapone..................45
carbinoxamine maleate oral solution..........175
carbinoxamine maleate oral tablet 4 mg.... 175
carbinoxamine maleate oral tablet 6 mg.... 176
carboxymethylcellulose sodium ophthalmic
solution.......................................................169
CARDIZEM.................................................. 65
CARDIZEM CD............................................ 65
CARDIZEM LA............................................. 65
CARDURA................................................... 62
CARDURA XL............................................ 128
CARESTART COVID-19 HOME TEST......153
CARETOUCH 2 CPAP HOSE HANGER... 153
CARETOUCH CONTROL SOL LEVEL 2.... 87
CARETOUCH CPAP & BIPAP HOSE....... 153
CARETOUCH CPAP MASK WIPES..........154
CARETOUCH CPAP PRE-WASH SOLN.. 154
CARETOUCH CPAP TUBE BRUSH......... 154
CARETOUCH MONITOR SYSTEM.............87
CARETOUCH TEST.................................... 87
CARETOUCH UNIVERSL CPAP FILTER. 154
carglumic acid.............................................. 92
carisoprodol oral.........................................198
carisoprodol-aspirin-codeine...................... 198
CARNITOR ORAL SOLUTION.................. 126
CARNITOR ORAL TABLET....................... 126
CARNITOR SF...........................................126
CAROSPIR.................................................. 67
carteolol hcl................................................ 168
218
cartia xt.........................................................65
carvedilol...................................................... 64
carvedilol phosphate er................................ 64
CASODEX....................................................40
CASTIVA WARMING................................. 154
CATAFLAM.................................................... 4
CATAPRES-TTS-1.......................................62
CATAPRES-TTS-2.......................................62
CATAPRES-TTS-3.......................................62
cavarest........................................................92
CAVILON..................................................... 35
CAYA......................................................... 154
CAYSTON..................................................179
caziant........................................................135
cefaclor er.................................................... 21
cefaclor oral capsule.................................... 21
cefaclor oral suspension reconstituted 250
mg/5ml......................................................... 21
cefadroxil......................................................21
cefazolin sodium-dextrose intravenous
solution 2-4 gm/100ml-%............................. 21
cefdinir..........................................................21
cefixime........................................................ 21
cefpodoxime proxetil.................................... 21
cefprozil........................................................21
cefuroxime axetil.......................................... 21
CELEBREX.................................................... 4
celecoxib oral................................................. 4
CELEXA....................................................... 31
CELLCEPT.................................................145
CELONTIN................................................... 27
CENTANY.................................................... 81
CENTANY AT.............................................. 81
CENTRATEX............................................... 95
CENTRUM ADULTS ORAL TABLET
CHEWABLE............................................... 202
CENTRUM FLAVOR BURST.....................202
CENTRUM FLAVOR BURST ADULT........202
CENTRUM FLAVOR BURST KIDS........... 202
CENTRUM FRESH/FRUITY 50+...............202
CENTRUM FRESH/FRUITY ADULT......... 202
CENTRUM KIDS........................................202
CENTRUM MULTI + OMEGA 3.................202
CENTRUM SILVER ORAL TABLET
CHEWABLE............................................... 203
CENTRUM SPECIALIST PRENATAL....... 100
CENTRUM VITAMINTS............................. 203
cephalexin oral capsule 250 mg, 500 mg.....21
cephalexin oral capsule 750 mg...................21
cephalexin oral suspension reconstituted.... 21
cephalexin oral tablet 250 mg...................... 21
cephalexin oral tablet 500 mg...................... 21
CEQUA...................................................... 165
CERDELGA............................................... 126
cerovel..........................................................85
cerovite jr....................................................203
CERVIDIL...................................................132
cetiri-d........................................................ 186
cetirizine hcl oral solution........................... 176
cetirizine hcl oral tablet...............................176
cetirizine hcl oral tablet chewable.............. 176
cetirizine-pseudoephedrine er....................186
CETRAXAL................................................ 173
cevimeline hcl...............................................74
charlotte 24 fe............................................ 135
chateal........................................................135
chateal eq...................................................135
CHEMET...................................................... 98
CHEMSTRIP 10 MD.................................... 87
CHEMSTRIP 10/SG.....................................87
CHEMSTRIP 2 GP.......................................87
CHEMSTRIP 5 OB.......................................87
CHEMSTRIP 7............................................. 87
CHEMSTRIP 9............................................. 87
CHEMSTRIP K.............................................87
CHEMSTRIP MICRAL................................. 87
CHEMSTRIP UGK....................................... 87
CHENODAL............................................... 108
cherry cough drops...................................... 74
cherry menthol drops................................... 74
chest congest/cough child..........................191
chest congestion relief............................... 181
chest congestion relief dm oral syrup.........191
chewable c................................................. 203
chewable c with rose hips.......................... 203
chewable childrens vitamin........................ 203
chewy not chalky flavor.............................. 115
childrens acetaminophen............................. 11
childrens allergy oral liquid 12.5 mg/5ml.... 176
childrens animal shapes.............................203
childrens apap..............................................11
childrens aspirin oral tablet chewable 81
mg.............................................................. 154
childrens chewable vitamins...................... 100
childrens chewables/ex c........................... 100
childrens chewables/iron............................203
childrens cold & allergy.............................. 191
childrens complete oral tablet chewable 18
mg.............................................................. 203
childrens cough.......................................... 191
childrens loratadine.................................... 187
childrens mucus relief cough......................191
childrens non-aspirin.................................... 11
childrens silapap.......................................... 11
childrens soothe......................................... 115
childrens vitamins/extra c...........................100
childrens vitamins/iron................................203
childs non-aspirin......................................... 12
chlordiazepoxide hcl.....................................53
chlordiazepoxide-amitriptyline......................30
chlordiazepoxide-clidinium......................... 108
chlorhexidine gluconate mouth/throat.......... 74
chloroquine phosphate oral..........................44
chlor-pheniramine...................................... 187
chlorpheniramine maleate er......................187
chlorpheniramine maleate oral...................188
chlorpromazine hcl oral................................ 47
219
chlortabs.....................................................188
chlorthalidone...............................................68
CHLOR-TRIMETON...................................188
CHLOR-TRIMETON ALLERGY................. 188
chlorzoxazone oral tablet 375 mg, 750 mg 198
chlorzoxazone oral tablet 500 mg.............. 198
chocolate laxative pieces........................... 123
chocolated laxative.....................................123
CHOICEFUL MULTIVITAMIN ORAL
TABLET CHEWABLE................................ 203
CHOLBAM................................................. 126
cholestyramine light..................................... 69
cholestyramine oral...................................... 69
CHORIONIC GONADOTROPIN
INTRAMUSCULAR.................................... 131
CHROMAGEN............................................. 95
CIALIS ORAL TABLET 5 MG.....................128
CIBINQO...................................................... 85
ciclodan........................................................ 81
ciclopirox external gel...................................81
ciclopirox external shampoo.........................81
ciclopirox external solution........................... 81
ciclopirox olamine external cream................81
ciclopirox olamine suspension 0.77 %
external........................................................ 81
ciclopirox treatment...................................... 81
cilostazol...................................................... 61
CILOXAN................................................... 167
CIMDUO.......................................................51
cimetidine hcl............................................. 109
cimetidine oral............................................ 109
CIMZIA....................................................... 145
cinacalcet hcl..............................................150
CINRYZE................................................... 143
CIPRO HC..................................................173
CIPRO ORAL SUSPENSION
RECONSTITUTED.......................................22
CIPRO ORAL TABLET................................ 22
CIPRODEX................................................ 173
ciprofloxacin hcl ophthalmic....................... 167
ciprofloxacin hcl oral.....................................22
ciprofloxacin hcl otic................................... 173
ciprofloxacin-dexamethasone.................... 173
CIPROFLOXACIN-FLUOCINOLONE PF...173
CITALOPRAM HYDROBROMIDE ORAL
CAPSULE.................................................... 31
citalopram hydrobromide oral solution......... 31
citalopram hydrobromide oral tablet.............31
CITRANATAL 90 DHA............................... 100
CITRANATAL ASSURE............................. 100
CITRANATAL B-CALM.............................. 100
CITRANATAL BLOOM...............................100
CITRANATAL DHA.................................... 100
CITRANATAL HARMONY......................... 100
citroma....................................................... 123
CITRUCEL................................................. 123
citrus calcium/vitamin d................................ 95
claravis......................................................... 76
CLARINEX................................................. 176
CLARINEX-D 12 HOUR.............................181
clarithromycin er...........................................22
clarithromycin oral........................................ 22
CLARITIN ALLERGY CHILDRENS........... 188
CLARITIN CHILDRENS............................. 188
CLARITIN EYE...........................................173
CLARITIN ORAL CAPSULE...................... 188
CLARITIN ORAL TABLET......................... 188
CLARITIN ORAL TABLET CHEWABLE 5
MG............................................................. 188
CLARITIN REDITABS ORAL TABLET
DISPERSIBLE 10 MG................................188
CLARITIN REDITABS ORAL TABLET
DISPERSIBLE 5 MG..................................188
CLARITIN-D 12 HOUR.............................. 192
CLARITIN-D 24 HOUR.............................. 192
classic prenatal.......................................... 100
c-lax laxative.............................................. 154
CLEARCANAL EARWAX SOFTENER...... 174
CLEARDETECT COVID-19 AG HOME..... 154
clearlax oral powder 17 gm/scoop............. 121
clearskin..................................................... 154
clemastine fumarate oral tablet 2.68 mg.... 176
CLENPIQ................................................... 108
CLEOCIN ORAL.......................................... 20
CLEOCIN VAGINAL CREAM.......................20
CLEOCIN VAGINAL SUPPOSITORY..........20
CLEOCIN-T..................................................81
CLIMARA................................................... 135
CLIMARA PRO.......................................... 135
CLINDACIN ETZ EXTERNAL KIT............... 85
clindacin etz external swab.......................... 81
CLINDACIN PAC......................................... 85
clindacin-p.................................................... 81
CLINDAGEL.................................................81
clindamycin hcl oral......................................20
clindamycin palmitate hcl............................. 20
clindamycin phosphate external foam..........81
clindamycin phosphate external gel............. 81
clindamycin phosphate external lotion......... 81
clindamycin phosphate external solution..... 81
clindamycin phosphate external swab......... 81
clindamycin phosphate vaginal.................... 20
clindamycin phosphate-benzoyl peroxide.... 76
clindamycin-tretinoin.................................... 76
CLINDESSE.................................................20
CLINITEST RAPID COVID-19 TEST......... 154
CLINPRO 5000............................................ 92
clobazam oral suspension............................27
clobazam oral tablet..................................... 27
clobetasol prop emollient base.....................76
clobetasol propionate e................................ 76
clobetasol propionate emulsion....................76
clobetasol propionate external..................... 76
CLOBEX.......................................................76
CLOBEX SPRAY......................................... 76
clocortolone pivalate.................................... 77
CLODAN EXTERNAL KIT............................83
220
clodan external shampoo............................. 77
CLODERM................................................... 77
clomipramine hcl oral................................... 32
clonazepam oral tablet................................. 53
clonazepam oral tablet dispersible...............53
clonidine....................................................... 62
clonidine hcl er............................................. 71
clonidine hcl oral.......................................... 62
clopidogrel bisulfate oral.............................. 61
clorazepate dipotassium.............................. 53
clotrimazole 3............................................... 35
clotrimazole 7............................................... 35
clotrimazole external cream 1 %.................. 81
clotrimazole external solution 1 %................81
clotrimazole mouth/throat troche 10 mg.......34
clotrimazole vaginal......................................35
clotrimazole vaginal cream 1 %................... 35
clotrimazole-betamethasone........................ 79
clozapine...................................................... 48
CLOZARIL....................................................48
C-NATE DHA............................................. 100
co q-10 oral capsule 50 mg........................154
COAGADEX INTRAVENOUS SOLUTION
RECONSTITUTED 500 UNIT...................... 62
COARTEM................................................... 44
cod liver oil oral capsule , 1250-135 unit,
4000-200 unit............................................. 100
cod liver oil oral capsule 1250-133 unit......203
cod liver oil oral oil ....................................100
codeine sulfate............................................... 8
co-enzyme q10...........................................154
coenzyme q10 oral capsule 100 mg.......... 154
coenzyme q-10 oral capsule 100 mg......... 154
coenzyme q-10 oral capsule 200 mg......... 154
coenzyme q10 oral capsule 50 mg............ 154
coenzyme q10 oral tablet 200 mg.............. 154
COLACE.................................................... 123
COLAZAL...................................................149
COLCHICINE ORAL CAPSULE.................. 36
colchicine oral tablet.....................................36
colchicine-probenecid.................................. 36
COLCIGEL................................................. 154
COLCRYS....................................................36
cold & allergy..............................................192
cold & allergy childrens oral elixir 1-15
mg/5ml....................................................... 192
cold & cough childrens oral liquid 2.5-1-5
mg/5ml....................................................... 192
cold & cough dm childrens oral liquid 2.5-1-
5 mg/5ml.................................................... 192
cold & flu oral liquid 10-5-325 mg/15ml......181
cold & flu relief daytime.............................. 181
cold & sinus relief oral tablet 30-200 mg.... 192
cold max.....................................................181
cold max daytime....................................... 181
cold multi-symptom daytime.......................181
cold relief oral tablet 12.5-500 mg..............181
cold sore treatment external liquid 0.13-3
%.................................................................. 85
cold/cough..................................................192
cold/cough childrens.................................. 192
cold/cough dm childrens oral liquid 2.5-1-5
mg/5ml....................................................... 192
cold/cough dm oral liquid 2.5-1-5 mg/5ml.. 192
cold/flu daytime relief................................. 182
cold/flu relief daytime................................. 182
COLD-EEZE...............................................154
COLD-EEZE NATURAL MULTI-SYMP
MOUTH/THROAT...................................... 154
COLD-EEZE PLUS DEFENSE
MOUTH/THROAT...................................... 154
COLD-EEZE SUGAR FREE...................... 154
colesevelam hcl............................................69
COLESTID................................................... 69
COLESTID FLAVORED...............................69
colestipol hcl oral granules...........................69
colestipol hcl oral packet.............................. 69
colestipol hcl oral tablet................................69
colistimethate sodium (cba)......................... 20
col-rite oral capsule 250 mg....................... 123
COLY-MYCIN M...........................................20
COMBIGAN................................................165
COMBIPATCH........................................... 135
COMBIVENT RESPIMAT.......................... 190
COMBIVIR................................................... 51
COMETRIQ (100 MG DAILY DOSE)......... 163
COMETRIQ (140 MG DAILY DOSE)......... 163
COMETRIQ (60 MG DAILY DOSE)........... 163
comfort gel................................................. 115
comfort gel antacid anti-gas oral
suspension 400-400-40 mg/5ml.................115
COMFORT TOUCH LANCETS 31G............87
COMFORT TOUCH PLUS LANCETS 30G. 87
COMIRNATY..............................................154
COMPLERA................................................. 51
complete allergy......................................... 176
complete allergy medicine oral capsule..... 176
complete allergy relief................................ 176
COMPLETE NATAL DHA.......................... 100
COMPLETENATE......................................100
complex b-100-inositol............................... 100
COMPRESSOR NEBULIZER.................... 154
compro......................................................... 32
COMTAN......................................................45
COMTREX COLD & COUGH MAX ST...... 182
CO-NATAL FA........................................... 100
CONCEPT DHA......................................... 100
CONCEPT OB........................................... 100
CONCERTA................................................. 71
CONDOMS................................................ 154
CONDYLOX................................................. 79
constulose.................................................. 107
CONTOUR CONTROL SOLUTION........... 154
CONTOUR MONITOR................................. 87
CONTOUR NEXT EZ KIT W/DEVICE......... 88
CONTOUR NEXT GEN MONITOR..............88
CONTOUR NEXT LINK KIT W/DEVICE...... 88
221
CONTOUR NEXT MONITOR KIT
W/DEVICE................................................... 88
CONTOUR NEXT ONE KIT......................... 88
CONTOUR NEXT TEST STRIPS................ 88
CONTOUR TEST STRIPS...........................88
CONZIP..........................................................6
COOL MIST HUMIDIFER.......................... 154
COPAXONE.................................................73
COPIKTRA...................................................41
coq10 oral capsule 100 mg........................ 155
coq10 oral capsule 200 mg........................ 155
coq-10 oral capsule 200 mg.......................155
coq-10 oral capsule 50 mg.........................155
coral calcium oral capsule 185-50-100 mg-
mg-unit......................................................... 95
CORAL CALCIUM ORAL TABLET 1000
(390 CA) MG.............................................. 203
CORDRAN EXTERNAL CREAM 0.05 %.....77
CORDRAN EXTERNAL LOTION.................77
CORDRAN EXTERNAL OINTMENT........... 77
CORDRAN EXTERNAL TAPE.....................77
COREG........................................................ 64
COREG CR..................................................64
coremino...................................................... 23
CORGARD...................................................64
CORICIDIN HBP COUGH/COLD...............182
CORLANOR.................................................66
corn & callus remover................................ 155
CORTEF ORAL TABLET 10 MG, 5 MG.... 130
CORTEF ORAL TABLET 20 MG............... 130
CORTENEMA............................................ 149
CORTIFOAM..............................................149
CORTI-SAV..................................................36
cortisone maximum strength external gel.... 77
CORTISPORIN-TC.................................... 173
CORTROPHIN........................................... 130
CORVITA................................................... 203
CORVITE 150 ORAL TABLET.....................95
CORVITE 150 ORAL TABLET 150-1.25
MG............................................................. 203
CORVITE FE................................................95
COSENTYX............................................... 144
COSOPT.................................................... 165
COSOPT PF.............................................. 165
COTELLIC....................................................41
COTEMPLA XR-ODT...................................71
cough & chest congestion.......................... 192
cough & cold.............................................. 182
cough & cold hbp....................................... 182
cough & sore throat nighttime.................... 182
cough childrens.......................................... 192
cough dm................................................... 192
cough dm childrens.................................... 192
cough dm er............................................... 192
cough drops mouth/throat lozenge 5.4 mg...17
cough relief oral syrup 15 mg/5ml.............. 182
cough/chest congestion dm....................... 192
cough/cold hbp...........................................182
cough/sore throat daytime oral liquid 1000-
30 mg/30ml................................................ 182
cough/sore throat nighttime oral liquid 30-
12.5-1000 mg/30ml.................................... 182
COVARYX..................................................141
COVARYX HS............................................141
COVID-19 AT-HOME TEST.......................155
COVID-19 SPECIMEN COLLECTION.......155
COZAAR...................................................... 63
CREON...................................................... 126
CRESEMBA ORAL...................................... 34
CRESTOR....................................................69
CRINONE...................................................140
cromolyn sodium inhalation........................179
cromolyn sodium nasal.............................. 190
cromolyn sodium ophthalmic......................166
cromolyn sodium oral................................. 126
CRUEX PRESCRIPTION STRENGTH........36
crush vitamin c drops................................. 203
cryselle-28..................................................135
CUPRIMINE............................................... 128
cure-all....................................................... 155
CUROSURF INTRATRACHEAL
SUSPENSION 120 MG/1.5ML...................192
CUVPOSA..................................................108
cyanocobalamin injection solution 1000
mcg/ml........................................................207
cyclobenzaprine hcl er............................... 198
cyclobenzaprine hcl oral tablet 10 mg, 5
mg.............................................................. 198
cyclobenzaprine hcl oral tablet 7.5 mg.......198
CYCLOGYL OPHTHALMIC SOLUTION
0.5 %, 2 %..................................................165
CYCLOGYL OPHTHALMIC SOLUTION 1
%................................................................ 165
CYCLOMYDRIL......................................... 173
cyclopentolate hcl ophthalmic solution 0.5
%, 2 %........................................................165
cyclopentolate hcl ophthalmic solution 1 %165
cyclophosphamide injection solution
reconstituted 500 mg....................................39
cyclophosphamide oral capsule................... 39
CYCLOPHOSPHAMIDE ORAL TABLET.....39
cycloserine oral............................................ 39
CYCLOSET..................................................54
cyclosporine modified oral capsule 100 mg,
25 mg......................................................... 145
cyclosporine modified oral capsule 50 mg. 145
cyclosporine modified oral solution............ 145
cyclosporine ophthalmic.............................165
cyclosporine oral........................................ 145
CYMBALTA..................................................73
cyproheptadine hcl oral.............................. 176
cyred.......................................................... 135
cyred eq..................................................... 135
CYSTADANE............................................. 126
CYSTADROPS.......................................... 165
CYSTAGON............................................... 126
222
CYSTARAN................................................166
CYTOGAM................................................. 144
CYTOMEL..................................................142
CYTOTEC.................................................. 109
d3 high potency oral capsule 25 mcg (1000
ut)............................................................... 100
d3 oral capsule 10 mcg (400 unit), 50 mcg
(2000 ut).....................................................100
d3 oral capsule 125 mcg (5000 ut).............100
d3 oral capsule 25 mcg (1000 ut)...............100
d3 super strength....................................... 100
d-3-5...........................................................100
d3-50.......................................................... 100
daflonex-xl..................................................203
daily acne wash..........................................155
daily fiber oral capsule 0.52 gm................. 121
daily gummies............................................ 203
daily gummies adult................................... 203
daily multivitamins/iron............................... 203
daily vitamin formula+iron.......................... 203
dairy aid......................................................115
dairy relief fast acting oral tablet 9000 unit.115
dairy relief oral tablet 3000 unit.................. 115
dalfampridine er........................................... 73
DALIRESP................................................. 179
danazol oral................................................133
dandruff shampoo external lotion.................77
DANTRIUM ORAL....................................... 49
dantrolene sodium oral.................................49
dapsone external..........................................81
dapsone oral................................................ 39
DAPTACEL................................................ 147
DARAPRIM.................................................. 44
darifenacin hydrobromide er...................... 127
DARTISLA ODT......................................... 108
dasetta 1/35............................................... 135
dasetta 7/7/7.............................................. 135
DAURISMO..................................................41
day time cold & flu oral capsule................. 182
day time cold & flu relief............................. 182
day time cold/flu......................................... 182
DAYHIST ALLERGY 12 HOUR RELIEF....176
DAYPRO........................................................ 4
daysee........................................................135
daytime.......................................................182
daytime cold & flu oral liquid...................... 182
daytime cold & flu relief.............................. 182
daytime cold/flu ms relief............................182
daytime cold/flu oral capsule 10-5-325 mg 183
daytime cold/flu oral liquid 10-5-325
mg/15ml..................................................... 183
daytime cold/flu relief................................. 183
daytime cold/flu relief oral liquid 325-10-5
mg/15ml..................................................... 183
daytime liquid............................................. 183
DAYTRANA..................................................71
DAYVIGO...................................................199
D-CARE BLOOD GLUCOSE....................... 88
D-CARE GLUCOMETER............................. 88
DDAVP INJECTION...................................131
DDAVP ORAL............................................ 131
DDAVP PF................................................. 131
deblitane.....................................................140
DECARA ORAL CAPSULE 1.25 MG
(50000 UT)................................................. 100
DECARA ORAL CAPSULE 625 MCG
(25000 UT)................................................. 100
deep sea nasal spray................................. 183
deferasirox granules.....................................98
deferasirox oral packet.................................98
deferasirox oral tablet...................................98
deferasirox oral tablet soluble...................... 98
deferiprone................................................... 98
DELESTROGEN INTRAMUSCULAR OIL
10 MG/ML.................................................. 135
DELESTROGEN INTRAMUSCULAR OIL
40 MG/ML.................................................. 135
DELSTRIGO................................................ 51
DELSYM CGH/CHEST CONG DM CHILD 192
DELSYM COUGH CHILDRENS................ 192
DELSYM COUGH/CHEST CONGEST DM192
DELSYM ORAL SUSPENSION
EXTENDED RELEASE.............................. 192
delyla..........................................................135
DELZICOL..................................................149
demeclocycline hcl....................................... 23
DEMSER......................................................66
DENAVIR..................................................... 50
DENGVAXIA.............................................. 148
DENTA 5000 PLUS......................................92
DENTAGEL..................................................92
DEPAKOTE..................................................54
DEPAKOTE ER............................................54
DEPAKOTE SPRINKLES............................ 54
DEPEN TITRATABS.................................. 128
DEPO-ESTRADIOL................................... 135
DEPO-PROVERA...................................... 140
DEPO-SUBQ PROVERA 104.................... 140
DEPO-TESTOSTERONE.......................... 133
DERMACINRX ATRIX ANTIBAC WASH... 155
DERMACINRX ATRIX CLARIFY TONER..155
DERMACINRX DOTREMIN.......................203
DERMACINRX MULTITAM........................203
DERMACINRX PENETRAL....................... 155
DERMACINRX PROBISOL........................115
DERMACINRX PROBITRAN..................... 115
DERMACINRX RIBOTIN-E........................203
DERMACINRX UREA.................................. 85
DERMA-SMOOTHE/FS BODY.................... 77
DERMA-SMOOTHE/FS SCALP.................. 77
DERMELEVE ADVANCED FORMULA....... 85
DERMOTIC................................................ 173
DESCOVY....................................................51
DESENEX EXTERNAL POWDER...............36
DESENEX JOCK ITCH................................ 36
desgen dm oral liquid................................. 186
desipramine hcl oral..................................... 32
223
desloratadine oral tablet.............................176
desloratadine oral tablet dispersible 5 mg..176
desmopressin ace spray refrig................... 131
desmopressin acetate injection..................131
DESMOPRESSIN ACETATE NASAL........131
desmopressin acetate oral......................... 131
desmopressin acetate pf............................ 131
desmopressin acetate spray...................... 131
desogestrel-ethinyl estradiol...................... 135
desonide external cream..............................77
desonide external gel................................... 77
desonide external lotion............................... 77
desonide external ointment.......................... 77
DESOWEN...................................................77
desoximetasone external............................. 77
DESOXYN....................................................72
despec dm..................................................186
despec dm-g.............................................. 186
desrx............................................................ 77
DESVENLAFAXINE ER............................... 31
desvenlafaxine succinate er.........................31
DETROL.....................................................127
DETROL LA............................................... 127
dexamethasone intensol............................ 130
dexamethasone oral elixir.......................... 130
dexamethasone oral solution..................... 130
dexamethasone oral tablet 0.5 mg, 0.75
mg, 1 mg, 2 mg.......................................... 130
dexamethasone oral tablet 1.5 mg, 4 mg, 6
mg.............................................................. 130
dexamethasone oral tablet therapy pack... 130
dexamethasone sodium phosphate
ophthalmic..................................................168
DEXCOM G6 RECEIVER............................ 88
DEXCOM G6 SENSOR............................... 88
DEXCOM G6 TRANSMITTER................... 155
DEXEDRINE................................................ 72
DEXERYL.................................................. 155
DEXILANT..................................................110
DEXLANSOPRAZOLE...............................110
dexmethylphenidate hcl............................... 71
dexmethylphenidate hcl er........................... 71
dexrazoxane hcl........................................... 42
dextroamphetamine sulfate..........................72
dextroamphetamine sulfate er......................72
dextromethorphan polistirex er...................192
dextromethorphan-guaifenesin oral syrup..192
DHIVY.......................................................... 46
DIACOMIT....................................................28
DIALYVITE.................................................100
DIALYVITE 3000........................................203
DIALYVITE 5000........................................203
DIALYVITE 800 ORAL TABLET................ 100
DIALYVITE 800/ZINC................................ 101
DIALYVITE 800-ZINC 15........................... 101
DIALYVITE OMEGA-3 CONCENTRATE...155
DIALYVITE SUPREME D.......................... 203
DIALYVITE VITAMIN D 5000.....................101
DIALYVITE/ZINC....................................... 101
diamode..................................................... 107
diaper rash external ointment.......................83
diarrhea...................................................... 115
diarrhea relief............................................. 115
DIASTAT ACUDIAL..................................... 27
DIASTAT PEDIATRIC..................................27
DIASTIX....................................................... 88
DIATRUST COVID-19 HOME TEST..........155
diazepam intensol........................................ 53
diazepam oral...............................................53
diazepam rectal............................................27
diazoxide oral............................................... 56
DIBENZYLINE..............................................62
dibucaine (perianal)......................................83
DICLEGIS.................................................... 32
DICLOFENAC................................................ 4
DICLOFENAC PATCH 1.3%..........................4
diclofenac potassium oral capsule................. 4
diclofenac potassium oral tablet.....................4
diclofenac sodium er...................................... 4
diclofenac sodium external gel 1 %................4
diclofenac sodium external gel 3 %..............79
diclofenac sodium external solution............... 4
diclofenac sodium ophthalmic.................... 168
diclofenac sodium oral................................... 4
diclofenac-misoprostol................................... 4
DICLONA..................................................... 15
dicloxacillin sodium...................................... 21
dicyclomine hcl oral capsule...................... 108
dicyclomine hcl oral solution...................... 108
dicyclomine hcl oral tablet.......................... 108
DIFFERIN.....................................................76
DIFICID........................................................ 22
diflorasone diacetate external cream........... 77
diflorasone diacetate external ointment....... 77
DIFLUCAN................................................... 34
diflunisal oral.................................................. 4
difluprednate.............................................. 168
digestive probiotic oral capsule ................ 115
digestive probiotic oral capsule 250 mg..... 115
digitek...........................................................66
digox.............................................................66
digoxin oral solution..................................... 66
digoxin oral tablet 125 mcg, 250 mcg.......... 66
dihydroergotamine mesylate injection..........37
dihydroergotamine mesylate nasal.............. 37
DILANTIN INFATABS.................................. 28
DILANTIN ORAL CAPSULE 100 MG.......... 28
DILANTIN ORAL CAPSULE 30 MG............ 28
DILANTIN ORAL SUSPENSION................. 28
DILAUDID ORAL............................................8
diltiazem hcl er beads.................................. 65
diltiazem hcl er coated beads oral capsule
extended release 24 hour............................ 65
diltiazem hcl er coated beads oral tablet
extended release 24 hour............................ 65
diltiazem hcl er oral capsule extended
release 12 hour............................................ 65
224
diltiazem hcl er oral capsule extended
release 24 hour 120 mg, 180 mg................. 65
diltiazem hcl er oral capsule extended
release 24 hour 240 mg............................... 65
diltiazem hcl oral.......................................... 65
dilt-xr oral capsule extended release 24
hour 120 mg, 180 mg................................... 65
dilt-xr oral capsule extended release 24
hour 240 mg................................................. 65
dimaphen dm cold/cough........................... 193
dimethyl fumarate oral..................................73
dimethyl fumarate starter pack.....................73
diotame instydose...................................... 115
DIOVAN....................................................... 63
DIOVAN HCT............................................... 66
DIPENTUM................................................ 149
diphedryl allergy......................................... 176
diphen........................................................ 176
diphenhist...................................................176
diphenhydramine hcl oral........................... 176
diphenoxylate-atropine oral liquid.............. 107
diphenoxylate-atropine oral tablet.............. 107
DIPHTHERIA-TETANUS TOXOIDS DT.... 147
DIPROLENE................................................ 77
dipyridamole oral..........................................61
disopyramide phosphate.............................. 64
disulfiram oral tablet 250 mg........................ 18
disulfiram oral tablet 500 mg........................ 18
DITROPAN XL........................................... 127
DIURIL......................................................... 68
divalproex sodium er.................................... 54
divalproex sodium oral................................. 54
DIVIGEL..................................................... 135
dm maximum adult.....................................193
docosanol external....................................... 85
docu........................................................... 123
docu liquid.................................................. 123
docusate calcium....................................... 123
docusate mini............................................. 123
docusate sodium oral capsule....................123
docusate sodium oral liquid 100 mg/10ml,
50 mg/5ml.................................................. 123
docusate sodium oral syrup....................... 123
docusate sodium oral tablet....................... 123
DOCUSOL MINI.........................................123
docuzen......................................................123
DODEX...................................................... 207
dofetilide.......................................................64
dok oral tablet.............................................123
dolishale..................................................... 135
donepezil hcl oral tablet 10 mg, 5 mg.......... 29
donepezil hcl oral tablet 23 mg.................... 29
donepezil hcl oral tablet dispersible............. 29
DONNATAL................................................111
DOPTELET.................................................. 61
DORYX........................................................ 23
DORYX MPC............................................... 23
DORZOLAMIDE HCL SOLUTION 2 %
OPHTHALMIC............................................169
dorzolamide hcl solution 2 % ophthalmic... 169
dorzolamide hcl-timolol mal........................166
dorzolamide hcl-timolol mal pf....................166
dotti............................................................ 135
double antibiotic......................................... 155
DOVATO...................................................... 50
DOVONEX................................................... 79
doxazosin mesylate oral...............................62
doxepin hcl external..................................... 77
doxepin hcl oral capsule...............................32
doxepin hcl oral concentrate........................ 32
doxepin hcl oral tablet................................ 199
doxercalciferol oral..................................... 150
doxycycline...................................................23
doxycycline hyclate oral capsule..................23
doxycycline hyclate oral tablet 100 mg........ 23
doxycycline hyclate oral tablet 150 mg, 75
mg................................................................ 23
doxycycline hyclate oral tablet 20 mg.......... 23
doxycycline hyclate oral tablet 50 mg.......... 23
doxycycline hyclate oral tablet delayed
release 100 mg............................................ 23
doxycycline hyclate oral tablet delayed
release 150 mg, 75 mg................................ 23
doxycycline hyclate oral tablet delayed
release 200 mg, 50 mg................................ 23
DOXYCYCLINE HYCLATE ORAL TABLET
DELAYED RELEASE 80 MG....................... 23
doxycycline monohydrate oral capsule 100
mg................................................................ 23
doxycycline monohydrate oral capsule 150
mg, 75 mg.................................................... 23
doxycycline monohydrate oral capsule 50
mg................................................................ 23
doxycycline monohydrate oral suspension
reconstituted.................................................23
doxycycline monohydrate oral tablet 100
mg, 50 mg.................................................... 23
doxycycline monohydrate oral tablet 150
mg................................................................ 23
doxycycline monohydrate oral tablet 75 mg.23
doxylamine-pyridoxine................................. 32
DR SMITHS ADULT BARRIER....................83
DR SMITHS DIAPER QUICK RELIEF......... 83
driminate...................................................... 32
DRISDOL................................................... 203
DRIZALMA SPRINKLE................................ 73
dronabinol.................................................... 33
DROPSAFE ALCOHOL PREP.................. 155
drospiren-eth estrad-levomefol.................. 135
drospirenone-ethinyl estradiol.................... 135
DROXIA ORAL CAPSULE 200 MG, 300
MG............................................................... 60
DROXIA ORAL CAPSULE 400 MG............. 60
droxidopa..................................................... 62
dry eye relief ophthalmic gel 0.4-0.3 %...... 170
dry mouth..................................................... 74
dry-eye relief nighttime...............................170
225
DRYSOL.................................................... 155
dss..............................................................123
DUAKLIR PRESSAIR................................ 190
DUAVEE.................................................... 135
DUETACT.................................................... 55
DUEXIS..........................................................4
DULERA.....................................................190
duloxetine hcl oral........................................ 73
DUOBRII...................................................... 80
DUOPA........................................................ 46
DUPIXENT................................................. 144
DUREZOL.................................................. 168
dutasteride oral.......................................... 128
dutasteride-tamsulosin hcl......................... 128
D-VI-SOL....................................................101
d-vite pediatric............................................101
DYANAVEL XR............................................ 72
DYMISTA................................................... 176
DYRENIUM.................................................. 67
e................................................................. 207
E.E.S. 400.................................................... 22
E.E.S. GRANULES...................................... 22
e-400-clear................................................. 207
ear drops.................................................... 174
ear wax kit.................................................. 174
ear wax removal.........................................174
ear wax removal system............................ 174
earwax removal..........................................174
earwax removal drops................................174
earwax removal kit otic solution 6.5 %....... 174
EASIVENT................................................. 155
EASIVENT MASK LARGE......................... 155
EASIVENT MASK MEDIUM.......................155
EASIVENT MASK SMALL......................... 155
EASY TOUCH TEST....................................88
easygel.........................................................92
easy-lax plus.............................................. 123
EASYMAX 15 LEVEL 2 CONTROL............. 88
EASYMAX 15 LEVEL 2-3 CONTROL..........88
EASYMAX 15 TEST.....................................88
EASYMAX CONTROL............................... 156
EASYMAX NG BLOOD GLUCOSE............. 88
EASYMAX V BLOOD GLUCOSE................ 89
EBASE CONTROLLER KIT....................... 156
EC-NAPROSYN.............................................4
ec-naproxen................................................... 4
econazole nitrate external............................ 81
econtra ez.................................................. 141
econtra one-step........................................ 141
ECZEMOL..................................................156
ED A-HIST ORAL LIQUID..........................186
ed bron gp.................................................. 183
ed chlorped jr............................................. 188
ed-apap........................................................ 12
EDARBI........................................................63
EDARBYCLOR............................................ 66
EDECRIN..................................................... 67
EDLUAR.....................................................199
ED-SPAZ....................................................156
EDURANT....................................................51
EEMT......................................................... 141
efavirenz.......................................................51
efavirenz-emtricitab-tenofovir.......................51
efavirenz-lamivudine-tenofovir..................... 51
EFFER-K ORAL TABLET
EFFERVESCENT 10 MEQ, 20 MEQ........... 95
effer-k oral tablet effervescent 25 meq.......203
effervescent formula...................................203
EFFEXOR XR.............................................. 31
EFFIENT...................................................... 61
EFUDEX.......................................................80
EGRIFTA SV..............................................131
ELDERTONIC............................................ 101
electrolyte solution....................................... 95
ELEMAR PATCH......................................... 17
ELEPSIA XR................................................ 26
ELESTRIN..................................................135
ELETONE.................................................. 156
eletriptan hydrobromide............................... 38
ELFOLATE.................................................203
ELIDEL.........................................................77
ELIGARD................................................... 142
elinest.........................................................135
ELIQUIS....................................................... 60
ELIQUIS DVT/PE STARTER PACK............ 60
ELITE-OB...................................................101
ELLA.......................................................... 140
ELLUME COVID-19 HOME TEST............. 156
ELMIRON...................................................128
ELOCTATE.................................................. 62
eluryng....................................................... 135
ELYXYB......................................................... 4
EMCYT.........................................................40
EMEND ORAL............................................. 33
EMEND TRI-PACK...................................... 33
EMETROL....................................................34
EMFLAZA...................................................130
EMGALITY................................................... 37
EMGALITY (300 MG DOSE)........................37
emoquette.................................................. 135
EMPAVELI................................................... 54
EMSAM........................................................ 30
emtricitabine.................................................51
emtricitabine-tenofovir df..............................51
EMTRIVA..................................................... 51
EMVERM..................................................... 43
enalapril maleate oral solution..................... 63
enalapril maleate oral tablet......................... 63
enalapril-hydrochlorothiazide....................... 66
ENBRACE HR............................................101
ENBREL.....................................................145
ENDACOF-DM...........................................193
ENDARI........................................................92
endocet.......................................................... 8
ENDOMETRIN........................................... 140
enema........................................................ 115
enema disposable...................................... 115
226
enema mineral oil.......................................121
enema ready-to-use................................... 115
enema rectal enema 16-6 gm/133ml, 19-7
gm/118ml................................................... 115
ENEMEEZ MINI......................................... 123
ENFAMIL ENFALYTE.................................. 95
ENFAMIL EXPECTA..................................101
ENGERIX-B............................................... 147
ENLITE GLUCOSE SENSOR......................89
enoxaparin sodium.......................................60
enpresse-28............................................... 135
enskyce...................................................... 135
ENSPRYNG............................................... 145
ENSTILAR....................................................80
entacapone.................................................. 45
entecavir.......................................................49
ENTEREG..................................................116
enteric aspirin.............................................156
enteric fish oil............................................. 156
ENTRESTO..................................................66
enulose.......................................................107
ENVARSUS XR......................................... 145
ENZADYNE................................................116
EPANED...................................................... 63
EPCLUSA ORAL PACKET.......................... 50
EPCLUSA ORAL TABLET 200-50 MG........ 50
EPCLUSA ORAL TABLET 400-100 MG...... 50
ephrine nose drops.................................... 183
EPIDIOLEX.................................................. 26
EPIDUO....................................................... 76
EPIDUO FORTE.......................................... 76
EPIFOAM..................................................... 80
epinastine hcl............................................. 166
epinephrine injection solution auto-injector
0.15 mg/0.15ml.......................................... 178
epinephrine solution auto-injector 0.15
mg/0.3ml injection...................................... 178
epinephrine solution auto-injector 0.3
mg/0.3ml injection...................................... 178
EPIPEN 2-PAK...........................................178
EPIPEN JR 2-PAK..................................... 178
epitol.............................................................28
EPIVIR......................................................... 51
EPIVIR HBV................................................. 49
eplerenone................................................... 67
EPOGEN......................................................60
EPRONTIA...................................................26
EPSOLAY.................................................. 156
EPZICOM.....................................................51
EQUETRO................................................... 54
ergocalciferol oral capsule......................... 203
ergoloid mesylates oral................................ 29
ERGOMAR...................................................37
ergotamine-caffeine..................................... 37
ERIVEDGE...................................................41
ERLEADA.................................................... 40
erlotinib hcl................................................. 163
errin............................................................ 140
ERTACZO.................................................... 81
ery................................................................ 81
ERYGEL.......................................................81
ERYPED 200............................................... 22
ERYPED 400............................................... 22
ERY-TAB......................................................22
ERYTHROCIN STEARATE......................... 22
erythromycin base........................................22
erythromycin ethylsuccinate oral..................22
erythromycin external...................................81
erythromycin ophthalmic............................ 167
erythromycin oral..........................................22
ESBRIET....................................................180
escitalopram oxalate oral............................. 31
ESGIC ORAL CAPSULE............................... 8
ESGIC ORAL TABLET...................................8
esomeprazole magnesium oral capsule
delayed release..........................................110
esomeprazole magnesium oral packet...... 110
ESPEROCT................................................. 62
est estrogens-methyltest............................ 141
est estrogens-methyltest ds....................... 141
est estrogens-methyltest hs....................... 141
estarylla......................................................135
estazolam...................................................199
ester-c oral tablet....................................... 203
ESTRACE.................................................. 135
estradiol oral...............................................135
estradiol transdermal..................................135
estradiol vaginal cream.............................. 135
estradiol vaginal tablet............................... 135
estradiol valerate intramuscular oil 40
mg/ml......................................................... 135
estradiol-norethindrone acet...................... 135
ESTRING................................................... 135
estro vital nutrients ex st............................ 156
eszopiclone oral tablet 1 mg...................... 199
eszopiclone oral tablet 2 mg, 3 mg............ 199
ethacrynic acid............................................. 67
ethambutol hcl oral tablet 100 mg................ 39
ethambutol hcl oral tablet 400 mg................ 39
ethosuximide oral......................................... 27
ethynodiol diac-eth estradiol...................... 135
etodolac..........................................................4
etodolac er..................................................... 4
etonogestrel-ethinyl estradiol..................... 135
etoposide oral...............................................41
etravirine...................................................... 51
EUCRISA..................................................... 77
EULEXIN......................................................40
euthyrox..................................................... 142
EVAC......................................................... 121
EVAMIST................................................... 136
EVEKEO...................................................... 72
EVEKEO ODT..............................................72
evening primrose oil oral capsule 500 mg..156
everolimus oral tablet 0.25 mg, 0.5 mg,
0.75 mg, 1 mg............................................ 145
227
everolimus oral tablet 10 mg, 2.5 mg, 5
mg, 7.5 mg................................................... 41
everolimus oral tablet soluble.......................41
everyday care probiotic.............................. 116
EVISTA...................................................... 141
EVOCLIN..................................................... 81
EVOTAZ.......................................................52
EVOXAC...................................................... 74
EVRYSDI................................................... 126
EXCEDRIN EXTRA STRENGTH TABLET
250-250-65 MG ORAL................................. 12
EXCEDRIN MIGRAINE................................12
EXCEDRIN TENSION HEADACHE.............12
EXELON.......................................................29
exemestane..................................................41
EXFORGE....................................................66
EXFORGE HCT........................................... 66
EXJADE....................................................... 98
EXKIVITY..................................................... 41
EX-LAX...................................................... 123
EX-LAX MAXIMUM STRENGTH............... 123
EX-LAX ULTRA..........................................156
EXSERVAN..................................................72
EXTAVIA...................................................... 73
EXTINA........................................................ 81
eye allergy relief......................................... 173
eye drops advanced relief.......................... 170
eye drops long lasting................................ 170
eye drops ophthalmic solution 0.05 %....... 170
eye drops ophthalmic solution 0.05-0.1-1-1
%................................................................ 170
eye drops ophthalmic solution 0.05-0.25 %170
eye itch relief ophthalmic solution 0.025 % 173
eye lubricant...............................................170
EYSUVIS....................................................168
EZALLOR SPRINKLE.................................. 69
ezetimibe......................................................69
ezetimibe-simvastatin...................................69
EZFE 200..................................................... 95
fa-8............................................................. 156
fabb............................................................ 101
FABIOR........................................................76
falmina........................................................136
famciclovir oral............................................. 50
famotidine oral suspension reconstituted
40 mg/5ml.................................................. 109
famotidine oral tablet 10 mg.......................109
famotidine oral tablet 20 mg, 40 mg...........109
famotidine orig st........................................109
FANAPT....................................................... 47
FANAPT TITRATION PACK........................ 47
FARESTON..................................................40
FARXIGA..................................................... 55
FASENRA PEN..........................................181
fast relief laxative....................................... 156
fayosim.......................................................136
fe c tab......................................................... 95
febuxostat.....................................................36
felbamate..................................................... 26
FELBATOL...................................................26
FELDENE.......................................................4
felodipine er..................................................65
FEM PH........................................................24
FEMARA...................................................... 41
FEMCAP.................................................... 156
FEMRING...................................................136
femynor...................................................... 136
fenofibrate micronized oral capsule 130
mg, 134 mg, 200 mg, 43 mg, 67 mg............ 68
FENOFIBRATE MICRONIZED ORAL
CAPSULE 30 MG, 90 MG............................68
fenofibrate oral capsule................................68
fenofibrate oral tablet 120 mg, 40 mg.......... 68
fenofibrate oral tablet 145 mg, 48 mg.......... 68
fenofibrate oral tablet 160 mg, 54 mg.......... 68
fenofibric acid oral capsule delayed release 68
fenofibric acid oral tablet.............................. 70
FENOGLIDE................................................ 68
fenoprofen calcium oral capsule 400 mg....... 4
fenoprofen calcium oral tablet........................ 4
FENSOLVI (6 MONTH)..............................142
fentanyl...........................................................6
fentanyl citrate buccal lozenge on a handle... 8
FENTANYL CITRATE BUCCAL TABLET......8
FENTORA...................................................... 8
ferate............................................................ 95
FER-IN-SOL.................................................95
FERIVA 21/7................................................ 95
FERIVAFA....................................................95
ferocon......................................................... 95
ferosul.......................................................... 95
ferotrinsic......................................................95
FERRALET 90............................................. 95
FERRAPLUS 90...........................................95
ferretts.......................................................... 95
ferrex 150 capsule 150 mg oral....................96
FERREX 150 CAPSULE 150 MG ORAL..... 96
FERRIC X-150............................................. 96
FERRIPROX ORAL SOLUTION.................. 98
FERRIPROX ORAL TABLET.......................98
FERRIPROX TWICE-A-DAY....................... 98
FERRO-PLEX.............................................. 96
ferrous fumarate oral tablet 324 (106 fe)
mg................................................................ 96
ferrous gluconate oral tablet 240 (27 fe) mg 96
ferrous gluconate oral tablet 324 (37.5 fe)
mg................................................................ 96
ferrous gluconate oral tablet 324 (38 fe) mg 96
ferrous sulfate oral elixir............................... 96
ferrous sulfate oral solution 75 (15 fe)
mg/ml........................................................... 96
ferrous sulfate oral syrup..............................96
ferrous sulfate oral tablet 325 (65 fe) mg..... 96
ferrous sulfate oral tablet delayed release... 96
FETZIMA......................................................31
FETZIMA TITRATION..................................31
fever reducer/pain reliever........................... 12
228
fever reducing childrens............................... 12
feverall adults............................................... 12
feverall childrens.......................................... 12
FEVERALL INFANTS.................................. 12
FEVERALL JUNIOR STRENGTH................12
fe-vite iron.................................................... 96
FEXMID......................................................198
fexofenadine hcl oral.................................. 188
fexofenadine/pse er....................................193
fexofenadine-pseudoephed er................... 193
FIASP...........................................................57
FIASP FLEXTOUCH.................................... 57
FIASP PENFILL........................................... 57
fiber laxative + calcium...............................123
fiber laxative oral capsule 0.52 gm.............121
fiber laxative oral tablet 500 mg................. 124
fiber oral capsule 0.52 gm..........................121
fiber oral powder 28.3 %............................ 121
fiber oral powder 48.57 %.......................... 121
fiber oral powder 58.6 %............................ 121
fiber oral tablet 500 mg.............................. 124
fiber oral tablet 625 mg.............................. 124
fiber therapy oral capsule 0.52 gm.............121
fiber therapy oral powder 28.3 %............... 121
fiber therapy oral tablet 500 mg................. 124
fiber therapy oral tablet 625 mg................. 124
fiber-caps................................................... 124
fiber-lax...................................................... 124
FIBRICOR.................................................... 70
FILTER AIR PP.......................................... 156
FINACEA......................................................76
finasteride oral tablet 5 mg.........................128
FINTEPLA.................................................... 26
FIORICET...................................................... 8
FIORICET/CODEINE..................................... 8
FIRAZYR....................................................143
FIRDAPSE................................................... 72
first aid antibiotic external ointment 1 %.......24
first aid antibiotic external ointment 3.5-
400-5000 , 3.5-400-5000 mg-unit.................24
first aid antiseptic external solution 10 %..... 24
FIRVANQ..................................................... 20
fish oil concentrate oral capsule 1000 mg..156
fish oil half-the-size.................................... 156
fish oil oral capsule 1000 mg......................156
fish oil oral capsule 1200 mg......................156
fish oil oral capsule 500 mg........................156
fish oil oral capsule delayed release 1000
mg.............................................................. 156
fish oil oral capsule delayed release 1200
mg.............................................................. 156
flac..............................................................173
FLAGYL....................................................... 20
flanders buttocks.......................................... 83
FLAREX..................................................... 168
flavoxate hcl............................................... 127
FLEBOGAMMA DIF INTRAVENOUS
SOLUTION 0.5 GM/10ML, 20 GM/400ML. 144
flecainide acetate......................................... 64
FLECTOR...................................................... 4
FLEET BISACODYL.................................. 156
FLEET ENEMA.......................................... 116
FLEET OIL................................................. 121
FLEET PEDIATRIC....................................116
FLEQSUVY.................................................. 49
flexgen........................................................203
FLEXICHAMBER....................................... 156
FLEXICHAMBER ADULT MASK/SMALL.. 156
FLEXICHAMBER CHILD MASK/LARGE... 156
FLEXICHAMBER CHILD MASK/SMALL... 156
flintstones multivitamin............................... 101
FLOMAX.................................................... 128
FLORANEX ONE....................................... 116
floranex tablet oral......................................116
FLORANEX TABLET ORAL...................... 116
FLORIVA ORAL LIQUID.............................. 96
FLORIVA ORAL TABLET CHEWABLE..... 101
FLORIVA PLUS......................................... 101
FLOVENT DISKUS.................................... 177
FLOVENT HFA.......................................... 177
FLOWFLEX COVID-19 AG HOME TEST.. 156
flu/cold/daytime.......................................... 183
flu/severe cold & cough day....................... 183
flu/severe cold daytime oral liquid 10-5-325
mg/15ml..................................................... 183
flu/severe cold daytime oral packet 20-10-
500 mg....................................................... 183
FLUAD QUADRIVALENT.......................... 148
FLUARIX QUADRIVALENT....................... 148
FLUBLOK QUADRIVALENT......................148
FLUCELVAX QUADRIVALENT................. 148
fluconazole oral............................................ 34
flucytosine oral capsule 250 mg...................34
flucytosine oral capsule 500 mg...................34
fludrocortisone acetate oral........................130
FLUID ADMINISTRATION SET................. 156
FLULAVAL QUADRIVALENT.................... 148
flunisolide nasal..........................................177
fluocinolone acetonide body.........................77
fluocinolone acetonide external cream 0.01
%.................................................................. 77
fluocinolone acetonide external cream
0.025 %........................................................ 77
fluocinolone acetonide external ointment.....77
fluocinolone acetonide external solution...... 78
fluocinolone acetonide otic.........................173
fluocinolone acetonide scalp........................ 78
fluocinonide emulsified base........................ 78
fluocinonide external cream 0.05 %............. 78
fluocinonide external cream 0.1 %............... 78
fluocinonide external gel.............................. 78
fluocinonide external ointment..................... 78
fluocinonide external solution.......................78
FLUORIDEX.................................................92
FLUORIDEX ENHANCED WHITENING......92
FLUORIDEX SENSITIVITY RELIEF............ 92
229
FLUORIMAX 5000....................................... 92
FLUORIMAX 5000 SENSITIVE................... 92
fluorometholone......................................... 168
FLUOROURACIL EXTERNAL CREAM 0.5
%.................................................................. 80
fluorouracil external cream 5 %....................80
fluorouracil external solution........................ 80
fluoxetine hcl (pmdd)....................................31
fluoxetine hcl oral......................................... 31
fluphenazine decanoate injection.................47
fluphenazine hcl injection............................. 47
fluphenazine hcl oral concentrate................ 47
fluphenazine hcl oral elixir............................47
fluphenazine hcl oral tablet.......................... 47
flurandrenolide external cream.....................78
flurandrenolide external lotion...................... 78
flurandrenolide external ointment.................78
flurazepam hcl............................................199
flurbiprofen oral tablet 100 mg....................... 4
flurbiprofen sodium.....................................168
flutamide.......................................................40
FLUTICASONE FUROATE-VILANTEROL 190
fluticasone propionate external cream......... 78
fluticasone propionate external lotion...........78
fluticasone propionate external ointment..... 78
FLUTICASONE PROPIONATE HFA......... 177
fluticasone propionate nasal...................... 177
fluticasone-salmeterol aerosol powder
breath activated 100-50 mcg/act inhalation190
fluticasone-salmeterol aerosol powder
breath activated 250-50 mcg/act inhalation190
fluticasone-salmeterol aerosol powder
breath activated 500-50 mcg/act inhalation190
FLUTICASONE-SALMETEROL
INHALATION AEROSOL POWDER
BREATH ACTIVATED 113-14 MCG/ACT,
232-14 MCG/ACT, 55-14 MCG/ACT..........190
fluvastatin sodium........................................ 69
fluvastatin sodium er.................................... 69
fluvoxamine maleate.................................... 31
fluvoxamine maleate er................................ 31
FLUZONE HIGH-DOSE QUADRIVALENT 148
FLUZONE QUADRIVALENT..................... 148
FML............................................................ 168
FML FORTE...............................................168
FML LIQUIFILM......................................... 168
foaming antacid oral tablet chewable 80-20
mg.............................................................. 116
FOCALIN......................................................71
FOCALIN XR................................................71
FOLAMAX.................................................. 203
FOLGARD RX............................................101
folic acid oral tablet 1 mg........................... 156
folic acid oral tablet 400 mcg, 800 mcg......156
FOLIFLEX.................................................. 204
FOLITE.......................................................101
FOLITIN-Z.................................................. 204
FOLIVANE-F................................................ 96
FOLIVANE-OB........................................... 101
foltabs 800..................................................101
FOLTANX...................................................101
FOLTRATE................................................ 101
foltrin............................................................ 96
fondaparinux sodium subcutaneous
solution 10 mg/0.8ml, 7.5 mg/0.6ml............. 60
fondaparinux sodium subcutaneous
solution 2.5 mg/0.5ml, 5 mg/0.4ml............... 60
foot & sneaker............................................ 156
foot care (terbinafine)................................... 36
for sty relief.................................................170
FORDAGEL................................................. 85
FORFIVO XL................................................30
formoterol fumarate inhalation................... 178
FORMULA 3 THE TREATMENT............... 157
FORMULA 7 THE SOLUTION................... 157
FORTEO.................................................... 150
FORTESTA................................................ 133
FORTISCARE CONTROL......................... 157
FORTISCARE G1 TEST STRIP.................. 89
FORTISCARE T1 GLUCOSE SYSTEM...... 89
FORTISCARE TEST....................................89
FOSAMAX..................................................150
FOSAMAX PLUS D....................................150
fosamprenavir calcium................................. 52
fosfomycin tromethamine............................. 20
fosinopril sodium.......................................... 63
fosinopril sodium-hctz.................................. 66
FOSRENOL................................................. 99
FOTIVDA....................................................163
FRAGMIN.....................................................60
FREESTYLE LIBRE 14 DAY READER....... 89
FREESTYLE LIBRE 14 DAY SENSOR....... 89
FREESTYLE LIBRE 2 READER..................89
FREESTYLE LIBRE 2 SENSOR..................89
FREESTYLE LIBRE 3 SENSOR..................89
FREESTYLE LIBRE READER.....................89
FREESTYLE PRECISION NEO SYSTEM...89
FREESTYLE PRECISION NEO TEST........ 89
freeze dried acidophilus............................. 116
FROVA.........................................................38
frovatriptan succinate................................... 38
fruity c.........................................................204
full spectrum b/vitamin c.............................101
FULPHILA.................................................... 60
fungi-guard................................................. 157
FUNGOID TINCTURE................................. 36
furosemide oral............................................ 67
FUZEON...................................................... 51
fyavolv........................................................ 136
FYCOMPA................................................... 26
g tussin ac.................................................. 193
gabapentin oral capsule............................... 27
gabapentin oral solution 250 mg/5ml........... 27
gabapentin oral tablet...................................27
GABITRIL.....................................................27
GABLOFEN INTRATHECAL SOLUTION
PREFILLED SYRINGE 50 MCG/ML............ 49
230
GALAFOLD................................................ 126
galantamine hydrobromide er...................... 29
galantamine hydrobromide oral solution...... 29
galantamine hydrobromide oral tablet..........29
GALZIN ORAL CAPSULE 25 MG................96
GALZIN ORAL CAPSULE 50 MG................96
GAMASTAN............................................... 144
GAMMAPLEX INTRAVENOUS
SOLUTION 20 GM/400ML......................... 144
GAMUNEX-C INJECTION SOLUTION 40
GM/400ML................................................. 144
GARDASIL 9.............................................. 147
gas relief antiflatuent.................................. 116
gas relief drops infants............................... 116
gas relief extra strength..............................116
gas relief extstrength..................................116
gas relief infants......................................... 116
gas relief infants drops............................... 116
gas relief infants oral suspension...............116
gas relief oral capsule 125 mg................... 116
gas relief oral capsule 180 mg................... 116
gas relief oral tablet chewable....................116
gas relief oral tablet chewable 125 mg.......116
gas relief ultra strength...............................116
gas relief ultstrength...................................116
GASTROCROM......................................... 126
GAS-X EXTRA STRENGTH ORAL
CAPSULE.................................................. 116
GAS-X EXTRA STRENGTH ORAL
TABLET CHEWABLE................................ 116
GAS-X ULTRA STRENGTH...................... 117
gatifloxacin ophthalmic...............................167
GATTEX.....................................................108
gavilax oral powder.................................... 121
gavilyte-c.................................................... 108
gavilyte-g....................................................108
gavilyte-n with flavor pack.......................... 108
GAVISCON................................................ 117
GAVISCON EXTRA RELIEF FORMULA... 117
GAVISCON EXTRA STRENGTH.............. 117
GAVRETO..................................................163
GEBAUERS PAIN EASE............................. 17
GEBAUERS SPRAY AND STRETCH......... 17
GELNIQUE.................................................127
GELUSIL.................................................... 117
gemfibrozil oral.............................................68
gemmily......................................................136
GEMTESA....................................................48
GENADUR EXTERNAL............................. 157
GENERESS FE..........................................136
generlac..................................................... 107
gengraf....................................................... 145
GENOTROPIN........................................... 131
GENOTROPIN MINIQUICK....................... 131
gentak........................................................ 167
gentamicin sulfate external.......................... 81
gentamicin sulfate ophthalmic....................167
GENTEAL SEVERE...................................170
GENTEAL TEARS MODERATE PF.......... 170
GENTEAL TEARS NIGHT-TIME............... 170
SOLUTION 0.1-0.2-0.3 %.......................... 170
GENTEAL TEARS PF................................170
GENTEAL TEARS SEVERE DAY/NIGHT. 170
gentle laxative oral tablet delayed release
5 mg........................................................... 157
gentle laxative rectal suppository 10 mg.... 157
gentle laxative womens..............................157
gentlelax.....................................................121
GENTLE-LET PLATFORMS........................ 92
genuine aspirin...........................................157
GENVOYA................................................... 50
GEODON ORAL.......................................... 47
geri-dryl...................................................... 176
geri-kot....................................................... 124
geri-lanta.................................................... 117
geri-mox..................................................... 117
geri-tussin dm.............................................193
GILENYA ORAL CAPSULE 0.5 MG............ 73
GILOTRIF...................................................163
giltuss severe sinus....................................193
GIMOTI........................................................ 32
GIVLAARI...................................................126
glatiramer acetate........................................ 73
glatopa......................................................... 73
GLEEVEC.................................................. 163
glimepiride....................................................55
glipizide er.................................................... 55
glipizide ir..................................................... 55
glipizide xl.....................................................55
glipizide-metformin hcl................................. 55
GLOPERBA................................................. 36
GLUCAGEN HYPOKIT................................ 56
GLUCAGON EMERGENCY INJECTION
SOLUTION RECONSTITUTED................... 56
glucagon emergency kit 1 mg injection........ 56
GLUCAGON EMERGENCY KIT 1 MG
INJECTION.................................................. 56
GLUCOCARD EXPRESSION TEST............89
GLUCOCARD SHINE TEST........................ 89
GLUCOCARD VITAL TEST......................... 89
GLUCOSE CONTROL SOLUTION IN
VITRO LIQUID........................................... 157
GLUCOSE CONTROL SOLUTION IN
VITRO SOLUTION.......................................90
GLUCOSE CONTROL SOLUTION IN
VITRO SOLUTION HIGH...........................157
GLUCOSE CONTROL SOLUTION IN
VITRO SOLUTION LOW............................157
GLUCOSE CONTROL SOLUTION IN
VITRO SOLUTION NORMAL.................... 157
GLUCOSE CONTROL SOLUTIONS........... 88
glucose liquid shot oral liquid ..................... 59
GLUCOSE METER TEST STRIPS..............90
GLUCOSE NURSETTE............................... 59
glucose oral tablet chewable 4 gm...............59
glucose oral tablet chewable 4-6 gm-mg..... 59
231
GLUCOTROL XL......................................... 55
GLUMETZA..................................................55
glutamine oral capsule............................... 204
glutose 5.......................................................59
glyburide micronized.................................... 55
glyburide oral................................................55
glyburide-metformin..................................... 55
GLYCATE.................................................. 108
glycerin (adult) rectal suppository 2 gm..... 124
glycerin (infants & children) rectal
suppository 1 gm........................................124
glycerin adult rectal suppository 2 gm........124
glycerin child rectal suppository 1 gm, 1.2
gm.............................................................. 124
glycerin childrens....................................... 124
glycerin external........................................... 84
glycerin external liquid 99.5 %..................... 84
glycerin pediatric rectal suppository 1.2 gm
....................................................................124
glycolax...................................................... 121
glycopyrrolate oral solution........................ 108
glycopyrrolate oral tablet 1 mg................... 108
GLYCOPYRROLATE ORAL TABLET 1.5
MG............................................................. 108
glycopyrrolate oral tablet 2 mg................... 108
GLYNASE.................................................... 55
GLYTACTIN COMPLETE 10PE................ 157
GLYXAMBI...................................................55
GOCOVRI.................................................... 45
GOLYTELY................................................ 108
GONITRO.................................................... 70
GOOD START 5% GLUCOSE WATER.......59
goodsense milk of magnesia......................117
gormel.......................................................... 85
gormel 10..................................................... 85
G-PREPROTEIN........................................157
GRALISE......................................................72
granisetron hcl oral.......................................33
GRANIX....................................................... 60
griseofulvin microsize oral............................34
griseofulvin ultramicrosize............................34
guaiatussin ac............................................ 193
guaicon dms...............................................193
guaifenesin ac............................................ 193
guaifenesin oral tablet 400 mg................... 183
guaifenesin-codeine................................... 193
guaifenesin-dm oral syrup..........................193
guanfacine hcl.............................................. 62
guanfacine hcl er..........................................71
GUARDIAN LINK 3 TRANSMITTER..........157
GUARDIAN REAL-TIME REPLACE PED....90
GUARDIAN SENSOR (3).............................90
gummy dinos..............................................204
gummy multivitamin kids............................ 204
GVOKE HYPOPEN 1-PACK........................56
GVOKE HYPOPEN 2-PACK........................56
GVOKE KIT..................................................56
GVOKE PFS................................................ 56
GYNAZOLE-1.............................................. 34
GYNE-LOTRIMIN.........................................36
GYNE-LOTRIMIN 3......................................36
habitrol......................................................... 18
HAEGARDA............................................... 143
hailey 1.5/30...............................................136
hailey 24 fe.................................................136
hailey fe 1.5/30...........................................136
hailey fe 1/20..............................................136
halcinonide................................................... 78
HALCION................................................... 199
HALDOL DECANOATE............................... 47
halobetasol propionate external cream........ 78
HALOBETASOL PROPIONATE
EXTERNAL FOAM.......................................78
halobetasol propionate external ointment.... 78
HALOG.........................................................78
haloperidol decanoate intramuscular........... 47
haloperidol lactate oral................................. 47
haloperidol oral.............................................47
HALUCORT............................................... 157
HARD NAILS..............................................204
HARVONI ORAL PACKET...........................50
HARVONI ORAL TABLET 45-200 MG........ 50
HARVONI ORAL TABLET 90-400 MG........ 50
HAVRIX......................................................147
HCU EASY.................................................157
headache formula........................................ 12
headache relief.............................................12
headache relief extra str...............................12
heartburn antacid....................................... 117
heartburn antacid ex st...............................117
heartburn prevention oral tablet 10 mg...... 109
heartburn relief ex st.................................. 117
heartburn relief oral tablet 10 mg............... 109
heartburn relief oral tablet 200 mg............. 109
heartburn relief oral tablet chewable 160-
105 mg....................................................... 117
heather....................................................... 140
h-e-b aspirin............................................... 157
h-e-b childrens allergy................................176
HELIDAC THERAPY..................................108
HEMADY....................................................130
HEMANGEOL.............................................. 64
HEMATOGEN.............................................. 96
HEMATOGEN FA........................................ 96
HEMATRON-AF...........................................96
HEMAX........................................................ 96
HEMLIBRA...................................................62
HEMMOREX-HC..........................................37
HEMOCYTE PLUS...................................... 96
hemorrhoidal rectal ointment 0.25-3-14-
71.9 %.......................................................... 85
hemorrhoidal rectal suppository 0.25-3-
85.5 %.......................................................... 85
heparin sodium (porcine)............................. 60
heparin sodium (porcine) pf......................... 60
HEPLISAV-B.............................................. 148
HEPSERA.................................................... 49
232
HETLIOZ.................................................... 199
HETLIOZ LQ.............................................. 199
HEXATRIONE............................................131
hi cal.............................................................96
HIBERIX.....................................................147
HIBICLENS................................................ 157
HIDEX 6-DAY.............................................130
high potency iron..........................................96
high potency probiotic................................ 117
HIPREX........................................................20
HISTEX PD................................................ 188
HISTEX-AC................................................ 193
HONEY BEARS......................................... 204
HONEY BEARS W/IRON-ZINC................. 204
honey lemon drops.......................................74
HORIZANT...................................................72
HPR PLUS EXTERNAL CREAM............... 157
HUMALOG................................................... 57
HUMALOG JUNIOR KWIKPEN................... 57
HUMALOG KWIKPEN SUBCUTANEOUS
SOLUTION PEN-INJECTOR 100 UNIT/ML.57
HUMALOG KWIKPEN SUBCUTANEOUS
SOLUTION PEN-INJECTOR 200 UNIT/ML.57
HUMALOG MIX 50/50..................................57
HUMALOG MIX 50/50 KWIKPEN................ 57
HUMALOG MIX 75/25..................................57
HUMALOG MIX 75/25 KWIKPEN................ 57
HUMATIN.....................................................20
HUMATROPE............................................ 131
HUMATROPEN FOR 12MG...................... 157
HUMATROPEN FOR 24MG...................... 157
HUMATROPEN FOR 6MG........................ 157
HUMIRA PEN-PEDIATRIC UC START..... 146
HUMIRA PEN-PSOR/UVEIT STARTER....146
HUMIRA SUBCUTANEOUS PEN-
INJECTOR KIT 40 MG/0.4ML, 40
MG/0.8ML.................................................. 146
HUMIRA SUBCUTANEOUS PEN-
INJECTOR KIT 80 MG/0.8ML....................146
HUMIRA SUBCUTANEOUS PREFILLED
SYRINGE KIT 10 MG/0.1ML, 20
MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML,
80 MG/0.8ML, 80 MG/0.8ML &
40MG/0.4ML.............................................. 146
HUMULIN 70/30 KWIKPEN......................... 57
HUMULIN 70/30 VIAL.................................. 57
HUMULIN N KWIKPEN................................57
HUMULIN N VIAL........................................ 57
HUMULIN R U-500 KWIKPEN.....................57
HUMULIN R U-500 VIAL
(CONCENTRATED).....................................57
HUMULIN R VIAL........................................ 57
HURRICAINE MOUTH/THROAT GEL.........74
HYCAMTIN ORAL........................................41
HYCODAN................................................. 183
hydralazine hcl oral...................................... 70
HYDREA...................................................... 40
hydrocerin.................................................... 84
hydrochlorothiazide oral............................... 68
hydrocodone bitartrate er oral capsule
extended release 12 hour.............................. 6
hydrocodone bitartrate er oral tablet er 24
hour abuse-deterrent 100 mg, 120 mg, 20
mg, 30 mg, 40 mg, 60 mg, 80 mg.................. 6
hydrocodone bit-homatrop mbr.................. 183
hydrocodone polst-cpm polst er................. 193
hydrocodone-acetaminophen oral solution
7.5-325 mg/15ml............................................ 8
hydrocodone-acetaminophen oral tablet
10-300 mg, 7.5-300 mg..................................9
hydrocodone-acetaminophen oral tablet
10-325 mg, 5-325 mg, 7.5-325 mg.................9
hydrocodone-acetaminophen oral tablet 5-
300 mg........................................................... 9
hydrocodone-ibuprofen.................................. 9
hydrocortisone (perianal)........................... 149
hydrocortisone ace-pramoxine external....... 80
hydrocortisone acetate external cream........ 84
hydrocortisone acetate external ointment.... 84
hydrocortisone acetate rectal....................... 37
hydrocortisone anti-itch external cream 0.5
%.................................................................. 78
hydrocortisone butyr lipo base..................... 78
hydrocortisone butyrate................................78
hydrocortisone external cream 0.5 %, 2.5
%.................................................................. 78
hydrocortisone external cream 1 %..............78
hydrocortisone external lotion 2.5 %............ 78
hydrocortisone external ointment 0.5 %.......78
hydrocortisone external ointment 1 %..........78
hydrocortisone external ointment 2.5 %.......78
hydrocortisone oral tablet 10 mg, 20 mg, 5
mg.............................................................. 130
hydrocortisone plus external cream 1 %...... 85
hydrocortisone rectal enema 100 mg/60ml 149
hydrocortisone valerate................................78
hydrocortisone/aloe......................................85
hydrocortisone/aloe max str......................... 86
hydrocortisone-acetic acid......................... 173
hydrocortisone-aloe......................................86
hydrocortisone-aloe max st.......................... 86
hydrocortisone-iodoquinol............................ 36
hydrocort-pramoxine (perianal).................... 80
hydrolatum................................................... 84
hydromet.................................................... 183
hydromorphone hcl er oral tablet extended
release 24 hour 12 mg, 16 mg, 32 mg, 8
mg.................................................................. 6
hydromorphone hcl oral................................. 9
hydromorphone hcl rectal...............................9
hydroxychloroquine sulfate oral................... 44
hydroxyurea oral.......................................... 40
hydroxyzine hcl oral..................................... 53
hydroxyzine pamoate oral............................ 53
HYLAFEM.................................................. 157
HYLATOPIC PLUS.................................... 157
HYLAVITE..................................................101
233
hyoscyamine sulfate er.............................. 157
hyoscyamine sulfate oral............................157
hyoscyamine sulfate sl............................... 157
hyoscyamine sulfate sublingual................. 157
hyosyne......................................................157
HYPERRHO S/D........................................144
HYPERSAL................................................ 193
HYPERTET................................................ 148
HYPOTEARS............................................. 170
HYSINGLA ER ORAL TABLET ER 24
HOUR ABUSE-DETERRENT 100 MG, 120
MG, 20 MG, 30 MG, 40 MG, 60 MG, 80
MG................................................................. 6
HYZAAR.......................................................66
ibandronate sodium oral.............................150
IBRANCE..................................................... 41
IBSRELA.................................................... 107
ibu-200........................................................... 4
ibuprofen........................................................ 4
ibuprofen childrens oral tablet chewable
100 mg........................................................... 4
ibuprofen cold & sinus................................193
ibuprofen cold/sinus oral tablet 30-200 mg 193
ibu-profen cold/sinus oral tablet 30-200 mg
....................................................................193
ibuprofen ib childrens..................................... 4
ibuprofen ib oral tablet 200 mg.......................5
ibuprofen ib oral tablet chewable 100 mg...... 5
ibuprofen infants oral suspension 50
mg/1.25ml...................................................... 5
ibuprofen jr oral tablet 100 mg....................... 5
ibuprofen junior.............................................. 5
ibuprofen junior strength................................ 5
ibuprofen oral capsule 200 mg.......................5
ibuprofen oral suspension 100 mg/5ml.......... 5
ibuprofen oral tablet 200 mg.......................... 5
ibuprofen oral tablet 400 mg, 600 mg, 800
mg.................................................................. 5
ibuprofen-famotidine...................................... 5
ICAR-C.........................................................96
icatibant acetate......................................... 143
ICHTHAMMOL DRAWING SALVE............ 157
iclevia......................................................... 136
ICLUSIG.....................................................163
icosapent ethyl............................................. 69
IDELVION.................................................... 62
IDHIFA......................................................... 41
iferex 150..................................................... 96
iferex 150 forte............................................. 96
IGALMI......................................................... 53
IHEALTH COVID-19 RAPID TEST............ 157
ILARIS........................................................144
ILEVRO...................................................... 168
ILUMYA......................................................144
imatinib mesylate....................................... 163
IMBRUVICA............................................... 163
imipramine hcl oral....................................... 32
imipramine pamoate.....................................32
imiquimod external cream 3.75 %................80
imiquimod external cream 5 %.....................80
imiquimod pump...........................................80
IMITREX.......................................................38
IMITREX STATDOSE REFILL..................... 38
IMITREX STATDOSE SYSTEM.................. 38
IMODIUM A-D ORAL LIQUID.................... 107
IMODIUM A-D ORAL TABLET...................107
IMODIUM MULTI-SYMPTOM RELIEF...... 117
IMPEKLO..................................................... 78
IMUBOLIC..................................................157
IMURAN..................................................... 146
INBRIJA....................................................... 46
incassia...................................................... 140
INCRELEX................................................. 131
INCRUSE ELLIPTA....................................178
indapamide...................................................68
INDERAL LA................................................ 64
INDERAL XL................................................ 64
INDICAID COVID-19 RAPID TEST............157
INDOCIN........................................................ 5
indomethacin er..............................................5
indomethacin oral capsule 25 mg, 50 mg...... 5
indoor/outdoor allergy rlf............................ 176
INFANRIX.................................................. 147
infant gas relief...........................................117
INFANTS ADVIL............................................ 5
infants gas relief......................................... 117
infants ibuprofen.............................................5
infants pain & fever...................................... 12
infants pain relief drops................................ 12
infants pain/fever..........................................12
infants simethicone.................................... 117
INGREZZA................................................... 72
INLYTA.......................................................163
inner ear plus............................................. 101
INNOPRAN XL.............................................64
INQOVI.........................................................41
INREBIC.......................................................41
INSPIRACHAMBER/LARGE......................157
INSPIRACHAMBER/MEDIUM................... 157
INSPIRACHAMBER/MOUTHPIECE..........157
INSPIRACHAMBER/SMALL...................... 157
INSPIREASE..............................................157
INSPIREASE RESERVOIR BAGS............ 157
INSPRA........................................................67
instacort 5.....................................................78
instant oral pain relief max........................... 74
INSULIN ASP PROT & ASP FLEXPEN.......57
INSULIN ASPART........................................57
INSULIN ASPART FLEXPEN...................... 57
INSULIN ASPART PENFILL........................ 58
INSULIN ASPART PROT & ASPART..........58
INSULIN GLARGINE................................... 58
INSULIN GLARGINE SOLOSTAR...............58
INSULIN GLARGINE-YFGN........................ 58
INSULIN LISPRO.........................................58
INSULIN LISPRO (1 UNIT DIAL)................. 58
INSULIN LISPRO JUNIOR KWIKPEN.........58
234
INSULIN LISPRO PROT & LISPRO............ 58
INSULIN PEN NEEDLES.............................90
INSULIN PEN NEEDLES 29G X 12.7MM..157
INSULIN PEN NEEDLES 29G X 12MM ,
31G X 6 MM............................................... 157
INSULIN PEN NEEDLES 29G X 5MM ,
29G X 8MM , 31G X 4 MM.........................157
INSULIN PEN NEEDLES 31G X 5 MM ,
31G X 8 MM............................................... 157
INSULIN PEN NEEDLES 32G X 4 MM ,
32G X 5 MM , 32G X 6 MM..........................90
INSULIN PEN NEEDLES 32G X 8 MM ,
33G X 4 MM , 33G X 5 MM , 33G X 6 MM.157
INSULIN SYRINGES 27G X 1/2" 0.5 ML,
27G X 1/2" 1 ML.........................................157
INSULIN SYRINGES 28G X 1/2" 0.5 ML,
28G X 1/2" 1 ML.........................................157
INSULIN SYRINGES 28G X 5/16" 1 ML....157
INSULIN SYRINGES 29G X 1/2" 0.3 ML...157
INSULIN SYRINGES 29G X 1/2" 0.5 ML,
29G X 1/2" 1 ML, 30G X 5/16" 1 ML.......... 157
INSULIN SYRINGES 29G X 5/16" 1 ML....157
INSULIN SYRINGES 30G X 1/2" 0.3 ML,
30G X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G
X 5/16" 1 ML...............................................157
INSULIN SYRINGES 30G X 5/16" 0.3 ML,
30G X 5/16" 0.5 ML....................................157
INSULIN SYRINGES 31G X 15/64" 0.3
ML, 31G X 15/64" 0.5 ML...........................157
INSULIN SYRINGES 31G X 5/16" 0.3 ML,
31G X 5/16" 0.5 ML....................................157
INTEGRA F.................................................. 97
INTELENCE................................................. 51
INTELISWAB COVID-19 RAPID TEST......157
INTRON A.................................................. 145
introvale......................................................136
INTUNIV.......................................................71
INVEGA........................................................47
INVEGA HAFYERA......................................47
INVEGA SUSTENNA................................... 47
INVEGA TRINZA..........................................47
INVELTYS..................................................168
INVOKAMET................................................ 55
INVOKAMET XR.......................................... 55
INVOKANA...................................................55
iodine tincture external tincture 2 %............. 25
iodoquinol-hc-aloe polysacch.......................36
IOPIDINE................................................... 169
IPOL........................................................... 147
ipratropium bromide inhalation...................178
ipratropium bromide nasal..........................178
ipratropium-albuterol.................................. 190
irbesartan..................................................... 63
irbesartan-hydrochlorothiazide.....................66
IRESSA...................................................... 163
iron 100/c..................................................... 97
iron oral tablet 200 (65 fe) mg...................... 97
iron oral tablet 240 (27 fe) mg...................... 97
iron oral tablet 27 mg................................... 97
iron oral tablet 325 (65 fe) mg...................... 97
iron oral tablet extended release 142 (45
fe) mg........................................................... 97
iron slow release oral tablet extended
release 160 (50 fe) mg................................. 97
iron supplement............................................97
iron supplement childrens............................ 97
IROSPAN 24/6............................................. 97
ISENTRESS.................................................50
ISENTRESS HD...........................................50
isibloom...................................................... 136
isoniazid oral................................................ 39
ISOPTO ATROPINE.................................. 166
ISOPTO TEARS.........................................170
ISORDIL TITRADOSE................................. 70
isosorb dinitrate-hydralazine........................ 66
isosorbide dinitrate....................................... 70
isosorbide mononitrate.................................70
isosorbide mononitrate er.............................70
isotretinoin oral.............................................76
isoxsuprine hcl oral tablet 10 mg..................70
isradipine......................................................65
ISTALOL.................................................... 168
ISTURISA...................................................142
itraconazole oral...........................................34
ivermectin external....................................... 81
ivermectin oral..............................................43
JADENU.......................................................98
JADENU SPRINKLE.................................... 98
jaimiess...................................................... 136
JAKAFI......................................................... 41
JALYN........................................................ 128
JANSSEN COVID-19 VACCINE................ 207
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5
mg, 3 mg, 4 mg, 5 mg, 7.5 mg..................... 60
jantoven oral tablet 6 mg..............................60
JANUMET.................................................... 55
JANUMET XR.............................................. 55
JANUVIA...................................................... 55
JARDIANCE.................................................55
jasmiel........................................................ 136
JATENZO...................................................133
jencycla...................................................... 140
JENTADUETO............................................. 55
JENTADUETO XR....................................... 55
jinteli........................................................... 136
jock itch external cream 1 %........................ 36
jock itch max st...........................................157
jock itch spray powder................................158
jolessa........................................................ 136
JORNAY PM................................................ 71
JUBLIA......................................................... 81
juleber........................................................ 136
JULUCA....................................................... 50
junel 1.5/30.................................................136
junel 1/20....................................................136
junel fe........................................................136
JUST RIGHT 5000....................................... 92
235
JUXTAPID....................................................69
JYNARQUE ORAL TABLET........................ 98
JYNARQUE ORAL TABLET THERAPY
PACK 15 MG, 45 & 15 MG, 60 & 30 MG,
90 & 30 MG.................................................. 98
JYNARQUE ORAL TABLET THERAPY
PACK 30 & 15 MG....................................... 98
kaitlib fe...................................................... 136
KALETRA ORAL SOLUTION.......................52
KALETRA ORAL TABLET........................... 52
kalliga......................................................... 136
KALYDECO................................................179
KAPSPARGO SPRINKLE............................64
KAPVAY.......................................................71
KARBINAL ER........................................... 176
kariva..........................................................136
KATERZIA....................................................65
KAZANO...................................................... 55
kelnor 1/35................................................. 136
kelnor 1/50................................................. 136
kelp oral tablet 0.15 mg................................97
kelp-b6-lecithin-vinegar.............................. 158
KENALOG EXTERNAL................................78
KEPPRA ORAL............................................26
KEPPRA XR.................................................26
KERALYT EXTERNAL GEL 6 %............... 158
KERALYT EXTERNAL SHAMPOO........... 158
KERENDIA...................................................66
KERYDIN..................................................... 81
KESIMPTA................................................... 73
ketoconazole external cream....................... 81
ketoconazole external foam......................... 81
ketoconazole external shampoo.................. 81
ketoconazole oral......................................... 34
ketodan external foam..................................81
KETODAN EXTERNAL KIT......................... 36
KETO-DIASTIX............................................ 90
KETONE CARE........................................... 90
KETONE TEST............................................ 90
ketoprofen er.................................................. 5
KETOROLAC TROMETHAMINE NASAL...... 5
ketorolac tromethamine ophthalmic
solution 0.4 %.............................................168
ketorolac tromethamine ophthalmic
solution 0.5 %.............................................168
ketorolac tromethamine oral...........................5
KETOSTIX................................................... 90
ketotifen fumarate ophthalmic.................... 173
KEVEYIS....................................................126
KEVZARA.................................................. 144
KHAPZORY................................................. 42
KINERET....................................................144
KISQALI (200 MG DOSE)............................41
KISQALI (400 MG DOSE)............................41
KISQALI (600 MG DOSE)............................41
KISQALI FEMARA (400 MG DOSE)............41
KISQALI FEMARA (600 MG DOSE)............41
KISQALI FEMARA(200 MG DOSE).............42
KITABIS PAK............................................. 179
KLARITY-A.................................................167
KLARON...................................................... 81
KLONOPIN...................................................53
klor-con........................................................ 92
klor-con 10................................................... 92
klor-con m10................................................ 92
klor-con m15................................................ 92
klor-con m20................................................ 92
klor-con/ef.................................................. 204
KLOXXADO................................................. 18
KOMBIGLYZE XR........................................55
konsyl daily fiber oral powder 28.3 %.........121
korean ginseng oral capsule 250 mg, 350
mg.............................................................. 158
KORLYM.................................................... 132
KOSELUGO................................................. 42
K-PHOS....................................................... 97
K-PHOS NO 2.............................................. 97
K-PHOS-NEUTRAL..................................... 97
k-prime....................................................... 204
KRINTAFEL................................................. 44
KRISTALOSE.............................................107
K-TAB...........................................................92
k-tan plus......................................................97
kurvelo........................................................136
KUVAN.......................................................126
KYNMOBI.....................................................46
labetalol hcl oral........................................... 64
LAC-HYDRIN FIVE...................................... 78
lacosamide oral............................................ 28
LACRISERT............................................... 166
LACTAID.................................................... 117
LACTAID FAST ACT ORAL TABLET........ 117
lactase enzyme.......................................... 117
lactase enzyme ultra str............................. 117
lactase fast acting...................................... 117
lactobacillus oral tablet...............................117
lacto-pectin.................................................117
lactose fast acting relief oral tablet.............117
lactulose encephalopathy...........................107
lactulose oral packet.................................. 107
lactulose oral solution.................................107
LAGEVRIO...................................................53
LAMICTAL....................................................26
LAMICTAL ODT........................................... 26
LAMICTAL STARTER..................................26
LAMICTAL XR..............................................26
LAMISIL AT EXTERNAL CREAM................36
LAMISIL AT JOCK ITCH CREAM 1 %
EXTERNAL.................................................. 36
lamivudine oral solution................................51
lamivudine oral tablet 100 mg...................... 49
lamivudine oral tablet 150 mg, 300 mg........ 51
lamivudine-zidovudine..................................51
lamotrigine er............................................... 26
lamotrigine oral kit........................................ 26
lamotrigine oral tablet...................................26
lamotrigine oral tablet chewable...................26
236
lamotrigine oral tablet dispersible.................26
lamotrigine starter kit-blue............................26
lamotrigine starter kit-green......................... 26
lamotrigine starter kit-orange....................... 26
LAMPIT........................................................ 44
LANAPHILIC................................................ 84
LANCETS...............................................90, 92
LANOXIN ORAL TABLET 125 MCG, 250
MCG.............................................................66
lansoprazole oral capsule delayed release
15 mg......................................................... 110
lansoprazole oral capsule delayed release
30 mg......................................................... 110
lansoprazole oral tablet delayed release
dispersible 15 mg, 30 mg........................... 110
lanthanum carbonate................................... 99
LANTUS SOLOSTAR.................................. 58
LANTUS U-100 VIAL................................... 58
lapatinib ditosylate......................................163
l-arginine oral capsule................................ 158
larin 1.5/30................................................. 136
larin 1/20.................................................... 136
larin 24 fe................................................... 136
larin fe 1.5/30............................................. 136
larin fe 1/20................................................ 136
larissia........................................................ 136
LASIX........................................................... 67
latanoprost ophthalmic............................... 165
LATUDA....................................................... 47
laxacin........................................................ 124
laxaclear.....................................................121
laxative max str.......................................... 124
laxative maximum strength oral tablet 25
mg.............................................................. 124
laxative oral powder 17 gm/scoop..............121
laxative oral tablet chewable 15 mg........... 124
laxative oral tablet delayed release 5 mg...158
laxative pills max st.................................... 124
laxative pills oral tablet 25 mg.................... 124
laxative rectal suppository 10 mg...............158
laxative regular strength.............................124
layolis fe..................................................... 136
l-carnitine....................................................204
LDO PLUS................................................... 16
lecithin oral capsule....................................158
LEDIPASVIR-SOFOSBUVIR....................... 50
leena.......................................................... 136
leflunomide oral..........................................146
lenalidomide................................................. 40
LENVIMA (10 MG DAILY DOSE)...............163
LENVIMA (12 MG DAILY DOSE)...............163
LENVIMA (14 MG DAILY DOSE)...............163
LENVIMA (18 MG DAILY DOSE)...............163
LENVIMA (20 MG DAILY DOSE)...............163
LENVIMA (24 MG DAILY DOSE)...............163
LENVIMA (4 MG DAILY DOSE).................163
LENVIMA (8 MG DAILY DOSE).................164
LESCOL XL..................................................69
lessina........................................................ 136
LETAIRIS................................................... 180
letrozole oral.................................................41
leucovorin calcium injection solution 500
mg/50ml....................................................... 42
leucovorin calcium oral.................................42
LEUKERAN..................................................39
LEUKINE......................................................60
leuprolide acetate injection.........................142
levalbuterol hcl inhalation...........................178
LEVALBUTEROL HFA INHALATION
AEROSOL 45 MCG/ACT........................... 178
LEVBID...................................................... 158
LEVEMIR U-100 FLEXTOUCH....................58
LEVEMIR U-100 VIAL..................................58
levetiracetam er............................................26
levetiracetam oral.........................................26
levobunolol hcl........................................... 168
levocarnitine oral solution...........................126
levocarnitine oral tablet.............................. 126
levocarnitine sf........................................... 126
levocetirizine dihydrochloride oral.............. 176
levofloxacin ophthalmic.............................. 167
levofloxacin oral........................................... 22
levoleucovorin calcium pf intravenous
solution 250 mg/25ml................................... 42
levonest......................................................136
levonorgest-eth est & eth est..................... 137
levonorgest-eth estrad 91-day................... 137
levonorgestrel.............................................141
levonorgestrel-ethinyl estrad...................... 137
levonorg-eth estrad triphasic......................137
levora 0.15/30 (28)..................................... 137
levorphanol tartrate oral................................. 7
levo-t.......................................................... 142
LEVOTHYROXINE SODIUM ORAL
CAPSULE.................................................. 142
levothyroxine sodium oral tablet.................142
levoxyl........................................................ 142
LEVSIN ORAL............................................158
LEVSIN/SL................................................. 158
LEVULAN KERASTICK............................... 80
LEXAPRO.................................................... 31
LEXETTE..................................................... 78
LEXIVA.........................................................52
LIALDA.......................................................149
LIBRAX...................................................... 108
LICART.......................................................... 6
lice killing................................................44, 81
lice killing max st.......................................... 44
lice killing max strength................................ 44
lice killing maximum strength....................... 44
lice maximum strength................................. 44
lice solution combination kit ....................... 44
lice treatment creme rinse............................81
lice treatment external liquid 1 %................. 81
lice treatment external lotion 1 %................. 81
lice treatment external shampoo 0.33-4 %...44
LIDO BDK.................................................... 16
237
lidocaine external cream 4 %....................... 16
lidocaine external ointment 5 %................... 16
lidocaine external patch 5 %........................ 16
lidocaine hcl external cream 3 %................. 16
lidocaine hcl external cream 4 %................. 16
lidocaine hcl external solution...................... 16
lidocaine hcl mouth/throat............................ 16
lidocaine hcl urethral/mucosal external gel.. 16
lidocaine maximum strength........................ 16
lidocaine pain relieving external cream 4 %.16
lidocaine plus............................................... 16
lidocaine viscous hcl.................................... 16
lidocaine-hydrocort (perianal).......................84
LIDOCAINE-HYDROCORTISONE ACE
RECTAL GEL...............................................84
lidocaine-hydrocortisone ace rectal kit 2-2
%.................................................................. 84
lidocaine-hydrocortisone ace rectal kit 3-
0.5 %, 3-2.5 %..............................................84
lidocaine-hydrocortisone ace rectal kit 3-1
%.................................................................. 84
lidocaine-prilocaine external cream..............16
lidocaine-prilocaine external kit.................... 16
LIDOCORT...................................................84
LIDODERM.................................................. 16
lidopin external cream 3 %...........................16
LIDOPRIL.....................................................16
LIDOPRIL XR...............................................16
LIDO-PRILO CAINE PACK.......................... 16
lillow........................................................... 137
lindane..........................................................81
linezolid oral suspension reconstituted........ 20
linezolid oral tablet....................................... 20
LINZESS ORAL CAPSULE 145 MCG, 290
MCG...........................................................107
LINZESS ORAL CAPSULE 72 MCG......... 107
LIORESAL INTRATHECAL SOLUTION
0.05 MG/ML, 10 MG/5ML.............................49
liothyronine sodium oral............................. 142
LIPITOR....................................................... 69
LIPOFEN......................................................68
lipoflavovit.................................................. 101
liquid acetaminophen................................... 12
liquid allergy relief...................................... 176
liquid calcium with d3 oral capsule 600-500
mg-unit......................................................... 97
liquid calcium/vitamin d.............................. 204
liquid pain relief............................................ 12
lisinopril oral................................................. 63
lisinopril-hydrochlorothiazide........................66
lithium carbonate er......................................54
lithium carbonate oral...................................54
LITHOBID.....................................................54
LITHOSTAT............................................... 128
little ones childrens.....................................101
LIVALO.........................................................69
LIVIXIL PAK................................................. 16
LIVMARLI...................................................158
LIVTENCITY................................................ 52
l-lysine hcl oral tablet 500 mg.....................158
l-lysine oral tablet 1000 mg, 500 mg.......... 158
l-lysine oral tablet 500 mg.......................... 204
l-methylfolate..............................................204
l-methylfolate calcium oral..........................204
l-methylfolate-b6-b12................................. 101
LMX 4...........................................................16
LO LOESTRIN FE......................................137
LOCOID....................................................... 78
LOCOID LIPOCREAM................................. 78
LODINE..........................................................6
LODOSYN....................................................46
LOESTRIN 1.5/30 (21)...............................137
LOESTRIN 1/20 (21)..................................137
LOESTRIN FE 1.5/30.................................137
LOESTRIN FE 1/20....................................137
LOFENA.........................................................6
lojaimiess................................................... 137
LOKELMA.................................................... 99
LOLLICAINE................................................ 75
LOMOTIL................................................... 107
long acting nasal spray.............................. 193
long lasting antacid.................................... 117
long lasting nasal spray..............................193
LONHALA MAGNAIR REFILL KIT.............178
LONHALA MAGNAIR STARTER KIT........ 178
LONSURF.................................................... 41
loperamide hcl oral capsule....................... 107
loperamide hcl oral liquid 1 mg/7.5ml.........107
loperamide hcl oral suspension..................107
loperamide hcl oral tablet........................... 107
loperamide-simethicone............................. 117
LOPID.......................................................... 68
lopinavir-ritonavir oral solution..................... 52
lopinavir-ritonavir oral tablet......................... 52
LOPRESSOR...............................................64
LOPROX EXTERNAL CREAM.................... 82
LOPROX EXTERNAL KIT 0.77 %............... 36
LOPROX EXTERNAL KIT 0.77 % (SUSP).. 36
LOPROX EXTERNAL SHAMPOO...............82
LOPROX EXTERNAL SUSPENSION..........82
loradamed.................................................. 188
lorata-d....................................................... 193
loratadine allergy relief oral tablet 10 mg... 188
loratadine allergy relief oral tablet
dispersible 10 mg....................................... 188
loratadine childrens oral solution 5 mg/5ml 188
loratadine childrens oral syrup................... 188
loratadine childrens oral tablet chewable... 188
lorata-dine d............................................... 193
loratadine d 12hr........................................ 193
loratadine oral capsule............................... 188
loratadine oral syrup...................................188
loratadine oral tablet...................................188
loratadine oral tablet dispersible 10 mg..... 188
loratadine-d................................................ 193
loratadine-d 12hr........................................ 193
loratadine-d 24hr........................................ 193
238
lorazepam intensol....................................... 53
lorazepam oral concentrate 2 mg/ml............53
lorazepam oral tablet....................................53
LORBRENA............................................... 164
LOREEV XR.................................................53
LORID........................................................ 101
LORTAB.........................................................9
loryna......................................................... 137
LORZONE..................................................198
losartan potassium oral................................ 63
losartan potassium-hctz............................... 66
LOSEASONIQUE.......................................137
LOTEMAX.................................................. 168
LOTEMAX SM............................................168
LOTENSIN................................................... 63
LOTENSIN HCT...........................................66
loteprednol etabonate................................ 168
LOTREL....................................................... 66
LOTRONEX............................................... 107
lovastatin oral............................................... 69
LOVAZA....................................................... 69
LOVENOX....................................................60
low-ogestrel................................................137
loxapine succinate........................................47
lo-zumandimine..........................................137
LTXF PRIM CNV PIN MICRODRIP........... 158
LTXF PRIM IV SET/CNVT PIN.................. 158
LTXF SECONDARY/CNV PIN/32INC........158
l-tyrosine oral capsule................................ 204
LUBIPROSTONE....................................... 107
lubricant drops fast act............................... 170
lubricant drops long last............................. 170
lubricant drops ophthalmic gel 0.25-0.3 %. 170
lubricant drops ophthalmic solution............170
lubricant eye drops (pf) ophthalmic solution
0.4-0.3 %....................................................170
lubricant eye drops (pf) ophthalmic solution
0.5 %.......................................................... 170
lubricant eye drops ophthalmic solution
0.4-0.3 %....................................................170
lubricant eye drops ophthalmic solution 0.5
%................................................................ 170
lubricant eye drops ophthalmic solution 0.6
%................................................................ 171
lubricant eye drops pf.................................171
lubricant eye nighttime............................... 171
lubricant eye ophthalmic solution 0.4-0.3 %
....................................................................171
lubricant eye ophthalmic solution 1-0.3 %..171
lubricant eye pm.........................................171
lubricant pm................................................171
lubricating eye drop....................................171
lubricating eye drops.................................. 171
lubricating eye/overnight............................ 171
lubricating plus........................................... 171
lubricating plus eye drops.......................... 171
lubricating tears..........................................171
lubricating tears eye drops......................... 171
lubricating/dry eye...................................... 171
LUCEMYRA................................................. 18
LUGOLS STRONG IODINE.........................25
LULICONAZOLE..........................................82
LUMAKRAS................................................. 43
LUMIGAN...................................................165
LUNESTA ORAL TABLET 1 MG............... 199
LUNESTA ORAL TABLET 2 MG, 3 MG.....199
LUPKYNIS................................................. 143
LUPRON DEPOT (1-MONTH)
INTRAMUSCULAR KIT 3.75 MG...............142
LUPRON DEPOT (1-MONTH)
INTRAMUSCULAR KIT 7.5 MG.................142
LUPRON DEPOT (3-MONTH)
INTRAMUSCULAR KIT 11.25 MG.............142
LUPRON DEPOT (3-MONTH)
INTRAMUSCULAR KIT 22.5 MG...............142
LUPRON DEPOT (4-MONTH)
INTRAMUSCULAR KIT 30MG...................142
LUPRON DEPOT (6-MONTH)
INTRAMUSCULAR KIT 45MG...................142
LUPRON DEPOT-PED (1-MONTH).......... 143
LUPRON DEPOT-PED (3-MONTH).......... 143
lutera.......................................................... 137
LUXIQ.......................................................... 78
LUZU............................................................82
LYBALVI.......................................................47
lyleq............................................................140
lyllana......................................................... 137
LYMEPAK.................................................... 23
LYNPARZA.................................................. 42
LYRICA........................................................ 73
LYRICA CR.................................................. 73
lysine hcl oral tablet 1000 mg.....................158
lysiplex plus oral tablet............................... 204
LYSODREN............................................... 142
LYSTEDA.....................................................61
LYUMJEV.....................................................58
LYUMJEV KWIKPEN................................... 58
LYVISPAH....................................................49
lyza.............................................................140
m2 magnesium...........................................204
MAALOX CHILDRENS.............................. 117
MAALOX MAX ORAL SUSPENSION........ 117
MAALOX MULTI SYMPTOM MAX ST.......118
MACRILEN.................................................158
MACROBID..................................................20
MACRODANTIN.......................................... 20
mafenide acetate external............................82
MAG-200......................................................97
mag-al plus.................................................118
mag-al plus xs............................................ 118
mag-g........................................................... 97
MAGNEBIND 300........................................ 97
magnesium citrate oral solution................. 124
magnesium oral capsule 300 mg............... 204
magnesium oral capsule 500 mg................. 97
magnesium oral tablet 250 mg, 30 mg.......204
239
magnesium oral tablet 500 mg.....................97
magnesium oxide oral tablet 200 mg........... 97
magnesium oxide oral tablet 400 (240 mg)
mg................................................................ 97
magnesium oxide oral tablet 400 mg......... 158
magnesium oxide oral tablet 500 mg........... 97
magnesium-oxide.........................................97
mag-oxide.................................................... 97
mag-oxide magnesium.................................97
MALARONE................................................. 44
malathion......................................................81
mapap acetaminophen extra str...................12
mapap arthritis pain......................................12
mapap childrens...........................................12
mapap cold formula multi-sympt................ 183
mapap oral capsule......................................12
maraviroc..................................................... 51
MAR-COF CG EXPECTORANT................ 194
MARGENZA...............................................164
MARINOL.....................................................33
marlissa......................................................137
MARPLAN....................................................30
MASK VORTEX/CHILD/FROG.................. 158
MASK VORTEX/TODDLER/LADYBUG.....158
MATULANE..................................................39
matzim la......................................................65
MAVENCLAD (10 TABS)............................. 73
MAVENCLAD (4 TABS)............................... 73
MAVENCLAD (5 TABS)............................... 73
MAVENCLAD (6 TABS)............................... 73
MAVENCLAD (7 TABS)............................... 73
MAVENCLAD (8 TABS)............................... 73
MAVENCLAD (9 TABS)............................... 73
MAVYRET....................................................50
MAXALT.......................................................38
MAXIDEX................................................... 168
MAXITROL.................................................166
maxi-tuss ac............................................... 194
maxi-tuss cd............................................... 194
maxi-tuss gmx............................................ 194
maxi-tuss pe max....................................... 183
MAXZIDE..................................................... 66
MAXZIDE-25................................................ 67
MAYZENT.................................................... 73
MAYZENT STARTER PACK....................... 73
m-clear wc..................................................194
m-dryl......................................................... 176
me/naphos/mb/hyo1...................................129
meclizine hcl oral tablet................................32
meclizine hcl oral tablet chewable................32
meclofenamate sodium oral........................... 6
medicated spot...........................................158
medifin 400.................................................183
medi-first triple antibiotic.............................. 25
mediproxen.................................................... 6
MEDISENSE GLUCOSE KETONE
CONTR........................................................ 90
MEDISENSE HI/MID/LOW CONTROL........ 90
MEDROL ORAL TABLET 16 MG, 32 MG,
4 MG, 8 MG................................................130
MEDROL ORAL TABLET 2 MG.................130
MEDROL ORAL TABLET THERAPY
PACK......................................................... 130
medroxyprogesterone acetate
intramuscular..............................................140
medroxyprogesterone acetate oral............ 140
mefenamic acid oral....................................... 6
mefloquine hcl.............................................. 44
mega multiple/chelated mineral................. 101
mega probiotic............................................118
megestrol acetate oral suspension 40
mg/ml, 625 mg/5ml.....................................140
megestrol acetate oral tablet 20 mg...........140
megestrol acetate oral tablet 40 mg...........140
meijer allergy relief-d..................................194
meijer antacid.............................................118
meijer anti-diarrheal................................... 107
MEKINIST.................................................... 42
MEKTOVI..................................................... 42
meloxicam oral capsule..................................6
meloxicam oral tablet..................................... 6
melphalan.....................................................43
memantine hcl er..........................................29
memantine hcl oral solution 2 mg/ml............29
memantine hcl oral tablet............................. 29
MENACTRA............................................... 147
M-END PE..................................................194
MENEST.................................................... 137
MENOSTAR...............................................137
MENQUADFI..............................................147
mens daily gummies.................................. 204
menstrual pain relief.....................................12
MENTAX...................................................... 82
menthol drops.............................................. 75
MENVEO....................................................147
meperidine hcl oral.........................................9
MEPHYTON...............................................101
meprobamate............................................... 53
MEPRON..................................................... 44
mercaptopurine oral..................................... 40
MERIBIN.................................................... 204
merzee....................................................... 137
mesalamine er oral capsule extended
release....................................................... 149
mesalamine er oral capsule extended
release 24 hour.......................................... 149
mesalamine oral capsule delayed release
400 mg....................................................... 149
mesalamine oral tablet delayed release.....149
mesalamine rectal enema.......................... 149
mesalamine rectal suppository...................149
mesalamine-cleanser................................. 149
MESNEX ORAL........................................... 42
MESTINON.................................................. 38
metaxalone oral tablet 400 mg...................198
metaxalone oral tablet 800 mg...................198
metformin hcl er........................................... 55
240
metformin hcl er (mod)................................. 55
metformin hcl er (osm)................................. 55
metformin hcl oral solution........................... 55
metformin hcl oral tablet 1000 mg, 500 mg,
850 mg......................................................... 55
metformin hcl oral tablet 625 mg..................55
methadone hcl intensol.................................. 7
methadone hcl oral concentrate.....................7
methadone hcl oral solution........................... 7
methadone hcl oral tablet...............................7
methadone hcl oral tablet soluble.................. 7
methadose oral concentrate 10 mg/ml...........7
methadose oral tablet soluble........................ 7
methadose sugar-free.................................... 7
methamphetamine hcl..................................72
methazolamide oral....................................169
methenamine hippurate............................... 20
methenamine mandelate oral.......................25
methergine................................................. 132
methimazole oral........................................143
METHITEST...............................................133
methocarbamol oral................................... 198
methotrexate oral....................................... 146
methotrexate sodium (pf)........................... 146
methotrexate sodium injection................... 146
methotrexate sodium oral...........................146
methoxsalen rapid........................................80
methscopolamine bromide oral.................. 108
methyldopa...................................................62
methylergonovine maleate oral.................. 132
METHYLIN................................................... 71
methylphenidate hcl er................................. 71
methylphenidate hcl er (cd)..........................71
methylphenidate hcl er (la)...........................71
methylphenidate hcl er (osm) oral tablet
extended release 18 mg, 27 mg, 36 mg.......71
methylphenidate hcl er (osm) oral tablet
extended release 72 mg...............................71
methylphenidate hcl er (osm) tablet
extended release 54 mg oral........................71
methylphenidate hcl er (xr)...........................71
methylphenidate hcl oral solution.................71
methylphenidate hcl oral tablet.................... 71
methylphenidate hcl oral tablet chewable.... 71
methylprednisolone oral............................. 130
methyltestosterone oral..............................133
metoclopramide hcl oral solution..................32
metoclopramide hcl oral tablet..................... 32
metoclopramide hcl oral tablet dispersible... 32
metolazone...................................................68
METOPIRONE........................................... 158
metoprolol succinate er................................ 64
metoprolol tartrate oral................................. 64
metoprolol-hydrochlorothiazide.................... 67
METROCREAM........................................... 20
METROGEL................................................. 20
METROLOTION...........................................20
metronidazole external.................................20
metronidazole oral capsule.......................... 20
metronidazole oral tablet..............................20
metronidazole vaginal.................................. 20
metyrosine....................................................67
mexiletine hcl oral........................................ 64
micaderm..................................................... 36
MICARDIS....................................................63
MICARDIS HCT........................................... 67
MICATIN...................................................... 36
miconazole 1................................................ 34
miconazole 1 combo pack............................34
miconazole 3................................................ 34
miconazole 3 applicator vaginal kit 200 & 2
mg-% (9gm)................................................. 34
miconazole 3 combo pack app.....................34
miconazole 3 combo pack vaginal kit 200 &
2 mg-% (9gm).............................................. 34
miconazole 7 day treatment......................... 34
miconazole 7 vaginal cream 2 %................. 34
miconazole 7 vaginal suppository 100 mg... 34
miconazole antifungal.................................. 36
miconazole nitrate external.......................... 36
miconazole nitrate vaginal............................34
MICONAZOLE-ZINC OXIDE-PETROLAT... 82
miconazorb af...............................................36
MICOTRIN AL............................................ 158
MICOTRIN AP..............................................36
MICRHOGAM ULTRA-FILTERED PLUS...144
MICRODOT TEST....................................... 90
microgestin 1.5/30......................................137
microgestin 1/20.........................................137
microgestin 24 fe........................................137
microgestin fe 1.5/30..................................137
microgestin fe 1/20.....................................137
midazolam hcl oral....................................... 53
midodrine hcl................................................62
MIFEPREX.................................................132
mifepristone................................................132
MIGERGOT..................................................37
miglitol.......................................................... 55
miglustat.....................................................126
migraine formula.......................................... 12
migraine relief...............................................12
MIGRANAL.................................................. 37
mili..............................................................137
milk of magnesia........................................ 118
milk of magnesia concentrate.................... 118
MILLIPRED................................................ 130
mimvey.......................................................137
MIMYX....................................................... 158
MINASTRIN 24 FE.....................................137
mineral oil enema.......................................121
mineral oil heavy oral................................. 122
mineral oil oral oil ..................................... 122
mineral oil rectal enema ........................... 122
minerin creme.............................................. 84
MINI COMPRESSOR.................................158
mini nicotine................................................. 19
241
MINILINK REAL-TIME TRANSMITTER.....158
MINIPRESS................................................. 62
MINIVELLE................................................ 137
MINOCYCLINE HCL ER ORAL CAPSULE
EXTENDED RELEASE 24 HOUR............... 23
minocycline hcl er oral tablet extended
release 24 hour............................................ 23
minocycline hcl oral capsule 100 mg........... 23
minocycline hcl oral capsule 50 mg............. 23
minocycline hcl oral capsule 75 mg............. 23
minocycline hcl oral tablet 100 mg............... 23
minocycline hcl oral tablet 50 mg, 75 mg..... 23
MINOLIRA....................................................24
minoxidil oral................................................ 70
mintox maximum strength.......................... 118
mintox plus................................................. 118
MIRALAX ORAL POWDER....................... 122
MIRAPEX ER............................................... 46
MIRCERA INJECTION SOLUTION
PREFILLED SYRINGE 100 MCG/0.3ML,
200 MCG/0.3ML, 50 MCG/0.3ML, 75
MCG/0.3ML..................................................62
MIRCERA INJECTION SOLUTION
PREFILLED SYRINGE 150 MCG/0.3ML,
30 MCG/0.3ML.............................................62
MIRCETTE.................................................137
mirtazapine oral............................................30
MIRVASO.....................................................76
misoprostol oral..........................................109
MITIGARE....................................................36
mm arthritis pain...........................................12
mm clearlax................................................122
MM EASY TOUCH GLUCOSE METER.......90
mm stool softener laxative......................... 124
M-M-R II..................................................... 147
M-NATAL PLUS......................................... 101
modafinil.....................................................200
MODERNA COVID-19 VAC (BOOSTER)..158
MODERNA COVID-19 VACC 6M-5Y.........158
MODERNA COVID-19 VACCINE.............. 148
moexipril hcl................................................. 63
moisturel.......................................................86
molindone hcl............................................... 47
mometasone furoate external...................... 78
mometasone furoate nasal.........................177
mondoxyne nl...............................................24
mono-linyah................................................137
MONSELS FERRIC SUBSULFATE.............62
montelukast sodium oral............................ 177
MONUROL...................................................20
mood support probiotic...............................118
MORCIN.....................................................158
morphine sulfate (concentrate) oral
solution 100 mg/5ml, 20 mg/ml...................... 9
morphine sulfate (pf) intravenous solution 1
mg/ml............................................................. 7
morphine sulfate er........................................ 7
morphine sulfate er beads..............................7
morphine sulfate oral......................................9
morphine sulfate rectal...................................9
MOTEGRITY..............................................107
motion sickness oral tablet 50 mg................32
motion sickness relief oral tablet 50 mg....... 32
motion sickness relief oral tablet chewable
25 mg........................................................... 32
motion-time.................................................. 33
MOTOFEN................................................. 107
MOTRIN CHILDRENS................................... 6
MOTRIN IB.....................................................6
MOTRIN INFANTS DROPS...........................6
MOUNJARO.................................................59
MOUTH KOTE REMINT.............................. 75
MOVANTIK................................................ 107
MOVIPREP................................................ 108
moxifloxacin hcl (2x day)............................167
moxifloxacin hcl ophthalmic solution.......... 167
moxifloxacin hcl oral.....................................22
MOZOBIL..................................................... 60
m-pap........................................................... 13
MS CONTIN................................................... 7
MSUD EASY.............................................. 158
MUCINEX CHILDRENS FREEFROM
ORAL LIQUID 5-100 MG/5ML................... 194
MUCINEX CHILDRENS STUFFY NOSE...194
MUCINEX COUGH CHILDRENS.............. 194
MUCINEX D............................................... 194
MUCINEX D MAX STRENGTH................. 194
MUCINEX DM............................................ 194
mucinex fast-max cong headache............. 183
MUCINEX FAST-MAX DM MAX................ 194
MUCINEX MAXIMUM STRENGTH........... 183
MUCINEX SINUS-MAX CLEAR & COOL.. 194
MUCINEX SINUS-MAX SEV CONG/PN
ORAL CAPSULE........................................183
MUCINEX SINUS-MAX SINUS/ALLRGY.. 194
MUCOSITISRX............................................ 75
mucus & cough relief child......................... 194
mucus & cough relief childrens.................. 194
mucus d......................................................194
mucus d extended release......................... 194
mucus d max st er......................................194
mucus dm...................................................194
mucus dm extended release oral tablet
extended release 12 hour 30-600 mg........ 194
mucus er maximum str...............................184
mucus er oral tablet extended release 12
hour 1200 mg............................................. 184
mucus extended release oral tablet
extended release 12 hour 1200 mg........... 184
mucus relief 12 hour max st....................... 184
mucus relief chest oral tablet 400 mg........ 184
mucus relief cough children....................... 194
mucus relief cough childrens......................194
mucus relief d max strength....................... 195
mucus relief d oral tablet extended release
12 hour 60-600 mg.....................................195
mucus relief dm max oral liquid..................195
242
mucus relief dm oral liquid 20-400 mg/20ml
....................................................................195
mucus relief dm oral tablet extended
release 12 hour 30-600 mg........................ 195
mucus relief er oral tablet extended release
12 hour 1200 mg........................................ 184
mucus relief max st.................................... 184
mucus relief max strength oral tablet
extended release 12 hour 1200 mg........... 184
mucus relief oral tablet 400 mg.................. 184
mucus relief oral tablet extended release
12 hour 1200 mg........................................ 184
mucus-d..................................................... 195
mucus-dm.................................................. 195
mucus-er oral tablet extended release 12
hour 1200 mg............................................. 184
MULPLETA.................................................. 60
MULTAQ...................................................... 64
multi symptom flu/severe cold....................184
MULTI-MAC............................................... 101
multiple vitamins/iron..................................204
MULTIVITAMIN CHILDRENS GUMMIES..204
multi-vitamin hp/minerals........................... 101
multi-vitamin/fluoride.................................. 101
multi-vitamin/fluoride/iron........................... 101
multi-vitamin/iron........................................ 204
mupirocin calcium........................................ 82
mupirocin external........................................82
MURO 128 OPHTHALMIC OINTMENT.....171
MURO 128 OPHTHALMIC SOLUTION 5
%................................................................ 171
my choice................................................... 141
my way....................................................... 141
MYALEPT.................................................. 108
MYAMBUTOL.............................................. 39
MYCAPSSA............................................... 143
MYCOBUTIN................................................39
mycophenolate mofetil oral........................ 146
mycophenolate sodium.............................. 146
MYCOZYL AL............................................ 158
MYCOZYL AP.............................................. 36
MYDAYIS..................................................... 72
MYFEMBREE............................................ 106
MYFORTIC................................................ 146
MYLERAN....................................................39
MYLICON INFANTS GAS RELIEF............ 118
mynephrocaps oral capsule 1 mg.............. 101
MYNEPHRON............................................101
myorisan.......................................................76
MYRBETRIQ ORAL SUSPENSION
RECONSTITUTED ER...............................127
MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HOUR.................................. 127
MYSOLINE...................................................27
MYTESI......................................................107
nabumetone oral............................................ 6
nadolol oral...................................................64
naftifine hcl................................................... 82
NAFTIN........................................................ 82
NALFON ORAL CAPSULE............................ 6
NALFON ORAL TABLET............................... 6
naloxone hcl injection...................................18
naloxone hcl nasal....................................... 18
naltrexone hcl oral........................................18
NAMENDA................................................... 29
NAMENDA TITRATION PAK....................... 29
NAMENDA XR............................................. 29
NAMZARIC ORAL CAPSULE ER 24
HOUR THERAPY PACK..............................29
NAMZARIC ORAL CAPSULE EXTENDED
RELEASE 24 HOUR.................................... 29
NAPHCON-A..............................................173
NAPRELAN ORAL TABLET EXTENDED
RELEASE 24 HOUR 375 MG, 750 MG......... 6
NAPRELAN ORAL TABLET EXTENDED
RELEASE 24 HOUR 500 MG........................ 6
NAPROSYN................................................... 6
naproxen oral suspension.............................. 6
naproxen oral tablet....................................... 6
naproxen oral tablet delayed release............. 6
naproxen sodium er oral tablet extended
release 24 hour 375 mg................................. 6
naproxen sodium er oral tablet extended
release 24 hour 500 mg................................. 6
NAPROXEN SODIUM ER ORAL TABLET
EXTENDED RELEASE 24 HOUR 750 MG....6
naproxen sodium oral tablet 220 mg..............6
naproxen sodium oral tablet 275 mg..............6
naproxen sodium oral tablet 550 mg..............6
naproxen-esomeprazole................................ 6
NARAMIN...................................................176
naratriptan hcl.............................................. 38
NARCAN...................................................... 18
NARDIL........................................................ 30
NASACORT ALLERGY 24HR................... 189
NASACORT ALLERGY 24HR CHILDREN 189
nasal allergy 24 hour..................................189
nasal allergy nasal aerosol 55 mcg/act...... 189
nasal allergy spray..................................... 189
nasal decongestant 12 hour.......................195
nasal decongestant 12hr............................195
nasal decongestant max st........................ 195
nasal decongestant oral tablet 30 mg........ 195
nasal decongestant oral tablet extended
release 12 hour 120 mg............................. 195
nasal decongestant pe max st................... 184
nasal decongestant pe oral tablet 10 mg... 184
nasal decongestant spray.......................... 195
nasal four................................................... 184
nasal four spray..........................................184
nasal mist nasal solution............................ 195
NASAL MOIST NASAL SOLUTION...........184
nasal moisturizing spray.............................184
nasal relief..................................................195
nasal relief moisturizing..............................195
nasal spray.................................................195
nasal spray 12 hour....................................195
243
nasal spray extra moist.............................. 195
nasal spray extra moisturizing....................195
nasal spray fast acting............................... 184
nasal spray moisturizing.............................196
nasal spray no drip.....................................196
nasal spray saline...................................... 184
nasal spray sinus....................................... 196
NASALCROM............................................ 190
NASCOBAL................................................207
NATACYN.................................................. 167
NATAZIA.................................................... 137
nateglinide....................................................55
NATESTO.................................................. 133
NATPARA.................................................. 150
NATROBA....................................................81
natural daily fiber........................................122
natural fiber laxative oral powder 58.6 %... 122
natural fiber oral capsule 0.52 gm..............122
natural fiber oral powder 28.3 %................ 122
natural fiber oral powder 48.57 %.............. 122
natural fiber oral powder 58.6 %................ 122
natural fiber supplement.............................122
natural fish oil oral capsule 1000 mg..........158
natural fish oil oral capsule 1200 mg..........158
natural laxative........................................... 124
natural magnesium.....................................204
natural senna laxative................................ 124
natural tears pf........................................... 171
natural vegetable........................................122
natural vegetable fiber................................122
natural vegetable laxative oral tablet 8.6
mg.............................................................. 124
natural vitamin e.........................................207
natura-lax................................................... 122
nausea control..............................................34
nausea relief.................................................34
NAYZILAM................................................... 27
nebivolol hcl................................................. 64
NEBULIZER MASK ADULT....................... 158
NEBULIZER MASK CHILD........................ 158
NEBUPENT..................................................44
necon 0.5/35 (28)....................................... 138
nefazodone hcl.............................................31
NEODOT THERMOMETER.......................158
neomycin sulfate oral................................... 20
neomycin-bacitracin zn-polymyx................ 167
neomycin-polymyxin-dexameth ophthalmic
ointment..................................................... 166
neomycin-polymyxin-dexameth ophthalmic
suspension 3.5-10000-0.1 .........................166
neomycin-polymyxin-gramicidin................. 167
neomycin-polymyxin-hc ophthalmic........... 166
neomycin-polymyxin-hc otic....................... 173
NEONATAL COMPLETE ORAL TABLET
27-1 MG..................................................... 101
NEONATAL COMPLETE ORAL TABLET
29-1 MG..................................................... 101
NEONATAL PLUS TABLET 27-1 MG
ORAL................................................. 101, 102
NEONATAL VITAMIN................................ 102
neo-polycin.................................................167
neo-polycin hc............................................ 166
NEORAL.................................................... 146
NEOSALUS EXTERNAL CREAM..............158
NEOSALUS EXTERNAL LOTION............. 158
NEOSPORIN + PAIN RELIEF MAX ST....... 25
NEOSPORIN ORIGINAL............................. 25
NEO-SYNALAR EXTERNAL CREAM......... 80
NEO-SYNALAR EXTERNAL KIT.................25
NEO-SYNEPHRINE COLD/ALLRGY EXT.184
NEPHPLEX RX.......................................... 102
nephro vitamins..........................................102
nephronex oral tablet................................. 102
NEPHRO-VITE...........................................102
NEPHRO-VITE RX.....................................102
NERLYNX.................................................. 164
NERVE PAIN RELIEF................................158
NESINA........................................................55
NESTABS.................................................. 102
NESTABS DHA..........................................102
NESTABS ONE..........................................102
neuac external gel........................................76
NEUAC EXTERNAL KIT.............................. 84
NEULASTA.................................................. 60
NEULASTA ONPRO.................................... 60
NEUPOGEN.................................................60
NEUPRO......................................................46
NEURAGEN PN.........................................158
NEURONTIN................................................27
NEUTEK 2TEK CONTROL.......................... 90
NEUTEK 2TEK TEST.................................. 90
NEUTROGENA OIL-FREE ACNE WASH. 158
NEVANAC..................................................168
nevirapine.....................................................51
nevirapine er................................................ 51
new day......................................................141
NEWFLORA PROBIOTIC.......................... 118
NEXAVAR.................................................... 42
NEXICLON XR.............................................62
NEXIUM ORAL CAPSULE DELAYED
RELEASE...................................................110
NEXIUM ORAL PACKET........................... 110
NEXLETOL.................................................. 69
NEXLIZET.................................................... 69
NEXTSTELLIS........................................... 106
niacin er (antihyperlipidemic)....................... 69
niacin er oral capsule extended release
250 mg....................................................... 102
niacin er oral capsule extended release
500 mg....................................................... 102
niacin er oral tablet extended release........ 102
niacin flush free oral capsule 400-100 mg. 102
niacin oral tablet 100 mg, 250 mg, 50 mg.. 102
NIASPAN..................................................... 69
NICAPRIN.................................................. 158
nicardipine hcl oral....................................... 65
NICODERM CQ........................................... 18
244
NICOMIDE................................................. 102
NICORETTE................................................ 19
NICORETTE MINI........................................19
NICORETTE STARTER KIT........................ 19
nicotinamide oral........................................ 102
nicotine gum mouth/throat gum 2 mg...........19
nicotine gum mouth/throat gum 4 mg...........19
nicotine gum mouth/throat lozenge 2 mg..... 19
nicotine gum mouth/throat lozenge 4 mg..... 19
nicotine mini................................................. 19
nicotine mouth/throat gum 2 mg...................19
nicotine mouth/throat gum 4 mg...................19
nicotine mouth/throat lozenge 2 mg............. 19
nicotine mouth/throat lozenge 4 mg............. 19
nicotine polacrilex mini................................. 19
nicotine polacrilex mouth/throat................... 19
nicotine step 1.............................................. 18
nicotine step 2.............................................. 18
nicotine step 3.............................................. 18
nicotine transdermal kit 21-14-7 mg/24hr.....18
nicotine transdermal patch 24 hour 14
mg/24hr, 7 mg/24hr......................................18
nicotine transdermal patch 24 hour 21
mg/24hr........................................................ 18
nicotine transdermal system........................ 18
NICOTROL...................................................18
NICOTROL NS.............................................18
nifedipine er..................................................65
nifedipine er osmotic release....................... 65
nifedipine oral...............................................65
NIFEREX......................................................97
night time cold/flu relief oral liquid 15-6.25-
500 mg/15ml.............................................. 184
night time sleep aid.................................... 200
nighttime cold medicine..............................184
nighttime cold/flu relief oral liquid 15-6.25-
500 mg/15ml.............................................. 184
nighttime dry-eye relief...............................171
nighttime sleep aid max st..........................200
nighttime sleep aid oral capsule 25 mg......200
nighttime sleep aid oral tablet 25 mg......... 200
nikki............................................................ 138
NILANDRON................................................ 40
nilutamide.....................................................40
nimodipine oral.............................................65
NINJACOF-XG...........................................196
NINLARO..................................................... 41
nisoldipine er................................................ 65
nitazoxanide oral.......................................... 44
nitisinone.................................................... 126
NITRO-BID...................................................70
NITRO-DUR................................................. 70
nitrofurantoin................................................ 20
nitrofurantoin macrocrystal...........................20
nitrofurantoin monohydrate macrocrystals... 20
nitroglycerin sublingual.................................70
nitroglycerin transdermal..............................70
nitroglycerin translingual.............................. 70
NITROLINGUAL...........................................70
NITROSTAT SUBLINGUAL TABLET
SUBLINGUAL 0.3 MG, 0.6 MG....................70
NITROSTAT TABLET SUBLINGUAL 0.4
MG SUBLINGUAL........................................70
NITYR........................................................ 126
NIVA-PLUS................................................ 102
NIVATOPIC PLUS..................................... 158
NIVESTYM...................................................60
nizatidine.................................................... 109
no drip nasal relief......................................196
no drip nasal spray.....................................196
no flush niacin oral capsule........................102
NOCDURNA.............................................. 131
nohist-lq......................................................186
nolix..............................................................78
non-aspirin................................................... 13
non-aspirin 8 hour........................................ 13
non-aspirin childrens.................................... 13
non-aspirin extra strength............................ 13
non-aspirin jr strength.................................. 13
non-aspirin pain relief...................................13
non-pseudo sinus decongestant................ 184
nora-be.......................................................140
NORDIPEN 5 INJECTION DEVICE...........158
NORDIPEN DELIVERY SYSTEM..............158
NORDITROPIN FLEXPRO........................ 131
norethin ace-eth estrad-fe.......................... 138
norethindrone acetate oral......................... 140
norethindrone acet-ethinyl est....................138
norethindrone oral...................................... 140
norethindrone-eth estradiol........................ 138
norethin-eth estradiol-fe............................. 138
NORGESIC................................................ 198
NORGESIC FORTE...................................198
norgestimate-eth estradiol..........................138
norgestimate-ethinyl estradiol triphasic......138
NORITATE................................................... 20
NORLIQVA...................................................65
norlyda....................................................... 140
norlyroc...................................................... 140
NORPACE................................................... 64
NORPACE CR............................................. 64
NORPRAMIN............................................... 32
NORTHERA................................................. 62
nortrel 0.5/35 (28).......................................138
nortrel 1/35 (21)..........................................138
nortrel 1/35 (28)..........................................138
nortrel 7/7/7................................................ 138
nortriptyline hcl oral...................................... 32
NORVASC................................................... 65
NORVIR ORAL PACKET............................. 52
NORVIR ORAL SOLUTION......................... 52
NORVIR ORAL TABLET..............................52
nose drops extstrength...............................184
nose drops nasal decongest...................... 184
nose drops nasal solution 1 %................... 184
NOURIANZ.................................................. 45
NOVAREL.................................................. 131
245
NOVOLIN 70/30 FLEXPEN..........................58
NOVOLIN 70/30 FLEXPEN RELION........... 58
NOVOLIN 70/30 RELION.............................58
NOVOLIN 70/30 VIAL.................................. 58
NOVOLIN N FLEXPEN................................ 58
NOVOLIN N FLEXPEN RELION..................58
NOVOLIN N RELION................................... 58
NOVOLIN N VIAL.........................................58
NOVOLIN R FLEXPEN................................ 58
NOVOLIN R FLEXPEN RELION..................58
NOVOLIN R RELION................................... 58
NOVOLIN R VIAL.........................................58
NOVOLOG 70/30 FLEXPEN RELION......... 58
NOVOLOG FLEXPEN..................................58
NOVOLOG FLEXPEN RELION................... 58
NOVOLOG MIX 70/30 FLEXPEN................ 58
NOVOLOG MIX 70/30 RELION................... 58
NOVOLOG MIX 70/30 VIAL.........................58
NOVOLOG PENFILL................................... 59
NOVOLOG RELION.....................................59
NOVOLOG U-100 VIAL............................... 59
NOXAFIL ORAL SUSPENSION.................. 34
NOXAFIL ORAL TABLET DELAYED
RELEASE.....................................................34
np thyroid................................................... 142
NUBEQA...................................................... 40
NUCALA SUBCUTANEOUS SOLUTION
AUTO-INJECTOR...................................... 181
NUCALA SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 100 MG/ML...........181
NUCALA SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 40 MG/0.4ML........181
NUCYNTA......................................................9
NUCYNTA ER................................................7
NUEDEXTA..................................................72
NUFERA...................................................... 97
NU-IRON......................................................97
NULEV....................................................... 158
NU-MAG.......................................................97
NUPERCAINAL............................................84
NUPLAZID................................................... 47
NURTEC...................................................... 37
NUTRAPLUS............................................... 86
NUTRASEB..................................................84
NUTRIARX CREAMPAK..............................86
NUTRICAP.................................................204
nutrifac zx...................................................204
NUTROPIN AQ NUSPIN 10.......................131
NUTROPIN AQ NUSPIN 20.......................131
NUTROPIN AQ NUSPIN 5.........................131
NUVAIL...................................................... 158
NUVARING................................................ 138
NUVESSA.................................................... 20
NUVIGIL.....................................................200
NUWIQ INTRAVENOUS KIT 1000 UNIT,
2000 UNIT, 250 UNIT, 2500 UNIT, 3000
UNIT, 4000 UNIT, 500 UNIT........................ 61
NUZYRA ORAL............................................24
nyamyc.........................................................82
nylia 1/35....................................................138
nylia 7/7/7...................................................138
NYMALIZE................................................... 65
nymyo.........................................................138
nystatin external........................................... 82
nystatin mouth/throat....................................34
nystatin oral..................................................34
nystatin-triamcinolone.................................. 80
nystop...........................................................82
NYVEPRIA................................................. 158
OB COMPLETE......................................... 102
OB COMPLETE ONE................................ 102
OB COMPLETE PETITE............................102
OB COMPLETE PREMIER........................102
OB COMPLETE/DHA.................................102
OBSTETRIX DHA...................................... 102
OBSTETRIX EC.........................................204
OBTREX.................................................... 204
OCALIVA....................................................108
OCEAN FOR KIDS.................................... 184
OCEAN NASAL SPRAY............................ 184
ocella..........................................................138
octreotide acetate.......................................143
OCUFLOX..................................................167
ODEFSEY.................................................... 51
ODOMZO..................................................... 42
odorless coated fish oil...............................158
OFEV......................................................... 180
ofloxacin ophthalmic...................................167
ofloxacin oral................................................ 22
ofloxacin otic.............................................. 173
ointment base...............................................84
olanzapine oral.............................................47
olanzapine-fluoxetine hcl oral capsule 12-
25 mg, 12-50 mg, 6-50 mg...........................30
olanzapine-fluoxetine hcl oral capsule 3-25
mg................................................................ 30
olanzapine-fluoxetine hcl oral capsule 6-25
mg................................................................ 30
olmesartan medoxomil oral.......................... 63
olmesartan medoxomil-hctz......................... 67
olmesartan-amlodipine-hctz......................... 67
olopatadine hcl nasal................................. 176
olopatadine hcl ophthalmic.........................166
OLUMIANT ORAL TABLET 1 MG, 2 MG...144
OLUMIANT ORAL TABLET 4 MG............. 144
OLUX........................................................... 79
OLUX-E........................................................79
OMECLAMOX-PAK................................... 108
omega-3 fish oil oral capsule 1000 mg...... 159
omega-3 fish oil oral capsule 1200 mg...... 159
omega-3 fish oil oral capsule 300 mg........ 159
omega-3 fish oil oral capsule delayed
release 1200 mg........................................ 159
omega-3 oral capsule 1000 mg..................159
omega-3 oral capsule 1400 mg..................159
omega-3-acid ethyl esters............................69
246
omeprazole magnesium oral capsule
delayed release..........................................110
omeprazole magnesium oral tablet delayed
release....................................................... 110
omeprazole oral capsule delayed release
10 mg, 20 mg, 20.6 (20 base) mg, 40 mg.. 110
omeprazole oral tablet delayed release 20
mg.............................................................. 110
omeprazole-sod bicarbonate......................110
omeprazole-sodium bicarb oral capsule 20-
1100 mg..................................................... 110
omeprazole-sodium bicarbonate................110
OMNARIS.................................................. 177
OMNIFLEX DIAPHRAGM.......................... 159
OMNIPOD 5 G6 INTRO (GEN 5)...............159
OMNIPOD 5 G6 POD (GEN 5).................. 159
OMNITROPE............................................. 131
OMNITROPE PEN 5 INJ DEVICE............. 159
ON/GO COVID-19 ANTIGEN TEST.......... 159
ON/GO ONE COVID-19 HOME TEST.......159
ondansetron hcl oral solution....................... 33
ondansetron hcl oral tablet 4 mg, 8 mg........33
ondansetron odt........................................... 33
one daily womens health oral tablet .........102
ONE VITE WOMENS.................................102
ONE VITE WOMENS PLUS...................... 102
one-daily multi-vitamin/iron........................ 204
one-daily/iron..............................................204
ONELAX.....................................................159
ONETOUCH SOLUTIONS STARTER KIT 159
ONETOUCH SURESOFT LANCING
DEVICE........................................................92
ONETOUCH ULTRA 2 KIT W/DEVICE....... 90
ONETOUCH ULTRA CONTROL................. 90
ONETOUCH ULTRA MINI KIT W/DEVICE..90
ONETOUCH ULTRA TEST STRIPS............90
ONETOUCH VERIO FLEX SYSTEM...........90
ONETOUCH VERIO IN VITRO SOLUTION 90
ONETOUCH VERIO IN VITRO SOLUTION
HIGH.......................................................... 159
ONETOUCH VERIO IQ SYSTEM................90
ONETOUCH VERIO KIT W/DEVICE........... 90
ONETOUCH VERIO REFLECT KIT
W/DEVICE................................................... 90
ONETOUCH VERIO TEST STRIPS............ 90
ONEVITE................................................... 204
ONEXTON................................................... 76
ONFI.............................................................27
ONGENTYS................................................. 45
ONGLYZA.................................................... 55
ONUREG..................................................... 40
ONZETRA XSAIL.........................................38
opcicon one-step........................................141
opium......................................................... 107
OPSUMIT...................................................180
option 2...................................................... 141
OPTIONS GYNOL II CONTRACEPTIVE...129
OPTIUMEZ TEST........................................ 90
OPZELURA..................................................86
ORACEA...................................................... 24
ORACIT........................................................97
oral anesthetic max str................................. 75
oral pain relief mouth/throat gel 20 %.......... 75
ORALAIR................................................... 144
ORALAIR ADULT STARTER PACK.......... 144
oralone......................................................... 74
oralyte freezer pops..................................... 97
ORAPRED ODT ORAL TABLET
DISPERSIBLE 10 MG, 30 MG................... 130
ORAPRED ODT ORAL TABLET
DISPERSIBLE 15 MG................................130
ORAVIG....................................................... 35
ORENCIA CLICKJECT.............................. 145
ORENCIA SUBCUTANEOUS....................145
ORENITRAM..............................................180
ORFADIN................................................... 126
ORGOVYX................................................... 19
ORIAHNN...................................................143
ORILISSA...................................................143
ORKAMBI...................................................179
ORLADEYO............................................... 159
orphenadrine citrate er............................... 198
orphenadrine-aspirin-caffeine.................... 198
ORPHENGESIC FORTE........................... 198
ORTIKOS................................................... 149
OS-CAL CALCIUM + D3..............................97
OS-CAL EXTRA D3..................................... 97
OSCIMIN....................................................159
oseltamivir phosphate oral........................... 52
OSENI.......................................................... 55
OSMOLEX ER............................................. 45
OSMOPREP.............................................. 108
OSPHENA..................................................141
OTEZLA..................................................... 145
OTOVEL.....................................................173
OTREXUP..................................................146
OVACE PLUS WASH................................ 159
OVACE WASH...........................................159
OVIDE.......................................................... 81
OVIDREL................................................... 132
oxandrolone oral........................................ 132
oxaprozin........................................................6
OXAYDO ORAL TABLET 5 MG...................15
OXAYDO ORAL TABLET 7.5 MG................15
oxazepam.....................................................53
OXBRYTA ORAL TABLET...........................60
OXBRYTA ORAL TABLET SOLUBLE......... 60
oxcarbazepine..............................................28
OXERVATE................................................166
oxiconazole nitrate....................................... 82
OXISTAT EXTERNAL CREAM....................82
OXISTAT EXTERNAL LOTION................... 82
OXTELLAR XR............................................ 28
oxybutynin chloride er................................ 127
oxybutynin chloride oral............................. 127
OXYCODONE HCL ER..................................7
247
oxycodone hcl oral capsule............................9
oxycodone hcl oral concentrate 100
mg/5ml........................................................... 9
oxycodone hcl oral solution............................9
oxycodone hcl oral tablet............................. 15
OXYCODONE-ACETAMINOPHEN ORAL
SOLUTION 5-325 MG/5ML............................9
oxycodone-acetaminophen oral tablet 10-
325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg.................................................................. 9
OXYCONTIN..................................................7
oxymorphone hcl............................................9
oxymorphone hcl er........................................7
OXYTROL.................................................. 127
OXYTROL FOR WOMEN.......................... 127
oysco 500+d.................................................97
oyster shell calcium + d oral tablet 500-400
mg-unit......................................................... 97
oyster shell calcium + d3..............................97
oyster shell calcium 500 + d.......................204
oyster shell calcium oral tablet 500 mg...... 204
oyster shell calcium plus d........................... 97
oyster shell calcium w/d............................... 97
oyster shell calcium/d oral tablet 250-125
mg-unit....................................................... 204
oyster shell calcium/vit d.............................. 97
oyster shell calcium/vit d3............................ 97
oyster shell calcium/vitamin d oral tablet
250-125 mg-unit......................................... 204
oyster shell calcium/vitamin d oral tablet
500-200 mg-unit........................................... 97
oyster shell calcium-vit d.............................. 97
OZEMPIC.....................................................55
OZEMPIC (2 MG/DOSE)............................. 55
p col-rite..................................................... 124
PACERONE ORAL TABLET 100 MG, 400
MG............................................................... 64
PACERONE ORAL TABLET 200 MG..........64
pain & fever child..........................................13
pain & fever childrens...................................13
pain & fever childrens oral suspension 160
mg/5ml......................................................... 13
pain & fever infants...................................... 13
pain relief childrens oral tablet chewable
160 mg......................................................... 13
pain relief external cream 4 %......................16
pain relief extra st.........................................13
pain relief extra strength...............................13
pain relief infants oral suspension 160
mg/5ml......................................................... 13
pain relief oral liquid 500 mg/15ml............... 13
pain relief oral tablet 325 mg........................13
pain relief oral tablet 500 mg........................13
pain relief oral tablet extended release 650
mg................................................................ 13
pain relief regular st......................................13
pain relief regular strength........................... 13
pain relief/rapid burst....................................13
pain relieve child dye-free............................ 13
pain reliever..................................................14
pain reliever childrens oral suspension 160
mg/5ml......................................................... 14
pain reliever ex st oral liquid 500 mg/15ml...14
pain reliever ex st oral tablet 500 mg........... 14
pain reliever ex st oral tablet extended
release 650 mg............................................ 14
pain reliever extra strength oral tablet 250-
250-65 mg.................................................... 14
pain reliever extra strength oral tablet 500
mg................................................................ 14
pain reliever infants oral suspension 160
mg/5ml......................................................... 14
pain reliever oral tablet.................................14
pain reliever plus.......................................... 14
pain relieving + lidocaine..............................17
pain relieving external cream 4 %................ 17
pain-off......................................................... 14
PALFORZIA (12 MG DAILY DOSE).......... 159
PALFORZIA (120 MG DAILY DOSE)........ 159
PALFORZIA (160 MG DAILY DOSE)........ 159
PALFORZIA (20 MG DAILY DOSE).......... 159
PALFORZIA (200 MG DAILY DOSE)........ 159
PALFORZIA (240 MG DAILY DOSE)........ 159
PALFORZIA (3 MG DAILY DOSE)............ 159
PALFORZIA (300 MG MAINTENANCE)....159
PALFORZIA (300 MG TITRATION)........... 159
PALFORZIA (40 MG DAILY DOSE).......... 159
PALFORZIA (6 MG DAILY DOSE)............ 159
PALFORZIA (80 MG DAILY DOSE).......... 159
PALFORZIA INITIAL ESCALATION.......... 159
paliperidone er............................................. 48
PALYNZIQ................................................. 126
PAMELOR....................................................32
PANADOL CHILDRENS.............................. 14
PANADOL EXTRA....................................... 14
PANADOL EXTRA STRENGTH.................. 14
PANADOL INFANTS....................................14
PANCREAZE ORAL CAPSULE DELAYED
RELEASE PARTICLES 10500-35500
UNIT, 16800-56800 UNIT, 21000-54700
UNIT, 37000-97300 UNIT, 4200-14200
UNIT...........................................................126
PANCREAZE ORAL CAPSULE DELAYED
RELEASE PARTICLES 2600-8800 UNIT.. 126
PANDEL.......................................................79
PANOXYL.................................................. 159
PANRETIN................................................... 42
pantoprazole sodium oral packet............... 110
pantoprazole sodium oral tablet delayed
release....................................................... 110
pantothenic acid......................................... 207
PARADIGM REAL-TIME TRANSMITTER. 159
PAREMYD................................................. 171
PARI ALTERA NEBULIZER HANDSET.... 159
PARI ALTERA NEBULIZER SYSTEM.......159
PARI BABY CONVERSION KIT................ 159
PARI ERAPID NEBULIZER HANDSET..... 159
248
PARI ERAPID NEBULIZER SYSTEM....... 160
PARI LC PLUS NEB SET PED MASK.......160
PARI LC PLUS NEBULIZER......................160
PARI LC PLUS VIOS PRO NEB................ 160
PARI LC SPRINT NEBULIZER SET..........160
PARI PRONEB MAX LC PLUS..................160
PARI PRONEB MAX LC SPRINT.............. 160
PARI SINUS AEROSOL SYSTEM.............160
PARI SMARTMASK BABY/ELBOW.......... 160
PARI TREK S COMBO PACK................... 160
PARI TREK S W/12V DC ADAPTOR........ 160
PARI VIOS PRO LC PLUS SYSTEM.........160
PARI VIOS PRO LC SPRINT SYSTEM.....160
PARI VORTEX ADULT MASK................... 161
paricalcitol oral........................................... 150
PARLODEL.................................................. 46
PARNATE.................................................... 30
paromomycin sulfate oral............................. 20
paroxetine hcl...............................................31
paroxetine hcl er...........................................31
paroxetine mesylate..................................... 31
PASER......................................................... 39
PATADAY OPHTHALMIC SOLUTION 0.1
%, 0.2 %.....................................................166
PATANASE................................................ 176
PAXIL........................................................... 31
PAXIL CR.....................................................31
PAXLOVID................................................... 53
pb-hyoscy-atropine-scopolamine............... 111
ped electrolyte freeze pop............................97
pediaclear pd childrens.............................. 188
PEDIA-LAX ORAL LIQUID.........................124
PEDIALYTE FREEZER POPS.....................97
PEDIALYTE ORAL SOLUTION................... 97
PEDIALYTE SINGLES.................................97
PEDIAPRED.............................................. 130
PEDIARIX.................................................. 147
PEDIATRIC COMPRESSOR NEBULIZER 161
pediatric electrolyte oral solution ................97
PEDVAX HIB..............................................147
peg 3350 oral powder................................ 122
peg 3350-kcl-na bicarb-nacl.......................108
peg-3350/electrolytes.................................108
peg-3350/electrolytes/ascorbat.................. 108
PEGASYS.................................................. 145
peg-kcl-nacl-nasulf-na asc-c...................... 108
PEMAZYRE................................................. 41
PEMETREXED DISODIUM
INTRAVENOUS SOLUTION........................40
pemetrexed disodium intravenous solution
reconstituted 1000 mg, 750 mg....................40
PEMETREXED INTRAVENOUS
SOLUTION 1 GM/40ML, 100 MG/4ML........ 40
penicillamine oral....................................... 128
penicillin v potassium................................... 21
PENLET II BLOOD SAMPLER.................... 90
PENLET II REPLACEMENT CAP................92
PENNSAID.....................................................6
PENTACEL................................................ 147
pentamidine isethionate inhalation...............44
PENTASA.................................................. 149
pentazocine-naloxone hcl.............................. 9
pentoxifylline er............................................ 67
PEPCID......................................................109
PEPTO-BISMOL ORAL SUSPENSION
524 MG/30ML............................................ 118
PERCOCET................................................... 9
PERDIEM OVERNIGHT RELIEF...............124
PERFOROMIST.........................................178
PERIDEX..................................................... 74
PERIDIN-C.................................................204
perindopril erbumine.................................... 63
periogard...................................................... 74
permethrin external...................................... 81
perphenazine oral........................................ 33
perphenazine-amitriptyline oral tablet 2-10
mg, 4-10 mg, 4-25 mg, 4-50 mg...................30
perphenazine-amitriptyline oral tablet 2-25
mg................................................................ 30
PERSERIS................................................... 48
PERTZYE...................................................126
PEXEVA ORAL TABLET 10 MG, 20 MG,
30 MG.......................................................... 31
PFIZER COVID-19 VAC-TRIS 5-11Y........ 148
PFIZER COVID-19 VAC-TRIS 6M-4Y....... 161
PFIZER-BIONT COVID-19 VAC-TRIS.......161
PFIZER-BIONTECH COVID-19 VACC...... 148
pharbechlor................................................ 188
pharbedryl.................................................. 176
PHARBETOL EXTRA STRENGTH..............14
PHARBETOL ORAL TABLET 325 MG........ 14
pharbinex................................................... 184
PHAZYME..................................................118
PHAZYME ULTRA STRENGTH................ 118
phenazo oral tablet 200 mg........................129
phenazo oral tablet 95 mg..........................129
phenazopyridine hcl oral tablet 100 mg..... 129
phenazopyridine hcl oral tablet 200 mg..... 129
phenelzine sulfate oral................................. 30
phenobarbital oral........................................ 27
phenobarbital-belladonna alk..................... 111
PHENOHYTRO..........................................111
phenoxybenzamine hcl oral......................... 62
phenylephrine hcl ophthalmic.....................166
phenylephrine hcl oral................................ 184
PHENYTEK..................................................28
phenytoin infatabs........................................ 28
phenytoin oral suspension 125 mg/5ml........28
phenytoin oral tablet chewable.....................28
phenytoin sodium extended......................... 28
PHEXXI...................................................... 129
philith..........................................................138
PHILLIPS MILK OF MAGNESIA ORAL
SUSPENSION 400 MG/5ML......................118
PHOSLYRA..................................................99
PHOS-NAK.................................................. 97
249
PHOSPHA 250 NEUTRAL...........................97
PHOSPHOLINE IODIDE............................169
phosphorous................................................ 98
phosphorus supplement...............................98
phosphorus w/sod & potassium................... 98
phospho-trin 250 neutral.............................. 98
PHOSPHO-TRIN K500................................ 98
phytonadione oral.......................................102
PIFELTRO....................................................51
pilocarpine hcl ophthalmic..........................169
pilocarpine hcl oral....................................... 74
pimecrolimus................................................ 79
pimozide.......................................................47
pimtrea....................................................... 138
pindolol.........................................................64
pink bismuth maximum strength................ 118
pink bismuth oral suspension 262 mg/15ml
....................................................................118
pink bismuth oral tablet 262 mg................. 118
pink bismuth oral tablet chewable 262 mg. 118
pink-bismuth...............................................118
pioglitazone hcl............................................ 55
pioglitazone hcl-glimepiride..........................55
pioglitazone hcl-metformin hcl......................55
PIQRAY (200 MG DAILY DOSE).................42
PIQRAY (250 MG DAILY DOSE).................42
PIQRAY (300 MG DAILY DOSE).................42
pirfenidone................................................. 180
pirmella 1/35...............................................138
pirmella 7/7/7..............................................138
piroxicam oral.................................................6
PKU EASY................................................. 161
PKU EASY MICROTABS...........................161
PLAN B ONE-STEP................................... 141
PLAQUENIL................................................. 44
PLAVIX.........................................................61
PLEGRIDY................................................... 73
PLEGRIDY STARTER PACK...................... 73
PLENVU.....................................................108
PLEXION CLEANSER................................. 84
PLEXION NS..............................................161
PNEUMOVAX 23....................................... 148
pnv-dha...................................................... 102
pnv-dha+docusate......................................102
pnv-omega................................................. 102
pnv-select...................................................102
podocon-25................................................ 161
podofilox external......................................... 80
poly bacitracin............................................ 161
polycin........................................................ 167
polyethylene glycol 3350 oral powder........ 122
polyethylene glycol 3350-grx oral powder 122
poly-iron 150................................................ 98
poly-iron 150 forte........................................ 98
polymyxin b-trimethoprim........................... 167
polysaccharide iron complex........................98
polysaccharide iron forte.............................. 98
polysaccharide-iron complex........................98
POLYSPORIN............................................161
POLYTRIM.................................................167
poly-tussin ac............................................. 196
polytussin dm............................................. 186
POLY-VI-FLOR ORAL SUSPENSION.......102
POLY-VI-FLOR ORAL TABLET
CHEWABLE 0.25 MG................................ 102
POLY-VI-FLOR ORAL TABLET
CHEWABLE 0.5 MG, 1 MG....................... 102
POLY-VI-FLOR/IRON................................ 102
polyvinyl alcohol ophthalmic.......................171
POLY-VI-SOL.............................................205
POLY-VITE PEDIATRIC............................ 205
POMALYST..................................................40
PONARIS................................................... 196
PONVORY................................................. 164
PONVORY STARTER PACK.....................164
portia-28..................................................... 138
posaconazole............................................... 35
pot & sod cit-cit ac......................................205
potassium chloride crys er........................... 92
potassium chloride er................................... 92
potassium chloride oral packet.....................93
potassium chloride oral solution 20
meq/15ml (10%), 40 meq/15ml (20%)......... 93
potassium citrate er oral tablet extended
release 10 meq (1080 mg)........................... 93
potassium citrate er oral tablet extended
release 15 meq (1620 mg)........................... 93
potassium citrate er oral tablet extended
release 5 meq (540 mg)............................... 93
potassium citrate-citric acid..........................98
povidone iodine............................................ 25
povidone-iodine external solution.................25
POVIDONE-IODINE OPHTHALMIC.......... 173
PRADAXA.................................................... 60
PRALUENT.................................................. 69
pramipexole dihydrochloride........................ 46
pramipexole dihydrochloride er.................... 46
PRAMOSONE..............................................80
prasugrel hcl.................................................61
pravastatin sodium....................................... 69
praziquantel oral...........................................43
prazosin hcl oral........................................... 62
pre protein oral tablet................................. 161
PRECISION GLUCOSE KETONE CONTR. 90
PRECISION XTRA.......................................90
PRECISION XTRA BLOOD GLUCOSE.......90
PRECISION XTRA KETONE....................... 90
PRECOSE....................................................55
PRED FORTE............................................ 168
PRED MILD................................................168
PRED-G..................................................... 166
PRED-G S.O.P...........................................166
prednicarbate............................................... 79
prednisolone acetate ophthalmic............... 168
prednisolone acetate p-f.............................168
prednisolone oral........................................130
250
prednisolone sodium phosphate
ophthalmic..................................................168
prednisolone sodium phosphate oral
solution 10 mg/5ml, 20 mg/5ml.................. 130
prednisolone sodium phosphate oral
solution 15 mg/5ml, 25 mg/5ml.................. 130
prednisolone sodium phosphate oral
solution 6.7 (5 base) mg/5ml......................130
prednisolone sodium phosphate oral tablet
dispersible 10 mg, 30 mg........................... 130
prednisolone sodium phosphate oral tablet
dispersible 15 mg....................................... 130
prednisone intensol.................................... 130
prednisone oral solution............................. 130
prednisone oral tablet.................................130
prednisone oral tablet therapy pack 10 mg
(21).............................................................130
prednisone oral tablet therapy pack 10 mg
(48), 5 mg (21), 5 mg (48).......................... 130
PREFEST...................................................138
pregabalin.................................................... 73
pregabalin er................................................ 73
PREGNYL.................................................. 131
PREHEVBRIO............................................147
PREMARIN ORAL..................................... 138
PREMARIN VAGINAL................................138
PREMESISRX............................................102
PREMIUM BLOOD GLUCOSE TEST..........90
PREMIUM CONDOMS LUBRICATED.......161
premium lidocaine........................................ 17
PREMPHASE.............................................138
PREMPRO................................................. 138
PRENAISSANCE....................................... 103
PRENAISSANCE PLUS.............................103
PRENATABS RX....................................... 103
prenatal 19................................................. 103
prenatal formula oral tablet 28-0.8 mg....... 103
prenatal gummy oral tablet chewable 0.18-
25 mg......................................................... 103
prenatal gummy oral tablet chewable 0.4-
113.5 mg.................................................... 205
prenatal gummy oral tablet chewable 0.4-
25 mg......................................................... 103
prenatal multi+dha......................................103
prenatal multivitamins................................ 103
prenatal oral tablet 27-0.8 mg.................... 103
prenatal oral tablet 27-1 mg....................... 103
prenatal oral tablet 28-0.8 mg.................... 103
prenatal plus...............................................103
prenatal plus vitamin/mineral..................... 103
prenatal vitamin plus low iron.....................103
prenatal vitamins oral tablet 28-0.8 mg...... 103
prenatal/folic acid+dha............................... 103
prenatal/iron............................................... 103
PRENATE.................................................. 103
PRENATE AM............................................103
PRENATE DHA..........................................103
PRENATE ELITE....................................... 103
PRENATE ENHANCE................................103
PRENATE ESSENTIAL............................. 103
PRENATE MINI..........................................103
PRENATE PIXIE........................................ 103
PRENATE RESTORE................................103
PRENATVITE RX.......................................103
PREPIDIL...................................................132
PREPROTEIN............................................161
PREPROTEIN 20.......................................161
PRETOMANID............................................. 39
PREVACID.................................................110
PREVACID 24HR.......................................110
PREVACID SOLUTAB............................... 111
prevalite........................................................69
PREVIDENT 5000 BOOSTER PLUS...........93
PREVIDENT 5000 DRY MOUTH.................93
PREVIDENT 5000 ENAMEL PROTECT......93
PREVIDENT 5000 ORTHO DEFENSE........93
PREVIDENT 5000 PLUS............................. 93
PREVIDENT 5000 SENSITIVE....................93
PREVIDENT DENTAL................................. 93
PREVIDENT MOUTH/THROAT...................93
previfem..................................................... 138
PREVNAR 13.............................................148
PREVNAR 20.............................................148
PREVYMIS ORAL........................................49
PREZCOBIX................................................ 52
PREZISTA....................................................52
PRID...........................................................161
PRIFTIN....................................................... 39
PRILOLID.....................................................17
PRILOSEC................................................. 111
PRILOSEC OTC........................................ 111
PRILOVIX.....................................................17
PRILOVIX LITE............................................ 17
PRILOVIX LITE PLUS..................................17
PRILOVIX PLUS.......................................... 17
PRILOVIX ULTRALITE................................ 17
PRILOVIX ULTRALITE PLUS......................17
PRIMACARE..............................................103
primaquine phosphate..................................44
PRIMIDAR..................................................118
primidone oral.............................................. 27
PRISTIQ.......................................................31
PRO HERS RX.......................................... 205
PRO HIS RX.............................................. 205
PRO PCOS RX.......................................... 205
PROAIR DIGIHALER................................. 178
PROAIR HFA............................................. 179
PROAIR RESPICLICK............................... 179
probenecid................................................... 36
PROBINATE.............................................. 118
probiotic adult 50+......................................118
probiotic blend............................................119
probiotic colon care.................................... 119
probiotic complex....................................... 119
probiotic maximum strength....................... 119
probiotic oral capsule ............................... 119
probiotic oral capsule 250 mg.................... 119
251
probiotic pearls ex st.................................. 119
PROCARDIA XL.......................................... 65
PROCENTRA...............................................72
prochlorperazine.......................................... 33
prochlorperazine maleate oral......................33
PROCORT................................................... 80
PROCRIT..................................................... 60
PROCTOCORT EXTERNAL......................149
PROCTOCORT RECTAL............................ 37
PROCTOFOAM HC..................................... 80
procto-med hc............................................ 149
procto-pak.................................................. 149
proctosol hc................................................149
proctozone-hc............................................ 149
PROCYSBI ORAL CAPSULE DELAYED
RELEASE...................................................127
PROCYSBI ORAL PACKET...................... 127
PRODIGEN................................................ 119
progesterone intramuscular....................... 140
progesterone oral....................................... 141
PROGLYCEM.............................................. 56
PROGRAF ORAL CAPSULE 0.5 MG, 5
MG............................................................. 146
PROGRAF ORAL CAPSULE 1 MG........... 146
PROGRAF ORAL PACKET....................... 146
PROLENSA................................................168
PROLEVA.................................................. 161
PROMACTA ORAL PACKET.......................61
PROMACTA ORAL TABLET....................... 61
promethazine hcl oral...................................33
promethazine hcl rectal................................ 33
promethazine vc.........................................181
promethazine vc/codeine........................... 196
promethazine-codeine................................196
promethazine-dm....................................... 196
promethazine-phenyleph-codeine..............196
promethazine-phenylephrine......................181
promethegan................................................ 33
PROMETRIUM...........................................141
PROMISEB.................................................. 84
PRONEB ULTRA FILTER SET..................161
PRONUTRIENTS COQ10..........................161
PRONUTRIENTS VITAMIN D3..................103
propafenone hcl........................................... 64
propafenone hcl er....................................... 64
propranolol hcl er......................................... 64
propranolol hcl oral.......................................65
propylthiouracil oral.................................... 143
PROQUAD................................................. 147
PROSCAR................................................. 128
PROSILK EXTERNAL..................................84
PROTECT IRON........................................ 205
PROTEINEX ORAL LIQUID.......................205
proteinex oral tablet....................................161
PROTEINEX P100..................................... 205
PROTEINEX P18....................................... 205
PROTEINEX-18......................................... 205
PROTONIX ORAL PACKET...................... 111
PROTONIX ORAL TABLET DELAYED
RELEASE...................................................111
PROTOPIC.................................................. 79
protriptyline hcl............................................. 32
PROVAD.................................................... 119
PROVENTIL HFA.......................................179
PROVERA..................................................141
PROVIGIL.................................................. 200
PROZAC...................................................... 31
PRUCLAIR................................................. 161
PRUDOXIN.................................................. 79
PRUMYX....................................................161
pseudoephedrine hcl 12 hr.........................196
pseudoephedrine hcl er..............................196
pseudoephedrine hcl oral tablet 30 mg...... 196
pseudoephedrine-bromphen-dm................184
pseudoephedrine-guaifenesin er................196
PSORCON................................................... 79
PSORIZIDE FORTE...................................161
PSORIZIDE ULTRA................................... 161
PSS SELECT PLATFORMS........................ 92
PULMICORT FLEXHALER........................ 177
PULMICORT SUSPENSION..................... 177
PULMOZYME............................................ 179
pure & gentle lubricant............................... 171
pure l-arginine hcl.......................................161
pure l-tyrosine............................................ 205
purelax oral powder....................................122
purevit dualfe plus........................................ 98
PURIXAN..................................................... 40
PYLERA..................................................... 109
pyrazinamide oral.........................................39
PYRIDIUM..................................................129
pyridostigmine bromide er............................38
pyridostigmine bromide oral solution............38
pyridostigmine bromide oral tablet............... 38
pyridoxine hcl oral...................................... 207
pyrimethamine tablet 25 mg oral..................44
PYRUKYND................................................. 61
PYRUKYND TAPER PACK......................... 61
QBRELIS......................................................63
QBREXZA.................................................... 80
qc anti-itch aloe............................................ 86
qc chocolated laxative................................124
qc gentle laxative womens......................... 161
qc triple antibiotic......................................... 25
QDOLO.......................................................... 9
QELBREE.................................................... 53
QINLOCK................................................... 164
QNASL....................................................... 177
QNASL CHILDRENS................................. 177
QTERN.........................................................55
quad-probiotic............................................ 119
QUADRACEL INTRAMUSCULAR
SUSPENSION............................................147
QUALAQUIN................................................ 44
QUARTETTE............................................. 138
QUDEXY XR................................................ 26
QUESTRAN................................................. 69
252
QUESTRAN LIGHT......................................69
quetiapine fumarate..................................... 48
quetiapine fumarate er................................. 48
QUFLORA FE............................................ 103
QUFLORA FE PEDIATRIC........................ 103
QUFLORA GUMMIES................................103
QUFLORA PEDIATRIC ORAL SOLUTION
0.25 MG/ML............................................... 103
QUFLORA PEDIATRIC ORAL SOLUTION
0.5 MG/ML................................................. 103
QUICKVUE AT-HOME COVID-19 TEST... 161
QUILLICHEW ER.........................................71
QUILLIVANT XR.......................................... 71
quinapril hcl.................................................. 63
quinapril-hydrochlorothiazide....................... 67
quinidine gluconate er.................................. 64
quinidine sulfate........................................... 64
quinine sulfate oral....................................... 44
QUINTET AC BLOOD GLUCOSE............... 90
QUINTET AC BLOOD GLUCOSE TEST..... 90
QUINTET BLOOD GLUCOSE SYSTEM..... 90
QUINTET BLOOD GLUCOSE TEST........... 91
QUINTET CONTROL HIGH/NORMAL........ 91
quit2............................................................. 19
quit4............................................................. 19
QULIPTA......................................................37
QUVIVIQ.................................................... 200
QVAR REDIHALER................................... 177
RABEPRAZOLE SODIUM ORAL
CAPSULE SPRINKLE................................111
rabeprazole sodium oral tablet delayed
release....................................................... 111
radiance platinum vitamin d3..................... 103
RADICAVA ORS.......................................... 72
RADICAVA ORS STARTER KIT..................72
raloxifene hcl.............................................. 141
ramelteon................................................... 199
ramipril......................................................... 63
RANEXA...................................................... 67
ranolazine er................................................ 67
RAPAFLO.................................................. 128
RAPAMUNE ORAL SOLUTION.................146
RAPAMUNE ORAL TABLET 0.5 MG, 1
MG............................................................. 146
RAPAMUNE ORAL TABLET 2 MG............146
RAPID GEL RX.......................................... 161
rapid melts junior oral tablet dispersible
160 mg......................................................... 14
rasagiline mesylate oral............................... 46
RASUVO.................................................... 146
RAVICTI..................................................... 127
RAYALDEE................................................ 150
RAYOS.......................................................130
RAZADYNE ER............................................29
react........................................................... 141
REBIF...........................................................73
REBIF REBIDOSE....................................... 73
REBIF REBIDOSE TITRATION PACK........ 73
REBIF TITRATION PACK............................73
RECARBRIO................................................21
reclipsen.....................................................138
RECOMBIVAX HB..................................... 147
RECORLEV............................................... 142
RECOTHROM..............................................62
RECOTHROM SPRAY KIT..........................62
RECTIV........................................................ 70
REDITREX................................................. 146
redness relief ophthalmic solution 0.012-
0.2 %.......................................................... 173
refenesen 400............................................ 184
REFRESH LACRI-LUBE............................171
REFRESH OPTIVE OPHTHALMIC
SOLUTION.................................................171
REFRESH OPTIVE PF.............................. 171
REFRESH P.M...........................................171
REFRESH PLUS........................................171
REFRESH RELIEVA..................................171
REFRESH RELIEVA PF OPHTHALMIC
SOLUTION 0.5-0.9 %................................ 171
REFRESH TEARS..................................... 171
REGLAN...................................................... 33
REHYDRALYTE...........................................98
REJUVAFLOR........................................... 119
RELADOR PAK............................................17
RELADOR PAK PLUS................................. 17
RELAFEN.......................................................6
RELAFEN DS.................................................6
RELENZA DISKHALER............................... 52
RELEUKO.................................................... 61
relexxii.......................................................... 71
relief eye drops...........................................171
RELION TRUE MET AIR GLUC METER.....91
RELION TRUE METRIX TEST STRIPS...... 91
RELION ULTIMA GLUCOSE SYSTEM....... 91
RELION ULTIMA TEST............................... 91
RELISTOR................................................. 107
RELNATE DHA.......................................... 103
RELPAX....................................................... 38
RELTONE.................................................. 109
REMERON...................................................30
REMERON SOLTAB ORAL TABLET
DISPERSIBLE 15 MG, 30 MG..................... 30
REMIGEN.................................................. 161
REMODULIN..............................................180
RENAGEL.................................................... 99
RENAL....................................................... 103
RENAL MULTIVITAMIN FORMULA.......... 103
renal-vite.................................................... 103
rena-vite..................................................... 103
renewal soothing bath.................................. 84
RENVELA.................................................... 99
repaglinide....................................................55
REPATHA.................................................... 69
REPLACEMENT FILTERS........................ 161
RESORCINOL-SULFUR..............................86
rest simply.................................................. 200
253
RESTASIS................................................. 166
RESTASIS MULTIDOSE........................... 166
RESTORA..................................................119
restore plus lubricant eye........................... 171
restore pm.................................................. 171
RESTORIL ORAL CAPSULE 15 MG, 30
MG, 7.5 MG................................................199
RESTORIL ORAL CAPSULE 22.5 MG......199
RETACRIT INJECTION SOLUTION 10000
UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML,
4000 UNIT/ML, 40000 UNIT/ML.................. 61
RETACRIT INJECTION SOLUTION 20000
UNIT/ML.......................................................61
RETEVMO................................................. 164
RETIN-A.......................................................76
RETIN-A MICRO GEL 0.04 %, 0.1 %.......... 76
RETIN-A MICRO PUMP.............................. 76
RETROVIR ORAL........................................51
REVATIO INTRAVENOUS........................ 180
REVATIO ORAL.........................................180
REVLIMID.................................................... 40
REXULTI...................................................... 48
REYATAZ ORAL CAPSULE........................ 52
REYATAZ ORAL PACKET.......................... 52
REYVOW..................................................... 38
RHOFADE....................................................76
RHOGAM ULTRA-FILTERED PLUS......... 144
RHOPHYLAC.............................................144
RHOPRESSA.............................................169
ribavirin inhalation...................................... 181
ribavirin oral..................................................50
RID LICE KILLING SHAMPOO....................44
RIDAURA................................................... 145
rifabutin........................................................ 39
rifampin oral................................................. 39
RILUTEK...................................................... 72
riluzole..........................................................72
rimantadine hcl.............................................52
RINVOQ..................................................... 145
RIOMET....................................................... 55
risanoid plus............................................... 103
RISAQUAD................................................ 119
RISAQUAD-2............................................. 119
risedronate sodium.....................................150
RISPERDAL CONSTA.................................48
RISPERDAL ORAL SOLUTION...................48
RISPERDAL ORAL TABLET....................... 48
risperidone oral solution............................... 48
risperidone oral tablet...................................48
risperidone oral tablet dispersible................ 48
RITALIN....................................................... 71
RITALIN LA.................................................. 71
ritonavir........................................................ 52
RITUXAN................................................... 164
rivastigmine.................................................. 29
rivastigmine tartrate......................................29
rivelsa.........................................................138
rizatriptan benzoate......................................38
robafen cf multi-symptom cold................... 186
ROBINUL................................................... 108
ROBINUL-FORTE......................................108
ROBITUSSIN 12 HOUR COUGH.............. 196
ROBITUSSIN 12 HOUR COUGH CHILD.. 196
ROBITUSSIN COUGH+CHEST CONG
DM ORAL LIQUID 20-400 MG/20ML.........196
ROBITUSSIN PEAK COLD MULTI-SYM...186
ROCALTROL............................................. 150
ROCKLATAN............................................. 166
ropinirole hcl.................................................46
ropinirole hcl er.............................................46
rosadan external cream............................... 20
rosadan external gel.....................................20
ROSADAN EXTERNAL KIT.........................86
rosuvastatin calcium.....................................69
ROTARIX................................................... 147
ROTATEQ..................................................147
ROWASA................................................... 149
roweepra...................................................... 26
ROXICODONE.............................................15
ROXYBOND ORAL TABLET ABUSE-
DETERRENT 15 MG, 30 MG.........................7
ROXYBOND ORAL TABLET ABUSE-
DETERRENT 5 MG....................................... 7
ROZEREM................................................. 199
ROZLYTREK................................................42
RUBRACA....................................................42
RUCONEST............................................... 143
rufinamide.................................................... 28
RUKOBIA..................................................... 51
RYBELSUS.................................................. 55
RYCLORA..................................................176
RYDAPT.......................................................42
rymed......................................................... 186
rynex dm.................................................... 196
rynex pe..................................................... 196
rynex pse....................................................196
RYTARY.......................................................46
RYTHMOL SR..............................................64
ryvent......................................................... 176
S2 (RACEPINEPHRINE)........................... 190
SABRIL........................................................ 27
saccharomyces boulardii............................119
SAFE-T-LANCE........................................... 91
SAFYRAL...................................................138
SAIZEN...................................................... 131
SAIZENPREP............................................ 131
sajazir.........................................................143
SALAGEN.................................................... 74
salicylic acid external foam........................ 161
salicylic acid external gel............................161
salicylic acid external shampoo..................161
salicylic acid wart remover......................... 161
salicylic acid-cleanser.................................. 84
saline enema..............................................119
saline mist spray........................................ 184
saline nasal spray...................................... 184
SALIVAMAX.................................................75
254
salsalate oral................................................ 15
SALVAX..................................................... 161
sam-e.p.a................................................... 161
SAMSCA...................................................... 99
SANADERMRX SKIN REPAIR.................... 86
SANCUSO................................................... 33
SANDIMMUNE ORAL................................146
SANDOSTATIN..........................................143
SAPHRIS..................................................... 48
sapropterin dihydrochloride........................127
SAVAYSA.................................................... 60
SAVELLA..................................................... 73
SAVELLA TITRATION PACK...................... 73
sb arthritis pain relief.................................... 14
sb docusate sodium/senna........................ 125
sb lice killing max st..................................... 44
sb mucus relief........................................... 184
sb pain reliever childrens............................. 14
SCARCIN EXTERNAL LIQUID.................. 161
SCEMBLIX................................................... 43
scopolamine................................................. 33
SCRUB CARE POVIDONE-IODINE............ 25
sea-omega................................................. 161
SEASONIQUE........................................... 138
SECUADO................................................... 48
SEGLENTIS................................................... 9
SEGLUROMET............................................ 55
SELECT-OB ORAL TABLET CHEWABLE
29-0.6-0.4 MG............................................ 104
SELECT-OB ORAL TABLET CHEWABLE
29-1 MG..................................................... 104
SELECT-OB+DHA..................................... 104
selegiline hcl oral..........................................46
selenium sulfide external lotion.................... 79
selenium sulfide external shampoo 2.25 %..79
selenium sulfide external shampoo 2.3 %....79
SELZENTRY................................................ 51
SEMGLEE (YFGN)...................................... 59
SE-NATAL 19.............................................104
senexon-s...................................................125
senior probiotic...........................................119
senna lax....................................................125
senna laxative............................................ 125
senna oral capsule..................................... 125
senna oral liquid......................................... 125
senna oral syrup.........................................125
senna oral tablet.........................................125
senna plus oral tablet................................. 125
senna s.......................................................125
senna smooth.............................................125
senna-docusate sodium............................. 125
senna-extra................................................ 125
senna-lax....................................................125
senna-plus..................................................125
senna-s...................................................... 125
senna-tabs................................................. 125
senna-time................................................. 125
senna-time s...............................................125
sennazon....................................................125
SENOKOT..................................................125
SENOKOT EXTRA STRENGTH................125
SENOKOT S.............................................. 125
SENSIPAR................................................. 150
SEREVENT DISKUS................................. 179
SEROQUEL................................................. 48
SEROQUEL XR........................................... 48
SEROSTIM................................................ 131
SERTRALINE HCL ORAL CAPSULE..........31
sertraline hcl oral concentrate...................... 31
sertraline hcl oral tablet................................ 31
sesame oil nasal spray...............................196
se-tan plus....................................................98
setlakin....................................................... 138
sevelamer carbonate....................................99
sevelamer hcl............................................... 99
SEVENFACT..............................................161
severe allergy.............................................184
severe cold/cough...................................... 184
severe cold/cough daytime........................ 184
severe cold/flu daytime.............................. 184
sf.................................................................. 93
sf 5000 plus..................................................93
SFROWASA...............................................149
sharobel..................................................... 141
SHINGRIX..................................................148
SIGNIFOR..................................................143
SIKLOS........................................................ 61
silace oral liquid..........................................125
silace oral syrup......................................... 125
siladryl allergy............................................ 176
sildenafil citrate intravenous.......................180
sildenafil citrate oral suspension
reconstituted...............................................180
sildenafil citrate oral tablet 20 mg...............180
SILENOR................................................... 199
SILIQ.......................................................... 145
silodosin..................................................... 128
siltussin sa..................................................184
siltussin-dm alcohol free.............................196
SILVADENE................................................. 80
silver sulfadiazine external........................... 80
SIMBRINZA................................................169
simeped......................................................119
simethicone drops infants.......................... 119
simethicone oral......................................... 119
simethicone ultra strength.......................... 119
simliya........................................................ 138
simpesse.................................................... 139
SIMPLY SLEEP......................................... 200
SIMPONI.................................................... 146
simvastatin oral............................................ 69
SINEMET..................................................... 46
SINGULAIR................................................177
sinus 12 hour..............................................196
sinus 12-hour............................................. 196
sinus congestion max strength...................196
sinus nasal spray....................................... 196
255
sinus pe decongestant............................... 184
sinus relief ext st........................................ 184
sinus relief extra strength........................... 184
sinus/congestion relief pe...........................184
sirolimus oral solution.................................146
sirolimus oral tablet 0.5 mg, 1 mg.............. 146
sirolimus oral tablet 2 mg........................... 146
SIRTURO..................................................... 39
SITAVIG....................................................... 50
SIVEXTRO ORAL........................................ 20
SKYRIZI (150 MG DOSE)..........................145
SKYRIZI PEN.............................................145
SKYRIZI SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE.............................. 145
SKYTROFA................................................132
sleep aid (diphenhydramine)......................200
sleep aid max st......................................... 200
sleep aid nighttime oral capsule 25 mg......200
sleep aid nighttime oral tablet 25 mg......... 200
sleep aid oral capsule 50 mg..................... 200
sleep aid oral tablet 25 mg......................... 200
sleep ii........................................................ 200
sleep tabs...................................................200
sleepaid (diphenhydramine).......................200
sleep-aid max st......................................... 200
sleep-aid nighttime oral capsule 25 mg......200
sleep-aid nighttime oral capsule 50 mg......201
sleep-aid oral capsule................................ 201
sleeptime oral capsule............................... 201
SLO-NIACIN...............................................104
SLOW FE..................................................... 98
slow release iron oral tablet extended
release 143 (45 fe) mg................................. 98
SLOW-MAG................................................. 98
SLOWMAG MG MUSCLE/HEART.............. 98
SLYND....................................................... 141
smooth antacid ex st oral tablet chewable
750 mg....................................................... 119
smooth antacid extra st.............................. 119
smooth antacid extra strength....................119
smooth lax oral powder.............................. 122
SOAANZ ORAL TABLET 20 MG................. 67
SOAANZ ORAL TABLET 40 MG, 60 MG.... 67
sod chloride hypertonicity...........................171
sod citrate-citric acid.................................... 98
sodium bicarbonate oral tablet................... 119
sodium chloride (hypertonic) ophthalmic
ointment..................................................... 171
sodium chloride (hypertonic) ophthalmic
solution.......................................................172
sodium chloride inhalation nebulization
solution 0.9 %, 10 %, 3 %.......................... 196
sodium chloride inhalation nebulization
solution 7 %................................................197
sodium chloride ophthalmic ointment 5 %..172
sodium chloride ophthalmic solution 5 %... 172
sodium fluoride 5000 enamel....................... 93
sodium fluoride 5000 plus............................ 93
sodium fluoride 5000 ppm dental cream...... 93
sodium fluoride 5000 ppm dental gel........... 93
sodium fluoride 5000 ppm dental paste....... 93
sodium fluoride 5000 sensitive.....................93
sodium fluoride dental cream....................... 93
sodium fluoride dental gel............................ 93
sodium fluoride mouth/throat........................93
sodium fluoride oral solution 1.1 (0.5 f)
mg/ml........................................................... 93
sodium fluoride oral tablet chewable............93
sodium phenylbutyrate oral........................ 127
sodium polystyrene sulfonate.......................99
sodium sulfacetamide external shampoo
9.8 %.......................................................... 161
sodium sulfacetamide wash....................... 161
SOFOSBUVIR-VELPATASVIR....................50
soft glucose.................................................. 59
solifenacin succinate.................................. 127
SOLIQUA..................................................... 56
SOLODYN....................................................24
SOLOSEC....................................................20
SOLTAMOX................................................. 40
soluble fiber therapy...................................125
SOLUTION TRANSFER DEVICE.............. 161
soluvita e.................................................... 207
SOMA.........................................................198
SOMAVERT............................................... 143
SOOLANTRA............................................... 81
soothe maximum strength..........................119
soothe oral suspension.............................. 119
soothe oral tablet........................................120
soothe oral tablet chewable....................... 120
sorafenib tosylate......................................... 42
SORBIDON HYDRATE................................84
sorbitol oral.................................................122
sore throat mouth/throat lozenge 6-10 mg... 75
SORILUX..................................................... 80
sotalol hcl (af)...............................................64
sotalol hcl oral.............................................. 64
SOTYLIZE....................................................64
SOVALDI ORAL PACKET........................... 50
SOVALDI ORAL TABLET 200 MG.............. 50
SOVALDI ORAL TABLET 400 MG.............. 50
soya lecithin............................................... 161
spectravite adult 50+ oral tablet chewable.205
spectravite women oral tablet chewable.... 205
SPEEDGEL RX..........................................161
SPIKEVAX COVID-19 VACCINE...............148
spinosad.......................................................81
SPIRIVA HANDIHALER.............................178
SPIRIVA RESPIMAT..................................178
spironolactone oral.......................................67
spironolactone-hctz...................................... 67
SPORANOX.................................................35
SPORANOX PULSEPAK.............................35
SPRAVATO (56 MG DOSE)........................ 30
SPRAVATO (84 MG DOSE)........................ 30
sprintec 28..................................................139
SPRITAM..................................................... 26
256
SPRIX............................................................ 6
SPRYCEL.................................................. 164
sps................................................................99
sronyx.........................................................139
ssd................................................................80
sss 10-5 external cream...............................84
sss 10-5 external foam.................................84
ST JOSEPH LOW DOSE ORAL TABLET
CHEWABLE............................................... 161
STALEVO 100..............................................45
STALEVO 125..............................................45
STALEVO 150..............................................45
STALEVO 200..............................................45
STALEVO 50................................................45
STALEVO 75................................................45
stavudine......................................................51
STEGLATRO............................................... 56
STEGLUJAN................................................ 56
STELARA SUBCUTANEOUS....................145
STIMATE....................................................131
stimulant laxative oral tablet 8.6-50 mg......125
STIOLTO RESPIMAT................................ 190
STIVARGA................................................... 42
stomach relief extra strength......................120
stomach relief max st oral suspension 525
mg/15ml..................................................... 120
stomach relief oral suspension 1050
mg/30ml, 525 mg/15ml...............................120
stomach relief oral suspension 262
mg/15ml, 525 mg/30ml, 527 mg/30ml........120
stomach relief oral tablet 262 mg............... 120
stomach relief oral tablet chewable 262 mg
....................................................................120
stomach relief plus..................................... 120
stomach relief ultra.....................................120
stool softener laxative oral capsule............ 125
stool softener oral capsule 100 mg............ 125
stool softener oral capsule 240 mg............ 125
stool softener oral capsule 250 mg............ 125
stool softener oral capsule 50 mg.............. 125
stool softener oral tablet 100 mg................125
stool softener pls laxative...........................125
stool softener plus laxative.........................125
stool softener/laxative................................ 125
stool softener/laxative oral tablet................125
stop lice complete treatment........................ 44
STRATA CTX.............................................161
STRATA MARK..........................................161
STRATA XRT.............................................161
STRATTERA................................................71
STRENSIQ.................................................127
stress formula/iron......................................205
stress formula/zinc (b-compl)..................... 104
stress formula/zinc oral tablet .................. 104
STRIBILD..................................................... 50
STRIVERDI RESPIMAT.............................179
STROMECTOL............................................ 43
STROVITE FORTE ORAL TABLET...........205
STROVITE ONE........................................ 205
stye ophthalmic solution.............................172
SUBLOCADE............................................... 18
SUBOXONE.................................................18
subvenite......................................................27
subvenite starter kit-blue.............................. 27
subvenite starter kit-green............................27
subvenite starter kit-orange..........................27
sucralfate oral.............................................109
SUDAFED.................................................. 197
SUDAFED CHILDRENS............................ 197
SUDAFED PE CONGESTION ORAL
TABLET 10 MG..........................................184
SUDAFED PE SINUS CONGESTION....... 185
SUDAFED SINUS CONGESTION.............197
SUDAFED SINUS CONGESTION 12HR...197
sudogest 12 hour....................................... 197
sudogest maximum strength...................... 197
sudogest oral tablet 30 mg.........................197
SULAR......................................................... 65
sulfacetamide sodium (acne)....................... 82
sulfacetamide sodium (cleans)...................161
sulfacetamide sodium external...................161
sulfacetamide sodium ophthalmic ointment167
sulfacetamide sodium ophthalmic solution.167
sulfacetamide sodium-sulfur external
cream 10-2 %...............................................84
sulfacetamide sodium-sulfur external
cream 10-5 %...............................................84
sulfacetamide sodium-sulfur external liquid
10-2 %..........................................................84
sulfacetamide sodium-sulfur external liquid
10-5 %..........................................................84
sulfacetamide sodium-sulfur external liquid
9.8-4.8 %......................................................84
sulfacetamide sodium-sulfur external liquid
9-4.5 %.........................................................84
sulfacetamide sodium-sulfur external pad
10-4 %..........................................................84
sulfacetamide sodium-sulfur external
suspension 8-4 %.........................................84
sulfacetamide sodium-sulfur liquid 9-4 %
external........................................................ 84
sulfacetamide sod-sulfur wash external
liquid 9-4 %.................................................. 85
sulfacetamide sod-sulfur wash external
liquid 9-4.5 %............................................... 85
sulfacetamide-prednisolone....................... 166
sulfacetamide-sulfur in urea......................... 85
SULFACLEANSE 8/4...................................85
sulfadiazine oral........................................... 22
sulfamethoxazole-trimethoprim oral............. 22
sulfamez wash............................................. 85
SULFAMYLON EXTERNAL CREAM...........82
SULFAMYLON EXTERNAL PACKET......... 82
sulfasalazine oral....................................... 149
sulfatrim pediatric......................................... 22
sulindac oral................................................... 6
SUMADAN WASH....................................... 85
257
SUMADAN XLT............................................85
sumatriptan nasal.........................................38
sumatriptan succinate oral........................... 38
sumatriptan succinate refill...........................38
sumatriptan succinate subcutaneous...........38
sumatriptan-naproxen sodium......................38
SUMAXIN.....................................................85
SUMAXIN CP...............................................85
sunitinib malate............................................ 42
SUNOSI..................................................... 200
super b complex/c...................................... 104
super b/c.................................................... 104
SUPER B-50 B COMPLEX........................ 104
SUPERVITE...............................................104
suphedrine 12hour..................................... 197
suphedrine maximum strength...................197
suphedrine oral tablet 30 mg......................197
suphedrine oral tablet extended release 12
hour 120 mg............................................... 197
SUPRAX ORAL CAPSULE..........................21
SUPRAX ORAL SUSPENSION
RECONSTITUTED 200 MG/5ML.................21
SUPRAX ORAL SUSPENSION
RECONSTITUTED 500 MG/5ML.................21
SUPRAX ORAL TABLET CHEWABLE........21
SUPREP BOWEL PREP KIT..................... 109
sure result sr relief......................................161
surelac........................................................120
SUSTIVA......................................................51
SUTAB......................................................... 25
SUTENT.......................................................42
syeda..........................................................139
SYMBICORT..............................................190
SYMBYAX ORAL CAPSULE 3-25 MG........ 30
SYMBYAX ORAL CAPSULE 6-25 MG........ 30
SYMDEKO................................................. 179
SYMFI.......................................................... 51
SYMFI LO.................................................... 51
SYMJEPI....................................................179
SYMLINPEN 120......................................... 56
SYMLINPEN 60........................................... 56
SYMPAZAN................................................. 27
SYMPROIC................................................ 107
SYMTUZA.................................................... 52
SYNAGIS................................................... 145
SYNALAR.................................................... 79
SYNALAR (CREAM).................................... 85
SYNALAR (OINTMENT).............................. 85
SYNALAR TS...............................................86
SYNAREL.................................................. 143
SYNERA...................................................... 17
SYNJARDY.................................................. 56
SYNJARDY XR............................................ 56
SYNRIBO..................................................... 41
SYNTHROID.............................................. 142
SYPRINE..................................................... 99
SYSTANE.................................................. 172
SYSTANE BALANCE.................................172
SYSTANE COMPLETE..............................172
SYSTANE CONTACTS..............................172
SYSTANE HYDRATION PF.......................172
SYSTANE ICAPS AREDS2 ORAL
TABLET CHEWABLE................................ 205
SYSTANE NIGHTTIME..............................172
SYSTANE PRESERVATIVE FREE........... 172
SYSTANE ULTRA......................................172
SYSTANE ULTRA PF................................ 172
tab tussin....................................................185
TABLOID......................................................40
TABRECTA................................................ 164
TACLONEX..................................................80
tacrolimus external....................................... 79
tacrolimus oral capsule 0.5 mg, 5 mg........ 146
tacrolimus oral capsule 1 mg..................... 146
tadalafil (pah)............................................. 180
tadalafil oral tablet 5 mg............................. 128
TAFINLAR....................................................42
TAGRISSO.................................................164
take action..................................................141
TAKHZYRO................................................143
TALICIA......................................................109
TALIVA.......................................................104
TALTZ SUBCUTANEOUS SOLUTION
AUTO-INJECTOR...................................... 145
TALTZ SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE.............................. 145
TALZENNA.................................................. 42
TAMIFLU......................................................52
tamoxifen citrate oral....................................40
tamsulosin hcl............................................ 128
TAPERDEX 12-DAY.................................. 130
TAPERDEX 6-DAY.................................... 130
TAPERDEX 7-DAY.................................... 130
TARCEVA.................................................. 164
TARGADOX................................................. 24
TARGRETIN................................................ 42
tarina 24 fe................................................. 139
tarina fe 1/20.............................................. 139
tarina fe 1/20 eq......................................... 139
TARON FORTE......................................... 205
TARON-C DHA.......................................... 104
TARON-PREX............................................104
TARPEYO.................................................. 149
TASIGNA................................................... 164
TASMAR...................................................... 45
tavaborole.................................................... 82
TAVALISSE..................................................61
TAVNEOS.................................................. 161
taysofy........................................................139
TAYTULLA................................................. 139
tazarotene external cream........................... 76
TAZAROTENE EXTERNAL FOAM..............76
TAZORAC EXTERNAL CREAM 0.05 %......76
TAZORAC EXTERNAL CREAM 0.1 %........76
TAZORAC EXTERNAL GEL 0.05 %............76
TAZORAC EXTERNAL GEL 0.1 %..............76
taztia xt.........................................................65
258
TAZVERIK....................................................41
TDVAX....................................................... 148
TECFIDERA.................................................73
TEGRETOL..................................................28
TEGRETOL-XR............................................28
TEGSEDI................................................... 127
TEKTURNA..................................................67
TEKTURNA HCT......................................... 67
telmisartan....................................................63
telmisartan-amlodipine................................. 67
telmisartan-hctz............................................67
temazepam oral capsule 15 mg, 30 mg..... 199
temazepam oral capsule 22.5 mg.............. 199
temazepam oral capsule 7.5 mg................ 199
TEMODAR ORAL........................................ 39
TEMOVATE................................................. 79
temozolomide...............................................39
TENCON........................................................ 9
TENIVAC....................................................148
tenofovir disoproxil fumarate........................ 51
TENORETIC 100......................................... 67
TENORETIC 50........................................... 67
TENORMIN.................................................. 65
tension headache.........................................14
TEPMETKO................................................. 42
terazosin hcl............................................... 128
terbinafine hcl external................................. 36
terbinafine hcl oral........................................35
terbinafine hydrochloride external cream 1
%.................................................................. 36
terbutaline sulfate oral................................179
terconazole...................................................35
TERIPARATIDE (RECOMBINANT)........... 150
TESTIM...................................................... 133
testosterone cypionate intramuscular........ 133
testosterone enanthate intramuscular........133
testosterone transdermal gel 1.62 %, 20.25
mg/act (1.62%)...........................................133
testosterone transdermal gel 10 mg/act
(2%)............................................................133
testosterone transdermal gel 12.5 mg/act
(1%)............................................................133
testosterone transdermal gel 20.25
mg/1.25gm (1.62%)....................................133
testosterone transdermal gel 25 mg/2.5gm
(1%), 50 mg/5gm (1%)............................... 133
testosterone transdermal gel 40.5
mg/2.5gm (1.62%)......................................133
testosterone transdermal solution.............. 133
TETANUS-DIPHTHERIA TOXOIDS TD.... 148
tetrabenazine............................................... 72
tetracycline hcl oral...................................... 24
TETRIX...................................................... 161
TEXACORT..................................................79
THALITONE................................................. 68
THALOMID...................................................40
the magic bullet.......................................... 161
THEO-24.................................................... 179
theophylline................................................ 179
theophylline er............................................179
THERAFLU EXPRESSMAX...................... 185
THERAFLU EXPRESSMAX SEV CLD/CG
ORAL TABLET 10-5-325 MG.....................185
THERAFLU SEVERE COLD......................185
THERAFLU SEVERE COLD/CGH DAY.... 185
thiamine hcl oral......................................... 207
thiamine mononitrate oral...........................104
THIOLA...................................................... 128
THIOLA EC................................................ 128
thioridazine hcl oral...................................... 47
thiothixene....................................................47
THRIVE........................................................ 19
THRIVITE 19..............................................205
THRIVITE RX.............................................104
THROMBOGEN........................................... 61
THYQUIDITY............................................. 142
tiadylt er........................................................65
tiagabine hcl................................................. 27
TIAZAC........................................................ 65
TIBSOVO..................................................... 42
TIGLUTIK..................................................... 72
TIKOSYN..................................................... 64
tilia fe..........................................................139
timolol maleate (once-daily)....................... 168
timolol maleate ocudose............................ 168
timolol maleate ophthalmic.........................168
timolol maleate oral...................................... 37
timolol maleate pf....................................... 168
TIMOPTIC.................................................. 168
TIMOPTIC OCUDOSE...............................168
TIMOPTIC-XE............................................ 168
TINACTIN EXTERNAL AEROSOL............ 161
TINACTIN EXTERNAL CREAM.................161
tinaspore.................................................... 161
tinidazole oral tablet 250 mg........................ 20
tinidazole oral tablet 500 mg........................ 20
tioconazole 1 vaginal ointment 6.5 %...........36
tioconazole-1................................................36
tiopronin..................................................... 128
TIROSINT.................................................. 142
TIROSINT-SOL.......................................... 142
TITRALAC..................................................120
TIVICAY....................................................... 50
TIVICAY PD................................................. 50
tizanidine hcl oral capsule 2 mg................... 49
tizanidine hcl oral capsule 4 mg, 6 mg......... 49
tizanidine hcl oral tablet................................49
TLANDO.....................................................133
tl-hem 150.................................................... 98
TOBI NEBULIZER......................................179
TOBI PODHALER...................................... 179
TOBRADEX............................................... 166
TOBRADEX ST..........................................166
tobramycin inhalation nebulization solution
300 mg/4ml................................................ 179
259
tobramycin nebulization solution 300
mg/5ml inhalation....................................... 179
TOBRAMYCIN NEBULIZATION
SOLUTION 300 MG/5ML INHALATION.... 179
tobramycin ophthalmic............................... 167
tobramycin-dexamethasone.......................166
TOBREX.................................................... 167
tolcapone......................................................45
tolnaftate antifungal....................................161
tolnaftate external cream............................161
tolnaftate external powder..........................161
TOLSURA.................................................... 35
tolterodine tartrate...................................... 127
tolterodine tartrate er..................................127
tolvaptan oral tablet 30 mg...........................99
TOPAMAX....................................................27
TOPAMAX SPRINKLE.................................27
TOPICORT...................................................79
TOPICORT SPRAY..................................... 79
topiramate er................................................ 27
topiramate oral capsule sprinkle.................. 27
topiramate oral tablet................................... 27
TOPROL XL................................................. 65
toremifene citrate......................................... 40
torsemide..................................................... 67
TOSYMRA................................................... 38
total allergy.................................................176
total allergy medicine................................. 176
totalday multiple......................................... 205
TOTECT.......................................................42
TOUJEO MAX SOLOSTAR......................... 59
TOUJEO SOLOSTAR.................................. 59
tovet external foam.......................................79
TOVET EXTERNAL KIT...............................85
TOVIAZ...................................................... 127
TPOXX ORAL.............................................. 52
TRACLEER................................................ 180
TRADJENTA................................................ 56
tramadol hcl er (biphasic)...............................7
TRAMADOL HCL ER ORAL CAPSULE
EXTENDED RELEASE 24 HOUR................. 7
tramadol hcl er oral tablet extended
release 24 hour.............................................. 7
TRAMADOL HCL ORAL SOLUTION.............9
tramadol hcl oral tablet...................................9
tramadol-acetaminophen............................... 9
trandolapril................................................... 63
trandolapril-verapamil hcl er.........................67
tranexamic acid oral..................................... 61
TRANSDERM-SCOP................................... 33
TRANXENE-T.............................................. 53
tranylcypromine sulfate................................ 30
TRANZGEL................................................ 161
TRAUMEEL EXTERNAL............................161
TRAVATAN Z.............................................165
travel ease....................................................33
travoprost (bak free)...................................165
TRAZIMERA INTRAVENOUS SOLUTION
RECONSTITUTED 150 MG.......................164
trazodone hcl oral.........................................31
TRECATOR................................................. 39
TRELEGY ELLIPTA................................... 190
TREMFYA.................................................. 145
treprostinil...................................................180
TRESIBA......................................................59
TRESIBA FLEXTOUCH............................... 59
tretinoin external...........................................76
tretinoin microsphere....................................76
tretinoin microsphere pump..........................76
tretinoin oral................................................. 42
TREXALL................................................... 146
TREXIMET................................................... 38
TREZIX.......................................................... 9
tri femynor.................................................. 139
TRIADIME-80...............................................86
triamcinolone acetonide external aerosol
solution.........................................................79
triamcinolone acetonide external cream...... 79
triamcinolone acetonide external lotion
0.025 %........................................................ 79
triamcinolone acetonide external lotion 0.1
%.................................................................. 79
triamcinolone acetonide external ointment
0.025 %, 0.1 %, 0.5 %..................................79
triamcinolone acetonide external ointment
0.05 %.......................................................... 79
triamcinolone acetonide mouth/throat.......... 74
triamcinolone in absorbase.......................... 79
TRIAMINIC ALLERCHEWS....................... 188
triamterene oral............................................ 67
triamterene-hctz........................................... 67
TRIANEX......................................................79
triazolam.....................................................199
TRIBENZOR................................................ 67
tri-buffered aspirin........................................ 15
tricitrates.....................................................205
TRICON....................................................... 98
TRICOR....................................................... 68
triderm.......................................................... 79
TRIDESILON................................................79
trientine hcl...................................................99
tri-estarylla..................................................139
trifluoperazine hcl......................................... 47
trifluridine....................................................167
TRIHEAL-80.................................................86
trihexyphenidyl hcl........................................45
TRIJARDY XR..............................................56
TRIKAFTA..................................................179
tri-legest fe................................................. 139
TRILEPTAL.................................................. 28
tri-linyah......................................................139
TRILIPIX.......................................................68
tri-lo-estarylla..............................................139
tri-lo-marzia................................................ 139
tri-lo-mili......................................................139
tri-lo-sprintec.............................................. 139
TRI-LUMA.................................................... 85
260
trimethobenzamide hcl oral.......................... 33
trimethoprim oral.......................................... 20
tri-mili..........................................................139
trimipramine maleate oral.............................32
TRIMO-SAN VAGINAL GEL 0.025-0.01 %..25
TRINATAL RX 1.........................................104
TRINTELLIX.................................................31
tri-nymyo.................................................... 139
triphrocaps................................................. 104
triple antibiotic.............................................. 25
triple antibiotic max st...................................25
triple antibiotic original..................................25
triple antibiotic pain relief..............................25
triple antibiotic plus.......................................25
triple antibiotic plus max st........................... 25
triple antibiotic/pain...................................... 25
triple antibiotic+pain relief.............................25
triprolidine hcl oral...................................... 188
TRIPTODUR.............................................. 143
tri-sprintec.................................................. 139
TRISTART DHA......................................... 104
TRISTART ONE.........................................104
tritocin...........................................................79
TRIUMEQ.....................................................51
TRIUMEQ PD...............................................51
TRI-VI-FLOR ORAL SUSPENSION 0.25
MG/ML....................................................... 104
TRI-VI-FLOR ORAL SUSPENSION 0.5
MG/ML....................................................... 104
TRI-VI-FLORO ORAL SUSPENSION 0.25
MG/ML....................................................... 104
TRI-VI-FLORO ORAL SUSPENSION 0.5
MG/ML....................................................... 104
tri-vite pediatric...........................................104
tri-vite/fluoride oral solution 0.25 mg/ml..... 205
tri-vite/fluoride oral solution 0.5 mg/ml....... 205
TRIVIX..........................................................86
trivora (28)..................................................139
tri-vylibra.....................................................139
tri-vylibra lo.................................................139
TRIZIVIR...................................................... 51
TROKENDI XR.............................................27
TROMBONEX............................................ 205
TROMBONEX-D........................................ 206
trospium chloride........................................127
trospium chloride er....................................127
TRUDHESA................................................. 38
TRUE FOCUS BLOOD GLUCOSE STRIP.. 91
TRUE METRIX AIR GLUCOSE METER
DEVICE........................................................91
TRUE METRIX AIR GLUCOSE METER
KIT................................................................91
TRUE METRIX BLOOD GLUCOSE TEST
STRIP IN VITRO.......................................... 91
TRUE METRIX GO GLUCOSE METER...... 91
TRUE METRIX METER KIT W/DEVICE......91
TRUECONTROL GLUCOSE CONT LEV 0. 91
TRUECONTROL GLUCOSE CONT LEV 1. 91
TRUEPLUS GLUCOSE ON THE GO.......... 59
TRUEPLUS GLUCOSE ORAL GEL............ 59
TRUEPLUS GLUCOSE ORAL TABLET
CHEWABLE................................................. 59
TRUEPLUS LANCETS 30G.........................91
TRUEPLUS SAFETY LANCETS 28G..........91
TRUETRACK BLOOD GLUCOSE DEVICE.91
TRUETRACK TEST..................................... 91
TRULANCE................................................107
TRULICITY...................................................56
TRUMENBA............................................... 148
TRUSELTIQ (100MG DAILY DOSE)......... 106
TRUSELTIQ (125MG DAILY DOSE)......... 106
TRUSELTIQ (50MG DAILY DOSE)........... 106
TRUSELTIQ (75MG DAILY DOSE)........... 106
TRUSOPT.................................................. 169
TRUVADA.................................................... 51
trymine cg...................................................197
TUBING/WING TIP.................................... 161
TUDORZA PRESSAIR...............................178
TUKYSA.....................................................164
tulana......................................................... 141
TUMS......................................................... 120
TUMS CHEWY BITES............................... 120
TUMS E-X 750........................................... 120
TUMS EXTRA STRENGTH 750................ 120
TUMS LASTING EFFECTS....................... 120
TUMS SMOOTHIES.................................. 120
TUMS ULTRA 1000................................... 120
TURALIO....................................................164
TUSNEL C................................................. 197
tussin adult multi-symptom.........................186
tussin cf cough & cold oral syrup 5-10-100
mg/5ml....................................................... 186
tussin cf multi-symptom cold...................... 186
tussin cf oral liquid 30-10-100 mg/5ml....... 197
tussin cf oral liquid 5-10-100 mg/5ml......... 186
tussin chest congestion oral syrup 100
mg/5ml....................................................... 185
tussin cough dm sugar free........................197
tussin cough long acting.............................185
tussin cough long-acting............................ 185
tussin cough oral syrup.............................. 185
tussin cough/chest congest oral syrup 100-
10 mg/5ml.................................................. 197
tussin cough/chest dm max oral liquid 10-
200 mg/5ml................................................ 197
tussin dm cough/chest cong.......................197
tussin dm cough/chest oral syrup 10-100
mg/5ml....................................................... 197
tussin dm max adult................................... 197
tussin dm max daytime.............................. 197
tussin dm max oral liquid 20-400 mg/20ml.197
tussin dm max st........................................ 198
tussin dm oral syrup 100-10 mg/5ml.......... 198
tussin maximum strength oral syrup 15
mg/5ml....................................................... 185
tussin mucus+chest congestion oral syrup 185
tussin multi-symptom cold cf...................... 186
261
tussin oral syrup 100 mg/5ml..................... 185
TWINRIX.................................................... 148
TWIRLA......................................................141
TWYNEO..................................................... 76
tyblume.......................................................139
TYBOST.......................................................51
tydemy........................................................139
TYKERB.....................................................164
TYLACTIN COMPLETE 15 PE.................. 161
TYLENOL FOR CHILDREN + ADULTS.......14
TYLENOL ORAL SUSPENSION 160
MG/5ML....................................................... 14
TYLENOL ORAL TABLET 325 MG, 500
MG............................................................... 15
TYLENOL ORAL TABLET CHEWABLE
160 MG........................................................ 15
TYLENOL ORAL TABLET EXTENDED
RELEASE 650 MG.......................................15
TYMLOS.................................................... 150
TYR EASY................................................. 161
TYRVAYA.................................................. 166
TYVASO.....................................................180
TYVASO DPI MAINTENANCE KIT............180
TYVASO DPI TITRATION KIT................... 180
TYVASO REFILL....................................... 180
TYVASO STARTER...................................180
UBRELVY.................................................... 37
UCERIS......................................................149
UDAMIN SP............................................... 206
UDENYCA....................................................61
ULORIC........................................................36
ultra dairy digestive.................................... 120
ultra energy................................................ 161
ultra fresh................................................... 172
ultra fresh pm............................................. 172
ULTRA HERS RX...................................... 161
ULTRA HIS................................................ 161
ultra lubricant drop..................................... 172
ultra lubricating eye drops.......................... 172
ultra lubricating eye drops pf...................... 172
ULTRA PCOS............................................ 161
ULTRACET.................................................... 9
ULTRAM........................................................ 9
ultra-mega.................................................. 206
ULTRASONIC MINI NEBULIZER.............. 161
ULTRAVATE................................................ 79
UNISTRIP CONTROL................................161
UNISTRIP1 GENERIC................................. 91
unithroid..................................................... 142
UPTRAVI ORAL.........................................180
urea 20 intensive hydrating.......................... 86
urea external cream 39 %............................ 86
urea external cream 40 %............................ 86
urea external cream 41 %............................ 86
urea external lotion.......................................86
urea hydrating.............................................. 85
ureacin-10.................................................... 86
ureacin-20.................................................... 86
uredeb.......................................................... 86
URELLE..................................................... 129
UREMEZ-40.................................................86
URIMAR-T..................................................129
urin ds........................................................ 129
urinary pain relief oral tablet 95 mg............129
URO-458.................................................... 129
UROCIT-K 10...............................................93
UROCIT-K 15...............................................93
UROCIT-K 5.................................................93
UROGESIC-BLUE..................................... 129
URO-MP.....................................................129
urosex........................................................ 206
UROXATRAL............................................. 128
URSO 250..................................................109
URSO FORTE............................................109
URSODIOL ORAL CAPSULE 200 MG,
400 MG...................................................... 109
ursodiol oral capsule 300 mg..................... 109
ursodiol oral tablet......................................109
UTIRA-C.....................................................129
VAGIFEM................................................... 139
valacyclovir hcl oral...................................... 50
VALCHLOR..................................................39
VALCYTE ORAL SOLUTION
RECONSTITUTED.......................................49
VALCYTE ORAL TABLET........................... 49
valganciclovir hcl oral solution
reconstituted.................................................49
valganciclovir hcl oral tablet......................... 49
VALIUM........................................................53
valproic acid oral.......................................... 27
VALSARTAN ORAL SOLUTION..................63
valsartan oral tablet......................................63
valsartan-hydrochlorothiazide...................... 67
VALTOCO 10 MG DOSE............................. 27
VALTOCO 15 MG DOSE............................. 27
VALTOCO 20 MG DOSE............................. 28
VALTOCO 5 MG DOSE............................... 28
VALTREX.....................................................50
VANADOM................................................. 198
VANCOCIN.................................................. 20
vancomycin hcl in nacl intravenous solution
1-0.9 gm/200ml-%........................................20
vancomycin hcl oral capsule........................ 20
vancomycin hcl oral solution reconstituted...20
vandazole.....................................................21
VANICREAM EXTERNAL OINTMENT........ 85
VANOS.........................................................79
VAPORIZER WARM STEAM.....................161
VAQTA....................................................... 148
varenicline tartrate........................................19
VARIVAX....................................................148
VARUBI (180 MG DOSE)............................ 33
VASCEPA.................................................... 69
VASERETIC.................................................67
vasoflex forte..............................................206
vasoflex hd................................................. 206
VASOFLEX ORAL CAPSULE....................206
262
vasoflex oral tablet..................................... 206
VASOTEC.................................................... 63
VAXNEUVANCE........................................ 148
VCF VAGINAL CONTRACEPTIVE
VAGINAL FILM.......................................... 129
VCF VAGINAL CONTRACEPTIVE
VAGINAL FOAM........................................ 129
vcf vaginal contraceptive vaginal gel..........129
VECAMYL.................................................... 67
VECTICAL....................................................80
vegetable lax+stool softener...................... 126
vegetable laxative...................................... 126
velivet......................................................... 139
VELPHORO................................................. 99
VELTASSA...................................................99
VELTIN.........................................................76
VEMLIDY..................................................... 49
VENCLEXTA................................................42
VENCLEXTA STARTING PACK..................42
VENEXA.....................................................206
VENEXA FE............................................... 206
venlafaxine hcl............................................. 31
venlafaxine hcl er......................................... 31
VENTAVIS INHALATION SOLUTION 20
MCG/ML.....................................................180
VENTOLIN HFA......................................... 179
VENTRIXYL............................................... 206
VENTRIXYL FE..........................................206
verapamil hcl er oral capsule extended
release 24 hour 100 mg, 200 mg, 300 mg... 65
verapamil hcl er oral capsule extended
release 24 hour 120 mg, 180 mg, 240 mg,
360 mg......................................................... 66
verapamil hcl er oral tablet extended
release......................................................... 66
verapamil hcl oral......................................... 66
VEREGEN....................................................80
VERELAN.................................................... 66
VERELAN PM.............................................. 66
VERQUVO................................................... 70
VERSACLOZ............................................... 48
VERZENIO...................................................42
VESICARE................................................. 127
VESICARE LS............................................127
vestura....................................................... 139
VEXATROL.................................................. 17
VFEND ORAL SUSPENSION
RECONSTITUTED.......................................35
VFEND ORAL TABLET................................35
VIBERZI..................................................... 107
VIBRAMYCIN ORAL CAPSULE.................. 24
VIBRAMYCIN ORAL SUSPENSION
RECONSTITUTED.......................................24
VIBRAMYCIN ORAL SYRUP.......................24
VICTOZA......................................................56
VIEKIRA PAK...............................................50
vienva.........................................................139
vigabatrin......................................................28
vigadrone..................................................... 28
VIGAMOX.................................................. 167
VIIBRYD.......................................................31
VIIBRYD STARTER PACK.......................... 31
VIJOICE....................................................... 43
VILAMIT MB...............................................129
vilazodone hcl.............................................. 31
VILEVEV MB..............................................129
VIMOVO.........................................................6
VIMPAT ORAL............................................. 28
VINATE ONE............................................. 104
VIOKACE................................................... 127
viorele.........................................................139
VIOS AEROSOL DELIVERY SYSTEM......161
VIOS LC PLUS...........................................162
VIOS LC PLUS DELUXE........................... 162
VIOS LC PLUS PEDIATRIC...................... 162
VIOS LC SPRINT.......................................162
VIOS LC SPRINT PEDIATRIC...................162
VIRACEPT................................................... 52
VIRASAL.................................................... 162
VIRAZOLE................................................. 181
VIREAD ORAL POWDER............................51
VIREAD ORAL TABLET 150 MG, 200 MG..51
VIREAD ORAL TABLET 250 MG.................51
VIREAD ORAL TABLET 300 MG.................51
virt-c dha.................................................... 104
virt-caps......................................................104
virt-gard...................................................... 104
virt-nate dha............................................... 104
virt-pn dha.................................................. 104
VISBIOME HIGH POTENCY ORAL
CAPSULE.................................................. 120
VISINE....................................................... 173
VISTARIL..................................................... 53
vit c/rose hips............................................. 206
vita s forte...................................................206
vitacel......................................................... 206
vitachew multiple vitamin........................... 206
vitachew vitamin d3....................................105
VITAFOL FE+.............................................105
VITAFOL GUMMIES.................................. 105
VITAFOL STRIPS...................................... 105
VITAFOL ULTRA....................................... 105
VITAFOL-NANO.........................................105
VITAFOL-OB..............................................105
VITAFOL-OB+DHA.................................... 105
VITAFOL-ONE........................................... 105
VITAL-D RX............................................... 105
VITAMEZ....................................................105
vitamin a oral capsule 2400 mcg (8000 ut),
3 mg (10000 ut)..........................................105
vitamin b complex-c................................... 105
vitamin b1...................................................207
vitamin b-1 oral tablet 100 mg....................105
vitamin b-1 oral tablet 250 mg....................207
vitamin b-12 er oral tablet extended
release 1000 mcg.......................................207
263
vitamin b-12 oral tablet 100 mcg, 1000
mcg, 250 mcg, 500 mcg.............................207
vitamin b12 oral tablet 1000 mcg............... 207
vitamin b12 oral tablet extended release
1000 mcg................................................... 207
vitamin b12 oral tablet extended release
2000 mcg................................................... 207
vitamin b-12 oral tablet extended release
2000 mcg................................................... 207
vitamin b12 sublingual liquid 3000 mcg/ml.207
vitamin b-12 sublingual tablet sublingual
2500 mcg, 5000 mcg..................................207
vitamin b-12 tr oral tablet extended release
1000 mcg................................................... 207
vitamin b-2 oral tablet 100 mg, 25 mg........206
vitamin b-6..................................................207
vitamin b-6 er............................................. 207
vitamin c cr oral tablet extended release ..206
vitamin c cr oral tablet extended release
500 mg....................................................... 206
vitamin c drops mouth/throat lozenge 60
mg.............................................................. 206
vitamin c er oral capsule extended release 206
vitamin c er oral tablet extended release
1500 mg..................................................... 206
vitamin c oral tablet 1000 mg, 250 mg....... 206
vitamin c oral tablet 500 mg....................... 206
vitamin c oral tablet chewable 100 mg, 250
mg.............................................................. 206
vitamin c oral tablet chewable 500 mg....... 206
vitamin c/acerola........................................ 206
vitamin c/bioflavonoids............................... 206
vitamin c/rose hips oral tablet 1000 mg......206
vitamin c/rose hips oral tablet 500 mg........206
vitamin c-rose hips oral tablet.................... 206
vitamin d (cholecalciferol) oral tablet 10
mcg (400 unit)............................................ 105
vitamin d (cholecalciferol) oral tablet 25
mcg (1000 ut)............................................. 105
vitamin d (ergocalciferol) oral capsule 1.25
mg (50000 ut), 50000 unit.......................... 206
vitamin d oral capsule 25 mcg (1000 ut).... 105
vitamin d oral liquid.................................... 105
vitamin d oral tablet chewable 10 mcg (400
unit)............................................................ 105
vitamin d3 gummies................................... 105
vitamin d3 oral capsule 1.25 mg (50000 ut)
....................................................................105
vitamin d3 oral capsule 125 mcg (5000 ut) 105
vitamin d-3 oral capsule 125 mcg (5000 ut)
....................................................................105
vitamin d3 oral capsule 25 mcg (1000 ut).. 105
vitamin d3 oral capsule 250 mcg (10000 ut)
....................................................................105
vitamin d3 oral capsule 50 mcg (2000 ut).. 105
vitamin d-3 oral capsule 50 mcg (2000 ut). 105
vitamin d3 oral liquid 10 mcg/ml.................105
vitamin d3 oral liquid 125 mcg/ml...............105
vitamin d3 oral tablet 10 mcg (400 unit)..... 105
vitamin d3 oral tablet 125 mcg (5000 ut)....105
vitamin d3 oral tablet 25 mcg (1000 ut)......105
vitamin d-3 oral tablet 25 mcg (1000 ut).....105
vitamin d3 oral tablet 50 mcg (2000 ut)......106
vitamin d3 oral tablet chewable 10 mcg
(400 unit).................................................... 106
vitamin d3 oral tablet chewable 25 mcg, 25
mcg (1000 ut)............................................. 106
vitamin d-400..............................................106
vitamin e natural.........................................207
vitamin e oral capsule 134 mg (200 unit),
45 mg (100 unit), 450 mg (1000 ut), 90 mg
(200 unit).................................................... 207
vitamin e oral capsule 180 mg (400 unit),
268 mg (400 unit)....................................... 207
vitamin e oral solution 6.75 mg/0.3ml.........207
vitamin k (phytonadione)............................ 106
vitamin-b complex...................................... 106
vitamins acd-fluoride.................................. 206
vitamins complete childrens....................... 206
VITAROCA PLUS...................................... 206
VITASURE................................................. 106
VITATHELY WITH GINGER...................... 106
VITRAKVI.....................................................42
VITRAMYN.................................................206
VITRANOL FE............................................206
VITREXYL..................................................206
VITREXYL + IRON.....................................206
VIVA DHA.................................................. 106
VIVELLE-DOT............................................139
VIVITROL.....................................................18
VIZIMPRO..................................................164
VOCABRIA...................................................37
VOGELXO..................................................133
VOGELXO PUMP...................................... 133
volnea.........................................................139
VONJO.........................................................42
VOQUEZNA DUAL PAK............................ 120
VOQUEZNA TRIPLE PAK......................... 106
voriconazole oral suspension reconstituted. 35
voriconazole oral tablet................................ 35
VORTEX HOLD CHMBR/MASK/CHILD.... 162
VORTEX HOLD
CHMBR/MASK/TODDLER.........................162
VORTEX VALVED HOLDING CHAMBER.162
VOSEVI........................................................50
VOTRIENT................................................. 164
VOXZOGO................................................. 126
vp-vite rx.....................................................106
VRAYLAR.................................................... 48
VTAMA.........................................................86
VTOL LQ........................................................ 9
VUITY.........................................................169
VUMERITY...................................................73
VUSION....................................................... 82
vyfemla.......................................................139
vylibra.........................................................139
VYNDAMAX............................................... 127
264
VYNDAQEL................................................127
VYTORIN..................................................... 69
VYVANSE ORAL CAPSULE........................72
VYVANSE ORAL TABLET CHEWABLE......72
VYZULTA................................................... 165
WAKIX........................................................200
warfarin sodium oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg........ 60
warfarin sodium oral tablet 6 mg.................. 60
wart remover external liquid 17 %..............162
wart remover maximum strength external
liquid...........................................................162
weekly-d..................................................... 106
WELCHOL................................................... 69
WELIREG.....................................................43
WELLBUTRIN SR........................................ 30
WELLBUTRIN XL.........................................30
wera........................................................... 139
WESCAP-C DHA....................................... 106
WESCAP-PN DHA.....................................106
wescaps..................................................... 106
WESNATE DHA.........................................106
WESTAB MAX........................................... 106
westab mini................................................ 106
WESTAB PLUS..........................................106
WESTGEL DHA......................................... 106
WIDE-SEAL DIAPHRAGM 60....................162
WIDE-SEAL DIAPHRAGM 65....................162
WIDE-SEAL DIAPHRAGM 70....................162
WIDE-SEAL DIAPHRAGM 75....................162
WIDE-SEAL DIAPHRAGM 80....................162
WIDE-SEAL DIAPHRAGM 85....................162
WIDE-SEAL DIAPHRAGM 90....................162
WIDE-SEAL DIAPHRAGM 95....................162
WILZIN......................................................... 98
WINRHO SDF............................................ 144
wixela inhub............................................... 190
womans laxative.........................................162
womens 50 billion.......................................120
womens daily gummies..............................206
womens gentle laxative..............................162
womens laxative.........................................162
womens prenatal+dha................................106
wymzya fe.................................................. 139
XADAGO......................................................46
XALATAN...................................................165
XALKORI....................................................164
XANAX......................................................... 53
XANAX XR................................................... 53
XARELTO ORAL SUSPENSION
RECONSTITUTED.......................................60
XARELTO ORAL TABLET........................... 60
XARELTO STARTER PACK........................60
XATMEP.................................................... 146
XCOPRI....................................................... 27
XCOPRI (250 MG DAILY DOSE).................27
XCOPRI (350 MG DAILY DOSE).................27
XELJANZ................................................... 145
XELJANZ XR............................................. 145
XELODA.......................................................43
XELPROS.................................................. 165
XENAZINE................................................... 72
XENLETA ORAL.......................................... 21
XEPI............................................................. 82
XERAC AC...................................................86
XERALUX.................................................. 162
XERESE.......................................................80
XERMELO..................................................107
XEROSTOMIA RELIEF SPRAY.................. 75
XHANCE.................................................... 177
XIFAXAN......................................................21
XIGDUO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 10-1000 MG, 10-500
MG............................................................... 56
XIGDUO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 2.5-1000 MG, 5-1000
MG, 5-500 MG............................................. 56
XIIDRA....................................................... 166
XIMINO........................................................ 24
XOFLUZA (40 MG DOSE)........................... 52
XOFLUZA (80 MG DOSE)........................... 52
XOLAIR...................................................... 145
XOLIDO XP..................................................17
XOPENEX CONCENTRATE..................... 179
XOPENEX HFA..........................................179
XOPENEX NEB......................................... 179
XOSPATA.................................................. 164
XPECT....................................................... 185
XPOVIO (100 MG ONCE WEEKLY)............41
XPOVIO (40 MG ONCE WEEKLY)..............41
XPOVIO (40 MG TWICE WEEKLY).............41
XPOVIO (60 MG ONCE WEEKLY)..............41
XPOVIO (60 MG TWICE WEEKLY).............41
XPOVIO (80 MG ONCE WEEKLY)..............41
XPOVIO (80 MG TWICE WEEKLY).............41
XTAMPZA ER................................................ 7
XTANDI........................................................ 40
xulane.........................................................139
XULTOPHY..................................................56
xurea............................................................ 86
XVITE.........................................................106
XYOSTED.................................................. 133
XYREM...................................................... 200
XYWAV...................................................... 198
XYZMUNE..................................................162
YASMIN 28................................................ 139
YAZ............................................................ 140
YONSA.........................................................40
YUPELRI....................................................178
yuvafem......................................................140
ZADITOR................................................... 173
zafemy........................................................140
zafirlukast................................................... 177
zaleplon......................................................199
ZANAFLEX ORAL CAPSULE 2 MG............ 49
ZANAFLEX ORAL CAPSULE 4 MG, 6 MG. 49
ZANAFLEX ORAL TABLET......................... 49
265
ZARONTIN...................................................27
ZARXIO........................................................61
ZATEAN-PN DHA...................................... 106
ZAVESCA.................................................. 127
ZEASORB-AF.............................................. 36
ZEBUTAL....................................................... 9
ZEEL ARTHIRITIS PAIN RELIEF
EXTERNAL................................................ 162
ZEGALOGUE.............................................129
ZEGERID................................................... 111
ZEJULA........................................................42
ZELAC........................................................120
ZELAPAR.....................................................46
ZELBORAF.................................................. 42
ZELDANA...................................................106
ZELNORM..................................................107
ZEMBRACE SYMTOUCH............................38
ZEMPLAR ORAL....................................... 150
zenatane...................................................... 76
ZENPEP.....................................................127
ZENZEDI......................................................72
ZEPATIER....................................................50
ZE-PLUS.................................................... 106
ZEPOSIA......................................................73
ZEPOSIA 7-DAY STARTER PACK............. 73
ZEPOSIA STARTER KIT............................. 73
ZERUVIA......................................................17
ZERVIATE..................................................166
ZESTORETIC.............................................. 67
ZESTRIL...................................................... 63
ZETIA........................................................... 69
ZETONNA.................................................. 177
ZIAC............................................................. 67
ZIAGEN........................................................51
ZIANA...........................................................76
zidovudine.................................................... 51
ZIEXTENZO................................................. 61
ZILACTIN BABY...........................................75
zileuton er...................................................177
ZILXI.............................................................86
ZIMHI........................................................... 18
zinc gluconate oral tablet 100 mg................ 98
zinc gluconate oral tablet 50 mg.................. 98
zinc oral lozenge........................................ 206
zinc oral tablet 50 mg........................... 98, 206
zinc oxide external ointment 40 %............... 85
zinc sulfate oral tablet 220 (50 zn) mg....... 206
ZIOPTAN....................................................165
ziprasidone hcl............................................. 48
ZIPSOR..........................................................6
ZIRGAN........................................................49
ZITHROMAX ORAL..................................... 22
ZITHROMAX TRI-PAK.................................22
ZITHROMAX Z-PAK.................................... 22
ZOCOR........................................................ 69
ZOKINVY................................................... 162
ZOLADEX.................................................. 143
ZOLINZA...................................................... 41
ZOLMITRIPTAN NASAL SOLUTION 2.5
MG............................................................... 38
zolmitriptan nasal solution 5 mg...................38
zolmitriptan oral............................................38
ZOLOFT....................................................... 31
zolpidem tartrate er.................................... 199
zolpidem tartrate oral................................. 199
zolpidem tartrate sublingual....................... 199
ZOMACTON...............................................131
ZOMIG......................................................... 38
ZONALON....................................................79
ZONEGRAN.................................................28
zonisamide oral............................................ 28
ZONTIVITY.................................................. 60
ZORBTIVE................................................. 131
ZORTRESS ORAL TABLET 0.25 MG, 0.5
MG, 0.75 MG..............................................146
ZORTRESS ORAL TABLET 1 MG............ 146
ZORVOLEX....................................................6
ZOSTRIX HP..............................................162
zovia 1/35 (28)........................................... 140
ZOVIRAX..................................................... 50
z-sleep oral capsule 25 mg........................ 201
ZTALMY....................................................... 28
ZTLIDO........................................................ 17
ZUBSOLV.................................................... 18
zumandimine..............................................140
ZYCLARA.....................................................80
ZYCLARA PUMP......................................... 80
ZYDELIG......................................................42
ZYFLO........................................................177
ZYKADIA......................................................43
ZYLET........................................................ 166
ZYLOPRIM...................................................36
ZYMAXID................................................... 167
ZYPITAMAG................................................ 69
ZYPREXA ORAL..........................................48
ZYPREXA RELPREVV................................ 48
ZYPREXA ZYDIS.........................................48
ZYRTEC ALLERGY ORAL CAPSULE.......176
ZYRTEC ALLERGY ORAL TABLET..........176
ZYRTEC-D ALLERGY & CONGESTION...186
ZYTIGA........................................................ 40
ZYVEXOL...................................................162
ZYVIT......................................................... 162
ZYVOX ORAL SUSPENSION
RECONSTITUTED.......................................21
ZYVOX ORAL TABLET................................21
266
