I000000176_Medicaid-UCSNJQ1 Comm & State

PCA-1-24-00584-Clinical-QRG_02232024

Preferred Drug List (PDL)

New Jersey

Effective Date: July. 1, 2024

Discrimination is against the law. The company complies with applicable federal civil rights laws

and does not discriminate, exclude people, or treat them diﬀerently based on race, color, national

origin, age, disability, or sex (including gender identity and sexual orientation).

You have the right to ﬁle a complaint if you believe you were treated in a discriminatory way by us.

You can ﬁle a complaint or ask for help ﬁling a complaint by mail, phone, or email at:

Civil Rights Coordinator

UnitedHealthcare Civil Rights Grievance

P.O. Box 30608

Salt Lake City, UTAH 84130

[email protected]

You can also ﬁle a complaint with the U.S. Dept. of Health and Human Services.

Online:

https://www.hhs.gov/civil-rights/ﬁling-a-complaint/index.html

Phone:

Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail:

U.S. Dept. of Health and Human Services

200 Independence Avenue SW

Room 509F, HHH Building

Washington, D.C. 20201

We provide free auxiliary aids and services to people with

disabilities to communicate eﬀectively with us, such as:

• Qualiﬁed American Sign Language interpreters

• Written information in other formats (large print, audio,

accessible electronic formats, other formats)

We also provide free language services to people whose primary

language is not English, such as:

• Qualiﬁed interpreters

• Information written in other languages

If you need these services, please call Member Services at

1-800-941-4647, TTY 711. We’re here to help.

CSNJ24MD0171299_000

English: ATTENTION: Translation and other language assistance services are available at no cost

to you. If you need help, please call the number above.

Spanish: ATENCIÓN: La traducción y los servicios de asistencia de otros idiomas se encuentran

disponibles sin costo alguno para usted. Si necesita ayuda, llame al número que se indica arriba.

Chinese (Traditional): 注意：您可以免費獲得翻譯及其他語言協助服務。如果您需要協助，

請致電上列電話號碼。

Korean: 참고: 번역 및 기타 언어 지원 서비스를 무료로 제공해 드립니다. 도움이 필요하시면 위에

명시된 번호로 전화해 주십시오.

Portuguese: ATENÇÃO: a tradução e outros serviços de assistência linguística estão disponíveis

sem qualquer custo para si. Se precisar de ajuda, contacte o número indicado acima.

Gujarati:  :             



    ,  



      .

Polish: UWAGA: tłumaczenia i inne formy pomocy językowej są dostępne bezpłatnie. Aby uzyskać

pomoc, proszę zadzwonić pod numer powyżej.

Italian: ATTENZIONE: il servizio di traduzione e altri servizi di assistenza linguistica sono disponibili

gratuitamente. Se serve aiuto, si prega di chiamare il numero sopra indicato.





.



: :Arabic

.

Tagalog: ATENSYON: Ang pagsasalin at iba pang mga serbisyong tulong sa wika ay magagamit

mo nang walang bayad. Kung kailangan mo ng tulong, mangyaring tawagan ang numero sa itaas.

Russian: ВНИМАНИЕ! Услуги перевода, а также другие услуги языковой поддержки

предоставляются бесплатно. Если вам требуется помощь, пожалуйста, позвоните по

указанному выше номеру.

Haitian Creole: ATANSYON: Gen tradiksyon ak lòt sèvis èd pou lang ki disponib gratis pou ou. Si

w bezwen èd, tanpri rele nimewo ki mansyone anwo a.

Hindi: न  : अनुव और अ भष सहयत सेवएं आपके लिए लनः शु उपि ह। अगर आपको म

चलहए तो कृ प य  ऊपर लए गए नंबर पर कॉि कर।

Vietnamese: CHÚ Ý: Dịch vụ dịch thuật và hỗ trợ ngôn ngữ khác được cung cấp cho quý vị

miễn phí. Nếu quý vị cần trợ giúp, vui lòng gọi số ở trên.

French: ATTENTION : la traduction et d’autres services d’assistance linguistique sont disponibles

sans frais pour vous. Si vous avez besoin d’aide, veuillez appeler le numéro ci-dessus.

 :Urdu







1-800-941-4647, TTY 711

7/20/2021

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 the Preferred Drug List are the drugs covered by 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 < 1-800-493-4647> TTY 711.

Monday – Friday 8:00 a.m. to 6:00 p.m.

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:

· 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.)

7/20/2021

· 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.)

More information on these drugs are listed below.

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 < 1-800-493-4647,

TTY 711>.

Monday – Friday 8:00 a.m. to 6:00 p.m.

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.

· 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

7/20/2021

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 below 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> .

Find the name of your drug. The page number where you can find the drug will be next

to it.

7/20/2021

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.

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.

7/20/2021

- 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

 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

7/20/2021

 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 < 1-800-493-4647, TTY 711>.Monday –

Friday 8:00 a.m. to 6:00 p.m.

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

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.

7/20/2021

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 Tie

Tier 1 Generic

Tier 2 Brand

[ABBREVIATIONS]

OTC = Over the Counter

PA = Prior Authorization required

QL = Quantity Limit

ST = Step Therapy

SP = Specialty Pharmacy

[You can find information on what the symbols and abbreviations in this table mean by

looking

in the footnotes>]

UnitedHealthcare Community Plan of New Jersey

Table of Contents

Analgesics.....................................................................................................................................................................................................................4

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions......................................................................................................8

Anesthetics................................................................................................................................................................................................................. 16

Anti-Addiction/Substance Abuse Treatment Agents...................................................................................................................................................16

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence......................................................................................... 18

Antiandrogens - Hormone Suppressants....................................................................................................................................................................18

Antibacterials.............................................................................................................................................................................................................. 19

Antibacterials - Drugs to Treat Bacterial Infections.....................................................................................................................................................22

Anticonvulsants...........................................................................................................................................................................................................23

Anticonvulsants - Drugs to Treat Seizures..................................................................................................................................................................25

Antidementia Agents...................................................................................................................................................................................................25

Antidepressants.......................................................................................................................................................................................................... 26

Antiemetics................................................................................................................................................................................................................. 27

Antiemetics - Drugs to Treat Nausea and Vomiting....................................................................................................................................................28

Antifungals.................................................................................................................................................................................................................. 29

Antifungals - Drugs to Treat Fungal Infections............................................................................................................................................................30

Antigout Agents...........................................................................................................................................................................................................31

Antimigraine Agents....................................................................................................................................................................................................31

Antimigraine Agents - Drugs to Treat Migraines......................................................................................................................................................... 32

Antimyasthenic Agents............................................................................................................................................................................................... 32

Antimycobacterials......................................................................................................................................................................................................33

Antineoplastics............................................................................................................................................................................................................33

Antineoplastics - Drugs to Treat Cancer.....................................................................................................................................................................36

Antineoplastics, Other - Chemotherapy Agents..........................................................................................................................................................36

Anti-Obesity Agents - Drugs for Weight Loss............................................................................................................................................................. 36

Antiparasitics...............................................................................................................................................................................................................37

Antiparasitics - Drugs to Treat Parasitic Infections..................................................................................................................................................... 38

Antiparkinson Agents..................................................................................................................................................................................................38

Antipsychotics.............................................................................................................................................................................................................40

Antispasmodics, Urinary - Bladder Control Drugs...................................................................................................................................................... 41

Antispasticity Agents...................................................................................................................................................................................................41

Antivirals..................................................................................................................................................................................................................... 41

Antivirals - Drugs to Treat Viral Infections...................................................................................................................................................................45

Anxiolytics...................................................................................................................................................................................................................45

Anxiolytics - Drugs to Treat Anxiety............................................................................................................................................................................45

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs................................................................................................. 46

Bipolar Agents.............................................................................................................................................................................................................46

Blood Glucose Regulators.......................................................................................................................................................................................... 47

Blood Glucose Regulators - Drugs to Regulate Blood Sugar..................................................................................................................................... 50

Blood Products and Modifiers.....................................................................................................................................................................................51

Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders........................................................................................................53

Cardiovascular Agents................................................................................................................................................................................................53

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs...................................................................................................................................59

Central Nervous System Agents.................................................................................................................................................................................59

Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis............................................................................................................................................... 63

Dental and Oral Agents...............................................................................................................................................................................................64

Dermatological Agents................................................................................................................................................................................................64

Dermatological Agents - Drugs to Treat Skin Conditions............................................................................................................................................70

DEVICES.................................................................................................................................................................................................................... 72

Diabetes - Glucose Monitoring....................................................................................................................................................................................73

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs.............................................................................................. 75

Electrolytes/Minerals/Metals/Vitamins........................................................................................................................................................................ 76

Estrogens - Hormone Replacement/Modifying Drugs.................................................................................................................................................89

Gastrointestinal Agents...............................................................................................................................................................................................89

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions.................................................................................................. 93

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment.......................................................................................................... 110

Genitourinary Agents................................................................................................................................................................................................ 111

Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...................................................................................................... 112

Glycemic Agents - Diabetic Drugs............................................................................................................................................................................ 112

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)...............................................................................................................................113

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary).............................................................................................................................. 114

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones............................................................................ 114

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)................................................................................................................... 114

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)....................................................................................................115

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones.................................................. 123

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)............................................................................................................................... 123

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones..................................................................123

Hormonal Agents, Suppressant (Adrenal)................................................................................................................................................................ 123

Hormonal Agents, Suppressant (Pituitary)................................................................................................................................................................124

Hormonal Agents, Suppressant (Thyroid).................................................................................................................................................................124

Immune Suppressants - Immune System Drugs...................................................................................................................................................... 124

Immunological Agents...............................................................................................................................................................................................125

Immunological Agents - Drugs that Stimulate or Suppress the Immune System..................................................................................................... 128

Inflammatory Bowel Disease Agents........................................................................................................................................................................ 129

Metabolic Bone Disease Agents...............................................................................................................................................................................130

Miscellaneous Therapeutic Agents...........................................................................................................................................................................130

Molecular Target Inhibitors - Chemotherapy Agents................................................................................................................................................ 141

Multiple Sclerosis Agents - Multiple Sclerosis Drugs................................................................................................................................................ 142

Ophthalmic Agents....................................................................................................................................................................................................142

Ophthalmic Agents - Drugs to Treat Eye Conditions................................................................................................................................................ 145

Otic Agents............................................................................................................................................................................................................... 150

Otic Agents - Drugs to Treat Ear Conditions.............................................................................................................................................................150

Respiratory Tract/Pulmonary Agents........................................................................................................................................................................151

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions....................................................................... 158

Sedatives/Hypnotics - Drugs for Sedation and Sleep...............................................................................................................................................178

Skeletal Muscle Relaxants........................................................................................................................................................................................179

Sleep Disorder Agents..............................................................................................................................................................................................179

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies........................................................... 180

Vitamins.................................................................................................................................................................................................................... 184

Preferred Agents Non-Preferred Agents

Analgesics

Nonsteroidal Anti-inflammatory Drugs

ADVIL JUNIOR STRENGTH (brand for cvs ibuprofen childrens) - Tier

2; QL

ADVIL ORAL TABLET (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 50 mg - Tier 1; QL

diclofenac sodium er - Tier 1; QL

diclofenac sodium external gel 1 % (generic for ALEVE ARTHRITIS

PAIN) - Tier 1; Brand OTC and Generic; QL

diclofenac sodium external solution 1.5 % - Tier 1; PA; QL

diclofenac sodium oral - Tier 1; QL

ec-naproxen (generic for EC-NAPROSYN) - Tier 1; QL

DUEXIS (brand for ibuprofen-famotidine) - Tier 2; PA; QL

FLECTOR (brand for diclofenac epolamine) - Tier 2; PA; QL

LICART - 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 ORAL SUSPENSION (brand for naproxen) - Tier 2; PA; QL;

NAPROSYN ORAL TABLET (brand for naproxen) - Tier 2; PA; QL

etodolac (generic for LODINE) - Tier 1; QL

FLANAX (brand for all day pain relief) - Tier 2; QL

ft all day pain relief (generic for MEDIPROXEN) - Tier 1; QL

ft ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) -

Tier 1; QL

ft ibuprofen oral tablet (generic for MEDI-FIRST IBUPROFEN) - Tier 1;

ft pain relief oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN)

- Tier 1; QL

ibuprofen (generic for IBU) - Tier 1; QL

ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL

JUNIOR STRENGTH) - Tier 1; QL

ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier

1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

ibuprofen ib oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN)

- 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 oral tablet chewable 100 mg (generic for

ADVIL JUNIOR STRENGTH) - Tier 1; QL

ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS

ADVIL) - Tier 1; QL

ibuprofen oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN) -

Tier 1; QL

ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier

1; QL

indomethacin oral capsule - Tier 1; QL

INFANTS ADVIL (brand for cvs ibuprofen infants) - Tier 2; QL

infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; QL

ketoprofen oral capsule 25 mg (generic for KIPROFEN) - Tier 1; QL

ketorolac tromethamine oral - Tier 1; QL

medi-first ibuprofen (generic for MEDI-FIRST IBUPROFEN) - Tier 1;

mediproxen (generic for MEDIPROXEN) - Tier 1; QL

meloxicam oral tablet - Tier 1; QL

mm ibuprofen (generic for MEDI-FIRST IBUPROFEN) - Tier 1; QL

MOTRIN CHILDRENS (brand for cvs ibuprofen childrens) - Tier 2; QL

MOTRIN IB ORAL TABLET (brand for cvs ibuprofen) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

MOTRIN INFANTS DROPS (brand for cvs ibuprofen infants) - Tier 2;

nabumetone oral - Tier 1; QL

naproxen dr (generic for EC-NAPROSYN) - Tier 1; QL

naproxen oral suspension (generic for NAPROSYN) - Tier 1; QL; AL

naproxen oral tablet (generic for NAPROSYN) - Tier 1; QL

naproxen oral tablet delayed release (generic for EC-NAPROSYN) -

Tier 1; QL

naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier

1; QL

oxaprozin oral tablet (generic for DAYPRO) - Tier 1; QL

piroxicam oral - Tier 1; QL

sulindac oral - Tier 1; QL

Opioid Analgesics, Long-acting

buprenorphine (generic for BUTRANS) - Tier 1; PA; QL

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

50 mcg/hr, 75 mcg/hr - Tier 1; PA; QL

methadone hcl oral tablet soluble (generic for METHADOSE) - Tier 1;

DX2RX; QL

methadose oral tablet soluble (generic for METHADOSE) - Tier 1;

DX2RX; QL

morphine sulfate er (generic for MS CONTIN) - Tier 1; PA; QL

oxymorphone hcl er - Tier 1; PA; QL

BELBUCA - Tier 2; PA; QL

BUTRANS (brand for buprenorphine) - Tier 2; PA; QL

HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL

morphine sulfate er beads - Tier 1; PA; QL

NUCYNTA ER - Tier 2; PA; QL

OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG

- Tier 2; PA; QL

XTAMPZA ER - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Opioid Analgesics, Short-acting

acetaminophen-codeine - Tier 1; QL

ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL

bac (generic for BAC) - Tier 1; QL

butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON)

- Tier 1; QL

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;

butalbital-aspirin-caffeine - Tier 1; QL

butorphanol tartrate nasal - Tier 1; QL

codeine sulfate oral tablet 30 mg, 60 mg - Tier 1; QL

apap-caff-dihydrocodeine (generic for TREZIX) - Tier 1; PA; QL

NUCYNTA - Tier 2; PA; QL

SEGLENTIS - Tier 2; PA; QL

TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL

endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for

ENDOCET) - Tier 1; QL

hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1;

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) - Tier 1; QL

morphine sulfate oral - Tier 1; QL

morphine sulfate rectal - Tier 1; QL

oxycodone hcl oral concentrate - Tier 1; QL

oxycodone hcl oral solution - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 5-325 MG/5ML

- Tier 2; QL

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

mg (generic for ENDOCET) - Tier 1; QL

pentazocine-naloxone hcl - Tier 1; QL

TENCON (brand for butalbital-acetaminophen) - Tier 2; QL

tramadol hcl oral tablet 50 mg - Tier 1; QL

Opioid Dependence Treatments -

Antidotes/Deterrents/Protectants

buprenorphine hcl sublingual - Tier 1; QL

Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and

Joint Conditions

Analgesics - Miscellaneous Analgesics

8 hour arthritis pain (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 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1;

acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier

1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

acetaminophen childrens (generic for MAPAP CHILDRENS) - Tier 1;

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

acetaminophen ex st oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - Tier 1; QL

acetaminophen extra strength (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

acetaminophen infants (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

acetaminophen oral liquid 160 mg/5ml (generic for LITTLE REMEDIES

FOR FEVER) - Tier 1; QL

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 MAX RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1;

acetaminophen oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

apra (generic for MAX RELIEF JUNIOR) - 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

betatemp childrens (generic for MAX RELIEF JR CHILD PAIN/FEVER)

- Tier 1; QL

childrens acetaminophen (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

childrens apap (generic for MAPAP CHILDRENS) - Tier 1; QL

childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL

childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; QL

CURANOL - Tier 2; QL

ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; QL

EXCEDRIN EXTRA STRENGTH (brand for cvs headache relief) - Tier

EXCEDRIN MIGRAINE (brand for cvs headache relief) - Tier 2

fever reducer/pain reliever (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - 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

ft 8 hour pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

ft arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

ft children's pain/fever (generic for MAPAP CHILDRENS) - Tier 1; QL

ft migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1

ft pain & fever childrens (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

ft pain & fever infants (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

ft pain relief adult extra st (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

ft pain relief extra strength (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

ft pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

ft pain reliever ex str adult (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

headache formula oral tablet 250-250-65 mg (generic for EXCEDRIN

EXTRA STRENGTH) - Tier 1

headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH)

- Tier 1

headache relief oral tablet 250-250-65 mg (generic for EXCEDRIN

EXTRA STRENGTH) - Tier 1

infants pain & fever (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

infants pain relief drops (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

infants pain/fever (generic for MAX RELIEF JR CHILD PAIN/FEVER) -

Tier 1; QL

liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) -

Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 childrens (generic for MAPAP CHILDRENS) - Tier 1; QL

mapap oral capsule - Tier 1; QL

MAX RELIEF JR CHILD PAIN/FEVER (brand for acetaminophen) -

Tier 2; QL

MAX RELIEF JUNIOR (brand for apra) - Tier 2; QL

migraine formula oral tablet 250-250-65 mg (generic for EXCEDRIN

EXTRA STRENGTH) - Tier 1

migraine headache relief (generic for EXCEDRIN EXTRA

STRENGTH) - Tier 1

migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1

mm acetaminophen ex str (generic for MM ACETAMINOPHEN EX

STR) - Tier 1; QL

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 MM ACETAMINOPHEN EX STR) - 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 MM ACETAMINOPHEN EX

STR) - 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 MAX RELIEF JR CHILD PAIN/FEVER) -

Tier 1; QL

pain & fever childrens (generic for MAPAP CHILDRENS) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

pain & fever childrens oral suspension 160 mg/5ml (generic for MAX

RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

pain & fever infants oral suspension 160 mg/5ml (generic for MAX

RELIEF JR CHILD PAIN/FEVER) - Tier 1; QL

pain and fever relief kids (generic for LITTLE REMEDIES FOR

FEVER) - Tier 1; QL

pain relief childrens oral elixir 160 mg/5ml (generic for MAX RELIEF

JUNIOR) - Tier 1; QL

pain relief childrens oral suspension (generic for MAX RELIEF JR

CHILD PAIN/FEVER) - Tier 1; QL

pain relief childrens oral tablet chewable 160 mg (generic for MAPAP

CHILDRENS) - Tier 1; QL

pain relief extra st (generic for MM ACETAMINOPHEN EX STR) - Tier

1; QL

pain relief extra strength oral capsule 500 mg - Tier 1; QL

pain relief extra strength oral liquid 500 mg/15ml (generic for MAPAP

ACETAMINOPHEN EXTRA STR) - Tier 1

pain relief extra strength oral tablet 500 mg (generic for MM

ACETAMINOPHEN EX STR) - 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 MM ACETAMINOPHEN EX

STR) - Tier 1; QL

pain relief oral tablet extended release 650 mg (generic for TYLENOL

8 HOUR) - Tier 1; QL

pain relief regular strength (generic for PHARBETOL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA

STR) - Tier 1

pain reliever childrens oral suspension 160 mg/5ml (generic for MAX

RELIEF JR CHILD PAIN/FEVER) - 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 MM

ACETAMINOPHEN EX STR) - 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 MM

ACETAMINOPHEN EX STR) - Tier 1; QL

pain reliever oral tablet 325 mg (generic for PHARBETOL) - Tier 1; QL

pain reliever oral tablet 500 mg (generic for MM ACETAMINOPHEN

EX STR) - Tier 1; QL

pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier

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;

PANADOL INFANTS (brand for acetaminophen) - Tier 2; QL

PHARBETOL (brand for acetaminophen) - Tier 2; QL

PHARBETOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;

sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

sb pain reliever childrens (generic for MAX RELIEF JR CHILD

PAIN/FEVER) - Tier 1; QL

TYLENOL FOR CHILDREN + ADULTS (brand for acetaminophen) -

Tier 2; QL

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) - Tier 2; QL

Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory

Drugs

salsalate oral - Tier 1; QL

Opioid Analgesics, Short-acting

oxycodone hcl oral tablet 10 mg, 20 mg - Tier 1; QL

oxycodone hcl oral tablet 15 mg, 30 mg (generic for ROXICODONE) -

Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anesthetics

Local Anesthetics

ANECREAM EXTERNAL CREAM (brand for lidocaine) - Tier 2; QL

ASPERFLEX LIDOCAINE EXTERNAL CREAM (brand for lidocaine) -

Tier 2; QL

lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; QL

lidocaine external patch 5 % (generic for LIDOCAN) - Tier 1; DX2RX;

lidocaine hcl external cream 3 % - Tier 1; QL

lidocaine viscous hcl - Tier 1; QL

lidocaine-prilocaine external cream - Tier 1; QL

lidopin external cream 3 % - Tier 1; QL

LMX 4 (brand for lidocaine) - Tier 2; QL

PROXIVOL (brand for burn gel) - Tier 2; QL

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 SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; PA; QL

ZUBSOLV - Tier 2; PA; ^; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Opioid Reversal Agents

naloxone hcl injection solution - Tier 1; QL

naloxone hcl injection solution cartridge - Tier 1; QL

naloxone hcl injection solution prefilled syringe - Tier 1; ^; QL

naloxone hcl nasal (generic for NARCAN) - Tier 1; QL

NARCAN (brand for naloxone hcl) - Tier 2; QL

REXTOVY - Tier 2; QL

KLOXXADO - Tier 2; PA; ^; QL

ZIMHI - Tier 2; PA; ^; 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

NICOTROL NS - Tier 2; QL

varenicline tartrate (generic for CHANTIX) - Tier 1; QL

varenicline tartrate (starter) - Tier 1; QL

varenicline tartrate(continue) (generic for CHANTIX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anti-Addiction/Substance Abuse Treatment Agents - Drugs for

Overdose or Deterrence

Smoking Cessation Agents - Deterrents

ft nicotine (generic for KLS QUIT2) - Tier 1; QL

ft nicotine mini (generic for KLS QUIT2) - Tier 1; QL

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;

nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1;

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;

nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1;

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; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antibacterials

Aminoglycosides

neomycin sulfate oral - Tier 1; QL

Antibacterials, Other

clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) -

Tier 1; QL

clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL

clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL

FIRVANQ (brand for vancomycin hcl) - Tier 2; DX2RX; QL

linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1;

DX2RX; QL

linezolid oral tablet (generic for ZYVOX) - Tier 1; DX2RX

methenamine hippurate (generic for HIPREX) - Tier 1; QL

metronidazole external (generic for METROCREAM) - Tier 1; QL

metronidazole oral tablet - Tier 1; QL

metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL

nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL

CLINDESSE - Tier 2; PA; QL

METROGEL (brand for metronidazole) - Tier 2; PA; QL

NORITATE - Tier 2; PA

NUVESSA - Tier 2; PA; QL

SOLOSEC - Tier 2; PA; QL

VANCOCIN ORAL CAPSULE 250 MG (brand for vancomycin hcl) - Tier

2; PA; QL

XACIATO - Tier 2; PA; QL

XIFAXAN - Tier 2; PA; QL

nitrofurantoin monohydrate macrocrystals (generic for MACROBID) -

Tier 1; QL

nitrofurantoin oral suspension 25 mg/5ml - Tier 1; Members >= 8 years

of age will require PA; QL; AL

tinidazole oral tablet 250 mg - Tier 1

tinidazole oral tablet 500 mg - Tier 1; QL

trimethoprim oral - Tier 1; QL

vancomycin hcl oral solution reconstituted 25 mg/ml (generic for

FIRVANQ) - Tier 1; DX2RX; QL

VANDAZOLE (brand for metronidazole) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Beta-lactam, Cephalosporins

cefaclor oral capsule - Tier 1; QL

cefadroxil - Tier 1; QL

cefdinir - Tier 1; QL

cefixime oral capsule - Tier 1; QL

cefpodoxime proxetil oral tablet - 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

Beta-lactam, Penicillins

amoxicillin - Tier 1; QL

amoxicillin-potassium clavulanate (generic for AUGMENTIN) - Tier 1;

ampicillin - Tier 1; QL

dicloxacillin sodium - Tier 1; QL

penicillin v potassium - Tier 1; QL

Macrolides

azithromycin oral suspension reconstituted (generic for ZITHROMAX) -

Tier 1; QL

azithromycin oral tablet (generic for ZITHROMAX) - Tier 1; QL

clarithromycin er - Tier 1; QL

clarithromycin oral - Tier 1; QL

DIFICID - Tier 2; PA; QL

E.E.S. 400 (brand for erythromycin ethylsuccinate) - Tier 2; QL

ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2;

erythromycin base oral (generic for ERY-TAB) - Tier 1; QL

erythromycin ethylsuccinate oral (generic for E.E.S. 400) - Tier 1; QL

erythromycin oral (generic for ERY-TAB) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Quinolones

CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL

ciprofloxacin hcl oral (generic for CIPRO) - Tier 1; QL

levofloxacin oral tablet - Tier 1; QL

moxifloxacin hcl oral - Tier 1; QL

ofloxacin oral - Tier 1; QL

Sulfonamides

sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1;

sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL

Tetracyclines

doxycycline hyclate oral capsule (generic for VIBRAMYCIN) - Tier 1;

doxycycline hyclate oral tablet 100 mg - Tier 1; QL

doxycycline monohydrate oral capsule 100 mg (generic for

MONDOXYNE NL) - Tier 1; QL

doxycycline monohydrate oral capsule 50 mg - Tier 1; QL

minocycline hcl oral capsule 100 mg, 50 mg - Tier 1; QL

mondoxyne nl (generic for MONDOXYNE NL) - Tier 1; QL

NUZYRA ORAL - Tier 2; PA; QL

ORACEA (brand for doxycycline) - Tier 2; PA

SOLODYN (brand for minocycline hcl er) - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antibacterials - Drugs to Treat Bacterial Infections

Antibacterials, Other - Antibiotics

antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL

antiseptic (generic for BETADINE) - Tier 1

BETADINE EXTERNAL SOLUTION 10 % (brand for cvs povidone-

iodine) - Tier 2

first aid antibiotic external ointment , 3.5-400-5000 (generic for

NEOSPORIN ORIGINAL) - Tier 1; QL

first aid antiseptic external solution 10 % (generic for BETADINE) -

Tier 1

ft triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; QL

medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier

1; QL

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

SUTAB - Tier 2; PA

SCRUB CARE POVIDONE-IODINE (brand for cvs povidone-iodine) -

Tier 2

triple antibiotic external ointment , 3.5-400-5000 , 5-400-5000 , 5-400-

5000 mg-unit (generic for NEOSPORIN ORIGINAL) - Tier 1; QL

triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1;

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anticonvulsants

Anticonvulsants, Other

felbamate oral suspension - Tier 1; Members >= 8 years of age will

require PA; QL; AL

felbamate oral tablet (generic for FELBATOL) - Tier 1; QL

lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL

lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1;

Members >= 8 years of age will require PA; QL; AL

lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT-

BLUE) - Tier 1; *; QL

lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT-

GREEN) - Tier 1; *; QL

lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT-

ORANGE) - Tier 1; *; QL

levetiracetam oral solution (generic for KEPPRA) - Tier 1; Maximum

age of 9 years for solution; QL; AL

BRIVIACT ORAL - Tier 2; PA; QL

EPIDIOLEX - Tier 2; PA; SP; QL

FINTEPLA - Tier 2; PA; QL

FYCOMPA - Tier 2; PA; QL

TOPAMAX (brand for topiramate) - Tier 2; PA; QL

TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; PA; Members >= 8

years of age will require PA; QL; AL

TROKENDI XR (brand for topiramate er) - Tier 2; PA; QL

XCOPRI (250 MG DAILY DOSE) - Tier 2; PA; QL

XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL

XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG - Tier 2; PA;

XCOPRI ORAL TABLET THERAPY PACK - Tier 2; PA

levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL

roweepra (generic for ROWEEPRA) - Tier 1; QL

subvenite (generic for SUBVENITE) - Tier 1; QL

subvenite starter kit-blue (generic for SUBVENITE STARTER KIT-

BLUE) - Tier 1; *; QL

subvenite starter kit-green (generic for SUBVENITE STARTER KIT-

GREEN) - Tier 1; *; QL

subvenite starter kit-orange (generic for SUBVENITE STARTER KIT-

ORANGE) - Tier 1; *; QL

topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) -

Tier 1; Members >= 8 years of age will require PA; QL; AL

topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL

valproic acid oral - Tier 1; QL

Calcium Channel Modifying Agents

ethosuximide oral (generic for ZARONTIN) - Tier 1; QL

methsuximide (generic for CELONTIN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clobazam (generic for ONFI) - Tier 1; DX2RX; QL

diazepam rectal gel 10 mg, 20 mg - Tier 1

diazepam rectal gel 2.5 mg - Tier 1; QL

gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL

gabapentin oral tablet 600 mg, 800 mg (generic for NEURONTIN) -

Tier 1; QL

NAYZILAM - Tier 2; PA; QL

phenobarbital oral - Tier 1; QL

primidone oral tablet 250 mg, 50 mg (generic for MYSOLINE) - Tier 1;

tiagabine hcl - Tier 1; PA; QL; AL

vigabatrin oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QL

vigadrone oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QL

vigpoder (generic for VIGADRONE) - Tier 1; PA; SP; QL

gabapentin oral solution 250 mg/5ml (generic for NEURONTIN) - Tier 1;

PA; QL

NEURONTIN (brand for gabapentin) - Tier 2; PA; QL

SYMPAZAN - Tier 2; PA; QL

VALTOCO 10 MG DOSE - Tier 2; PA; QL

VALTOCO 15 MG DOSE - Tier 2; PA; QL

VALTOCO 20 MG DOSE - Tier 2; PA; QL

VALTOCO 5 MG DOSE - Tier 2; PA; QL

Sodium Channel Agents

carbamazepine er (generic for CARBATROL) - Tier 1; QL

carbamazepine oral (generic for EPITOL) - Tier 1; QL

DILANTIN ORAL CAPSULE 30 MG - Tier 2

epitol (generic for EPITOL) - Tier 1; QL

lacosamide oral tablet (generic for VIMPAT) - Tier 1; PA; QL; AL

oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1;

Maximum age of 9 years for solution; QL; AL

oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL

phenytek (generic for PHENYTEK) - Tier 1; QL

phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL

phenytoin oral (generic for DILANTIN) - Tier 1; QL

phenytoin sodium extended (generic for DILANTIN) - Tier 1; QL

rufinamide (generic for BANZEL) - Tier 1; DX2RX; QL

zonisamide oral (generic for ZONEGRAN) - Tier 1; QL

APTIOM - Tier 2; PA; QL

lacosamide oral solution 10 mg/ml (generic for VIMPAT) - Tier 1; PA; QL;

OXTELLAR XR - Tier 2; PA; QL

VIMPAT ORAL (brand for lacosamide) - Tier 2; PA; QL; AL

ZONEGRAN (brand for zonisamide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anticonvulsants - Drugs to Treat Seizures

Anticonvulsants, Other

DIACOMIT - Tier 2; PA; SP; QL

Antidementia Agents

Antidementia Agents, Other

NAMZARIC - Tier 2; PA; QL; AL

Cholinesterase Inhibitors

donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1;

Members <18 years of age will require PA; QL; AL

donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; ST;

Members <18 years of age will require PA; QL; AL

galantamine hydrobromide oral solution - Tier 1; QL; AL

galantamine hydrobromide oral tablet 12 mg, 8 mg - Tier 1; QL; AL

galantamine hydrobromide oral tablet 4 mg - Tier 1; Members <18

years of age will require PA; QL; AL

rivastigmine (generic for EXELON) - Tier 1; Members <18 years of age

will require PA; QL; AL

rivastigmine tartrate - Tier 1; QL; AL

EXELON (brand for rivastigmine) - Tier 2; PA; Members <18 years of age

will require PA; QL; AL

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl oral solution - Tier 1; QL

memantine hcl oral tablet (generic for NAMENDA TITRATION PAK) -

Tier 1; Members <18 years of age will require PA; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antidepressants

Antidepressants, Other

bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; QL

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

mg (generic for WELLBUTRIN XL) - Tier 1; ^; QL

bupropion hcl oral - Tier 1; QL

mirtazapine oral tablet 15 mg, 30 mg (generic for REMERON) - Tier 1;

Tabs (not soltabs); QL

mirtazapine oral tablet 45 mg, 7.5 mg - Tier 1; QL

perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50

mg - Tier 1

perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; QL

ZULRESSO - Tier 2; ^

FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; PA; ^; QL

SPRAVATO (84 MG DOSE) - 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; QL

SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin

and Norepinephrine Reuptake Inhibitors)

citalopram hydrobromide oral solution - Tier 1; QL

citalopram hydrobromide oral tablet (generic for CELEXA) - Tier 1; QL

escitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QL

fluoxetine hcl oral capsule (generic for PROZAC) - Tier 1; QL

fluoxetine hcl oral solution - Tier 1; QL

fluvoxamine maleate - Tier 1; QL

paroxetine hcl oral tablet (generic for PAXIL) - Tier 1; QL

sertraline hcl oral concentrate (generic for ZOLOFT) - Tier 1; QL

sertraline hcl oral tablet (generic for ZOLOFT) - Tier 1; QL

trazodone hcl oral tablet 100 mg, 150 mg, 50 mg - Tier 1; QL

venlafaxine hcl - Tier 1; QL

venlafaxine hcl er oral capsule extended release 24 hour (generic for

EFFEXOR XR) - Tier 1; QL

FETZIMA - Tier 2; PA; ^; QL

PRISTIQ (brand for desvenlafaxine succinate er) - Tier 2; PA; ^; QL

TRINTELLIX - Tier 2; PA; ^; QL

VIIBRYD (brand for vilazodone hcl) - Tier 2; PA; ^; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Tricyclics

amitriptyline hcl oral - Tier 1; QL

amoxapine - Tier 1; QL

clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; QL

desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL

doxepin hcl oral capsule - Tier 1; QL

doxepin hcl oral concentrate - Tier 1; QL

imipramine hcl oral - Tier 1; QL

nortriptyline hcl oral (generic for PAMELOR) - Tier 1; QL

Antiemetics

Antiemetics, Other

ANTIVERT ORAL TABLET CHEWABLE (brand for cvs motion

sickness relief) - Tier 2

BONINE (brand for cvs motion sickness relief) - Tier 2

compro (generic for COMPRO) - Tier 1; QL

driminate (generic for DRIMINATE) - Tier 1

ft motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1

meclizine hcl oral tablet 12.5 mg - Tier 1; QL

meclizine hcl oral tablet 25 mg (generic for DRAMAMINE) - Tier 1; QL

meclizine hcl oral tablet chewable (generic for ANTIVERT) - Tier 1

metoclopramide hcl oral solution 5 mg/5ml - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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; QL

prochlorperazine (generic for COMPRO) - Tier 1; QL

prochlorperazine maleate oral - Tier 1; QL

promethazine hcl oral - Tier 1; QL

promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL

promethegan (generic for PROMETHEGAN) - Tier 1; QL

travel ease (generic for ANTIVERT) - Tier 1

trimethobenzamide hcl oral - Tier 1; QL

Emetogenic Therapy Adjuncts

aprepitant (generic for EMEND) - Tier 1; QL

dronabinol (generic for MARINOL) - Tier 1; PA; QL

ondansetron hcl oral tablet 4 mg, 8 mg - Tier 1; QL

ondansetron odt - Tier 1; QL

AKYNZEO ORAL - Tier 2; PA; QL

EMEND ORAL (brand for aprepitant) - Tier 2; PA; QL

SANCUSO - Tier 2; PA; QL

Antiemetics - Drugs to Treat Nausea and Vomiting

Antiemetics, Other - Nausea and Vomiting Drugs

anti-nausea (generic for EMETROL) - Tier 1

anti-nausea relief (generic for EMETROL) - Tier 1

EMETROL ORAL SOLUTION (brand for anti-nausea) - Tier 2

nausea control (generic for EMETROL) - Tier 1

nausea relief oral solution 1.87-1.87-21.5 (generic for EMETROL) -

Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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

ft miconazole 3 combo pack (generic for MONISTAT 3 COMBO PACK

APP) - Tier 1; QL

ft miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1; QL

griseofulvin microsize oral - Tier 1; QL

griseofulvin ultramicrosize - Tier 1; QL

itraconazole oral (generic for SPORANOX) - Tier 1; PA; 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

CRESEMBA ORAL CAPSULE 186 MG - Tier 2; PA; QL

GYNAZOLE-1 - Tier 2; PA; QL

NOXAFIL ORAL PACKET - Tier 2; PA; QL; AL

NOXAFIL ORAL SUSPENSION (brand for posaconazole) - Tier 2; PA

NOXAFIL ORAL TABLET DELAYED RELEASE (brand for posaconazole)

- Tier 2; PA; QL

VFEND (brand for voriconazole) - Tier 2; PA; QL

miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for

MONISTAT 3 COMBO PACK APP) - 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

nystatin oral - Tier 1; QL

terbinafine hcl oral - Tier 1; QL

terconazole vaginal cream - Tier 1; QL

voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antifungals - Drugs to Treat Fungal Infections

Antifungals - Fungal Infection Drugs

3 day vaginal - Tier 1

3-day vaginal vaginal cream 2 % - Tier 1

antifungal external cream (generic for MICATIN) - 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 MICATIN) - Tier 1

atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) -

Tier 1

athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; 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

baza antifungal (generic for MICATIN) - Tier 1

clotrimazole 3 - Tier 1

clotrimazole 7 - Tier 1; QL

clotrimazole vaginal - Tier 1; QL

clotrimazole vaginal cream 1 % - Tier 1; QL

CRITIC-AID CLEAR AF - Tier 2

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; QL

ft antifungal external cream 2 % (generic for MICATIN) - Tier 1

ft athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; QL

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 (brand for athletes foot (terbinafine)) - Tier 2;

micaderm (generic for MICATIN) - Tier 1

MICATIN (brand for antifungal) - Tier 2

miconazole antifungal (generic for MICATIN) - Tier 1

miconazole nitrate external cream (generic for MICATIN) - Tier 1

miconazorb af (generic for DESENEX) - Tier 1; QL

MICRO GUARD (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 tablet 100 mg, 300 mg - Tier 1; QL

colchicine oral tablet - Tier 1; QL

febuxostat (generic for ULORIC) - Tier 1; ST; QL

probenecid - Tier 1; QL

colchicine oral capsule (generic for MITIGARE) - Tier 1; PA; QL

MITIGARE (brand for colchicine) - Tier 2; PA; QL

Antimigraine Agents

Ergot Alkaloids

dihydroergotamine mesylate injection - Tier 1; QL

MIGERGOT - Tier 2; QL

MIGRANAL (brand for dihydroergotamine mesylate) - Tier 2; PA; QL

QULIPTA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Prophylactic

AIMOVIG - Tier 2; PA; QL

AJOVY - Tier 2; PA; 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

Serotonin (5-HT) Receptor Agonists - Migraine Drugs

naratriptan hcl - Tier 1; ST; QL

rizatriptan benzoate (generic for MAXALT) - Tier 1; QL

sumatriptan nasal - 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

FROVA (brand for frovatriptan succinate) - Tier 2; PA; QL

IMITREX (brand for sumatriptan succinate) - Tier 2; PA; QL

MAXALT (brand for rizatriptan benzoate) - Tier 2; PA; QL

RELPAX (brand for eletriptan hydrobromide) - Tier 2; PA; QL

REYVOW - Tier 2; PA; QL

TREXIMET (brand for sumatriptan-naproxen sodium) - Tier 2; PA; QL

ZOMIG NASAL (brand for zolmitriptan) - Tier 2; PA; QL

Antimyasthenic Agents

Parasympathomimetics

pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL

pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1;

pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) -

Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antimycobacterials

Antimycobacterials, Other

dapsone oral - Tier 1; QL

rifabutin (generic for MYCOBUTIN) - Tier 1; 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;

isoniazid oral - Tier 1; QL

PRIFTIN - Tier 2; QL

pyrazinamide oral - Tier 1; QL

rifampin oral - Tier 1; QL

SIRTURO - Tier 2; QL

TRECATOR - Tier 2; QL

Antineoplastics

Alkylating Agents

cyclophosphamide oral capsule - Tier 1

CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2

LEUKERAN - Tier 2

MATULANE - Tier 2; SP; QL

MYLERAN - Tier 2

temozolomide - Tier 1; PA; SP; QL

Antiandrogens

abiraterone acetate (generic for ZYTIGA) - Tier 1; PA; SP; QL

bicalutamide (generic for CASODEX) - Tier 1; QL

ERLEADA - Tier 2; PA; SP; QL

EULEXIN - Tier 2; QL

NUBEQA - Tier 2; PA; SP; QL

XTANDI - Tier 2; PA; SP; QL

ZYTIGA (brand for abiraterone acetate) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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

Antimetabolites

hydroxyurea oral (generic for HYDREA) - Tier 1; QL

mercaptopurine oral - Tier 1; QL

TABLOID - Tier 2; SP

Antineoplastics, Other

IDHIFA - Tier 2; PA; SP; QL

LONSURF - Tier 2; PA; SP; QL

NINLARO - Tier 2; PA; SP; QL

ZOLINZA - Tier 2; PA; SP; 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

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

Enzyme Inhibitors

etoposide oral - Tier 1

HYCAMTIN ORAL - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 ORAL CAPSULE - Tier 2; PA; SP; QL

IBRANCE ORAL TABLET - Tier 2; PA; QL

JAKAFI - Tier 2; PA; SP; QL

LYNPARZA - Tier 2; PA; SP; QL

MEKINIST - Tier 2; PA; SP; QL

ODOMZO - Tier 2; PA; SP; QL

AFINITOR (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

KISQALI (200 MG DOSE) - Tier 2; PA; SP; QL

KISQALI (400 MG DOSE) - Tier 2; PA; SP; QL

KISQALI (600 MG DOSE) - Tier 2; PA; SP; QL

KISQALI FEMARA (200 MG DOSE) - Tier 2; PA; SP; QL

KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; QL

KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; QL

KOSELUGO - Tier 2; PA; SP; QL

MEKTOVI - Tier 2; PA; SP; QL

NEXAVAR (brand for sorafenib tosylate) - Tier 2; PA; SP; QL

SUTENT (brand for sunitinib malate) - 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 ORAL CAPSULE - Tier 2; PA; SP; QL

ROZLYTREK ORAL PACKET - Tier 2; PA; SP; QL; AL

RUBRACA - Tier 2; PA; SP; QL

RYDAPT - Tier 2; PA; SP; QL

sorafenib tosylate (generic for NEXAVAR) - Tier 1; PA; SP; QL

STIVARGA - Tier 2; PA; SP; QL

sunitinib malate (generic for SUTENT) - Tier 1; PA; SP; QL

TAFINLAR - 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

TALZENNA ORAL CAPSULE 0.25 MG, 0.5 MG, 0.75 MG, 1 MG - Tier 2;

PA; SP; QL

TEPMETKO - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

VERZENIO - Tier 2; PA; SP; QL

VITRAKVI - Tier 2; PA; SP; QL

ZEJULA - Tier 2; PA; SP; QL; AL

ZELBORAF - Tier 2; PA; SP; QL

ZYDELIG - Tier 2; PA; SP; QL

Retinoids

bexarotene (generic for TARGRETIN) - Tier 1; PA; SP; QL

tretinoin oral - Tier 1; SP; QL

Treatment Adjuncts

leucovorin calcium oral tablet 10 mg - Tier 1

leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg - Tier 1; QL

MESNEX ORAL - Tier 2; SP; QL

Antineoplastics - Drugs to Treat Cancer

Antimetabolites - Chemotherapy Agents

capecitabine (generic for XELODA) - Tier 1; SP; QL

Molecular Target Inhibitors - Chemotherapy Agents

SCEMBLIX - Tier 2; PA; SP; QL

Antineoplastics, Other - Chemotherapy Agents

Antineoplastics - Drugs to Treat Cancer

ZYKADIA - Tier 2; PA; SP; QL LUMAKRAS - Tier 2; PA; SP; QL

Anti-Obesity Agents - Drugs for Weight Loss

WEGOVY - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antiparasitics

Anthelmintics

albendazole oral - Tier 1; DX2RX; QL

ivermectin oral (generic for STROMECTOL) - Tier 1; DX2RX; QL

praziquantel oral (generic for BILTRICIDE) - Tier 1; DX2RX; QL

EMVERM - Tier 2; PA; QL

Antiprotozoals

atovaquone (generic for MEPRON) - Tier 1; PA; QL

atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; QL

BENZNIDAZOLE - Tier 2; DX2RX; QL

chloroquine phosphate oral - Tier 1; QL

hydroxychloroquine sulfate oral tablet 200 mg (generic for SOVUNA) -

Tier 1; DX2RX; QL

KRINTAFEL - Tier 2; QL

mefloquine hcl - Tier 1; QL

nitazoxanide oral (generic for ALINIA) - Tier 1; DX2RX; QL

pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1

primaquine phosphate - Tier 1

pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL

SOVUNA ORAL TABLET 200 MG (brand for hydroxychloroquine

sulfate) - Tier 2; DX2RX; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antiparasitics - Drugs to Treat Parasitic Infections

Pediculicides/Scabicides - Scabies and Lice Drugs

ft lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier

lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1

lice killing max st external shampoo 0.33-4 % (generic for RID LICE

KILLING SHAMPOO) - Tier 1

lice killing max str (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 killing shampoo max str (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

sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier

Antiparkinson Agents

Anticholinergics

benztropine mesylate oral - Tier 1; QL

trihexyphenidyl hcl oral tablet - Tier 1; QL

Antiparkinson Agents, Other

amantadine hcl oral capsule - Tier 1; QL

amantadine hcl oral solution - Tier 1; QL

entacapone - Tier 1; QL

tolcapone (generic for TASMAR) - Tier 1; QL

GOCOVRI - Tier 2; PA; QL

NOURIANZ - Tier 2; PA; QL

ONGENTYS - Tier 2; PA; QL

OSMOLEX ER - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Dopamine Agonists

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 1

mg, 1.5 mg - Tier 1; QL

pramipexole dihydrochloride oral tablet 0.75 mg - Tier 1

ropinirole hcl - Tier 1; QL

APOKYN (brand for apomorphine hcl) - Tier 2; PA; SP; QL

NEUPRO - Tier 2; 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

DHIVY (brand for carbidopa-levodopa) - Tier 2; QL

DUOPA - Tier 2; PA

INBRIJA - Tier 2; PA; SP; QL

RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-

145 MG, 61.25-245 MG - Tier 2; PA

RYTARY ORAL CAPSULE EXTENDED RELEASE 48.75-195 MG - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antipsychotics

1st Generation/Typical

chlorpromazine hcl oral tablet - Tier 1; QL

fluphenazine decanoate injection - Tier 1; QL

fluphenazine hcl injection - Tier 1

fluphenazine hcl oral concentrate - Tier 1

fluphenazine hcl oral elixir - Tier 1

fluphenazine hcl oral tablet - Tier 1; QL

haloperidol decanoate intramuscular (generic for HALDOL

DECANOATE) - Tier 1; QL

haloperidol oral - Tier 1; QL

loxapine succinate - Tier 1; QL

pimozide - Tier 1; QL; AL

thioridazine hcl oral - Tier 1; QL

thiothixene - Tier 1; QL

trifluoperazine hcl - Tier 1; QL

2nd Generation/Atypical

ABILIFY ASIMTUFII - Tier 2; PA; ^; QL; AL

ABILIFY MAINTENA - Tier 2; DX2RX; ST; ^; QL; AL

aripiprazole oral tablet (generic for ABILIFY) - Tier 1; QL; AL

ARISTADA - Tier 2; DX2RX; ST; ^; QL; AL

INVEGA HAFYERA - Tier 2; PA; ^; QL; AL

INVEGA SUSTENNA - Tier 2; DX2RX; ST; ^; QL; AL

INVEGA TRINZA - Tier 2; DX2RX; ST; ^; QL; AL

lurasidone hcl (generic for LATUDA) - Tier 1; QL; AL

olanzapine oral tablet (generic for ZYPREXA) - Tier 1; QL; AL

PERSERIS - Tier 2; DX2RX; ST; ^; QL; AL

quetiapine fumarate (generic for SEROQUEL) - Tier 1; QL; AL

quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; QL; AL

risperidone microspheres er (generic for RISPERDAL CONSTA) - Tier

1; DX2RX; ST; ^; QL; AL

ABILIFY (brand for aripiprazole) - Tier 2; PA; QL; AL

aripiprazole oral solution - Tier 1; PA; ^; QL; AL

aripiprazole oral tablet dispersible - Tier 1; PA; ^; QL; AL

ARISTADA INITIO - Tier 2; DX2RX; ^; QL; AL

CAPLYTA - Tier 2; PA; ^; QL; AL

FANAPT - Tier 2; PA; ^; QL; AL

FANAPT TITRATION PACK - Tier 2; PA; ^; QL; AL

GEODON ORAL (brand for ziprasidone hcl) - Tier 2; PA; QL; AL

INVEGA (brand for paliperidone er) - Tier 2; PA; ^; QL; AL

LATUDA (brand for lurasidone hcl) - Tier 2; PA; QL; AL

LYBALVI - Tier 2; PA; ^; QL; AL

olanzapine oral tablet dispersible (generic for ZYPREXA ZYDIS) - Tier 1;

PA; ^; QL; AL

paliperidone er (generic for INVEGA) - Tier 1; PA; ^; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

risperidone oral solution (generic for RISPERDAL) - Tier 1; Members

>= 8 years of age will require PA; QL; AL

risperidone oral tablet (generic for RISPERDAL) - Tier 1; QL; AL

RYKINDO - Tier 2; PA; ^; QL

UZEDY SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 100

MG/0.28ML - Tier 2; PA; ^; QL; AL

ziprasidone hcl (generic for GEODON) - Tier 1; QL; AL

REXULTI - Tier 2; PA; ^; QL; AL

RISPERDAL CONSTA (brand for risperidone microspheres er) - Tier 2;

DX2RX; ST; ^; QL; AL

RISPERDAL ORAL SOLUTION (brand for risperidone) - Tier 2; PA;

Members >= 8 years of age will require PA; QL; AL

RISPERDAL ORAL TABLET (brand for risperidone) - Tier 2; PA; QL; AL

risperidone oral tablet dispersible - Tier 1; PA; ^; QL; AL

SAPHRIS (brand for asenapine maleate) - Tier 2; PA; ^; QL; AL

SEROQUEL (brand for quetiapine fumarate) - Tier 2; PA; QL; AL

SEROQUEL XR (brand for quetiapine fumarate er) - Tier 2; PA; QL; AL

VRAYLAR - Tier 2; PA; ^; QL; AL

ZYPREXA ORAL (brand for olanzapine) - Tier 2; PA; QL; AL

ZYPREXA ZYDIS (brand for olanzapine) - Tier 2; PA; ^; QL; AL

Treatment-Resistant

clozapine oral tablet (generic for CLOZARIL) - Tier 1; QL; AL

CLOZARIL (brand for clozapine) - Tier 2; PA; QL; AL

VERSACLOZ - Tier 2; PA; ^; QL; AL

Antispasmodics, Urinary - Bladder Control Drugs

Genitourinary Agents - Drugs to Treat Bladder, Genital and

Kidney Conditions

GEMTESA - Tier 2; PA; QL

Antispasticity Agents

baclofen oral tablet 10 mg, 20 mg, 5 mg - Tier 1; QL

dantrolene sodium oral (generic for DANTRIUM) - Tier 1; QL

tizanidine hcl oral tablet (generic for ZANAFLEX) - Tier 1; QL

ZANAFLEX ORAL CAPSULE 2 MG (brand for tizanidine hcl) - Tier 2; PA;

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

valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anti-hepatitis B (HBV) Agents

BARACLUDE ORAL SOLUTION - Tier 2; QL

entecavir (generic for BARACLUDE) - Tier 1; QL

lamivudine oral tablet 100 mg - Tier 1; QL

Anti-hepatitis C (HCV) Agents

MAVYRET ORAL PACKET - Tier 2; PA; QL

MAVYRET ORAL TABLET - Tier 2; PA; Preferred for Genotypes 1, 2,

3, 4, 5,& 6; QL

ribavirin oral - Tier 1; QL

SOFOSBUVIR-VELPATASVIR (brand for sofosbuvir-velpatasvir) - Tier

2; PA; QL

ZEPATIER - Tier 2; PA; QL

EPCLUSA (brand for sofosbuvir-velpatasvir) - Tier 2; PA; QL

HARVONI (brand for ledipasvir-sofosbuvir) - Tier 2; PA; QL

LEDIPASVIR-SOFOSBUVIR (brand for ledipasvir-sofosbuvir) - Tier 2; PA;

SOVALDI - Tier 2; PA; QL

VOSEVI - Tier 2; PA; QL

Antiherpetic Agents

acyclovir external ointment (generic for ZOVIRAX) - Tier 1; QL

acyclovir oral - Tier 1; QL

valacyclovir hcl oral (generic for VALTREX) - Tier 1; 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 HD - Tier 2; QL

ISENTRESS ORAL PACKET - Tier 2; Members >= 2 years of age will

require PA; QL; AL

ISENTRESS ORAL TABLET - Tier 2; QL

ISENTRESS ORAL TABLET CHEWABLE - Tier 2; QL

JULUCA - Tier 2; QL

STRIBILD - Tier 2; QL

TIVICAY - Tier 2; QL

TIVICAY PD - Tier 2; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors (NNRTI)

COMPLERA - Tier 2; QL

DELSTRIGO - Tier 2; QL

EDURANT - Tier 2; QL

efavirenz (generic for SUSTIVA) - Tier 1; QL

efavirenz-emtricitab-tenofo df (generic for ATRIPLA) - Tier 1; QL

efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; QL

etravirine (generic for INTELENCE) - Tier 1; QL

INTELENCE ORAL TABLET 25 MG - Tier 2; QL

nevirapine - Tier 1; QL

nevirapine er - Tier 1; QL

PIFELTRO - Tier 2; QL

SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL

SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; PA; QL

Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors (NRTI)

abacavir sulfate (generic for ZIAGEN) - Tier 1; QL

abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; QL

CIMDUO - Tier 2; QL

DESCOVY - Tier 2; QL

emtricitabine (generic for EMTRIVA) - Tier 1; QL

emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; QL

EMTRIVA ORAL SOLUTION - Tier 2; QL

lamivudine oral solution (generic for EPIVIR) - Tier 1; QL

lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1;

lamivudine-zidovudine - Tier 1; QL

ODEFSEY - Tier 2; QL

tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; QL

TRIUMEQ - Tier 2; QL

TRUVADA (brand for emtricitabine-tenofovir df) - Tier 2; PA; QL

TRIUMEQ PD - Tier 2; QL

VIREAD ORAL POWDER - Tier 2; QL

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; QL

zidovudine (generic for RETROVIR) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anti-HIV Agents, Other

FUZEON - Tier 2; QL

maraviroc (generic for SELZENTRY) - Tier 1; QL

RUKOBIA - Tier 2; QL

SELZENTRY ORAL SOLUTION - Tier 2; QL

TYBOST - Tier 2; QL

Anti-HIV Agents, Protease Inhibitors (PI)

APTIVUS - Tier 2; QL

atazanavir sulfate (generic for REYATAZ) - Tier 1; QL

EVOTAZ - Tier 2; QL

fosamprenavir calcium (generic for LEXIVA) - Tier 1; QL

lopinavir-ritonavir (generic for KALETRA) - Tier 1; QL

NORVIR ORAL PACKET - Tier 2; QL

PREZCOBIX - Tier 2; QL

REYATAZ ORAL PACKET - Tier 2; Members >= 8 years of age will

require PA; QL; AL

ritonavir (generic for NORVIR) - Tier 1; QL

SYMTUZA - Tier 2; QL

VIRACEPT - Tier 2; QL

KALETRA (brand for lopinavir-ritonavir) - Tier 2; PA; QL

REYATAZ ORAL CAPSULE (brand for atazanavir sulfate) - Tier 2; PA;

Anti-influenza Agents

oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QL

oseltamivir phosphate oral suspension reconstituted (generic for

TAMIFLU) - Tier 1; QL; AL

RELENZA DISKHALER - Tier 2; QL

rimantadine hcl - Tier 1; QL

TAMIFLU ORAL CAPSULE (brand for oseltamivir phosphate) - Tier 2; PA;

TAMIFLU ORAL SUSPENSION RECONSTITUTED (brand for oseltamivir

phosphate) - Tier 2; PA; QL; AL

XOFLUZA (40 MG DOSE) - Tier 2; PA; QL

XOFLUZA (80 MG DOSE) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Antivirals - Drugs to Treat Viral Infections

Antivirals

LAGEVRIO - Tier 2; QL

PAXLOVID (150/100) - Tier 2; QL

PAXLOVID (300/100) - 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

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 - Tier 1; QL

diazepam oral solution - Tier 1; QL

diazepam oral tablet (generic for VALIUM) - Tier 1; QL

lorazepam injection (generic for ATIVAN) - Tier 1; ^

lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL

oxazepam - Tier 1; QL

LOREEV XR - Tier 2; PA; ^; QL

Anxiolytics - Drugs to Treat Anxiety

Benzodiazepines - Anxiety Drugs

DORAL (brand for quazepam) - Tier 2; PA; QL

quazepam (generic for DORAL) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Attention Deficit Hyperactivity Disorder Agents, Non-

amphetamines - ADHD Drugs

Central Nervous System Agents - Drugs to Treat Nerve

Conditions

QELBREE - Tier 2; PA; ^; QL; AL

Bipolar Agents

Mood Stabilizers

divalproex sodium er (generic for DEPAKOTE ER) - Tier 1; *; QL

divalproex sodium oral capsule delayed release sprinkle (generic for

DEPAKOTE SPRINKLES) - Tier 1; Members >= 8 years of age will

require PA; QL; AL

divalproex sodium oral tablet delayed release (generic for

DEPAKOTE) - Tier 1; Minimum age of 2 years; QL

lithium - Tier 1; QL

lithium carbonate er (generic for LITHOBID) - Tier 1; QL

lithium carbonate oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Blood Glucose Regulators

Antidiabetic Agents

acarbose oral - Tier 1; QL

ALOGLIPTIN BENZOATE - Tier 2; ST; QL

ALOGLIPTIN-METFORMIN HCL - Tier 2; ST; QL

ALOGLIPTIN-PIOGLITAZONE - Tier 2; ST; QL

DAPAGLIFLOZIN PROPANEDIOL (brand for dapagliflozin

propanediol) - Tier 2; PA; QL

FARXIGA (brand for dapagliflozin propanediol) - Tier 2; PA; QL

glimepiride - Tier 1; QL

glipizide er (generic for GLUCOTROL XL) - Tier 1; QL

glipizide oral tablet 10 mg, 5 mg - Tier 1; QL

glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL

glyburide micronized - Tier 1; QL

glyburide oral - Tier 1; QL

glyburide-metformin - Tier 1; QL

BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL

BYETTA 10 MCG PEN - Tier 2; PA; QL

BYETTA 5 MCG PEN - Tier 2; PA; QL

GLYXAMBI - Tier 2; PA

INVOKAMET - Tier 2; PA; QL

INVOKAMET XR - Tier 2; PA; QL

INVOKANA - Tier 2; PA; QL

JANUMET - Tier 2; PA; QL

JANUMET XR - Tier 2; PA; QL

JANUVIA - Tier 2; PA; QL

JARDIANCE - Tier 2; PA; QL

JENTADUETO - Tier 2; PA; QL

JENTADUETO XR - Tier 2; PA; QL

ONGLYZA (brand for saxagliptin hcl) - Tier 2; PA; QL

metformin hcl er (osm) - Tier 1; PA; QL

metformin hcl er oral tablet extended release 24 hour 500 mg - Tier 1;

metformin hcl er oral tablet extended release 24 hour 750 mg - Tier 1

metformin hcl oral tablet 1000 mg, 500 mg, 850 mg - Tier 1; QL

nateglinide - Tier 1; QL

OZEMPIC - Tier 2; PA; QL

OZEMPIC (2 MG/DOSE) - Tier 2; PA; QL

pioglitazone hcl (generic for ACTOS) - Tier 1; QL

repaglinide - Tier 1; QL

RYBELSUS - Tier 2; PA; QL

saxagliptin hcl (generic for ONGLYZA) - Tier 1; QL

SEGLUROMET - Tier 2; ST; QL

SOLIQUA - Tier 2; ST; QL

QTERN - Tier 2; PA; QL

STEGLUJAN - Tier 2; PA; QL

SYMLINPEN 120 - Tier 2; PA; QL

SYMLINPEN 60 - Tier 2; PA; QL

SYNJARDY - Tier 2; PA; QL

SYNJARDY XR - Tier 2; PA; QL

TRADJENTA - Tier 2; PA; QL

TRIJARDY XR - Tier 2; PA; QL

TRULICITY - Tier 2; PA; QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000

MG (brand for dapagliflozin pro-metformin er) - Tier 2; PA

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-500

MG, 5-500 MG - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

STEGLATRO - Tier 2; ST; QL

VICTOZA - Tier 2; PA; ST; QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000

MG - Tier 2; PA; QL

XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000

MG (brand for dapagliflozin pro-metformin er) - Tier 2; PA; QL

XULTOPHY - Tier 2; PA; QL

Glycemic Agents

BAQSIMI ONE PACK - Tier 2; QL

BAQSIMI TWO PACK - Tier 2; QL

glucagon emergency injection kit - Tier 1; QL

GLUCAGON EMERGENCY INJECTION SOLUTION

RECONSTITUTED - Tier 2; QL

GVOKE HYPOPEN 1-PACK - Tier 2; QL

GVOKE HYPOPEN 2-PACK - Tier 2; QL

GVOKE KIT - Tier 2; QL

GVOKE PFS - Tier 2; QL

Insulins

HUMULIN 70/30 VIAL - Tier 2; QL

HUMULIN N VIAL - Tier 2; QL

HUMULIN R VIAL - 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; ST; QL

INSULIN LISPRO JUNIOR KWIKPEN (brand for insulin lispro junior

kwikpen) - Tier 2; ST; 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

ADMELOG (brand for insulin lispro) - Tier 2; PA; QL

ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2; PA;

ST; QL

AFREZZA - Tier 2; PA; QL

APIDRA SOLOSTAR - Tier 2; PA; QL

APIDRA VIAL - Tier 2; PA; QL

BASAGLAR KWIKPEN (brand for insulin glargine solostar) - Tier 2; PA;

BASAGLAR TEMPO PEN - Tier 2; PA; QL

FIASP - Tier 2; PA; QL

FIASP FLEXTOUCH - Tier 2; PA; QL

FIASP PENFILL - Tier 2; PA; QL

HUMALOG (brand for insulin lispro) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

NOVOLIN 70/30 RELION - Tier 2; QL

NOVOLIN 70/30 VIAL - Tier 2; QL

NOVOLIN N RELION - Tier 2; QL

NOVOLIN N VIAL - Tier 2; QL

NOVOLIN R RELION - Tier 2; QL

NOVOLIN R VIAL - Tier 2; QL

NOVOLOG FLEXPEN RELION (brand for insulin aspart flexpen) - Tier

2; QL

NOVOLOG RELION (brand for insulin aspart) - Tier 2; QL

HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen) -

Tier 2; PA; ST; QL

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

100 UNIT/ML (brand for insulin lispro (1 unit dial)) - Tier 2; PA; ST; QL

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

200 UNIT/ML - Tier 2; PA; QL

HUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QL

HUMALOG MIX 75/25 - Tier 2; PA; QL

HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro) -

Tier 2; PA; QL

HUMALOG TEMPO PEN - Tier 2; PA; QL

HUMULIN 70/30 KWIKPEN - Tier 2; PA; QL

HUMULIN N KWIKPEN - Tier 2; PA; QL

HUMULIN R U-500 KWIKPEN - Tier 2; PA; QL

HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QL

INSULIN ASPART (brand for insulin aspart) - Tier 2; PA; QL

INSULIN DEGLUDEC (brand for insulin degludec) - Tier 2; PA; QL

INSULIN DEGLUDEC FLEXTOUCH (brand for insulin degludec flextouch)

- Tier 2; PA; QL

INSULIN GLARGINE-YFGN (brand for insulin glargine-yfgn) - Tier 2; PA;

LEVEMIR FLEXPEN - Tier 2; PA; QL

LEVEMIR U-100 VIAL - Tier 2; PA; QL

LYUMJEV - Tier 2; PA; QL

LYUMJEV KWIKPEN - Tier 2; PA; QL

LYUMJEV TEMPO PEN - Tier 2; PA; QL

NOVOLIN 70/30 FLEXPEN - Tier 2; PA; QL

NOVOLIN N FLEXPEN - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

NOVOLIN R FLEXPEN - Tier 2; PA; QL

NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL

NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp

flexpen) - Tier 2; PA; QL

NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) - Tier

2; PA; QL

NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL

NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; PA; QL

SEMGLEE (YFGN) (brand for insulin glargine-yfgn) - Tier 2; PA; QL

TOUJEO MAX SOLOSTAR (brand for insulin glargine max solostar) - Tier

2; PA; QL

TOUJEO SOLOSTAR (brand for insulin glargine solostar) - Tier 2; PA; QL

TRESIBA (brand for insulin degludec) - Tier 2; PA; QL

TRESIBA FLEXTOUCH (brand for insulin degludec flextouch) - Tier 2;

PA; QL

Blood Glucose Regulators - Drugs to Regulate Blood Sugar

Glycemic Agents - Diabetic Drugs

GLUCO TO GO (brand for cvs glucose) - Tier 2; QL

glucose oral tablet chewable 4 gm (generic for GLUCO TO GO) - Tier

1; QL

soft glucose (generic for GLUCO TO GO) - Tier 1; QL

TRUEPLUS GLUCOSE ON THE GO (brand for cvs glucose) - Tier 2;

TRUEPLUS GLUCOSE ORAL TABLET CHEWABLE (brand for cvs

glucose) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Insulins - Diabetic Drugs

CAREPOINT POLY HUB NEEDLE 18G X 1" (brand for carepoint poly

hub needle) - Tier 2; QL

MONOJECT HYPODERMIC NEEDLE 18G X 1" (brand for carepoint

poly hub needle) - Tier 2; QL

NOKOR VENTED NEEDLE (brand for carepoint poly hub needle) -

Tier 2; QL

REZVOGLAR KWIKPEN - Tier 2; QL

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) injection solution 1000 unit/ml, 20000 unit/ml

- Tier 1; QL

heparin sodium (porcine) injection solution 10000 unit/ml, 5000 unit/ml

- Tier 1

heparin sodium (porcine) injection solution prefilled syringe - Tier 1; QL

heparin sodium (porcine) pf injection solution 1000 unit/ml - Tier 1; QL

heparin sodium (porcine) pf injection solution 5000 unit/0.5ml, 5000

unit/ml - 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 ORAL CAPSULE (brand for dabigatran etexilate mesylate) -

Tier 2; PA; QL

PRADAXA ORAL PACKET - Tier 2; PA; QL; AL

XARELTO - Tier 2; PA; QL

XARELTO STARTER PACK - Tier 2; PA; QL

SAVAYSA - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Blood Products and Modifiers, Other

anagrelide hcl (generic for AGRYLIN) - Tier 1

ARANESP (ALBUMIN FREE) - Tier 2; PA; SP; QL

DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2

DROXIA ORAL CAPSULE 400 MG - Tier 2; QL

EPOGEN - Tier 2; PA; SP; QL

LEUKINE - Tier 2; PA; SP; QL

MULPLETA - Tier 2; PA; SP; QL

NEULASTA - Tier 2; PA; SP; QL

NEULASTA ONPRO - Tier 2; PA; SP; QL

plerixafor (generic for MOZOBIL) - Tier 1; PA; SP; QL

PROCRIT - Tier 2; PA; SP; QL

PROMACTA ORAL TABLET - Tier 2; PA; 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

FULPHILA - Tier 2; PA; SP; QL

GRANIX - Tier 2; PA; SP; QL

NEUPOGEN - Tier 2; PA; SP; QL

NIVESTYM - Tier 2; PA; SP; QL

NYVEPRIA - Tier 2; PA; SP

OXBRYTA ORAL TABLET 300 MG - Tier 2; PA; SP; QL; AL

OXBRYTA ORAL TABLET 500 MG - Tier 2; PA; QL

OXBRYTA ORAL TABLET SOLUBLE - Tier 2; PA; SP; QL

PROMACTA ORAL PACKET 12.5 MG - Tier 2; PA; SP; QL

RELEUKO - Tier 2; PA; SP

SIKLOS - Tier 2; PA; QL

ZIEXTENZO - Tier 2; PA; SP

RETACRIT INJECTION SOLUTION 20000 UNIT/ML - Tier 2; PA; SP

UDENYCA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;

PA; SP

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE -

Tier 2; PA; SP; QL

ZARXIO - Tier 2; PA; SP; QL

Hemostasis Agents

aminocaproic acid oral - Tier 1; QL

tranexamic acid oral - Tier 1; DX2RX; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Platelet Modifying Agents

BRILINTA - Tier 2; DX2RX; QL

CABLIVI - Tier 2; PA; SP; 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; DX2RX; QL

DOPTELET - Tier 2; PA; SP; QL

EFFIENT (brand for prasugrel hcl) - Tier 2; DX2RX; QL

TAVALISSE - Tier 2; PA; SP; QL

Blood Products/Modifiers/Volume Expanders - Drugs to Treat

Blood Disorders

Hemostasis Agents - Drugs to Stop Bleeding

HEMLIBRA SUBCUTANEOUS SOLUTION 105 MG/0.7ML, 12

MG/0.4ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML - Tier 2; PA; SP;

HEMLIBRA SUBCUTANEOUS SOLUTION 300 MG/2ML - Tier 2; SP;

Cardiovascular Agents

Alpha-adrenergic Agonists

clonidine hcl oral - Tier 1; QL

guanfacine hcl - Tier 1; QL

METHYLDOPA - Tier 2; QL

midodrine hcl - Tier 1; QL

Alpha-adrenergic Blocking Agents

doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL

prazosin hcl oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

telmisartan (generic for MICARDIS) - Tier 1; QL

valsartan oral tablet (generic for DIOVAN) - Tier 1; QL

EDARBI - 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 solution (generic for EPANED) - Tier 1;

Members >= 8 years of age will require PA; QL; AL

enalapril maleate oral tablet (generic for VASOTEC) - Tier 1; QL

fosinopril sodium - Tier 1; QL

lisinopril oral (generic for ZESTRIL) - Tier 1; QL

quinapril hcl (generic for ACCUPRIL) - Tier 1; QL

ramipril (generic for ALTACE) - Tier 1; QL

trandolapril - Tier 1; QL

Antiarrhythmics

amiodarone hcl oral tablet 200 mg, 400 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

propafenone hcl - Tier 1; QL

quinidine gluconate er - Tier 1; 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

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

PACERONE (brand for amiodarone hcl) - Tier 2; PA; QL

TIKOSYN (brand for dofetilide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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

carvedilol (generic for COREG) - Tier 1; QL

labetalol hcl oral - Tier 1; QL

metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL

metoprolol tartrate oral tablet 100 mg, 50 mg (generic for

LOPRESSOR) - Tier 1; QL

metoprolol tartrate oral tablet 25 mg - Tier 1; QL

metoprolol tartrate oral tablet 37.5 mg, 75 mg - Tier 1

nadolol oral (generic for CORGARD) - Tier 1; QL

propranolol hcl er (generic for INDERAL LA) - Tier 1; QL

propranolol hcl oral solution 20 mg/5ml - Tier 1; QL

HEMANGEOL - Tier 2; PA; QL

propranolol hcl oral solution 40 mg/5ml - Tier 1

propranolol hcl oral tablet - Tier 1; QL

Calcium Channel Blocking Agents, Dihydropyridines

amlodipine besylate oral (generic for NORVASC) - Tier 1; QL

felodipine er - Tier 1; QL

nifedipine er - Tier 1; QL

nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1;

nifedipine oral - Tier 1; QL

nimodipine oral - Tier 1; QL

NYMALIZE - Tier 2; QL

KATERZIA - Tier 2; PA; QL

NORLIQVA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Calcium Channel Blocking Agents, Nondihydropyridines

cartia xt (generic for CARTIA XT) - Tier 1; QL

diltiazem hcl er beads (generic for TIADYLT ER) - Tier 1; QL

diltiazem hcl er coated beads (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 - Tier 1; QL

diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL

dilt-xr - Tier 1; QL

tiadylt er (generic for TIADYLT ER) - Tier 1; QL

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 - Tier 1; QL

verapamil hcl oral - Tier 1; 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

amlodipine-olmesartan (generic for AZOR) - Tier 1

atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL

benazepril-hydrochlorothiazide (generic for LOTENSIN HCT) - Tier 1;

bisoprolol-hydrochlorothiazide - Tier 1; QL

captopril-hydrochlorothiazide - Tier 1; QL

digoxin oral solution - Tier 1

digoxin oral tablet 125 mcg, 250 mcg (generic for DIGOX) - Tier 1; QL

enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL

CORLANOR - Tier 2; PA; QL

EDARBYCLOR - Tier 2; PA; QL

KERENDIA - Tier 2; PA; QL

TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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

olmesartan medoxomil-hctz (generic for BENICAR HCT) - 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 - Tier 1; QL

triamterene-hctz - Tier 1; QL

valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1; QL

Diuretics, Loop

bumetanide oral (generic for BUMEX) - Tier 1; QL

furosemide oral solution 10 mg/ml - Tier 1; QL

furosemide oral tablet (generic for LASIX) - Tier 1; QL

SOAANZ ORAL TABLET 20 MG (brand for torsemide) - Tier 2; QL

torsemide (generic for SOAANZ) - Tier 1; QL

FUROSCIX - Tier 2; PA; QL

Diuretics, Potassium-sparing

amiloride hcl oral - Tier 1; QL

spironolactone oral tablet (generic for ALDACTONE) - Tier 1; QL

Diuretics, Thiazide

chlorthalidone - Tier 1; QL

DIURIL - Tier 2; QL

hydrochlorothiazide oral capsule - Tier 1; QL

hydrochlorothiazide oral tablet 12.5 mg - Tier 1

hydrochlorothiazide oral tablet 25 mg, 50 mg - Tier 1; QL

indapamide - Tier 1; QL

metolazone - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1;

fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; QL

fenofibrate oral tablet 145 mg, 48 mg (generic for TRICOR) - Tier 1;

fenofibrate oral tablet 160 mg, 54 mg - Tier 1; QL

gemfibrozil oral (generic for LOPID) - Tier 1; QL

FENOGLIDE (brand for fenofibrate) - Tier 2; PA; QL

LIPOFEN (brand for fenofibrate) - Tier 2; PA

TRICOR (brand for fenofibrate) - Tier 2; PA; QL

TRILIPIX (brand for fenofibric acid) - Tier 2; PA; QL

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium oral (generic for LIPITOR) - Tier 1; QL

lovastatin oral - Tier 1; QL; AL

pravastatin sodium - Tier 1; QL

rosuvastatin calcium oral (generic for CRESTOR) - Tier 1; QL

simvastatin oral (generic for ZOCOR) - Tier 1; QL

ALTOPREV - Tier 2; PA; QL

ATORVALIQ - Tier 2; PA; QL

CRESTOR (brand for rosuvastatin calcium) - Tier 2; PA; QL

LESCOL XL (brand for fluvastatin sodium er) - Tier 2; PA

LIPITOR (brand for atorvastatin calcium) - Tier 2; PA; QL

LIVALO (brand for pitavastatin calcium) - Tier 2; PA; QL

ZOCOR (brand for simvastatin) - Tier 2; PA; QL

ZYPITAMAG - Tier 2; PA; QL

Dyslipidemics, Other

cholestyramine light oral powder (generic for PREVALITE) - Tier 1; QL

cholestyramine oral powder (generic for QUESTRAN) - Tier 1; Only

the bulk products are covered (cans) Individual packets are not

covered; QL

ezetimibe (generic for ZETIA) - Tier 1; QL

niacin er (antihyperlipidemic) - Tier 1; QL

omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL

prevalite oral powder (generic for PREVALITE) - Tier 1; QL

REPATHA - Tier 2; PA; NDC starting w/72511 Preferred w/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

PRALUENT - Tier 2; PA; NDC starting w/72733 Preferred w/PA; SP; QL

VASCEPA (brand for icosapent ethyl) - Tier 2; PA; QL

VYTORIN (brand for ezetimibe-simvastatin) - Tier 2; PA; QL

Vasodilators, Direct-acting Arterial

hydralazine hcl oral - Tier 1; QL

minoxidil oral - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 rectal (generic for RECTIV) - Tier 1; DX2RX; 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

Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs

Cardiovascular Agents - Drugs to Treat Heart and Circulation

Conditions

VERQUVO - Tier 2; PA; QL

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Non-

amphetamines

atomoxetine hcl (generic for STRATTERA) - Tier 1; DX2RX; Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider||Diagnosis required for 18 years of age and older; ^; QL; AL

dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; DX2RX;

Diagnosis required for 18 years of age and older||Medical office

attestation needed if prescribed by behavioral health provider Full Prior

Authorization needed if prescribed by non-behavioral health provider;

^; QL; AL

dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; DX2RX;

Medical office attestation needed if prescribed by behavioral health

provider Full Prior Authorization needed if prescribed by non-

behavioral health provider||Diagnosis required for 18 years of age and

older; ^; QL; AL

JORNAY PM - Tier 2; PA; ^; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

guanfacine hcl er (generic for INTUNIV) - Tier 1; DX2RX; Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider||Diagnosis required for 18 years of age and older; ^; QL; AL

methylphenidate hcl er - Tier 1; DX2RX; Medical office attestation

needed if prescribed by behavioral health provider Full Prior

Authorization needed if prescribed by non-behavioral health

provider||Diagnosis required for 18 years of age and older; ^; QL; AL

methylphenidate hcl er (cd) (generic for METADATE CD) - Tier 1;

DX2RX; Medical office attestation needed if prescribed by behavioral

health provider Full Prior Authorization needed if prescribed by non-

behavioral health provider||Diagnosis required for 18 years of age and

older; ^; QL; AL

methylphenidate hcl er (la) oral capsule extended release 24 hour 20

mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; DX2RX; Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider||Diagnosis required for 18 years of age and older; ^; QL; AL

methylphenidate hcl er (osm) oral tablet extended release 18 mg, 27

mg, 36 mg, 54 mg (generic for CONCERTA) - Tier 1; DX2RX; Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider||Diagnosis required for 18 years of age and older; ^; QL; AL

methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; DX2RX;

Medical office attestation needed if prescribed by behavioral health

provider Full Prior Authorization needed if prescribed by non-

behavioral health provider||Diagnosis required for 18 years of age and

older; ^; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

ADDERALL (brand for amphetamine-dextroamphetamine) - Tier 2;

DX2RX; Diagnosis required for 18 years of age and older||Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider; ^; QL; AL

ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2;

DX2RX; Diagnosis required for 18 years of age and older||Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider; ^; QL; AL

AZSTARYS - Tier 2; PA; ^; QL; AL

VYVANSE ORAL TABLET CHEWABLE (brand for lisdexamfetamine

dimesylate) - Tier 2; PA; ^; QL

amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1;

DX2RX; Diagnosis required for 18 years of age and older||Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider; ^; QL; AL

amphetamine-dextroamphetamine er (generic for ADDERALL XR) -

Tier 1; DX2RX; Diagnosis required for 18 years of age and

older||Medical office attestation needed if prescribed by behavioral

health provider Full Prior Authorization needed if prescribed by non-

behavioral health provider; ^; QL; AL

dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1;

DX2RX; Diagnosis required for 18 years of age and older||Medical

office attestation needed if prescribed by behavioral health provider

Full Prior Authorization needed if prescribed by non-behavioral health

provider; ^; QL; AL

dextroamphetamine sulfate oral tablet 10 mg, 5 mg (generic for

ZENZEDI) - Tier 1; DX2RX; Diagnosis required for 18 years of age

and older||Medical office attestation needed if prescribed by behavioral

health provider Full Prior Authorization needed if prescribed by non-

behavioral health provider; ^; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

lisdexamfetamine dimesylate oral capsule (generic for VYVANSE) -

Tier 1; DX2RX; ST; Medical office attestation needed if prescribed by

behavioral health provider Full Prior Authorization needed if prescribed

by non-behavioral health provider||Diagnosis required for 18 years of

age and older; ^; QL; AL

VYVANSE ORAL CAPSULE (brand for lisdexamfetamine dimesylate) -

Tier 2; DX2RX; ST; Medical office attestation needed if prescribed by

behavioral health provider Full Prior Authorization needed if prescribed

by non-behavioral health provider||Diagnosis required for 18 years of

age and older; ^; QL; AL

Central Nervous System, Other

AUSTEDO - Tier 2; PA; SP; QL

caffeine citrate oral - Tier 1; QL; AL

INGREZZA - Tier 2; PA; SP; QL

NUEDEXTA - Tier 2; DX2RX; QL

riluzole - Tier 1; QL

tetrabenazine (generic for XENAZINE) - Tier 1; DX2RX; SP; QL

AUSTEDO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 6 MG -

Tier 2; PA; SP; QL

GRALISE ORAL TABLET 300 MG, 600 MG (brand for gabapentin (once-

daily)) - Tier 2; PA; QL

HORIZANT - Tier 2; PA; QL

RADICAVA ORS - Tier 2; PA; SP; QL

RADICAVA ORS STARTER KIT - Tier 2; PA; SP; QL

XENAZINE (brand for tetrabenazine) - Tier 2; DX2RX; SP; QL

Fibromyalgia Agents

duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60

mg (generic for CYMBALTA) - Tier 1; QL

pregabalin oral (generic for LYRICA) - Tier 1; QL

CYMBALTA (brand for duloxetine hcl) - Tier 2; PA; QL

LYRICA CR (brand for pregabalin er) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Multiple Sclerosis Agents

dalfampridine er (generic for AMPYRA) - Tier 1; DX2RX; SP; QL

dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; DX2RX; SP;

dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1;

DX2RX; SP; QL

fingolimod hcl (generic for GILENYA) - Tier 1; DX2RX; SP; QL

glatiramer acetate (generic for GLATOPA) - Tier 1; DX2RX; SP; QL

glatopa (generic for GLATOPA) - Tier 1; DX2RX; SP; QL

MAYZENT - Tier 2; PA; SP; QL

MAYZENT STARTER PACK - Tier 2; PA; SP; QL

PLEGRIDY STARTER PACK - Tier 2; DX2RX; SP; QL

PLEGRIDY SUBCUTANEOUS - Tier 2; DX2RX; SP; QL

teriflunomide (generic for AUBAGIO) - Tier 1; DX2RX; SP; QL

AUBAGIO (brand for teriflunomide) - Tier 2; DX2RX; SP; QL

AVONEX PEN - Tier 2; PA; SP; QL

AVONEX PREFILLED - Tier 2; PA; SP; QL

BAFIERTAM - Tier 2; PA; SP; QL

BETASERON - Tier 2; PA; SP; QL

COPAXONE (brand for glatiramer acetate) - Tier 2; DX2RX; SP; QL

EXTAVIA - Tier 2; PA; SP; QL

GILENYA (brand for fingolimod hcl) - Tier 2; DX2RX; 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

MAVENCLAD (9 TABS) - Tier 2; PA; SP; QL

PLEGRIDY INTRAMUSCULAR - Tier 2; PA; SP; QL

REBIF - Tier 2; PA; SP; QL

REBIF REBIDOSE - Tier 2; PA; SP; QL

REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL

REBIF TITRATION PACK - Tier 2; PA; SP; QL

TECFIDERA ORAL CAPSULE DELAYED RELEASE (brand for dimethyl

fumarate) - Tier 2; DX2RX; SP; QL

VUMERITY - Tier 2; PA; SP; QL

ZEPOSIA - Tier 2; PA; SP; QL

ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA; SP; QL

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Dental and Oral Agents

chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier

1; QL

kourzeq (generic for KOURZEQ) - Tier 1; QL

oralone (generic for KOURZEQ) - Tier 1; QL

periogard (generic for PERIOGARD) - Tier 1; QL

pilocarpine hcl oral tablet 5 mg (generic for SALAGEN) - Tier 1; QL

pilocarpine hcl oral tablet 7.5 mg (generic for SALAGEN) - Tier 1

triamcinolone acetonide mouth/throat (generic for KOURZEQ) - Tier 1;

Dermatological Agents

Acne and Rosacea Agents

acitretin - Tier 1; PA; QL

amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL

azelaic acid external (generic for FINACEA) - Tier 1; QL

claravis (generic for AMNESTEEM) - Tier 1; PA; QL

DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene) - Tier 2; QL

isotretinoin oral capsule 10 mg, 20 mg, 40 mg (generic for

AMNESTEEM) - Tier 1; PA; QL

isotretinoin oral capsule 30 mg (generic for CLARAVIS) - Tier 1; PA;

tretinoin external cream (generic for RETIN-A) - Tier 1; ST; QL; AL

zenatane (generic for AMNESTEEM) - 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

ALTRENO - Tier 2; PA; QL; AL

ARAZLO - Tier 2; PA; QL

ATRALIN (brand for tretinoin) - Tier 2; PA; QL; AL

BENZAMYCIN (brand for benzoyl peroxide-erythromycin) - Tier 2; PA; QL

DIFFERIN EXTERNAL CREAM (brand for adapalene) - Tier 2; PA; QL

DIFFERIN EXTERNAL GEL 0.3 % (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

FINACEA EXTERNAL FOAM - Tier 2; PA; QL

MIRVASO (brand for brimonidine tartrate) - Tier 2; PA; QL

ONEXTON (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

RETIN-A EXTERNAL CREAM (brand for tretinoin) - Tier 2; PA; ST; QL;

RETIN-A EXTERNAL GEL (brand for tretinoin) - Tier 2; PA; QL; AL

RETIN-A MICRO GEL 0.04 %, 0.1 % (brand for tretinoin microsphere) -

Tier 2; PA; QL; AL

RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL; AL

RETIN-A MICRO PUMP EXTERNAL GEL 0.08 % (brand for tretinoin

microsphere) - Tier 2; PA; QL; AL

RHOFADE - Tier 2; PA; QL

TAZORAC EXTERNAL CREAM 0.1 % (brand for tazarotene) - Tier 2; PA;

TAZORAC EXTERNAL GEL (brand for tazarotene) - Tier 2; PA; QL

ZIANA (brand for clindamycin-tretinoin) - Tier 2; PA; QL

Dermatitis and Pruitus Agents

ala-cort (generic for MEDI-FIRST HYDROCORTISONE) - Tier 1; QL

alclometasone dipropionate external ointment - Tier 1; QL

ammonium lactate external (generic for AL12) - Tier 1; QL

anti-itch aloe (generic for MEDI-FIRST HYDROCORTISONE) - Tier 1;

anti-itch intensive heal (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

anti-itch max str external cream 1 % (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

anti-itch maximum strength external cream 1 % (generic for MEDI-

FIRST HYDROCORTISONE) - Tier 1; QL

betamethasone dipropionate aug (generic for DIPROLENE) - Tier 1;

betamethasone dipropionate external lotion - Tier 1

BRYHALI - Tier 2; PA; QL

CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL

CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL

doxepin hcl external (generic for PRUDOXIN) - Tier 1; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

betamethasone dipropionate external ointment - Tier 1; QL

betamethasone valerate external cream - Tier 1; QL

betamethasone valerate external lotion - Tier 1; QL

betamethasone valerate external ointment - Tier 1; QL

clobetasol propionate e - Tier 1; QL

clobetasol propionate external cream - Tier 1; QL

clobetasol propionate external ointment - Tier 1; QL

clobetasol propionate external solution - Tier 1; QL

cortisone maximum strength external cream (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

EUCRISA - Tier 2; ST; QL

fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS

BODY) - Tier 1; QL

fluocinolone acetonide external cream 0.025 % (generic for

SYNALAR) - Tier 1; QL

fluocinolone acetonide external ointment (generic for SYNALAR) - Tier

1; QL

fluocinolone acetonide external solution - Tier 1; QL

fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS

SCALP) - Tier 1; QL

fluocinonide emulsified base - Tier 1; QL

fluocinonide external cream (generic for VANOS) - Tier 1; QL

fluocinonide external solution - Tier 1; QL

fluticasone propionate external cream - Tier 1; QL

fluticasone propionate external ointment - Tier 1; QL

ft itch relief max strength external cream (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

ft itch relief/aloe max str (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

halobetasol propionate external cream - Tier 1; QL

hydrocortisone anti-itch (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone butyrate external ointment - Tier 1; QL

hydrocortisone butyrate external solution - Tier 1; QL

hydrocortisone external cream 0.5 %, 2.5 % - Tier 1; QL

hydrocortisone external cream 1 % (generic for MEDI-FIRST

HYDROCORTISONE) - 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 CHILDREN) - Tier 1; QL

hydrocortisone external ointment 2.5 % - Tier 1; QL

hydrocortisone max st external cream (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone max st/12 moist (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

hydrocortisone plus (generic for MEDI-FIRST HYDROCORTISONE) -

Tier 1; QL

hydrocortisone/aloe (generic for MEDI-FIRST HYDROCORTISONE) -

Tier 1; QL

hydrocortisone/aloe max str (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

instacort 5 - Tier 1; QL

LAC-HYDRIN FIVE - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

medi-first hydrocortisone (generic for MEDI-FIRST

HYDROCORTISONE) - Tier 1; QL

mometasone furoate external - Tier 1; QL

pimecrolimus (generic for ELIDEL) - Tier 1; ST; Minimum age of 2

years; QL; AL

selenium sulfide external lotion - Tier 1; QL

tacrolimus external ointment 0.03 % - Tier 1; ST; Minimum age of 2

years; QL; AL

tacrolimus external ointment 0.1 % - Tier 1; ST; Minimum age of 16

years; QL; AL

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

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

1; QL

triderm (generic for TRIDERM) - Tier 1; QL

Dermatological Agents, Other

calcipotriene external cream - Tier 1; ST; QL

calcipotriene external ointment (generic for CALCITRENE) - Tier 1;

ST; QL

calcipotriene external solution - Tier 1; QL

calcitriol external (generic for VECTICAL) - Tier 1; ST; QL

clotrimazole-betamethasone - Tier 1; QL

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

podofilox external solution - Tier 1; QL

silver sulfadiazine external (generic for SSD) - Tier 1; QL

ssd (generic for SSD) - Tier 1; QL

CARAC (brand for fluorouracil) - Tier 2; PA; QL

DUOBRII - Tier 2; PA; QL

EFUDEX (brand for fluorouracil) - Tier 2; PA; QL

ENSTILAR - Tier 2; PA; QL

PROCTOFOAM HC - Tier 2; PA

QBREXZA - 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; ST; QL

ZYCLARA (brand for imiquimod) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Pediculicides/Scabicides

CROTAN LOTION 10 % EXTERNAL - Tier 2; QL

CROTAN LOTION 10 % EXTERNAL - Tier 2; PA; QL

lice killing (generic for NIX CREME RINSE) - Tier 1

lice treatment external liquid 1 % (generic for NIX CREME RINSE) -

Tier 1

malathion (generic for OVIDE) - Tier 1; QL

permethrin external - Tier 1; QL

spinosad (generic for NATROBA) - Tier 1; QL

SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL

Topical Anti-infectives

ciclodan (generic for CICLODAN) - Tier 1; QL

ciclopirox external solution (generic for CICLODAN) - Tier 1; QL

clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QL

clindacin-p (generic for CLINDACIN ETZ) - Tier 1; QL

clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1;

clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier

1; QL

clindamycin phosphate external solution - Tier 1; QL

clindamycin phosphate external swab (generic for CLINDACIN ETZ) -

Tier 1; QL

clotrimazole external cream 1 % (generic for DESENEX) - Tier 1; QL

clotrimazole external solution 1 % - Tier 1; QL

erythromycin external (generic for ERYGEL) - Tier 1; QL

AMZEEQ - Tier 2; PA

JUBLIA - Tier 2; PA; QL

XEPI - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

gentamicin sulfate external - Tier 1; QL

ketoconazole external cream - Tier 1; QL

ketoconazole external shampoo - Tier 1; QL

klayesta (generic for KLAYESTA) - Tier 1; QL

mupirocin external - Tier 1; QL

nyamyc (generic for KLAYESTA) - Tier 1; QL

nystatin external (generic for KLAYESTA) - Tier 1; QL

nystop (generic for KLAYESTA) - Tier 1; QL

tgt clotrimazole external cream 1 % (generic for DESENEX) - Tier 1;

Dermatological Agents - Drugs to Treat Skin Conditions

advanced healing external ointment (generic for HYDROLATUM) -

Tier 1

astringent (generic for DOMEBORO) - Tier 1

astringent solution (generic for DOMEBORO) - Tier 1

AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2

AVAR-E GREEN (brand for sss 10-5) - 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

boro-packs (generic for DOMEBORO) - Tier 1

boudreauxs butt paste ointment 40 % external (generic for

BOUDREAUXS BUTT PASTE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 DIAPER - Tier 2; QL

glycerin external liquid , 99.5 % - Tier 1

hydrolatum (generic for HYDROLATUM) - Tier 1

hydrophor (generic for HYDROLATUM) - Tier 1

ointment base (generic for HYDROLATUM) - 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

sulfacetamide sodium-sulfur external cream 10-5 % (generic for

AVAR-E EMOLLIENT) - Tier 1

sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for

SUMADAN WASH) - Tier 1; QL

sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for

SUMADAN WASH) - Tier 1; QL

sulfamez wash - Tier 1

SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2;

zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT

PASTE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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

docosanol external (generic for ABREVA) - Tier 1; QL

ft docosanol (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

NUTRAPLUS (brand for gormel 10) - Tier 2; QL

urea 20 intensive hydrating - Tier 1; QL

urea external cream 10 % (generic for NUTRAPLUS) - Tier 1; QL

urea external cream 20 % - Tier 1; QL

urea external lotion (generic for NUTRAPLUS) - Tier 1; QL

ureacin-10 (generic for NUTRAPLUS) - Tier 1; QL

CIBINQO - Tier 2; PA; SP; QL

OPZELURA - Tier 2; PA; SP; QL

ZILXI - Tier 2; PA; QL

ureacin-20 - Tier 1; QL

XERAC AC - Tier 2

DEVICES

MEDICAL SUPPLIES

PEAK FLOW METER UNIVERSAL RANG (brand for peak flow meter

universal rang) - Tier 2; QL

PURE COMFORT FLOW METER ADULT (brand for peak flow meter

universal rang) - Tier 2; QL

PURE COMFORT FLOW METER CHILD (brand for peak flow meter

universal rang) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 ULTRA-FINE PEN NEEDLES (brand for 1st tier unifine pentips) -

Tier 2; QL

CARESENS CONTROL SOLUTION A/B (brand for element compact

control 2) - Tier 2; QL

CARETOUCH CONTROL SOL LEVEL 2 (brand for element compact

control 2) - Tier 2; QL

ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for blood glucose test) -

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 blood glucose monitor

system) - Tier 2; PA; QL

ACCU-CHEK GUIDE KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

ACCU-CHEK SMARTVIEW (brand for blood glucose test) - Tier 2; PA; QL

ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite

device/lancets) - Tier 2; PA; QL

BD ULTRA-FINE PEN NEEDLES (brand for 1st tier unifine pentips) - Tier

2; PA; 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

DEXCOM G6 RECEIVER - Tier 2; PA; QL

DEXCOM G6 SENSOR (brand for guardian sensor 3) - Tier 2; PA; QL

DEXCOM G7 RECEIVER - Tier 2; PA; QL

DEXCOM G7 SENSOR (brand for guardian sensor 3) - Tier 2; PA; QL

EASYMAX 15 LEVEL 2 CONTROL (brand for element compact

control 2) - Tier 2; QL

BLOOD GLUCOSE TEST STRIPS (brand for blood glucose test) - Tier 2;

PA; QL

CONTOUR NEXT EZ KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

CONTOUR NEXT GEN MONITOR KIT (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 blood glucose monitoring 333) -

Tier 2; PA; QL

CONTOUR NEXT GEN TEST STRIPS (brand for blood glucose test) -

Tier 2; PA; QL

CONTOUR TEST STRIPS (brand for blood glucose test) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 guardian sensor 3) -

Tier 2; PA; QL

FREESTYLE LIBRE 2 READER - Tier 2; PA; QL

FREESTYLE LIBRE 2 SENSOR (brand for guardian sensor 3) - Tier 2;

PA; QL

FREESTYLE LIBRE READER - Tier 2; PA; QL

KETO-DIASTIX - Tier 2; QL

KETONE CARE - Tier 2; QL

KETONE TEST (brand for ketone test) - Tier 2; QL

FREESTYLE LIBRE 3 SENSOR (brand for guardian sensor 3) - Tier 2;

PA; QL

FREESTYLE PRECISION NEO TEST (brand for blood glucose test) - Tier

2; PA; QL

FREESTYLE TEST (brand for blood glucose test) - Tier 2; PA; QL

GUARDIAN SENSOR (3) (brand for guardian sensor 3) - Tier 2; PA; QL

GUARDIAN SENSOR 3 (brand for guardian sensor 3) - Tier 2; PA; QL

INSULIN PEN NEEDLES 32G X 4 MM , 32G X 6 MM (brand for 1st tier

unifine pentips) - Tier 2; PA; QL

ONETOUCH ULTRA 2 KIT W/DEVICE (brand for blood glucose monitor

system) - Tier 2; PA; QL

ONETOUCH ULTRA STRIP IN VITRO (brand for blood glucose test) -

Tier 2; PA; QL

KETOSTIX (brand for ketone test) - Tier 2; QL

LANCETS (brand for cvs lancets original) - Tier 2; 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 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

ONETOUCH ULTRA IN VITRO LIQUID (brand for element compact

control 2) - Tier 2; QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for blood

glucose monitor system) - Tier 2; PA; QL

ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood glucose

monitor system) - Tier 2; PA; QL

ONETOUCH VERIO STRIP IN VITRO (brand for blood glucose test) -

Tier 2; PA; QL

PRECISION XTRA BLOOD GLUCOSE (brand for blood glucose test) -

Tier 2; PA; QL

RELION TRUE METRIX TEST STRIPS (brand for blood glucose test) -

Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

ONETOUCH ULTRA STRIP IN VITRO (brand for blood glucose test) -

Tier 2; QL for non-insulin dependent members: allow twice daily

testing; QL

ONETOUCH ULTRA TEST (brand for blood glucose test) - Tier 2; QL

for non-insulin dependent members: allow twice daily testing; QL

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for blood

glucose monitor system) - Tier 2; QL

ONETOUCH VERIO IN VITRO LIQUID (brand for element compact

control 2) - Tier 2; QL

ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood

glucose monitor system) - Tier 2; QL

ONETOUCH VERIO STRIP IN VITRO (brand for blood glucose test) -

Tier 2; QL for non-insulin dependent members: allow twice daily

testing; QL

PIP GLUCOSE CONTROL SOLUTION (brand for element compact

control 2) - 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

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

VIVAGUARD INO CONTROL SOLUTION (brand for element compact

control 2) - Tier 2; QL

Electrolyte/Mineral Replacement - Vitamin, Mineral and Body

Fluid Deficiency Drugs

Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat

Vitamin, Mineral and Body Fluid Deficiencies

ACCRUFER - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Electrolytes/Minerals/Metals/Vitamins

Electrolyte/Mineral Replacement

carglumic acid (generic for CARBAGLU) - Tier 1; PA; SP; QL

DENTA 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL

DENTAGEL (brand for sf) - Tier 2

easygel - Tier 1

fluoridex daily renewal - 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 m20 (generic for KLOR-CON M20) - Tier 1; QL

potassium chloride crys er oral tablet extended release 10 meq

(generic for KLOR-CON M10) - Tier 1; QL

potassium chloride crys er oral tablet extended release 20 meq

(generic for KLOR-CON M20) - Tier 1; QL

ENDARI - Tier 2; PA; QL

potassium chloride er oral capsule extended release 10 meq - Tier 1;

potassium chloride er oral tablet extended release 10 meq (generic for

KLOR-CON 10) - Tier 1; QL

potassium chloride er oral tablet extended release 20 meq (generic for

K-TAB) - Tier 1; QL

potassium chloride er oral tablet extended release 8 meq (generic for

KLOR-CON) - Tier 1; QL

potassium chloride oral (generic for KLOR-CON) - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

potassium citrate er oral tablet extended release 5 meq (540 mg)

(generic for UROCIT-K 5) - Tier 1

PREVIDENT (brand for sf) - Tier 2

PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2

PREVIDENT 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL

sf (generic for DENTAGEL) - Tier 1

sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL

sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1;

sodium fluoride 5000 ppm dental cream (generic for DENTA 5000

PLUS) - Tier 1; QL

sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1;

sodium fluoride dental gel (generic for DENTAGEL) - Tier 1

sodium fluoride oral solution - Tier 1; QL

sodium fluoride oral tablet chewable - Tier 1; QL

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 + vitamin d3 oral tablet 500-5 mg-mcg (generic for OYSCO

500+D) - 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

calcium 600/vitamin d - Tier 1; QL

calcium 600/vitamin d-3 - Tier 1; QL

calcium 600+d oral tablet 600-10 mg-mcg - Tier 1; QL

calcium carb-cholecalciferol oral tablet 600-10 mg-mcg, 600-5 mg-mcg

- Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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 315-6.25 mg-mcg (generic for

CALCITRATE) - Tier 1

calcium citrate+d3 oral tablet (generic for ADVANCED

CALCIUM/D/MAGNESIUM) - Tier 1; QL

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 315-5 mg-mcg - 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

electrolyte solution (generic for ENFAMIL ENFALYTE) - 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

ferretts - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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, 324 mg (generic for

FERROCITE) - Tier 1

ferrous gluconate - 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 (generic for FEROSUL) - Tier 1; QL

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

ft magnesium oxide (generic for MAGNESIUM-OXIDE) - Tier 1

hi cal (generic for OYSCO 500+D) - Tier 1; QL

iferex 150 (generic for FERREX 150) - Tier 1

iferex 150 forte (generic for IFEREX 150 FORTE) - Tier 1

iron (ferrous sulfate) oral solution (generic for BPROTECTED PEDIA

IRON) - Tier 1; QL

iron infant/toddler (generic for BPROTECTED PEDIA IRON) - Tier 1;

iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; QL

iron supplement childrens (generic for BPROTECTED PEDIA IRON) -

Tier 1; QL

K-PHOS - Tier 2; QL

magnesium oral tablet 500 mg - Tier 1

magnesium oxide -mg supplement oral tablet 400 (240 mg) mg

(generic for MAGNESIUM-OXIDE) - Tier 1

magnesium oxide -mg supplement oral tablet 500 mg - Tier 1

magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1

NU-IRON (brand for polysaccharide iron complex) - Tier 2

OS-CAL CALCIUM + D3 (brand for calcium + vitamin d3) - Tier 2; QL

oysco 500+d (generic for OYSCO 500+D) - Tier 1; QL

oyster shell calcium + d oral tablet 500-10 mg-mcg - 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/d oral tablet 250-6.25 mg-mcg - Tier 1

oyster shell calcium/vit d (generic for OYSCO 500+D) - Tier 1; QL

oyster shell calcium/vit d3 - Tier 1

oyster shell calcium/vit d3 oral tablet 500-5 mg-mcg (generic for

OYSCO 500+D) - Tier 1; QL

oyster shell calcium/vitamin d oral tablet 500-5 mg-mcg (generic for

OYSCO 500+D) - Tier 1; QL

oyster shell calcium-vit d - Tier 1; QL

ped electrolyte freeze pop (generic for ENFAMIL ENFALYTE) - Tier 1;

PEDIALYTE FREEZER POPS (brand for cvs electrolyte solution) -

Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

PEDIALYTE IMMUNE SUPPORT (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 ENFAMIL ENFALYTE) -

Tier 1; QL

PHOSPHA 250 NEUTRAL (brand for phosphorous) - Tier 2; QL

phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1;

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 oral solution 500-334 mg/5ml - Tier 1

TRICON (brand for ferocon) - Tier 2

TRUE FERROUS SULFATE - Tier 2; QL

TRUE MAGNESIUM OXIDE ORAL TABLET 500 MG - Tier 2

true magnesium oxide tablet 400 mg oral (generic for MAGNESIUM-

OXIDE) - Tier 1

TRUE MAGNESIUM OXIDE TABLET 400 MG ORAL (brand for ft

magnesium oxide) - Tier 2

ultra calcium + vitamin d3 - Tier 1; QL

wes-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) -

Tier 1; QL

zinc gluconate - Tier 1; QL

zinc gluconate oral tablet 50 mg - Tier 1; QL

zinc oral tablet 50 mg - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Electrolyte/Mineral/Metal Modifiers

CHEMET - Tier 2; QL

deferasirox (generic for EXJADE) - Tier 1; PA; SP; QL

deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA;

SP; QL

trientine hcl oral capsule 250 mg (generic for SYPRINE) - Tier 1; PA;

SP; QL

FERRIPROX TWICE-A-DAY - Tier 2; PA; SP; QL

JYNARQUE ORAL TABLET THERAPY PACK 15 MG - Tier 2; PA; SP;

Phosphate Binders

calcium acetate (phos binder) (generic for CALPHRON) - Tier 1; QL

calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1;

sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; ST;

AURYXIA - Tier 2; PA; QL

VELPHORO - Tier 2; PA; QL

Potassium Binders

LOKELMA - Tier 2; PA; QL

SPS - Tier 2; QL

VELTASSA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Vitamins

a-25 - Tier 1; QL

ALTRIXA (brand for daily multiple vitamins) - Tier 2

aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier

1; QL

b complex vitamins - Tier 1; QL

b complex-b12 - Tier 1

b-complex oral tablet - Tier 1

b-complex with b-12 - Tier 1

b-complex/b-12 oral - Tier 1

BPROTECTED PEDIA D-VITE (brand for aqueous vitamin d) - Tier 2;

CENTRUM SPECIALIST PRENATAL - Tier 2

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, 25 mcg (1000 ut) (generic for

PRONUTRIENTS VITAMIN D3) - Tier 1

d3 high potency oral capsule 250 mcg (10000 ut) (generic for IS-D

10,000) - Tier 1

d3 max st (generic for IS-D 10,000) - Tier 1

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 oral capsule 250 mcg (generic for IS-D 10,000) - Tier 1

d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1

d3-50 (generic for D3-50) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

daily multiple vitamins (generic for TAB-A-VITE/BETA CAROTENE) -

Tier 1

daily vitamins (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

daily vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

daily vites (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

daily-vite (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

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 800 ORAL TABLET (brand for full spectrum b/vitamin c) -

Tier 2; QL

DIALYVITE VITAMIN D 5000 (brand for cvs d3) - Tier 2

D-VI-SOL (brand for aqueous vitamin d) - Tier 2; QL

d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1;

ENFAMIL EXPECTA - Tier 2; QL

essential one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier

essentials (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

FOLCYTEINE (brand for daily multiple vitamins) - Tier 2

ft vitamin d3 oral tablet (generic for THERA-D 2000) - Tier 1; QL

full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; QL

healthy hair/skin/nails (generic for TAB-A-VITE/BETA CAROTENE) -

Tier 1

M-NATAL PLUS (brand for prenatal) - Tier 2; QL

multi vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

multi vitamin w/d-3 (generic for TAB-A-VITE/BETA CAROTENE) - Tier

multiple vitamin-folic acid (generic for TAB-A-VITE/BETA CAROTENE)

- Tier 1

multiple vitamins essential (generic for TAB-A-VITE/BETA

CAROTENE) - Tier 1

multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

multivitamin w/fluoride (generic for MULTI-VIT-FLOR) - Tier 1; QL

multi-vitamin/fluoride (generic for FLORIVA PLUS) - Tier 1; QL

multivitamin/fluoride oral tablet chewable (generic for MULTI-VIT-

FLOR) - 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

NEOMULTIVITE (brand for daily multiple vitamins) - Tier 2

NEONATAL PLUS (brand for prenatal) - Tier 2; QL

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 1000 mg - Tier 1

niacin er oral tablet extended release 250 mg, 500 mg (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

OBSTETRIX DHA - Tier 2; QL

once daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

one daily (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

ONE DAILY ESSENTIALS (brand for daily multiple vitamins) - Tier 2

ONE VITE DAILY MULTIVITAMIN (brand for daily multiple vitamins) -

Tier 2

ONE VITE WOMENS - Tier 2; QL

ONE VITE WOMENS PLUS (brand for prenatal) - Tier 2; QL

one-daily multi vitamins (generic for TAB-A-VITE/BETA CAROTENE) -

Tier 1

one-daily multi-vitamin (generic for TAB-A-VITE/BETA CAROTENE) -

Tier 1

phytonadione oral - Tier 1; QL

prenatal 19 oral tablet - Tier 1; QL

prenatal formula - Tier 1

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;

prenatal oral tablet 28-0.8 mg - Tier 1; QL

prenatal vitamins - Tier 1; QL

prenatal/iron - Tier 1; 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

radiance platinum vitamin d3 (generic for RADIANCE PLATINUM

VITAMIN D3) - Tier 1

RENAL (brand for triphrocaps) - Tier 2

rena-vite (generic for DIALYVITE 800) - Tier 1; QL

SE-NATAL 19 ORAL TABLET - Tier 2; QL

SLO-NIACIN (brand for niacin er) - Tier 2

stress formula (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

STUART ONE - Tier 2

tab-a-vite/beta carotene (generic for TAB-A-VITE/BETA CAROTENE) -

Tier 1

THERA (brand for daily multiple vitamins) - Tier 2

thera-tabs (generic for TAB-A-VITE/BETA CAROTENE) - Tier 1

thiamine mononitrate oral - Tier 1; QL

THRIVITE RX - Tier 2; QL

triphrocaps (generic for MYNEPHRON) - Tier 1

tri-vite pediatric - Tier 1; QL

TRUE DAILY VITE (brand for daily multiple vitamins) - Tier 2

TRUE MULTIVITAMIN (brand for daily multiple vitamins) - Tier 2

TRUE VITAMIN A - Tier 2; QL

TRUE VITAMIN B1 ORAL TABLET 100 MG - Tier 2; QL

TRUE VITAMIN B3 ORAL TABLET 100 MG, 250 MG, 50 MG - Tier 2

TRUE VITAMIN D3 ORAL CAPSULE 1.25 MG (50000 UT) (brand for

vitamin d3) - Tier 2; QL

TRUE VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT) - Tier 2; QL

TRUE VITAMIN D3 ORAL CAPSULE 125 MCG (5000 UT), 25 MCG

(1000 UT) (brand for cvs d3) - Tier 2

TRUE VITAMIN D3 ORAL CAPSULE 250 MCG (10000 UT) - Tier 2

TRUE VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

TRUE VITAMIN D3 ORAL TABLET 125 MCG (5000 UT) (brand for

vitamin d3) - Tier 2

TRUE VITAMIN D3 ORAL TABLET 25 MCG (1000 UT) - Tier 2

virt-caps (generic for MYNEPHRON) - Tier 1

vitachew vitamin d3 (generic for KIDS FIRST VITAMIN D3 GUMMIES)

- Tier 1

vitamin a oral capsule 2400 mcg (8000 ut), 3 mg, 3 mg (10000 ut) -

Tier 1; QL

vitamin b complex oral capsule - Tier 1; QL

vitamin b complex w/b-12 - 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; QL

vitamin d oral tablet chewable 10 mcg (400 unit) - Tier 1

vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1;

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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; QL

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

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) - Tier 1

vitamin d3 oral tablet chewable 25 mcg (1000 ut) (generic for KIDS

FIRST VITAMIN D3 GUMMIES) - Tier 1

vitamin d-400 oral tablet 10 mcg (400 unit) - Tier 1; QL

vitamin-b complex - Tier 1

weekly-d (generic for D3-50) - Tier 1; QL

wescaps (generic for MYNEPHRON) - Tier 1

WESNATAL DHA COMPLETE - Tier 2; QL

WESTAB PLUS (brand for prenatal) - Tier 2; QL

womens prenatal+dha - Tier 1; 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; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Anti-Constipation Agents

constulose - Tier 1; QL

enulose - Tier 1; QL

generlac - Tier 1; QL

lactulose encephalopathy oral solution 10 gm/15ml - Tier 1; QL

lactulose oral solution - Tier 1; QL

lubiprostone (generic for AMITIZA) - Tier 1; DX2RX; ST; QL

MOTEGRITY - Tier 2; ST; QL

MOVANTIK - Tier 2; DX2RX; ST; QL

AMITIZA ORAL CAPSULE 24 MCG (brand for lubiprostone) - Tier 2;

DX2RX; ST; QL

LINZESS - Tier 2; PA; QL

RELISTOR - Tier 2; PA; QL

SYMPROIC - Tier 2; PA; QL

TRULANCE - Tier 2; DX2RX; ST; QL

Anti-Constipation AgentsOther

IBSRELA - Tier 2; PA; QL

Anti-Diarrheal Agents

anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1

diamode (generic for IMODIUM A-D) - Tier 1

diphenoxylate-atropine (generic for LOMOTIL) - Tier 1; QL

ft anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1

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

MYTESI - Tier 2; DX2RX; QL

VIBERZI - Tier 2; PA; QL

Antispasmodics, Gastrointestinal

dicyclomine hcl oral - Tier 1; QL

glycopyrrolate oral tablet 1 mg (generic for ROBINUL) - Tier 1

glycopyrrolate oral tablet 2 mg (generic for ROBINUL-FORTE) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

Gastrointestinal Agents, Other

GATTEX - Tier 2; PA; SP; QL

gavilyte-c - 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

HELIDAC THERAPY - Tier 2; QL

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

ursodiol oral capsule 300 mg - Tier 1; QL

ursodiol oral tablet (generic for URSO 250) - Tier 1

CLENPIQ - Tier 2; PA; QL

MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA; QL

OCALIVA ORAL TABLET 5 MG - Tier 2; PA; SP; QL

PLENVU - Tier 2; PA; QL

PYLERA (brand for bis subcit-metronid-tetracyc) - Tier 2; PA

SUPREP BOWEL PREP KIT (brand for na sulfate-k sulfate-mg sulf) - Tier

2; PA; QL

TALICIA - Tier 2; PA; QL

Histamine2 (H2) Receptor Antagonists

acid controller oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL

acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL

acid reducer oral tablet 200 mg (generic for TAGAMET HB 200) - Tier

cimetidine hcl - Tier 1

cimetidine oral tablet 200 mg (generic for TAGAMET HB 200) - Tier 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg - Tier 1; QL

famotidine acid reducer oral tablet 10 mg (generic for PEPCID AC) -

Tier 1; QL

famotidine oral suspension reconstituted - Tier 1; QL; AL

famotidine oral tablet (generic for MM ACID-PEP MAXIMUM

STRENGTH) - Tier 1; QL

famotidine orig st (generic for PEPCID AC) - Tier 1; QL

ft acid reducer oral tablet (generic for PEPCID AC) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier

1; QL

heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1; QL

heartburn relief oral tablet 200 mg (generic for TAGAMET HB 200) -

Tier 1

PEPCID AC (brand for acid controller) - Tier 2; QL

TAGAMET HB 200 (brand for cimetidine) - Tier 2

Protectants

misoprostol oral (generic for CYTOTEC) - Tier 1; QL

sucralfate oral suspension (generic for CARAFATE) - Tier 1; Members

10 years of age up to 65 years of age will require PA; QL

sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL

Proton Pump Inhibitors

acid reducer oral capsule delayed release 20.6 (20 base) mg - Tier 1;

esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1;

Members >= 2 years of age will require PA; QL; AL

ft acid reducer oral capsule delayed release (generic for PREVACID

24HR) - 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

lansoprazole oral tablet delayed release dispersible 15 mg (generic for

PREVACID SOLUTAB) - Tier 1; QL; AL

NEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; Members >= 2 years

of age will require PA; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

omeprazole magnesium - Tier 1; 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

PREVACID 24HR (brand for eq lansoprazole) - Tier 2; QL

Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and

Stomach Conditions

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

acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) -

Tier 1

adult 50+ probiotic (generic for FLORA VANCE) - Tier 1; QL

adult probiotic (generic for FLORA VANCE) - Tier 1; QL

advanced antacid (generic for MINTOX) - Tier 1; QL

almacone double strength (generic for ALMACONE DOUBLE

STRENGTH) - Tier 1; QL

alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for

MINTOX) - Tier 1; QL

antacid & antigas oral suspension 2400-2400-240 mg/30ml (generic

for ALMACONE DOUBLE STRENGTH) - Tier 1; QL

antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for

ALMACONE DOUBLE STRENGTH) - Tier 1; QL

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 oral suspension 400-400-40 mg/5ml (generic

for ALMACONE DOUBLE STRENGTH) - Tier 1; QL

antacid anti-gas (generic for MINTOX) - Tier 1; QL

antacid anti-gas max strength (generic for ALMACONE DOUBLE

STRENGTH) - Tier 1; QL

antacid calcium (generic for CAL-GEST ANTACID) - Tier 1

antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1

antacid extra str (generic for CVS CHEWY NOT CHALKY FLAVOR) -

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1; QL

antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier

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 oral suspension 400-400-40 mg/5ml

(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

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 regular strength oral suspension 200-200-20 mg/5ml (generic

for MINTOX) - Tier 1; QL

antacid supreme - Tier 1

antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1

antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS

ULTRA 1000) - Tier 1

antacid/antigas (generic for MINTOX) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

antacid/anti-gas max st (generic for ALMACONE DOUBLE

STRENGTH) - Tier 1; QL

antacid/anti-gas oral suspension 200-200-20 mg/5ml, 400-400-40

mg/10ml (generic for MINTOX) - Tier 1; QL

antacid/anti-gas oral suspension 400-400-40 mg/5ml (generic for

ALMACONE DOUBLE STRENGTH) - 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 oral tablet 2-125 mg (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

biotinex (generic for ABATINEX) - Tier 1

bismuth (generic for SOOTHE) - Tier 1; QL

bismuth subsalicylate oral (generic for SOOTHE) - Tier 1; QL

BOLSITOL (brand for acidophilus) - Tier 2

calcium antacid (generic for CAL-GEST ANTACID) - Tier 1

calcium antacid ex st oral tablet chewable 750 mg (generic for CVS

CHEWY NOT CHALKY FLAVOR) - Tier 1

calcium antacid extra strength (generic for CVS CHEWY NOT

CHALKY FLAVOR) - Tier 1

calcium carbonate antacid oral suspension - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

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

diarrhea (generic for SOOTHE) - Tier 1

diarrhea relief (generic for SOOTHE) - Tier 1

digestive probiotic oral capsule (generic for FLORA VANCE) - Tier 1;

digestive probiotic oral capsule 250 mg (generic for FLORASTOR) -

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

enema rectal enema 16-6 gm/133ml (generic for FLEET ENEMA) -

Tier 1

FLEET ENEMA (brand for cvs enema disposable) - Tier 2

FLEET PEDIATRIC (brand for enema pediatric) - Tier 2

FLORA VANCE (brand for cvs adult 50+ probiotic) - Tier 2; QL

floranex tablet oral (generic for FLORANEX) - Tier 1

FLORANEX TABLET ORAL (brand for cvs acidophilus probiotic) - Tier

foaming antacid oral tablet chewable 80-20 mg - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

freeze dried acidophilus (generic for ABATINEX) - Tier 1

ft antacid & antigas (generic for ALMACONE DOUBLE STRENGTH) -

Tier 1; QL

ft antacid extra strength (generic for CVS CHEWY NOT CHALKY

FLAVOR) - Tier 1

ft antacid regular strength (generic for CAL-GEST ANTACID) - Tier 1

ft anti-diarrheal/anti-gas (generic for IMODIUM MULTI-SYMPTOM

RELIEF) - Tier 1

ft enema saline (generic for FLEET ENEMA) - Tier 1

ft gas relief - Tier 1

ft gas relief extra strength (generic for GAS-X EXTRA STRENGTH) -

Tier 1

ft gas relief infants (generic for MYLICON INFANTS GAS RELIEF) -

Tier 1

ft gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) -

Tier 1

ft milk of magnesia (generic for DULCOLAX) - Tier 1

ft stomach relief oral suspension (generic for SOOTHE) - Tier 1

ft stomach relief oral tablet (generic for KAOPECTATE) - Tier 1

ft stomach relief oral tablet chewable (generic for SOOTHE) - 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

gas relief infants drops oral suspension 40 mg/0.6ml (generic for

MYLICON INFANTS GAS RELIEF) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

gas relief infants oral suspension 20 mg/0.3ml (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 125 mg (generic for GAS-X EXTRA

STRENGTH) - Tier 1

gas relief oral tablet chewable 80 mg - Tier 1

gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier

gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1

GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for eq gas relief)

- Tier 2

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 maximum strength (generic for ALMACONE DOUBLE

STRENGTH) - Tier 1; QL

geri-lanta oral suspension 200-200-20 mg/5ml (generic for MINTOX) -

Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Preferred Agents Non-Preferred Agents

geri-lanta supreme - Tier 1

geri-mox (generic for MINTOX) - Tier 1; QL

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

heartland gas relief - Tier 1

IMODIUM MULTI-SYMPTOM RELIEF (brand for eql anti-diarrheal

anti-gas) - Tier 2

infant gas relief (generic for MYLICON INFANTS GAS RELIEF) - Tier

infants gas relief (generic for MYLICON INFANTS GAS RELIEF) - Tier

intestinex (generic for ABATINEX) - Tier 1

lactobacillus oral tablet (generic for FLORANEX) - Tier 1

lacto-pectin (generic for FLORA VANCE) - Tier 1; QL

long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1

loperamide-simethicone (generic for IMODIUM MULTI-SYMPTOM

RELIEF) - Tier 1

MAALOX - Tier 2

MAALOX CHILDRENS (brand for childrens pepto) - Tier 2

MAALOX MAX ORAL SUSPENSION (brand for antacid & antigas) -

Tier 2; QL

MAALOX MULTI SYMPTOM MAX ST (brand for antacid & antigas) -

Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

mag-al plus (generic for MINTOX) - Tier 1; QL

mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier

1; QL

magnesium-aluminum-simethicone (generic for ALMACONE DOUBLE

STRENGTH) - Tier 1; QL

mega probiotic (generic for FLORA VANCE) - Tier 1; QL

meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier

1; QL

milk of magnesia (generic for DULCOLAX) - Tier 1

milk of magnesia oral suspension 1200 mg/15ml (generic for

DULCOLAX) - Tier 1

mintox maximum strength (generic for ALMACONE DOUBLE

STRENGTH) - Tier 1; QL

mintox plus - Tier 1

mood support probiotic (generic for FLORA VANCE) - Tier 1; QL

MYLICON INFANTS GAS RELIEF (brand for cvs gas relief infants) -

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

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 suspension 525 mg/15ml (generic for SOOTHE

MAXIMUM STRENGTH) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

pink bismuth oral tablet 262 mg (generic for KAOPECTATE) - Tier 1

pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier

1; QL

pink bismuth ultra str (generic for SOOTHE MAXIMUM STRENGTH) -

Tier 1

pink-bismuth (generic for SOOTHE) - Tier 1; QL

probiotic blend (generic for FLORA VANCE) - Tier 1; QL

probiotic colon care (generic for FLORA VANCE) - Tier 1; QL

probiotic complex (generic for FLORA VANCE) - Tier 1; QL

probiotic maximum strength (generic for FLORA VANCE) - Tier 1; QL

probiotic oral capsule (generic for FLORA VANCE) - Tier 1; QL

probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1

probiotic pearls ex st (generic for FLORA VANCE) - Tier 1; QL

ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier

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 FLORA VANCE) - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

soothe oral suspension (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 KAOPECTATE) - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

TEENY TUMMY GAS RELIEF DROPS (brand for cvs gas relief

infants) - Tier 2

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

ZELAC (brand for cvs adult 50+ probiotic) - Tier 2; QL

Laxatives - Bowel Treatment Drugs

clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;

ONLY powder bottle; QL

daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1

daily fiber oral powder 43 % (generic for REGULOID) - 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 43 % (generic for REGULOID) - Tier 1

fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH

TEXTURE) - Tier 1

fiber powder oral powder 43 % (generic for REGULOID) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

ft clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL

ft enema mineral oil (generic for FLEET OIL) - Tier 1

ft fiber oral powder 43 % (generic for REGULOID) - Tier 1

ft mineral oil - Tier 1

gavilax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder

bottle; QL

gentlelax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL

glycolax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL

laxaclear (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL

laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;

ONLY powder bottle; QL

METAMUCIL 4 IN 1 FIBER ORAL POWDER 43 % (brand for cvs

natural daily fiber) - Tier 2

METAMUCIL FREE & NATURAL (brand for cvs natural daily fiber) -

Tier 2

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 ft clearlax) - Tier 2; ONLY

powder bottle; QL

mm clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle;

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

natural daily fiber oral powder 43 % (generic for REGULOID) - Tier 1

natural daily fiber 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 58.6 % (generic for METAMUCIL SMOOTH

TEXTURE) - Tier 1

natural fiber supplement (generic for EVAC) - Tier 1

natural vegetable (generic for HYDROCIL) - Tier 1

natura-lax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; QL

peg 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder

bottle; QL

polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1;

ONLY powder bottle; QL

polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) -

Tier 1; ONLY powder bottle; QL

psyldex - Tier 1

purelax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder

bottle; QL

reguloid oral powder 43 % (generic for REGULOID) - Tier 1

smooth lax oral powder (generic for CLEARLAX) - Tier 1; ONLY

powder bottle; QL

sorbitol oral - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Laxatives - Drugs to treat Constipation

AVEDANA GLYCERIN (ADULT) (brand for cvs glycerin adult) - Tier 2

citroma (generic for CITROMA) - Tier 1

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

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

docusate sodium oral liquid (generic for ONELAX DOCUSATE

SODIUM) - Tier 1; QL

docusate sodium oral syrup - Tier 1

DOCUSOL MINI (brand for docusate mini) - Tier 2; QL

docuzen (generic for SENOKOT S) - Tier 1

dss (generic for COLACE) - Tier 1; QL

easy-lax plus (generic for SENOKOT 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

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

ft fiber laxative (generic for CITRUCEL) - Tier 1

ft magnesium citrate (generic for CITROMA) - Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ft senna laxative (generic for SENOKOT) - Tier 1; QL

ft senna laxatives (generic for SENOKOT) - Tier 1; QL

ft senna-s (generic for SENOKOT S) - Tier 1

ft stool softener oral capsule (generic for COLACE) - Tier 1; QL

ft stool softener oral tablet 50-8.6 mg (generic for SENOKOT S) - Tier

geri-kot (generic for SENOKOT) - Tier 1; QL

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 SENOKOT S) - Tier 1

laxative max str (generic for EX-LAX MAXIMUM STRENGTH) - 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

mm stool softener (generic for COLACE) - Tier 1; QL

mm stool softener laxative (generic for COLACE) - Tier 1; QL

natural senna laxative (generic for SENOKOT) - Tier 1; QL

natural vegetable laxative oral tablet 8.6 mg (generic for SENOKOT) -

Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ONELAX DOCUSATE SODIUM (brand for docusate sodium) - Tier 2;

ONELAX MAGNESIUM CITRATE (brand for cvs magnesium citrate) -

Tier 2

ONELAX SENNA (brand for senna) - Tier 2

p col-rite (generic for SENOKOT S) - Tier 1

PEDIA-LAX ORAL LIQUID - Tier 2

PERDIEM OVERNIGHT RELIEF (brand for laxative regular strength) -

Tier 2

sb docusate sodium/senna (generic for SENOKOT S) - Tier 1

senexon-s (generic for SENOKOT S) - Tier 1

senna lax (generic for SENOKOT) - Tier 1; QL

senna laxative (generic for SENOKOT) - Tier 1; QL

senna oral liquid (generic for ONELAX SENNA) - Tier 1

senna oral syrup (generic for ONELAX SENNA) - Tier 1

senna oral tablet (generic for SENOKOT) - Tier 1; QL

senna plus oral tablet (generic for SENOKOT S) - Tier 1

senna s (generic for SENOKOT S) - Tier 1

senna smooth (generic for SENNA SMOOTH) - Tier 1

senna-docusate sodium (generic for SENOKOT S) - Tier 1

senna-lax (generic for SENOKOT) - Tier 1; QL

senna-plus (generic for SENOKOT S) - Tier 1

senna-s oral tablet 8.6-50 mg (generic for SENOKOT S) - Tier 1

senna-tabs (generic for SENOKOT) - Tier 1; QL

senna-time (generic for SENOKOT) - Tier 1; QL

senna-time s (generic for SENOKOT S) - Tier 1

sennazon (generic for ONELAX SENNA) - Tier 1

SENOKOT (brand for cvs senna) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

SENOKOT S (brand for cvs senna plus) - Tier 2

soluble fiber therapy (generic for CITRUCEL) - Tier 1

stimulant lax plus (generic for SENOKOT S) - Tier 1

stimulant laxative (generic for SENOKOT 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

stool softener pls laxative (generic for SENOKOT S) - Tier 1

stool softener plus laxative (generic for SENOKOT S) - Tier 1

stool softener/laxative (generic for SENOKOT S) - Tier 1

stool softener/laxative oral tablet (generic for SENOKOT S) - Tier 1

vegetable lax+stool softener (generic for SENOKOT S) - Tier 1

vegetable laxative (generic for SENOKOT) - Tier 1; QL

Genetic or Enzyme or Protein Disorder: Replacement, Modifiers,

Treatment

CHOLBAM - Tier 2; PA; SP; QL

CREON - Tier 2

CYSTAGON - Tier 2; SP; QL

NITYR - Tier 2; DX2RX; SP; QL

RAVICTI - Tier 2; PA; SP; QL

sapropterin dihydrochloride (generic for JAVYGTOR) - Tier 1; DX2RX;

SP; QL

sodium phenylbutyrate oral powder (generic for BUPHENYL) - Tier 1;

DX2RX; SP; QL

STRENSIQ - Tier 2; PA; SP; QL

TEGSEDI - Tier 2; PA; SP; QL

VYNDAMAX - Tier 2; PA; SP; QL

VYNDAQEL - Tier 2; PA; SP; QL

BUPHENYL ORAL POWDER (brand for sodium phenylbutyrate) - Tier 2;

DX2RX; SP; QL

BUPHENYL ORAL TABLET (brand for sodium phenylbutyrate) - Tier 2;

PA; SP; QL

CERDELGA - Tier 2; PA; SP; QL

EVRYSDI - Tier 2; PA; SP; QL

JAVYGTOR ORAL PACKET 100 MG (brand for sapropterin

dihydrochloride) - Tier 2; DX2RX; SP; QL

ORFADIN (brand for nitisinone) - Tier 2; PA; SP; QL

PERTZYE - Tier 2; PA

PHEBURANE - Tier 2; PA; SP; QL

VIOKACE - Tier 2; PA

ZAVESCA (brand for miglustat) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-

32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000

UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT - Tier 2;

Genitourinary Agents

Antispasmodics, Urinary

oxybutynin chloride er - Tier 1; QL

oxybutynin chloride oral solution - Tier 1; QL

oxybutynin chloride oral tablet 5 mg - Tier 1; QL

OXYTROL FOR WOMEN - Tier 2; QL

solifenacin succinate (generic for VESICARE) - Tier 1; QL

tolterodine tartrate (generic for DETROL) - Tier 1; ST; QL

tolterodine tartrate er (generic for DETROL LA) - Tier 1; PA; QL

trospium chloride - Tier 1; QL

DETROL (brand for tolterodine tartrate) - Tier 2; PA; ST; QL

DETROL LA (brand for tolterodine tartrate er) - Tier 2; PA; QL

MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER - Tier 2; PA;

QL; AL

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR (brand

for mirabegron er) - Tier 2; PA; QL

TOVIAZ (brand for fesoterodine fumarate er) - Tier 2; PA; QL

VESICARE (brand for solifenacin succinate) - Tier 2; PA; QL

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL

finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL

tamsulosin hcl (generic for FLOMAX) - Tier 1; QL

terazosin hcl - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Genitourinary Agents, Other

bethanechol chloride oral - Tier 1

ELMIRON - Tier 2; DX2RX; QL

penicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1;

DX2RX; SP; QL

CUPRIMINE (brand for penicillamine) - Tier 2; PA; SP; QL

DEPEN TITRATABS (brand for penicillamine) - Tier 2; DX2RX; SP; QL

THIOLA (brand for tiopronin) - Tier 2; PA; SP; QL

THIOLA EC (brand for tiopronin) - Tier 2; PA; SP; QL

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

phenazopyridine hcl oral tablet 95 mg (generic for PHENAZO) - Tier 1

PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QL

urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1

URO-PAIN (brand for cvs urinary pain relief) - Tier 2

Glycemic Agents - Diabetic Drugs

Blood Glucose Regulators - Drugs to Regulate Blood Sugar

ZEGALOGUE - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

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

prednisolone oral solution - Tier 1; QL

prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

(generic for PEDIAPRED) - Tier 1; QL

ACTHAR - Tier 2; PA; SP; QL

CORTROPHIN - Tier 2; PA; SP; QL

EMFLAZA ORAL TABLET 6 MG (brand for deflazacort) - Tier 2; PA; SP;

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; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

CHORIONIC GONADOTROPIN INTRAMUSCULAR (brand for

chorionic gonadotropin) - Tier 2; DX2RX

desmopressin ace spray refrig - Tier 1; QL

desmopressin acetate oral (generic for DDAVP) - Tier 1; QL

desmopressin acetate spray - Tier 1; QL

EGRIFTA SV - Tier 2; DX2RX; SP; QL

INCRELEX - Tier 2; PA; SP; QL

NOCDURNA - Tier 2; PA; QL

NORDITROPIN FLEXPRO - Tier 2; PA; SP; QL

NOVAREL - Tier 2; DX2RX

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; DX2RX

GENOTROPIN - Tier 2; PA; SP; QL

GENOTROPIN MINIQUICK - Tier 2; PA; SP; QL

HUMATROPE - Tier 2; PA; SP; QL

OMNITROPE - Tier 2; PA; SP; QL

SAIZEN - Tier 2; PA; SP; QL

ZOMACTON - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -

Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -

Hormone Replacement/Modifying Drugs

OVIDREL - Tier 2; DX2RX SKYTROFA - Tier 2; PA; SP; QL

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

methergine (generic for METHERGINE) - Tier 1; QL

methylergonovine maleate oral (generic for METHERGINE) - Tier 1;

mifepristone oral tablet 300 mg (generic for KORLYM) - Tier 1; PA;

SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers)

Androgens

danazol oral - Tier 1; QL

testosterone cypionate intramuscular (generic for DEPO-

TESTOSTERONE) - Tier 1; PA; QL

testosterone enanthate intramuscular - Tier 1; PA; QL

testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) (generic

for ANDROGEL PUMP) - Tier 1; PA; QL

testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO

PUMP) - Tier 1; PA; QL

testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm

(1%) - Tier 1; PA; QL

testosterone transdermal gel 40.5 mg/2.5gm (1.62%) - Tier 1; PA

ANDRODERM - Tier 2; PA; QL

NATESTO - Tier 2; PA; QL

TESTIM (brand for testosterone) - Tier 2; PA; QL

VOGELXO (brand for testosterone) - Tier 2; PA; QL

XYOSTED - Tier 2; PA; QL

Estrogens

afirmelle (generic for AFIRMELLE) - Tier 1; QL; GE

ALORA (brand for estradiol) - Tier 2; QL

altavera (generic for ALTAVERA) - Tier 1; QL; GE

alyacen 1/35 (generic for DASETTA 1/35) - Tier 1; QL; GE

alyacen 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; GE

apri - Tier 1; QL; GE

aranelle - Tier 1; QL; GE

ashlyna (generic for ASHLYNA) - Tier 1; QL

aubra eq (generic for AFIRMELLE) - Tier 1; QL; GE

aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE

aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE

aurovela 24 fe - Tier 1; QL

aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE

aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

ACTIVELLA (brand for estradiol-norethindrone acet) - Tier 2; PA; QL

ANGELIQ - Tier 2; PA

ANNOVERA - Tier 2; PA; QL

BALCOLTRA (brand for levonorgest-eth estradiol-iron) - Tier 2; PA; QL

BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; QL

BIJUVA ORAL CAPSULE 1-100 MG - Tier 2; PA; QL

CLIMARA (brand for estradiol) - Tier 2; PA; QL

CLIMARA PRO - Tier 2; PA

COMBIPATCH - Tier 2; PA; QL

DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25

MG/1.25GM (brand for estradiol) - Tier 2; PA; QL

DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM (brand for

estradiol) - Tier 2; PA

ELESTRIN - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

aviane (generic for AFIRMELLE) - Tier 1; QL; GE

ayuna (generic for ALTAVERA) - Tier 1; QL; GE

azurette (generic for AZURETTE) - Tier 1; QL; GE

balziva (generic for BALZIVA) - Tier 1; QL; GE

blisovi 24 fe - Tier 1; QL

blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE

blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

briellyn (generic for BALZIVA) - Tier 1; QL; GE

camrese (generic for ASHLYNA) - Tier 1; QL

camrese lo (generic for CAMRESE LO) - Tier 1; QL

charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL; GE

chateal eq (generic for ALTAVERA) - Tier 1; QL; GE

cryselle-28 - Tier 1; QL; GE

cyred eq - Tier 1; QL; GE

EVAMIST - Tier 2; PA

FEMRING - Tier 2; PA; QL

LO LOESTRIN FE - Tier 2; PA; QL

MENEST - Tier 2; PA; QL

NATAZIA - Tier 2; PA; QL

NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; PA; QL; GE

PREMARIN VAGINAL - Tier 2; PA; QL

SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; QL

VAGIFEM (brand for estradiol) - Tier 2; PA; QL

VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL

YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; QL

YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; QL

dasetta 1/35 (generic for DASETTA 1/35) - Tier 1; QL; GE

dasetta 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; GE

daysee (generic for ASHLYNA) - Tier 1; QL

delyla (generic for AFIRMELLE) - Tier 1; QL; GE

DEPO-ESTRADIOL - Tier 2; QL

desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)

(generic for AZURETTE) - Tier 1; QL; GE

dotti (generic for DOTTI) - Tier 1; QL

drospirenone-ethinyl estradiol (generic for JASMIEL) - Tier 1; QL

DUAVEE - Tier 2; QL

elinest - Tier 1; QL; GE

eluryng (generic for ELURYNG) - Tier 1; QL; GE

enilloring (generic for ELURYNG) - Tier 1; QL; GE

enpresse-28 (generic for ENPRESSE-28) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

enskyce - Tier 1; QL; GE

estarylla (generic for ESTARYLLA) - Tier 1; QL; GE

estradiol oral (generic for ESTRACE) - Tier 1; QL

estradiol transdermal patch twice weekly (generic for DOTTI) - Tier 1;

estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL

estradiol vaginal (generic for ESTRACE) - Tier 1; QL

ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; QL;

etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; QL; GE

falmina (generic for AFIRMELLE) - Tier 1; QL; GE

finzala (generic for CHARLOTTE 24 FE) - Tier 1; QL; GE

hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE

hailey 24 fe - Tier 1; QL

hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE

hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

haloette (generic for ELURYNG) - Tier 1; QL; GE

iclevia (generic for ICLEVIA) - Tier 1; QL

introvale (generic for ICLEVIA) - Tier 1; QL

isibloom - Tier 1; QL; GE

jaimiess (generic for ASHLYNA) - Tier 1; QL

jasmiel (generic for JASMIEL) - Tier 1; QL

jolessa (generic for ICLEVIA) - Tier 1; QL

juleber - Tier 1; QL; GE

junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE

junel 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE

junel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30)

- Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) -

Tier 1; QL; GE

junel fe oral tablet 1-20 mg-mcg(24) - Tier 1; QL

kalliga - Tier 1; QL; GE

kariva (generic for AZURETTE) - Tier 1; QL; GE

kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; QL; GE

kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; QL; GE

kurvelo (generic for ALTAVERA) - Tier 1; QL; GE

larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE

larin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE

larin 24 fe - Tier 1; QL

larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; QL; GE

larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

leena - Tier 1; QL; GE

lessina (generic for AFIRMELLE) - Tier 1; QL; GE

levonest (generic for ENPRESSE-28) - Tier 1; QL; GE

levonorgest-eth estrad 91-day (generic for ASHLYNA) - Tier 1; QL

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for

AFIRMELLE) - Tier 1; QL; GE

levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for

ALTAVERA) - Tier 1; QL; GE

levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; QL;

levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; QL; GE

lojaimiess (generic for CAMRESE LO) - Tier 1; QL

loryna (generic for JASMIEL) - Tier 1; QL

low-ogestrel - Tier 1; QL; GE

lo-zumandimine (generic for JASMIEL) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

lutera (generic for AFIRMELLE) - Tier 1; QL; GE

lyllana (generic for DOTTI) - Tier 1; QL

marlissa (generic for ALTAVERA) - Tier 1; QL; GE

mibelas 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; QL; GE

microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; QL; GE

microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; QL; GE

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; GE

mili (generic for ESTARYLLA) - Tier 1; QL; GE

mono-linyah (generic for ESTARYLLA) - Tier 1; QL; GE

necon 0.5/35 (28) - Tier 1; QL; GE

nikki (generic for JASMIEL) - Tier 1; QL

norelgestromin-eth estradiol (generic for XULANE) - Tier 1; QL; GE

norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE

1.5/30) - Tier 1; QL; GE

norethin ace-eth estrad-fe oral tablet chewable (generic for

CHARLOTTE 24 FE) - Tier 1; QL; GE

norethindrone acet-ethinyl est (generic for AUROVELA 1.5/30) - Tier 1;

QL; GE

norethindron-ethinyl estrad-fe (generic for TILIA FE) - Tier 1; QL; GE

norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg (generic

for WYMZYA FE) - Tier 1; QL

norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; QL; GE

norgestimate-ethinyl estradiol triphasic (generic for TRI-ESTARYLLA) -

Tier 1; QL; GE

nortrel 0.5/35 (28) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

nortrel 1/35 (21) (generic for DASETTA 1/35) - Tier 1; QL; GE

nortrel 1/35 (28) (generic for DASETTA 1/35) - Tier 1; QL; GE

nortrel 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; GE

nylia 1/35 (generic for DASETTA 1/35) - Tier 1; QL; GE

nylia 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; QL; GE

nymyo (generic for ESTARYLLA) - Tier 1; QL; GE

ocella (generic for OCELLA) - Tier 1; QL

philith (generic for BALZIVA) - Tier 1; QL; GE

pimtrea (generic for AZURETTE) - Tier 1; QL; GE

portia-28 (generic for ALTAVERA) - Tier 1; QL; GE

PREMARIN ORAL - Tier 2; QL

PREMPHASE - Tier 2; QL

PREMPRO - Tier 2; QL

reclipsen - Tier 1; QL; GE

setlakin (generic for ICLEVIA) - Tier 1; QL

simliya (generic for AZURETTE) - Tier 1; QL; GE

simpesse (generic for ASHLYNA) - Tier 1; QL

sprintec 28 (generic for ESTARYLLA) - Tier 1; QL; GE

sronyx (generic for AFIRMELLE) - Tier 1; QL; GE

syeda (generic for OCELLA) - Tier 1; QL

tarina 24 fe - Tier 1; QL

tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; QL; GE

tilia fe (generic for TILIA FE) - Tier 1; QL; GE

tri-estarylla (generic for TRI-ESTARYLLA) - Tier 1; QL; GE

tri-legest fe (generic for TILIA FE) - Tier 1; QL; GE

tri-linyah (generic for TRI-ESTARYLLA) - Tier 1; QL; GE

tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE

tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

tri-mili (generic for TRI-ESTARYLLA) - Tier 1; QL; GE

tri-nymyo (generic for TRI-ESTARYLLA) - Tier 1; QL; GE

tri-sprintec (generic for TRI-ESTARYLLA) - Tier 1; QL; GE

trivora (28) (generic for ENPRESSE-28) - Tier 1; QL; GE

tri-vylibra (generic for TRI-ESTARYLLA) - Tier 1; QL; GE

tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; QL; GE

turqoz - Tier 1; QL; GE

TYBLUME - Tier 2; QL; GE

velivet - Tier 1; QL

vestura (generic for JASMIEL) - Tier 1; QL

vienva (generic for AFIRMELLE) - Tier 1; QL; GE

viorele (generic for AZURETTE) - Tier 1; QL; GE

volnea (generic for AZURETTE) - Tier 1; QL; GE

vyfemla (generic for BALZIVA) - Tier 1; QL; GE

vylibra (generic for ESTARYLLA) - Tier 1; QL; GE

wera - Tier 1; QL; GE

wymzya fe (generic for WYMZYA FE) - Tier 1; QL

xulane (generic for XULANE) - Tier 1; QL; GE

yuvafem (generic for YUVAFEM) - Tier 1; QL

zafemy (generic for XULANE) - Tier 1; QL; GE

zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; QL; GE

zumandimine (generic for OCELLA) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Progestins

camila (generic for CAMILA) - Tier 1; QL; GE

deblitane (generic for CAMILA) - Tier 1; QL; GE

ELLA - Tier 2; QL

emzahh (generic for CAMILA) - Tier 1; QL; GE

errin (generic for CAMILA) - Tier 1; QL; GE

heather (generic for CAMILA) - Tier 1; QL; GE

incassia (generic for CAMILA) - Tier 1; QL; GE

jencycla (generic for CAMILA) - Tier 1; QL; GE

lyleq (generic for CAMILA) - Tier 1; QL; GE

lyza (generic for CAMILA) - Tier 1; QL; GE

medroxyprogesterone acetate intramuscular (generic for DEPO-

PROVERA) - Tier 1; QL; GE

medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1;

DEPO-SUBQ PROVERA 104 - Tier 2; PA; QL

megestrol acetate oral suspension 40 mg/ml - 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; GE

norethindrone acetate oral - Tier 1; QL

norethindrone oral (generic for CAMILA) - Tier 1; QL; GE

norlyroc (generic for CAMILA) - Tier 1; QL; GE

progesterone oral (generic for PROMETRIUM) - Tier 1; DX2RX; QL

sharobel (generic for CAMILA) - Tier 1; QL; GE

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Hormonal Agents, Stimulant/Replacement/Modifying (Sex

Hormones/Modifiers) - Drugs to Regulate Hormones

Progestins - Hormone Replacement/Modifying Drugs

aftera (generic for AFTERA) - Tier 1; QL; GE

curae (generic for AFTERA) - Tier 1; QL; GE

econtra one-step (generic for AFTERA) - Tier 1; QL; GE

her style (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

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

ERMEZA - Tier 2; PA; QL

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG,

137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG,

88 MCG (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 (brand for niva thyroid) - Tier 2; PA; QL

Hormonal Agents, Suppressant (Adrenal)

LYSODREN - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Hormonal Agents, Suppressant (Pituitary)

cabergoline - Tier 1; QL

leuprolide acetate injection - Tier 1; PA; SP; QL

LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; QL

LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; QL

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2;

PA; SP; QL

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - 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

LUPRON DEPOT-PED (6-MONTH) - Tier 2; PA; SP; QL

octreotide acetate (generic for SANDOSTATIN) - Tier 1; SP; QL

ORILISSA - Tier 2; PA; QL

SIGNIFOR - Tier 2; PA; SP; QL

FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL

ORIAHNN - Tier 2; PA; QL

SYNAREL - Tier 2; PA

TRIPTODUR - Tier 2; PA; SP; QL

SOMAVERT - Tier 2; PA; SP; QL

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Immunological Agents

Angioedema Agents

HAEGARDA - Tier 2; PA; SP; QL

icatibant acetate (generic for SAJAZIR) - Tier 1; PA; SP; QL

RUCONEST - Tier 2; PA; SP; QL

sajazir (generic for SAJAZIR) - Tier 1; PA; SP; QL

BERINERT - Tier 2; PA; SP; QL

TAKHZYRO SUBCUTANEOUS SOLUTION - Tier 2; PA; SP; QL

TAKHZYRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150

MG/ML - Tier 2; PA; SP; QL; AL

TAKHZYRO SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 300

MG/2ML - Tier 2; PA; SP; QL

Immunological Agents, Other

COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150

MG/ML - Tier 2; PA; SP; QL

COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE

150 MG/ML, 75 MG/0.5ML - Tier 2; PA; SP; QL

COSENTYX UNOREADY - Tier 2; PA; 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

KINERET - 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; SP

OTEZLA - Tier 2; PA; SP; QL

SYNAGIS - 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 SOLUTION AUTO-INJECTOR - Tier 2;

PA; SP; 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 PEN - Tier 2; PA; SP; QL

SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;

PA; SP; QL

STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL

TALTZ - Tier 2; PA; SP; QL

XOLAIR - Tier 2; PA; SP; QL TREMFYA - Tier 2; PA; SP; QL

XELJANZ - Tier 2; PA; SP; QL

XELJANZ XR - Tier 2; PA; SP; QL

Immunostimulants

ACTIMMUNE - Tier 2; PA; SP; QL

PEGASYS - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Immunosuppressants

azathioprine oral tablet 50 mg (generic for IMURAN) - Tier 1; QL

CIMZIA (2 SYRINGE) - Tier 2; PA; SP; QL

CIMZIA VIAL KIT - Tier 2; PA; SP; QL

CIMZIA SUBCUTANEOUS PREFILLED SYRINGE KIT 6 X 200

MG/ML - Tier 2; PA; SP; QL

cyclosporine modified (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

gengraf oral capsule (generic for GENGRAF) - Tier 1; QL

leflunomide oral (generic for ARAVA) - Tier 1; QL

methotrexate sodium - Tier 1

methotrexate sodium (pf) - Tier 1

ENSPRYNG - Tier 2; PA; SP; QL

HUMIRA (2 PEN) SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.4ML,

80 MG/0.8ML - Tier 2; PA; SP; QL

HUMIRA (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE KIT 10

MG/0.1ML, 20 MG/0.2ML, 40 MG/0.4ML - Tier 2; PA; SP; QL

HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML - Tier 2;

PA; SP; QL

HUMIRA-PED<40KG CROHNS STARTER - Tier 2; PA; SP; QL

HUMIRA-PED>/=40KG CROHNS START - Tier 2; PA; SP; QL

HUMIRA-PED>/=40KG UC STARTER - Tier 2; PA; SP; QL

HUMIRA-PSORIASIS/UVEIT STARTER - Tier 2; PA; SP; QL

OTREXUP - Tier 2; PA; QL

RASUVO - Tier 2; PA; QL

SIMPONI - Tier 2; PA; SP; QL

mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL

mycophenolate sodium (generic for MYFORTIC) - Tier 1; QL

mycophenolic acid (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;

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

TREXALL - Tier 2; PA

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Vaccines

ACTHIB - Tier 2; QL

ADACEL - Tier 2; QL

BEXSERO - Tier 2; QL

BOOSTRIX - Tier 2; QL

DAPTACEL - Tier 2; QL

ENGERIX-B - Tier 2; QL

GARDASIL 9 - Tier 2; QL

HAVRIX - Tier 2; QL

HIBERIX - Tier 2; QL

INFANRIX - Tier 2; QL

IPOL - 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; QL

PENTACEL - Tier 2; QL

PREHEVBRIO - Tier 2; QL

PRIORIX - Tier 2; QL

PROQUAD - Tier 2; QL

QUADRACEL INTRAMUSCULAR SUSPENSION - Tier 2; QL

RECOMBIVAX HB - Tier 2; QL

ROTARIX - Tier 2; AL

ROTATEQ - Tier 2; QL

SHINGRIX - Tier 2; QL; AL

TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL

TENIVAC - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

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

FLUMIST 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 COVID-19 VACCINE - Tier 2; QL

PNEUMOVAX 23 - Tier 2; QL

PREVNAR 20 - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Inflammatory Bowel Disease Agents

Aminosalicylates

balsalazide disodium (generic for COLAZAL) - Tier 1; QL

mesalamine er oral capsule 0.375 gm (generic for APRISO) - Tier 1;

mesalamine oral tablet delayed release 1.2 gm (generic for LIALDA) -

Tier 1; QL

mesalamine rectal (generic for CANASA) - Tier 1; QL

SFROWASA - Tier 2; QL

sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL

APRISO (brand for mesalamine er) - 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

LIALDA (brand for mesalamine) - Tier 2; PA; QL

PENTASA (brand for mesalamine er) - Tier 2; PA; QL

Glucocorticoids

budesonide oral - Tier 1; DX2RX; QL

hydrocortisone (perianal) (generic for PREPARATION H) - Tier 1; QL

hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA)

- Tier 1; QL

PREPARATION H EXTERNAL CREAM 1 % (brand for hydrocortisone

(perianal)) - Tier 2; QL

procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL

proctosol hc (generic for PROCTO-MED HC) - Tier 1; QL

proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL

CORTIFOAM - Tier 2; PA; QL

UCERIS (brand for budesonide) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Metabolic Bone Disease Agents

alendronate sodium oral solution - Tier 1; QL

alendronate sodium oral tablet 10 mg, 35 mg - Tier 1; QL

alendronate sodium oral tablet 70 mg (generic for FOSAMAX) - Tier 1;

calcitonin (salmon) nasal - Tier 1; QL

calcitriol oral capsule (generic for ROCALTROL) - Tier 1; QL

calcitriol oral solution (generic for ROCALTROL) - Tier 1; Members >=

8 years of age will require PA; AL

cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; QL

TYMLOS - Tier 2; PA; SP; QL

ACTONEL ORAL TABLET 150 MG (brand for risedronate sodium) - Tier

2; PA

ACTONEL ORAL TABLET 35 MG (brand for risedronate sodium) - Tier 2;

PA; QL

ATELVIA (brand for risedronate sodium) - Tier 2; PA

FORTEO (brand for teriparatide) - Tier 2; PA; SP; QL

FOSAMAX (brand for alendronate sodium) - Tier 2; PA; QL

FOSAMAX PLUS D - Tier 2; PA; QL

RAYALDEE - Tier 2; PA; QL

TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION PEN-

INJECTOR 620 MCG/2.48ML - Tier 2; PA; SP; QL

Miscellaneous Therapeutic Agents

ABRYSVO - Tier 2; QL

acne control cleanser (generic for CLEARSKIN) - Tier 1

acne medication 10 external lotion - Tier 1; QL

acne medication 5 external lotion - Tier 1

acne treatment external cream 10 % (generic for CLEARSKIN) - Tier 1

ADALIMUMAB-ADBM (2 PEN) AUTO-INJECTOR KIT 40 MG/0.4ML

SUBCUTANEOUS - Tier 2; PA; SP; QL

ADALIMUMAB-ADBM (2 SYRINGE) SUBCUTANEOUS PREFILLED

SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML, 40 MG/0.4ML - Tier 2;

PA; SP; QL

ADALIMUMAB-ADBM(CD/UC/HS STRT) SUBCUTANEOUS AUTO-

INJECTOR KIT 40 MG/0.4ML - Tier 2; PA; SP; QL

ADALIMUMAB-ADBM(PS/UV STARTER) SUBCUTANEOUS AUTO-

INJECTOR KIT 40 MG/0.4ML - Tier 2; PA; SP; QL

AMJEVITA SOLUTION AUTO-INJECTOR 40 MG/0.8ML

SUBCUTANEOUS - Tier 2; PA; NDC(s) starting w/72511 Preferred w/PA;

SP; QL

AUVELITY - Tier 2; PA; ^; QL

BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier 2;

PA; QL

BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5

ML (brand for careone insulin syringe) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 1 ML, 31G X 15/64"

0.3 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

(brand for techlite insulin syringe) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES 31G X 15/64" 0.5 ML, 31G X

15/64" 1 ML (brand for global easy glide insulin syr) - Tier 2; PA; QL

BD ULTRA-FINE INSULIN SYRINGES - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ADALIMUMAB-FKJP - Tier 2; PA; SP; QL

ADALIMUMAB-FKJP (2 SYRINGE) - Tier 2; PA; SP; QL

adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE

WASH) - Tier 1

advanced acne spot treat (generic for CLEAN & CLEAR ACNE

SCRUB) - Tier 1

ALCOHOL PREP PADS PAD , 70 % (brand for alcohol prep) - Tier 2;

AMJEVITA SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40

MG/0.4ML, 80 MG/0.8ML - Tier 2; PA; SP; QL

AMJEVITA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE -

Tier 2; PA; SP; QL

AMJEVITA-PED 15KG TO <30KG - Tier 2; PA; SP; QL

ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; QL

BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM (brand for sure comfort

pen needles) - Tier 2; PA; QL

BD ULTRA-FINE PEN NEEDLES 31G X 8 MM (brand for 1st tier unifine

pentips) - Tier 2; PA; QL

EMPAVELI - Tier 2; PA; SP; QL

FYLNETRA - Tier 2; PA; SP

GUARDIAN CONNECT TRANSMITTER - Tier 2; PA; QL

GUARDIAN LINK 3 TRANSMITTER - Tier 2; PA; QL

HYFTOR - Tier 2; PA; 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 5 MM , 31G X 6 MM ,

31G X 8 MM (brand for 1st tier unifine pentips) - Tier 2; PA; QL

antibiotic (generic for BACITRAYCIN PLUS) - Tier 1; QL

antifungal (tolnaftate) (generic for TINACTIN) - Tier 1; QL

antifungal tolnaftate (generic for TINACTIN) - Tier 1; QL

AREXVY - Tier 2; QL

arthritis pain relieving - Tier 1; QL

aspirin adults (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

aspirin childrens (generic for BAYER LOW DOSE) - Tier 1; QL

aspirin ec oral tablet 325 mg (generic for MEDI-FIRST ASPIRIN) - Tier

1; QL

aspirin ec oral tablet delayed release 325 mg (generic for BAYER

ASPIRIN) - Tier 1; QL

aspirin ec oral tablet delayed release 81 mg (generic for BAYER

ASPIRIN EC LOW DOSE) - Tier 1; 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; PA; QL

INSULIN SYRINGES 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16"

0.3 ML (brand for eql insulin syringe) - Tier 2; PA; QL

INSULIN SYRINGES 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML (brand for aq

insulin syringe) - Tier 2; PA; QL

INSULIN SYRINGES 30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML, 31G X

5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (brand for techlite

insulin syringe) - Tier 2; PA; QL

INSULIN SYRINGES 30G X 5/16" 1 ML (brand for easy comfort insulin

syringe) - Tier 2; PA; QL

KRAZATI - Tier 2; PA; SP; QL

LITFULO - Tier 2; PA

OMNIPOD 5 G6 INTRO (GEN 5) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

aspirin oral tablet 325 mg (generic for MEDI-FIRST ASPIRIN) - Tier 1;

aspirin oral tablet chewable 81 mg (generic for BAYER LOW DOSE) -

Tier 1; QL

aspirin oral tablet delayed release 325 mg (generic for BAYER

ASPIRIN) - Tier 1; QL

aspirin oral tablet delayed release 81 mg (generic for BAYER ASPIRIN

EC LOW DOSE) - Tier 1; QL

ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for

aspirin) - Tier 2; QL

aspirin rectal suppository 300 mg - Tier 1

aspirin regimen (generic for BAYER ASPIRIN EC LOW DOSE) - Tier

1; QL

OMNIPOD 5 G6 PODS (GEN 5) - Tier 2; PA; QL

ORLADEYO - Tier 2; PA; SP; QL

PREZISTA ORAL TABLET 600 MG, 800 MG (brand for darunavir) - Tier

2; PA; QL

QUVIVIQ - Tier 2; PA; QL

RELYVRIO - Tier 2; PA; SP; QL

REZDIFFRA ORAL TABLET 80 MG - Tier 2; PA; SP; QL

RYALTRIS - Tier 2; PA; QL; AL

SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; PA; SP;

SOTYKTU - Tier 2; PA; SP; QL

STIMUFEND - Tier 2; PA; SP

VIVJOA - Tier 2; PA; QL

VOQUEZNA DUAL PAK - Tier 2; PA; QL

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; QL

athletes foot powder spray external aerosol powder 1 % (generic for

ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1

athletes foot relief (generic for TINACTIN) - Tier 1

AUM ALCOHOL PREP PADS (brand for alcohol prep) - Tier 2; QL

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

VTAMA - Tier 2; PA; QL

WINLEVI - Tier 2; PA; QL

XPHOZAH ORAL TABLET 20 MG - Tier 2; PA; SP; QL; AL

YONSA - Tier 2; PA; SP; QL

ZORYVE EXTERNAL CREAM - Tier 2; PA; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

BAYER LOW DOSE ORAL TABLET CHEWABLE (brand for aspirin) -

Tier 2; QL

BD ECLIPSE NEEDLE 25G X 5/8" (brand for carepoint poly hub

needle) - Tier 2; QL

BD ULTRA-FINE INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for

techlite insulin syringe) - Tier 2; QL

BD ULTRA-FINE PEN NEEDLES 31G X 5 MM (brand for 1st tier

unifine pentips) - Tier 2; QL

BENZAC AC WASH (brand for benzoyl peroxide wash) - Tier 2; QL

benzoyl peroxide external gel 2.5 % - Tier 1; QL

benzoyl peroxide external liquid (generic for MEDPURA BENZOYL

PEROXIDE) - Tier 1; QL

benzoyl peroxide wash external liquid 5 % (generic for BENZAC AC

WASH) - Tier 1; QL

BINAXNOW COVID-19 AG HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1; QL

bisacodyl laxative (generic for EX-LAX ULTRA) - Tier 1; QL

bisacodyl oral (generic for EX-LAX ULTRA) - Tier 1; QL

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

calamine external lotion - Tier 1

CALQUENCE - Tier 2; PA; SP; QL

capsaicin cream 0.025 % external (generic for DERMACINRX

PENETRAL) - Tier 1; QL

capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

CAREPOINT POLY HUB NEEDLE 25G X 5/8" (brand for carepoint

poly hub needle) - Tier 2; QL

CAREPOINT SAFETY 1ST NEEDLE 25G X 5/8" (brand for carepoint

poly hub needle) - Tier 2; QL

CARESTART COVID-19 HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

CARETOUCH HYPODERMIC NEEDLE 25G X 5/8" (brand for

carepoint poly hub needle) - Tier 2; QL

CASTIVA WARMING - Tier 2; QL

CAYA - Tier 2; QL

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; QL

CLEARDETECT COVID-19 AG HOME (brand for covid-19 at home

antigen test) - Tier 2; QL

clearskin (generic for CLEARSKIN) - Tier 1

CLINITEST RAPID COVID-19 TEST KIT IN VITRO (brand for covid-19

at home antigen test) - Tier 2; AL

CLINITEST RAPID COVID-19 TEST KIT IN VITRO (brand for covid-19

at home antigen test) - Tier 2; QL

COMIRNATY - Tier 2; QL

CONDOMS - Tier 2; QL

COOL MIST HUMIDIFER (brand for cvs cool mist humidifer) - Tier 2;

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

corn & callus remover (generic for COMPOUND W) - Tier 1

corn and callus remover (generic for COMPOUND W) - Tier 1

COVID-19 AT HOME ANTIGEN TEST (brand for covid-19 at home

antigen test) - Tier 2; AL

COVID-19 AT HOME TEST KIT (brand for covid-19 at home antigen

test) - Tier 2; AL

COVID-19 AT-HOME TEST KIT IN VITRO (brand for covid-19 at home

antigen test) - Tier 2; AL

COVID-19 AT-HOME TEST KIT IN VITRO (brand for covid-19 at home

antigen test) - Tier 2; QL

daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH)

- Tier 1

darunavir (generic for PREZISTA) - Tier 1; QL

DERMELEVE ADVANCED FORMULA - Tier 2

DERMELEVE ANTI-ITCH SCALP (brand for aluminum acetate) - Tier

DEXCOM G6 TRANSMITTER - Tier 2; PA; QL

DIATRUST COVID-19 HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

double antibiotic external ointment 500-10000 unit/gm (generic for

POLYSPORIN) - Tier 1

DROPSAFE ALCOHOL PREP (brand for alcohol prep) - Tier 2; QL

DUREX EXTRA SENSITIVE THIN DEVICE (brand for true cover) -

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

EASIVENT MASK MEDIUM (brand for breathe comfort chamber/adult)

- Tier 2; QL

EASIVENT MASK SMALL (brand for breathe comfort chamber/adult) -

Tier 2; QL

ELLUME COVID-19 HOME TEST (brand for covid-19 at home antigen

test) - Tier 2; QL

enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; QL

EX-LAX ULTRA (brand for bisacodyl) - Tier 2; QL

fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; QL

FASTEP COVID-19 ANTIGEN TEST (brand for covid-19 at home

antigen test) - Tier 2; AL

FLEET BISACODYL - Tier 2; QL

FLOWFLEX COVID-19 AG HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

folic acid oral tablet 1 mg - Tier 1; QL

folic acid oral tablet 400 mcg, 800 mcg - Tier 1

foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER

SPRAY) - Tier 1

ft antibiotic - Tier 1; QL

ft antifungal external cream 1 % (generic for TINACTIN) - Tier 1; QL

ft aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

ft aspirin low dose (generic for BAYER ASPIRIN EC LOW DOSE) -

Tier 1; QL

ft double antibiotic (generic for POLYSPORIN) - Tier 1

ft enteric coated aspirin (generic for BAYER ASPIRIN) - Tier 1; QL

ft gentle laxative (generic for THE MAGIC BULLET) - Tier 1; QL

ft laxative (generic for EX-LAX ULTRA) - Tier 1; QL

fungi-guard (generic for TINACTIN) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

gentle laxative (generic for EX-LAX ULTRA) - Tier 1; QL

gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1; QL

genuine aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

HADLIMA - Tier 2; PA; SP; QL

HADLIMA PUSHTOUCH - Tier 2; PA; SP; QL

h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1;

hydrocodone bit-homatrop mbr (generic for HYCODAN) - Tier 1; QL;

hydromet (generic for HYCODAN) - Tier 1; QL; AL

hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL

hyoscyamine sulfate oral (generic for ANASPAZ) - 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

antigen test) - Tier 2; QL

INDICAID COVID-19 RAPID TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

INSPIREASE (brand for breathe comfort chamber/adult) - Tier 2; QL

INSPIREASE RESERVOIR BAGS - Tier 2; QL

INTELISWAB COVID-19 RAPID TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

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; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) -

Tier 1; QL

LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL

liquid corn & callus rem (generic for COMPOUND W) - Tier 1

liquid wart remover (generic for COMPOUND W) - Tier 1

liquid wart remover max st (generic for COMPOUND W) - Tier 1

magnesium oxide oral tablet 400 mg - Tier 1

magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1

MAOX (brand for magnesium oxide) - Tier 2

MASK VORTEX/CHILD/FROG - Tier 2; QL

MASK VORTEX/TODDLER/LADYBUG - Tier 2; QL

medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1

medi-first aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

medique aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; QL

MEDPURA BENZOYL PEROXIDE (brand for acne medication 10) -

Tier 2; QL

mm aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1; QL

MODERNA COVID-19 VAC 6M-11Y - Tier 2; QL

MOUNJARO - Tier 2; PA; 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

OMNIFLEX DIAPHRAGM - Tier 2; QL; GE

ON/GO COVID-19 ANTIGEN TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

ON/GO ONE COVID-19 HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ONELAX (brand for bisacodyl) - Tier 2; QL

OPILL - Tier 2; QL

OVACE PLUS WASH EXTERNAL LIQUID (brand for sodium

sulfacetamide wash) - Tier 2

OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2

PANOXYL (brand for bp wash) - Tier 2

PENBRAYA - Tier 2; QL

PFIZER COVID-19 VAC-TRIS 5-11Y - Tier 2; QL

PFIZER COVID-19 VAC-TRIS 6M-4Y - Tier 2; QL

PILOT COVID-19 AT-HOME TEST (brand for covid-19 at home

antigen test) - Tier 2; AL

poly bacitracin (generic for POLYSPORIN) - Tier 1

POLYSPORIN (brand for cvs poly bacitracin) - Tier 2

PREZISTA ORAL SUSPENSION - Tier 2; QL

PREZISTA ORAL TABLET 150 MG, 75 MG - Tier 2; QL

QUICKVUE AT-HOME COVID-19 TEST (brand for covid-19 at home

antigen test) - Tier 2; QL

scalp relief external liquid 3 % (generic for SCALPICIN) - Tier 1

sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1

SPEEDY SWAB COVID-19 ANTIGEN (brand for covid-19 at home

antigen test) - Tier 2; AL

SPIKEVAX - Tier 2; QL

ST JOSEPH LOW DOSE (brand for aspirin) - Tier 2; QL

STRIVE DUAL ZONE PEAK FLOW MTR (brand for peak flow meter

universal rang) - Tier 2; QL

sulfacetamide sodium external (generic for OVACE PLUS WASH) -

Tier 1

SUNLENCA ORAL - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1;

the magic bullet (generic for THE MAGIC BULLET) - Tier 1; QL

TINACTIN EXTERNAL CREAM (brand for antifungal (tolnaftate)) - Tier

2; QL

tolnaftate antifungal external cream (generic for TINACTIN) - Tier 1;

tolnaftate external cream (generic for TINACTIN) - Tier 1; QL

tolnaftate external powder (generic for LOTRIMIN AF) - Tier 1

TRUE COVER (brand for true cover) - Tier 2; QL

TRUE FOLIC ACID ORAL TABLET 400 MCG - Tier 2

true folic acid tablet 1 mg oral - Tier 1; QL

TRUE FOLIC ACID TABLET 1 MG ORAL - Tier 2; QL

VAPORIZER WARM STEAM - Tier 2; QL

VAXELIS - Tier 2; QL

wart remover external liquid 17 % (generic for COMPOUND W) - Tier

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; QL

womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1; QL

womens laxative (generic for EX-LAX ULTRA) - Tier 1; QL

ZOSTRIX HP (brand for capsaicin) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Molecular Target Inhibitors - Chemotherapy Agents

Antineoplastics - Drugs to Treat Cancer

ALECENSA - Tier 2; PA; SP; QL

ALUNBRIG - Tier 2; PA; SP; QL

BOSULIF ORAL CAPSULE - Tier 2; SP; QL

BOSULIF ORAL TABLET - Tier 2; PA; SP; QL

BRUKINSA - Tier 2; PA; SP

CABOMETYX - 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

gefitinib (generic for IRESSA) - Tier 1; PA; SP; QL

GILOTRIF - Tier 2; PA; SP; QL

ICLUSIG - Tier 2; PA; SP; QL

GAVRETO - Tier 2; PA; SP; QL

GLEEVEC (brand for imatinib mesylate) - Tier 2; PA; SP; QL

IRESSA (brand for gefitinib) - Tier 2; PA; SP; QL

LORBRENA - Tier 2; PA; SP; QL

RETEVMO - Tier 2; PA; SP; QL

TABRECTA - Tier 2; PA; SP; QL

TAGRISSO - Tier 2; PA; SP; QL

TARCEVA (brand for erlotinib hcl) - Tier 2; PA; SP; QL

VIZIMPRO - Tier 2; PA; SP; QL

VOTRIENT (brand for pazopanib hcl) - Tier 2; PA; SP; QL

XOSPATA - 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

lapatinib ditosylate (generic for TYKERB) - Tier 1; 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

LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; QL

LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; QL

pazopanib hcl (generic for VOTRIENT) - Tier 1; PA; SP; QL

SPRYCEL - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

TASIGNA - Tier 2; PA; SP; QL

TURALIO - Tier 2; SP; QL; AL

XALKORI - Tier 2; PA; SP; QL

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

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogs

latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QL

TRAVATAN Z (brand for travoprost (bak free)) - Tier 2; PA; QL

VYZULTA - Tier 2; PA; QL

XALATAN (brand for latanoprost) - Tier 2; PA; QL

XELPROS - Tier 2; PA; QL

ZIOPTAN (brand for tafluprost (pf)) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Ophthalmic Agents, Other

altafrin (generic for ALTAFRIN) - Tier 1

atropine sulfate ophthalmic ointment - Tier 1

atropine sulfate ophthalmic solution 1 % - Tier 1; QL

bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier

1; QL

cyclopentolate hcl ophthalmic (generic for CYCLOGYL) - Tier 1; QL

CYSTARAN - Tier 2; DX2RX; SP; QL

dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL

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

phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1

CEQUA - Tier 2; PA; QL

COMBIGAN (brand for brimonidine tartrate-timolol) - 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

RESTASIS (brand for cyclosporine) - Tier 2; PA; QL

RESTASIS MULTIDOSE (brand for cyclosporine) - Tier 2; PA; QL

ROCKLATAN - Tier 2; PA; QL

TOBRADEX ST - Tier 2; PA; QL

TYRVAYA - Tier 2; PA; QL

VERKAZIA - Tier 2; PA; QL

ZYLET - Tier 2; PA; QL

sulfacetamide-prednisolone - Tier 1

TOBRADEX - Tier 2; QL

tobramycin-dexamethasone - Tier 1

XIIDRA - Tier 2; PA; QL

Ophthalmic Anti-allergy Agents

azelastine hcl ophthalmic - Tier 1; ST

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Ophthalmic Anti-Infectives

bacitracin ophthalmic - Tier 1; QL

bacitracin-polymyxin b (generic for POLYCIN) - Tier 1

ciprofloxacin hcl ophthalmic - Tier 1; QL

erythromycin ophthalmic - Tier 1; QL

gentamicin sulfate ophthalmic - Tier 1; QL

moxifloxacin hcl (2x day) - Tier 1; QL

moxifloxacin hcl ophthalmic (generic for VIGAMOX) - Tier 1; QL

neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1;

neomycin-polymyxin-gramicidin - Tier 1; QL

neo-polycin (generic for NEO-POLYCIN) - Tier 1; QL

ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL

polycin (generic for POLYCIN) - Tier 1

polymyxin b-trimethoprim - Tier 1; QL

AZASITE - Tier 2; PA; QL

BESIVANCE - Tier 2; PA; QL

VIGAMOX (brand for moxifloxacin hcl) - Tier 2; PA; QL

sulfacetamide sodium ophthalmic - Tier 1; QL

tobramycin ophthalmic - Tier 1; QL

trifluridine - Tier 1; QL

Ophthalmic Anti-inflammatories

dexamethasone sodium phosphate ophthalmic - Tier 1

diclofenac sodium ophthalmic - Tier 1; QL

fluorometholone (generic for FML LIQUIFILM) - Tier 1

flurbiprofen sodium - Tier 1; 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

prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1;

PREDNISOLONE ACETATE P-F (brand for prednisolone acetate) -

Tier 2; QL

prednisolone sodium phosphate ophthalmic - Tier 1

ACULAR LS (brand for ketorolac tromethamine) - Tier 2; PA

ACUVAIL - Tier 2; PA; QL

BROMSITE (brand for bromfenac sodium) - Tier 2; PA; QL

EYSUVIS - Tier 2; PA; QL

FLAREX - Tier 2; PA; QL

FML FORTE - Tier 2; PA; QL

ILEVRO - Tier 2; PA; QL

INVELTYS - Tier 2; PA; QL

LOTEMAX (brand for loteprednol etabonate) - Tier 2; PA; QL

LOTEMAX SM - Tier 2; PA; QL

NEVANAC - Tier 2; PA; QL

PRED FORTE (brand for prednisolone acetate) - Tier 2; PA; QL

PROLENSA (brand for bromfenac sodium) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Ophthalmic Beta-Adrenergic Blocking Agents

betaxolol hcl ophthalmic - Tier 1; QL

carteolol hcl - Tier 1

levobunolol hcl - Tier 1; QL

timolol maleate ophthalmic solution - 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

TIMOPTIC OCUDOSE (brand for timolol maleate pf) - Tier 2; PA; QL

Ophthalmic Intraocular Pressure Lowering Agents, Other

apraclonidine hcl - Tier 1; QL

brimonidine tartrate ophthalmic solution 0.15 % (generic for

ALPHAGAN P) - Tier 1; QL

brimonidine tartrate ophthalmic solution 0.2 % - Tier 1; QL

DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL

dorzolamide hcl solution 2 % ophthalmic - Tier 1; QL

methazolamide oral - Tier 1; QL

PHOSPHOLINE IODIDE - Tier 2

pilocarpine hcl ophthalmic - Tier 1

ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL

AZOPT (brand for brinzolamide) - Tier 2; PA

RHOPRESSA - Tier 2; PA; QL

SIMBRINZA - Tier 2; PA; 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 tears ophthalmic solution (generic for GENTEAL TEARS) -

Tier 1

astringent eye drops (generic for VISINE-AC) - Tier 1; QL

BIOLLE TEARS (brand for cvs lubricant eye drops (pf)) - Tier 2

BION TEARS PF (brand for cvs natural tears pf) - Tier 2

carboxymethylcellulose sodium ophthalmic solution (generic for

ULTRA FRESH) - Tier 1; QL

dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; QL

eye drops adv relief - Tier 1; QL

eye drops advanced relief - Tier 1; QL

eye drops long lasting (generic for SYSTANE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

eye irritation relief drops (generic for VISINE-AC) - Tier 1; QL

eye lubricant (generic for ALTALUBE) - Tier 1; QL

eye lubricant nighttime (generic for ALTALUBE) - Tier 1; QL

EYES ALIVE (brand for cvs lubricant eye drops (pf)) - Tier 2

for sty relief (generic for ALTALUBE) - Tier 1; QL

ft eye drops (generic for VISINE RED EYE COMFORT) - Tier 1

ft lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for

SYSTANE) - Tier 1; QL

ft lubricant eye drops ophthalmic solution 0.5 % (generic for BIOLLE

TEARS) - Tier 1

GENTEAL SEVERE - Tier 2; QL

GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) -

Tier 2

GENTEAL TEARS NIGHT-TIME (brand for cvs dry-eye relief

nighttime) - Tier 2; QL

GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.2-0.3 % (brand

for artificial tears) - Tier 2

GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2

GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; QL

HYPOTEARS (brand for cvs dry-eye relief nighttime) - Tier 2; QL

lubricant drops fast act (generic for SYSTANE) - Tier 1; QL

lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

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 eye drops (generic for BIOLLE TEARS) - Tier 1

lubricating plus ophthalmic solution 0.5 % (generic for BIOLLE

TEARS) - Tier 1

lubricating plus pf (generic for BIOLLE TEARS) - Tier 1

lubricating tears ophthalmic solution 0.4-0.3 % (generic for SYSTANE)

- Tier 1; QL

lubrifresh p.m. (generic for ALTALUBE) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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 BION TEARS PF) - Tier 1

nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; QL

nighttime relief lub eye (generic for ALTALUBE) - Tier 1; QL

polyvinyl alcohol ophthalmic - Tier 1

pure & gentle lubricant - Tier 1

REFRESH LACRI-LUBE (brand for cvs dry-eye relief nighttime) - Tier

2; QL

REFRESH PLUS (brand for cvs lubricant eye drops (pf)) - Tier 2

REFRESH TEARS (brand for carboxymethylcellulose sodium) - Tier 2;

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

SENTIA (brand for cvs lubricant drops) - Tier 2; QL

sod chloride hypertonicity (generic for ALTACHLORE) - Tier 1

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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

SYSTANE BALANCE (brand for cvs lubricant drops) - Tier 2; QL

SYSTANE COMPLETE (brand for cvs lubricant drops) - Tier 2; QL

SYSTANE CONTACTS (brand for artificial tears) - Tier 2

SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) -

Tier 2; QL

SYSTANE NIGHTTIME (brand for cvs dry-eye relief nighttime) - Tier 2;

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;

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

Ophthalmic Anti-allergy Agents - Allergy, Infection and

Inflammation Drugs

NAPHCON-A (brand for allergy eye) - Tier 2

VASOCLEAR-A - Tier 2; QL

VISINE (brand for allergy eye) - Tier 2

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

eye itch relief ophthalmic solution 0.035 % (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; QL

ciprofloxacin-dexamethasone - Tier 1; DX2RX; QL

hydrocortisone-acetic acid - Tier 1

neomycin-polymyxin-hc otic - Tier 1; QL

ofloxacin otic - Tier 1; QL

Otic Agents - Drugs to Treat Ear Conditions

Otic Agents - Drugs for the Ear

CLEARCANAL EARWAX SOFTENER (brand for cvs ear drops) - Tier

CLINERE EARWAX REMOVAL KIT OTIC SOLUTION (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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

earwax removal kit otic solution 6.5 % (generic for CLEARCANAL

EARWAX SOFTENER) - Tier 1

ft earwax removal (generic for CLEARCANAL EARWAX SOFTENER)

- Tier 1

ft earwax removal kit (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;

allergy (cetirizine) (generic for KLS ALLER-TEC) - Tier 1; QL

allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1;

allergy childrens oral liquid (generic for RA DIPHEDRYL ALLERGY) -

Tier 1; QL

allergy medication (generic for BANOPHEN) - Tier 1; QL

allergy medicine (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

DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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;

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;

allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1; QL

allergy relief oral liquid 25 mg/10ml (generic for RA DIPHEDRYL

ALLERGY) - 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 solution 0.1 %, 137 mcg/spray - 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 ORAL LIQUID (brand for allergy

childrens) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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;

cetirizine allergy relief (generic for KLS ALLER-TEC) - 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 - Tier 1; QL

complete allergy (generic for BANOPHEN) - Tier 1; QL

complete allergy medicine (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

CURELIEF (brand for allergy childrens) - Tier 2; QL

cyproheptadine hcl oral - Tier 1; QL

DAYHIST ALLERGY 12 HOUR RELIEF - Tier 2; QL

diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

diphen (generic for BANOPHEN) - Tier 1; QL

diphenhydramine hcl childrens (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

diphenhydramine hcl oral (generic for BANOPHEN) - Tier 1; QL

ft all day allergy (generic for KLS ALLER-TEC) - Tier 1; QL

ft all day allergy 24 hour (generic for KLS ALLER-TEC) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ft allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; QL

ft allergy relief childrens oral liquid (generic for RA DIPHEDRYL

ALLERGY) - Tier 1; QL

ft allergy relief oral capsule (generic for BANOPHEN) - Tier 1; QL

ft allergy relief oral tablet 25 mg (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

levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY

24HR) - Tier 1; QL

liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1;

MAXALLERGY KIDS (brand for allergy childrens) - Tier 2; QL

m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; QL

MM ALLER-BEN (brand for allergy relief) - Tier 2; QL

NARAMIN (brand for allergy childrens) - Tier 2; 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;

ZYRTEC ALLERGY ORAL TABLET (brand for all day allergy) - Tier 2;

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Anti-inflammatories, Inhaled Corticosteroids

ASMANEX (120 METERED DOSES) - Tier 2; PA; QL

ASMANEX (14 METERED DOSES) - Tier 2; PA; QL

ASMANEX (30 METERED DOSES) - Tier 2; PA; QL

ASMANEX (60 METERED DOSES) - Tier 2; PA; QL

ASMANEX HFA - Tier 2; PA; Members >= 8 years of age will require

PA; QL

budesonide inhalation (generic for PULMICORT) - Tier 1; Members >=

5 years of age will require PA; QL; AL

FLUTICASONE PROPIONATE HFA - Tier 2; QL

fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL

ALVESCO - Tier 2; PA

ARNUITY ELLIPTA - Tier 2; PA; QL

OMNARIS - Tier 2; PA; QL

PULMICORT FLEXHALER - Tier 2; PA; QL

PULMICORT SUSPENSION (brand for budesonide) - Tier 2; PA;

Members >= 5 years of age will require PA; QL; AL

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

ACCOLATE (brand for zafirlukast) - Tier 2; PA; QL

SINGULAIR (brand for montelukast sodium) - Tier 2; PA; QL

zafirlukast (generic for ACCOLATE) - Tier 1; PA; QL

ZYFLO - Tier 2; PA

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 (brand for tiotropium bromide monohydrate) -

Tier 2; PA; QL

SPIRIVA RESPIMAT - Tier 2; PA; QL

YUPELRI - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Bronchodilators, Sympathomimetic

albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation

(generic for PROVENTIL HFA) - Tier 1; QL

ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE)

MCG/ACT INHALATION (brand for albuterol sulfate hfa) - Tier 2; QL

albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%,

2.5 mg/0.5ml - Tier 1; QL

albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25

mg/3ml - Tier 1; Members >= 8 years of age will require PA; QL; AL

albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier

1; QL

ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5%

INHALATION - Tier 2; QL

albuterol sulfate oral syrup - Tier 1; QL

AUVI-Q (brand for epinephrine) - Tier 2; PA; QL

EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL

EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL

PERFOROMIST (brand for formoterol fumarate) - Tier 2; PA; QL

PROAIR RESPICLICK - Tier 2; PA; QL

PROVENTIL HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL

SEREVENT DISKUS - Tier 2; PA; QL

VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; PA; QL

XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL

epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier

1; QL

levalbuterol hcl inhalation - Tier 1; ST; QL

STRIVERDI RESPIMAT - Tier 2; QL

Cystic Fibrosis Agents

CAYSTON - Tier 2; DX2RX; SP; QL

KALYDECO - Tier 2; PA; SP; QL

ORKAMBI - Tier 2; PA; SP; QL

PULMOZYME - Tier 2; DX2RX; SP; QL

SYMDEKO - Tier 2; PA; SP; QL

tobramycin inhalation nebulization solution 300 mg/4ml (generic for

BETHKIS) - Tier 1; DX2RX; SP; QL

TRIKAFTA ORAL TABLET THERAPY PACK - Tier 2; PA; SP; QL

TRIKAFTA ORAL THERAPY PACK - Tier 2; PA; SP; QL; AL

BETHKIS (brand for tobramycin) - Tier 2; DX2RX; SP; QL

TOBI PODHALER - Tier 2; PA; SP; QL

Mast Cell Stabilizers

cromolyn sodium inhalation - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Phosphodiesterase Inhibitors, Airways Disease

elixophyllin (generic for ELIXOPHYLLIN) - Tier 1; QL

THEO-24 - Tier 2

theophylline er oral tablet extended release 12 hour 100 mg, 200 mg,

300 mg - Tier 1; QL

theophylline er oral tablet extended release 12 hour 450 mg - Tier 1

theophylline er oral tablet extended release 24 hour 400 mg - Tier 1;

theophylline er oral tablet extended release 24 hour 600 mg - Tier 1

theophylline oral (generic for ELIXOPHYLLIN) - Tier 1; QL

Pulmonary Antihypertensives

ADEMPAS - Tier 2; DX2RX; SP; QL

ambrisentan (generic for LETAIRIS) - Tier 1; DX2RX; SP; QL

bosentan (generic for TRACLEER) - Tier 1; DX2RX; SP; QL

OPSUMIT - Tier 2; DX2RX; SP; QL

sildenafil citrate oral suspension reconstituted (generic for REVATIO) -

Tier 1; DX2RX; SP; QL

sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1;

DX2RX; SP; QL

ADCIRCA (brand for tadalafil (pah)) - Tier 2; PA; SP; QL

LETAIRIS (brand for ambrisentan) - Tier 2; DX2RX; SP; QL

ORENITRAM - Tier 2; PA; SP; QL

ORENITRAM MONTH 1 - Tier 2; PA; SP; QL; AL

ORENITRAM MONTH 2 - Tier 2; PA; SP; QL; AL

ORENITRAM MONTH 3 - Tier 2; PA; SP; QL; AL

REVATIO ORAL (brand for sildenafil citrate) - Tier 2; DX2RX; SP; QL

tadalafil (pah) (generic for ADCIRCA) - Tier 1; PA; SP; QL

TADLIQ - Tier 2; PA; SP; QL

TRACLEER (brand for bosentan) - Tier 2; DX2RX; SP; QL

TYVASO DPI MAINTENANCE KIT - Tier 2; PA; SP; QL

TYVASO DPI TITRATION KIT - Tier 2; PA; SP; QL

UPTRAVI ORAL - Tier 2; PA; SP; QL

Pulmonary Fibrosis Agents

OFEV - Tier 2; PA; SP; QL

pirfenidone oral capsule (generic for ESBRIET) - Tier 1; PA; SP; QL

pirfenidone oral tablet 267 mg, 801 mg (generic for ESBRIET) - Tier 1;

PA; SP; QL

ESBRIET (brand for pirfenidone) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Respiratory Tract Agents, Other

acetylcysteine inhalation solution 10 % - Tier 1; QL

acetylcysteine inhalation solution 20 % - Tier 1

FASENRA PEN - Tier 2; PA; SP; QL

NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;

PA; SP; QL

NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier

2; PA; SP; QL

promethazine vc - Tier 1; QL; AL

TEZSPIRE SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;

PA; SP; QL

Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,

Cough, Cold and Lung Conditions

4-WAY FAST ACTING (brand for cvs nasal spray) - Tier 2

4-WAY MENTHOL (brand for cvs nasal spray) - 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 TUSNEL-EX) - Tier 1; QL; AL

AYR (brand for altamist spray) - Tier 2

AYR NASAL MIST ALLERGY/SINUS - Tier 2

AYR SALINE NASAL DROPS - Tier 2

BABY AYR SALINE (brand for altamist spray) - Tier 2

BROMFED DM (brand for pseudoeph-bromphen-dm) - Tier 2; QL; AL

BUCKLEYS CHEST CONGESTION (brand for altarussin) - Tier 2; QL;

chest congestion relief oral liquid (generic for TUSNEL-EX) - Tier 1;

QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

chest congestion relief oral tablet (generic for XPECT) - Tier 1

CORICIDIN HBP COUGH/COLD (brand for cough & cold) - Tier 2; AL

cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1;

cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier

1; AL

cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH

LONG ACTING) - Tier 1; AL

cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1;

deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier

ed bron gp - Tier 1; AL

ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1

ft chest congestion relief (generic for XPECT) - Tier 1

ft mucus relief 12hr oral tablet extended release 12 hour 1200 mg

(generic for EQ MUCUS ER) - Tier 1; QL; AL

ft nasal decongestant pe (generic for SUDAFED PE SINUS

CONGESTION) - Tier 1

ft tussin adult (generic for TUSNEL-EX) - Tier 1; QL; AL

geri-tussin oral liquid (generic for TUSNEL-EX) - Tier 1; QL; AL

guaifenesin er oral tablet extended release 12 hour 1200 mg (generic

for EQ MUCUS ER) - Tier 1; QL; AL

guaifenesin oral liquid (generic for TUSNEL-EX) - Tier 1; QL; AL

guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1

MAX TUSSIN MUCUS & CHEST CONG (brand for altarussin) - Tier 2;

QL; AL

maxi-tuss pe max - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

medifin 400 (generic for XPECT) - Tier 1

medifin mucus relief child (generic for TUSNEL-EX) - Tier 1; QL; AL

MUCINEX FAST-MAX CHEST CONG MS (brand for altarussin) - Tier

2; QL; AL

MUCINEX MAXIMUM STRENGTH (brand for cvs mucus extended

release) - Tier 2; QL; AL

mucus & chest congestion (generic for TUSNEL-EX) - Tier 1; QL; AL

mucus er maximum str (generic for EQ MUCUS ER) - Tier 1; QL; AL

mucus er oral tablet extended release 12 hour 1200 mg (generic for

EQ MUCUS ER) - Tier 1; QL; AL

mucus extended release oral tablet extended release 12 hour 1200 mg

(generic for EQ MUCUS ER) - Tier 1; QL; AL

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

mucus relief childrens oral liquid 100 mg/5ml (generic for TUSNEL-EX)

- Tier 1; QL; AL

mucus relief er (generic for EQ MUCUS ER) - Tier 1; QL; AL

mucus relief er oral tablet extended release 12 hour 1200 mg (generic

for EQ MUCUS ER) - Tier 1; QL; AL

mucus relief max st (generic for EQ MUCUS ER) - Tier 1; QL; AL

mucus relief max strength oral tablet extended release 12 hour 1200

mg (generic for EQ MUCUS ER) - Tier 1; QL; AL

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; AL

mucus+chest congestion (generic for TUSNEL-EX) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

mucus-er oral tablet extended release 12 hour 1200 mg (generic for

EQ MUCUS ER) - Tier 1; QL; AL

nasal decongestant pe max st (generic for SUDAFED PE SINUS

CONGESTION) - Tier 1

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 nasal solution 1 % (generic for 4-WAY FAST ACTING) -

Tier 1

nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1

NEO-SYNEPHRINE COLD/ALLRG MILD - Tier 2

NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for cvs nasal spray) -

Tier 2

NEO-SYNEPHRINE COLD/ALLRGY REG - Tier 2

non-pseudo sinus decongestant (generic for SUDAFED PE SINUS

CONGESTION) - Tier 1

nose drops extstrength (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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

pseudoephedrine-bromphen-dm (generic for BROMFED DM) - Tier 1;

QL; AL

refenesen 400 (generic for XPECT) - Tier 1

ROBITUSSIN CHILD COUGH/COLD LA - Tier 2; AL

ROBITUSSIN CHILDRENS COUGH LA - Tier 2; AL

ROBITUSSIN NIGHTTIME COUGH - Tier 2; AL

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 TUSNEL-EX) - Tier 1; QL; AL

sinus pe decongestant (generic for SUDAFED PE SINUS

CONGESTION) - 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

SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for cvs

sinus pe decongestant) - Tier 2

SUDAFED PE SINUS CONGESTION (brand for cvs sinus pe

decongestant) - Tier 2

tab tussin (generic for XPECT) - Tier 1

TRUE NASAL MOISTURIZING (brand for altamist spray) - Tier 2

tusnel-ex (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin adult chest congest (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin chest congestion oral liquid 100 mg/5ml (generic for TUSNEL-

EX) - Tier 1; QL; AL

tussin cough long acting (generic for WAL-TUSSIN COUGH LONG

ACTING) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

tussin cough oral syrup (generic for WAL-TUSSIN COUGH LONG

ACTING) - Tier 1; AL

tussin expectorant adult (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin maximum strength oral syrup 15 mg/5ml (generic for WAL-

TUSSIN COUGH LONG ACTING) - Tier 1; AL

tussin mucus & chest cong (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus & chest congest (generic for TUSNEL-EX) - Tier 1; QL;

tussin mucus/chest congest (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus/congestion (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus+chest congest (generic for TUSNEL-EX) - Tier 1; QL; AL

tussin mucus+chest congestion (generic for TUSNEL-EX) - Tier 1; QL;

tussin oral liquid 100 mg/5ml (generic for TUSNEL-EX) - Tier 1; QL; AL

XPECT (brand for chest congestion relief) - Tier 2

Antihistamines - Allergy Drugs

12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

all day allergy-d oral tablet extended release 12 hour 5-120 mg

(generic for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief d oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief/nasal decongest oral tablet extended release 12 hour

(generic for KLS ALLER-TEC D) - Tier 1; QL; AL

allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLER-TEC D) - Tier 1; QL; AL

aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier

1; QL; AL

desgen dm oral liquid (generic for DESGEN DM) - Tier 1; AL

ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; QL; AL

ft all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; QL; AL

ft tussin cf adult (generic for DESGEN DM) - Tier 1; AL

nohist-lq (generic for ED A-HIST) - Tier 1; QL; AL

ROBAFEN CF MULTI-SYMPTOM COLD (brand for ft tussin cf adult) -

Tier 2; AL

ROBITUSSIN PEAK COLD MULTI-SYM (brand for ft tussin cf adult) -

Tier 2; AL

tussin cf oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier

1; AL

tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; AL

ZYRTEC-D ALLERGY & CONGESTION (brand for 12 hour allergy-d) -

Tier 2; QL; AL

ZYRTEC-D ALLERGY & SINUS (brand for 12 hour allergy-d) - Tier 2;

QL; AL

Antihistamines - Drugs to Treat Allergies

12hr allergy relief (generic for ALLEGRA ALLERGY) - Tier 1; QL

24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; QL

all day allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR)

- Tier 1; QL

ALLEGRA ALLERGY (brand for 12hr allergy relief) - Tier 2; QL

ALLEGRA HIVES 24HR (brand for 24hr allergy relief) - Tier 2; QL

allerclear (generic for KLS ALLERCLEAR) - Tier 1; QL

aller-ease oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1;

aller-fex (generic for KLS ALLER-FEX) - Tier 1; QL

allerg rel child (lorat) (generic for CLARITIN ALLERGY CHILDRENS) -

Tier 1; QL

allerg relief child (lorat) (generic for CLARITIN ALLERGY

CHILDRENS) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; QL

allergy childrens oral solution (generic for CLARITIN ALLERGY

CHILDRENS) - Tier 1; QL

allergy rel child (loratadine) (generic for CLARITIN ALLERGY

CHILDRENS) - Tier 1; QL

allergy relief (loratadine) oral tablet (generic for KLS ALLERCLEAR) -

Tier 1; QL

allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) -

Tier 1; QL

allergy relief childrens oral solution 5 mg/5ml (generic for CLARITIN

ALLERGY CHILDRENS) - Tier 1; QL

allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier

1; QL

allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1;

allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - 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

allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS

ALLER-FEX) - Tier 1; QL

childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) -

Tier 1; QL

chlorpheniramine maleate er (generic for CHLOR-TRIMETON

ALLERGY) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand

for cvs allergy relief) - Tier 2; QL

ed chlorped jr (generic for DIABETIC TUSSIN ALLERGY) - Tier 1; QL

fexofenadine hcl (generic for ALLEGRA ALLERGY) - Tier 1; QL

fexofenadine hcl oral (generic for ALLEGRA ALLERGY) - Tier 1; QL

ft all day allergy relief (generic for KLS ALLERCLEAR) - Tier 1; QL

ft allergy childrens (generic for CLARITIN ALLERGY CHILDRENS) -

Tier 1; QL

ft allergy relief 12 hour (generic for ALLEGRA ALLERGY) - Tier 1; QL

ft allergy relief 24 hour (generic for KLS ALLER-FEX) - Tier 1; QL

ft allergy relief loratadine (generic for KLS ALLERCLEAR) - Tier 1; QL

ft allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - 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 (generic for CLARITIN ALLERGY

CHILDRENS) - Tier 1; QL

loratadine oral solution (generic for CLARITIN ALLERGY

CHILDRENS) - Tier 1; QL

loratadine oral tablet (generic for KLS ALLERCLEAR) - Tier 1; QL

loratadine oral tablet dispersible (generic for CLARITIN REDITABS) -

Tier 1; QL

mm allergy relief 24 hour (generic for KLS ALLER-FEX) - Tier 1; QL

TRIAMINIC ALLERCHEWS (brand for cvs allergy relief) - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung

Drugs

24 hour nasal allergy (generic for NASACORT ALLERGY 24HR) - Tier

1; QL

allergy spray 24 hour nasal aerosol (generic for NASACORT

ALLERGY 24HR) - Tier 1; QL

ft 24 hour nasal allergy (generic for NASACORT ALLERGY 24HR) -

Tier 1; QL

NASACORT ALLERGY 24HR (brand for allergy spray 24 hour) - Tier

2; QL

nasal allergy 24 hour (generic for NASACORT ALLERGY 24HR) - Tier

1; QL

nasal allergy nasal aerosol 55 mcg/act (generic for NASACORT

ALLERGY 24HR) - Tier 1; QL

nasal allergy spray (generic for NASACORT ALLERGY 24HR) - Tier 1;

triamcinolone acetonide nasal (generic for NASACORT ALLERGY

24HR) - Tier 1; QL

Bronchodilators, Sympathomimetic - Asthma/Lung Drugs

ANORO ELLIPTA - Tier 2; QL

breyna (generic for BREYNA) - Tier 1; PA; QL

budesonide-formoterol fumarate (generic for BREYNA) - Tier 1; PA;

ST; QL

COMBIVENT RESPIMAT - Tier 2; QL

FLUTICASONE FUROATE-VILANTEROL (brand for fluticasone

furoate-vilanterol) - Tier 2; PA; QL

fluticasone-salmeterol inhalation aerosol powder breath activated 100-

50 mcg/act, 250-50 mcg/act, 500-50 mcg/act (generic for WIXELA

INHUB) - Tier 1; QL

FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER

BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14

MCG/ACT - Tier 2; QL

ipratropium-albuterol - Tier 1; QL

ADVAIR DISKUS (brand for fluticasone-salmeterol) - Tier 2; PA; QL

ADVAIR HFA (brand for fluticasone-salmeterol) - Tier 2; PA; QL

BEVESPI AEROSPHERE - Tier 2; PA; QL

BREO ELLIPTA INHALATION AEROSOL POWDER BREATH

ACTIVATED 100-25 MCG/ACT, 200-25 MCG/ACT (brand for fluticasone

furoate-vilanterol) - Tier 2; PA; QL

BREZTRI AEROSPHERE - Tier 2; PA; QL

DUAKLIR PRESSAIR - Tier 2; PA; QL

DULERA - Tier 2; PA; QL

SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA; QL

TRELEGY ELLIPTA - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

STIOLTO RESPIMAT - Tier 2; QL

wixela inhub (generic for WIXELA INHUB) - Tier 1; 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

ADVIL COLD/SINUS (brand for cold & sinus) - Tier 2; AL

AFRIN NODRIP ORIGINAL (brand for 12 hour decongestant) - Tier 2

allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1; QL;

allerclear d-24hr (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

allergy & congestion oral tablet extended release 24 hour 10-240 mg

(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

allergy & congestion relief (generic for KLS ALLERCLEAR D-12HR) -

Tier 1; QL; AL

allergy nasal mist no drip (generic for GILTUSS SEVERE SINUS) -

Tier 1

allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

QL; AL

allergy relief d-24 (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

allergy relief nasal decong (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

allergy relief/nasal decong (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

allergy relief/nasal decongest oral tablet extended release 24 hour

(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; QL; AL

allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic

for KLS ALLERCLEAR D-12HR) - Tier 1; QL; AL

allergy relief-d oral tablet extended release 24 hour 10-240 mg

(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; QL; AL

allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

QL; AL

allergy/congestion relief (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1;

QL; AL

altarussin-pe - Tier 1; AL

anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1

APRODINE (brand for cold & allergy d) - Tier 2; AL

benzonatate oral capsule 100 mg, 200 mg - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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; AL

childrens cold & allergy - Tier 1; AL

childrens cough (generic for DELSYM CGH/CHEST CONG DM

CHILD) - Tier 1

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; AL

CLARITIN-D 24 HOUR (brand for allergy relief d-24) - Tier 2; QL; AL

cold & allergy - Tier 1; AL

cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; AL

cold & cough childrens oral liquid 1-5-2.5 mg/5ml, 2.5-1-5 mg/5ml

(generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL

cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1; AL

cold & sinus relief oral tablet 30-200 mg (generic for ADVIL

COLD/SINUS) - Tier 1; AL

cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL;

cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) -

Tier 1; QL; AL

cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for

DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL

cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM

COLD/COUGH) - Tier 1; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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 childrens (generic for DELSYM) - Tier 1; QL; AL

cough dm er (generic for DELSYM) - Tier 1; QL; AL

cough dm oral suspension extended release 30 mg/5ml (generic for

DELSYM) - Tier 1; QL; AL

DELSYM CGH/CHEST CONG DM CHILD (brand for childrens cough)

- Tier 2

DELSYM COUGH CHILDRENS (brand for cough dm) - Tier 2; QL; AL

DELSYM COUGH/CHEST CONGEST DM (brand for childrens cough)

- Tier 2

DELSYM ORAL SUSPENSION EXTENDED RELEASE (brand for

cough dm) - Tier 2; QL; AL

dextromethorphan polistirex er (generic for DELSYM) - Tier 1; QL; AL

dextromethorphan-guaifenesin oral liquid 5-100 mg/5ml (generic for

DELSYM CGH/CHEST CONG DM CHILD) - Tier 1

dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM

COUGH CLEAR) - Tier 1; QL; AL

dibromm childrens cold/cgh (generic for DIMAPHEN DM

COLD/COUGH) - Tier 1; QL; AL

dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH)

- Tier 1; QL; AL

dm maximum adult (generic for DELSYM CGH/CHEST CONG DM

CHILD) - Tier 1

ENDACOF-DM (brand for cold & cough childrens) - Tier 2; QL; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ft 12 hour cough relief (generic for DELSYM) - Tier 1; QL; AL

ft allergy d-12 hour (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

QL; AL

ft allergy relief-d (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

ft cold & cough relief dm (generic for DIMAPHEN DM COLD/COUGH)

- Tier 1; QL; AL

ft mucus relief d 12 hour (generic for MUCINEX D) - Tier 1; AL

ft mucus relief dm oral tablet extended release 12 hour 30-600 mg

(generic for MUCINEX DM) - Tier 1; QL; AL

ft nasal decongestant max str oral tablet (generic for SUDOGEST) -

Tier 1; QL

ft nasal decongestant max str oral tablet extended release 12 hour

(generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1

ft nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1

ft tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM

CHILD) - Tier 1

g tussin ac - Tier 1; QL; AL

geri-tussin dm oral syrup (generic for ROBAFEN DM COUGH CLEAR)

- Tier 1; QL; AL

giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1

guaifenesin-codeine - Tier 1; QL; AL

guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH

CLEAR) - Tier 1; QL; AL

HYPERSAL INHALATION NEBULIZATION SOLUTION 7 % (brand for

sodium chloride) - Tier 2

ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL

COLD/SINUS) - Tier 1; AL

ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL

COLD/SINUS) - Tier 1; AL

long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier

long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier

lorata-d (generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier

1; QL; AL

lorata-dine d (generic for EQ ALLERGY RELIEF NASAL DECONG) -

Tier 1; QL; AL

loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

QL; AL

loratadine-d (generic for EQ ALLERGY RELIEF NASAL DECONG) -

Tier 1; QL; AL

loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1;

QL; AL

loratadine-d 24hr (generic for EQ ALLERGY RELIEF NASAL

DECONG) - Tier 1; QL; AL

maxi-tuss ac - Tier 1; QL; AL

maxi-tuss gmx (generic for DIABETIC TUSSIN DM MAX ST) - Tier 1;

meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier

1; QL; AL

MUCINEX COUGH CHILDRENS (brand for childrens cough) - Tier 2

MUCINEX D (brand for cvs mucus d extended release) - Tier 2; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

MUCINEX D MAX STRENGTH (brand for cvs mucus d max st er) -

Tier 2; AL

MUCINEX DM (brand for cvs mucus dm extended release) - Tier 2;

QL; AL

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 d (generic for MUCINEX D MAX STRENGTH) - Tier 1; AL

mucus d extended release (generic for MUCINEX D) - Tier 1; AL

mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier

1; AL

mucus dm (generic for MUCINEX DM) - Tier 1; QL; AL

mucus dm extended release oral tablet extended release 12 hour 30-

600 mg (generic for MUCINEX DM) - Tier 1; QL; AL

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; AL

mucus relief d oral tablet extended release 12 hour 120-1200 mg

(generic for MUCINEX D MAX STRENGTH) - Tier 1; AL

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

(generic for MUCINEX D) - Tier 1; AL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

mucus relief dm max oral liquid 20-400 mg/20ml, 5-100 mg/5ml

(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; AL

mucus-dm (generic for MUCINEX DM) - Tier 1; QL; AL

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 pe oral tablet 30 mg (generic for SUDOGEST) -

Tier 1; QL

nasal decongestant spray (generic for GILTUSS SEVERE SINUS) -

Tier 1

nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) -

Tier 1

nasal mist no drip (generic for GILTUSS SEVERE SINUS) - Tier 1

nasal relief (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

nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS)

- Tier 1

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

nasal spray nasal solution 0.05 % (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

NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % (brand for

sodium chloride) - Tier 2

no drip extra moisturizing (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

no drip original 12 hours (generic for GILTUSS SEVERE SINUS) - Tier

promethazine-codeine oral solution - Tier 1; QL; AL

promethazine-dm - Tier 1; QL; AL

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; AL

PULMOSAL (brand for sodium chloride) - Tier 2

ROBITUSSIN 12 HOUR COUGH (brand for cough dm) - Tier 2; QL;

ROBITUSSIN 12 HOUR COUGH CHILD (brand for cough dm) - Tier 2;

QL; AL

ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400

MG/20ML (brand for childrens cough) - Tier 2

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; QL; AL

rynex pe - Tier 1; AL

rynex pse - Tier 1; AL

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

sodium chloride inhalation nebulization solution 0.9 %, 10 % - Tier 1

sodium chloride inhalation nebulization solution 3 % (generic for

NEBUSAL) - 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

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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; AL

tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for

ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for

DIABETIC TUSSIN DM MAX ST) - Tier 1; AL

tussin cough/chest dm max oral liquid 20-400 mg/20ml (generic for

DELSYM CGH/CHEST CONG DM CHILD) - Tier 1

tussin dm cough + chest oral liquid 20-400 mg/20ml (generic for

DELSYM CGH/CHEST CONG DM CHILD) - Tier 1

tussin dm cough/chest cong (generic for ROBAFEN DM COUGH

CLEAR) - Tier 1; QL; AL

tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for

ROBAFEN DM COUGH CLEAR) - Tier 1; QL; AL

tussin dm max (generic for DELSYM CGH/CHEST CONG DM CHILD)

- Tier 1

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

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; AL

Sedatives/Hypnotics - Drugs for Sedation and Sleep

Sleep Disorders, Other - Miscellaneous Sedation and Sleep

Drugs

XYWAV - Tier 2; PA; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

orphenadrine citrate er - Tier 1; QL

AMRIX (brand for cyclobenzaprine hcl er) - Tier 2; PA; QL

LORZONE (brand for chlorzoxazone) - Tier 2; PA

Sleep Disorder Agents

Sleep Promoting Agents

eszopiclone (generic for LUNESTA) - 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 er (generic for AMBIEN CR) - Tier 1

zolpidem tartrate oral tablet (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

estazolam - Tier 1; PA; QL

HALCION (brand for triazolam) - Tier 2; PA; QL

LUNESTA ORAL TABLET 2 MG (brand for eszopiclone) - Tier 2; PA; QL

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;

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

Wakefulness Promoting Agents

armodafinil (generic for NUVIGIL) - Tier 1; DX2RX; QL

modafinil oral (generic for PROVIGIL) - Tier 1; DX2RX; QL

SODIUM OXYBATE (brand for sodium oxybate) - Tier 2; PA; SP; QL

SUNOSI - Tier 2; PA; QL

WAKIX - Tier 2; PA; QL

XYREM (brand for sodium oxybate) - Tier 2; PA; SP; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

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

animal shapes kids first (generic for CULTURELLE KIDS COMPLETE)

- Tier 1; QL

ascorbic acid oral tablet 500 mg (generic for EASY-C IMMUNE

HEALTH) - 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

BPROTECTED VITAMIN C (brand for vitamin c) - Tier 2; QL

c 500/rose hips (generic for EASY-C IMMUNE HEALTH) - Tier 1; QL

CADEAU DHA - Tier 2

calcidol (generic for CALCIDOL) - Tier 1; QL

calcium 600 - Tier 1; QL

calcium 600+d oral tablet 600-5 mg-mcg - Tier 1; QL

calcium carbonate - Tier 1; QL

calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; QL

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

cerovite jr (generic for CEROVITE JR) - Tier 1; QL

chewable c (generic for SUNKIST VITAMIN C) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1;

chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; QL

childrens animal shapes (generic for CEROVITE JR) - Tier 1; QL

childrens chewable vitamins (generic for CULTURELLE KIDS

COMPLETE) - Tier 1; QL

childrens chewables/ex c (generic for CULTURELLE KIDS

COMPLETE) - 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/extra c (generic for CULTURELLE KIDS

COMPLETE) - Tier 1; QL

childrens vitamins/iron (generic for LAND BEFORE TIME

MULTIVITAMIN) - Tier 1; QL

daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA

CAROTENE) - Tier 1; QL

EASY-C IMMUNE HEALTH (brand for ascorbic acid) - Tier 2; QL

effer-k oral tablet effervescent 25 meq - Tier 1; QL

ergocalciferol oral (generic for CALCIDOL) - Tier 1; QL

FOLAGENT DHA (brand for v-c forte) - Tier 2; QL

FOLAMED DHA (brand for v-c forte) - Tier 2; QL

fruity c - Tier 1; QL

klor-con/ef - Tier 1; QL

k-prime - Tier 1; QL

little ones childrens (generic for CULTURELLE KIDS COMPLETE) -

Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

LIVITA ADULTS (brand for support) - Tier 2; QL

lysiplex plus oral tablet (generic for LYSIPLEX PLUS) - Tier 1; QL

MENATROL (brand for v-c forte) - Tier 2; QL

multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA

CAROTENE) - Tier 1; QL

MULTIPRO (brand for v-c forte) - Tier 2; QL

multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) -

Tier 1; QL

NOVAMV PEDIATRIC MULTI-VITAMIN - Tier 2; QL

nutrifac zx (generic for LYSIPLEX PLUS) - Tier 1; QL

OBTREX - Tier 2

OCUVEL (brand for v-c forte) - Tier 2; QL

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 oral tablet 500 mg - Tier 1; QL

oyster shell calcium/d oral tablet 250-3.125 mg-mcg - Tier 1; QL

oyster shell calcium/vitamin d oral tablet 250-3.125 mg-mcg - Tier 1;

prenatal gummy oral tablet chewable 0.4-113.5 mg - Tier 1

stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE)

- Tier 1; QL

SUPPORT (brand for support) - Tier 2; QL

tri-vite/fluoride oral solution 0.25 mg/ml - Tier 1; QL

tri-vite/fluoride oral solution 0.5 mg/ml - Tier 1

TRUE VITAMIN C ORAL TABLET 250 MG - Tier 2; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

TRUE VITAMIN C ORAL TABLET 500 MG (brand for ascorbic acid) -

Tier 2; QL

true vitamin c tablet 1000 mg oral - Tier 1; QL

TRUE VITAMIN C TABLET 1000 MG ORAL - Tier 2; QL

v-c forte (generic for VIC-FORTE) - Tier 1; QL

vic-forte (generic for VIC-FORTE) - Tier 1; QL

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

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 liquid 500 mg/5ml (generic for BPROTECTED VITAMIN

C) - Tier 1; QL

vitamin c oral tablet 1000 mg, 250 mg - Tier 1; QL

vitamin c oral tablet 500 mg (generic for EASY-C IMMUNE HEALTH) -

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 EASY-C IMMUNE

HEALTH) - Tier 1; QL

vitamin c-rose hips (generic for EASY-C IMMUNE HEALTH) - Tier 1;

vitamin c-rose hips oral tablet (generic for EASY-C IMMUNE HEALTH)

- 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

vitamins complete childrens (generic for CEROVITE JR) - Tier 1; QL

zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs

b-1 - Tier 1; QL

b-12 oral tablet extended release - Tier 1

b6 - Tier 1; QL

cyanocobalamin injection solution 1000 mcg/ml (generic for DODEX) -

Tier 1; QL

DODEX (brand for cyanocobalamin) - Tier 2; QL

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

TRUE VITAMIN B6 ORAL TABLET 25 MG, 50 MG - Tier 2; QL

true vitamin b6 tablet 100 mg oral - Tier 1; QL

TRUE VITAMIN B6 TABLET 100 MG ORAL - Tier 2; QL

NASCOBAL (brand for cyanocobalamin) - Tier 2; PA; QL

TRUE VITAMIN E ORAL CAPSULE 180 MG - Tier 2; QL

TRUE VITAMIN E ORAL CAPSULE 450 MG, 90 MG - Tier 2

vitamin b1 - Tier 1; QL

vitamin b-1 oral tablet 250 mg - Tier 1; QL

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;

Vitamins

Electrolytes/Minerals/Metals/Vitamins

prenatal gummy oral tablet chewable 0.4 mg - Tier 1; QL

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Prior Authorization / Class Criteria

Tier 1: Generic; Tier 2: Brand; ^: Medical Office Attestation Needed if Prescribed by Behavioral Health Provider, Full Prior Authorization Needed

if Prescribed by Non-Behavioral Health Provider; *: Available without PA for participating Behavioral Health Prescribers; 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

Index of Drugs

12 hour allergy-d........................................ 163

12 hour decongestant................................ 168

12 hour nasal decongestant.......................168

12 hour nasal relief spray...........................168

12 hour nasal spray....................................168

12hr allergy relief........................................164

24 hour nasal allergy..................................167

24hr allergy relief........................................164

3 day............................................................ 29

3 day vaginal................................................ 30

3-day vaginal vaginal cream 2 %................. 30

4-WAY FAST ACTING............................... 158

4-WAY MENTHOL..................................... 158

8 hour arthritis pain........................................ 8

8 hour arthritis relief....................................... 8

8 hour pain relief oral tablet extended

release 650 mg.............................................. 8

8 hour pain reliever........................................ 8

8 hr arthritis pain relief....................................8

8hr arthritis pain relief.....................................8

8hr muscle aches & pain................................8

a-25.............................................................. 83

abacavir sulfate............................................ 43

abacavir sulfate-lamivudine..........................43

abatinex........................................................93

ABILIFY........................................................40

ABILIFY ASIMTUFII..................................... 40

ABILIFY MAINTENA.................................... 40

abiraterone acetate...................................... 33

ABREVA.......................................................72

ABRYSVO..................................................130

ABSORICA...................................................64

ABSORICA LD............................................. 64

acamprosate calcium................................... 16

ACANYA...................................................... 64

acarbose oral............................................... 47

ACCOLATE................................................155

ACCRUFER................................................. 75

ACCU-CHEK AVIVA DEVICE......................73

ACCU-CHEK AVIVA PLUS TEST STRIPS..73

ACCU-CHEK FASTCLIX LANCET KIT........73

ACCU-CHEK GUIDE CONTROL.................73

ACCU-CHEK GUIDE KIT W/DEVICE.......... 73

ACCU-CHEK GUIDE TEST STRIPS........... 73

ACCU-CHEK SMARTVIEW......................... 73

ACCU-CHEK SMARTVIEW CONTROL...... 73

ACCU-CHEK SOFTCLIX LANCET

DEVICE KIT................................................. 73

ACCUTREND GLUCOSE CONTROL......... 73

acebutolol hcl oral........................................ 55

acetaminophen 8 hour................................... 8

acetaminophen 8 hours..................................8

acetaminophen 8hr arth pain......................... 8

acetaminophen 8hr musc ache...................... 8

acetaminophen childrens............................... 8

acetaminophen er.......................................... 9

acetaminophen ex st oral liquid 500

mg/15ml......................................................... 9

acetaminophen ex st oral tablet 500 mg........ 9

acetaminophen extra strength........................9

acetaminophen infants................................... 9

acetaminophen oral liquid 160 mg/5ml.......... 9

acetaminophen oral solution 160 mg/5ml,

325 mg/10.15ml, 650 mg/20.3ml....................9

acetaminophen oral suspension 160

mg/5ml, 650 mg/20.3ml..................................9

acetaminophen oral tablet 325 mg.................9

acetaminophen oral tablet 500 mg.................9

acetaminophen oral tablet chewable 160

mg.................................................................. 9

acetaminophen rectal suppository 120 mg.... 9

acetaminophen rectal suppository 650 mg.... 9

acetaminophen-codeine.................................7

acetazolamide er..........................................56

acetazolamide oral....................................... 56

acetic acid otic............................................150

acetylcysteine inhalation solution 10 %......158

acetylcysteine inhalation solution 20 %......158

acid controller oral tablet 10 mg................... 91

acid gone......................................................93

acid reducer oral capsule delayed release

20.6 (20 base) mg........................................ 92

acid reducer oral tablet 10 mg......................91

acid reducer oral tablet 200 mg....................91

acidophilus lactobacillus oral........................93

acidophilus oral capsule , 10 mg.................93

acidophilus probiotic oral capsule 10 mg..... 93

acidophilus probiotic oral tablet , 0.5 mg.....93

acitretin.........................................................64

acne control cleanser................................. 130

acne medication 10 external lotion.............130

acne medication 5 external lotion...............130

acne treatment external cream 10 %......... 130

ACTEMRA ACTPEN.................................. 125

ACTEMRA SUBCUTANEOUS...................125

ACTHAR.................................................... 113

ACTHIB...................................................... 127

ACTIMMUNE............................................. 125

ACTIVELLA................................................115

ACTONEL ORAL TABLET 150 MG........... 130

ACTONEL ORAL TABLET 35 MG............. 130

ACULAR LS............................................... 144

ACUVAIL....................................................144

acyclovir external ointment...........................42

acyclovir oral................................................ 42

ADACEL.....................................................127

ADALIMUMAB-ADBM (2 PEN) AUTO-

INJECTOR KIT 40 MG/0.4ML

SUBCUTANEOUS..................................... 130

ADALIMUMAB-ADBM (2 SYRINGE)

SUBCUTANEOUS PREFILLED SYRINGE

KIT 10 MG/0.2ML, 20 MG/0.4ML, 40

MG/0.4ML.................................................. 130

186

ADALIMUMAB-ADBM(CD/UC/HS STRT)

SUBCUTANEOUS AUTO-INJECTOR KIT

40 MG/0.4ML............................................. 130

ADALIMUMAB-ADBM(PS/UV STARTER)

SUBCUTANEOUS AUTO-INJECTOR KIT

40 MG/0.4ML............................................. 130

ADALIMUMAB-FKJP................................. 130

ADALIMUMAB-FKJP (2 SYRINGE)...........131

ADBRY.......................................................125

adc/f (0.5mg/ml)......................................... 180

ADCIRCA................................................... 157

ADDERALL.................................................. 61

ADDERALL XR............................................ 61

ADEMPAS..................................................157

ADMELOG................................................... 48

ADMELOG SOLOSTAR...............................48

adult 50+ probiotic........................................93

adult probiotic...............................................93

adv acne spot treatment.............................131

ADVAIR DISKUS....................................... 167

ADVAIR HFA..............................................167

advanced acne spot treat...........................131

advanced antacid......................................... 93

advanced healing external ointment .......... 70

ADVIL COLD/SINUS..................................168

ADVIL JUNIOR STRENGTH..........................4

ADVIL ORAL TABLET................................... 4

AFINITOR.................................................... 35

afirmelle......................................................115

AFLURIA QUADRIVALENT....................... 128

AFREZZA.....................................................48

AFRIN NODRIP ORIGINAL....................... 168

AFRIN SALINE NASAL MIST.................... 158

aftera.......................................................... 123

AIMOVIG......................................................32

AJOVY......................................................... 32

AKYNZEO ORAL......................................... 28

ala-cort......................................................... 65

ALAWAY.................................................... 150

ALAWAY CHILDRENS ALLERGY.............150

albendazole oral...........................................37

albuterol sulfate hfa aerosol solution 108

(90 base) mcg/act inhalation...................... 156

ALBUTEROL SULFATE HFA AEROSOL

SOLUTION 108 (90 BASE) MCG/ACT

INHALATION..............................................156

albuterol sulfate inhalation nebulization

solution (2.5 mg/3ml) 0.083%, 2.5

mg/0.5ml.................................................... 156

albuterol sulfate inhalation nebulization

solution 0.63 mg/3ml, 1.25 mg/3ml............ 156

albuterol sulfate nebulization solution (5

mg/ml) 0.5% inhalation...............................156

ALBUTEROL SULFATE NEBULIZATION

SOLUTION (5 MG/ML) 0.5% INHALATION

....................................................................156

albuterol sulfate oral syrup......................... 156

alclometasone dipropionate external

ointment....................................................... 65

ALCOHOL PREP PADS PAD , 70 %........131

ALECENSA................................................ 141

alendronate sodium oral solution............... 130

alendronate sodium oral tablet 10 mg, 35

mg.............................................................. 130

alendronate sodium oral tablet 70 mg........130

ALEVE ORAL TABLET.................................. 4

alfuzosin hcl er........................................... 111

all day allergy d.......................................... 163

all day allergy oral tablet 10 mg................. 151

all day allergy relief oral tablet 10 mg.........164

all day allergy-d oral tablet extended

release 12 hour 5-120 mg.......................... 163

all day pain relief............................................ 4

all day relief.................................................... 4

ALLEGRA ALLERGY................................. 164

ALLEGRA HIVES 24HR.............................164

allerclear.....................................................164

allerclear d-12hr......................................... 168

allerclear d-24hr......................................... 168

aller-ease oral tablet 180 mg......................164

aller-fex...................................................... 164

allerg rel child (lorat)...................................164

allerg relief child (lorat)...............................164

allergy & congestion oral tablet extended

release 24 hour 10-240 mg........................ 168

allergy & congestion relief.......................... 168

allergy (cetirizine)....................................... 151

allergy 24hour indoor/outdoor.................... 151

allergy 24-hr............................................... 164

allergy childrens oral liquid.........................151

allergy childrens oral solution.....................165

allergy eye drops........................................150

allergy medication...................................... 151

allergy medicine......................................... 151

allergy nasal mist no drip........................... 169

allergy oral capsule 25 mg......................... 151

allergy oral liquid 12.5 mg/5ml................... 151

allergy oral tablet 25 mg.............................151

allergy rel child (loratadine)........................ 165

allergy relief (cetirizine) oral tablet 10 mg.. 151

allergy relief (loratadine) oral tablet............165

allergy relief adult....................................... 152

allergy relief cetirizine.................................152

allergy relief child....................................... 165

allergy relief childrens oral liquid 12.5

mg/5ml....................................................... 152

allergy relief childrens oral solution 5

mg/5ml....................................................... 165

allergy relief childrens oral tablet chewable

12.5 mg...................................................... 152

allergy relief d oral tablet extended release

12 hour 5-120 mg.......................................163

allergy relief d-12........................................169

allergy relief d-24........................................169

allergy relief max st.................................... 152

allergy relief nasal decong......................... 169

allergy relief oral capsule 25 mg................ 152

187

allergy relief oral liquid 25 mg/10ml............152

allergy relief oral tablet 10 mg.................... 165

allergy relief oral tablet 180 mg.................. 165

allergy relief oral tablet 25 mg.................... 152

allergy relief oral tablet 60 mg.................... 165

allergy relief oral tablet chewable 12.5 mg.152

allergy relief oral tablet dispersible 10 mg..165

allergy relief oral tablet extended release

12 hour 5-120 mg.......................................163

allergy relief oral tablet extended release

12 mg......................................................... 165

allergy relief(cetirizine)............................... 152

allergy relief/indoor/outdoor oral tablet 10

mg.............................................................. 152

allergy relief/indoor/outdoor oral tablet 180

mg.............................................................. 165

allergy relief/nasal decong......................... 169

allergy relief/nasal decongest oral tablet

extended release 12 hour.......................... 163

allergy relief/nasal decongest oral tablet

extended release 24 hour.......................... 169

allergy relief-d oral tablet extended release

12 hour 5-120 mg...............................163, 169

allergy relief-d oral tablet extended release

24 hour 10-240 mg.....................................169

allergy relief-d12.........................................169

allergy spray 24 hour nasal aerosol........... 167

allergy/congestion relief............................. 169

aller-tec...................................................... 152

aller-tec d................................................... 163

allopurinol oral tablet 100 mg, 300 mg......... 31

almacone double strength............................93

ALOGLIPTIN BENZOATE............................47

ALOGLIPTIN-METFORMIN HCL.................47

ALOGLIPTIN-PIOGLITAZONE.................... 47

ALORA....................................................... 115

ALPHAGAN P............................................ 145

alprazolam oral tablet...................................45

altachlore ophthalmic ointment.................. 145

altachlore ophthalmic solution....................145

altafrin........................................................ 143

altalube.......................................................145

altamist spray............................................. 158

altarussin....................................................158

altarussin dm..............................................169

altarussin-pe...............................................169

altavera...................................................... 115

ALTOPREV.................................................. 58

ALTRENO.................................................... 64

ALTRIXA...................................................... 83

alum & mag hydroxide-simeth......................93

ALUNBRIG.................................................141

ALVESCO.................................................. 155

alyacen 1/35...............................................115

alyacen 7/7/7..............................................115

amantadine hcl oral capsule........................ 38

amantadine hcl oral solution........................ 38

AMBIEN..................................................... 179

AMBIEN CR............................................... 179

ambrisentan............................................... 157

amiloride hcl oral.......................................... 57

amiloride-hydrochlorothiazide...................... 56

aminocaproic acid oral................................. 52

amiodarone hcl oral tablet 200 mg, 400 mg.54

AMITIZA ORAL CAPSULE 24 MCG............ 90

amitriptyline hcl oral..................................... 27

AMJEVITA SOLUTION AUTO-INJECTOR

40 MG/0.8ML SUBCUTANEOUS.............. 131

AMJEVITA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 40 MG/0.4ML, 80

MG/0.8ML.................................................. 131

AMJEVITA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE.............................. 131

AMJEVITA-PED 15KG TO <30KG ......... 131

amlodipine besylate oral.............................. 55

amlodipine besylate-benazepril hcl.............. 56

amlodipine besylate-valsartan......................56

amlodipine-olmesartan.................................56

ammonium lactate external.......................... 65

amnesteem.................................................. 64

amoxapine....................................................27

amoxicillin.....................................................20

amoxicillin-potassium clavulanate................20

amphetamine-dextroamphetamine.............. 61

amphetamine-dextroamphetamine er.......... 61

ampicillin...................................................... 20

AMRIX........................................................179

AMZEEQ...................................................... 69

anagrelide hcl...............................................52

ANASPAZ.................................................. 131

anastrozole oral............................................34

ANDRODERM............................................115

ANECREAM EXTERNAL CREAM...............16

anefrin spray.............................................. 169

ANGELIQ................................................... 115

animal shapes complete............................ 180

animal shapes kids first..............................180

ANNOVERA............................................... 115

ANORO ELLIPTA.......................................167

antacid & anti-gas oral suspension 200-

200-20 mg/5ml............................................. 93

antacid & antigas oral suspension 2400-

2400-240 mg/30ml....................................... 94

antacid & anti-gas oral suspension 400-

400-40 mg/5ml............................................. 94

antacid & gas relief.......................................94

antacid advanced......................................... 94

antacid advanced max st oral suspension

400-400-40 mg/5ml...................................... 94

antacid anti-gas............................................94

antacid anti-gas max strength...................... 94

antacid calcium............................................ 94

antacid calcium rich......................................94

antacid extra str............................................94

antacid extra strength oral suspension........ 94

antacid extra strength oral tablet chewable

160-105 mg.................................................. 94

188

antacid extra strength oral tablet chewable

750 mg......................................................... 94

antacid fast relief.......................................... 94

antacid i........................................................94

antacid iii...................................................... 94

antacid kids.................................................. 95

antacid liquid................................................ 95

antacid m......................................................95

antacid maximum......................................... 95

antacid maximum strength oral suspension

400-400-40 mg/5ml...................................... 95

antacid maximum strength oral tablet

chewable 1000 mg....................................... 95

antacid oral suspension 200-200-20

mg/5ml, 400-400-40 mg/10ml...................... 95

antacid oral tablet chewable 1000 mg..........95

antacid oral tablet chewable 500 mg............95

antacid oral tablet chewable 750 mg............95

antacid plus antigas..................................... 95

antacid regular strength oral suspension

200-200-20 mg/5ml...................................... 95

antacid supreme...........................................95

antacid ultra strength....................................95

antacid ultra strength oral tablet chewable

1000 mg....................................................... 95

antacid/antigas............................................. 95

antacid/anti-gas max st................................ 95

antacid/anti-gas oral suspension 200-200-

20 mg/5ml, 400-400-40 mg/10ml................. 96

antacid/anti-gas oral suspension 400-400-

40 mg/5ml.................................................... 96

antacid/gas relief max st.............................. 96

antibiotic............................................... 22, 131

anti-diarr/ant-gas.......................................... 96

anti-diarrheal anti-gas oral tablet 2-125 mg. 96

anti-diarrheal oral suspension 262 mg/15ml 96

anti-diarrheal oral tablet 2 mg...................... 90

anti-diarrheal/anti-gas.................................. 96

antifungal (tolnaftate)................................. 131

antifungal external cream.............................30

antifungal external powder........................... 30

antifungal foot care.......................................30

antifungal miconazole.................................. 30

antifungal tolnaftate....................................131

anti-gas oral capsule 180 mg....................... 96

anti-hist allergy........................................... 152

anti-itch aloe.................................................65

anti-itch intensive heal..................................65

anti-itch max str external cream 1 %............65

anti-itch maximum strength external cream

1 %............................................................... 65

anti-nausea.................................................. 28

anti-nausea relief..........................................28

antiseptic...................................................... 22

ANTIVERT ORAL TABLET CHEWABLE.....27

apap-caff-dihydrocodeine...............................7

APIDRA SOLOSTAR................................... 48

APIDRA VIAL............................................... 48

APOKYN...................................................... 39

apra................................................................ 9

apraclonidine hcl........................................ 145

aprepitant..................................................... 28

apri............................................................. 115

APRISO......................................................129

APRODINE................................................ 169

APTIOM....................................................... 24

APTIVUS......................................................44

aqueous vitamin d........................................ 83

aranelle...................................................... 115

ARANESP (ALBUMIN FREE)...................... 52

ARAZLO.......................................................64

AREXVY.....................................................131

aripiprazole oral solution.............................. 40

aripiprazole oral tablet..................................40

aripiprazole oral tablet dispersible................40

ARISTADA................................................... 40

ARISTADA INITIO........................................40

armodafinil..................................................179

ARMOUR THYROID.................................. 123

ARNUITY ELLIPTA.................................... 155

arthritis pain oral tablet extended release

650 mg......................................................... 10

arthritis pain relief oral tablet extended

release 650 mg............................................ 10

arthritis pain reliever oral..............................10

arthritis pain relieving................................. 131

artificial tears ophthalmic solution ............ 145

ascomp-codeine.............................................7

ascorbic acid oral tablet 500 mg................ 180

ashlyna.......................................................115

ASMANEX (120 METERED DOSES)........ 155

ASMANEX (14 METERED DOSES).......... 155

ASMANEX (30 METERED DOSES).......... 155

ASMANEX (60 METERED DOSES).......... 155

ASMANEX HFA......................................... 155

ASPERFLEX LIDOCAINE EXTERNAL

CREAM........................................................ 16

aspirin adults.............................................. 131

aspirin childrens......................................... 131

aspirin ec oral tablet 325 mg...................... 131

aspirin ec oral tablet delayed release 325

mg.............................................................. 131

aspirin ec oral tablet delayed release 81

mg.............................................................. 131

aspirin oral tablet 325 mg...........................131

aspirin oral tablet chewable 81 mg.............132

aspirin oral tablet delayed release 325 mg 132

aspirin oral tablet delayed release 81 mg.. 132

ASPIRIN ORAL TABLET DELAYED

RELEASE 81 MG.......................................132

aspirin rectal suppository 300 mg.............. 132

aspirin regimen...........................................132

astringent..................................................... 70

astringent eye drops...................................145

astringent solution........................................ 70

atazanavir sulfate......................................... 44

ATELVIA.................................................... 130

189

atenolol oral..................................................55

atenolol-chlorthalidone................................. 56

atheletes foot................................................30

athletes foot (terbinafine)............................. 30

athletes foot (tolnaftate) external aerosol

powder 1 %................................................ 132

athletes foot (tolnaftate) external cream 1

%................................................................ 132

athletes foot external aerosol powder 2 %... 30

athletes foot external cream 1 %..................30

athletes foot external powder 2 %................30

athletes foot powder spray external aerosol

powder 1 %................................................ 132

athletes foot powder spray external aerosol

powder 2 %.................................................. 30

athletes foot relief.......................................132

athletes foot spray external aerosol 2 %...... 30

atomoxetine hcl............................................ 59

ATORVALIQ.................................................58

atorvastatin calcium oral.............................. 58

atovaquone.................................................. 37

atovaquone-proguanil hcl.............................37

ATRALIN...................................................... 64

atropine sulfate ophthalmic ointment......... 143

atropine sulfate ophthalmic solution 1 %....143

ATROVENT HFA....................................... 155

AUBAGIO.....................................................63

aubra eq..................................................... 115

AUM ALCOHOL PREP PADS................... 132

aurovela 1.5/30.......................................... 115

aurovela 1/20............................................. 115

aurovela 24 fe............................................ 115

aurovela fe 1.5/30...................................... 115

aurovela fe 1/20......................................... 115

AURYXIA..................................................... 82

AUSTEDO....................................................62

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HOUR 6 MG......62

AUVELITY..................................................132

AUVI-Q.......................................................156

AVAR-E EMOLLIENT.................................. 70

AVAR-E GREEN.......................................... 70

AVEDANA GLYCERIN (ADULT)............... 107

aviane.........................................................115

AVONEX PEN..............................................63

AVONEX PREFILLED..................................63

AYR............................................................158

AYR NASAL MIST ALLERGY/SINUS........158

AYR SALINE NASAL DROPS................... 158

ayuna......................................................... 116

AZASITE.................................................... 144

azathioprine oral tablet 50 mg....................126

azelaic acid external.....................................64

azelastine hcl nasal solution 0.1 %, 137

mcg/spray...................................................152

azelastine hcl ophthalmic........................... 143

azithromycin oral suspension reconstituted. 20

azithromycin oral tablet................................ 20

azo............................................................. 112

AZOPT....................................................... 145

AZSTARYS.................................................. 61

azurette...................................................... 116

b complex vitamins.......................................83

b complex-b12..............................................83

b-1.............................................................. 184

b-12 oral tablet extended release...............184

b6............................................................... 184

BABY AYR SALINE................................... 158

baby basics diaper rash............................... 70

bac................................................................. 7

bacitracin external...................................... 132

bacitracin ophthalmic................................. 144

bacitracin zinc external...............................132

bacitracin zinc first aid................................132

bacitracin zinc-aloe.................................... 132

bacitracin-polymyxin b................................144

bacitra-neomycin-polymyxin-hc..................143

baclofen oral tablet 10 mg, 20 mg, 5 mg......41

BAFIERTAM.................................................63

BALCOLTRA..............................................116

balsalazide disodium..................................129

BALVERSA.................................................. 35

balziva........................................................ 116

banophen oral capsule 25 mg....................152

banophen oral tablet.................................. 152

BAQSIMI ONE PACK...................................48

BAQSIMI TWO PACK.................................. 48

BARACLUDE ORAL SOLUTION................. 42

BASAGLAR KWIKPEN................................ 48

BASAGLAR TEMPO PEN............................48

BAYER ASPIRIN........................................132

BAYER LOW DOSE ORAL TABLET

CHEWABLE............................................... 132

baza antifungal.............................................30

b-complex oral tablet ..................................83

b-complex with b-12..................................... 83

b-complex/b-12 oral..................................... 83

BD AUTOSHIELD DUO PEN NEEDLES... 133

BD ECLIPSE NEEDLE 25G X 5/8"............ 133

BD ULTRA-FINE INSULIN SYRINGES..... 133

BD ULTRA-FINE INSULIN SYRINGES

30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML...... 133

BD ULTRA-FINE INSULIN SYRINGES

30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML,

31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML,

31G X 5/16" 1 ML.......................................133

BD ULTRA-FINE INSULIN SYRINGES

31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML. 133

BD ULTRA-FINE INSULIN SYRINGES

31G X 5/16" 0.3 ML....................................133

BD ULTRA-FINE PEN NEEDLES................73

BD ULTRA-FINE PEN NEEDLES 29G X

12.7MM...................................................... 133

BD ULTRA-FINE PEN NEEDLES 31G X 5

MM............................................................. 133

BD ULTRA-FINE PEN NEEDLES 31G X 8

MM............................................................. 133

190

beauty 360 pure glycerin..............................70

beauty 360 soothing bath.............................70

BELBUCA...................................................... 6

BELSOMRA............................................... 179

BENADRYL ALLERGY CHILDRENS

ORAL LIQUID............................................ 152

BENADRYL ALLERGY CHILDRENS

ORAL TABLET CHEWABLE......................152

BENADRYL ALLERGY ORAL TABLET.....153

BENADRYL ALLERGY ULTRATABS........ 153

benazepril hcl oral........................................ 54

benazepril-hydrochlorothiazide.................... 56

BENLYSTA SUBCUTANEOUS

SOLUTION AUTO-INJECTOR...................125

BENZAC AC WASH...................................133

BENZAMYCIN..............................................64

BENZNIDAZOLE..........................................37

benzonatate oral capsule 100 mg, 200 mg 169

benzoyl peroxide external gel 2.5 %.......... 133

benzoyl peroxide external liquid.................133

benzoyl peroxide wash external liquid 5 % 133

benztropine mesylate oral............................ 38

BERINERT................................................. 125

BESIVANCE...............................................144

BETADINE EXTERNAL SOLUTION 10 %...22

betamethasone dipropionate aug.................65

betamethasone dipropionate external lotion 65

betamethasone dipropionate external

ointment....................................................... 65

betamethasone valerate external cream......66

betamethasone valerate external lotion....... 66

betamethasone valerate external ointment.. 66

BETAPACE.................................................. 54

BETAPACE AF............................................ 54

BETASERON............................................... 63

betatemp childrens.......................................10

betaxolol hcl ophthalmic.............................145

betaxolol hcl oral.......................................... 55

bethanechol chloride oral........................... 112

BETHKIS....................................................156

BETIMOL................................................... 145

BETOPTIC-S..............................................145

BEVESPI AEROSPHERE..........................167

bexarotene................................................... 36

BEXSERO..................................................127

BEYAZ....................................................... 116

bicalutamide................................................. 33

BIJUVA ORAL CAPSULE 1-100 MG......... 116

BIKTARVY ORAL TABLET 30-120-15 MG..42

BIKTARVY ORAL TABLET 50-200-25 MG..42

BINAXNOW COVID-19 AG HOME TEST..133

biocel..........................................................180

BIOLLE TEARS..........................................145

BION TEARS PF........................................145

biotinex.........................................................96

bisacodyl ec............................................... 133

bisacodyl laxative....................................... 133

bisacodyl oral............................................. 133

bisacodyl rectal.......................................... 133

bismuth.........................................................96

bismuth subsalicylate oral............................ 96

bisoprolol fumarate oral................................55

bisoprolol-hydrochlorothiazide..................... 56

blisovi 24 fe................................................ 116

blisovi fe 1.5/30.......................................... 116

blisovi fe 1/20............................................. 116

BLOOD GLUCOSE TEST STRIPS..............73

BOLSITOL....................................................96

BONINE....................................................... 27

BOOSTRIX.................................................127

boro-packs................................................... 70

bosentan.................................................... 157

BOSULIF ORAL CAPSULE....................... 141

BOSULIF ORAL TABLET.......................... 141

boudreauxs butt paste ointment 40 %

external........................................................ 70

BOUDREAUXS BUTT PASTE OINTMENT

40 % EXTERNAL......................................... 70

bp 10-1......................................................... 71

bp wash external liquid 2.5 %.................... 133

b-plex plus..................................................180

BPROTECTED PEDIA D-VITE.................... 83

BPROTECTED PEDIA IRON.......................77

BPROTECTED PEDIA POLY-VITE/FE..... 180

BPROTECTED VITAMIN C....................... 180

BRAFTOVI................................................... 35

BREATHE COMFORT HUMIDIFIER......... 133

BREO ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100-25

MCG/ACT, 200-25 MCG/ACT....................167

breyna........................................................ 167

BREZTRI AEROSPHERE..........................167

briellyn........................................................116

BRILINTA..................................................... 53

brimonidine tartrate ophthalmic solution

0.15 %........................................................ 145

brimonidine tartrate ophthalmic solution 0.2

%................................................................ 145

BRIVIACT ORAL..........................................23

BROMFED DM...........................................158

BROMSITE................................................ 144

BRONCHITOL..............................................63

BRUKINSA.................................................141

BRYHALI......................................................66

BUCKLEYS CHEST CONGESTION..........158

budesonide inhalation................................ 155

budesonide oral..........................................129

budesonide-formoterol fumarate................ 167

bumetanide oral........................................... 57

BUPHENYL ORAL POWDER....................110

BUPHENYL ORAL TABLET...................... 110

buprenorphine................................................ 6

buprenorphine hcl sublingual......................... 8

buprenorphine hcl-naloxone hcl................... 16

bupropion hcl er (smoking det).....................17

bupropion hcl er (sr)..................................... 26

191

bupropion hcl er (xl) oral tablet extended

release 24 hour 150 mg, 300 mg................. 26

bupropion hcl oral.........................................26

buspirone hcl oral.........................................45

butalbital-acetaminophen oral tablet 50-

325 mg........................................................... 7

butalbital-apap-caff-cod oral capsule 50-

325-40-30 mg.................................................7

butalbital-apap-caffeine oral capsule 50-

325-40 mg...................................................... 7

butalbital-apap-caffeine oral tablet................. 7

butalbital-asa-caff-codeine............................. 7

butalbital-aspirin-caffeine............................... 7

butorphanol tartrate nasal.............................. 7

BUTRANS...................................................... 6

BYDUREON BCISE AUTOINJECTOR........ 47

BYETTA 10 MCG PEN................................ 47

BYETTA 5 MCG PEN.................................. 47

c 500/rose hips...........................................180

cabergoline.................................................124

CABLIVI....................................................... 53

CABOMETYX.............................................141

CADEAU DHA............................................180

caffeine citrate oral.......................................62

cal mag zinc +d3.......................................... 77

calamine external lotion ........................... 133

calamine external lotion , 8-8 %.................. 72

calamine-zinc oxide external lotion.............. 72

calcidol....................................................... 180

calcipotriene external cream........................ 68

calcipotriene external ointment.................... 68

calcipotriene external solution......................68

calcitonin (salmon) nasal............................130

calcitriol external.......................................... 68

calcitriol oral capsule..................................130

calcitriol oral solution..................................130

calcium + vitamin d3 oral tablet 500-5 mg-

mcg.............................................................. 77

calcium 500/vitamin d3.................................77

calcium 600................................................ 180

calcium 600/vit d/minerals oral tablet 600-

200 mg-unit.................................................. 77

calcium 600/vit d/minerals oral tablet

chewable 600-400 mg-unit...........................77

calcium 600/vitamin d...................................77

calcium 600/vitamin d-3............................... 77

calcium 600+d oral tablet 600-10 mg-mcg...77

calcium 600+d oral tablet 600-5 mg-mcg...180

calcium acetate (phos binder)...................... 82

calcium acetate oral tablet 667 mg.............. 82

calcium antacid............................................ 96

calcium antacid ex st oral tablet chewable

750 mg......................................................... 96

calcium antacid extra strength..................... 96

calcium carb-cholecalciferol oral tablet

600-10 mg-mcg, 600-5 mg-mcg...................77

calcium carbonate...................................... 180

calcium carbonate antacid oral suspension. 96

calcium carbonate antacid oral tablet...........96

calcium carbonate antacid oral tablet

chewable...................................................... 97

calcium carbonate oral tablet 1500 (600

ca) mg........................................................ 180

calcium carbonate oral tablet chewable

1250 (500 ca) mg....................................... 180

calcium cit plus vit d-3.................................. 77

calcium citrate + d3 maximum......................78

calcium citrate +d3....................................... 78

calcium citrate oral tablet 950 (200 ca) mg.. 78

calcium citrate plus vit d............................... 78

calcium citrate+d oral tablet 315-6.25 mg-

mcg.............................................................. 78

calcium citrate+d3 oral tablet ..................... 78

calcium citrate+d3 w/magne.........................78

calcium citrate-vit d...................................... 78

calcium citrate-vitamin d oral tablet 315-5

mg-mcg........................................................ 78

calcium fast dissolution.............................. 180

calcium high potency..................................180

calcium high potency/vitamin d.................... 78

calcium oral tablet 1500 (600 ca) mg......... 180

calcium oyster shell oral tablet 1250 (500

ca) mg........................................................ 180

calcium plus vitamin d.................................. 78

calcium plus vitamin d3................................ 78

calcium soft chews oral tablet chewable

500-200-40 mg-unt-mcg.............................180

calcium/minerals/vitamin d........................... 78

calcium-magnesium-zinc oral tablet 333-

133-5 mg, 333.33-133.33-5 mg....................78

cal-gest antacid............................................ 97

CALQUENCE.............................................133

camila.........................................................122

camrese..................................................... 116

camrese lo..................................................116

CANASA.................................................... 129

capecitabine................................................. 36

CAPLYTA.....................................................40

CAPRELSA................................................ 141

capsaicin cream 0.025 % external............. 133

capsaicin external cream 0.1 %................. 133

capsaicin hp............................................... 133

capsaicin pain relief....................................134

captopril oral.................................................54

captopril-hydrochlorothiazide....................... 56

capzix......................................................... 134

CARAC.........................................................68

carbamazepine er........................................ 24

carbamazepine oral......................................24

carbidopa-levodopa er................................. 39

carbidopa-levodopa oral tablet.....................39

carboxymethylcellulose sodium ophthalmic

solution.......................................................145

CAREPOINT POLY HUB NEEDLE 18G X

1"..................................................................51

CAREPOINT POLY HUB NEEDLE 25G X

5/8".............................................................134

192

CAREPOINT SAFETY 1ST NEEDLE 25G

X 5/8"..........................................................134

CARESENS CONTROL SOLUTION A/B.....73

CARESTART COVID-19 HOME TEST......134

CARETOUCH CONTROL SOL LEVEL 2.... 73

CARETOUCH HYPODERMIC NEEDLE

25G X 5/8"..................................................134

carglumic acid.............................................. 76

carteolol hcl................................................ 145

cartia xt.........................................................56

carvedilol...................................................... 55

CASTIVA WARMING................................. 134

CAYA......................................................... 134

CAYSTON..................................................156

cefaclor oral capsule.................................... 20

cefadroxil......................................................20

cefdinir..........................................................20

cefixime oral capsule....................................20

cefpodoxime proxetil oral tablet................... 20

cefprozil........................................................20

cefuroxime axetil.......................................... 20

celecoxib oral................................................. 4

CENTRUM SPECIALIST PRENATAL......... 83

cephalexin oral capsule 250 mg, 500 mg.....20

cephalexin oral suspension reconstituted.... 20

CEQUA...................................................... 143

CERDELGA............................................... 110

cerovite jr....................................................180

cetiri-d........................................................ 163

cetirizine allergy relief.................................153

cetirizine hcl oral solution........................... 153

cetirizine hcl oral tablet...............................153

cetirizine-pseudoephedrine er....................163

charlotte 24 fe............................................ 116

chateal eq...................................................116

CHEMET...................................................... 82

CHEMSTRIP 10 MD.................................... 73

CHEMSTRIP 10/SG.....................................73

CHEMSTRIP 2 GP.......................................73

CHEMSTRIP 5 OB.......................................73

CHEMSTRIP 7............................................. 73

CHEMSTRIP 9............................................. 73

CHEMSTRIP K.............................................73

CHEMSTRIP UGK....................................... 73

chest congest/cough child..........................169

chest congestion relief dm oral syrup.........170

chest congestion relief oral liquid............... 158

chest congestion relief oral tablet...............158

chewable c................................................. 180

chewable c with rose hips.......................... 180

chewable childrens vitamin........................ 181

chewy not chalky flavor................................ 97

childrens acetaminophen............................. 10

childrens allergy oral liquid 12.5 mg/5ml.... 153

childrens animal shapes.............................181

childrens apap..............................................10

childrens aspirin oral tablet chewable 81

mg.............................................................. 134

childrens chewable vitamins...................... 181

childrens chewables/ex c........................... 181

childrens chewables/iron............................181

childrens cold & allergy.............................. 170

childrens complete oral tablet chewable 18

mg.............................................................. 181

childrens cough.......................................... 170

childrens loratadine.................................... 165

childrens mucus relief cough......................170

childrens non-aspirin.................................... 10

childrens soothe........................................... 97

childrens vitamins/extra c...........................181

childrens vitamins/iron................................181

childs non-aspirin......................................... 10

chlordiazepoxide hcl.....................................45

chlorhexidine gluconate mouth/throat.......... 64

chloroquine phosphate oral..........................37

chlorpheniramine maleate er......................165

chlorpromazine hcl oral tablet...................... 40

chlorthalidone...............................................57

CHLOR-TRIMETON ALLERGY................. 165

chlorzoxazone oral tablet 500 mg.............. 179

CHOLBAM................................................. 110

cholestyramine light oral powder..................58

cholestyramine oral powder......................... 58

CHORIONIC GONADOTROPIN

INTRAMUSCULAR.................................... 114

CIBINQO...................................................... 72

ciclodan........................................................ 69

ciclopirox external solution........................... 69

cilostazol...................................................... 53

CIMDUO.......................................................43

cimetidine hcl............................................... 91

cimetidine oral tablet 200 mg....................... 91

cimetidine oral tablet 300 mg, 400 mg, 800

mg................................................................ 91

CIMZIA (2 SYRINGE)................................ 126

CIMZIA SUBCUTANEOUS PREFILLED

SYRINGE KIT 6 X 200 MG/ML.................. 126

CIMZIA VIAL KIT........................................126

cinacalcet hcl..............................................130

CIPRO ORAL SUSPENSION

RECONSTITUTED.......................................21

ciprofloxacin hcl ophthalmic....................... 144

ciprofloxacin hcl oral.....................................21

ciprofloxacin-dexamethasone.................... 150

citalopram hydrobromide oral solution......... 26

citalopram hydrobromide oral tablet.............26

citroma....................................................... 107

CITRUCEL................................................. 107

claravis......................................................... 64

clarithromycin er...........................................20

clarithromycin oral........................................ 20

CLARITIN ALLERGY CHILDRENS........... 166

CLARITIN ORAL TABLET......................... 166

CLARITIN REDITABS ORAL TABLET

DISPERSIBLE 10 MG................................166

CLARITIN-D 12 HOUR.............................. 170

CLARITIN-D 24 HOUR.............................. 170

193

classic prenatal............................................ 83

c-lax laxative.............................................. 134

CLEARCANAL EARWAX SOFTENER...... 150

CLEARDETECT COVID-19 AG HOME..... 134

clearlax oral powder 17 gm/scoop............. 104

clearskin..................................................... 134

clemastine fumarate oral............................153

CLENPIQ..................................................... 91

CLIMARA................................................... 116

CLIMARA PRO.......................................... 116

clindacin etz external swab.......................... 69

clindacin-p.................................................... 69

clindamycin hcl oral capsule 150 mg, 300

mg................................................................ 19

clindamycin palmitate hcl............................. 19

clindamycin phosphate external gel............. 69

clindamycin phosphate external lotion......... 69

clindamycin phosphate external solution..... 69

clindamycin phosphate external swab......... 69

clindamycin phosphate vaginal.................... 19

CLINDESSE.................................................19

CLINERE EARWAX REMOVAL KIT OTIC

SOLUTION.................................................150

CLINITEST RAPID COVID-19 TEST KIT

IN VITRO....................................................134

clobazam......................................................24

clobetasol propionate e................................ 66

clobetasol propionate external cream.......... 66

clobetasol propionate external ointment...... 66

clobetasol propionate external solution........66

CLOBEX.......................................................66

CLOBEX SPRAY......................................... 66

clomipramine hcl oral................................... 27

clonazepam oral tablet................................. 45

clonidine hcl oral.......................................... 53

clopidogrel bisulfate oral.............................. 53

clorazepate dipotassium.............................. 45

clotrimazole 3............................................... 30

clotrimazole 7............................................... 30

clotrimazole external cream 1 %.................. 69

clotrimazole external solution 1 %................69

clotrimazole mouth/throat troche 10 mg.......29

clotrimazole vaginal......................................30

clotrimazole vaginal cream 1 %................... 30

clotrimazole-betamethasone........................ 68

clozapine oral tablet..................................... 41

CLOZARIL....................................................41

codeine sulfate oral tablet 30 mg, 60 mg....... 7

COLACE.................................................... 107

COLAZAL...................................................129

colchicine oral capsule................................. 31

colchicine oral tablet.....................................31

cold & allergy..............................................170

cold & allergy childrens oral elixir 1-15

mg/5ml....................................................... 170

cold & cough childrens oral liquid 1-5-2.5

mg/5ml, 2.5-1-5 mg/5ml............................. 170

cold & sinus................................................170

cold & sinus relief oral tablet 30-200 mg.... 170

cold/cough..................................................170

cold/cough childrens.................................. 170

cold/cough dm childrens oral liquid 2.5-1-5

mg/5ml....................................................... 170

cold/cough dm oral liquid 2.5-1-5 mg/5ml.. 170

col-rite oral capsule 250 mg....................... 107

COMBIGAN................................................143

COMBIPATCH........................................... 116

COMBIVENT RESPIMAT.......................... 167

COMETRIQ (100 MG DAILY DOSE)......... 141

COMETRIQ (140 MG DAILY DOSE)......... 141

COMETRIQ (60 MG DAILY DOSE)........... 141

comfort gel................................................... 97

comfort gel antacid anti-gas oral

suspension 400-400-40 mg/5ml...................97

COMIRNATY..............................................134

COMPLERA................................................. 43

complete allergy......................................... 153

complete allergy medicine..........................153

complete allergy medicine oral capsule..... 153

complete allergy relief................................ 153

COMPLETE NATAL DHA............................ 83

compro......................................................... 27

CO-NATAL FA............................................. 83

CONDOMS................................................ 134

constulose.................................................... 90

CONTOUR NEXT EZ KIT W/DEVICE......... 73

CONTOUR NEXT GEN MONITOR KIT....... 73

CONTOUR NEXT GEN TEST STRIPS....... 73

CONTOUR NEXT MONITOR KIT

W/DEVICE................................................... 73

CONTOUR NEXT ONE KIT......................... 73

CONTOUR TEST STRIPS...........................73

COOL MIST HUMIDIFER.......................... 134

COPAXONE.................................................63

COPIKTRA...................................................35

CORICIDIN HBP COUGH/COLD...............159

CORLANOR.................................................56

corn & callus remover................................ 134

corn and callus remover.............................135

CORTIFOAM..............................................129

cortisone maximum strength external

cream........................................................... 66

CORTROPHIN........................................... 113

COSENTYX SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 150 MG/ML

....................................................................125

COSENTYX SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 150

MG/ML, 75 MG/0.5ML................................125

COSENTYX UNOREADY.......................... 125

COSOPT.................................................... 143

COSOPT PF.............................................. 143

COTELLIC....................................................35

cough & chest congestion.......................... 170

cough & cold.............................................. 159

cough & cold hbp....................................... 159

cough childrens.......................................... 171

194

cough dm childrens.................................... 171

cough dm er............................................... 171

cough dm oral suspension extended

release 30 mg/5ml......................................171

cough relief oral syrup 15 mg/5ml.............. 159

cough/cold hbp...........................................159

COVID-19 AT HOME ANTIGEN TEST...... 135

COVID-19 AT HOME TEST KIT................ 135

COVID-19 AT-HOME TEST KIT IN VITRO135

CREON...................................................... 110

CRESEMBA ORAL CAPSULE 186 MG.......29

CRESTOR....................................................58

CRITIC-AID CLEAR AF............................... 30

cromolyn sodium inhalation........................156

cromolyn sodium nasal.............................. 168

cromolyn sodium ophthalmic......................143

CROTAN LOTION 10 % EXTERNAL.......... 69

CRUEX PRESCRIPTION STRENGTH........30

cryselle-28..................................................116

CUPRIMINE............................................... 112

curae.......................................................... 123

CURANOL....................................................10

CURELIEF................................................. 153

cyanocobalamin injection solution 1000

mcg/ml........................................................184

cyclobenzaprine hcl oral tablet 10 mg, 5

mg.............................................................. 179

cyclopentolate hcl ophthalmic.................... 143

cyclophosphamide oral capsule................... 33

CYCLOPHOSPHAMIDE ORAL TABLET.....33

cycloserine oral............................................ 33

cyclosporine modified.................................126

cyclosporine oral........................................ 126

CYMBALTA..................................................62

cyproheptadine hcl oral.............................. 153

cyred eq..................................................... 116

CYSTAGON............................................... 110

CYSTARAN................................................143

d3 high potency oral capsule 25 mcg, 25

mcg (1000 ut)............................................... 83

d3 high potency oral capsule 250 mcg

(10000 ut).....................................................83

d3 max st......................................................83

d3 oral capsule 10 mcg (400 unit), 50 mcg

(2000 ut).......................................................83

d3 oral capsule 125 mcg (5000 ut)...............83

d3 oral capsule 25 mcg (1000 ut).................83

d3 oral capsule 250 mcg.............................. 83

d-3-5.............................................................83

d3-50............................................................ 83

daily acne wash..........................................135

daily fiber oral capsule 0.52 gm................. 104

daily fiber oral powder 43 %.......................104

daily multiple vitamins.................................. 83

daily multivitamins/iron............................... 181

daily vitamins................................................84

daily vite....................................................... 84

daily vites..................................................... 84

daily-vite....................................................... 84

dalfampridine er........................................... 63

danazol oral................................................115

dantrolene sodium oral.................................41

DAPAGLIFLOZIN PROPANEDIOL..............47

dapsone oral................................................ 33

DAPTACEL................................................ 127

darunavir.................................................... 135

dasetta 1/35............................................... 116

dasetta 7/7/7.............................................. 116

DAURISMO..................................................35

DAYHIST ALLERGY 12 HOUR RELIEF....153

daysee........................................................116

DAYVIGO...................................................179

deblitane.....................................................122

DECARA ORAL CAPSULE 1.25 MG

(50000 UT)................................................... 84

DECARA ORAL CAPSULE 625 MCG

(25000 UT)................................................... 84

deep sea nasal spray................................. 159

deferasirox................................................... 82

deferasirox granules.....................................82

DELSTRIGO................................................ 43

DELSYM CGH/CHEST CONG DM CHILD 171

DELSYM COUGH CHILDRENS................ 171

DELSYM COUGH/CHEST CONGEST DM171

DELSYM ORAL SUSPENSION

EXTENDED RELEASE.............................. 171

delyla..........................................................116

DELZICOL..................................................129

DENGVAXIA.............................................. 128

DENTA 5000 PLUS......................................76

DENTAGEL..................................................76

DEPEN TITRATABS.................................. 112

DEPO-ESTRADIOL................................... 116

DEPO-SUBQ PROVERA 104.................... 122

DERMELEVE ADVANCED FORMULA..... 135

DERMELEVE ANTI-ITCH SCALP............. 135

DESCOVY....................................................43

DESENEX EXTERNAL POWDER...............30

DESENEX JOCK ITCH................................ 30

desgen dm oral liquid................................. 164

desipramine hcl oral..................................... 27

desmopressin ace spray refrig................... 114

desmopressin acetate oral......................... 114

desmopressin acetate spray...................... 114

desogestrel-ethinyl estradiol oral tablet

0.15-0.02/0.01 mg (21/5)............................116

DETROL.....................................................111

DETROL LA............................................... 111

dexamethasone intensol............................ 113

dexamethasone oral elixir.......................... 113

dexamethasone oral solution..................... 113

dexamethasone oral tablet 0.5 mg, 0.75

mg, 1 mg, 2 mg.......................................... 113

dexamethasone oral tablet 1.5 mg, 4 mg, 6

mg.............................................................. 113

195

dexamethasone sodium phosphate

ophthalmic..................................................144

DEXCOM G6 RECEIVER............................ 73

DEXCOM G6 SENSOR............................... 73

DEXCOM G6 TRANSMITTER................... 135

DEXCOM G7 RECEIVER............................ 73

DEXCOM G7 SENSOR............................... 73

dexmethylphenidate hcl............................... 59

dexmethylphenidate hcl er........................... 59

dextroamphetamine sulfate er......................61

dextroamphetamine sulfate oral tablet 10

mg, 5 mg...................................................... 61

dextromethorphan polistirex er...................171

dextromethorphan-guaifenesin oral liquid

5-100 mg/5ml............................................. 171

dextromethorphan-guaifenesin oral syrup..171

DHIVY.......................................................... 39

DIACOMIT....................................................25

DIALYVITE 800 ORAL TABLET.................. 84

DIALYVITE VITAMIN D 5000.......................84

diamode....................................................... 90

diaper rash external ointment.......................71

diarrhea........................................................ 97

diarrhea relief............................................... 97

DIATRUST COVID-19 HOME TEST..........135

diazepam oral solution................................. 45

diazepam oral tablet.....................................45

diazepam rectal gel 10 mg, 20 mg............... 24

diazepam rectal gel 2.5 mg.......................... 24

dibromm childrens cold/cgh....................... 171

diclofenac potassium oral tablet 50 mg..........4

diclofenac sodium er...................................... 4

diclofenac sodium external gel 1 %................4

diclofenac sodium external solution 1.5 %..... 4

diclofenac sodium ophthalmic.................... 144

diclofenac sodium oral................................... 4

dicloxacillin sodium...................................... 20

dicyclomine hcl oral......................................90

DIFFERIN EXTERNAL CREAM...................64

DIFFERIN EXTERNAL GEL 0.1 %.............. 64

DIFFERIN EXTERNAL GEL 0.3 %.............. 64

DIFICID........................................................ 20

digestive probiotic oral capsule .................. 97

digestive probiotic oral capsule 250 mg....... 97

digoxin oral solution..................................... 56

digoxin oral tablet 125 mcg, 250 mcg.......... 56

dihydroergotamine mesylate injection..........31

DILANTIN ORAL CAPSULE 30 MG............ 24

diltiazem hcl er beads.................................. 56

diltiazem hcl er coated beads.......................56

diltiazem hcl er oral capsule extended

release 12 hour............................................ 56

diltiazem hcl er oral capsule extended

release 24 hour............................................ 56

diltiazem hcl oral.......................................... 56

dilt-xr............................................................ 56

dimaphen dm cold/cough........................... 171

dimethyl fumarate oral..................................63

dimethyl fumarate starter pack.....................63

DIPENTUM................................................ 129

diphedryl allergy......................................... 153

diphen........................................................ 153

diphenhydramine hcl childrens...................153

diphenhydramine hcl oral........................... 153

diphenoxylate-atropine.................................90

dipyridamole oral..........................................53

disopyramide phosphate.............................. 54

disulfiram oral tablet 250 mg........................ 16

disulfiram oral tablet 500 mg........................ 16

DIURIL......................................................... 57

divalproex sodium er.................................... 46

divalproex sodium oral capsule delayed

release sprinkle............................................ 46

divalproex sodium oral tablet delayed

release......................................................... 46

DIVIGEL TRANSDERMAL GEL 0.25

MG/0.25GM, 0.75 MG/0.75GM, 1.25

MG/1.25GM................................................116

DIVIGEL TRANSDERMAL GEL 0.5

MG/0.5GM, 1 MG/GM................................ 116

dm maximum adult.....................................171

docosanol external....................................... 72

docusate calcium....................................... 107

docusate mini............................................. 107

docusate sodium oral capsule....................107

docusate sodium oral liquid........................107

docusate sodium oral syrup....................... 107

DOCUSOL MINI.........................................107

docuzen......................................................107

DODEX...................................................... 184

dofetilide.......................................................54

donepezil hcl oral tablet 10 mg, 5 mg.......... 25

donepezil hcl oral tablet 23 mg.................... 25

DOPTELET.................................................. 53

DORAL.........................................................45

DORZOLAMIDE HCL SOLUTION 2 %

OPHTHALMIC............................................145

dorzolamide hcl solution 2 % ophthalmic... 145

dorzolamide hcl-timolol mal........................143

dotti............................................................ 116

double antibiotic external ointment 500-

10000 unit/gm............................................ 135

DOVATO...................................................... 42

doxazosin mesylate oral...............................53

doxepin hcl external..................................... 66

doxepin hcl oral capsule...............................27

doxepin hcl oral concentrate........................ 27

doxepin hcl oral tablet................................ 179

doxycycline hyclate oral capsule..................21

doxycycline hyclate oral tablet 100 mg........ 21

doxycycline monohydrate oral capsule 100

mg................................................................ 21

doxycycline monohydrate oral capsule 50

mg................................................................ 21

DR SMITHS DIAPER................................... 71

driminate...................................................... 27

dronabinol.................................................... 28

196

DROPSAFE ALCOHOL PREP.................. 135

drospirenone-ethinyl estradiol.................... 116

DROXIA ORAL CAPSULE 200 MG, 300

MG............................................................... 52

DROXIA ORAL CAPSULE 400 MG............. 52

dry-eye relief nighttime...............................145

dss..............................................................107

DUAKLIR PRESSAIR................................ 167

DUAVEE.................................................... 116

DUEXIS..........................................................4

DULERA.....................................................167

duloxetine hcl oral capsule delayed release

particles 20 mg, 30 mg, 60 mg.....................62

DUOBRII...................................................... 68

DUOPA........................................................ 39

DUPIXENT................................................. 125

DUREX EXTRA SENSITIVE THIN

DEVICE......................................................135

D-VI-SOL......................................................84

d-vite pediatric..............................................84

DYMISTA................................................... 153

e................................................................. 184

E.E.S. 400.................................................... 20

e-400-clear................................................. 184

ear drops.................................................... 150

ear wax kit.................................................. 150

ear wax removal.........................................150

ear wax removal system............................ 150

earwax removal..........................................150

earwax removal drops................................150

earwax removal kit otic solution 6.5 %....... 150

EASIVENT................................................. 135

EASIVENT MASK LARGE......................... 135

EASIVENT MASK MEDIUM.......................135

EASIVENT MASK SMALL......................... 136

EASY-C IMMUNE HEALTH....................... 181

easygel.........................................................76

easy-lax plus.............................................. 107

EASYMAX 15 LEVEL 2 CONTROL............. 73

EASYMAX 15 LEVEL 2-3 CONTROL..........73

ec-naproxen................................................... 4

econtra one-step........................................ 123

ED A-HIST ORAL LIQUID..........................164

ed bron gp.................................................. 159

ed chlorped jr............................................. 166

ed-apap........................................................ 10

EDARBI........................................................54

EDARBYCLOR............................................ 56

EDLUAR.....................................................179

EDURANT....................................................43

efavirenz.......................................................43

efavirenz-emtricitab-tenofo df.......................43

efavirenz-lamivudine-tenofovir..................... 43

effer-k oral tablet effervescent 25 meq.......181

EFFIENT...................................................... 53

EFUDEX.......................................................68

EGRIFTA SV..............................................114

electrolyte solution....................................... 78

ELESTRIN..................................................116

elinest.........................................................116

ELIQUIS....................................................... 51

ELIQUIS DVT/PE STARTER PACK............ 51

elixophyllin..................................................157

ELLA.......................................................... 122

ELLUME COVID-19 HOME TEST............. 136

ELMIRON...................................................112

eluryng....................................................... 116

EMEND ORAL............................................. 28

EMETROL ORAL SOLUTION......................28

EMFLAZA ORAL TABLET 6 MG............... 113

EMGALITY................................................... 32

EMGALITY (300 MG DOSE)........................32

EMPAVELI................................................. 136

emtricitabine.................................................43

emtricitabine-tenofovir df..............................43

EMTRIVA ORAL SOLUTION....................... 43

EMVERM..................................................... 37

emzahh...................................................... 122

enalapril maleate oral solution..................... 54

enalapril maleate oral tablet......................... 54

enalapril-hydrochlorothiazide....................... 56

ENBREL.....................................................126

ENDACOF-DM...........................................171

ENDARI........................................................76

endocet oral tablet 10-325 mg, 5-325 mg,

7.5-325 mg..................................................... 7

enema.......................................................... 97

enema disposable........................................ 97

enema mineral oil.......................................104

enema ready-to-use..................................... 97

enema rectal enema 16-6 gm/133ml........... 97

ENEMEEZ MINI......................................... 107

ENFAMIL ENFALYTE.................................. 78

ENFAMIL EXPECTA....................................84

ENGERIX-B............................................... 127

enilloring.....................................................116

enoxaparin sodium.......................................51

enpresse-28............................................... 116

enskyce...................................................... 116

ENSPRYNG............................................... 126

ENSTILAR....................................................68

entacapone.................................................. 38

entecavir.......................................................42

enteric aspirin.............................................136

ENTRESTO..................................................56

enulose.........................................................90

EPCLUSA.................................................... 42

ephrine nose drops.................................... 159

EPIDIOLEX.................................................. 23

EPIDUO....................................................... 64

EPIDUO FORTE.......................................... 64

epinephrine injection solution auto-injector 156

EPIPEN 2-PAK...........................................156

EPIPEN JR 2-PAK..................................... 156

epitol.............................................................24

EPOGEN......................................................52

ergocalciferol oral.......................................181

197

ERIVEDGE...................................................35

ERLEADA.................................................... 33

erlotinib hcl................................................. 141

ERMEZA.................................................... 123

errin............................................................ 122

ERYTHROCIN STEARATE......................... 20

erythromycin base oral.................................20

erythromycin ethylsuccinate oral..................20

erythromycin external...................................69

erythromycin ophthalmic............................ 144

erythromycin oral..........................................20

ESBRIET....................................................157

escitalopram oxalate oral tablet................... 26

esomeprazole magnesium oral packet........ 92

essential one daily........................................84

essentials..................................................... 84

estarylla......................................................117

estazolam...................................................179

estradiol oral...............................................117

estradiol transdermal patch twice weekly...117

estradiol transdermal patch weekly............117

estradiol vaginal......................................... 117

eszopiclone................................................ 179

ethambutol hcl oral tablet 100 mg................ 33

ethambutol hcl oral tablet 400 mg................ 33

ethosuximide oral......................................... 23

ethynodiol diac-eth estradiol...................... 117

etodolac..........................................................4

etonogestrel-ethinyl estradiol..................... 117

etoposide oral...............................................34

etravirine...................................................... 43

EUCRISA..................................................... 66

EULEXIN......................................................33

euthyrox..................................................... 123

EVAC......................................................... 104

EVAMIST................................................... 117

everolimus oral tablet 0.25 mg, 0.5 mg,

0.75 mg, 1 mg............................................ 126

everolimus oral tablet 10 mg, 2.5 mg, 5

mg, 7.5 mg................................................... 35

everolimus oral tablet soluble.......................35

EVISTA...................................................... 122

EVOTAZ.......................................................44

EVRYSDI................................................... 110

EXCEDRIN EXTRA STRENGTH.................10

EXCEDRIN MIGRAINE................................10

EXELON.......................................................25

exemestane..................................................34

EXKIVITY..................................................... 35

EX-LAX MAXIMUM STRENGTH............... 107

EX-LAX ULTRA..........................................136

EXTAVIA...................................................... 63

eye drops adv relief....................................145

eye drops advanced relief.......................... 145

eye drops long lasting................................ 145

eye drops ophthalmic solution 0.05 %....... 145

eye drops ophthalmic solution 0.05-0.1-1-1

%................................................................ 146

eye drops ophthalmic solution 0.05-0.25 %146

eye irritation relief drops.............................146

eye itch relief ophthalmic solution 0.035 % 150

eye lubricant...............................................146

eye lubricant nighttime............................... 146

EYES ALIVE.............................................. 146

EYSUVIS....................................................144

ezetimibe......................................................58

EZFE 200..................................................... 78

falmina........................................................117

famotidine acid reducer oral tablet 10 mg.... 91

famotidine oral suspension reconstituted.....91

famotidine oral tablet....................................91

famotidine orig st..........................................91

FANAPT....................................................... 40

FANAPT TITRATION PACK........................ 40

FARXIGA..................................................... 47

FASENRA PEN..........................................158

fast relief laxative....................................... 136

FASTEP COVID-19 ANTIGEN TEST........ 136

febuxostat.....................................................31

felbamate oral suspension........................... 23

felbamate oral tablet.....................................23

felodipine er..................................................55

FEMRING...................................................117

fenofibrate micronized oral capsule 134

mg, 200 mg, 67 mg...................................... 58

fenofibrate oral capsule 134 mg, 200 mg,

67 mg........................................................... 58

fenofibrate oral tablet 145 mg, 48 mg.......... 58

fenofibrate oral tablet 160 mg, 54 mg.......... 58

FENOGLIDE................................................ 58

FENSOLVI (6 MONTH)..............................124

fentanyl transdermal patch 72 hour 100

mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,

75 mcg/hr....................................................... 6

ferate............................................................ 78

FER-IN-SOL.................................................78

ferocon......................................................... 78

ferosul.......................................................... 78

ferotrinsic......................................................78

ferretts.......................................................... 78

ferrex 150 capsule 150 mg oral....................78

FERREX 150 CAPSULE 150 MG ORAL..... 79

FERRIC X-150............................................. 79

FERRIPROX TWICE-A-DAY....................... 82

ferrous fumarate oral tablet 324 (106 fe)

mg, 324 mg.................................................. 79

ferrous gluconate......................................... 79

ferrous gluconate oral tablet 240 (27 fe) mg 79

ferrous gluconate oral tablet 324 (37.5 fe)

mg................................................................ 79

ferrous gluconate oral tablet 324 (38 fe) mg 79

ferrous sulfate.............................................. 79

ferrous sulfate oral solution 75 (15 fe)

mg/ml........................................................... 79

ferrous sulfate oral tablet 325 (65 fe) mg..... 79

ferrous sulfate oral tablet delayed release... 79

198

FETZIMA......................................................26

fever reducer/pain reliever........................... 10

fever reducing childrens............................... 10

feverall adults............................................... 10

feverall childrens.......................................... 10

FEVERALL INFANTS.................................. 10

FEVERALL JUNIOR STRENGTH................10

fe-vite iron.................................................... 79

fexofenadine hcl......................................... 166

fexofenadine hcl oral.................................. 166

FIASP...........................................................48

FIASP FLEXTOUCH.................................... 48

FIASP PENFILL........................................... 48

fiber laxative + calcium...............................107

fiber laxative oral capsule 0.52 gm.............104

fiber laxative oral tablet 500 mg................. 107

fiber oral capsule 0.52 gm..........................104

fiber oral powder 28.3 %............................ 104

fiber oral powder 43 %............................... 104

fiber oral powder 58.6 %............................ 104

fiber oral tablet 500 mg.............................. 107

fiber oral tablet 625 mg.............................. 107

fiber powder oral powder 43 %.................. 104

fiber therapy oral capsule 0.52 gm.............104

fiber therapy oral powder 28.3 %............... 105

fiber therapy oral tablet 500 mg................. 107

fiber therapy oral tablet 625 mg................. 107

fiber-caps................................................... 107

fiber-lax...................................................... 107

FINACEA EXTERNAL FOAM...................... 64

finasteride oral tablet 5 mg.........................111

fingolimod hcl............................................... 63

FINTEPLA.................................................... 23

finzala.........................................................117

first aid antibiotic external ointment , 3.5-

400-5000 ..................................................... 22

first aid antiseptic external solution 10 %..... 22

FIRVANQ..................................................... 19

FLANAX......................................................... 4

FLAREX..................................................... 144

flecainide acetate......................................... 54

FLECTOR...................................................... 4

FLEET BISACODYL.................................. 136

FLEET ENEMA............................................ 97

FLEET OIL................................................. 105

FLEET PEDIATRIC......................................97

FLORA VANCE............................................97

floranex tablet oral........................................97

FLORANEX TABLET ORAL........................ 97

FLOWFLEX COVID-19 AG HOME TEST.. 136

FLUAD QUADRIVALENT.......................... 128

FLUARIX QUADRIVALENT....................... 128

FLUBLOK QUADRIVALENT......................128

FLUCELVAX QUADRIVALENT................. 128

fluconazole oral............................................ 29

fludrocortisone acetate oral........................113

FLULAVAL QUADRIVALENT.................... 128

FLUMIST QUADRIVALENT.......................128

fluocinolone acetonide body.........................66

fluocinolone acetonide external cream

0.025 %........................................................ 66

fluocinolone acetonide external ointment.....66

fluocinolone acetonide external solution...... 66

fluocinolone acetonide scalp........................ 66

fluocinonide emulsified base........................ 66

fluocinonide external cream......................... 66

fluocinonide external solution.......................66

fluoridex daily renewal..................................76

fluorometholone......................................... 144

fluorouracil external cream 5 %....................68

fluorouracil external solution........................ 68

fluoxetine hcl oral capsule............................26

fluoxetine hcl oral solution............................26

fluphenazine decanoate injection.................40

fluphenazine hcl injection............................. 40

fluphenazine hcl oral concentrate................ 40

fluphenazine hcl oral elixir............................40

fluphenazine hcl oral tablet.......................... 40

flurbiprofen sodium.....................................144

FLUTICASONE FUROATE-VILANTEROL 167

fluticasone propionate external cream......... 66

fluticasone propionate external ointment..... 66

FLUTICASONE PROPIONATE HFA......... 155

fluticasone propionate nasal...................... 155

fluticasone-salmeterol inhalation aerosol

powder breath activated 100-50 mcg/act,

250-50 mcg/act, 500-50 mcg/act................167

FLUTICASONE-SALMETEROL

INHALATION AEROSOL POWDER

BREATH ACTIVATED 113-14 MCG/ACT,

232-14 MCG/ACT, 55-14 MCG/ACT..........167

fluvoxamine maleate.................................... 26

FLUZONE HIGH-DOSE QUADRIVALENT 128

FLUZONE QUADRIVALENT..................... 128

FML FORTE...............................................144

foaming antacid oral tablet chewable 80-20

mg................................................................ 97

FOLAGENT DHA....................................... 181

FOLAMED DHA......................................... 181

FOLCYTEINE...............................................84

folic acid oral tablet 1 mg........................... 136

folic acid oral tablet 400 mcg, 800 mcg......136

foltrin............................................................ 79

foot & sneaker............................................ 136

foot care (terbinafine)................................... 30

for sty relief.................................................146

FORFIVO XL................................................26

FORTEO.................................................... 130

FOSAMAX..................................................130

FOSAMAX PLUS D....................................130

fosamprenavir calcium................................. 44

fosinopril sodium.......................................... 54

fosinopril sodium-hctz.................................. 57

FREESTYLE LIBRE 14 DAY READER....... 74

FREESTYLE LIBRE 14 DAY SENSOR....... 74

FREESTYLE LIBRE 2 READER..................74

FREESTYLE LIBRE 2 SENSOR..................74

199

FREESTYLE LIBRE 3 SENSOR..................74

FREESTYLE LIBRE READER.....................74

FREESTYLE PRECISION NEO TEST........ 74

FREESTYLE TEST...................................... 74

freeze dried acidophilus............................... 97

FROVA.........................................................32

fruity c.........................................................181

ft 12 hour cough relief................................ 171

ft 24 hour nasal allergy...............................167

ft 8 hour pain relief....................................... 10

ft acid reducer oral capsule delayed

release......................................................... 92

ft acid reducer oral tablet..............................91

ft all day allergy.......................................... 153

ft all day allergy 24 hour............................. 153

ft all day allergy relief................................. 166

ft all day allergy-d....................................... 164

ft all day pain relief......................................... 4

ft allergy childrens...................................... 166

ft allergy d-12 hour..................................... 172

ft allergy relief 12 hour................................166

ft allergy relief 24 hour................................166

ft allergy relief cetirizine..............................153

ft allergy relief childrens oral liquid............. 154

ft allergy relief loratadine............................ 166

ft allergy relief oral capsule........................ 154

ft allergy relief oral tablet 180 mg............... 166

ft allergy relief oral tablet 25 mg................. 154

ft allergy relief-d..........................................172

ft antacid & antigas.......................................98

ft antacid extra strength................................98

ft antacid regular strength............................ 98

ft antibiotic.................................................. 136

ft anti-diarrheal oral tablet............................ 90

ft anti-diarrheal/anti-gas............................... 98

ft antifungal external cream 1 %.................136

ft antifungal external cream 2 %...................31

ft arthritis pain reliever..................................10

ft aspirin......................................................136

ft aspirin low dose...................................... 136

ft athletes foot (terbinafine).......................... 31

ft chest congestion relief............................ 159

ft children's pain/fever.................................. 10

ft clearlax....................................................105

ft cold & cough relief dm.............................172

ft docosanol..................................................72

ft double antibiotic...................................... 136

ft earwax removal.......................................151

ft earwax removal kit.................................. 151

ft enema mineral oil....................................105

ft enema saline.............................................98

ft enteric coated aspirin.............................. 136

ft eye drops................................................ 146

ft fiber laxative............................................ 107

ft fiber oral powder 43 %............................ 105

ft gas relief....................................................98

ft gas relief extra strength.............................98

ft gas relief infants........................................ 98

ft gas relief ultra strength..............................98

ft gentle laxative......................................... 136

ft ibuprofen ib childrens.................................. 4

ft ibuprofen oral tablet.................................... 4

ft itch relief max strength external cream..... 66

ft itch relief/aloe max str............................... 66

ft laxative.................................................... 136

ft lice killing max st....................................... 38

ft lubricant eye drops ophthalmic solution

0.4-0.3 %....................................................146

ft lubricant eye drops ophthalmic solution

0.5 %.......................................................... 146

ft magnesium citrate...................................107

ft magnesium oxide...................................... 79

ft miconazole 3 combo pack.........................29

ft miconazole 7............................................. 29

ft migraine relief............................................11

ft milk of magnesia....................................... 98

ft mineral oil................................................105

ft motion sickness oral tablet 50 mg.............27

ft mucus relief 12hr oral tablet extended

release 12 hour 1200 mg........................... 159

ft mucus relief d 12 hour.............................172

ft mucus relief dm oral tablet extended

release 12 hour 30-600 mg........................ 172

ft nasal decongestant max str oral tablet... 172

ft nasal decongestant max str oral tablet

extended release 12 hour.......................... 172

ft nasal decongestant pe............................ 159

ft nasal spray..............................................172

ft nicotine......................................................18

ft nicotine mini.............................................. 18

ft pain & fever childrens................................11

ft pain & fever infants................................... 11

ft pain relief adult extra st............................. 11

ft pain relief extra strength............................11

ft pain relief oral tablet 200 mg.......................4

ft pain relief oral tablet 325 mg.....................11

ft pain reliever ex str adult............................ 11

ft senna laxative......................................... 107

ft senna laxatives....................................... 108

ft senna-s................................................... 108

ft stomach relief oral suspension..................98

ft stomach relief oral tablet........................... 98

ft stomach relief oral tablet chewable...........98

ft stool softener oral capsule...................... 108

ft stool softener oral tablet 50-8.6 mg.........108

ft triple antibiotic........................................... 22

ft tussin adult.............................................. 159

ft tussin cf adult.......................................... 164

ft tussin dm max adult................................ 172

ft vitamin d3 oral tablet................................. 84

full spectrum b/vitamin c...............................84

FULPHILA.................................................... 52

fungi-guard................................................. 136

FUROSCIX...................................................57

furosemide oral solution 10 mg/ml............... 57

furosemide oral tablet...................................57

FUZEON...................................................... 44

200

FYCOMPA................................................... 23

FYLNETRA................................................ 136

g tussin ac.................................................. 172

gabapentin oral capsule............................... 24

gabapentin oral solution 250 mg/5ml........... 24

gabapentin oral tablet 600 mg, 800 mg........24

galantamine hydrobromide oral solution...... 25

galantamine hydrobromide oral tablet 12

mg, 8 mg...................................................... 25

galantamine hydrobromide oral tablet 4 mg.25

GARDASIL 9.............................................. 127

gas relief extra strength................................98

gas relief extstrength....................................98

gas relief infants........................................... 98

gas relief infants drops oral suspension 40

mg/0.6ml...................................................... 98

gas relief infants oral suspension 20

mg/0.3ml...................................................... 98

gas relief oral capsule 125 mg..................... 99

gas relief oral capsule 180 mg..................... 99

gas relief oral tablet chewable 125 mg.........99

gas relief oral tablet chewable 80 mg...........99

gas relief ultra strength.................................99

gas relief ultstrength.....................................99

GAS-X EXTRA STRENGTH ORAL

CAPSULE.................................................... 99

GAS-X EXTRA STRENGTH ORAL

TABLET CHEWABLE.................................. 99

GAS-X ULTRA STRENGTH........................ 99

GATTEX.......................................................91

gavilax oral powder.................................... 105

gavilyte-c...................................................... 91

gavilyte-g......................................................91

gavilyte-n with flavor pack............................ 91

GAVISCON.................................................. 99

GAVISCON EXTRA RELIEF FORMULA..... 99

GAVISCON EXTRA STRENGTH................ 99

GAVRETO..................................................141

gefitinib.......................................................141

GELUSIL...................................................... 99

gemfibrozil oral.............................................58

GEMTESA....................................................41

generlac....................................................... 90

gengraf oral capsule...................................126

GENOTROPIN........................................... 114

GENOTROPIN MINIQUICK....................... 114

gentamicin sulfate external.......................... 69

gentamicin sulfate ophthalmic....................144

GENTEAL SEVERE...................................146

GENTEAL TEARS MODERATE PF.......... 146

GENTEAL TEARS NIGHT-TIME............... 146

GENTEAL TEARS OPHTHALMIC

SOLUTION 0.1-0.2-0.3 %.......................... 146

GENTEAL TEARS PF................................146

GENTEAL TEARS SEVERE DAY/NIGHT. 146

gentle laxative............................................ 136

gentle laxative womens..............................137

gentlelax.....................................................105

genuine aspirin...........................................137

GENVOYA................................................... 42

GEODON ORAL.......................................... 40

geri-dryl...................................................... 154

geri-kot....................................................... 108

geri-lanta maximum strength........................99

geri-lanta oral suspension 200-200-20

mg/5ml......................................................... 99

geri-lanta supreme....................................... 99

geri-mox..................................................... 100

geri-tussin dm oral syrup............................172

geri-tussin oral liquid.................................. 159

GILENYA......................................................63

GILOTRIF...................................................141

giltuss severe sinus....................................172

glatiramer acetate........................................ 63

glatopa......................................................... 63

GLEEVEC.................................................. 141

glimepiride....................................................47

glipizide er.................................................... 47

glipizide oral tablet 10 mg, 5 mg.................. 47

glipizide xl.....................................................47

glucagon emergency injection kit................. 48

GLUCAGON EMERGENCY INJECTION

SOLUTION RECONSTITUTED................... 48

GLUCO TO GO............................................50

GLUCOSE CONTROL SOLUTIONS........... 74

glucose oral tablet chewable 4 gm...............50

glyburide micronized.................................... 47

glyburide oral................................................47

glyburide-metformin..................................... 47

glycerin (adult) rectal suppository 2 gm..... 108

glycerin (infants & children) rectal

suppository 1 gm........................................108

glycerin adult rectal suppository 2 gm........108

glycerin child rectal suppository 1 gm, 1.2

gm.............................................................. 108

glycerin childrens....................................... 108

glycerin external liquid , 99.5 %.................. 71

glycerin pediatric rectal suppository 1.2 gm

....................................................................108

glycolax...................................................... 105

glycopyrrolate oral tablet 1 mg..................... 90

glycopyrrolate oral tablet 2 mg..................... 90

GLYXAMBI...................................................47

GOCOVRI.................................................... 38

gormel.......................................................... 72

gormel 10..................................................... 72

GRALISE ORAL TABLET 300 MG, 600

MG............................................................... 62

GRANIX....................................................... 52

griseofulvin microsize oral............................29

griseofulvin ultramicrosize............................29

guaifenesin er oral tablet extended release

12 hour 1200 mg........................................ 159

guaifenesin oral liquid................................ 159

guaifenesin oral tablet 400 mg................... 159

guaifenesin-codeine................................... 172

guaifenesin-dm oral syrup..........................172

201

guanfacine hcl.............................................. 53

guanfacine hcl er..........................................59

GUARDIAN CONNECT TRANSMITTER...137

GUARDIAN LINK 3 TRANSMITTER..........137

GUARDIAN SENSOR (3).............................74

GUARDIAN SENSOR 3............................... 74

GVOKE HYPOPEN 1-PACK........................48

GVOKE HYPOPEN 2-PACK........................48

GVOKE KIT..................................................48

GVOKE PFS................................................ 48

GYNAZOLE-1.............................................. 29

habitrol......................................................... 17

HADLIMA................................................... 137

HADLIMA PUSHTOUCH........................... 137

HAEGARDA............................................... 125

hailey 1.5/30...............................................117

hailey 24 fe.................................................117

hailey fe 1.5/30...........................................117

hailey fe 1/20..............................................117

HALCION................................................... 179

halobetasol propionate external cream........ 67

haloette...................................................... 117

haloperidol decanoate intramuscular........... 40

haloperidol oral.............................................40

HARVONI.....................................................42

HAVRIX......................................................127

headache formula oral tablet 250-250-65

mg................................................................ 11

headache relief extra str...............................11

headache relief oral tablet 250-250-65 mg.. 11

healthy hair/skin/nails...................................84

heartburn antacid....................................... 100

heartburn antacid ex st...............................100

heartburn prevention oral tablet 10 mg........ 91

heartburn relief ex st.................................. 100

heartburn relief oral tablet 10 mg................. 92

heartburn relief oral tablet 200 mg............... 92

heartburn relief oral tablet chewable 160-

105 mg....................................................... 100

heartland gas relief.....................................100

heather....................................................... 122

h-e-b aspirin............................................... 137

h-e-b childrens allergy................................154

HELIDAC THERAPY....................................91

HEMANGEOL.............................................. 55

HEMLIBRA SUBCUTANEOUS SOLUTION

105 MG/0.7ML, 12 MG/0.4ML, 150

MG/ML, 30 MG/ML, 60 MG/0.4ML...............53

HEMLIBRA SUBCUTANEOUS SOLUTION

300 MG/2ML................................................ 53

hemorrhoidal rectal suppository 0.25-3-

85.5 %.......................................................... 72

heparin sodium (porcine) injection solution

1000 unit/ml, 20000 unit/ml.......................... 51

heparin sodium (porcine) injection solution

10000 unit/ml, 5000 unit/ml.......................... 51

heparin sodium (porcine) injection solution

prefilled syringe............................................ 51

heparin sodium (porcine) pf injection

solution 1000 unit/ml.................................... 51

heparin sodium (porcine) pf injection

solution 5000 unit/0.5ml, 5000 unit/ml..........51

HEPLISAV-B.............................................. 128

her style......................................................123

hi cal.............................................................79

HIBERIX.....................................................127

HORIZANT...................................................62

HUMALOG................................................... 48

HUMALOG JUNIOR KWIKPEN................... 48

HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML.49

HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 200 UNIT/ML.49

HUMALOG MIX 50/50 KWIKPEN................ 49

HUMALOG MIX 75/25..................................49

HUMALOG MIX 75/25 KWIKPEN................ 49

HUMALOG TEMPO PEN.............................49

HUMATROPE............................................ 114

HUMIRA (2 PEN) SUBCUTANEOUS PEN-

INJECTOR KIT 40 MG/0.4ML, 80

MG/0.8ML.................................................. 126

HUMIRA (2 SYRINGE) SUBCUTANEOUS

PREFILLED SYRINGE KIT 10 MG/0.1ML,

20 MG/0.2ML, 40 MG/0.4ML......................126

HUMIRA SUBCUTANEOUS PEN-

INJECTOR KIT 80 MG/0.8ML....................126

HUMIRA-PED<40KG CROHNS STARTER.................................................. 126

HUMIRA-PED>/=40KG CROHNS START.126

HUMIRA-PED>/=40KG UC STARTER...... 126

HUMIRA-PSORIASIS/UVEIT STARTER... 126

HUMULIN 70/30 KWIKPEN......................... 49

HUMULIN 70/30 VIAL.................................. 49

HUMULIN N KWIKPEN................................49

HUMULIN N VIAL........................................ 49

HUMULIN R U-500 KWIKPEN.....................49

HUMULIN R U-500 VIAL

(CONCENTRATED).....................................49

HUMULIN R VIAL........................................ 49

HYCAMTIN ORAL........................................34

hydralazine hcl oral...................................... 58

hydrochlorothiazide oral capsule..................57

hydrochlorothiazide oral tablet 12.5 mg....... 57

hydrochlorothiazide oral tablet 25 mg, 50

mg................................................................ 57

hydrocodone bit-homatrop mbr.................. 137

hydrocodone-acetaminophen oral solution

7.5-325 mg/15ml............................................ 7

hydrocodone-acetaminophen oral tablet

10-325 mg, 5-325 mg, 7.5-325 mg.................7

hydrocortisone (perianal)........................... 129

hydrocortisone anti-itch................................ 67

hydrocortisone butyrate external ointment... 67

hydrocortisone butyrate external solution.... 67

hydrocortisone external cream 0.5 %, 2.5

%.................................................................. 67

hydrocortisone external cream 1 %..............67

hydrocortisone external lotion 2.5 %............ 67

202

hydrocortisone external ointment 0.5 %.......67

hydrocortisone external ointment 1 %..........67

hydrocortisone external ointment 2.5 %.......67

hydrocortisone max st external cream......... 67

hydrocortisone max st/12 moist................... 67

hydrocortisone oral tablet 10 mg, 20 mg, 5

mg.............................................................. 113

hydrocortisone plus...................................... 67

hydrocortisone rectal enema 100 mg/60ml 129

hydrocortisone/aloe......................................67

hydrocortisone/aloe max str......................... 67

hydrocortisone-acetic acid......................... 150

hydrolatum................................................... 71

hydromet.................................................... 137

hydromorphone hcl oral................................. 7

hydromorphone hcl rectal...............................7

hydrophor..................................................... 71

hydroxychloroquine sulfate oral tablet 200

mg................................................................ 37

hydroxyurea oral.......................................... 34

hydroxyzine hcl oral..................................... 45

hydroxyzine pamoate oral............................ 45

HYFTOR.................................................... 137

hyoscyamine sulfate er.............................. 137

hyoscyamine sulfate oral............................137

hyoscyamine sulfate sublingual................. 137

hyosyne......................................................137

HYPERSAL INHALATION NEBULIZATION

SOLUTION 7 %..........................................172

HYPERTET................................................ 128

HYPOTEARS............................................. 146

HYSINGLA ER............................................... 6

IBRANCE ORAL CAPSULE.........................35

IBRANCE ORAL TABLET............................35

IBSRELA...................................................... 90

ibuprofen........................................................ 4

ibuprofen childrens oral tablet chewable

100 mg........................................................... 4

ibuprofen cold & sinus................................172

ibuprofen cold/sinus oral tablet 30-200 mg 172

ibu-profen cold/sinus oral tablet 30-200 mg

....................................................................173

ibuprofen ib childrens..................................... 4

ibuprofen ib oral tablet 200 mg.......................4

ibuprofen infants oral suspension 50

mg/1.25ml...................................................... 5

ibuprofen jr oral tablet 100 mg....................... 5

ibuprofen junior.............................................. 5

ibuprofen junior strength oral tablet

chewable 100 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

icatibant acetate......................................... 125

iclevia......................................................... 117

ICLUSIG.....................................................141

IDHIFA......................................................... 34

iferex 150..................................................... 79

iferex 150 forte............................................. 79

IHEALTH COVID-19 RAPID TEST............ 137

ILARIS........................................................125

ILEVRO...................................................... 144

ILUMYA......................................................125

imatinib mesylate....................................... 141

IMBRUVICA............................................... 141

imipramine hcl oral....................................... 27

imiquimod external cream 5 %.....................68

IMITREX.......................................................32

IMODIUM A-D ORAL TABLET.....................90

IMODIUM MULTI-SYMPTOM RELIEF...... 100

INBRIJA....................................................... 39

incassia...................................................... 122

INCRELEX................................................. 114

INCRUSE ELLIPTA....................................155

indapamide...................................................57

INDICAID COVID-19 RAPID TEST............137

indomethacin oral capsule............................. 5

indoor/outdoor allergy rlf............................ 154

INFANRIX.................................................. 127

infant gas relief...........................................100

INFANTS ADVIL............................................ 5

infants gas relief......................................... 100

infants ibuprofen.............................................5

infants pain & fever...................................... 11

infants pain relief drops................................ 11

infants pain/fever..........................................11

INGREZZA................................................... 62

INLYTA.......................................................141

INSPIREASE..............................................137

INSPIREASE RESERVOIR BAGS............ 137

instacort 5.....................................................67

INSULIN ASPART........................................49

INSULIN ASPART PROT & ASPART..........49

INSULIN DEGLUDEC.................................. 49

INSULIN DEGLUDEC FLEXTOUCH........... 49

INSULIN GLARGINE-YFGN........................ 49

INSULIN LISPRO.........................................49

INSULIN LISPRO (1 UNIT DIAL)................. 49

INSULIN LISPRO JUNIOR KWIKPEN.........49

INSULIN LISPRO PROT & LISPRO............ 49

INSULIN PEN NEEDLES 29G X 12.7MM..137

INSULIN PEN NEEDLES 29G X 12MM ,

31G X 5 MM , 31G X 6 MM , 31G X 8 MM.137

INSULIN PEN NEEDLES 32G X 4 MM ,

32G X 6 MM................................................. 74

INSULIN SYRINGES 28G X 1/2" 0.5 ML,

28G X 1/2" 1 ML.........................................137

INSULIN SYRINGES 29G X 1/2" 0.3 ML,

29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML.... 137

INSULIN SYRINGES 29G X 1/2" 1 ML,

30G X 5/16" 0.5 ML....................................137

INSULIN SYRINGES 30G X 1/2" 1 ML,

31G X 15/64" 0.3 ML, 31G X 5/16" 0.3 ML,

31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML..... 137

INSULIN SYRINGES 30G X 5/16" 1 ML....137

INTELENCE ORAL TABLET 25 MG............43

203

INTELISWAB COVID-19 RAPID TEST......137

intestinex.................................................... 100

introvale......................................................117

INVEGA........................................................40

INVEGA HAFYERA......................................40

INVEGA SUSTENNA................................... 40

INVEGA TRINZA..........................................40

INVELTYS..................................................144

INVOKAMET................................................ 47

INVOKAMET XR.......................................... 47

INVOKANA...................................................47

IPOL........................................................... 127

ipratropium bromide inhalation...................155

ipratropium bromide nasal..........................155

ipratropium-albuterol.................................. 167

irbesartan..................................................... 54

irbesartan-hydrochlorothiazide.....................57

IRESSA...................................................... 141

iron (ferrous sulfate) oral solution.................79

iron infant/toddler......................................... 79

iron oral tablet 240 (27 fe) mg...................... 79

iron oral tablet 325 (65 fe) mg...................... 79

iron supplement childrens............................ 80

ISENTRESS HD...........................................42

ISENTRESS ORAL PACKET.......................42

ISENTRESS ORAL TABLET....................... 42

ISENTRESS ORAL TABLET CHEWABLE.. 42

isibloom...................................................... 117

isoniazid oral................................................ 33

isosorbide dinitrate....................................... 59

isosorbide mononitrate.................................59

isosorbide mononitrate er.............................59

isotretinoin oral capsule 10 mg, 20 mg, 40

mg................................................................ 64

isotretinoin oral capsule 30 mg.................... 64

ISTALOL.................................................... 145

itraconazole oral...........................................29

ivermectin oral..............................................37

jaimiess...................................................... 117

JAKAFI......................................................... 35

jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5

mg, 3 mg, 4 mg, 5 mg, 7.5 mg..................... 51

jantoven oral tablet 6 mg..............................51

JANUMET.................................................... 47

JANUMET XR.............................................. 47

JANUVIA...................................................... 47

JARDIANCE.................................................47

jasmiel........................................................ 117

JAVYGTOR ORAL PACKET 100 MG........110

jencycla...................................................... 122

JENTADUETO............................................. 47

JENTADUETO XR....................................... 47

jock itch external cream 1 %........................ 31

jock itch max st...........................................137

jock itch spray powder................................137

jolessa........................................................ 117

JORNAY PM................................................ 60

JUBLIA......................................................... 70

juleber........................................................ 117

JULUCA....................................................... 42

junel 1.5/30.................................................117

junel 1/20....................................................117

junel fe oral tablet 1.5-30 mg-mcg..............117

junel fe oral tablet 1-20 mg-mcg.................117

junel fe oral tablet 1-20 mg-mcg(24).......... 118

JYNARQUE ORAL TABLET THERAPY

PACK 15 MG................................................82

KALETRA.....................................................44

kalliga......................................................... 118

KALYDECO................................................156

kariva..........................................................118

KATERZIA....................................................55

kelnor 1/35................................................. 118

kelnor 1/50................................................. 118

KERENDIA...................................................57

KESIMPTA................................................... 63

ketoconazole external cream....................... 70

ketoconazole external shampoo.................. 70

ketoconazole oral......................................... 29

KETO-DIASTIX............................................ 74

KETONE CARE........................................... 74

KETONE TEST............................................ 74

ketoprofen oral capsule 25 mg.......................5

ketorolac tromethamine ophthalmic

solution 0.4 %.............................................144

ketorolac tromethamine ophthalmic

solution 0.5 %.............................................144

ketorolac tromethamine oral...........................5

KETOSTIX................................................... 74

ketotifen fumarate ophthalmic.................... 150

KEVZARA.................................................. 125

KINERET....................................................125

KISQALI (200 MG DOSE)............................35

KISQALI (400 MG DOSE)............................35

KISQALI (600 MG DOSE)............................35

KISQALI FEMARA (200 MG DOSE)............35

KISQALI FEMARA (400 MG DOSE)............35

KISQALI FEMARA (600 MG DOSE)............35

klayesta........................................................ 70

klor-con........................................................ 76

klor-con 10................................................... 76

klor-con m10................................................ 76

klor-con m20................................................ 76

klor-con/ef.................................................. 181

KLOXXADO................................................. 17

KOSELUGO................................................. 35

kourzeq........................................................ 64

K-PHOS....................................................... 80

k-prime....................................................... 181

KRAZATI.................................................... 137

KRINTAFEL................................................. 37

kurvelo........................................................118

labetalol hcl oral........................................... 55

LAC-HYDRIN FIVE...................................... 67

lacosamide oral solution 10 mg/ml...............24

lacosamide oral tablet.................................. 24

lactobacillus oral tablet...............................100

204

lacto-pectin.................................................100

lactulose encephalopathy oral solution 10

gm/15ml....................................................... 90

lactulose oral solution...................................90

LAGEVRIO...................................................45

LAMISIL AT EXTERNAL CREAM................31

LAMISIL AT JOCK ITCH..............................31

lamivudine oral solution................................43

lamivudine oral tablet 100 mg...................... 42

lamivudine oral tablet 150 mg, 300 mg........ 43

lamivudine-zidovudine..................................43

lamotrigine oral tablet...................................23

lamotrigine oral tablet chewable...................23

lamotrigine starter kit-blue............................23

lamotrigine starter kit-green......................... 23

lamotrigine starter kit-orange....................... 23

LANCETS.....................................................74

lansoprazole oral capsule delayed release

15 mg........................................................... 92

lansoprazole oral capsule delayed release

30 mg........................................................... 92

lansoprazole oral tablet delayed release

dispersible 15 mg......................................... 92

LANTUS SOLOSTAR.................................. 49

LANTUS U-100 VIAL................................... 49

lapatinib ditosylate......................................141

larin 1.5/30................................................. 118

larin 1/20.................................................... 118

larin 24 fe................................................... 118

larin fe 1.5/30............................................. 118

larin fe 1/20................................................ 118

latanoprost ophthalmic............................... 142

LATUDA....................................................... 40

laxacin........................................................ 108

laxaclear.....................................................105

laxative max str.......................................... 108

laxative oral powder 17 gm/scoop..............105

laxative oral tablet delayed release 5 mg...137

laxative pills max st.................................... 108

laxative pills oral tablet 25 mg.................... 108

laxative rectal suppository 10 mg...............137

laxative regular strength.............................108

LEDIPASVIR-SOFOSBUVIR....................... 42

leena.......................................................... 118

leflunomide oral..........................................126

lenalidomide................................................. 34

LENVIMA (10 MG DAILY DOSE)...............141

LENVIMA (12 MG DAILY DOSE)...............141

LENVIMA (14 MG DAILY DOSE)...............141

LENVIMA (18 MG DAILY DOSE)...............141

LENVIMA (20 MG DAILY DOSE)...............141

LENVIMA (24 MG DAILY DOSE)...............141

LENVIMA (4 MG DAILY DOSE).................141

LENVIMA (8 MG DAILY DOSE).................141

LESCOL XL..................................................58

lessina........................................................ 118

LETAIRIS................................................... 157

letrozole oral.................................................34

leucovorin calcium oral tablet 10 mg............36

leucovorin calcium oral tablet 15 mg, 25

mg, 5 mg...................................................... 36

LEUKERAN..................................................33

LEUKINE......................................................52

leuprolide acetate injection.........................124

levalbuterol hcl inhalation...........................156

LEVBID...................................................... 138

LEVEMIR FLEXPEN.................................... 49

LEVEMIR U-100 VIAL..................................49

levetiracetam oral solution........................... 23

levetiracetam oral tablet............................... 23

levobunolol hcl........................................... 145

levocetirizine dihydrochloride oral tablet.... 154

levofloxacin oral tablet..................................21

levonest......................................................118

levonorgest-eth estrad 91-day................... 118

levonorgestrel.............................................123

levonorgestrel-ethinyl estrad oral tablet

0.1-20 mg-mcg........................................... 118

levonorgestrel-ethinyl estrad oral tablet

0.15-30 mg-mcg......................................... 118

levonorg-eth estrad triphasic......................118

levora 0.15/30 (28)..................................... 118

levo-t.......................................................... 123

levothyroxine sodium oral tablet.................123

levoxyl........................................................ 123

LIALDA.......................................................129

LICART.......................................................... 5

lice killing................................................38, 69

lice killing max st external shampoo 0.33-4

%.................................................................. 38

lice killing max str......................................... 38

lice killing max strength................................ 38

lice killing maximum strength....................... 38

lice killing shampoo max str......................... 38

lice maximum strength................................. 38

lice treatment external liquid 1 %................. 69

lice treatment external shampoo 0.33-4 %...38

lidocaine external cream 4 %....................... 16

lidocaine external patch 5 %........................ 16

lidocaine hcl external cream 3 %................. 16

lidocaine viscous hcl.................................... 16

lidocaine-prilocaine external cream..............16

lidopin external cream 3 %...........................16

linezolid oral suspension reconstituted........ 19

linezolid oral tablet....................................... 19

LINZESS...................................................... 90

liothyronine sodium oral............................. 123

LIPITOR....................................................... 58

LIPOFEN......................................................58

liquid acetaminophen................................... 11

liquid allergy relief...................................... 154

liquid corn & callus rem.............................. 138

liquid pain relief............................................ 11

liquid wart remover.....................................138

liquid wart remover max st......................... 138

lisdexamfetamine dimesylate oral capsule...61

lisinopril oral................................................. 54

205

lisinopril-hydrochlorothiazide........................57

LITFULO.................................................... 138

lithium...........................................................46

lithium carbonate er......................................46

lithium carbonate oral...................................46

little ones childrens.....................................181

LIVALO.........................................................58

LIVITA ADULTS......................................... 181

LMX 4...........................................................16

LO LOESTRIN FE......................................118

lojaimiess................................................... 118

LOKELMA.................................................... 82

long acting nasal spray.............................. 173

long lasting antacid.................................... 100

long lasting nasal spray..............................173

LONSURF.................................................... 34

loperamide hcl oral capsule......................... 90

loperamide hcl oral tablet............................. 90

loperamide-simethicone............................. 100

lopinavir-ritonavir..........................................44

loradamed.................................................. 166

lorata-d....................................................... 173

loratadine allergy relief oral tablet 10 mg... 166

loratadine allergy relief oral tablet

dispersible 10 mg....................................... 166

loratadine childrens oral solution................166

lorata-dine d............................................... 173

loratadine d 12hr........................................ 173

loratadine oral solution............................... 166

loratadine oral tablet...................................166

loratadine oral tablet dispersible................ 166

loratadine-d................................................ 173

loratadine-d 12hr........................................ 173

loratadine-d 24hr........................................ 173

lorazepam injection...................................... 45

lorazepam oral tablet....................................45

LORBRENA............................................... 141

LOREEV XR.................................................45

loryna......................................................... 118

LORZONE..................................................179

losartan potassium oral................................ 54

losartan potassium-hctz............................... 57

LOTEMAX.................................................. 144

LOTEMAX SM............................................144

lovastatin oral............................................... 58

LOVAZA....................................................... 58

low-ogestrel................................................118

loxapine succinate........................................40

lo-zumandimine..........................................118

lubiprostone..................................................90

lubricant drops fast act............................... 146

lubricant drops ophthalmic gel 0.25-0.3 %. 146

lubricant drops ophthalmic solution............146

lubricant eye drops (pf) ophthalmic solution

0.4-0.3 %....................................................147

lubricant eye drops (pf) ophthalmic solution

0.5 %.......................................................... 147

lubricant eye drops ophthalmic solution

0.4-0.3 %....................................................147

lubricant eye drops ophthalmic solution 0.5

%................................................................ 147

lubricant eye drops ophthalmic solution 0.6

%................................................................ 147

lubricant eye drops pf.................................147

lubricant eye nighttime............................... 147

lubricant eye ophthalmic solution 0.4-0.3 %

....................................................................147

lubricant eye pm.........................................147

lubricant pm................................................147

lubricating eye drop....................................147

lubricating eye drops.................................. 147

lubricating eye/overnight............................ 147

lubricating plus eye drops.......................... 147

lubricating plus ophthalmic solution 0.5 %. 147

lubricating plus pf....................................... 147

lubricating tears ophthalmic solution 0.4-

0.3 %.......................................................... 147

lubrifresh p.m............................................. 147

LUMAKRAS................................................. 36

LUMIGAN...................................................142

LUNESTA ORAL TABLET 2 MG............... 179

LUPKYNIS................................................. 124

LUPRON DEPOT (1-MONTH)................... 124

LUPRON DEPOT (3-MONTH)................... 124

LUPRON DEPOT (4-MONTH)

INTRAMUSCULAR KIT 30MG...................124

LUPRON DEPOT (6-MONTH)

INTRAMUSCULAR KIT 45MG...................124

LUPRON DEPOT-PED (1-MONTH).......... 124

LUPRON DEPOT-PED (3-MONTH).......... 124

LUPRON DEPOT-PED (6-MONTH).......... 124

lurasidone hcl............................................... 40

lutera.......................................................... 118

LYBALVI.......................................................40

lyleq............................................................122

lyllana......................................................... 119

LYNPARZA.................................................. 35

LYRICA CR.................................................. 62

lysiplex plus oral tablet............................... 182

LYSODREN............................................... 123

LYUMJEV.....................................................49

LYUMJEV KWIKPEN................................... 49

LYUMJEV TEMPO PEN.............................. 49

lyza.............................................................122

MAALOX.................................................... 100

MAALOX CHILDRENS.............................. 100

MAALOX MAX ORAL SUSPENSION........ 100

MAALOX MULTI SYMPTOM MAX ST.......100

mag-al plus.................................................100

mag-al plus xs............................................ 101

magnesium citrate oral solution................. 108

magnesium oral tablet 500 mg.....................80

magnesium oxide -mg supplement oral

tablet 400 (240 mg) mg................................ 80

magnesium oxide -mg supplement oral

tablet 500 mg............................................... 80

magnesium oxide oral tablet 400 mg......... 138

206

magnesium oxide oral tablet 420 mg......... 138

magnesium-aluminum-simethicone........... 101

magnesium-oxide.........................................80

malathion......................................................69

MAOX.........................................................138

mapap acetaminophen extra str...................12

mapap childrens...........................................12

mapap oral capsule......................................12

maraviroc..................................................... 44

marlissa......................................................119

MASK VORTEX/CHILD/FROG.................. 138

MASK VORTEX/TODDLER/LADYBUG.....138

MATULANE..................................................33

MAVENCLAD (10 TABS)............................. 63

MAVENCLAD (4 TABS)............................... 63

MAVENCLAD (5 TABS)............................... 63

MAVENCLAD (6 TABS)............................... 63

MAVENCLAD (7 TABS)............................... 63

MAVENCLAD (8 TABS)............................... 63

MAVENCLAD (9 TABS)............................... 63

MAVYRET ORAL PACKET..........................42

MAVYRET ORAL TABLET.......................... 42

MAX RELIEF JR CHILD PAIN/FEVER........ 12

MAX RELIEF JUNIOR................................. 12

MAX TUSSIN MUCUS & CHEST CONG...159

MAXALLERGY KIDS................................. 154

MAXALT.......................................................32

maxi-tuss ac............................................... 173

maxi-tuss gmx............................................ 173

maxi-tuss pe max....................................... 159

MAYZENT.................................................... 63

MAYZENT STARTER PACK....................... 63

m-dryl......................................................... 154

meclizine hcl oral tablet 12.5 mg..................27

meclizine hcl oral tablet 25 mg.....................27

meclizine hcl oral tablet chewable................27

medicated spot...........................................138

medifin 400.................................................159

medifin mucus relief child...........................160

medi-first aspirin.........................................138

medi-first hydrocortisone..............................67

medi-first ibuprofen........................................ 5

medi-first triple antibiotic.............................. 22

mediproxen.................................................... 5

medique aspirin..........................................138

MEDISENSE GLUCOSE KETONE

CONTR........................................................ 74

MEDISENSE HI/MID/LOW CONTROL........ 74

MEDPURA BENZOYL PEROXIDE............138

MEDROL ORAL TABLET 2 MG.................113

medroxyprogesterone acetate

intramuscular..............................................122

medroxyprogesterone acetate oral............ 122

mefloquine hcl.............................................. 37

mega probiotic............................................101

megestrol acetate oral suspension 40

mg/ml......................................................... 122

megestrol acetate oral tablet 20 mg...........122

megestrol acetate oral tablet 40 mg...........122

meijer allergy relief-d..................................173

meijer antacid.............................................101

meijer anti-diarrheal..................................... 90

MEKINIST.................................................... 35

MEKTOVI..................................................... 35

meloxicam oral tablet..................................... 5

memantine hcl oral solution......................... 25

memantine hcl oral tablet............................. 25

MENATROL............................................... 182

MENEST.................................................... 119

MENQUADFI..............................................127

MENVEO....................................................127

mercaptopurine oral..................................... 34

mesalamine er oral capsule 0.375 gm....... 129

mesalamine oral tablet delayed release 1.2

gm.............................................................. 129

mesalamine rectal...................................... 129

MESNEX ORAL........................................... 36

METAMUCIL 4 IN 1 FIBER ORAL

POWDER 43 %..........................................105

METAMUCIL FREE & NATURAL.............. 105

metformin hcl er (osm)................................. 47

metformin hcl er oral tablet extended

release 24 hour 500 mg............................... 47

metformin hcl er oral tablet extended

release 24 hour 750 mg............................... 47

metformin hcl oral tablet 1000 mg, 500 mg,

850 mg......................................................... 47

methadone hcl oral tablet soluble.................. 6

methadose oral tablet soluble........................ 6

methazolamide oral....................................145

methenamine hippurate............................... 19

methergine................................................. 114

methimazole oral........................................124

methocarbamol oral................................... 179

methotrexate sodium..................................126

methotrexate sodium (pf)........................... 126

methoxsalen rapid........................................68

methsuximide............................................... 23

METHYLDOPA............................................ 53

methylergonovine maleate oral.................. 114

methylphenidate hcl er................................. 60

methylphenidate hcl er (cd)..........................60

methylphenidate hcl er (la) oral capsule

extended release 24 hour 20 mg, 30 mg,

40 mg........................................................... 60

methylphenidate hcl er (osm) oral tablet

extended release 18 mg, 27 mg, 36 mg, 54

mg................................................................ 60

methylphenidate hcl oral tablet.................... 60

methylprednisolone oral............................. 113

metoclopramide hcl oral solution 5 mg/5ml..27

metoclopramide hcl oral tablet..................... 27

metolazone...................................................57

metoprolol succinate er................................ 55

metoprolol tartrate oral tablet 100 mg, 50

mg................................................................ 55

207

metoprolol tartrate oral tablet 25 mg............ 55

metoprolol tartrate oral tablet 37.5 mg, 75

mg................................................................ 55

METROGEL................................................. 19

metronidazole external.................................19

metronidazole oral tablet..............................19

metronidazole vaginal.................................. 19

mexiletine hcl oral........................................ 54

mibelas 24 fe..............................................119

micaderm..................................................... 31

MICATIN...................................................... 31

miconazole 3................................................ 29

miconazole 3 applicator vaginal kit 200 & 2

mg-% (9gm)................................................. 29

miconazole 3 combo pack vaginal kit 200 &

2 mg-% (9gm).............................................. 29

miconazole 7 vaginal cream 2 %................. 29

miconazole 7 vaginal suppository 100 mg... 29

miconazole antifungal.................................. 31

miconazole nitrate external cream............... 31

miconazole nitrate vaginal............................29

miconazorb af...............................................31

MICRO GUARD........................................... 31

microgestin 1.5/30......................................119

microgestin 1/20.........................................119

microgestin 24 fe........................................119

microgestin fe 1.5/30..................................119

microgestin fe 1/20.....................................119

midodrine hcl................................................53

mifepristone oral tablet 300 mg..................114

MIGERGOT..................................................31

migraine formula oral tablet 250-250-65 mg 12

migraine headache relief..............................12

migraine relief...............................................12

MIGRANAL.................................................. 31

mili..............................................................119

milk of magnesia........................................ 101

milk of magnesia oral suspension 1200

mg/15ml..................................................... 101

mineral oil enema.......................................105

mineral oil heavy oral................................. 105

mineral oil oral oil ..................................... 105

mineral oil rectal enema ........................... 105

mini nicotine................................................. 18

minocycline hcl oral capsule 100 mg, 50

mg................................................................ 21

minoxidil oral................................................ 58

mintox maximum strength.......................... 101

mintox plus................................................. 101

MIRALAX ORAL POWDER....................... 105

mirtazapine oral tablet 15 mg, 30 mg...........26

mirtazapine oral tablet 45 mg, 7.5 mg..........26

MIRVASO.....................................................64

misoprostol oral............................................92

MITIGARE....................................................31

mm acetaminophen ex str............................12

MM ALLER-BEN........................................ 154

mm allergy relief 24 hour............................166

mm arthritis pain...........................................12

mm aspirin..................................................138

mm clearlax................................................105

mm ibuprofen................................................. 5

mm stool softener.......................................108

mm stool softener laxative......................... 108

M-M-R II..................................................... 127

M-NATAL PLUS........................................... 84

modafinil oral..............................................179

MODERNA COVID-19 VAC 6M-11Y......... 138

mometasone furoate external...................... 68

mondoxyne nl...............................................21

MONOJECT HYPODERMIC NEEDLE 18G

X 1"...............................................................51

mono-linyah................................................119

montelukast sodium oral............................ 155

mood support probiotic...............................101

morphine sulfate (concentrate)...................... 7

morphine sulfate er........................................ 6

morphine sulfate er beads..............................6

morphine sulfate oral......................................7

morphine sulfate rectal...................................7

MOTEGRITY................................................90

motion sickness oral tablet 50 mg................27

motion sickness relief oral tablet 50 mg....... 27

motion sickness relief oral tablet chewable

25 mg........................................................... 27

motion-time.................................................. 28

MOTRIN CHILDRENS................................... 5

MOTRIN IB ORAL TABLET........................... 5

MOTRIN INFANTS DROPS...........................5

MOUNJARO...............................................138

MOVANTIK.................................................. 90

MOVIPREP.................................................. 91

moxifloxacin hcl (2x day)............................144

moxifloxacin hcl ophthalmic....................... 144

moxifloxacin hcl oral.....................................21

m-pap........................................................... 12

MUCINEX COUGH CHILDRENS.............. 173

MUCINEX D............................................... 173

MUCINEX D MAX STRENGTH................. 173

MUCINEX DM............................................ 174

MUCINEX FAST-MAX CHEST CONG MS 160

MUCINEX FAST-MAX DM MAX................ 174

MUCINEX MAXIMUM STRENGTH........... 160

MUCINEX SINUS-MAX CLEAR & COOL.. 174

MUCINEX SINUS-MAX SINUS/ALLRGY.. 174

mucus & chest congestion......................... 160

mucus & cough relief child......................... 174

mucus d......................................................174

mucus d extended release......................... 174

mucus d max st er......................................174

mucus dm...................................................174

mucus dm extended release oral tablet

extended release 12 hour 30-600 mg........ 174

mucus er maximum str...............................160

mucus er oral tablet extended release 12

hour 1200 mg............................................. 160

208

mucus extended release oral tablet

extended release 12 hour 1200 mg........... 160

mucus relief 12 hour max st....................... 160

mucus relief chest oral tablet 400 mg........ 160

mucus relief childrens oral liquid 100

mg/5ml....................................................... 160

mucus relief cough childrens......................174

mucus relief d max strength....................... 174

mucus relief d oral tablet extended release

12 hour 120-1200 mg.................................174

mucus relief d oral tablet extended release

12 hour 60-600 mg.....................................174

mucus relief dm max oral liquid 20-400

mg/20ml, 5-100 mg/5ml............................. 174

mucus relief dm oral liquid 20-400 mg/20ml

....................................................................175

mucus relief dm oral tablet extended

release 12 hour 30-600 mg........................ 175

mucus relief er............................................160

mucus relief er oral tablet extended release

12 hour 1200 mg........................................ 160

mucus relief max st.................................... 160

mucus relief max strength oral tablet

extended release 12 hour 1200 mg........... 160

mucus relief oral tablet 400 mg.................. 160

mucus relief oral tablet extended release

12 hour 1200 mg........................................ 160

mucus+chest congestion............................160

mucus-dm.................................................. 175

mucus-er oral tablet extended release 12

hour 1200 mg............................................. 160

MULPLETA.................................................. 52

MULTAQ...................................................... 54

multi vitamin................................................. 84

multi vitamin w/d-3....................................... 84

multiple vitamin-folic acid............................. 85

multiple vitamins essential........................... 85

multiple vitamins/iron..................................182

MULTIPRO.................................................182

multi-vitamin................................................. 85

multivitamin w/fluoride..................................85

multi-vitamin/fluoride.................................... 85

multivitamin/fluoride oral tablet chewable.... 85

multi-vitamin/fluoride/iron............................. 85

multi-vitamin/iron........................................ 182

mupirocin external........................................70

MURO 128 OPHTHALMIC OINTMENT.....147

MURO 128 OPHTHALMIC SOLUTION 5

%................................................................ 148

my choice................................................... 123

my way....................................................... 123

mycophenolate mofetil oral........................ 126

mycophenolate sodium.............................. 126

mycophenolic acid......................................126

MYFEMBREE.............................................. 89

MYLERAN....................................................33

MYLICON INFANTS GAS RELIEF............ 101

mynephrocaps oral capsule 1 mg................ 85

MYNEPHRON..............................................85

MYRBETRIQ ORAL SUSPENSION

RECONSTITUTED ER...............................111

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HOUR.................................. 111

MYTESI........................................................90

nabumetone oral............................................ 6

nadolol oral...................................................55

naloxone hcl injection solution..................... 17

naloxone hcl injection solution cartridge...... 17

naloxone hcl injection solution prefilled

syringe..........................................................17

naloxone hcl nasal....................................... 17

naltrexone hcl oral........................................16

NAMZARIC.................................................. 25

NAPHCON-A..............................................149

NAPRELAN ORAL TABLET EXTENDED

RELEASE 24 HOUR 375 MG, 750 MG......... 6

NAPRELAN ORAL TABLET EXTENDED

RELEASE 24 HOUR 500 MG........................ 6

NAPROSYN ORAL SUSPENSION................6

NAPROSYN ORAL TABLET..........................6

naproxen dr.................................................... 6

naproxen oral suspension.............................. 6

naproxen oral tablet....................................... 6

naproxen oral tablet delayed release............. 6

naproxen sodium oral tablet 220 mg..............6

NARAMIN...................................................154

naratriptan hcl.............................................. 32

NARCAN...................................................... 17

NASACORT ALLERGY 24HR................... 167

nasal allergy 24 hour..................................167

nasal allergy nasal aerosol 55 mcg/act...... 167

nasal allergy spray..................................... 167

nasal decongestant 12hr............................175

nasal decongestant max st........................ 175

nasal decongestant oral tablet 30 mg........ 175

nasal decongestant oral tablet extended

release 12 hour 120 mg............................. 175

nasal decongestant pe max st................... 161

nasal decongestant pe oral tablet 10 mg... 161

nasal decongestant pe oral tablet 30 mg... 175

nasal decongestant spray.......................... 175

nasal four................................................... 161

nasal four spray..........................................161

nasal mist nasal solution............................ 175

nasal mist no drip....................................... 175

NASAL MOIST NASAL SOLUTION...........161

nasal moisturizing spray.............................161

nasal relief..................................................175

nasal spray 12 hour....................................175

nasal spray extra moist.............................. 175

nasal spray extra moisturizing....................175

nasal spray fast acting............................... 161

nasal spray nasal solution 0.05 %..............175

nasal spray nasal solution 1 %...................161

nasal spray no drip.....................................176

nasal spray saline...................................... 161

nasal spray sinus....................................... 176

209

NASALCROM............................................ 168

NASCOBAL................................................184

NATAZIA.................................................... 119

nateglinide....................................................47

NATESTO.................................................. 115

natural daily fiber oral powder 43 %...........105

natural daily fiber oral powder 58.6 %........106

natural fiber oral capsule 0.52 gm..............106

natural fiber oral powder 28.3 %................ 106

natural fiber oral powder 58.6 %................ 106

natural fiber supplement.............................106

natural senna laxative................................ 108

natural tears pf........................................... 148

natural vegetable........................................106

natural vegetable laxative oral tablet 8.6

mg.............................................................. 108

natural vitamin e.........................................184

natura-lax................................................... 106

nausea control..............................................28

nausea relief oral solution 1.87-1.87-21.5 ...28

NAYZILAM................................................... 24

NEBUSAL INHALATION NEBULIZATION

SOLUTION 3 %..........................................176

necon 0.5/35 (28)....................................... 119

NEODOT THERMOMETER.......................138

NEOMULTIVITE...........................................85

neomycin sulfate oral................................... 19

neomycin-bacitracin zn-polymyx................ 144

neomycin-polymyxin-dexameth ophthalmic

ointment..................................................... 143

neomycin-polymyxin-dexameth ophthalmic

suspension 3.5-10000-0.1 .........................143

neomycin-polymyxin-gramicidin................. 144

neomycin-polymyxin-hc otic....................... 150

NEONATAL PLUS....................................... 85

neo-polycin.................................................144

neo-polycin hc............................................ 143

NEOSPORIN ORIGINAL............................. 22

NEO-SYNEPHRINE COLD/ALLRG MILD. 161

NEO-SYNEPHRINE COLD/ALLRGY EXT.161

NEO-SYNEPHRINE COLD/ALLRGY REG 161

nephro vitamins............................................85

NEPHRO-VITE.............................................85

NEULASTA.................................................. 52

NEULASTA ONPRO.................................... 52

NEUPOGEN.................................................52

NEUPRO......................................................39

NEURONTIN................................................24

NEUTEK 2TEK CONTROL.......................... 74

NEUTROGENA OIL-FREE ACNE WASH. 138

NEVANAC..................................................144

nevirapine.....................................................43

nevirapine er................................................ 43

new day......................................................123

NEXAVAR.................................................... 35

NEXIUM ORAL PACKET 2.5 MG, 5 MG..... 92

NEXLETOL.................................................. 58

NEXLIZET.................................................... 58

NEXTSTELLIS............................................. 89

niacin er (antihyperlipidemic)....................... 58

niacin er oral capsule extended release

250 mg......................................................... 85

niacin er oral capsule extended release

500 mg......................................................... 85

niacin er oral tablet extended release 1000

mg................................................................ 85

niacin er oral tablet extended release 250

mg, 500 mg.................................................. 85

niacin oral tablet 100 mg, 250 mg, 50 mg.... 85

NICODERM CQ........................................... 17

NICORETTE................................................ 18

NICORETTE MINI........................................18

NICORETTE STARTER KIT........................ 18

nicotine gum mouth/throat gum 2 mg...........18

nicotine gum mouth/throat gum 4 mg...........18

nicotine gum mouth/throat lozenge 2 mg..... 18

nicotine gum mouth/throat lozenge 4 mg..... 18

nicotine mini................................................. 18

nicotine mouth/throat gum 2 mg...................18

nicotine mouth/throat gum 4 mg...................18

nicotine mouth/throat lozenge 2 mg............. 18

nicotine mouth/throat lozenge 4 mg............. 18

nicotine polacrilex mini................................. 18

nicotine polacrilex mouth/throat................... 18

nicotine step 1.............................................. 17

nicotine step 2.............................................. 17

nicotine step 3.............................................. 17

nicotine transdermal patch 24 hour 14

mg/24hr, 7 mg/24hr......................................17

nicotine transdermal patch 24 hour 21

mg/24hr........................................................ 17

nicotine transdermal system........................ 17

NICOTROL...................................................17

NICOTROL NS.............................................17

nifedipine er..................................................55

nifedipine er osmotic release....................... 55

nifedipine oral...............................................55

nighttime dry-eye relief...............................148

nighttime relief lub eye............................... 148

nikki............................................................ 119

nimodipine oral.............................................55

NINLARO..................................................... 34

nitazoxanide oral.......................................... 37

NITRO-BID...................................................59

nitrofurantoin macrocrystal...........................19

nitrofurantoin monohydrate macrocrystals... 19

nitrofurantoin oral suspension 25 mg/5ml.... 19

nitroglycerin rectal........................................ 59

nitroglycerin sublingual.................................59

nitroglycerin transdermal..............................59

nitroglycerin translingual.............................. 59

NITYR........................................................ 110

NIVA-PLUS.................................................. 85

NIVESTYM...................................................52

no drip extra moisturizing........................... 176

no drip nasal relief......................................176

no drip nasal spray.....................................176

210

no drip original 12 hours.............................176

NOCDURNA.............................................. 114

nohist-lq......................................................164

NOKOR VENTED NEEDLE......................... 51

non-aspirin................................................... 12

non-aspirin 8 hour........................................ 12

non-aspirin childrens.................................... 12

non-aspirin extra strength............................ 12

non-aspirin jr strength.................................. 12

non-aspirin pain relief...................................12

non-pseudo sinus decongestant................ 161

nora-be.......................................................122

NORDITROPIN FLEXPRO........................ 114

norelgestromin-eth estradiol.......................119

norethin ace-eth estrad-fe oral tablet......... 119

norethin ace-eth estrad-fe oral tablet

chewable.................................................... 119

norethindrone acetate oral......................... 122

norethindrone acet-ethinyl est....................119

norethindrone oral...................................... 122

norethindron-ethinyl estrad-fe.................... 119

norethin-eth estradiol-fe oral tablet

chewable 0.4-35 mg-mcg...........................119

norgestimate-eth estradiol..........................119

norgestimate-ethinyl estradiol triphasic......119

NORITATE................................................... 19

NORLIQVA...................................................55

norlyroc...................................................... 122

NORPACE CR............................................. 54

nortrel 0.5/35 (28).......................................119

nortrel 1/35 (21)..........................................119

nortrel 1/35 (28)..........................................120

nortrel 7/7/7................................................ 120

nortriptyline hcl oral...................................... 27

NORVIR ORAL PACKET............................. 44

nose drops extstrength...............................161

NOURIANZ.................................................. 38

NOVAMV PEDIATRIC MULTI-VITAMIN....182

NOVAREL.................................................. 114

NOVAVAX COVID-19 VACCINE............... 128

NOVOLIN 70/30 FLEXPEN..........................49

NOVOLIN 70/30 RELION.............................49

NOVOLIN 70/30 VIAL.................................. 49

NOVOLIN N FLEXPEN................................ 49

NOVOLIN N RELION................................... 49

NOVOLIN N VIAL.........................................49

NOVOLIN R FLEXPEN................................ 49

NOVOLIN R RELION................................... 50

NOVOLIN R VIAL.........................................50

NOVOLOG FLEXPEN..................................50

NOVOLOG FLEXPEN RELION................... 50

NOVOLOG MIX 70/30 FLEXPEN................ 50

NOVOLOG MIX 70/30 VIAL.........................50

NOVOLOG PENFILL................................... 50

NOVOLOG RELION.....................................50

NOVOLOG U-100 VIAL............................... 50

NOXAFIL ORAL PACKET............................29

NOXAFIL ORAL SUSPENSION.................. 29

NOXAFIL ORAL TABLET DELAYED

RELEASE.....................................................29

NUBEQA...................................................... 33

NUCALA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR...................................... 158

NUCALA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE.............................. 158

NUCYNTA......................................................7

NUCYNTA ER................................................6

NUEDEXTA..................................................62

NU-IRON......................................................80

NULEV....................................................... 138

NURTEC...................................................... 32

NUTRAPLUS............................................... 72

nutrifac zx...................................................182

NUTROPIN AQ NUSPIN 10.......................114

NUTROPIN AQ NUSPIN 20.......................114

NUTROPIN AQ NUSPIN 5.........................114

NUVARING................................................ 120

NUVESSA.................................................... 19

NUZYRA ORAL............................................21

nyamyc.........................................................70

nylia 1/35....................................................120

nylia 7/7/7...................................................120

NYMALIZE................................................... 55

nymyo.........................................................120

nystatin external........................................... 70

nystatin mouth/throat....................................29

nystatin oral..................................................29

nystop...........................................................70

NYVEPRIA................................................... 52

OBSTETRIX DHA........................................ 85

OBTREX.................................................... 182

OCALIVA ORAL TABLET 5 MG.................. 91

OCEAN FOR KIDS.................................... 161

OCEAN NASAL SPRAY............................ 161

ocella..........................................................120

octreotide acetate.......................................124

OCUVEL.................................................... 182

ODEFSEY.................................................... 43

ODOMZO..................................................... 35

OFEV......................................................... 157

ofloxacin ophthalmic...................................144

ofloxacin oral................................................ 21

ofloxacin otic.............................................. 150

ointment base...............................................71

olanzapine oral tablet................................... 40

olanzapine oral tablet dispersible.................40

olmesartan medoxomil oral.......................... 54

olmesartan medoxomil-hctz......................... 57

olopatadine hcl ophthalmic.........................143

OLUMIANT ORAL TABLET 1 MG, 2 MG...125

OLUMIANT ORAL TABLET 4 MG............. 125

omega-3-acid ethyl esters............................58

omeprazole magnesium...............................92

omeprazole magnesium oral capsule

delayed release............................................93

omeprazole oral capsule delayed release

10 mg, 20 mg, 20.6 (20 base) mg, 40 mg.... 93

211

OMNARIS.................................................. 155

OMNIFLEX DIAPHRAGM.......................... 138

OMNIPOD 5 G6 INTRO (GEN 5)...............138

OMNIPOD 5 G6 PODS (GEN 5)................138

OMNITROPE............................................. 114

ON/GO COVID-19 ANTIGEN TEST.......... 138

ON/GO ONE COVID-19 HOME TEST.......138

once daily..................................................... 85

ondansetron hcl oral tablet 4 mg, 8 mg........28

ondansetron odt........................................... 28

one daily.......................................................85

ONE DAILY ESSENTIALS...........................85

ONE VITE DAILY MULTIVITAMIN...............86

ONE VITE WOMENS...................................86

ONE VITE WOMENS PLUS........................ 86

one-daily multi vitamins................................86

one-daily multi-vitamin................................. 86

one-daily multi-vitamin/iron........................ 182

one-daily/iron..............................................182

ONELAX.....................................................138

ONELAX DOCUSATE SODIUM................ 108

ONELAX MAGNESIUM CITRATE............. 109

ONELAX SENNA....................................... 109

ONETOUCH ULTRA 2 KIT W/DEVICE....... 74

ONETOUCH ULTRA CONTROL................. 74

ONETOUCH ULTRA IN VITRO LIQUID...... 74

ONETOUCH ULTRA STRIP IN VITRO..74, 75

ONETOUCH ULTRA TEST..........................75

ONETOUCH VERIO FLEX SYSTEM KIT

W/DEVICE................................................... 75

ONETOUCH VERIO IN VITRO LIQUID.......75

ONETOUCH VERIO REFLECT KIT

W/DEVICE................................................... 75

ONETOUCH VERIO STRIP IN VITRO........ 75

ONEXTON................................................... 64

ONGENTYS................................................. 38

ONGLYZA.................................................... 47

opcicon one-step........................................123

OPILL......................................................... 139

OPSUMIT...................................................157

option 2...................................................... 123

OPZELURA..................................................72

ORACEA...................................................... 21

oralone......................................................... 64

ORENCIA CLICKJECT.............................. 125

ORENCIA SUBCUTANEOUS....................125

ORENITRAM..............................................157

ORENITRAM MONTH 1............................ 157

ORENITRAM MONTH 2............................ 157

ORENITRAM MONTH 3............................ 157

ORFADIN................................................... 110

ORGOVYX................................................... 18

ORIAHNN...................................................124

ORILISSA...................................................124

ORKAMBI...................................................156

ORLADEYO............................................... 139

orphenadrine citrate er............................... 179

OS-CAL CALCIUM + D3..............................80

oseltamivir phosphate oral capsule..............44

oseltamivir phosphate oral suspension

reconstituted.................................................44

OSMOLEX ER............................................. 38

OSPHENA..................................................122

OTEZLA..................................................... 125

OTREXUP..................................................126

OVACE PLUS WASH EXTERNAL LIQUID139

OVACE WASH...........................................139

OVIDREL................................................... 114

oxaprozin oral tablet.......................................6

oxazepam.....................................................45

OXBRYTA ORAL TABLET 300 MG.............52

OXBRYTA ORAL TABLET 500 MG.............52

OXBRYTA ORAL TABLET SOLUBLE......... 52

oxcarbazepine oral suspension....................24

oxcarbazepine oral tablet............................. 24

OXTELLAR XR............................................ 24

oxybutynin chloride er................................ 111

oxybutynin chloride oral solution................ 111

oxybutynin chloride oral tablet 5 mg...........111

oxycodone hcl oral concentrate..................... 7

oxycodone hcl oral solution............................7

oxycodone hcl oral tablet 10 mg, 20 mg...... 15

oxycodone hcl oral tablet 15 mg, 30 mg...... 15

OXYCODONE-ACETAMINOPHEN ORAL

SOLUTION 5-325 MG/5ML............................7

oxycodone-acetaminophen oral tablet 10-

325 mg, 5-325 mg, 7.5-325 mg......................8

OXYCONTIN..................................................6

oxymorphone hcl er........................................6

OXYTROL FOR WOMEN.......................... 111

oysco 500+d.................................................80

oyster shell calcium + d oral tablet 500-10

mg-mcg........................................................ 80

oyster shell calcium + d3..............................80

oyster shell calcium oral tablet 500 mg...... 182

oyster shell calcium plus d........................... 80

oyster shell calcium w/d............................... 80

oyster shell calcium/d oral tablet 250-3.125

mg-mcg...................................................... 182

oyster shell calcium/d oral tablet 250-6.25

mg-mcg........................................................ 80

oyster shell calcium/vit d.............................. 80

oyster shell calcium/vit d3............................ 80

oyster shell calcium/vit d3 oral tablet 500-5

mg-mcg........................................................ 80

oyster shell calcium/vitamin d oral tablet

250-3.125 mg-mcg..................................... 182

oyster shell calcium/vitamin d oral tablet

500-5 mg-mcg.............................................. 80

oyster shell calcium-vit d.............................. 80

OZEMPIC.....................................................47

OZEMPIC (2 MG/DOSE)............................. 47

p col-rite..................................................... 109

PACERONE................................................. 54

pain & fever child..........................................12

pain & fever childrens...................................12

212

pain & fever childrens oral suspension 160

mg/5ml......................................................... 12

pain & fever infants oral suspension 160

mg/5ml......................................................... 13

pain and fever relief kids.............................. 13

pain relief childrens oral elixir 160 mg/5ml... 13

pain relief childrens oral suspension............ 13

pain relief childrens oral tablet chewable

160 mg......................................................... 13

pain relief extra st.........................................13

pain relief extra strength oral capsule 500

mg................................................................ 13

pain relief extra strength oral liquid 500

mg/15ml....................................................... 13

pain relief extra strength oral tablet 500 mg.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 strength........................... 13

pain relief/rapid burst....................................13

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 extra strength oral tablet 250-

250-65 mg.................................................... 14

pain reliever extra strength oral tablet 500

mg................................................................ 14

pain reliever oral tablet 325 mg....................14

pain reliever oral tablet 500 mg....................14

pain reliever plus.......................................... 14

pain-off......................................................... 14

paliperidone er............................................. 40

PANADOL CHILDRENS.............................. 14

PANADOL EXTRA STRENGTH.................. 14

PANADOL INFANTS....................................14

PANOXYL.................................................. 139

pantoprazole sodium oral tablet delayed

release......................................................... 93

paroxetine hcl oral tablet.............................. 26

PATADAY OPHTHALMIC SOLUTION 0.1

%, 0.2 %.....................................................143

PAXLOVID (150/100)...................................45

PAXLOVID (300/100)...................................45

pazopanib hcl............................................. 141

PEAK FLOW METER UNIVERSAL RANG..72

ped electrolyte freeze pop............................80

PEDIA-LAX ORAL LIQUID.........................109

PEDIALYTE FREEZER POPS.....................80

PEDIALYTE IMMUNE SUPPORT............... 80

PEDIALYTE ORAL SOLUTION................... 81

PEDIALYTE SINGLES.................................81

PEDIARIX.................................................. 127

pediatric electrolyte oral solution ................81

PEDVAX HIB..............................................127

peg 3350 oral powder................................ 106

peg 3350-kcl-na bicarb-nacl.........................91

peg-3350/electrolytes...................................91

PEGASYS.................................................. 125

PENBRAYA................................................139

penicillamine oral tablet..............................112

penicillin v potassium................................... 20

PENTACEL................................................ 127

pentamidine isethionate inhalation...............37

PENTASA.................................................. 129

pentazocine-naloxone hcl.............................. 8

pentoxifylline er............................................ 57

PEPCID AC..................................................92

PEPTO-BISMOL ORAL SUSPENSION

524 MG/30ML............................................ 101

PERDIEM OVERNIGHT RELIEF...............109

PERFOROMIST.........................................156

periogard...................................................... 64

permethrin external...................................... 69

perphenazine oral........................................ 28

perphenazine-amitriptyline oral tablet 2-10

mg, 4-10 mg, 4-25 mg, 4-50 mg...................26

perphenazine-amitriptyline oral tablet 2-25

mg................................................................ 26

PERSERIS................................................... 40

PERTZYE...................................................110

PFIZER COVID-19 VAC-TRIS 5-11Y........ 139

PFIZER COVID-19 VAC-TRIS 6M-4Y....... 139

pharbedryl.................................................. 154

PHARBETOL............................................... 14

PHARBETOL EXTRA STRENGTH..............14

pharbinex................................................... 161

PHAZYME..................................................101

PHAZYME ULTRA STRENGTH................ 101

PHEBURANE.............................................110

phenazo oral tablet 200 mg........................112

phenazo oral tablet 95 mg..........................112

phenazopyridine hcl oral tablet 100 mg..... 112

phenazopyridine hcl oral tablet 200 mg..... 112

phenazopyridine hcl oral tablet 95 mg....... 112

phenobarbital oral........................................ 24

phenylephrine hcl ophthalmic.....................143

phenylephrine hcl oral................................ 161

phenytek.......................................................24

phenytoin infatabs........................................ 24

phenytoin oral...............................................24

phenytoin sodium extended......................... 24

philith..........................................................120

PHOSPHA 250 NEUTRAL...........................81

PHOSPHOLINE IODIDE............................145

phosphorous................................................ 81

phospho-trin 250 neutral.............................. 81

PHOSPHO-TRIN K500................................ 81

phytonadione oral.........................................86

PIFELTRO....................................................43

pilocarpine hcl ophthalmic..........................145

pilocarpine hcl oral tablet 5 mg.................... 64

pilocarpine hcl oral tablet 7.5 mg................. 64

PILOT COVID-19 AT-HOME TEST........... 139

213

pimecrolimus................................................ 68

pimozide.......................................................40

pimtrea....................................................... 120

pink bismuth maximum strength................ 101

pink bismuth oral suspension 262 mg/15ml

....................................................................101

pink bismuth oral suspension 525 mg/15ml

....................................................................101

pink bismuth oral tablet 262 mg................. 101

pink bismuth oral tablet chewable 262 mg. 102

pink bismuth ultra str.................................. 102

pink-bismuth...............................................102

pioglitazone hcl............................................ 47

PIP GLUCOSE CONTROL SOLUTION.......75

PIQRAY (200 MG DAILY DOSE).................35

PIQRAY (250 MG DAILY DOSE).................35

PIQRAY (300 MG DAILY DOSE).................35

pirfenidone oral capsule............................. 157

pirfenidone oral tablet 267 mg, 801 mg......157

piroxicam oral.................................................6

PLAN B ONE-STEP................................... 123

PLEGRIDY INTRAMUSCULAR................... 63

PLEGRIDY STARTER PACK...................... 63

PLEGRIDY SUBCUTANEOUS.................... 63

PLENVU.......................................................91

plerixafor...................................................... 52

PNEUMOVAX 23....................................... 128

podofilox external solution............................68

poly bacitracin............................................ 139

polycin........................................................ 144

polyethylene glycol 3350 oral powder........ 106

polyethylene glycol 3350-grx oral powder 106

poly-iron 150................................................ 81

poly-iron 150 forte........................................ 81

polymyxin b-trimethoprim........................... 144

polysaccharide iron complex........................81

polysaccharide iron forte.............................. 81

polysaccharide-iron complex........................81

POLYSPORIN............................................139

polyvinyl alcohol ophthalmic.......................148

POMALYST..................................................34

PONVORY................................................. 142

PONVORY STARTER PACK.....................142

portia-28..................................................... 120

potassium chloride crys er oral tablet

extended release 10 meq.............................76

potassium chloride crys er oral tablet

extended release 20 meq.............................76

potassium chloride er oral capsule

extended release 10 meq.............................76

potassium chloride er oral tablet extended

release 10 meq............................................ 76

potassium chloride er oral tablet extended

release 20 meq............................................ 76

potassium chloride er oral tablet extended

release 8 meq.............................................. 76

potassium chloride oral................................ 76

potassium citrate er oral tablet extended

release 10 meq (1080 mg)........................... 76

potassium citrate er oral tablet extended

release 15 meq (1620 mg)........................... 76

potassium citrate er oral tablet extended

release 5 meq (540 mg)............................... 76

potassium citrate-citric acid..........................81

povidone iodine............................................ 22

povidone-iodine external solution.................22

PRADAXA ORAL CAPSULE....................... 51

PRADAXA ORAL PACKET..........................51

PRALUENT.................................................. 58

pramipexole dihydrochloride oral tablet

0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg... 39

pramipexole dihydrochloride oral tablet

0.75 mg........................................................ 39

prasugrel hcl.................................................53

pravastatin sodium....................................... 58

praziquantel oral...........................................37

prazosin hcl oral........................................... 53

PRECISION GLUCOSE KETONE CONTR. 75

PRECISION XTRA BLOOD GLUCOSE.......75

PRED FORTE............................................ 144

prednisolone acetate ophthalmic............... 144

PREDNISOLONE ACETATE P-F.............. 144

prednisolone oral solution.......................... 113

prednisolone sodium phosphate

ophthalmic..................................................144

prednisolone sodium phosphate oral

solution 15 mg/5ml..................................... 113

prednisolone sodium phosphate oral

solution 6.7 (5 base) mg/5ml......................113

prednisone oral solution............................. 113

prednisone oral tablet.................................113

prednisone oral tablet therapy pack 10 mg

(21).............................................................113

prednisone oral tablet therapy pack 10 mg

(48), 5 mg (21), 5 mg (48).......................... 113

pregabalin oral............................................. 62

PREGNYL.................................................. 114

PREHEVBRIO............................................127

PREMARIN ORAL..................................... 120

PREMARIN VAGINAL................................120

PREMPHASE.............................................120

PREMPRO................................................. 120

prenatal 19 oral tablet.................................. 86

prenatal formula........................................... 86

prenatal formula oral tablet 28-0.8 mg......... 86

prenatal gummy oral tablet chewable 0.4

mg.............................................................. 184

prenatal gummy oral tablet chewable 0.4-

113.5 mg.................................................... 182

prenatal gummy oral tablet chewable 0.4-

25 mg........................................................... 86

prenatal multi+dha........................................86

prenatal multivitamins.................................. 86

prenatal oral tablet 27-0.8 mg...................... 86

prenatal oral tablet 27-1 mg......................... 86

prenatal oral tablet 28-0.8 mg...................... 86

prenatal vitamins.......................................... 86

214

prenatal/iron................................................. 86

PREPARATION H EXTERNAL CREAM 1

%................................................................ 129

PREVACID 24HR.........................................93

prevalite oral powder....................................58

PREVIDENT.................................................77

PREVIDENT 5000 DRY MOUTH.................77

PREVIDENT 5000 PLUS............................. 77

PREVNAR 20.............................................128

PREZCOBIX................................................ 44

PREZISTA ORAL SUSPENSION.............. 139

PREZISTA ORAL TABLET 150 MG, 75

MG............................................................. 139

PREZISTA ORAL TABLET 600 MG, 800

MG............................................................. 139

PRIFTIN....................................................... 33

primaquine phosphate..................................37

primidone oral tablet 250 mg, 50 mg............24

PRIORIX.................................................... 127

PRISTIQ.......................................................26

PROAIR RESPICLICK............................... 156

probenecid................................................... 31

probiotic blend............................................102

probiotic colon care.................................... 102

probiotic complex....................................... 102

probiotic maximum strength....................... 102

probiotic oral capsule................................. 102

probiotic oral capsule 250 mg.................... 102

probiotic pearls ex st.................................. 102

prochlorperazine.......................................... 28

prochlorperazine maleate oral......................28

PROCRIT..................................................... 52

PROCTOFOAM HC..................................... 68

procto-med hc............................................ 129

proctosol hc................................................129

proctozone-hc............................................ 129

progesterone oral....................................... 122

PROLENSA................................................144

PROMACTA ORAL PACKET 12.5 MG........52

PROMACTA ORAL TABLET....................... 52

promethazine hcl oral...................................28

promethazine hcl rectal................................ 28

promethazine vc.........................................158

promethazine-codeine oral solution........... 176

promethazine-dm....................................... 176

promethegan................................................ 28

PRONUTRIENTS VITAMIN D3....................86

propafenone hcl........................................... 54

propranolol hcl er......................................... 55

propranolol hcl oral solution 20 mg/5ml....... 55

propranolol hcl oral solution 40 mg/5ml....... 55

propranolol hcl oral tablet.............................55

propylthiouracil oral.................................... 124

PROQUAD................................................. 127

PROVENTIL HFA.......................................156

PROXIVOL...................................................16

pseudoephedrine hcl 12 hr.........................176

pseudoephedrine hcl er..............................176

pseudoephedrine hcl oral tablet 30 mg...... 176

pseudoephedrine-bromphen-dm................161

pseudoephedrine-guaifenesin er................176

psyldex....................................................... 106

PULMICORT FLEXHALER........................ 155

PULMICORT SUSPENSION..................... 155

PULMOSAL................................................176

PULMOZYME............................................ 156

pure & gentle lubricant............................... 148

PURE COMFORT FLOW METER ADULT.. 72

PURE COMFORT FLOW METER CHILD... 72

purelax oral powder....................................106

PYLERA....................................................... 91

pyrazinamide oral.........................................33

PYRIDIUM..................................................112

pyridostigmine bromide er............................32

pyridostigmine bromide oral solution............32

pyridostigmine bromide oral tablet 60 mg.... 32

pyridoxine hcl oral...................................... 184

pyrimethamine oral.......................................37

QBREXZA.................................................... 68

QELBREE.................................................... 46

QNASL....................................................... 155

QNASL CHILDRENS................................. 155

QTERN.........................................................47

QUADRACEL INTRAMUSCULAR

SUSPENSION............................................127

quazepam.................................................... 45

quetiapine fumarate..................................... 40

quetiapine fumarate er................................. 40

QUFLORA PEDIATRIC ORAL SOLUTION

0.5 MG/ML................................................... 86

QUICKVUE AT-HOME COVID-19 TEST... 139

quinapril hcl.................................................. 54

quinapril-hydrochlorothiazide....................... 57

quinidine gluconate er.................................. 54

quinidine sulfate........................................... 54

QUINTET CONTROL HIGH/NORMAL........ 75

quit2............................................................. 18

quit4............................................................. 18

QULIPTA......................................................31

QUVIVIQ.................................................... 139

QVAR REDIHALER................................... 155

radiance platinum vitamin d3....................... 86

RADICAVA ORS.......................................... 62

RADICAVA ORS STARTER KIT..................62

raloxifene hcl.............................................. 122

ramelteon................................................... 179

ramipril......................................................... 54

ranolazine er................................................ 57

RASUVO.................................................... 126

RAVICTI..................................................... 110

RAYALDEE................................................ 130

react........................................................... 123

ready-to-use enema rectal enema ........... 102

REBIF...........................................................63

REBIF REBIDOSE....................................... 63

REBIF REBIDOSE TITRATION PACK........ 63

REBIF TITRATION PACK............................63

215

reclipsen.....................................................120

RECOMBIVAX HB..................................... 127

refenesen 400............................................ 162

REFRESH LACRI-LUBE............................148

REFRESH PLUS........................................148

REFRESH TEARS..................................... 148

reguloid oral powder 43 %......................... 106

REHYDRALYTE...........................................81

RELENZA DISKHALER............................... 44

RELEUKO.................................................... 52

relief eye drops...........................................148

RELION TRUE METRIX TEST STRIPS...... 75

RELISTOR................................................... 90

RELPAX....................................................... 32

RELYVRIO................................................. 139

RENAL......................................................... 87

rena-vite....................................................... 87

renewal soothing bath.................................. 71

repaglinide....................................................47

REPATHA.................................................... 58

RESTASIS................................................. 143

RESTASIS MULTIDOSE........................... 143

RESTORA..................................................102

restore plus lubricant eye........................... 148

restore pm.................................................. 148

RESTORIL ORAL CAPSULE 15 MG, 30

MG, 7.5 MG................................................179

RESTORIL ORAL CAPSULE 22.5 MG......179

RETACRIT INJECTION SOLUTION 10000

UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML,

4000 UNIT/ML, 40000 UNIT/ML.................. 52

RETACRIT INJECTION SOLUTION 20000

UNIT/ML.......................................................52

RETEVMO................................................. 141

RETIN-A EXTERNAL CREAM.....................64

RETIN-A EXTERNAL GEL...........................65

RETIN-A MICRO GEL 0.04 %, 0.1 %.......... 65

RETIN-A MICRO PUMP EXTERNAL GEL

0.06 %.......................................................... 65

RETIN-A MICRO PUMP EXTERNAL GEL

0.08 %.......................................................... 65

REVATIO ORAL.........................................157

REVLIMID.................................................... 34

REXTOVY.................................................... 17

REXULTI...................................................... 40

REYATAZ ORAL CAPSULE........................ 44

REYATAZ ORAL PACKET.......................... 44

REYVOW..................................................... 32

REZDIFFRA ORAL TABLET 80 MG..........139

REZVOGLAR KWIKPEN............................. 51

RHOFADE....................................................65

RHOPRESSA.............................................145

ribavirin oral..................................................42

rifabutin........................................................ 33

rifampin oral................................................. 33

riluzole..........................................................62

rimantadine hcl.............................................44

RINVOQ..................................................... 125

RISAQUAD................................................ 102

RISAQUAD-2............................................. 102

RISPERDAL CONSTA.................................41

RISPERDAL ORAL SOLUTION...................41

RISPERDAL ORAL TABLET....................... 41

risperidone microspheres er.........................41

risperidone oral solution............................... 41

risperidone oral tablet...................................41

risperidone oral tablet dispersible................ 41

ritonavir........................................................ 44

rivastigmine.................................................. 25

rivastigmine tartrate......................................25

rizatriptan benzoate......................................32

ROBAFEN CF MULTI-SYMPTOM COLD..164

ROBITUSSIN 12 HOUR COUGH.............. 176

ROBITUSSIN 12 HOUR COUGH CHILD.. 176

ROBITUSSIN CHILD COUGH/COLD LA...162

ROBITUSSIN CHILDRENS COUGH LA....162

ROBITUSSIN COUGH+CHEST CONG

DM ORAL LIQUID 20-400 MG/20ML.........176

ROBITUSSIN NIGHTTIME COUGH.......... 162

ROBITUSSIN PEAK COLD MULTI-SYM...164

ROCKLATAN............................................. 143

ropinirole hcl.................................................39

rosuvastatin calcium oral..............................58

ROTARIX................................................... 127

ROTATEQ..................................................127

roweepra...................................................... 23

ROXYBOND ORAL TABLET ABUSE-

DETERRENT 15 MG, 30 MG, 5 MG..............6

ROZEREM................................................. 179

ROZLYTREK ORAL CAPSULE................... 35

ROZLYTREK ORAL PACKET..................... 35

RUBRACA....................................................35

RUCONEST............................................... 125

rufinamide.................................................... 24

RUKOBIA..................................................... 44

RYALTRIS..................................................139

RYBELSUS.................................................. 47

RYDAPT.......................................................35

RYKINDO.....................................................41

rynex dm.................................................... 176

rynex pe..................................................... 177

rynex pse....................................................177

RYTARY ORAL CAPSULE EXTENDED

RELEASE 23.75-95 MG, 36.25-145 MG,

61.25-245 MG.............................................. 39

RYTARY ORAL CAPSULE EXTENDED

RELEASE 48.75-195 MG.............................39

saccharomyces boulardii............................102

SAFYRAL...................................................120

SAIZEN...................................................... 114

sajazir.........................................................125

saline enema..............................................102

saline mist spray........................................ 162

saline nasal spray...................................... 162

salsalate oral................................................ 15

SANCUSO................................................... 28

SAPHRIS..................................................... 41

216

sapropterin dihydrochloride........................110

SAVAYSA.................................................... 51

saxagliptin hcl...............................................47

sb arthritis pain relief.................................... 14

sb docusate sodium/senna........................ 109

sb lice killing max st..................................... 38

sb mucus relief........................................... 162

sb pain reliever childrens............................. 14

scalp relief external liquid 3 %....................139

SCEMBLIX................................................... 36

SCRUB CARE POVIDONE-IODINE............ 22

SEGLENTIS................................................... 8

SEGLUROMET............................................ 47

selegiline hcl oral..........................................39

selenium sulfide external lotion.................... 68

SELZENTRY ORAL SOLUTION..................44

SEMGLEE (YFGN)...................................... 50

SE-NATAL 19 ORAL TABLET..................... 87

senexon-s...................................................109

senior probiotic...........................................102

senna lax....................................................109

senna laxative............................................ 109

senna oral liquid......................................... 109

senna oral syrup.........................................109

senna oral tablet.........................................109

senna plus oral tablet................................. 109

senna s.......................................................109

senna smooth.............................................109

senna-docusate sodium............................. 109

senna-lax....................................................109

senna-plus..................................................109

senna-s oral tablet 8.6-50 mg.................... 109

senna-tabs................................................. 109

senna-time................................................. 109

senna-time s...............................................109

sennazon....................................................109

SENOKOT..................................................109

SENOKOT S.............................................. 109

SENTIA...................................................... 148

SEREVENT DISKUS................................. 156

SEROQUEL................................................. 41

SEROQUEL XR........................................... 41

sertraline hcl oral concentrate...................... 26

sertraline hcl oral tablet................................ 26

setlakin....................................................... 120

sevelamer carbonate oral tablet...................82

sf.................................................................. 77

sf 5000 plus..................................................77

SFROWASA...............................................129

sharobel..................................................... 122

SHINGRIX..................................................127

SIGNIFOR..................................................124

SIKLOS........................................................ 52

siladryl allergy............................................ 154

sildenafil citrate oral suspension

reconstituted...............................................157

sildenafil citrate oral tablet 20 mg...............157

SILENOR................................................... 179

SILIQ.......................................................... 125

siltussin sa..................................................162

silver sulfadiazine external........................... 68

SIMBRINZA................................................145

simeped......................................................102

simethicone drops infants.......................... 102

simethicone oral......................................... 102

simethicone ultra strength.......................... 102

simliya........................................................ 120

simpesse.................................................... 120

SIMPONI.................................................... 126

simvastatin oral............................................ 58

SINEMET..................................................... 39

SINGULAIR................................................155

sinus 12 hour..............................................177

sinus 12-hour............................................. 177

sinus congestion max strength...................177

sinus nasal spray....................................... 177

sinus pe decongestant............................... 162

sinus relief extra strength........................... 162

sinus/congestion relief pe...........................162

sirolimus oral solution.................................126

sirolimus oral tablet 0.5 mg, 1 mg.............. 126

sirolimus oral tablet 2 mg........................... 126

SIRTURO..................................................... 33

SKYRIZI PEN.............................................125

SKYRIZI SUBCUTANEOUS SOLUTION

CARTRIDGE.............................................. 139

SKYRIZI SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE.............................. 125

SKYTROFA................................................114

SLO-NIACIN.................................................87

smooth antacid ex st oral tablet chewable

750 mg....................................................... 102

smooth antacid extra st.............................. 103

smooth antacid extra strength....................103

smooth lax oral powder.............................. 106

SOAANZ ORAL TABLET 20 MG................. 57

sod chloride hypertonicity...........................148

sod citrate-citric acid oral solution 500-334

mg/5ml......................................................... 81

sodium bicarbonate oral tablet................... 103

sodium chloride (hypertonic) ophthalmic

ointment..................................................... 148

sodium chloride (hypertonic) ophthalmic

solution.......................................................148

sodium chloride inhalation nebulization

solution 0.9 %, 10 %.................................. 177

sodium chloride inhalation nebulization

solution 3 %................................................177

sodium chloride inhalation nebulization

solution 7 %................................................177

sodium chloride ophthalmic ointment 5 %..148

sodium chloride ophthalmic solution 5 %... 148

sodium fluoride 5000 plus............................ 77

sodium fluoride 5000 ppm dental cream...... 77

sodium fluoride dental cream....................... 77

sodium fluoride dental gel............................ 77

sodium fluoride oral solution........................ 77

217

sodium fluoride oral tablet chewable............77

SODIUM OXYBATE...................................179

sodium phenylbutyrate oral powder........... 110

sodium sulfacetamide wash....................... 139

SOFOSBUVIR-VELPATASVIR....................42

soft glucose.................................................. 50

solifenacin succinate.................................. 111

SOLIQUA..................................................... 47

SOLODYN....................................................21

SOLOSEC....................................................19

soluble fiber therapy...................................110

SOMAVERT............................................... 124

SOOLANTRA............................................... 69

soothe maximum strength..........................103

soothe oral suspension.............................. 103

soothe oral tablet chewable....................... 103

sorafenib tosylate......................................... 35

sorbitol oral.................................................106

SORILUX..................................................... 68

sotalol hcl (af)...............................................54

sotalol hcl oral.............................................. 54

SOTYKTU.................................................. 139

SOVALDI......................................................42

SOVUNA ORAL TABLET 200 MG...............37

SPEEDY SWAB COVID-19 ANTIGEN...... 139

SPIKEVAX................................................. 139

spinosad.......................................................69

SPIRIVA HANDIHALER.............................155

SPIRIVA RESPIMAT..................................155

spironolactone oral tablet............................. 57

spironolactone-hctz...................................... 57

SPRAVATO (84 MG DOSE)........................ 26

sprintec 28..................................................120

SPRYCEL.................................................. 141

SPS.............................................................. 82

sronyx.........................................................120

ssd................................................................68

sss 10-5 external cream...............................71

ST JOSEPH LOW DOSE...........................139

STEGLATRO............................................... 47

STEGLUJAN................................................ 48

STELARA SUBCUTANEOUS....................125

STIMUFEND.............................................. 139

stimulant lax plus........................................110

stimulant laxative........................................110

STIOLTO RESPIMAT................................ 167

STIVARGA................................................... 35

stomach relief extra strength......................103

stomach relief max st oral suspension 525

mg/15ml..................................................... 103

stomach relief oral suspension 1050

mg/30ml, 525 mg/15ml...............................103

stomach relief oral suspension 262

mg/15ml, 525 mg/30ml, 527 mg/30ml........103

stomach relief oral tablet 262 mg............... 103

stomach relief oral tablet chewable 262 mg

....................................................................103

stomach relief plus..................................... 103

stomach relief ultra.....................................103

stool softener laxative oral capsule............ 110

stool softener oral capsule 100 mg............ 110

stool softener oral capsule 240 mg............ 110

stool softener oral capsule 250 mg............ 110

stool softener oral capsule 50 mg.............. 110

stool softener pls laxative...........................110

stool softener plus laxative.........................110

stool softener/laxative................................ 110

stool softener/laxative oral tablet................110

STRENSIQ.................................................110

stress formula...............................................87

stress formula/iron......................................182

STRIBILD..................................................... 42

STRIVE DUAL ZONE PEAK FLOW MTR..139

STRIVERDI RESPIMAT.............................156

STUART ONE.............................................. 87

SUBOXONE.................................................16

subvenite......................................................23

subvenite starter kit-blue.............................. 23

subvenite starter kit-green............................23

subvenite starter kit-orange..........................23

sucralfate oral suspension........................... 92

sucralfate oral tablet.....................................92

SUDAFED.................................................. 177

SUDAFED CHILDRENS............................ 177

SUDAFED PE CONGESTION ORAL

TABLET 10 MG..........................................162

SUDAFED PE SINUS CONGESTION....... 162

SUDAFED SINUS CONGESTION.............177

SUDAFED SINUS CONGESTION 12HR...177

sudogest 12 hour....................................... 177

sudogest maximum strength...................... 177

sudogest oral tablet 30 mg.........................177

sulfacetamide sodium external...................139

sulfacetamide sodium ophthalmic.............. 144

sulfacetamide sodium-sulfur external

cream 10-5 %...............................................71

sulfacetamide sodium-sulfur external liquid

9-4.5 %.........................................................71

sulfacetamide sod-sulfur wash external

liquid 9-4.5 %............................................... 71

sulfacetamide-prednisolone....................... 143

sulfamethoxazole-trimethoprim oral............. 21

sulfamez wash............................................. 71

sulfasalazine oral....................................... 129

sulfatrim pediatric......................................... 21

sulindac oral................................................... 6

SUMADAN WASH....................................... 71

sumatriptan nasal.........................................32

sumatriptan succinate oral........................... 32

sumatriptan succinate refill...........................32

sumatriptan succinate subcutaneous...........32

sunitinib malate............................................ 35

SUNLENCA ORAL.....................................139

SUNOSI..................................................... 179

suphedrine 12hour..................................... 177

suphedrine maximum strength...................177

suphedrine oral tablet 30 mg......................177

218

suphedrine oral tablet extended release 12

hour 120 mg............................................... 178

SUPPORT..................................................182

SUPREP BOWEL PREP KIT....................... 91

sure result sr relief......................................139

SUTAB......................................................... 22

SUTENT.......................................................35

syeda..........................................................120

SYMBICORT..............................................168

SYMDEKO................................................. 156

SYMFI.......................................................... 43

SYMFI LO.................................................... 43

SYMLINPEN 120......................................... 48

SYMLINPEN 60........................................... 48

SYMPAZAN................................................. 24

SYMPROIC.................................................. 90

SYMTUZA.................................................... 44

SYNAGIS................................................... 125

SYNAREL.................................................. 124

SYNJARDY.................................................. 48

SYNJARDY XR............................................ 48

SYSTANE.................................................. 148

SYSTANE BALANCE.................................148

SYSTANE COMPLETE..............................149

SYSTANE CONTACTS..............................149

SYSTANE HYDRATION PF.......................149

SYSTANE NIGHTTIME..............................149

SYSTANE PRESERVATIVE FREE........... 149

SYSTANE ULTRA......................................149

SYSTANE ULTRA PF................................ 149

tab tussin....................................................162

tab-a-vite/beta carotene............................... 87

TABLOID......................................................34

TABRECTA................................................ 141

TACLONEX..................................................68

tacrolimus external ointment 0.03 %............ 68

tacrolimus external ointment 0.1 %.............. 68

tacrolimus oral capsule 0.5 mg, 5 mg........ 126

tacrolimus oral capsule 1 mg..................... 126

tadalafil (pah)............................................. 157

TADLIQ...................................................... 157

TAFINLAR....................................................35

TAGAMET HB 200.......................................92

TAGRISSO.................................................141

take action..................................................123

TAKHZYRO SUBCUTANEOUS

SOLUTION.................................................125

TAKHZYRO SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 150

MG/ML....................................................... 125

TAKHZYRO SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 300

MG/2ML..................................................... 125

TALICIA........................................................91

TALTZ........................................................ 125

TALZENNA ORAL CAPSULE 0.25 MG,

0.5 MG, 0.75 MG, 1 MG...............................35

TAMIFLU ORAL CAPSULE......................... 44

TAMIFLU ORAL SUSPENSION

RECONSTITUTED.......................................44

tamoxifen citrate oral....................................34

tamsulosin hcl............................................ 111

TARCEVA.................................................. 141

tarina 24 fe................................................. 120

tarina fe 1/20 eq......................................... 120

TASIGNA................................................... 141

TAVALISSE..................................................53

TAZORAC EXTERNAL CREAM 0.1 %........65

TAZORAC EXTERNAL GEL........................65

TDVAX....................................................... 127

TECFIDERA ORAL CAPSULE DELAYED

RELEASE.....................................................63

TEENY TUMMY GAS RELIEF DROPS..... 103

TEGSEDI................................................... 110

TEKTURNA..................................................57

telmisartan....................................................54

temazepam oral capsule 15 mg, 30 mg..... 179

temazepam oral capsule 22.5 mg.............. 179

temazepam oral capsule 7.5 mg................ 179

temozolomide...............................................33

TENCON........................................................ 8

TENIVAC....................................................127

tenofovir disoproxil fumarate........................ 43

TEPMETKO................................................. 35

terazosin hcl............................................... 111

terbinafine hcl external................................. 31

terbinafine hcl oral........................................29

terbinafine hydrochloride external cream 1

%.................................................................. 31

terconazole vaginal cream........................... 29

teriflunomide.................................................63

TERIPARATIDE (RECOMBINANT)

SUBCUTANEOUS SOLUTION PEN-

INJECTOR 620 MCG/2.48ML....................130

TESTIM...................................................... 115

testosterone cypionate intramuscular........ 115

testosterone enanthate intramuscular........115

testosterone transdermal gel 1.62 %, 20.25

mg/act (1.62%)...........................................115

testosterone transdermal gel 12.5 mg/act

(1%)............................................................115

testosterone transdermal gel 20.25

mg/1.25gm (1.62%), 25 mg/2.5gm (1%).... 115

testosterone transdermal gel 40.5

mg/2.5gm (1.62%)......................................115

TETANUS-DIPHTHERIA TOXOIDS TD.... 127

tetrabenazine............................................... 62

TEZSPIRE SUBCUTANEOUS SOLUTION

AUTO-INJECTOR...................................... 158

tgt clotrimazole external cream 1 %............. 70

THALOMID...................................................34

the magic bullet.......................................... 140

THEO-24.................................................... 157

theophylline er oral tablet extended release

12 hour 100 mg, 200 mg, 300 mg.............. 157

theophylline er oral tablet extended release

12 hour 450 mg.......................................... 157

219

theophylline er oral tablet extended release

24 hour 400 mg.......................................... 157

theophylline er oral tablet extended release

24 hour 600 mg.......................................... 157

theophylline oral......................................... 157

THERA......................................................... 87

thera-tabs..................................................... 87

thiamine hcl oral......................................... 184

thiamine mononitrate oral.............................87

THIOLA...................................................... 112

THIOLA EC................................................ 112

thioridazine hcl oral...................................... 40

thiothixene....................................................40

THRIVE........................................................ 18

THRIVITE RX...............................................87

tiadylt er........................................................56

tiagabine hcl................................................. 24

TIBSOVO..................................................... 35

TIKOSYN..................................................... 54

tilia fe..........................................................120

timolol maleate ophthalmic solution........... 145

TIMOPTIC OCUDOSE...............................145

TINACTIN EXTERNAL CREAM.................140

tinidazole oral tablet 250 mg........................ 19

tinidazole oral tablet 500 mg........................ 19

TIROSINT ORAL CAPSULE 100 MCG,

112 MCG, 125 MCG, 13 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25 MCG,

50 MCG, 75 MCG, 88 MCG....................... 123

TIROSINT-SOL.......................................... 123

TIVICAY....................................................... 42

TIVICAY PD................................................. 42

tizanidine hcl oral tablet................................41

TOBI PODHALER...................................... 156

TOBRADEX............................................... 143

TOBRADEX ST..........................................143

tobramycin inhalation nebulization solution

300 mg/4ml................................................ 156

tobramycin ophthalmic............................... 144

tobramycin-dexamethasone.......................143

tolcapone......................................................38

tolnaftate antifungal external cream........... 140

tolnaftate external cream............................140

tolnaftate external powder..........................140

tolterodine tartrate...................................... 111

tolterodine tartrate er..................................111

TOPAMAX....................................................23

TOPAMAX SPRINKLE.................................23

topiramate oral capsule sprinkle.................. 23

topiramate oral tablet................................... 23

toremifene citrate......................................... 34

torsemide..................................................... 57

total allergy.................................................154

total allergy medicine................................. 154

TOUJEO MAX SOLOSTAR......................... 50

TOUJEO SOLOSTAR.................................. 50

TOVIAZ...................................................... 111

TRACLEER................................................ 157

TRADJENTA................................................ 48

tramadol hcl oral tablet 50 mg........................8

trandolapril................................................... 54

tranexamic acid oral..................................... 52

tranylcypromine sulfate................................ 26

TRAVATAN Z.............................................142

travel ease....................................................28

trazodone hcl oral tablet 100 mg, 150 mg,

50 mg........................................................... 26

TRECATOR................................................. 33

TRELEGY ELLIPTA................................... 168

TREMFYA.................................................. 125

TRESIBA......................................................50

TRESIBA FLEXTOUCH............................... 50

tretinoin external cream................................65

tretinoin oral................................................. 36

TREXALL................................................... 126

TREXIMET................................................... 32

TREZIX.......................................................... 8

triamcinolone acetonide external cream...... 68

triamcinolone acetonide external lotion

0.025 %........................................................ 68

triamcinolone acetonide external lotion 0.1

%.................................................................. 68

triamcinolone acetonide external ointment

0.025 %, 0.1 %, 0.5 %..................................68

triamcinolone acetonide mouth/throat.......... 64

triamcinolone acetonide nasal....................167

TRIAMINIC ALLERCHEWS....................... 166

triamterene-hctz........................................... 57

triazolam.....................................................179

TRICON....................................................... 81

TRICOR....................................................... 58

triderm.......................................................... 68

trientine hcl oral capsule 250 mg................. 82

tri-estarylla..................................................120

trifluoperazine hcl......................................... 40

trifluridine....................................................144

trihexyphenidyl hcl oral tablet.......................38

TRIJARDY XR..............................................48

TRIKAFTA ORAL TABLET THERAPY

PACK......................................................... 156

TRIKAFTA ORAL THERAPY PACK.......... 156

tri-legest fe................................................. 120

tri-linyah......................................................120

TRILIPIX.......................................................58

tri-lo-estarylla..............................................120

tri-lo-marzia................................................ 120

trimethobenzamide hcl oral.......................... 28

trimethoprim oral.......................................... 19

tri-mili..........................................................120

TRINTELLIX.................................................26

tri-nymyo.................................................... 121

triphrocaps................................................... 87

triple antibiotic external ointment , 3.5-400-

5000 , 5-400-5000 , 5-400-5000 mg-unit..... 22

triple antibiotic original..................................22

TRIPTODUR.............................................. 124

tri-sprintec.................................................. 121

220

TRIUMEQ.....................................................43

TRIUMEQ PD...............................................43

tri-vite pediatric.............................................87

tri-vite/fluoride oral solution 0.25 mg/ml..... 182

tri-vite/fluoride oral solution 0.5 mg/ml....... 182

trivora (28)..................................................121

tri-vylibra.....................................................121

tri-vylibra lo.................................................121

TROKENDI XR.............................................23

trospium chloride........................................111

TRUE COVER............................................140

TRUE DAILY VITE....................................... 87

TRUE FERROUS SULFATE........................81

TRUE FOLIC ACID ORAL TABLET 400

MCG...........................................................140

true folic acid tablet 1 mg oral.................... 140

TRUE FOLIC ACID TABLET 1 MG ORAL. 140

TRUE MAGNESIUM OXIDE ORAL

TABLET 500 MG..........................................81

true magnesium oxide tablet 400 mg oral.... 81

TRUE MAGNESIUM OXIDE TABLET 400

MG ORAL.....................................................81

TRUE MULTIVITAMIN................................. 87

TRUE NASAL MOISTURIZING................. 162

TRUE VITAMIN A........................................ 87

TRUE VITAMIN B1 ORAL TABLET 100

MG............................................................... 87

TRUE VITAMIN B3 ORAL TABLET 100

MG, 250 MG, 50 MG....................................87

TRUE VITAMIN B6 ORAL TABLET 25 MG,

50 MG........................................................ 184

true vitamin b6 tablet 100 mg oral..............184

TRUE VITAMIN B6 TABLET 100 MG

ORAL......................................................... 184

TRUE VITAMIN C ORAL TABLET 250 MG

....................................................................182

TRUE VITAMIN C ORAL TABLET 500 MG

....................................................................182

true vitamin c tablet 1000 mg oral.............. 183

TRUE VITAMIN C TABLET 1000 MG

ORAL......................................................... 183

TRUE VITAMIN D3 ORAL CAPSULE 1.25

MG (50000 UT)............................................ 87

TRUE VITAMIN D3 ORAL CAPSULE 10

MCG (400 UNIT).......................................... 87

TRUE VITAMIN D3 ORAL CAPSULE 125

MCG (5000 UT), 25 MCG (1000 UT)........... 87

TRUE VITAMIN D3 ORAL CAPSULE 250

MCG (10000 UT)..........................................87

TRUE VITAMIN D3 ORAL TABLET 10

MCG (400 UNIT).......................................... 87

TRUE VITAMIN D3 ORAL TABLET 125

MCG (5000 UT)............................................87

TRUE VITAMIN D3 ORAL TABLET 25

MCG (1000 UT)............................................88

TRUE VITAMIN E ORAL CAPSULE 180

MG............................................................. 184

TRUE VITAMIN E ORAL CAPSULE 450

MG, 90 MG.................................................184

TRUECONTROL GLUCOSE CONT LEV 0. 75

TRUECONTROL GLUCOSE CONT LEV 1. 75

TRUEPLUS GLUCOSE ON THE GO.......... 50

TRUEPLUS GLUCOSE ORAL TABLET

CHEWABLE................................................. 50

TRULANCE..................................................90

TRULICITY...................................................48

TRUMENBA............................................... 128

TRUVADA.................................................... 43

TUMS......................................................... 104

TUMS CHEWY BITES............................... 104

TUMS E-X 750........................................... 104

TUMS EXTRA STRENGTH 750................ 104

TUMS LASTING EFFECTS....................... 104

TUMS SMOOTHIES.................................. 104

TUMS ULTRA 1000................................... 104

TURALIO....................................................142

turqoz......................................................... 121

tusnel-ex.....................................................162

tussin adult chest congest..........................162

tussin cf oral liquid 30-10-100 mg/5ml....... 178

tussin cf oral liquid 5-10-100 mg/5ml......... 164

tussin chest congestion oral liquid 100

mg/5ml....................................................... 162

tussin cough dm sugar free........................178

tussin cough long acting.............................162

tussin cough oral syrup.............................. 162

tussin cough/chest congest oral syrup 100-

10 mg/5ml.................................................. 178

tussin cough/chest dm max oral liquid 10-

200 mg/5ml................................................ 178

tussin cough/chest dm max oral liquid 20-

400 mg/20ml.............................................. 178

tussin dm cough + chest oral liquid 20-400

mg/20ml..................................................... 178

tussin dm cough/chest cong.......................178

tussin dm cough/chest oral syrup 10-100

mg/5ml....................................................... 178

tussin dm max............................................ 178

tussin dm max adult................................... 178

tussin dm max daytime.............................. 178

tussin dm max st........................................ 178

tussin dm oral syrup 100-10 mg/5ml.......... 178

tussin expectorant adult............................. 163

tussin maximum strength oral syrup 15

mg/5ml....................................................... 163

tussin mucus & chest cong........................ 163

tussin mucus & chest congest....................163

tussin mucus/chest congest....................... 163

tussin mucus/congestion............................163

tussin mucus+chest congest......................163

tussin mucus+chest congestion................. 163

tussin multi-symptom cold cf...................... 164

tussin oral liquid 100 mg/5ml......................163

TWINRIX.................................................... 128

TYBLUME.................................................. 121

TYBOST.......................................................44

TYLENOL FOR CHILDREN + ADULTS.......15

221

TYLENOL ORAL SUSPENSION 160

MG/5ML....................................................... 15

TYLENOL ORAL TABLET 325 MG, 500

MG............................................................... 15

TYLENOL ORAL TABLET CHEWABLE

160 MG........................................................ 15

TYLENOL ORAL TABLET EXTENDED

RELEASE 650 MG.......................................15

TYMLOS.................................................... 130

TYRVAYA.................................................. 143

TYVASO DPI MAINTENANCE KIT............157

TYVASO DPI TITRATION KIT................... 157

UBRELVY.................................................... 32

UCERIS......................................................129

UDENYCA SUBCUTANEOUS SOLUTION

AUTO-INJECTOR........................................ 52

UDENYCA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE................................ 52

ultra calcium + vitamin d3.............................81

ultra fresh................................................... 149

ultra fresh pm............................................. 149

ultra lubricant drop..................................... 149

ultra lubricating eye drops.......................... 149

ultra lubricating eye drops pf...................... 149

unithroid..................................................... 123

UPTRAVI ORAL.........................................157

urea 20 intensive hydrating.......................... 72

urea external cream 10 %............................ 72

urea external cream 20 %............................ 72

urea external lotion.......................................72

ureacin-10.................................................... 72

ureacin-20.................................................... 72

urinary pain relief oral tablet 95 mg............112

URO-PAIN..................................................112

ursodiol oral capsule 300 mg....................... 91

ursodiol oral tablet........................................91

UZEDY SUBCUTANEOUS SUSPENSION

PREFILLED SYRINGE 100 MG/0.28ML......41

VAGIFEM................................................... 121

valacyclovir hcl oral...................................... 42

valganciclovir hcl oral tablet......................... 41

valproic acid oral.......................................... 23

valsartan oral tablet......................................54

valsartan-hydrochlorothiazide...................... 57

VALTOCO 10 MG DOSE............................. 24

VALTOCO 15 MG DOSE............................. 24

VALTOCO 20 MG DOSE............................. 24

VALTOCO 5 MG DOSE............................... 24

VANCOCIN ORAL CAPSULE 250 MG........19

vancomycin hcl oral solution reconstituted

25 mg/ml...................................................... 19

VANDAZOLE............................................... 19

VAPORIZER WARM STEAM.....................140

VAQTA....................................................... 128

varenicline tartrate........................................17

varenicline tartrate (starter).......................... 17

varenicline tartrate(continue)........................17

VARIVAX....................................................128

VASCEPA.................................................... 58

VASOCLEAR-A..........................................149

VAXELIS.................................................... 140

VAXNEUVANCE........................................ 128

v-c forte...................................................... 183

VECTICAL....................................................68

vegetable lax+stool softener...................... 110

vegetable laxative...................................... 110

velivet......................................................... 121

VELPHORO................................................. 82

VELTASSA...................................................82

VENCLEXTA................................................35

VENCLEXTA STARTING PACK..................35

venlafaxine hcl............................................. 26

venlafaxine hcl er oral capsule extended

release 24 hour............................................ 26

VENTOLIN HFA......................................... 156

verapamil hcl er oral capsule extended

release 24 hour 120 mg, 180 mg, 240 mg,

360 mg......................................................... 56

verapamil hcl er oral tablet extended

release......................................................... 56

verapamil hcl oral......................................... 56

VERKAZIA................................................. 143

VERQUVO................................................... 59

VERSACLOZ............................................... 41

VERZENIO...................................................35

VESICARE................................................. 111

vestura....................................................... 121

VFEND......................................................... 29

VIBERZI....................................................... 90

vic-forte...................................................... 183

VICTOZA......................................................48

vienva.........................................................121

vigabatrin oral packet................................... 24

vigadrone oral packet...................................24

VIGAMOX.................................................. 144

vigpoder....................................................... 24

VIIBRYD.......................................................26

VIMPAT ORAL............................................. 24

VIOKACE................................................... 110

viorele.........................................................121

VIRACEPT................................................... 44

VIREAD ORAL POWDER............................43

VIREAD ORAL TABLET 150 MG, 200 MG,

250 MG........................................................ 43

virt-caps........................................................88

VISINE....................................................... 149

vit c/rose hips............................................. 183

vita s forte...................................................183

vitacel......................................................... 183

vitachew vitamin d3......................................88

vitamin a oral capsule 2400 mcg (8000 ut),

3 mg, 3 mg (10000 ut)..................................88

vitamin b complex oral capsule.................... 88

vitamin b complex w/b-12.............................88

vitamin b1...................................................184

vitamin b-1 oral tablet 100 mg......................88

vitamin b-1 oral tablet 250 mg....................184

222

vitamin b-12 er oral tablet extended

release 1000 mcg.......................................184

vitamin b12 oral tablet extended release

1000 mcg................................................... 184

vitamin b-12 tr oral tablet extended release

1000 mcg................................................... 184

vitamin b-6..................................................184

vitamin b-6 er............................................. 184

vitamin c cr oral tablet extended release

500 mg....................................................... 183

vitamin c er oral tablet extended release

1500 mg..................................................... 183

vitamin c oral liquid 500 mg/5ml.................183

vitamin c oral tablet 1000 mg, 250 mg....... 183

vitamin c oral tablet 500 mg....................... 183

vitamin c oral tablet chewable 100 mg, 250

mg.............................................................. 183

vitamin c oral tablet chewable 500 mg....... 183

vitamin c/acerola........................................ 183

vitamin c/rose hips oral tablet 1000 mg......183

vitamin c/rose hips oral tablet 500 mg........183

vitamin c-rose hips..................................... 183

vitamin c-rose hips oral tablet.................... 183

vitamin d (cholecalciferol) oral tablet 10

mcg (400 unit).............................................. 88

vitamin d (cholecalciferol) oral tablet 25

mcg (1000 ut)............................................... 88

vitamin d (ergocalciferol) oral capsule 1.25

mg (50000 ut), 50000 unit.......................... 183

vitamin d oral capsule 25 mcg (1000 ut)...... 88

vitamin d oral liquid...................................... 88

vitamin d oral tablet chewable 10 mcg (400

unit).............................................................. 88

vitamin d3 oral capsule 1.25 mg (50000 ut). 88

vitamin d3 oral capsule 125 mcg (5000 ut).. 88

vitamin d-3 oral capsule 125 mcg (5000 ut). 88

vitamin d3 oral capsule 25 mcg (1000 ut).... 88

vitamin d3 oral capsule 250 mcg (10000 ut) 88

vitamin d3 oral capsule 50 mcg (2000 ut).... 89

vitamin d-3 oral capsule 50 mcg (2000 ut)... 89

vitamin d3 oral liquid 10 mcg/ml...................89

vitamin d3 oral tablet 10 mcg (400 unit)....... 89

vitamin d3 oral tablet 125 mcg (5000 ut)......89

vitamin d3 oral tablet 25 mcg (1000 ut)........89

vitamin d-3 oral tablet 25 mcg (1000 ut).......89

vitamin d3 oral tablet 50 mcg (2000 ut)........89

vitamin d3 oral tablet chewable 10 mcg

(400 unit)...................................................... 89

vitamin d3 oral tablet chewable 25 mcg

(1000 ut).......................................................89

vitamin d-400 oral tablet 10 mcg (400 unit)..89

vitamin e natural.........................................184

vitamin e oral capsule 134 mg (200 unit),

45 mg (100 unit), 450 mg (1000 ut), 90 mg

(200 unit).................................................... 184

vitamin e oral capsule 180 mg (400 unit),

268 mg (400 unit)....................................... 184

vitamin-b complex........................................ 89

vitamins acd-fluoride.................................. 183

vitamins complete childrens....................... 183

VITRAKVI.....................................................36

VIVAGUARD INO CONTROL SOLUTION...75

VIVELLE-DOT............................................121

VIVITROL.....................................................16

VIVJOA...................................................... 140

VIZIMPRO..................................................142

VOGELXO..................................................115

volnea.........................................................121

VOQUEZNA DUAL PAK............................ 140

VOQUEZNA TRIPLE PAK........................... 89

voriconazole oral tablet................................ 29

VOSEVI........................................................42

VOTRIENT................................................. 142

VRAYLAR.................................................... 41

VTAMA.......................................................140

VUMERITY...................................................63

vyfemla.......................................................121

vylibra.........................................................121

VYNDAMAX............................................... 110

VYNDAQEL................................................110

VYTORIN..................................................... 58

VYVANSE ORAL CAPSULE........................62

VYVANSE ORAL TABLET CHEWABLE......62

VYZULTA................................................... 142

WAKIX........................................................179

warfarin sodium oral tablet 1 mg, 10 mg, 2

mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg........ 51

warfarin sodium oral tablet 6 mg.................. 51

wart remover external liquid 17 %..............140

wart remover maximum strength external

liquid...........................................................140

weekly-d....................................................... 89

WEGOVY..................................................... 36

WELLBUTRIN XL.........................................26

wera........................................................... 121

wescaps....................................................... 89

WESNATAL DHA COMPLETE.................... 89

wes-phos 250 neutral...................................81

WESTAB PLUS............................................89

WIDE-SEAL DIAPHRAGM 60....................140

WIDE-SEAL DIAPHRAGM 65....................140

WIDE-SEAL DIAPHRAGM 70....................140

WIDE-SEAL DIAPHRAGM 75....................140

WIDE-SEAL DIAPHRAGM 80....................140

WIDE-SEAL DIAPHRAGM 85....................140

WIDE-SEAL DIAPHRAGM 90....................140

WIDE-SEAL DIAPHRAGM 95....................140

WINLEVI.................................................... 140

wixela inhub............................................... 168

womans laxative.........................................140

womens gentle laxative..............................140

womens laxative.........................................140

womens prenatal+dha..................................89

wymzya fe.................................................. 121

XACIATO..................................................... 19

XALATAN...................................................142

XALKORI....................................................142

223

XARELTO.................................................... 51

XARELTO STARTER PACK........................51

XCOPRI (250 MG DAILY DOSE).................23

XCOPRI (350 MG DAILY DOSE).................23

XCOPRI ORAL TABLET 100 MG, 150 MG,

200 MG, 50 MG............................................23

XCOPRI ORAL TABLET THERAPY PACK. 23

XELJANZ................................................... 125

XELJANZ XR............................................. 125

XELPROS.................................................. 142

XENAZINE................................................... 62

XEPI............................................................. 70

XERAC AC...................................................72

XHANCE.................................................... 155

XIFAXAN......................................................19

XIGDUO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-1000 MG............... 48

XIGDUO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-500 MG, 5-500

MG............................................................... 48

XIGDUO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 2.5-1000 MG.............. 48

XIGDUO XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 5-1000 MG................. 48

XIIDRA....................................................... 143

XOFLUZA (40 MG DOSE)........................... 44

XOFLUZA (80 MG DOSE)........................... 44

XOLAIR...................................................... 125

XOPENEX HFA..........................................156

XOSPATA.................................................. 142

XPECT....................................................... 163

XPHOZAH ORAL TABLET 20 MG.............140

XPOVIO (100 MG ONCE WEEKLY)............34

XPOVIO (40 MG ONCE WEEKLY)..............34

XPOVIO (40 MG TWICE WEEKLY).............34

XPOVIO (60 MG ONCE WEEKLY)..............34

XPOVIO (80 MG ONCE WEEKLY)..............34

XTAMPZA ER................................................ 6

XTANDI........................................................ 33

xulane.........................................................121

XULTOPHY..................................................48

XYOSTED.................................................. 115

XYREM...................................................... 179

XYWAV...................................................... 178

YASMIN 28................................................ 121

YAZ............................................................ 121

YONSA.......................................................140

YUPELRI....................................................155

yuvafem......................................................121

ZADITOR................................................... 150

zafemy........................................................121

zafirlukast................................................... 155

zaleplon......................................................179

ZANAFLEX ORAL CAPSULE 2 MG............ 41

ZANAFLEX ORAL CAPSULE 4 MG, 6 MG. 41

ZANAFLEX ORAL TABLET......................... 41

ZARXIO........................................................52

ZAVESCA.................................................. 110

ZEASORB-AF.............................................. 31

ZEGALOGUE.............................................112

ZEJULA........................................................36

ZELAC........................................................104

ZELBORAF.................................................. 36

zenatane...................................................... 65

ZENPEP ORAL CAPSULE DELAYED

RELEASE PARTICLES 10000-32000

UNIT, 15000-47000 UNIT, 20000-63000

UNIT, 25000-79000 UNIT, 3000-10000

UNIT, 40000-126000 UNIT, 5000-24000

UNIT...........................................................110

ZEPATIER....................................................42

ZEPOSIA......................................................63

ZEPOSIA 7-DAY STARTER PACK............. 63

ZETONNA.................................................. 155

ZIANA...........................................................65

zidovudine.................................................... 43

ZIEXTENZO................................................. 52

ZILXI.............................................................72

ZIMHI........................................................... 17

zinc gluconate.............................................. 81

zinc gluconate oral tablet 50 mg.................. 81

zinc oral tablet 50 mg........................... 81, 183

zinc oxide external ointment 40 %............... 71

ZIOPTAN....................................................142

ziprasidone hcl............................................. 41

ZOCOR........................................................ 58

ZOLINZA...................................................... 34

zolpidem tartrate er.................................... 179

zolpidem tartrate oral tablet........................179

ZOMACTON...............................................114

ZOMIG NASAL.............................................32

ZONEGRAN.................................................24

zonisamide oral............................................ 24

ZORYVE EXTERNAL CREAM.................. 140

ZOSTRIX HP..............................................140

zovia 1/35 (28)........................................... 121

ZUBSOLV.................................................... 16

ZULRESSO..................................................26

zumandimine..............................................121

ZYCLARA.....................................................68

ZYDELIG......................................................36

ZYFLO........................................................155

ZYKADIA......................................................36

ZYLET........................................................ 143

ZYPITAMAG................................................ 58

ZYPREXA ORAL..........................................41

ZYPREXA ZYDIS.........................................41

ZYRTEC ALLERGY ORAL TABLET..........154

ZYRTEC-D ALLERGY & CONGESTION...164

ZYRTEC-D ALLERGY & SINUS................ 164

ZYTIGA........................................................ 33

224